The innovative and revolutionary scholarship of the eminent Austrian legal theorist and professor of Roman law, Eugen Ehrlich, is of a very high..

When a patient lacks decision-making capacity, then according to standard clinical ethics practice in the United States, the health care team should seek guidance from a surrogate decision-maker, either previously selected by the patient or appointed by the courts. If there are no surrogates willing or able to exercise substituted judgment, then the team is to choose interventions that promote a patient’s best interests. We argue that, even when there is input from a surrogate, patient preferences should be an additional (...) source of guidance for decisions about patients who lack decision-making capacity. (shrink)

The clinical application of the concept of patient autonomy has centered on the ability to deliberate and make treatment decisions (decisional autonomy) to the virtual exclusion of the capacity to execute the treatment plan (executive autonomy). However, the one-component concept of autonomy is problematic in the context of multiple chronic conditions. Adherence to complex treatments commonly breaks down when patients have functional, educational, and cognitive barriers that impair their capacity to plan, sequence, and carry out tasks associated with chronic care. (...) The purpose of this article is to call for a two-component re-conceptualization of autonomy and to argue that the clinical assessment of capacity for patients with chronic conditions should be expanded to include both autonomous decision-making and autonomous execution of the agreed-upon treatment plan. We explain how the concept of autonomy should be expanded to include both decisional and executive autonomy, describe the biopsychosocial correlates of the two-component concept of autonomy, and recommend diagnostic and treatment strategies to support patients with deficits in executive autonomy. (shrink)

Medical clinicians – doctors, nurses, nurse practitioners etc. – are charged to act for the good of their patients. But not all ways of acting for a patient's good are on par: some are paternalistic; others are not. What does it mean to act paternalistically, both in general and specifically in a medical context? And when, if ever, is it permissible for a clinician to act paternalistically? In Medical Paternalism Part 1, I answered the first question. This paper answers the (...) second. The place of paternalism in clinical medicine is best understood, I argue, in terms of the potential for conflict between the autonomy principle and the beneficence principle. The first enjoins clinicians to respect the decisions of patients with respect to their (the patients') own care. The second enjoins clinicians to act for the good of their patients. Clinicians act paternalistically, I argue, when they act on the beneficence principle to the exclusion of the autonomy principle. Understanding just what these principles amount to (particularly the autonomy principle) reveals that the autonomy principle defeasibly trumps the beneficence principle and that, as a result, acting paternalistically (at least when it comes to competent patients) is presumptively impermissible. (shrink)

Health services internationally struggle to ensure health care is “person-centered” (or similar). In part, this is because there are many interpretations of “person-centered care” (and near synonyms), some of which seem unrealistic for some patients or situations and obscure the intrinsic value of patients’ experiences of health care delivery. The general concern behind calls for person-centered care is an ethical one: Patients should be “treated as persons.” We made novel use of insights from the capabilities approach to characterize person-centered care (...) as care that recognizes and cultivates the capabilities associated with the concept of persons. This characterization unifies key features from previous characterisations and can render person-centered care applicable to diverse patients and situations. By tying person-centered care to intrinsically valuable capability outcomes, it incorporates a requirement for responsiveness to individuals and explains why person-centered care is required independently of any contribution it may make to health gain. (shrink)

Health services internationally struggle to ensure health care is “person-centered” (or similar). In part, this is because there are many interpretations of “person-centered care” (and near synonyms), some of which seem unrealistic for some patients or situations and obscure the intrinsic value of patients’ experiences of health care delivery. The general concern behind calls for person-centered care is an ethical one: Patients should be “treated as persons.” We made novel use of insights from the capabilities approach to characterize person-centered care (...) as care that recognizes and cultivates the capabilities associated with the concept of persons. This characterization unifies key features from previous characterisations and can render person-centered care applicable to diverse patients and situations. By tying person-centered care to intrinsically valuable capability outcomes, it incorporates a requirement for responsiveness to individuals and explains why person-centered care is required independently of any contribution it may make to health gain. (shrink)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

The law of informed consent to medical treatment has recently been extensively overhauled in England. The 2015 Montgomery judgment has done away with the long-held position that the information to be disclosed by doctors when obtaining valid consent from patients should be determined on the basis of what a reasonable body of medical opinion agree ought to be disclosed in the circumstances. The UK Supreme Court concluded that the information that is material to a patient’s decision should instead be judged (...) by reference to a new two-limbed test founded on the notions of the ‘reasonable person’ and the ‘particular patient’. The rationale outlined in Montgomery for this new test of materiality, and academic comment on the ruling’s significance, has focused on the central ethical importance that the law now accords to respect for patient autonomy in the process of obtaining consent from patients. In this paper, we dispute the claim that the new test of materiality articulated in Montgomery equates with respect for autonomy being given primacy in re-shaping the development of the law in this area. We also defend this position, arguing that our revised interpretation of Montgomery’s significance does not equate with a failure by the courts to give due legal consideration to what is owed to patients as autonomous decision-makers in the consent process. Instead, Montgomery correctly implies that doctors are ethically obliged to attend to a number of relevant ethical considerations in framing decisions about consent to treatment, which include subtle interpretations of the values of autonomy and well-being. Doctors should give appropriate consideration to how these values are fleshed out and balanced in context in order to specify precisely what information ought to be disclosed to a patient as a requirement of obtaining consent, and as a core component of shared decision-making within medical encounters more generally. (shrink)

The demands of respect for persons when conducting clinical research are often reduced to respect for autonomy. In this paper, I re-examine the concept of respect for persons in light of important intuitions from our ordinary language usage of respect. I propose that there are many ways to respect persons as persons and that the core elements of respect for persons are: appreciating what is valuable or important about a person, recognizing the constraints or demands that such a valuation places (...) on one's own conduct, and acting in a way that expresses that recognition. On this account, in addition to autonomous agency, respect demands attention to important subjective experiences, persons' existence as part of communities, and considerations of comportment. This account has important implications for the conduct of clinical research with persons who are autonomous as well as with those who are not. Its implications, however, are different for these two populations, particularly with regard to concerns about well-being. (shrink)

S. 39: "My project in this paper is to develop the initial distinction which I have drawn between recognition and appraisal respect into a more detailed and specific account of each. These accounts will not merely be of intrinsic interest. Ultimately I will use them to illuminate the puzzles with which this paper began and to understand the idea of self-respect." 42 " Thus, insofar as respect within such a pursuit will depend on an appraisal of the participant from the (...) perspective of whatever standards are held to be appropriate to the pursuit, such respect will depend on a judgement to which excellences of character are thought relevant. Note that exactly what aspect of the person's character is thought to be relevant in this instance is his recognition respect (or lack of it) for the standards of the pursuit." 44 "This attitude fails of being appraisal respect in that my having it toward the person is conditional on those traits being such as to make him server a particular purpose that I happen to have" 44 - 45 "To sum up: Appraisal respect is an attitude of positibe appraisal of a person either judged as a person or as engaged in some more specific pursuit. In the first case, the appropriate grounds are features of the person's character: dispositions to act for particular reasons or a higher-level disposition to act for the best reasons. In the second case, though features of character do not exhaust the appropriate grounds for appraisal respect, some such character traits will be relevant (recognition respect for the standards of a particular pursuit). Also, the other features which constitute the appoprate excellences of the pursuit must be related to traits of character in the way specified. In both cases, the positive appraisal of the person, and of his traits, must be categorical. It cannot depend on the fact that the person, because of his traits, serves an interest or purpose of one's own." 45 "To have recognition respect for someone as a person is to give appropriate weight to the fact that he or she is a person by being willing to constrain one's behaviour in ways required by that fact." 45 "This is rather different from having an attitude of appraisal respect for someone as a person. The latter is a positive appraisal oif an individual made with regard ti those features which are excellences of persons. As such, it is not owed to everone, for it may or may not be merited. When it is, what is merited is just the positive appraisal itself." 47 "Second, the only beings who are approriate objects of appraisal respect are those who are capable of acting for reasons and hence capable of conceiving of various facts as meriting more or less consideration in deliberation.". (shrink)

We believe we owe one another respect. We believe we ought to pay what we owe by treating one another ‘with respect.’ If we could understand these beliefs we would be well on the way to understanding morality itself. If we could justify these beliefs we could vindicate a central part of our moral experience.Respect comes in many varieties. We respect some people for their upright character, others for their exceptional achievements. There are people we respect as forces of nature: (...) we go to great lengths to accommodate their moods, wiles, and demands. Finally, most of us seem to respect people simply because they are people. This is the sort of respect of special interest to moral theory.In order to be worthy of this last sort of respect, it is not only sufficient but necessary that one be a person. We can, of course, take a similar attitude towardnonpersons. (shrink)

We believe we owe one another respect. We believe we ought to pay what we owe by treating one another ‘with respect.’ If we could understand these beliefs we would be well on the way to understanding morality itself. If we could justify these beliefs we could vindicate a central part of our moral experience.Respect comes in many varieties. We respect some people for their upright character, others for their exceptional achievements. There are people we respect as forces of nature: (...) we go to great lengths to accommodate their moods, wiles, and demands. Finally, most of us seem to respect people simply because they are people. This is the sort of respect of special interest to moral theory.In order to be worthy of this last sort of respect, it is not only sufficient but necessary that one be a person. We can, of course, take a similar attitude towardnonpersons. (shrink)

The concept of the sick role entered sociology in 1951 when Talcott Parsons creatively separated the sick person out of the doctor–patient dyad. The idea became fundamental in the subdiscipline of medical sociology. By the 1990s, the concept had almost disappeared from the research literature. Beyond the generational and theoretical changes that explain how the sick role idea could become irrelevant or unnecessary to sociologists, there were two immediate factors: the negative politicization of the concept and the shift of medical (...) sociologists to a focus on applied health behavior. In the later, fragmented discipline of sociology, final, total abandonment was still uncertain. (shrink)

The right of adults with sound mind to consent to treatment or risk their own health for the benefit of the community in a clinical trial is unequivocally recognised by the law. But what about those vulnerable by virtue of their age, nature or position in society? Experts from the fields of medicine, philosophy, theology and law, explore the ethical and legal principles which seek to reconcile the individual's right to autonomy with the need to protect vulnerable groups. Discussions refer (...) both to specific groups and specific issues. (shrink)

Over the course of its first seven editions, Principles of Biomedical Ethics has proved to be, globally, the most widely used, authored work in biomedical ethics. It is unique in being a book in bioethics used in numerous disciplines for purposes of instruction in bioethics. Its framework of moral principles is authoritative for many professional associations and biomedical institutions-for instruction in both clinical ethics and research ethics. It has been widely used in several disciplines for purposes of teaching in the (...) classroom, during conferences, etc. (shrink)

In this reprint of Law's Empire,Ronald Dworkin reflects on the nature of the law, its given authority, its application in democracy, the prominent role of interpretation in judgement, and the relations of lawmakers and lawgivers to the community on whose behalf they pronounce. For that community, Law's Empire provides a judicious and coherent introduction to the place of law in our lives.Previously Published by Harper Collins. Reprinted (1998) by Hart Publishing.

Embryo research, cloning, assisted conception, neonatal care, savior siblings, organ transplants, drug trials – modern developments have transformed the field of medicine almost beyond recognition in recent decades and the law struggles to keep up. At the same time legal claims against doctors and the NHS has grown and doctors feel under siege. In this highly acclaimed and very accessible book, Margaret Brazier and Emma Cave provide an incisive survey of the legal situation in areas as diverse as fertility treatment, (...) surrogacy, patient consent, euthanasia and the definition of death, malpractice and medical privacy. (shrink)

The result is nothing less than a fundamental reorientation of moral theory that enables it at last to account for morality's supreme authority--an account that ...

Protecting the Vulnerable explores the reality of patient control and choice in health care and analyzes how decisions should be made on behalf of those deemed incapable of making decisions. The contributors, distinguished experts from the disciplines of medicine, ethics, theology, and law, look at the complex problem of autonomy and consent in health care and clinical research today from an illuminating perspective--its impact on the vulnerable members of society. The essays move from the exploration of lingering paternalism in health (...) care to the acute dilemma of treatment of and research on newborn babies. In covering both general and specific problems the collection reveals how exploitation can occur when the right of autonomy is eroded and where informed consent is illusory. Particularly vulnerable groups, such as children and people with mental handicaps, are discussed alongside cases where the vulnerability is itself an issue. Other areas covered include: `gesture' suicides, the practical problems of doctors in dealing with dependent patients, and the limits of proxy consent. All health care professionals, ethicists, policy makers, and lawyers currently engaged in the study or practice of health care ethics will find Protecting the Vulnerable to be a vital source of information for many years to come. (shrink)

This book provides an analysis of the debate surrounding cultural diversity, and attempts to reconcile the seemingly opposing views of "ethical imperialism," the belief that each individual is entitled to fundamental human rights, and cultural relativism, the belief that ethics must be relative to particular cultures and societies. The author examines the role of cultural tradition, often used as a defense against critical ethical judgments. Key issues in health and medicine are explored in the context of cultural diversity: the physician-patient (...) relationship, disclosing a diagnosis of a fatal illness, informed consent, brain death and organ transplantation, rituals surrounding birth and death, female genital mutilation, sex selection of offspring, fertility regulation, and biomedical research involving human subjects. Among the conclusions the author reaches are that ethical universals exist, but must not be confused with ethical absolutes. The existence of ethical universals is compatible with a variety of culturally relative interpretations, and some rights related to medicine and health care should be considered human rights. Illustrative examples are drawn from the author's experiences serving on international ethical review committees and her travels to countries in Africa, Asia, and Latin America, where she conducted educational workshops and carried out out her own research. (shrink)

Informed consent is a central topic in contemporary biomedical ethics. Yet attempts to set defensible and feasible standards for consenting have led to persistent difficulties. In Rethinking Informed Consent in Bioethics Neil Manson and Onora O'Neill set debates about informed consent in medicine and research in a fresh light. They show why informed consent cannot be fully specific or fully explicit, and why more specific consent is not always ethically better. They argue that consent needs distinctive communicative transactions, by which (...) other obligations, prohibitions, and rights can be waived or set aside in controlled and specific ways. Their book offers a coherent, wide-ranging and practical account of the role of consent in biomedicine which will be valuable to readers working in a range of areas in bioethics, medicine and law. (shrink)

From Hippocrates to paternalism to autonomy : the new hegemony -- From autonomy to consent -- Consent, autonomy, and the law -- Autonomy at the end of life -- Autonomy and pregnancy -- Autonomy and genetic information -- Autonomy and organ transplantation -- Autonomy, consent, and the law.