Medical decisionmaking would be a messier but better thing if it honored what is morally valuable about patients' families. The concerns of intimates have a legitimate call upon us even when we are ill.

Recent articles in biomedical ethics have begun to explore both the relevance of family interests in treatment decisions and the resultant ramifications for physicians' obligations to patients. This article addresses two important questions regarding physicians' obligations vis-a-vis family interests: (1) What should a physician do when the exercise of patient autonomy threatens to negate the patient's moral obligations to other family members? (2) Does respect for patient autonomy typically require efforts on the part of physicians to keep patients' treatment decisions (...) from being influenced by family considerations? A series of clarifications about the concept of autonomy is also presented. (shrink)

Bioethicists think about families in terms of conflicting interests. This mistake results from an impoverished notion of informed consent. Only by adequately characterizing the process of informed consent can we capture the phenomenon of shared decisionmaking.

Clinicians' work depends on sincere and complete disclosures from their patients; they honour this candidness by confidentially safeguarding the information received. Breaching confidentiality causes harms that are not commensurable with the possible benefits gained. Limitations or exceptions put on confidentiality would destroy it, for the confider would become suspicious and un-co-operative, the confidant would become untrustworthy and the whole climate of the clinical encounter would suffer irreversible erosion. Excusing breaches of confidence on grounds of superior moral values introduces arbitrariness and (...) ethical unreliability into the medical context. Physicians who breach the agreement of confidentiality are being unfair, thus opening the way for, and becoming vulnerable to, the morally obtuse conduct of others. Confidentiality should not be seen as the cosy but dispensable atmosphere of clinical settings; rather, it constitutes a guarantee of fairness in medical actions. Possible perils that might accrue to society are no greater than those accepted when granting inviolable custody of information to priests, lawyers and bankers. To jeopardize the integrity of confidential medical relationships is too high a price to pay for the hypothetical benefits this might bring to the prevailing social order. (shrink)

It is broadly held that confidentiality may be breached when doing so can avert grave harm to a third party. This essay challenges the conventional wisdom. Neither legal duties, personal morality nor personal values are sufficient to ground professional obligations. A methodology is developed drawing on core professional values, the nature of professions, and the justification for distinct professional obligations. Though doctors have a professional obligation to prevent public peril, they do not honor it by breaching confidentiality. It is shown (...) how the protective purpose to be furthered by reporting is defeated by the practice of reporting. Hence there is no conflict between confidentiality and the professional responsibility to protect endangered third parties. (shrink)

What are the appropriate criteria for assessing a theory of morality? In this enlightening work, Brad Hooker begins by answering this question. He then argues for a rule-consequentialist theory which, in part, asserts that acts should be assessed morally in terms of impartially justified rules. In the end, he considers the implications of rule-consequentialism for several current controversies in practical ethics, making this clearly written, engaging book the best overall statement of this approach to ethics.

The prevalent ethic of patient autonomy ignores family interests in medical treatment decisions. Acknowledging these interests as legitimate forces basic changes in ethical theory and the moral practice of medicine.

We are beginning to recognize that the prevalent ethic of patient autonomy simply will not do. Since demands for health care are virtually unlimited, giving autonomous patients the health care they want will bankrupt our health care system. We can no longer simply buy our way out of difficult questions of justice by expanding the health care pie until there is enough to satisfy the wants and needs of everyone. The requirements of justice and the needs of other patients must (...) temper the claims of autonomous patients. (shrink)

The American Medical Association has provided a list of patient responsibilities, said to be derived from patient autonomy, without providing any justification for this derivation. In this article, the virtue of moral responsibility is proposed as a way to justify these kinds of limits on respect for individual autonomy. The need for such limits is explained by examining the traditional principles of health care ethics. What is missing in health care decision making, and can be provided by the virtue of (...) moral responsibility, is a careful consideration of the impact of individual decisions on particular others and the community, as a whole. The concept of moral responsibility as a virtue is then developed and examples of its application to health care decision making are provided. Finally, the roles of both physicians and health care ethicists in promoting the morally responsible exercise of individual autonomy are explored. (shrink)

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

Many AIDS-related issues are polarised. At the social level, civil rights or liberties are seen as being in conflict with general utility, and an analogous distinction is often assumed to exist at the one-to-one, individual level at which doctors work. In this paper the latter form of the distinction is argued to be false. By seeing autonomy as part of welfare, doctors can think more directly about such issues as paternalism, confidentiality, and consent. A number of these issues are discussed (...) in the light of the revised conception of welfare, in the form of simplified case studies. (shrink)

Our culture is well on its way to reducing medical ethics to legal requirements, general citizen ethics, or personal values. A distinctive ethic for medicine provides critical distance and moral meaning for the profession and an enriched societal ethic.

The equipoise requirement in clinical research demands that, if patients are to be randomly assigned to one of two interventions in a clinical trial, there must be genuine doubt about which is better. This reflects the traditional view that physicians must never knowingly compromise the care of their patients, even for the sake of future patients. Equipoise has proven to be deeply problematic, especially in the Third World. Some recent critics have argued against equipoise on the grounds that clinical research (...) is fundamentally distinct from clinical care, and thus should be governed by different norms. I argue against this "difference position," and instead take issue with the traditional, exclusively patient-centered account of physicians' obligations that equipoise presupposes. In place of this traditional view, I propose a Kantian test for the reasonable partiality that physicians should show their patients, focusing on its application in clinical research and medical education. (shrink)

The Patient in the Family diagnoses the ways in which the worlds of home and hospital misunderstand each other. The authors explore how medicine, through its new reproductive technologies, is altering the stucture of families, how families can participate more fully in medical decision-making, and how to understand the impact on families of medical advances to extend life but not vitality.

When philosophers address personal identity, they usually explore numerical identity: what are the criteria for a person's continuing existence? When non-philosophers address personal identity, they often have in mind narrative identity: Which characteristics of a particular person are salient to her self-conception? This book develops accounts of both senses of identity, arguing that both are normatively important, and is unique in its exploration of a range of issues in bioethics through the lens of identity. Defending a biological view of our (...) numerical identity and a framework for understanding narrative identity, DeGrazia investigates various issues for which considerations of identity prove critical: the definition of death; the authority of advance directives in cases of severe dementia; the use of enhancement technologies; prenatal genetic interventions; and certain types of reproductive choices. He demonstrates the power of personal identity theory to illuminate issues in bioethics as they bring philosophical theory to life. (shrink)