It is an established Hellenistic topos that philosophy is the ‘medicine’ of the soul, in charge of ‘healing’ the soul in the same way as medicine is in charge of healing the body. The ‘diseases’ of the soul deemed to be in need of healing are its passions, that is, its fears and desires, and the moral ‘health’ that philosophers pledge to grant their followers is freedom from passions and hence peace of mind.

Over the last decade, personalized medicine has become a buzz word, which covers a broad spectrum of meanings and generates many different opinions. The purpose of this article is to achieve a better understanding of the reasons why personalized medicine gives rise to such conflicting opinions. We show that a major issue of personalized medicine is the gap existing between its claims and its reality. We then present and analyze different possible reasons for this gap. We (...) propose an hypothesis inspired by the Windelband’s distinction between nomothetic and idiographic methodology. We argue that the fuzzy situation of personalized medicine results from a mix between idiographic claims and nomothetic methodological procedures. Hence we suggest that the current quandary about personalized medicine cannot be solved without getting involved in a discussion about the complex epistemological and methodological status of medicine. To conclude, we show that the Gadamer’s view of medicine as a dialogical process can be fruitfully used and reveals that personalization is not a theoretical task, but a practical one, which takes place within the clinical encounter. (shrink)

Definition of the problem: Compromise is an ethical category. During the last 20 years it has rarely been considered, although there are many controversial ethical issues in medicine with no willingness for consensus. In the process of ethics consultation, dissatisfaction with the consultation or afterwards with the decision to act was also noticed.Arguments: Ethics consultation must take into account the anti-ethical implications. Therefore, it must consider the meaning of ethical compromise (1) as an existential option, (2) as a moment (...) in moral development, and (3) as a presupposition for medical interactions.Conclusion: Compromise means to act competently to mediate between morals and situational challenges. Thus, moral optimalism could easily become fundamentalism, which is the horizon of ethics consultation. (shrink)

Corporate Physicians: Between Medicine and Management. By Diana Chapman Walsh.

Philosophy, including moral philosophy, is the distillation of the spirit of an era. As society and science develop, sooner or later a given philosophy will gradually change form so that the resulting metamorphosis will better meet the needs of the society at that time. Traditional Chinese ethical thought is an outcome of the Chinese closed natural economy and ancient low-level science and is suitable for traditional Chinese medicine. Its superstable structure and character, which have evolved over more than 2,000 (...) years, are rooted deeply in the minds of the Chinese people; hence, it is difficult for them to accept new bioethical views and to adapt to the developments of modern medicine and the changes in society. In China, owing to the strongly rooted values of the old tradition, the consequences of modern medicine have produced an alienating phenomenon that deviates from the goals of modern medicine and leads to conflicts between ethics and science, between old medical ethics and new medical ethics. (shrink)

The central dilemma concerning randomized clinical trials (RCTs) arises out of some simple facts about causal methodology (RCTs are the best way to generate the reliable causal knowledge necessary for optimally-informed action) and a prima facie plausible principle concerning how physicians should treat their patients (always do what it is most reasonable to believe will be best for the patient). A number of arguments related to this in the literature are considered. Attempts to avoid the dilemma fail. Appeals to informed (...) consent and mechanisms for minimizing the resulting harm are important for policy, but informed consent is problematic and mechanisms for minimization of harm do not address the dilemma. Appeals to some sort of contract model of justification are promising and illuminating. Keywords: randomized clinical trials, ethics CiteULike Connotea Del.icio.us What's this? (shrink)

The policy changes governing the relations between the pharmaceutical, medical device and service industries and academic clinical research physicians, recommended by the Institute of Medicine,1 the American Academy of Medical Colleges,2 and much discussed in the media and on our campuses, aim to create some protective ethical firewalls. However, some potentially critical consequences of these steps are missed if we do not acknowledge what else is on the table, and who is sitting at it. By only reacting defensively (...) to the juggernaut of righteous indignation over the loss of purity in a faculty physician's approach to medical problem solving, we are allowing the process to blind us to the difficulties in establishing fair and equitable management of all of the potential conflicts of commitment and conflicts of interest we incur, not only as faculty members, but also as departments and academic medical centres . Critically, this involves all sources of revenue—private, commercial and public—that support our professional and institutional commitments as well as our personal finances.i To counter the present crackdown on inappropriate financial relationships effectively, we will need to reframe the questions, and convince all stakeholders to the process that there is more to this crisis than can be resolved through our public confessions of commercial largesse obliged. The Phrma Code guidelines3 have resulted in what is believed to be a defensible, if as yet legally untested, compartmentalisation of the commercial sector's marketing, medical education and research sponsorship activities. We at the AMC are a long way from understanding how those same missions, as they emanate from our multifarious commitments, can be isolated and individually managed. Defining the parameters for establishing institutional conflicts of interest and commitment are beyond our essay's scope, but with the very public emphasis on capitalist subversion of …. (shrink)

The relationship between medicine and money is a delicate one that all people involved need to handle responsibly. If one becomes a physician for the mere fact of pursuing money, s/he may soon find that another profession or activity may have fulfilled such a need in a better way. While in the practice of medicine the interest of the patient is paramount, this does not suggest that the welfare of the physician should be neglected at all. It (...) is much about a balance of priorities between the legal and ethical pursuit of money and the promotion of the health of society. Physicians are not called to a life of self-denial, poverty and destitution, as others may be tempted to suggest. The service of patients and the honest reward from one's labour are not incompatible. Where conflict of interest arises, it is prudent for a physician to always remember never to harm oneself, the profession and the patient more than what can be gained. (shrink)

This article summarizes the April 5–6, 2002 conference on Conflict of Interest and Its Significance in Science and Medicine. Several themes are identified and addressed, including the globalization of science, the widespread presence of conflicts, the increased interest and involvement in conflict of interest by a number of organizations, the difference between academic research and research conducted by industry, and the tension between science and medicine. At the heart of the matter lies objectivity in (...) research and the need for transparency to ensure objectivity. Several future activities were discussed, including the need to share specific examples of how conflict has been managed, and the need for behavioral research to provide a sound empirical understanding of the best ways to provide informed consent for research subjects. (shrink)

Recent economic and political advances in developing countries on the African continent and South East Asia are threatened by the rising death and morbidity rates of HIV/AIDS. In the first part of this paper we explain the reasons for the absence of affordable access to essential AIDS medication. In the second part we take a closer look at some of the pivotal frameworks relevant for this situation and undertake an ethical analysis of these frameworks. In the third part we discuss (...) a few of the proposed solutions to the problem and conclude with an argument in support of our preferred course of action. In this article we argue for compulsory licensing of essential AIDS medications in the current conditions of public health emergency. We argue on broadly consequentialist grounds that compulsory licensing is preferable both morally and pragmatically to the alternatives, notably the currently offered price cuts and drug donation schemes. (shrink)

La relación de discrepancia y coincidencia de las causas de muerte entre el diagnóstico clínico y anatomopatológico constituye de forma indirecta un indicador de calidad de la atención médica. Son múltiples los ejemplos de enfermedades descubiertas o esclarecidas gracias a la autopsia, que tiene en la correlación clinicopatológica un basamento fundamental. Se estableció como objetivo de investigación describir los principales vínculos históricos entre las especialidades de medicina interna y anatomía patológica, que tienen como enlace esencial la correlación clínico patológica, atendiendo (...) a que no puede existir contradicción antagónica entre enfermo y enfermedad; la medicina interna y la anatomía patológica no pueden verse aisladas ni separadas. The difference and similarity relationship of death causes between the clinical and anatomy-pathological diagnosis is, indirectly, a medical care quality indicator. Thanks to autopsy, which has the clinical-pathological correlation as a main basis, numerous diseases have been discovered or clarified. Discovering the main historical relations between Internal Medicine and Pathological Anatomy specialties was established as the objective of the research. These specialties have the clinical-pathological correlation as a main link, taking into account that there cannot be a conflicting contradiction between the sick and the disease; Internal Medicine and Pathological Anatomy cannot be seen in an isolated or separate way. (shrink)

The approach to AIDS as a disease and a threat for social discrimination is used as an example to illustrate a conceptual thesis. This thesis is a claim that concerns what we call a medical issue or not, what is medicalised or needs to be demedicalised. In the friction between medicalisation and demedicalisation as discursive strategies the latter approach can only be effected through the employment of discourses or discursive strategies other than medicine, such as those of the (...) law and of economics. These discourses each realise different values, promote a different subject, and have a different concept of man. The concept of discourse is briefly outlined against concepts such as the linear growth concept of science and the growth model of science as changes in paradigm. The issue of testing for AIDS shows a conflict between the medical and the legal discourse and illustrates the title of our contribution: the human body as field of conflict between discourses. (shrink)

Contents Acknowledgements Part 1--Medicine today 1 Why is medicine in trouble? 2 Conflicts of interest Part 2--Troublespots 3 The business of medicine 4 Sexual ...

Interactions between medicine and the pharmaceutical and device industries have become widespread in medicine. Despite their promise for improving patient care through innovation, there are ways in which these relationships may compromise patient care by creating conflicts of interest for physicians—both actual and perceived—that may result in delivery of poorly justified treatment, mistrust of doctors by the public, and an undermining of the integrity of the medical profession (IOM 2009). Conflicts of interest can arise in all arenas (...) of medicine, due to discord between the responsibility to patients and the opportunity for personal financial gain. But academic medicine presents an additional interest to protect: .. (shrink)

Professional sports with high rates of concussion have become increasingly concerned about the long-term effects of multiple head injuries. In this context, return-to-play decisions about concussion generate considerable ethical tensions for sports physicians. Team doctors clearly have an obligation to the welfare of their patient (the injured athlete) but they also have an obligation to their employer (the team), whose primary interest is typically success through winning. At times, a team’s interest in winning may not accord with the welfare of (...) an injured player, particularly when it comes to decisions about returning to play after injury. Australia’s two most popular professional football codes—rugby league and Australian Rules football—have adopted guidelines that prohibit concussed players from continuing to play on the same day. I suggest that conflicts of interest between doctors, patients, and teams may present a substantial obstacle to the proper adherence of concussion guidelines. Concussion management guidelines implemented by a sport’s governing body do not necessarily remove or resolve conflicts of interest in the doctor–patient–team triad. The instigation of a concussion exclusion rule appears to add a fourth party to this triad (the National Rugby League or the Australian Football League). In some instances, when conflicts of interest among stakeholders are ignored or insufficiently managed, they may facilitate attempts at circumventing concussion management guidelines to the detriment of player welfare. (shrink)

Given the sordid history of injustices linking genetics to race and ethnicity, considerations of justice are central to ensuring the responsible development of precision medicine programmes around the world. While considerations of justice may be in tension with other areas of concern, such as scientific value or privacy, there are also tensions between different aspects of justice. This paper focuses on three particular aspects of justice relevant to this precision medicine: social justice, distributive justice and human rights. (...) We describe the implications of each for the use of race and ethnicity in precision medicine, and also how they intersect and potentially conflict with each another. By attending to these intersections, we aim to enrich and add nuance to debates over how best to proceed with precision medicine initiatives. (shrink)

Given the sordid history of injustices linking genetics to race and ethnicity, considerations of justice are central to ensuring the responsible development of precision medicine programmes around the world. While considerations of justice may be in tension with other areas of concern, such as scientific value or privacy, there are also tensions between different aspects of justice. This paper focuses on three particular aspects of justice relevant to this precision medicine: social justice, distributive justice and human rights. (...) We describe the implications of each for the use of race and ethnicity in precision medicine, and also how they intersect and potentially conflict with each another. By attending to these intersections, we aim to enrich and add nuance to debates over how best to proceed with precision medicine initiatives. (shrink)

The use of platelet rich plasma as a novel treatment is discussed in the context of a qualitative research study comprising 38 interviews with sports medicine practitioners and other stakeholders working within the English Premier League during the 2013–16 seasons. Analysis of the data produced several overarching themes: conservatism versus experimentalism in medical attitudes; therapy perspectives divergence; conflicting versions of appropriate evidence; subcultures; community beliefs/practices; and negotiation of medical decision-making. The contested evidence base for the efficacy of PRP is (...) presented in the context of a broader professional shift towards evidence based medicine within sports medicine. Many of the participants while accepting this shift are still committed to casuistic practices where clinical judgment is flexible and does not recognize a context-free hierarchy of evidentiary standards to ethically justifiable practice. We also discuss a tendency in the data collected to consider the use of deceptive, placebo-like, practices among the clinician participants that challenge dominant understandings of informed consent in medical ethics. We conclude that the complex relation between evidence and ethics requires greater critical scrutiny for this emerging specialism within the medical community. (shrink)

The aim of this work is to evaluate the role played by Alfonso Luis Herrera and Isaac Ochoterena in the institutionalization of academic biology in Mexico in the early 20th century. As biology became institutionalized in Mexico, Herrera's basic approach to biology was displaced by Isaac Ochoterena's professional goals due to the prevailing political conditions at the end of 1929. The conflict arose from two different conceptions of biology, because Herrera and Ochoterena had different discourses that were incommensurable, not (...) only linguistically speaking, but also socioprofessionally. They had different links to influential groups related to education, having distinct political and socioprofessional interests. The conflict between Herrrera and Ochoterena determined the way in which professional biology education has developed in Mexico, as well as the advancement in specific research subjects and the neglect of others. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Conflicts—and Consensus—about Conflicts of Interest in MedicineMatthew K. Wynia and Bette–Jane Crigger*This fascinating collection of essays about individual experiences of conflict of interest leaves little doubt that physicians remain divided about the importance, impact and meaning of conflicts of interest in their work. These essays offer differing views about what conflicts of interest look and feel like “on the ground” and about whether specific conflicts of interest are (...) bad, just a fact of life, or maybe even good.Conflict, Conflict EverywhereThese essays situate conflict of interest in a variety of contexts: the treatment recommendations a physician makes for an individual patient; the relationship between teaching physician and medical student or practicing physician and health care organization; the interaction between academic researchers and industry collaborators or professional bodies and industry supporters. In this, the narratives taken together reflect the scope of concern about conflict of interest in medicine familiar in the literature. In his classic 1993 essay, Dennis Thompson noted that concerns about conflict of interest encompass issues of physician self–referral, risk sharing between physicians and health care institutions, gifts from industry, hospital purchasing practices, as well as sponsored research and research with patients (Thompson 1993). To that list have subsequently been added relationships with industry in medical education at all levels, physicians’ service as consultants to industry or members of industry speakers bureau, and development of clinical practice guidelines (Lo & Fields 2009).That almost none of these essays draw attention to some widely publicized situations of conflict of interest—for example, gifts to physicians or the provision of drug samples—should, we think, be seen more as an artifact of the authors’ varied individual experiences than as a failure by the authors to engage key concerns in the ongoing professional and public debate. It could also be that the authors, asked to submit personal stories, assumed that yet another essay about the ‘traditional’ issues in the conflicts of interest literature would be seen as redundant, routine or even boring. Or, there is the tantalizing possibility that the absence of some of the more familiar conflicts from these narratives is the early fruit of efforts to address these traditional issues through policies governing interactions between physicians and industry promulgated by academic medical centers and health systems, medical specialty societies, and industry.One significant area of concern that has emerged in recent years is conflict of interest in the development of clinical practice guidelines. E.g., Choudry et al. 2002; Sniderrman & Furberg 2009; Guyatt et al. 2010. Although none of the essays in this [End Page 101] collection address it head on, Perlmutter touches on several key issues. His depiction of how an FDA committee process limited the input he was able to provide as an expert, undermined his potential to contribute to the professional dialogue, and raised concerns about the objectivity of the drug approval process echoes concerns about objectivity, the role of expert opinion, and the presence on guideline development panels of individuals with financial interests in the recommendations to be developed that have been explored at some length in the literature, most recently by the Institute of Medicine in reports on evidentiary standards (Eden et al 2011) and principles for guideline development (Graham et al. 2011).Conflict of Interest or Dual Agency?Several essays set out physicians’ experience in navigating situations of diverging expectations. Bierut, for example, reflects on the disjunction between the goals and products of academic researchers and commercial sponsors. She saw herself advancing basic knowledge and was forced to grapple with the reality of sponsors’ goals to advance commercial ends as well. Nagldinne and Mikulec each recall struggles to reconcile their obligation to exercise professional judgment on behalf of patients with the demands of health care organizations focussed also on the bottom line. Cruz–Flores attests to the challenge of making recommendations for care when one is both a practicing clinician and a clinical investigator engaged in research that might offer benefit to a patient for whom there are limited options.Thompson defined conflicts of interest as “a set of conditions in which professional judgment concerning a primary interest (such as a patient’s welfare or the validity of... (shrink)

Während der größte Teil der Bevölkerung die kieferorthopädische Therapie, also die Veränderung der Zahn- bzw. Kieferstellung, als eine Behandlung betrachtet, die vor allem auf eine Verbesserung des Erscheinungsbildes zielt, sehen der kieferorthopädische und zahnärztliche Berufsstand sowie auch private und öffentliche Kostenträger in bestimmten Abweichungen von Zahn- oder Kieferstellungen eine Gefährdung der oralen Gesundheit und der Funktionsfähigkeit des Gebisses. Letztere Auffassung bestimmt das ärztliche Handeln in der Kieferorthopädie und begründet auch die Übernahme zumindest bestimmter Leistungen durch die gesetzlichen Krankenkassen. Anhand aktueller (...) wissenschaftlicher Erkenntnisse lassen sich jedoch in vielen Fällen keine (akuten oder potentiellen) gesundheitlichen oder essentiellen funktionellen Beeinträchtigungen und Risiken abweichender Zahnstellungen nachweisen. Ziel dieses Aufsatzes ist es, diesem Widerspruch nachzugehen. Im Folgenden werden wir aufzeigen, welche Faktoren die Anbieter kieferorthopädischer Leistungen beeinflussen, welches die entscheidenden Gründe und Grundlagen für die Behandlung sind und an welchen Kriterien sich die Leistungsübernahme durch die Krankenkassen orientiert. Dabei wird deutlich werden, dass die formalen Kriterien von Behandlung und Kostenübernahme, die tatsächliche Behandlungs- und Kostenerstattungspraxis, die Erwartungen derjenigen, die Behandlungsleistungen in Anspruch nehmen und der aktuelle Stand der Forschung zu erwartbaren Funktionsbeeinträchtigungen durch Zahnstellungsvariationen nicht zwanglos zu vereinbaren sind. Erforderlich erscheint ein interdisziplinärer normativer Diskurs über die Frage, wie die diagnostizierten Spannungen aufzulösen wären. Als Anregung für einen solchen Diskurs werden wir im Ausblick alternative Lösungsstrategien vorstellen. (shrink)

Informed consent is central to the law of the physicianpatient relationship, respecting patient autonomy. This paper addresses a conflict between law and medicine in defining informed consent. Additionally, it addresses the possibility that patients prefer not to be “informed“ and would defer decision-making to their physicians.

The approach to AIDS as a disease and a threat for social discrimination is used as an example to illustrate a conceptual thesis. This thesis is a claim that concerns what we call a medical issue or not, what is medicalised or needs to be demedicalised. In the friction between medicalisation and demedicalisation as discursive strategies the latter approach can only be effected through the employment of discourses or discursive strategies other than medicine, such as those of the (...) law and of economics. These discourses each realise different values, promote a different subject, and have a different concept of man. The concept of discourse is briefly outlined against concepts such as the linear growth concept of science and the growth model of science as changes in paradigm. The issue of testing for AIDS shows a conflict between the medical and the legal discourse and illustrates the title of our contribution: the human body as field of conflict between discourses. (shrink)

In Western literatures, "conflict" is a general term that refers to discord between two or more entities. In Islamic jurisprudence, however, in addition to the term "conflict", there is another term which is called tazāhum. The two terms, however, have different definitions. Conflict between two concepts, for instance, indicates that one is right and the other is wrong, while tazāhum does not necessarily have to be between right and wrong, and may appear between (...) two equally right concepts. Moreover, conflict exists on a legislative level, while tazāhum is a matter of obedience and adherence, meaning that in practice, both sides cannot continue to coexist. Conflict of interest is a known term in Western literatures, and according to D.F. Thompson, it refers to a situation where professional judgment regarding a primary interest is improperly and unjustifiably influenced by a secondary interest. Taking into account Thompson's definition and the distinction between "conflict" and "tazāhum", the English term "conflict of interest" translates to "tazāhum of interest" in Islamic jurisprudence as it refers to a person's action without reflecting right or wrong, and simply concerns priority of one interest over another. The resolution to tazāhum in Islamic jurisprudence lies in two principles: the principle of significance and the principle of choice. For instance, in case of conflict or tazāhum between the interests of patient and physician, the patient's interest should be the main concern based on the principle of significance. Although Western literatures propose methods such as disclosure or prohibition in order to resolve conflict of interest, the foundation for these solutions seems to have been the principle of significance. (shrink)

Schanbacer, William D: The Politics of Food: The Global Conflict Between Food Security and Food Sovereignty Content Type Journal Article DOI 10.1007/s10806-010-9267-1 Authors Cornelia Butler Flora, Iowa State University 317 East Hall Ames IA 50011-1070 USA Journal Journal of Agricultural and Environmental Ethics Online ISSN 1573-322X Print ISSN 1187-7863.

It is important and urgent to question therelationship between evidence-based medicineand power shifts in health care systems.Although definitions of EBM are phrased as ascientific approach to medicine, EBM is anormative concept: it aims to improve medicineand health care. Both proponents and opponentsuse a normative concept. More particularly,they provide particular views on positions,responsibilities, possibilities, norms andrelationships between professionals, patientgroups, governments and other parties in healthcare and society. From this perspective, wewant to analyse the role of EBM in modernwestern (...) societies. By using citizenshiptheory, we will argue that the role of EBM isnot fixed but depends on the relation betweenstate and society. We will first analyse thefundamental change in western societies duringthe past decades, from modern to post-modernsocieties. Then, we will elaborate a fourfoldmodel of possible relationships between stateand society, and discuss the issue of how EBM mayfit in, by giving some examples of the practiceof EBM in different European countries. On thisbasis, we conclude to consider EBM as a publicforum where proponents and opponents of EBMdiscuss diverse and possibly conflicting waysof changing medicine, health care, and healthpolicy. This requires the incorporation of theperspective of citizens and their socialnetworks, professionals with practical andtacit knowledge, and diverse public views onwhat is regarded as `a good life'. Inasmuch asEBM is expected to be practically relevant, itought to be tied to rather than separated fromthe normative world of emancipated patients anddiverse health care practices. Proponents andopponents of EBM should be prepared to defendthe normative claims and power effects that areinherently tied to any presentation ofevidence. (shrink)

Over the past few years, intercultural health has become an emerging issue in health policy. Intercultural health is an approach in health that aims at reducing the gap between indigenous and western health systems, on the basis of mutual respect and equal recognition of these knowledge systems. This article questions the applicability of such a concept in the context of Chile. Here, conflicting interests between the Mapuche and the Chilean state are related to aspects of economic development, modernity (...) processes, integration, intercultural relations, and indigenous rights and are deeply reflected also in projects for an intercultural health system. By analysing the experience of the intercultural practice of Makewe Hospital, this article argues that effective and equitable intercultural health practices will not take place unless there will be an integral valorisation of the Mapuche culture from a broader perspective. (shrink)

The conflict in Gaza and Israel that ignited on October 7, 2023 signals a catastrophic breakdown in the possibility of ethical dialogue in the region. The actions on both sides have revealed a dissolution of ethical restraints, with unimaginably cruel attacks on civilians, murder of children, destruction of health facilities, and denial of basic needs such as water, food, and shelter. There is a need both to understand the nature of the ethical singularity represented by this conflict and (...) what, if any, options are available to allow the reconstruction of communication between the warring parties. This article seeks to address these tasks by analysing the conflict as inherently an ethical one, in the sense that it exposes a rupture in the fabric of communicative relationships that has evolved systematically out of the deep cultural structures from which all protagonists have emerged. Drawing on the work of Levinas, Habermas, Arendt, and others, and referring to the specific circumstances in the region, it examines the ethical sources of the crisis and tries to identify conditions for its resolution. The possibility of reconciliation—that is, of refiguring relationships to open up a space for dialogue to create pathways to heal the ruptures—is examined. The dark legacy of the Holocaust is identified as an abiding cultural vulnerability for both societies. It is concluded, however, that the rich history of partnerships and collaborations between Jews and Palestinians provides a robust infrastructure on the basis of which a sustainable peace might be built, providing a much-needed source of hope. (shrink)

This paper aims to offer a new argument in defence bacterial species pluralism. To do so, I shall first present the particular issues derived from the conflict between the non-theoretical understanding of species as units of classification and the theoretical comprehension of them as units of evolution. Secondly, I shall justify the necessity of the concept of species for the bacterial world, and show how medicine and endosymbiotic evolutionary theory make use of different concepts of bacterial species (...) due to their distinctive purposes. Finally, I shall show how my argument provides a new source of defence for bacterial pluralism. (shrink)

ABSTRACT In contemporary American medical practice, certain physicians are critical and wary of the current emphasis on patient autonomy in medicine, questioning whether it really serves the complex needs of severely ill patients. Physicians such as Eric Cassell and Thomas Duffy argue that the duty of beneficence should override the duty to respect autonomy when conflicts arise in clinical situations. After evaluating their claim that severe illness robs patients of their autonomy, I will argue that this perceived conflict (...) between beneficence and autonomy is ill‐conceived, resting on misperceptions about both the capacity for autonomy and the meaning of hope. Considering insights on hope from phenomenologist Gabriel Marcel and theologian William Lynch, as well as drawing upon a case study involving a bone marrow patient, I claim that respecting and nurturing patients’ capacity for autonomy is a necessary condition for acting beneficently and fostering authentic hope. (shrink)

I argue that the imagination plays a central role in the thought of the Cambridge Platonist Henry More. First, physiological descriptions of melancholy and imagination were at the heart of his attack against enthusiasm and atheism. Second, in order to defend his metaphysical dualism, he had to respond to traditional accounts of the imagination as a mediating faculty between body and soul. Third, More also opposed the traditional view that the imagination was a material faculty, because in the context (...) of 17th century philosophy and medicine, such ideas could lead to materialism. More's metaphysics led him to propose a novel view in which the imagination was part of the immaterial soul and at the same level as reason. In his physiological descriptions, however, he retained a gradualist view on the imagination that suggested intermediate stages between material and immaterial substances. Although his metaphysical and physiological descriptions seem to conflict, I suggest that the conflict can be mitigated by his interpretation of the body as the instrument of the soul. (shrink)

The growing commercialization of research with its effect on the ethical conduct of researchers, and the advancement of scientific knowledge with its effect on the welfare or otherwise of patients, are areas of pressing concern today and need a serious, thorough study. Biomedical research, and its forward march, is becoming increasingly dependent on industry-academia proximity, both commercial and geographic. A realization of the commercial value of academic biomedical research coupled with its rapid and efficient utilization by industry is the major (...) propelling force here. A number of well-intentioned writers in the field look to the whole development with optimism. But this partnership is a double-edged sword, for it carries with it the potential of an exciting future as much as the prospect of misappropriation and malevolence. Moreover, such partnerships have sometimes eroded public trust in the research enterprise itself. Connected to the growing clout of industry in institutions is concern about the commercialization of research and resolving the 'patient or product' loyalty. There is ambivalence about industry funding and influence in academia, and a consequent 'approach-avoidance' conflict. If academia has to provide the patients and research talent, industry necessarily has to provide the finances and other facilities based on it. This is an invariable and essential agreement between the two parties that they can walk out of only at their own peril. The profound ethical concerns that industry funded research has brought center-stage need a close look, especially as they impact patients, research subjects, public trust, marketability of products, and research and professional credibility. How can the intermediate goal of industry serve the purpose of the final goal of academia is the basic struggle for conscientious research institutions /associations. And how best the goal of maximizing profits can be best served, albeit suitably camouflaged as patient welfare throughout, is the concern of the pharmaceutical industry. A very great potential conflict of interest lies in the fact that academia needs the sophisticated instruments that only big funding can provide, while at the same time resists the attempts of the fund provider to set the agenda of research, protocol, design, publication, the works. Conflicts arise at many steps and levels of functioning, and are related to the expectations, competing interests, and conflicting priorities of the different entities involved, whether they are the academic medical centers, the funding agencies, the patients and their families, or the investors and venture capitalists. The public expects access to new treatments. Its appetite for innovation has been bolstered by the constant attention given by the press to new treatments and by the implicit promise from researchers of continuing advances. Similarly, patients demand privacy and control over information about themselves. It makes greater sense for genuine researchers to associate with large long-term industry players who have a track record of genuine hard-core discoveries, even if the process is slow , and the funding less . The element of control venture capitalists exert over the pharmaceutical industry is an under researched area for obvious reasons. But it needs further probing, for that will lay bare the pulls and pressures under which industry works. It makes sense for ethically minded researchers and institutions not to fall in the trap of stocks and equity investments in industry, howsoever attractive they appear, and get rid of them as soon as possible if they have them. If at all they want, it makes more sense to own stocks of larger well established concerns, for the stock upheavals being less, the pressure of the market-place, and of venture sharks, is likely to be lower too. While active participation by the researcher in the commercialization process may be greatly desired by industry, ostensibly in the name of creating value, academia must realize it is a bait it might find hard to swallow in the long run. It makes more sense for the researcher and institution to forego such temptations and/or walk out of such investments as soon as possible. While mainstream medicine and research are booming, as is connected industry, concerns about professional commitment to patient welfare are growing too. Increasing corporate influence is challenging certain long held and fundamental values of patient care, which will have far reaching implications for biomedical care and the future progress of mainstream medicine. (shrink)

This paper analyzes one dimension of the frequently alleged contradiction between treating medicine as a business and as a profession, namely the incompatibility between viewing the physician patient relationship in economic and moral terms. The paper explores the utilitarian foundations of economics and the deontological foundations of professional medical ethics as one source for the business/medicine conflict that influences beliefs about the proper understanding of the therapeutic relationship. It, then, focuses on the contrast and distinction (...) between medicine as business and profession by critically analyzing the classic economic view of the moral status of medicine articulated by Kenneth Arrow. The paper concludes with a discussion of some advantages associated with regarding medicine as a business. (shrink)

Definitions of health and disease are of more than theoretical interest. Understanding what it means to be healthy has implications for choices in medical treatment, for ethically sound informed consent, and for accurate assessment of policies or programs. This deeper understanding can help us create more effective public policy for health and medicine. It is notable that such contentious legal initiatives as the Americans with Disability Act and the Patients' Bill of Rights fail to define adequately the medical terms (...) on which their effectiveness depends. In Ethics and the Metaphysics of Medicine, Kenneth Richman develops an "embedded instrumentalist" theory of health and applies it to practical problems in health care and medicine, addressing topics that range from the philosophy of science to knee surgery."Embedded instrumentalist" theories hold that health is a match between one's goals and one's ability to reach those goals, and that the relevant goals may vary from individual to individual. This captures the normative implications of the term health while avoiding problematic relativism. Richman's embedded instrumentalism differs from other theories of health in drawing a distinction between the health of individuals as biological organisms and the health of individuals as moral agents. This distinction illuminates many difficulties in patient-provider communication and helps us understand conflicts between promoting health and promoting ethically permissible behavior. After exploring, expanding, and defending this theory in the first part of the book, Richman examines its ethical implications, discussing such concerns as the connection between medical beneficence and respect for autonomy, patient-provider communication, living wills, and clinical education. (shrink)

A critical examination of Richard Miller's position in his recent "Children, Ethics, and Modern Medicine" on how to handle pediatric interventions in cases of cross-cultural conflict between parents and doctors with respect to treating young children. Particular emphasis is placed on Miller's interpretation of and arguments about a Hmong case extensively researched by Anne Fadiman in her "The Spirit Catches You and You Fall Down". The conclusion drawn is that Miller's position requires further nuance and development, and (...) some recommendations are made toward that end. (shrink)

Our society has long sanctioned, at least tacitly, a degree of conflict of interest in medical practice and clinical research as an unavoidable consequence of the different interests of the physician or clinical investigator, the patient or clinical research subject, third party payers or research sponsors, the government, and society as a whole, to name a few. In the past, resolution of these conflicts has been left to the conscience of the individual physician or clinical investigator and to professional (...) organizations. The public is no longer willing to allow health care providers to wholly govern their own conflicts of interest for several reasons. These include: new forms of health care financing and delivery that provide innovative and lucrative opportunities for physician or insurer enrichment at patient expense; the increased importance of commercial research support as peer-reviewed governmental research support has decreased; evidence that physicians and clinical investigators too frequently resolve conflicts of interest in their own favor; and a general societal mistrust of authority. This volume represents a multidisciplinary effort, drawing from philosophy, medicine, law, economics and public policy to identify and categorize conflicts of interest in medical practice and clinical research, and, where possible, to offer a mechanism for resolving them. Part I addresses conflicts of interest from a theoretical perspective, offering basic concepts and analytical frameworks. The second part discusses two topics prominent in current health care policy debates--self-referral and financial incentives to limit care. Part III examines conflicts of interest generated by pharmaceutical industry involvement in clinical practice and research. The final section deals with conflicts of interest in clinical research in several contexts, including institutional reviews boards, clinical trials, Cooperative Research and Development Agreements between government and private researchers, brokerage of research subjects by Contract Research Organizations, and cost-effectiveness studies. (shrink)

Conflicts between the ethical values of an organisation and the ethical values of the employees of that organisation can often lead to conflict. When the ethical values of the employee are considerably higher than those of the organisation the potential for catastrophic results is enormous. In recent years several high profile cases have exposed organisations with ethical weaknesses. Academic medical institutions have exhibited such weaknesses and when exposed their employees have almost invariably been vindicated by objective inquiry. The (...) mechanisms that work to produce such low ethical standards in what should be exemplary organisations are well documented and have been highlighted recently. The contribution of elements of medical training in eroding ethical standards of medical students have also been emphasised recently and strategies proposed to reduce or reverse this process. The ability to rapidly change the ethical and professional culture of graduate medical trainees may help to deal with some of the perceived problems of declining ethical standards in academic medicine. (shrink)

The position of clinical ethicist exists to help resolve conflicts in the hospital. Sometimes these conflicts arise because of fundamental cultural differences between the patient and the medical team, and such cases present special challenges. Should the ideology of modern medicine reject the wishes of those who hold ideologies from differing cultures? How can the medical ethicist help resolve such conflicts? To answer these questions, I rely on the works of Alasdair MacIntyre. Using MacIntyre’s philosophy, we can better (...) understand why traditions exist, how conflicts arise, and how opposing traditions can collaborate in shared decision making. In order to overcome conflict, I conclude that MacIntyre’s virtues of acknowledged dependence must be realized by the ethicist and those in disagreement over tradition. I use a case study of a young Amish patient to highlight the conflicts that arise and to help exhibit how shared decision making can be made possible. (shrink)

High-dose chemotherapy and autologous stem cell transplantation is used to treat some advanced malignancies. It is a traumatic procedure, with a high complication rate and significant mortality. ASCT patients and their carers draw on many sources of information as they seek to understand the procedure and its consequences. Some seek information from beyond orthodox medicine. Alternative beliefs and practices may conflict with conventional understanding of the theory and practice of ASCT, and ‘contested understandings’ might interfere with patient adherence (...) to the strict and demanding protocols required for successful ASCT.The present study, conducted in Sydney, Australia, examines narrative-style interviews with 10 sequentially recruited ASCT patients and nine of their carers conducted at the time of transplant and three months later. Transcripts were read for instances of mention of alternative advice, and for instances of contested understanding of information relevant to the transplant.Patients and carer pairs expressed closely concordant views about alternative advice. Five pairs were consulting alternative practitioners. Contested understanding was expressed in four domains—understandings of the transplant itself and its underlying theory, of the relationship between the components of the ‘transplant’, of the nature and role of stem cells, and of beliefs about bodily function and life-style. Contested understandings of the transplant treatment were expressed as predominantly personal interpretations of orthodox informationPatients and carers seemed to recognise that alternative and conventional systems were discordant, yet they were able to separate the two, and adhere to each practice without prejudicing their medical treatment. A single case of late, post-transplant repudiation of Western medicine is discussed to emphasise some of the possible determinants of dissonance when it does occur. (shrink)

BackgroundHealthcare professionals use the ethics of justice and care to construct moral reasoning. These ethics are conflicting in nature; different value systems and orders of justice and care are applied to the cause of actual moral conflict. We aim to clarify the structure and factors of healthcare professionals’ moral conflicts through the lens of justice and care to obtain suggestions for conflict resolutions.MethodSemi-structured interviews about experiences of moral conflict were conducted with Japanese nurses recruited using the snowball (...) sampling method. Interviews were conducted based on the real-life moral conflict and choice interview. Interviews were recorded and transcribed verbatim, then analyzed based on the interpretive method of data analysis. Verbatim transcripts were read four times, first to get an overall sense of the conflict, then to understand the person’s thoughts and actions that explain the conflict, and third and fourth to identify perspectives of justice and care, respectively. Each moral perspective was classified into categories according to Chally’s taxonomy.ResultsAmong 31 responses, 2 that did not mention moral conflict were excluded, leaving 29 responses that were analyzed. These responses were classified into six cases with conflict between both justice and care perspectives or within one perspective, and into two cases without conflict between perspectives. The “rules” category of justice and the “welfare of others” category of care were included in many cases of conflict between two perspectives, and they frequently occurred in each perspective.ConclusionsThe nurses in this study suggest that they make moral judgments based on moral values that are intertwined with justice and care perspectives complex manner.Organizational, professional, and patient-related factors influenced conflicts between justice and care. Additionally, multiple overlapping loyalties created conflicts within justice perspectives, and multifaceted aspects of care-provider’s responsibility and patient need created conflicts within care. Decision-making biased towards one perspective can be distorted. It is important to consider ethical issues from both perspectives to resolve conflicts, especially the effective use of the ethics of care is recommended. (shrink)

As the debate over how to manage or discourage physicians? financial conflicts of interest with the drug and medical device industries has become more heated, critics have questioned or dismissed the concept of ?conflict of interest? itself. A satisfactory definition relates conflict of interest to concerns about maintaining social trust and distinguishes between breaches of ethical duty and temptations to breach duty. Numerous objections to such a definition have been offered, none of which prevails on further analysis. (...) Those concerned about conflicts of interest have contributed to misunderstandings, however, by failing to demonstrate when social arrangements leading to temptations to breach duties are in themselves morally blameworthy. Clarifying ?conflict of interest? is important if we are eventually going to develop productive modes of engagement between medicine and for-profit industry that avoid the serious ethical pitfalls now in evidence. (shrink)

Non-financial interests, and the conflicts of interest that may result from them, are frequently overlooked in biomedicine. This is partly due to the complex and varied nature of these interests, and the limited evidence available regarding their prevalence and impact on biomedical research and clinical practice. We suggest that there are no meaningful conceptual distinctions, and few practical differences, between financial and non-financial conflicts of interest, and accordingly, that both require careful consideration. Further, a better understanding of the complexities (...) of non-financial conflicts of interest, and their entanglement with financial conflicts of interest, may assist in the development of a more sophisticated approach to all forms of conflicts of interest. (shrink)

Conflicts of interest serve as a cipher for a radical rupture in the Flexnerian paradigm of medicine, and they can only be addressed if we recognize that health care is now practiced by institutions, not just individual physicians. By showing how "appropriate utilization of services" or "that which is medically indicated" is a function of socioeconomic factors related to institutional responsibilities, I point toward an administrative and organizational ethic as a needed component for addressing conflicts of interest. The argument (...) is developed by reviewing three important books. First, I consider Mark Rodwin's attempt to configure the economic structures of medicine so that classical fiduciary and scientific ideals can be fostered. Second, I consider E. Haavi Morreim's attempt to modify the classical ideals in order to account for new economic realities. Finally, by considering essays in a recent volume on conflicts of interest edited by Spece, Shimm, and Buchanan, I argue for a constructive dialectic between the approaches of Rodwin and Morreim. In order to properly address conflicts of interest, there must be a radical reassessment of medicine that accounts for the interrelation between scientific, ethical, and economic concerns. Until institutions come into view and professional ethics is developed to account for their role, legitimate interests and obligations of diverse parties cannot be harmonized. (shrink)

Resistance by physicians, medical researchers, medical educators, and medical students to pharmaceutical industry influence in medicine is often based on the notion that physicians and the industry are in conflict. This criticism has taken the form of a professional movement opposing conflict of interest in medicine and medical education and has resulted in policies and guidelines that frame COI as the problem and outline measures to address this problem. In this paper, I offer a critique of (...) this focus on COI that is grounded in a broader critique of neo-liberalism, arguing it individualizes the relationship between physicians and industry, too neatly delineates between the two entities, and reduces the network of social, economic, and political relations to this one dilemma. (shrink)

The recent committee report from the Institute of Medicine in Washington, DC, containing proposals for controlling conflicts of interest 1 reflects the medical profession’s limited understanding of the actual scope of the issues and demonstrates how reactive academic physicians have become to media and congressional priorities instead of those of the medical field. The near-exclusive focus on the compromising of medical decision-making by the receipt of fungible support from the commercial sector fails to identify critical interdependencies of the relationship (...) between academic physicians and capitalist industry, the historical and economic context in which it takes place and the other stakeholders in the process who are trying to, or should be trying to, manage similar issues of ethical prioritisation of manpower and resources, allegiances and alliances.In the process of protecting ourselves, our patients and our institutions from the scourge of the market and its undue influence, we are participating in a much larger discussion, which we are so far neglecting. In redefining academia–industry relations, we are also negotiating over the means of support for translational clinical research, our educational mission as experts and our capacity to serve at centres of excellence in healthcare. Even more fundamentally, the process of examining ourselves and our institutions for conflicts of interest that negatively impact on our ability to protect and to treat our patients, as well as on how we educate the next generations of healthcare workers, goes to the moral core of what it means to be healing arts professionals.The Institute of Medicine report has chosen to overlook the existing complex …. (shrink)

It is in the interest of the totalitarian state that subjects not think for themselves, much less confer about their thinking. Writing under the hostile watch of the Prussian censorship, Immanuel Kant dared to argue the need for open argument, in the university if nowhere else. In this heroic criticism of repression, first published in 1798, he anticipated the crises that endanger the free expression of ideas in the name of national policy. Composed of three sections written at different times, (...) The Conflict of the Faculties dwells on the eternal combat between the "lower" faculty of philosophy, which is answerable only to individual reason, and the faculties of theology, law, and medicine, which get "higher" precedence in the world of affairs and whose teachings and practices are of interest to the government. Kant makes clear, for example, the close alliance between the theological faculty and the government that sanctions its teachings and can resort to force and censorship. All the more vital and precious, then, the faculty of philosophy, which encourages independent thought before action. The first section, "The Conflict of the Philosophy Faculty with the Theology Faculty," is essentially a vindication of the right of the philosophical faculty to freedom of expression. In the other sections the philosopher takes a long and penetrating look at medicine and law, the one preserving the physical "temple" and the other regulating its actions. (shrink)

Clinical ethics records offer bioethics researchers a rich source of cases that clinicians have identified as ethically complex. In this paper, we suggest that clinical ethics records can be used to point to types of cases that lack attention in the current bioethics literature, identifying new areas in need of more detailed bioethical work. We conducted an analysis of the clinical ethics records of one paediatric hospital in Australia, focusing specifically on conflicts between parents and health professionals about a (...) child’s medical treatment. We identified, analysed, and compared cases of this type from the clinical ethics records with cases of this type discussed in bioethics journals. While the cases from journals tended to describe situations involving imminent risk to the child’s life, a significant proportion of the clinical ethics records cases involved different stakes for the child involved. These included distress, poorer functional outcome, poorer psychosocial outcome, or increased risk of surgical complications. Our analysis suggests that one type of case that warrants more detailed ethics research is parental refusal of recommended treatment, where the refusal does not endanger the child’s life but rather some other aspect of the child’s well-being. (shrink)