This paper argues that we have wrongly and not for the patient’s benefit made a form of stark autonomy our highest value which allows physicians to slip out from under their basic duty which has always been to pursue a particular patient’s good. In general – I shall argue – it is the patient’s right to select his or her own goals and the physician’s duty to inform the patient of the feasibility of that goal and of the means needed (...) to attain it. If the goal is not one that is possible, the patient, with the physician and family, must select a feasible goal and then discuss the costs/benefits of various approaches. The physician should take a leading role in helping the patient select the goal. I argue that to simply present a laundry list of means and insist that patients choose for themselves is not only abandoning patients to their autonomy but is, in fact, a crass form of violating the patient’s autonomy. Freely choosing not to choose is a choice a patient with decisional capacity is entitled to make and one that needs to be respected. (shrink)
Elaborates an ethic in which beneficence on a personal and communal level has moral force; proposes the idea of an interplay between compassion and reason to help address moral problems; and sketches the conditions necessary for a democratic approach to such problems.
Bioethics and its offspring Health-care Ethics have a variety ofuses and obligations among which and perhaps most importantly istheir social obligation. This paper raises questions as toBioethics fulfilling the necessary criteria for a profession,suggests that it can serve as a link between individual andcommunal problems, discusses the task of health-care ethics as well as ways of teaching it, lists some of the obligationsof health-care ethics professionals and discusses the dangers to and failings of these health-care professionals today. Itconcludes that we (...) are at a crossroads in which we must choosebetween our own personal security and comfort and fulfilling our social role. (shrink)
In this paper I: (1) Describe something of the present situation in the United States and briefly contrast this with the state of affairs in other nations of the industrialised world. I emphasise health care but also allude to other social conditions: health care is merely one institution of a society and, just as do its other institutions, the system of health care reflects the basic world-view of that society. (2) Sketch the world-view and the philosophy which underwrites the use (...) of a market system in distributing what are acknowledged to be critically important social goods like health care and higher education. I show that a well-functioning market can indeed be useful when it comes to distributing some, but not when distributing other goods. (3) Suggest that when competition and the market are used to ‘regulate’ health care, technology—instead of being used to benefit patients—is apt to be used primarily to maximise individual profit: it becomes a weapon between what is often painted as ‘warfare’ among health care providers and institutions. I argue that this state of affairs is based on an undue emphasis upon the demands of individual freedom to the detriment of the community. Finally (4) I suggest an alternative approach to balancing individual with communal interests, an approach which is neither based on a predominance of one with neglect of the other, nor on a dialectic balance between them, but rather upon an approach which sees both individual and communal interests as modifying forces in a complex homeostatic balance. Individual success, in any civilised sense of the term, is possible only in a viable and well-functioning community, and a well-functioning community is not possible without individual success: the two are inevitably interdependent and linked. (shrink)
The question of whether physicians or other healthcare workers are ethically entitled to strike is troubling in that it entails a conflict in obligations. This question of a conflict of obligations (and the answer to it) has wider implications for many other workers.
At the end of the most violent century in human history, it is good to take stock of our commitments to human and other life forms, as well as to examine the rights and the duties that might flow from their biological makeup. Professor Thomasma and Professor Loewy have held a long-standing dialogue on whether there are moral differences between animals and humans. This dialogue was occasioned by a presentation Thomasma made some years ago at Loewy's invitation at the University (...) of Illinois, Peoria, Medical Center. During that presentation, Thomasma argued that human beings are sufficiently distinct from other animals genetically and otherwise to justify a moral difference in rights and obligations. In effect, he argued that there are species-specific rights. This essay will pick up the threads of that dialogue. (shrink)
Curiosity and imagination have been neglected in epistemology. This paper argues that the role of curiosity and imagination is central to the way we think, regardless of whether it is thinking about problems of ethics or problems of science. In our ever more materialistic society, curiosity and reason are either discouraged or narrowly channeled. I shall argue that the role of curiosity and imagination for both science and ethics is so important that nurturing them can be seen as an ethical (...) obligation and suppressing them as ethically problematic. (shrink)
This paper discusses the possibility of finding an ethic of at least partial and perhaps ever-growing content in a world not that of moral strangers (where we have nothing except our desire to live freely to unite us) and one of moral friends (in which values, goals and ways of doing things are held in common). I argue that both the world of moral strangers which Engelhardt's world view would support, as the world of moral friends which is the one (...) Pellegrino seeks both are untenable and that furthermore both can lead to a similar state of affairs. I suggest a dynamic world of moral acquaintances in which different belief systems and ways of doing things can come to some broad agreements about some essential thing. This is made possible because although we do not share the intimate framework Pellegrino might suggest, yet we are united by a much broader framework than the one moral strangers share. (shrink)
From time to time medical ethicists bemoan the loss of a religious perspective in medical ethics. The discipline had its origins in the thinking of explicitly religious thinkers such as Paul Ramsey and Joseph Fletcher. Furthermore, many of those who contributed to the early development of the discipline had training in theology. One thinks of Daniel Callahan, Richard McCormick, Albert Jonsen, Sam. Banks. As the discipline becomes more and more self-reflective, with attention being paid to methodological and conditional concerns, it (...) is only natural that the roots are due for a reexamination. The time has therefore come for some reassessment. The first steps here are taken in the form of a dialogue between the coauthors to clarify authentic contributions and weed out unauthentic ones. (shrink)
It is logical that to function properly ethics committees must be properly trained, and I believe that Griener and Starch's paper in this issue of CQ is an important contribution to such a point of view and to this field. Although written from the Canadian perspective, the paper should find broad resonance in other settings. Differences between national medical settings are interesting but not critical to the point Griener and Starch make, i.e., ethics committees should be trained and should continue (...) to be trained.Not all will agree on this position, because it rests on several presuppositions that not everyone will accept. According to such a thesis, ethics in general and medical ethics in particular has its own peculiar way of thinking, is based on a recognizable and acknowledged body of literature, and can be acquired by study. Further, such a view presupposes that persons who have acquired such a skill and broadened it by continual practice have developed an expertise lacking in others who have no familiarity with the field. (shrink)
In this paper I argue that, since institutions must reflect the societies in which they are placed, a socialist health-care system cannot be understood unless democratic socialism—which would assure all of basic necessities of existence, full education and health-care to all members of the community—is not incompatible with a flourishing market for other products. In contrasting single with multiple tiered health care systems, I suggest that a single tiered system in which all have equal access to health care and none (...) can buy more, is most consistent with the ideals of democratic socialism. (shrink)
Erhics committees and ethics consultants are becoming more involved in helping individuals make decisions and in advising institutions and legislatures about drafting policy. The role of these committees and consultants has been acknowledged in law, and their function is generally considered salutory and helpful. Ethics consultants and committees, furthermore, play a critical role in educating students and members of the hospital community and the public at large. More over, many ethicists engage in scholarky activities to expand the boundaries of our (...) understanding and, in turn, facilitate our capacity for helping. The role of the ethicist and of the ethics committee is thus manifold. Ethics committees and ethics consultants somehow “in competition” is a mistaken notion: when ethics committees, ethics consultants, and the community work smoothly together, much good can be accomplished. (shrink)
An ‘ideal’ health care system would be unencumbered by economic considerations and provide an ample supply of well-paid health care professionals who would supply culturally appropriate optimal health care to the level desired by patients. An ‘ideal’ health care system presupposes an ‘ideal’ society in which resources for all social goods are unlimited. Changes within health care systems occur both because of changes within the system and because of changes or demands in and by the ‘exterior environment’. Social systems must (...) be in a homeostatic balance. If one component fails to accommodate itself to other forces, needs and interests within the system, the system is imperiled. It is difficult to create a just health care system in an unjust society, just as it is difficult to practise truly ethical medicine in an ethically corrupt system. (shrink)
This paper argues that the world-wide debate about physician assisted dying is missing a golden opportunity to focus on the orchestration of the end of life. Such a process consists of far more than adequate pain control and is a skill which, like all other skills, needs to be learned and taught. The debate offers an opportunity to press for the teaching of this skill. Beyond this, the desire to assure that all can have access to palliative care makes sense (...) only within the embrace of a universal health-care system and the desire that all can have a death with dignity is meaningful only within the embrace of a life with dignity. (shrink)
This paper will discuss the role of compassion in ethics in general and in healthcare ethics in particular. My thesis is that compassion:1) as Rousseau pointed out, is a natural trait common to all higher animals ;2) can and does serve as one of the most important motivators and modulators of ethics in both theoretical and applied aspects;3) must be controlled by, and in turn control, reason if it is to serve its ethical as well as natural purposes; and4) as (...) a natural trait has survival value and, by virtue of being a natural trait, cannot be an obligation although there may very well be an obligation to do all that is necessary to nurture and not crush this sentiment. (shrink)
An argument based on Kant for access to health-care for all is a most helpful addition to prior discussions. My paper argues that while such a point of view is helpful it fails to be persuasive. What is needed, in addition to a notion of the legislative will, is a viewpoint of community which sees justice as originating not merely from considerations of reason alone but from a notion of community and from a framework of common human experiences and capabilities.
Virtue ethics attempts to identify certain commonly agreed-upon dispositions to act in certain ways, dispositions that would be accepted as ‘good’ by those affected, and to locate the goodness or badness of an act internal to the agent. Basically, virtue ethics is said to date back to Aristotle, but as Alisdair MacIntyre has pointed out, the whole idea of ‘virtue ethics’ would have been unintelligible in Greek philosophy for “a virtue was an excellence and ethics concerned excellence of character; all (...) ethics was virtue ethics.” Virtue ethics as a method to approach problems in medical ethics is said by some to lend itself to working through cases at the bedside or, at least, is better than the conventional method of handling ethical problems. In this paper I want to explore some of the shortcomings of this approach, examine other traditional approaches, indicate some of their limitations, and suggest a different conceptualization of the approach. (shrink)
This paper introduces a series of papers dealing with the topic of euthanasia as an introduction to a variety of attitudes by health-care professionals and philosophers interested in this issue. The lead in paperâand really the lead in ideaâstresses the fact that what we are discussing concerns only a minority of people lucky enough to live in conditions of acceptable sanitation and who have access to medical care. The topic of euthanasia and PAS really has three questions: (1) is killing (...) another ever ethically acceptable; (2) is the participation of health professionals ethically different and (3) is it wiser to permit and set criteria (being fully aware of some dangers that lurk in such a move) or to forbid (knowing that it will occur clandestinely and uncontrolled). This paper takes no definite stand although it is very troubled by useless suffering (not only pain) by many who would wish their life and with it their suffering ended. (shrink)
This paper makes the assumption that organ transplantation is, under some conditions at least, a proper use of communal medical resources. Proceeding from this assumption, the author: (1) sketches the history of the problem; (2) briefly examines the prevalent models of communal structure and offers an alternate version; (3) discusses notions of justice and obligation derived from these different models; (4) applies these to the practice of harvesting organs for transplantation; and then (5) offers a different process for harvesting organs (...) from the newly dead.If community is viewed as united by a set of shred goals and common values among which the value of community itself is important, then certain reciprocal obligations among members obtain. I suggest that routine salvage of organs from the newly dead be instituted but that it be routine salvage with a twist: rather early in life all members of the community are given the opportunity to refuse but their refusal carries the reciprocal condition that they cannot later become the recipients of that which they refuse to others. (shrink)
Health care systems in different countries and cultures differ and tend toreflect the particular values and, therefore, the particular socialstructure of a given society. Each of these has ethical problems unique toitself. Some of these problems are briefly discussed. So as to have anindividual ethical problem in the context of medical care, access tomedical care needs to be assured. It is argued that individual problems arethe primary issue in societies in which there is fair access whereas theyare of lesser importance (...) in societies which have thus far failed toprovide fair access. (shrink)
Donating, distributing and ultimately transplantingorgans each has distinct ethical problems. In thispaper I suggest that the first ethical question is notwhat should be done but what is a fair way in whicheach of these problems can be addressed. Experts âwhether these be transplant surgeons, policy analysts,political scientists or ethicists â can help guidebut cannot by themselves make such decisions. Inmaking these decisions the difference betweenidentified and non-identified lives is crucial. Isuggest that an approach in which reason is temperedby compassion (``compassionate (...) rationality'') whendealing with identified lives and in whichcompassion is controlled by reason (``rationalcompassion'') in dealing with unidentified lives mustserve us well. Ultimately decisions of this sort areprone to sturdy democratic process which is possibleonly when the preconditions of person, economic andeducational democracy are met. (shrink)
In this paper the authors address the recent argument that we have an obligation to seek or actively bring about our own death when we burden others too greatly. Some of the problems with this argument and some of the practical conseqeuences of adopting such a point of view are discussed in this paper. We argue that the argument rests on an individualistic approach which sees the family being burdened as standing alone instead of seeing it as embedded in a (...) burden-sharing community. (shrink)
This paper examines the reactions of physicians and other health-professionals when they become involved in decisions about the death of their patients. The way people understand the condition of death has a profound influence on attitudes towards death and dying issues. Four traditional views of death are explored. The problem that physicians have in helping patients die (be it by hastening death through pain control, assisting patients in suicide or by more active means) is analyzed. Physicians, in dealing with such (...) patients, must be mindful of their own, and their patients beliefs as well as mindful of the community in which such dying takes place. They must try to reconcile these often divergent views but can neither paternalistically deny patients their rational will, hide themselves behind an appeal to the law or go against their own deeply held moral views. When such views cannot be reconciled, compassionate transfer to a more compatible physician may be necessary. (shrink)
On many occasions, care givers are faced with problems in which “drastic” types of treatment seem clearly inappropriate but “lesser” interventions still appear to be advisable, if not indeed mandatory. In the hospital setting, examples are frequent: the demented elderly patient, still very much capable of brief social interactions and still able to enjoy at least limited life, who although clearly not a candidate for coronary bypass surgery is, nevertheless, a patient in whom an intercurrent pneumonia deserves treatment; the severely (...) retarded youngster in whom appendectomy seems clearly warranted but for whom long-term dialysis seems ill-advised. The examples are legion, and their variety defies an easy, stereotypical solution. Why, one may ask, is the treatment of intercurrent pneumonia or operating on an acute appendix “clearly indicated” while coronary bypass and long-term dialysis “clearly” are not? The reactions of care givers in the past have often consisted of attempts to give half-hearted treatment or to treat fully even against their better judgment. The lack of conceptual guidelines that might help sort out such problems has inevitably led either to an inflexible absolutism in which all possible treatment to sustain life or no treatment at all is given or has resulted in a pathetic attempt to act but act minimally with the hope that such actions will be ineffective. (shrink)
Issues of social justice have traditionally been given short shrift by American healthcare professionals, feeling that justice at the bedside is inapplicable and possibly even misplaced. However, perhaps motivated by the realization that escalating costs and maldistribution of healthcare represent an intolerable situation, an ever-growing amount of medical literature and healthcare ethics literature is turning to considerations of justice.
While Bioethics is now taught at all medical colleges in the United States as well as in other nations, and while discussions about Bioethics have become frequent in most medical journals there are increasing barriers to teaching and incorporating what has been taught into daily practice. I shall discuss some of these barriers and suggest that integrating the teaching of Bioethics throughout the curriculum after presenting some of the basic theory and methodology is the most effective way of teaching this (...) vital subject. Furthermore, courses in health care ethics are often taught as something distinct and distinguishable from one's medical practice. I shall emphasize what I consider to be the failure of Bioethics to participate effectively in creating a context whereby what has been taught can be put into praxis. In this brief article I will discuss such barriers and suggest several approaches and remedies. (shrink)
Virtually all persons who have had a hand in shaping the concept of ethics committees in this country accept the principle that the individuals making up the ethics committee should represent different interests, backgrounds, and viewpoints. In other words, ethics committees are intended mainly to represent the interests of the communities they serve. However, ethics committees often also serve hospitals that are religiously based and who, not unreasonably, may insist on affirming their own institutional morality and their own peculiar way (...) of looking at some problems. Deep-seated ethical quandaries, especially in shaping policy, are often unavoidable. (shrink)
Physicians accept fallibility in technical matters as a condition of medical practice. When it comes to moral considerations, physicians are often loathe to act without a good deal more certitude and seem less willing to accept error. This article argues that ethics is intrinsic to medical decision making, that error is the inevitable risk of any action and that inaction (clearly action by default) carries even greater risk of error. Whether in the moral or the technical sphere, error must be (...) accepted by physicians as part of the learning process which informs and enriches future decisions. Moral virtue, it is concluded, resides more in the making of a decision and in the agony of making it than it does in the potentially fallible decision itself. (shrink)
The history in which bioethics developed is well reviewed in a recent book written by Al Jonsen. This superb little volume gives a concise—even if a necessarily rather subjective—account of the development of the field. A more objective history of the contemporary development of the field cannot be expected from those who helped craft it and awaits historians of the future. What I have been asked to do here is to supply my own personal impressions of the development of this (...) field as I have experienced it. What I have been asked to do here is to supply my own personal impressions of the development of this field as I have experienced it. (shrink)
This paper inaugurates a new section on education, the focus of which is on education in a broader sense. The purpose is to stimulate discussion not only about techniques of education but also to initiate a dialogue concerninig more fundamental questions and issues. What are the goals of education generally and of and for ethics committees specifically? What, for an ethics committee, is “education”? What do we mean by education in this field? To function efficiently on an ethics committee, does (...) a member need specific training? Should the educational efforts of an ethics committee extend beyond the medical and nursing staff? If so, should they extend beyond the hospital and into the community? Is educating patients a legitimate function of an ethics committee? These are but a few of the questions that I hope will be debated over the years in the pages of this journal. (shrink)
In this paper, I want to try to put what has been termed the “care ethics” into a different perspective. While I will discuss primarily the use of that ethic or that term as it applies to the healthcare setting in general and to the deliberation of consultants or the function of committees more specifically, what I have to say is meant to be applicable to the problem of using a notion like “caring” as a fundamental precept in ethical decision (...) making. I will set out to examine the relationship between theoretical ethics, justice-based reasoning, and care-based reasoning and conclude by suggesting not only that all are part of a defensible solution when adjudicating individual cases, but that these three are linked and can, in fact, be mutually corrective. I will claim that using what has been called “the care ethic” alone is grossly insufficient for solving individual problems and that the term can be extremely dangerous. I will readily admit that while blindly using an approach based solely on theoretically derived principles is perhaps somewhat less dangerous, it is bound to be sterile, unsatisfying, and perhaps even cruel in individual situations. Care ethics, as I understand the concept, is basically a non- or truly an anti-intellectual kind of ethic in that it tries not only to value feeling over thought in deliberating problems of ethics, but indeed, would almost entirely substitute feeling for thought. Feeling when used to underwrite undisciplined and intuitive action without theory has no head and, therefore, no plan and no direction; theory eventuating in sterile rules and eventually resulting in action heedlessly based on such rules lacks humanity and heart. Neither one nor the other is complete in itself. There is no reason why we necessarily should be limited to choosing between these two extremes. (shrink)
It is often said that because physicians and other healthcare professionals frequently play a critical role in determining the fate of their patients, they ought if at all possible to be their patient's friend. The relationship of necessity is intimate: physicians have knowledge of their patients' histories and of their bodies which under other circumstances would be reserved to the most intimate of friends, and physicians and patients meet under more or less critical situations. In this paper, I briefly examine (...) the role of the physician as “friend,” an Issue to be much more extensively explored In a book In preparation. (shrink)