Moral philosophers agree that welfare matters. But they disagree about what it is, or how much it matters. In this vital new work, Wayne Sumner presents an original theory of welfare, investigating its nature and discussing its importance. He considers and rejects all notable theories of welfare, both objective and subjective, including hedonism and theories founded on desire or preference. His own theory connects welfare closely with happiness or life satisfaction. Reacting against the value pluralism that currently dominates moral philosophy, (...) he advances welfare as the only basic ethical value. He concludes by discussing the implications of this thesis for ethical and political theory. Written in clear, non-technical language, and including a definitive survey of other work in this area, Sumner's book is essential reading for moral philosophers, political theorists, and welfare economists. (shrink)

Clinical decision making is a challenging task that requires practical wisdom—the practised ability to help patients choose wisely among available diagnostic and treatment options. But practical wisdom is not a concept one typically hears mentioned in medical training and practice. Instead, emphasis is placed on clinical judgement. The author draws from Aristotle and Aquinas to describe the virtue of practical wisdom and compare it with clinical judgement. From this comparison, the author suggests that a more complete understanding of clinical judgement (...) requires its explicit integration with goals of care and ethical values. Although clinicians may be justified in assuming that goals of care and ethical values are implicit in routine decision making, it remains important for training purposes to encourage habits of clinical judgement that are consciously goal-directed and ethically informed. By connecting clinical judgement to patients' goals and values, clinical decisions are more likely to stay focused on the particular interests of individual patients. To cultivate wise clinical judgement among trainees, educational efforts should aim at the integration of clinical judgement, communication with patients about goals of care, and ethical reasoning. But ultimately, training in wise clinical judgement will take years of practice in the company of experienced clinicians who are able to demonstrate practical wisdom by example. By helping trainees develop clinical judgement that incorporates patients' goals of care and ethical reasoning, we may help lessen the risk that ‘clinical judgement’ will merely express ‘the clinician's judgement.’. (shrink)

Currently living people cannot be said to be wronged because of the wrongless emissons of greenhouse gases by past people. According to the usual subjunctive-historical understanding of harm, currently living people cannot be said to be harmed by the impact of greenhouse emissions on their well-being. By relying on a subjunctive-threshold notion of harm we can justify conclusions about both the present generation’s duties not to violate the rights of future generations, and the present generation’s duties to compensate currently living (...) people for the harms inflicted upon them through the lasting impact of wrongless past harms. This interpretation supports a forward-looking understanding of the grounds of our relating to wrongless past harms. The significance of past harms lies in their consequences for the well-being of currently living and future people. The subjunctive-threshold notion of harm lends support to a standard of minimal, general, and universal justice. Those actors who are in a position to fulfill its requirements are under a duty to do so. Especially the rich and powerful countries ought to counteract the harmful impact of past greenhouse emissions. (shrink)

US Supreme Court rulings concerning sanctions for juvenile offenders have drawn on the science of brain development and concluded that adolescents are inherently less mature than adults in ways that render them less culpable. This conclusion departs from arguments made in cases involving the mature minor doctrine, in which teenagers have been portrayed as comparable to adults in their capacity to make medical decisions. I attempt to reconcile these apparently incompatible views of adolescents’ decision-making competence. Adolescents are indeed less mature (...) than adults when making decisions under conditions that are characterized by emotional arousal and peer pressure, but adolescents aged 15 and older are just as mature as adults when emotional arousal is minimized and when they are not under the influence of peers, conditions that typically characterize medical decision-making. The mature minor doctrine, as applied to individuals 15 and older, is thus consistent with recent research on adolescent development. (shrink)

My comment makes a point out ofRousseau's original insight: that education forsocial participation ought to start within thestudent's lifeworld, and not, as in our days, with the immediatedemands of modern, time-ridden consumerculture. When time is turned into a commodityand place is turned into a transit point forpeople constantly on the move, presence in acommon lifeworld is lost. I take issue with thedominant thinking of education in terms of timeand efficiency, and suggest that we startthinking of education more in terms of (...) placeand presence. I propose that modern thinkers ofeducation – of which I mention a few here –contributed significantly to the pedagogy ofplace or presence. I don't see time as a stringmade up of past-present-future, but rather asan expanding mental and pragmatic universe ofhere-and-nows. The term kairos catchesthis presence as the capacity for doing theright thing at the right moment, that is, themoment when the past has prepared the ground sothat the future can come as a gift. Thisconception is, I think, an important ground forthe idea of an education for citizenship. (shrink)

Reporting peers’ counterproductive work behaviors (CWBs) is important for maintaining an ethical organization, but is a significant and potentially risky action. In Bandura’s Theory of Moral Thought and Action (Bandura, 1991) he states that such acts require significant moral agency, which is generated when an individual possesses adequate moral self-regulatory capacities to address the issue and is in a context that activates and reinforces those capacities. Guided by this theory, we assess moral potency (i.e., moral courage, moral efficacy, and moral (...) ownership) as key capacities predicting peer reporting intentions and assess three contextual factors influencing the generation and effects of moral potency: whether a potential informant (1) works for an ethical leader, (2) is embedded in a psychologically safe climate promoting interpersonal risk-taking, and (3) operates in a more normal or extreme context. We assess the proposed model across three field studies entailing both normal and extreme (i.e., firefighting units) contexts. Results show that ethical leaders raise employees’ moral potency, promoting greater willingness to report their peers’ CWBs. In normal work contexts, psychological safety positively moderated both the relationship between ethical leadership and moral potency and between moral potency and peer reporting intentions. However, psychological safety had the opposite effects in more extreme work contexts. Whereas psychological safety strengthens the positive association between moral potency and peer reporting intentions in normal work contexts, in contexts where individuals are more frequently exposed to extreme events, psychological safety weakens this relationship, thus highlighting the unforeseen downsides of psychological safety in extreme contexts. (shrink)

SETTING: Previous health policies in South Africa neglected the teaching of ethics and human rights to health professionals. In April 1995, a pilot course was run at the University of Cape Town in which the ethical dimensions of human rights issues in South Africa were explored. OBJECTIVES: To compare knowledge and attitudes of participating students with a group of control students. DESIGN: Retrospective cohort study. SUBJECTS: Seventeen fourth-year medical students who participated in the course and 13 control students from the (...) same class, matched for gender. INTERVENTIONS: Students participated in a one-week module on ethics and human rights. Five months after the course had been run, students completed a semi-structured questionnaire exploring their knowledge and attitudes with regards to ethics and human rights issues. MAIN OUTCOME MEASURES: Knowledge scores, attitude scores and various individual indicators of attitude. RESULTS: Clear benefits for overall knowledge score, for four out of five individual knowledge questions and for one of the attitude questions, were demonstrated. Participating students also appeared to be more convinced of the need for teaching on the ethical dimensions of human rights at postgraduate level and that such teaching should also be integrated in the curriculum. The low response rate amongst controls may have selected students who were more socially conscious, thereby leading to an underestimate of the true impact of the course. CONCLUSION: The evaluation indicates clear benefits of the course for undergraduate students, and supports arguments for the inclusion of such courses in the training of health professionals. This is particularly important given the challenges posed by the Truth and Reconciliation Commission to the health professions to address past complicity in human rights abuses through reorientation of medical training in South Africa. (shrink)

The legitimacy of the refusal of South Australian nurses to care for second trimester abortion patients on grounds of conscience is examined as a test case for a theory of permissible limits on the autonomy of health care professionals. In cases of health care professional (HCP) conscientious refusal, it is argued that a balance be struck between the HCPs' claims to autonomous action and the consequences to them of having their autonomous action restricted, and the entitlement of patients to care (...) and the consequences for them of being refused such care. Conscientious action that results in the disruption or termination of health care services, however, is always impermissible on two grounds. Firstly, because it is at this point that the action '... invades a patient's autonomy, puts a patient at serious risk ... [and] treats a patient unjustly' (1) Secondly, because the consequences of such refusals turn them into political acts--acts of civil disobedience. It is arguable that in order for acts of civil disobedience to be legitimate, certain obligations are required of the dissenter by the community. It is concluded that the actions of the South Australian nurses, which have over the last few years both terminated and disrupted second trimester services, are morally impermissible. (shrink)

This paper describes the change of emphasis that occurred in the teaching of ethics to small groups of clinical students. Although the original focus of the course was on the analysis of ethical dilemmas associated with individual patients known to the students, it soon became evident that there were, for the students themselves, more fundamental ethical dilemmas in their new role as clinical students. These included worries about how to respond when patients asked questions which their consultants had previously deceived (...) them about, worries about inflicting pain on patients, as with intravenous cannulation, and the role of the medical student in the clinical team. We emphasise the need to explore student experiences as part of the process of ethics teaching. (shrink)

My purpose in what follows is not so much to defend the basic principle of utilitarianism as to indicate the form of it which seems most promising as a basic moral and political position. I shall take the principle of utility as offering a criterion for two different sorts of evaluation: first, the merits of acts of government, social policies, and social institutions, and secondly, the ultimate moral evaluation of the actions of individuals. I do not take it as implying (...) that the individual should live his life on the basis of constant evaluations of this sort. For there are different levels of decision making each with its appropriate criteria. For example, we each inevitably make many of our decisions from the point of view of our own personal self-fulfilment and this cannot regularly take a directly utilitarian form, nor should the utilitarian want it to do so. His claim is at most that we should sometimes review our life from the point of view of a kind of impersonal moral truth of a universalistic utilitarian character. (shrink)

Patients and physicians can inhabit distinctive social worlds where they are guided by diverse understandings of moral practice. Despite the contemporary presence of multiple moral traditions, religious communities and ethnic backgrounds, two of the major methodological approaches in bioethics, casuistry and principlism, rely upon the notion of a common morality. However, the heterogeneity of ethnic, moral, and religious traditions raises questions concerning the singularity of common sense. Indeed, it might be more appropriate to consider plural traditions of moral reasoning. This (...) poses a considerable challenge for bioethicists because the existence of plural moral traditions can lead to difficulties regarding "closure" in moral reasoning. The topics of truth-telling, informed consent, euthanasia, and brain death and organ transplantation reveal the presence of different understandings of common sense. With regard to these subjects, plural accounts of "common sense" moral reasoning exist. (shrink)

In _Civilization and Its Discontents_, Freud made abundantly clear what he thought about the biblical injunction, first articulated in Leviticus 19:18 and then elaborated in Christian teachings, to love one's neighbor as oneself. "Let us adopt a naive attitude towards it," he proposed, "as though we were hearing it for the first time; we shall be unable then to suppress a feeling of surprise and bewilderment." After the horrors of World War II, the Holocaust, Stalinism, and Yugoslavia, Leviticus 19:18 seems (...) even less conceivable—but all the more urgent now—than Freud imagined. In _The Neighbor_, three of the most significant intellectuals working in psychoanalysis and critical theory collaborate to show how this problem of neighbor-love opens questions that are fundamental to ethical inquiry and that suggest a new theological configuration of political theory. Their three extended essays explore today's central historical problem: the persistence of the theological in the political. In "Towards a Political Theology of the Neighbor," Kenneth Reinhard supplements Carl Schmitt's political theology of the enemy and friend with a political theology of the neighbor based in psychoanalysis. In "Miracles Happen," Eric L. Santner extends the book's exploration of neighbor-love through a bracing reassessment of Benjamin and Rosenzweig. And in an impassioned plea for ethical violence, Slavoj Žižek's "Neighbors and Other Monsters" reconsiders the idea of excess to rehabilitate a positive sense of the inhuman and challenge the influence of Levinas on contemporary ethical thought. A rich and suggestive account of the interplay between love and hate, self and other, personal and political, _The Neighbor_ will prove to be a touchstone across the humanities and a crucial text for understanding the persistence of political theology in secular modernity. (shrink)

When Amartya Sen defends his capability theory of well-being he contrasts it with the utility theory advocated by the classical utilitarians, including John Stuart Mill. Yet a closer examination of the two theories reveals that they are much more similar than they appear. Each theory can be interpreted in either a subjective or an objective way. When both are interpreted subjectively the differences between them are slight, and likewise for the objective interpretations. Finally, whatever differences may remain are less important (...) than they might seem, since the two theories are developed by Sen and Mill for different purposes and are in that sense not genuine rivals. (shrink)

This paper analyses the complex issues faced by regulators of the infertility treatment industry in response to the social and technological changes that heralded a new openness in knowledge about genetics, paternity and the concomitant need for donor offspring to know their genetic origins. The imperative for full information about their donor and biological father, who contributed to their creation and half of their genome, was an outcome unanticipated by the architects of the donor insemination programme. Genetic paternity testing realised (...) the possibility of fixed and certain knowledge about paternity. This paper outlines medicine's role in the formation of normative families through the use of donor insemination. Extending information from an Australian study on the use of DNA paternity testing, it analyses what the social and scientific changes that have emerged and gained currency in the last several decades mean for the new ‘openness’ and the role of paternity testing in this context. It concludes with recommendations about how to deal with the verification of paternity in linking donor conceived adult children to their donor. (shrink)

Today, monitoring of patient complaints in healthcare services is being used as a tool for quality assurance systems and in the future development of services. This nationwide register study describes the number of all complaints processed, number of complaints between different state provinces, healthcare services and healthcare professionals, and outcomes of complaints in Finland during the period 2000–2004. All complaints processed at the State Provincial Offices and the National Authority for Medicolegal Affairs were analysed by statistical methods. Complaints about mental (...) healthcare were explored in greater detail. The analysis showed that the number of patient complaints increased considerably during the study period. There were changes in the number of complaints between study years in different provinces. Out of different healthcare services, an especially marked increase was seen in private healthcare. Nearly all complaints were lodged against physicians, and over half of the complaints were made because of medical error. In mental health care, patients more often complained about unsatisfactory certificates and statements and the use of compulsory hospital care. An analysis of the outcomes revealed that in mental health care complaints more seldom led to consequences. The results need to be utilised when planning interventions for advanced supervision, prevention of adverse events and patient safety in healthcare, and especially in mental health care. From the patients’ perspective, it is important to create a culture where most problem situations are handled where the treatment was provided, thus avoiding a complex complaints process. (shrink)

Time and philosophical fashion have not been kind to hedonism. After flourishing for three centuries or so in its native empiricist habitat, it has latterly all but disappeared from the scene. Does it now merit even passing attention, for other than nostalgic purposes? Like endangered species, discredited ideas do sometimes manage to make a comeback. Is hedonism due for a revival of this sort? Perhaps it is overly optimistic to think that it could ever flourish again in its original form; (...) the evolutionary changes which have rendered the philosophical environment hostile to the classical specimens of the theory are doubtless irreversible. None the less, it is still possible that certain features of the classical view can, and should, be recuperated—like bits of DNA which could contribute to the emergence of new and more robust species. So let us ask ourselves: what is living and what is dead in traditional hedonism? (shrink)

The use of human brain tissue in neuroscience research is increasing. Recent developments include transplanting neural tissue, growing or maintaining neural tissue in laboratories and using surgically removed tissue for experimentation. Also, it is likely that in the future there will be attempts at partial or complete brain transplants. A discussion of the ethical issues of using human brain tissue for research and brain transplantation has been organized around nine broadly defined topic areas. Criteria for human brain tissue transplantation and (...) laboratory use of brain tissue are proposed. (shrink)

There is no subject at the interface of law, psychiatry and medical ethics which is more controversial than psychosurgery. The divergent views of the treatment begin with its definition. The World Health Organisation1 and others2 define psychosurgery as the selective surgical removal or destruction of nerve pathways or normal brain tissue with a view to influencing behaviour. However, proponents of psychosurgery demur on the basis that the `modern' treatment is concerned predominantly with emotional illness, without any specific effect upon behaviour. (...) The alternative definition offered is `the surgical treatment of certain psychiatric illnesses by means of localised lesions placed in specific cerebral sites.3It is difficult entirely to accept this definition because, as examined below, scientific psychiatry is not yet in a position to directly treat psychiatric illness solely through surgical intervention. There is no reliable theoretical relationship between particular cerebral sites (which are normal and healthy) and an identifiable psychiatric illness or symptomatology. Given this state of psychiatric understanding, it is misleading to suggest fine distinctions between generalised alteration of behaviour or mood and treatment of an illness. Highly divergent practices and theories (relating to the multiplicity of conditions treated, surgical methods adopted and areas of the brain operated upon) further undermine exaggerated claims that psychosurgery can scientifically `treat' specific illness through precise surgical intervention. Nonetheless, contemporary psychosurgery does not contain quite the same `broadbrush' approach of its ancestors and it can lay some legitimate claim as an effective empirical treatment in narrowly limited circumstances. Major ethical problems still, however, arise and these will be discussed in this article. (shrink)

Quality improvement (QI) is fundamental to maintaining high standards of health care. Significant debate exists concerning the necessity for an ethical approval system for those QI projects that push the boundaries, appearing more similar to research than QI. The authors discuss this issue identifying the core ethical issues in family medicine (FM), drawing upon the fundamental principles of medical ethics, including principles of autonomy, utility, justice and non-maleficence. Recent debate concerning the application of QI ethics boards is discussed with relevance (...) to primary care and issues such as general practitioner (GP) intentions, the impact of QI on patients and the use of confidential patient data and the impact of dissemination. The authors conclude that a system of QI ethical approval leaves many issues unresolved and potentially creates several barriers to implementing QI. To ensure ethical QI work is generated within FM it is essential for GPs to learn about and engage in more ethical reflection so that they can better judge and resolve these issues. (shrink)

The aim of this study was to determine the opinions of private medical practitioners in Bloemfontein, South Africa, regarding euthanasia of terminally ill patients. This descriptive study was performed amongst a simple random sample of 100 of 230 private medical practitioners in Bloemfontein. Information was obtained through anonymous self-administered questionnaires. Written informed consent was obtained. 68 of the doctors selected completed the questionnaire. Only three refused participation because they were opposed to euthanasia. Respondents were mainly male (74.2%), married (91.9%) and (...) Afrikaans-speaking (91.9%). More were specialists (53.2%) than general practitioners (46.8%). A smaller percentage (35.5%) would never consider euthanasia for themselves compared to for their patients (46.8%). The decision should be made by the patient (50%), the patient’s doctor with two colleagues (46.8%), close family (45.2%) or a special committee of specialists in ethics and medicine (37.1%). The majority (46.9%) indicated that euthanasia should be performed by an independent doctor trained in euthanasia, followed by the patient’s doctor (30.7%). Notification should mainly be given to a special committee (49.9%). Only 9.8% felt that no notification was necessary. There was strong opposition to prescribing of medication to let the patient die. Withdrawal of essential medical treatment to speed up death was the most acceptable method. Although the responding group was fairly homogeneous, responses varied widely, indicating the complexity of opinions. (shrink)

Neglected and tropical diseases, pervasive in developing countries, are important contributors to global health inequalities. They remain largely untreated due to lack of effective and affordable treatments. Resource-poor countries cannot afford to develop the public health interventions needed to control neglected diseases. In addition, neglected diseases do not represent an attractive market for pharmaceutical industry. Although a number of international commitments, stated in the Millennium Development Goals, have been made to avert the risk of communicable diseases, tropical diseases still remain (...) neglected due to delays in international assistance. This delay can be explained by the form international cooperation has generally taken, which is limited to promoting countries’ national interests, rather than social justice at a global level. This restricts the international responsibility for global inequalities in health to a humanitarian assistance. We propose an alternative view, arguing that expanding the scope of international cooperation by promoting shared health and economic value at a global level will create new opportunities for innovative, effective and affordable interventions worldwide. It will also promote neglected diseases as a global research priority. We build our argument on a proposal to replace the patenting system that currently regulates pharmaceutical research with a global fund to reward this research based on actual decreases in morbidity and mortality at a global level. We argue that this approach is beneficent because it will decrease global health inequalities and promote social justice worldwide. (shrink)

The author, a consultant psychotherapist who works with dying patients in a National Health Service (NHS) hospital, argues that the moral issue is not simply whether or not to tell cancer patients the truth, but more importantly how to do so. Lies and the bald unprepared-for truth may both be damaging. Time and trouble is needed to understand patients and help them understand their situation. Dr Goldie warns that putting oneself into the patient's shoes, as doctors so often do, is (...) the best way of not knowing what another feels. Such misunderstanding may lead to medical decisions based on `nothing more than fantasies - uninspired guesses about what other people think and feel. It is the equivalent of prescribing for patients without examination'. (shrink)

Natural death act legislation which is intended to assist patients who wish to refuse or limit medical treatment may actually erode patients' rights. By use of a 'living will' the legislation intends to extend the patients' role in decision-making to the time when patients can no longer speak for themselves. However, the legislation erodes and constricts the right of refusal. The erosion is the result of two sets of conditions found in the legislation. The first requires that the patient be (...) qualified and certified by others before interventions can be withdrawn or withheld. The second delineates the physical condition which must be present before a living will can be followed. Patients have had to seek the assistance of the courts to enforce their common law rights of refusal of treatment against these requirements. Legislation is needed, but greater care must be taken to avoid the creation of a Kafkaesque legal nightmare for those we intend to assist. (shrink)

The federal government is funding a sea change in health care by investing in interventions targeting social determinants of health, which are significant contributors to illness and health inequity. This funding power has encouraged states, professional and accreditation organizations, health care entities, and providers to focus heavily on social determinants. We examine how this shift in focus affects clinical practice in the fields of oncology and emergency medicine, and highlight potential areas of reform.

A linguistic barrier between healthcare professional and patient is a challenging experience for both parties. In many cases, the absence of formally trained medical interpreters necessitates that an informal interpreter, drawn from the immediate environment, be used to facilitate communication. While the presence of an interpreter in a medical interview raises many questions about the effectiveness of the communication between healthcare professional and patient, it also gives rise to new speculations revolving on patient rights, medical ethics and patient privacy. In (...) this article we examine the concept of communication competency in medical interviews, as well as translation theory, and link these theories to Western medical ethics in order to identify potential areas in which informal interpretation could impact on the patient. (shrink)

Background and aim With the increasing interest in lifestyle, health and consequences of unhealthy lifestyles for the healthcare system, a new kind of solidarity is gaining importance: lifestyle solidarity. While it might not seem fair to let other people pay for the costs arising from an unhealthy lifestyle, it does not seem fair either to punish people for their lifestyle. However, it is not clear how solidarity is assessed by people, when considering disease risks or lifestyle risks. The aim of (...) this study was to investigate the degree of solidarity with lifestyle as well as with other factors that are related to health outcomes—for example, old age—and the relation between this degree of solidarity and various characteristics. Methods This cross-sectional study is part of the Dutch longitudinal SMILE study. Data on the degree of solidarity with different lifestyles and old age, and the relation between the degree of solidarity and various demographic and other variables were obtained in a questionnaire survey. Results Solidarity with smokers and overweight people was moderate, as was solidarity with older people. Respondents were ambivalent about athletes. Respondents who were younger, male and highly educated, and those with a healthy lifestyle, a small social network, high quality of life and an internal locus of control, showed low solidarity. Conclusions Solidarity with an unhealthy lifestyle and old age is moderate and the degree of solidarity varies among the different subgroups. (shrink)

There are very few medical ethics courses in British medical schools which are a formal part of the clinical curriculum. Such a programme is described in the following, along with the way in which the long-term curriculum committee of the University College and Middlesex Hospital Joint Medical School was persuaded to make it compulsory for first-year students. Pedagogical lessons which have been learned in its planning and implementation are outlined and teaching materials are included concerning student and course assessment which (...) should be useful for others engaged in similar work. Finally, some of the institutional obstacles facing such attempts are discussed, particularly problems concerning timetabling, different types of opposition and the consequent importance of building alliances among clinical teaching staff. (shrink)

It is always possible to construct a real function f, given random quantities X and Y with continuous distribution functions F and G, respectively, in such a way that f(X) and f(Y), also random quantities, have both the same distribution function, say H. This result of De Finetti introduces an alternative way to somehow describe the `opinion' of a group of experts about a continuous random quantity by the construction of Fields of coincidence of opinions (FCO). A Field of coincidence (...) of opinions is a finite union of intervals where the opinions of the experts coincide with respect to that quantity of interest. We speculate on (dis)advantages of Fields of Opinion compared to usual `probability' measures of a group and on their relation with a continuous version of the well-known Allais' paradox. (shrink)