The topic of developing professionalism dominated the content of many academic medicine publications and conference agendas during the past decade. Calls to address the development of professionalism among medical students and residents have come from professional societies, accrediting agencies, and a host of educators in the biomedical sciences. The language of the professionalism movement is now a given among those in academic medicine. We raise serious concerns about the professionalism discourse and how the specialized language of academic medicine disciplines has (...) defined, organized, contained, and made seemingly immutable a group of attitudes, values, and behaviors subsumed under the label of "professionalism." In particular, we argue that the professionalism discourse needs to pay more attention to the academic environment in which students are educated, that it should articulate specific positive behaviors, that the theory of professionalism must be constructed from a dialogue with those we are educating, and that this theoretical and practical discourse must aim at a deeper understanding of social justice and the role of medicine within a just society. (shrink)
Contemporary bioethics has been somewhat skewed by its focus on high-tech medicine and the resulting development of ethical frameworks based on an acute-care model of healthcare. Research and scholarship in bioethics have payed only cursory attention to ethical issues related to disability. I argue that bioethics should concern itself with the full range of theoretical and practical issues related to disability. This encounter with the disability community will enrich bioethics and, potentially, society as well. I suggest a number of items (...) that the bioethics agenda should include, such as the development of a casuistry of the right to healthcare and to community integration and an advocacy role in fostering an understanding among the public and policy makers of the need to reform research and treatment related to disability. (shrink)
I analyze the insights present in Elisabeth Kübler-Ross’s seminal work, On Death and Dying that have laid the foundation for contemporary clinical bioethics as it is practiced by clinical ethics co...
Immigrants lacking health insurance access the health care system through the emergency departments of non-profit hospitals. Because these persons lack health insurance, continued care can pose challenges to those institutions. I analyze the values of our health care institutions, utilizing a Walzerian approach that describes its appropriate sphere of justice. This particular sphere is dominated by a caring response to need. I suggest that the logic of this sphere would be best preserved by providing increased access to health insurance to (...) this population. This access would marry the rights of these members of our community to access care to our responsibility to contribute to financing of the system. I close with some considerations on what it means to be a member of the community. (shrink)
Spirituality or religion often presents as a foreign element to the clinical environment, and its language and reasoning can be a source of conflict there. As a result, the use of spirituality or religion by patients and families seems to be a solicitation that is destined to be unanswered and seems to open a distance between those who speak this language and those who do not. I argue that there are two promising approaches for engaging such language and helping patients (...) and their families to productively engage in the decision-making process. First, patient-centered interviewing techniques can be employed to explore the patient's religious or spiritual beliefs and successfully translate them into choices. Second, and more radically, I suggest that in some more recalcitrant conflicts regarding treatment plans, resolution may require that clinicians become more involved, personally engaging in discussion and disclosure of religious and spiritual worldviews. I believe that both these approaches are supported by rich models of informed consent such as the transparency model and identify considerations and circumstances that can justify such personal disclosures. I conclude by offering some considerations for curbing potential unprofessional excesses or abuses in discussing spirituality and religion with patients. (shrink)
I explore the possible meanings that the notion of the common morality can have in a contemporary communitarian approach to ethics and public policy. The common morality can be defined as the conditions for shared pursuit of the good or as the values, deliberations, traditions, and common construction of the narrative of a people. The former sense sees the common morality as the universal and invariant structures of morality while the second sense is much more contingent in nature. Nevertheless, the (...) communitarian sees both aspects as integral in devising solutions to public policy problems. I outline how both meanings follow from communitarian philosophical anthropology and illustrate how they work together when addressing a question such as that of providing universal health insurance in the United States. The common morality forms the basis of building an implicit consensus that is available to and reaffirmed by the shared reflections of the citizenry. (shrink)
ABSTRACTI consider objections to the use of living wills based upon the discontinuity of personal identity between the time of the execution of the directive anbd the time the person becomes incompetent. Recent authors, following Derek Parfit's “Complex View” of personal identity, have argued that there is often not sufficient identity interests between the competent person who executes the living will and the incompetent patient to warrant the use of the advance directive. I argue that such critics err by seeking (...) personal identity in a purely descriptive manner. By exploring Buchanan and Brock's concept of “surviving interests”, an argument is developed that certain future‐oriented acts have a normative force that contributes to the narrative unity which is constitutive of personal ideality. This narrative concept of the self is entailed by many of the our ordinary practices and challenges the philosophical consensus to view the self in a more dynamic and communitarian manner. (shrink)
I consider the problem liberalism poses for bioethics.Liberalism is a view that advocates that the state remain neutralto views of the good life. This view is sometimes supported by askeptical moral epistemology that tends to propel liberalismtoward libertarianism. I argue that the possibilities for sharedagreement on moral matters are more promising than is sometimesappreciated by such a view of liberalism. Using two examples ofpublic debates of moral issues, I show that commonly sharedintuitions may ground moral principles even if they may (...) be givendifferent weight by persons of different moral and religioustraditions. Nevertheless, the fact that the intuition andprinciple is widely shared may be sufficient to chart somedirections for public policy or cooperative action even if theydo not lead to complete agreement. As a result, I argue that aliberal communitarianism that presupposes a fairly minimalistepistemology is a legitimate approach to achieving sharedagreement in a pluralistic society. (shrink)
It has become common in medical ethics to discuss difficult cases in terms of the principles of respect for autonomy, beneficence, nonmaleficence, and justice. These moral concepts or principles serve as maxims that are suggestive of appropriate clinical behavior. Because this language evolved primarily in the acute care setting, I consider whether it is in need of supplementation in order to be useful in the long-term care setting. Through analysis of two typical cases involving residents of long-term care facilities, I (...) argue for the additional principles of candor and responsibility for narrative integrity. (shrink)
Medicine is in a very self-reflective mood. There is a revival of interest not only in medical ethics but also in medical history, the Hippocratic corpus, and various kinds of literature that indicate physicians are reexamining the foundations of medicine and what it is that gives meaning to medicine. That is, they are reexamining the physician's vocation, in the true sense of vocation as a calling. This interest has coincided with the concern of third parties such as accreditation agencies about (...) the professionalism of physicians. (shrink)
This paper describes the first three-year experience of the Consortium Ethics Program (CEP-1) of the University of Pittsburgh Center for Medical Ethics, and also outlines plans for the second three-year phase (CEP-2) of this experiment in continuing ethics education. In existence since 1990, the CEP has the primary goal of creating a cost-effective, permanent ethics resource network, by utilizing the educational resources of a university bioethics center and the practical expertise of a regional hospital council. The CEP's conception and specific (...) components stem from recognition of the need to make each hospital a major focus of educational efforts, and to provide academic support for the in-house activities of the representatives from each institution. (shrink)
This article considers contributions that the medical humanities have made to biomedical ethics. Philosophy has contributed methods of ethical justification to case analysis and has given birth to the New Professionalism movement. Taking biography as its paradigmatic resource, this movement has refocused medical education on the formation of physicians who not only have certain responsibilities to their patients, but also a regard for the role of the medical profession in working toward social justice. However, reliance on biography is now giving (...) way to a renewed emphasis on autobiography, as educators seek to support medical students through the personal and spiritual journey that confrontation with death, disease, and injustice naturally entails. Reflective methods and techniques characterize this emerging era as educators and students try to preserve and reinvigorate the soul of medicine. (shrink)
This special section deals with the new professionalism movement. The interest in the term “professionalism” has been growing steadily in medicine, and the word now seems to be everywhere. However, bioethicists have lagged behind our colleagues in medicine and nursing in explicitly contributing to this movement. This special section adds to the effort to catch up.
This dissertation examines the two most popular contemporary revivals of Aristotelian ethics, communitarianism and casuistry. I consider how these two schools of thought which take Aristotle's ethics as their starting point, can seem to be so diametrically opposed. The communitarian approach to ethics, personified by Alasdair MacIntyre, Michael Sandel, and Ezekiel J. Emanuel argues that a shared notion of the self or the good life must be sought prior to resolving ethical problems. Conversely, the new casuistic movement, exemplified by the (...) recent work of Albert Jonsen, Stephen Toulmin, and Carson Strong eschews such theoretical baggage in favor of a case-based ethics. By examining each school of thought in the light of their Aristotelian aspirations, namely, their desire to re-establish an ethics based upon prudence that overcomes the fact/value distinction, spurious elements of their rhetoric are rejected. This allows us to see the compatible strains in communitarianism and casuistry and to demonstrate the elements they must borrow from each other in order to be viable approaches to ethical and political philosophy. (shrink)
The ethics consultant attended two of the weekly nursing conferences on this unit to process the feelings that the nurses expressed about the case, to explain the kind of ethical reasoning that has evolved regarding the forgoing of life-sustaining treatment, and to acknowledge some things he could have done better. In particular, this consultant came to believe that he had made a mistake in inferring that his job was only to provide the information to the attending physician that was requested. (...) This physician had suggested that he would prefer to deal directly with the family and only needed information from the consultant. Although the physician continually held open the possibility that at some time in the near future he might ask the consultant to meet with the family, that request never came despite repeated offers of assistance. (shrink)
The patient was born at 29 weeks gestation. There was a prenatal diagnosis that the child's small intestine had developed outside of the abdominal cavity. The length of gestation had made the initial prognosis good. But after birth, surgery to place the intestine back into the abdominal cavity found that the baby actually had very little small intestine and a diagnosis of was made. The amount of small intestine was not compatible with survival. The transplant service saw the baby twice (...) and each time said the baby's profile did not meet the transplant protocol. (shrink)
The debate regarding physician-assisted suicide continues in our society. Despite the recent opinions of the United States Supreme Court, this issue is unlikely to go away anytime soon. For a variety of reasons, this debate is now conducted in the legalistic terms of individual rights and liberties. As a result, perhaps we philosophers have been left behind. This is now a matter for the legal arena and philosophy is likely to be irrelevant. I would like to suggest otherwise for two (...) reasons. (shrink)
The patient was a 19-year-old female who was transferred to this children's hospital from a community hospital in a neighboring state. She is well known to the hospital staff because she had a kidney transplanted and retransplanted several times there. Her first transplant as at age 8 and she was retransplanted most recently approximately 3 years ago. She immediately rejected her second kidney and received a third. She is currently admitted because she is again rejecting her kidney, probably due to (...) not taking her medication. The ethics consultant was called because the attending physician wanted to know if it was ethical to retransplant a patient. (shrink)
A 24-year-old Hispanic male came into the emergency room of a large public teaching hospital with acute cardiac failure and chest pain. He was admitted and diagnosed with rheumatic heart disease and regurgitation and stenosis of both mitral and aortic valves. Medical judgment concluded that the patient needed to be medically stabilized and then undergo cardiac surgery to repair heart valves. The patient spoke only Spanish. Investigation through an interpreter revealed that he was an illegal alien from a Central American (...) country who has lived in this country for five to seven years. He came to the United States so that he could receive treatment for his heart condition, evidently fearing that he would not receive treatment in his home country. The patient entered this country through the assistance of some distant relatives. He did not have a strong support system. (shrink)
The transplant coordinator scheduled a meeting that included numerous members of the multidisciplinary team, among them the transplant surgeon, a social worker, a psychologist, and an ethics consultant. The ethics consultant outlined the ethical issues and made a recommendation. The consultant argued that the question whether the patient should again be listed as a transplant candidate really came down to the kind of environment that could be provided during aftercare. That is, if a rather structured living environmentcould be found for (...) the patient, then retransplantation might be warranted. But without such an environment, the patient would again probably fail to adhere to the medical and psychological treatment regimen necessary for a successful life as a transplant recipient. The psychologist, who had been working closely with the ethics consultant, concurred in this opinion. (shrink)
