: This paper presents a method of moral problem solving in clinical practice that is inspired by the philosophy of John Dewey. This method, called "clinical pragmatism," integrates clinical and ethical decision making. Clinical pragmatism focuses on the interpersonal processes of assessment and consensus formation as well as the ethical analysis of relevant moral considerations. The steps in this method are delineated and then illustrated through a detailed case study. The implications of clinical (...) pragmatism for the use of principles in moral problem solving are discussed. (shrink)

: "Clinical pragmatism" is an important new method of moral problem solving in clinical practice. This method draws on the pragmatic philosophy of John Dewey and recommends an experimental approach to solving moral problems in clinical practice. Although the method may shed some light on how clinicians and their patients ought to interact when moral problems are at hand, it nonetheless is deficient in a number of respects. Clinical pragmatism fails to explain adequately how (...) moral problems can be solved experimentally, it underestimates the relevance and importance of judgment in clinical ethics, and it presents a questionable account of the role that moral principles should play in moral problem solving. (shrink)

: This response to Lynn Jansen's critique of clinical pragmatism concentrates on two themes: (1) contrasting approaches to moral epistemology and (2) the connection between theory and practice in clinical ethics. Particular attention is paid to the status of principles and the role of consensus, with some closing speculations on how Dewey might view the current state of bioethics.

This volume explores how conceptions of pragmatism set forth in American philosophy serve as orienting perspectives in psychotherapy. Drawing on the influential contributions of William James and John Dewey, the author demonstrates how realistic, comparative approaches to understanding strengthen everyday therapeutic practice. He also examines recent developments in neuroscience that shape training and practice in the broader field of psychotherapy, encompassing psychodynamic, behavioral, cognitive and humanistic traditions. By following a clinical pragmatism, psychotherapy can be viewed as an (...) instrumental project that is governed by _results_ rather than a commitment to particular theoretical perspectives, empirical findings, or technical strategies. Through a variety of case studies, this volume emphasizes the crucial role of experiential learning in change and growth, and the recognition of the person as an individual. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Beyond EngelClinical Pragmatism as the Foundation of Psychiatric PracticeDavid H. Brendel (bio)Keywordsbiopsychosocial model, pluralism, pragmatism, psychiatryFor many years now, there has been growing recognition of the powerful role of pragmatic reasoning in numerous disciplines, including bioethics, medicine, law, political science, and philosophy (Dickstein 1998; Rosenthal, Hausman, and Anderson 1999). But until recently, philosophical pragmatism was neglected by scholars exploring the clinical challenges and theoretical underpinnings (...) of psychiatry. In his noteworthy article The Biopsychosocial Model and Philosophic Pragmatism: Is George Engel a Pragmatist?, Bradley Lewis offers a significant contribution to the small but gradually increasing literature in this area. Lewis appropriately presents Engel as a major figure in twentieth-century American medicine and psychiatry, a critic and a visionary who dared to question the dominant paradigm of biomedical reductionism (Engel 1977)—a paradigm that led to important scientific advances, but also restricted the physician’s understanding of the patient as a complex individual with an inner world and interpersonal relationships. Lewis argues that medicine and psychiatry a generation after Engel’s seminal 1977 paper can be revitalized by reinterpreting Engel in the intellectual tradition of classical American pragmatism and neo-pragmatism. Placing Engel in the pragmatic tradition, Lewis suggests, could enhance the biopsychosocial model and have substantial benefits for both individual patients and society as a whole.There is no disputing Lewis’s argument that a pragmatic philosophy of medicine and psychiatry is a noble goal. In fact, in my book Healing Psychiatry: Bridging the Science/Humanism Divide (Brendel 2006), I present philosophical pragmatism as the most compelling theoretical approach to clinical psychiatry in the twenty-first century—the approach that is most likely to empower the clinician and the patient to collaboratively develop a treatment plan that heeds the multidimensional complexity of the patient’s life, recognizes the confusion and uncertainty that grows out of this complexity, and aims for a favorable therapeutic outcome. Drawing on work of the classical American pragmatists and contemporary pragmatic bioethicists, I identify four dimensions of philosophical pragmatism that provide a sound foundation for clinical work, which I call the “four ps”: (1) diagnostic formulations and treatment plans in psychiatry are practical insofar as they focus on results rather than a commitment to any particular theory; (2) they are pluralistic [End Page 311] insofar as they incorporate explanatory concepts that span the biopsychosocial spectrum; (3) they are participatory and collaborative, not imposed authoritatively by the clinician; and (4) they are provisional, open-ended, and malleable to newly acquired information and evolution of the patient’s condition.Lewis casts Engel as a philosophical pragmatist who battled the Goliath of biomedical reductionism that had come to dominate American medicine and psychiatry in the latter half of the twentieth century. Unfortunately, however, regardless of how elegantly Lewis reinterprets Engel, he cannot render him a full-blown pragmatist for the medicine and psychiatry of the twenty-first century. Lewis provides quotations to suggest that Engel valued a results-oriented clinical sensibility, for example “the value of a scientific model is measured not by whether it is right or wrong but by how useful it is” (Engel 1980). But Engel was not fully committed to clinical outcome as the supreme judge of theory in medicine and psychiatry. Lewis notes that Engel understood the biopsychosocial model as less “a matter of compassion and humanity” and more a matter of “rigorous application of the principles and practices of science”; he was a man of his time who could not fully escape the scientism of the day. Working within this scientistic world, he distinguished himself by reintroducing psychological, sociological, and humanistic concepts into clinical medicine, which had become obsessed with the power and robustness of the natural sciences but had neglected the suffering human subject and the social context of illness. Engel undoubtedly hoped the biopsychosocial model would lead to better clinical results but, unlike the classical American pragmatists and contemporary pragmatic bioethicists, he did not make a systematic case for privileging clinical outcome above strict adherence to scientific theory.In fact, Engel’s biopsychosocial model runs the risk of becoming a reified end in itself; those who unquestioningly espouse its basic tenets are in danger of... (shrink)

When addressing cultural and religious differences in the clinical setting we need to be realists. Despite our public homage to pluralism and good intentions, it is just not possible to overcome all the differences that might exist and achieve perfect understanding of others. Try as we may, we will never be able to see perfectly the world through another's eyes. Instead of reaching for such perfection, we should instead reach for an approximation of shared understanding that will promote discourse (...) and civility when peoples of different races, genders, cultures, religions, and sexual preferences interact in the clinic. (shrink)

Pragmatism is a distinctive approach to clinical research ethics that can guide bioethicists and members of institutional review boards (IRBs) as they struggle to balance the competing values of promoting medical research and protecting human subjects participating in it. After defining our understanding of pragmatism in the setting of clinical research ethics, we show how a pragmatic approach can provide guidance not only for the day-to-day functioning of the IRB, but also for evaluation of policy standards, (...) such as the one that addresses acceptable risks for healthy children in clinical research trials. We also show how pragmatic considerations might influence the debate about the use of deception in clinical research. Finally, we show how a pragmatic approach, by regarding the promotion of human research and the protection of human subjects as equally important values, helps to break down the false dichotomy between science and ethics in clinical research. (shrink)

In today’s pluralistic society, clinical ethics consultation cannot count on a pre-given set of rules and principles to be applied to a specific situation, because such an approach would deny the existence of different and divergent backgrounds by imposing a dogmatic and transcultural morality. Clinical ethics support (CES) needs to overcome this lack of foundations and conjugate the respect for the difference at stake with the necessity to find shared and workable solutions for ethical issues encountered in (...) class='Hi'>clinical practice. We argue that a pragmatist approach to CES, based on the philosophical theories of William James, John Dewey, and Charles Sanders Peirce, can help to achieve the goal of reaching practical solutions for moral problems in the context of today’s clinical environment, characterized by ethical pluralism. In this article, we outline a pragmatist theoretical framework for CES. Furthermore, we will show that moral case deliberation, making use of the dilemma method, can be regarded an example of a pragmatist approach to CES. (shrink)

Explanatory models in psychiatry reflect what clinicians deem valuable in rendering people's behavior intelligible and thus help guide treatment choices for mental illnesses. This article outlines some key scientific and ethical principles of clinical explanation in twenty-first century psychiatry. Recent work in philosophy of science, clinical psychiatry, and psychiatric ethics are critically reviewed in order to elucidate conceptual underpinnings of contemporary explanatory models. Many explanatory models in psychiatry are reductionistic or eclectic. The former restrict options for diagnostic and (...) therapeutic paradigm choice, while the latter lack a well-defined theoretical basis. These two methodological approaches stand in a dialectical relation to one another insofar as clinicians often move from one approach to its antithesis, ultimately seeking a synthesis of the two approaches that satisfies clinical needs. Pragmatic considerations can help to transcend the reductionism/eclecticism dialectic. In the absence of a completed science of mental disorders, psychiatrists must tolerate ambiguity and uncertainty as they strive to integrate diverse explanatory concepts in a rigorous and evidence-based fashion. A pragmatic explanatory model in clinical psychiatry must focus on favorable treatment outcomes for patients by respecting the pluralistic, participatory, and provisional nature of psychiatric explanation. (shrink)

Background Although methods proposed for the conduct of ethics consultation tend to be viewed as competing approaches, they may in fact function in a complementary manner. Methods We describe the experience of ethics consultation in two ethics committees at the University Hospitals of Geneva, Switzerland. Results Both committees provide case consultation by a multi-disciplinary team of committee members, but with different processes. These differences in process do not necessarily lead to differences in outcome. Discussion Different methods of ethics consultation are (...) not mutually exclusive, and can co-exist within the same institution. The practical application of one method of ethics consultation can lead to substantial variations in process between different groups of consultants. Conclusion Despite the importance of clarifying theoretical groundings, and consultation and deliberation processes, in ethics consultation, choosing between different processes may not be pressing. To assist these choices, exploration of the practical strengths and weaknesses of different methods will be necessary to assist clinical ethicists, and clinical ethics committees, in acquiring a flexible and evidence-based set of approaches to their work. (shrink)

This paper attempts to defend pragmatic approaches to bioethics against detractors, showing how particular critics have failed or succeeded. The paper divides bioethics from a pragmatic point of view into three groups. The first group is called "bioethical pragmatism" that will be represented by two book-chapters from the anthology, Pragmatic Bioethics . The second group is called "clinical pragmatism" championed by Fins, Baccetta, and Miller. Finally, a third group, which has roots in the legal tradition, has been (...) called "freestanding pragmatism" and is portrayed by Grey, Posner, and Wolf. Each group has been criticized in journal articles, and, in turn, this paper critiques some of the (mis)understandings put forth by Tollefsen, Jansen, and Arras about the capabilities and status of pragmatism in bioethical discussions. Finally, it concludes with cautionary notes about pragmatic bioethics in hopes that pragmatists will learn from their own insights about the human condition and the discipline of bioethics. (shrink)

Gilbert and colleagues point out the discrepancy between the limited empirical data illustrating changes in personality following implantation of deep brain stimulating electrodes and the vast number of conceptual neuroethics papers implying that these changes are widespread, deleterious, and clinically significant. Their findings are reminiscent of C. P. Snow’s essay on the divide between the two cultures of the humanities and the sciences. This division in the literature raises significant ethical concerns surrounding unjustified fear of personality changes in the context (...) of DBS and negative perceptions of clinician-scientists engaged in DBS. These concerns have real world implications for funding future innovative, DBS trials aimed to reduce suffering as well as hampering true interdisciplinary scholarship. We argue that the philosophical tradition of pragmatism and the value it places on empirical inquiry, experiential knowledge, and inter-disciplinary scholarship – reflecting diverse ways of knowing – provides a framework to start to address the important questions Gilbert and colleagues raise. In particular, we highlight the importance of expert clinician knowledge in contributing to the neuroethical questions raised by Gilbert and colleagues. Finally, we provide illustrative examples of some of our interdisciplinary empirical research that demonstrate the iterative cycle of inquiry characteristic of pragmatism in which conceptual neuroethics questions have led to empirical studies whose results then raise additional conceptual questions that give rise to new empirical studies in a way that highlights the contributions of the humanities and the sciences. (shrink)

Gilbert and colleagues point out the discrepancy between the limited empirical data illustrating changes in personality following implantation of deep brain stimulating electrodes and the vast number of conceptual neuroethics papers implying that these changes are widespread, deleterious, and clinically significant. Their findings are reminiscent of C. P. Snow’s essay on the divide between the two cultures of the humanities and the sciences. This division in the literature raises significant ethical concerns surrounding unjustified fear of personality changes in the context (...) of DBS and negative perceptions of clinician-scientists engaged in DBS. These concerns have real world implications for funding future innovative, DBS trials aimed to reduce suffering as well as hampering true interdisciplinary scholarship. We argue that the philosophical tradition of pragmatism and the value it places on empirical inquiry, experiential knowledge, and inter-disciplinary scholarship – reflecting diverse ways of knowing – provides a framework to start to address the important questions Gilbert and colleagues raise. In particular, we highlight the importance of expert clinician knowledge in contributing to the neuroethical questions raised by Gilbert and colleagues. Finally, we provide illustrative examples of some of our interdisciplinary empirical research that demonstrate the iterative cycle of inquiry characteristic of pragmatism in which conceptual neuroethics questions have led to empirical studies whose results then raise additional conceptual questions that give rise to new empirical studies in a way that highlights the contributions of the humanities and the sciences. (shrink)

Gilbert and colleagues point out the discrepancy between the limited empirical data illustrating changes in personality following implantation of deep brain stimulating electrodes and the vast number of conceptual neuroethics papers implying that these changes are widespread, deleterious, and clinically significant. Their findings are reminiscent of C. P. Snow’s essay on the divide between the two cultures of the humanities and the sciences. This division in the literature raises significant ethical concerns surrounding unjustified fear of personality changes in the context (...) of DBS and negative perceptions of clinician-scientists engaged in DBS. These concerns have real world implications for funding future innovative, DBS trials aimed to reduce suffering as well as hampering true interdisciplinary scholarship. We argue that the philosophical tradition of pragmatism and the value it places on empirical inquiry, experiential knowledge, and inter-disciplinary scholarship – reflecting diverse ways of knowing – provides a framework to start to address the important questions Gilbert and colleagues raise. In particular, we highlight the importance of expert clinician knowledge in contributing to the neuroethical questions raised by Gilbert and colleagues. Finally, we provide illustrative examples of some of our interdisciplinary empirical research that demonstrate the iterative cycle of inquiry characteristic of pragmatism in which conceptual neuroethics questions have led to empirical studies whose results then raise additional conceptual questions that give rise to new empirical studies in a way that highlights the contributions of the humanities and the sciences. (shrink)

Headlines in 2019 are inundated with claims about the “digital society,” making sweeping assertions of societal benefits and dangers caused by a range of technologies. This situation would seem an ideal motivation for ethics research, and indeed much research on this topic is published, with more every day. However, ethics researchers may feel a sense of déjà vu, as they recall decades of other heavily promoted technological platforms, from genomics and nanotechnology to machine learning. How should ethics researchers respond to (...) the waves of rhetoric and accompanying academic and policy-oriented research? What makes the digital society significant for ethics research? In this paper, we consider two examples of digital technologies (artificial intelligence and neural technologies), showing the pattern of societal and academic resources dedicated to them. This pattern, we argue, reveals the jointly sociological and ethical character of significance attributed to emerging technologies. By attending to insights from pragmatism and science and technology studies, ethics researchers can better understand how these features of significance affect their work and adjust their methods accordingly. In short, we argue that the significance driving ethics research should be grounded in public engagement, critical analysis of technology’s “vanguard visions,” and in a personal attitude of reflexivity. (shrink)

Recent developments in cognitive science provide compelling leads that need to be interpreted and synthesized within the context of semiotic and biosemiotic principles. To this end, we examine the impact of the mind-body unity on the sorts of choices that an organism is predisposed to making from its Umwelt. In multicellular organisms with brains, the relationship that an organism has with its Umwelt impacts on neural plasticity, the functional specialisations that develop within the brain, and its behaviour. Clinical observations, (...) such as those recorded by Norman Doidge, as well as historical observations from outside the field of semiotics (Plato, Aristotle, Hume) shed further light on this process, and serve to further substantiate our semiotic and biosemiotic paradigm. Our analysis develops a rather limited associationism (with reference to Peirce’s categories) into a more general and robust interpretation that is applicable to all mind-bodies, whether they be neurons, paramecia and amoebae, or humans, cats and dogs. Biosemiotics is a more universal semiotics that takes us beyond the confines of anthropocentrism, because it recognizes the role of the body in shaping Mind. (shrink)

Like other Arab countries, Jordan must find ways of responding to the rapid processes of change affecting many aspects of social life. This is particularly urgent in healthcare, where social and technical change is often manifested in tensions about ethical decision-making in the clinic. To explore the attitudes, beliefs and concerns relating to ethical decision-making among health professionals in Jordanian hospitals, a qualitative study was conducted involving face-to-face interviews with medical personnel in four hospitals in Amman, the capital of Jordan. (...) Data were analysed thematically in relation to a pre-existing set of ethical categories. Interviews were conducted with thirty-eight doctors covering most medical specialities. Five major themes emerged from the interviews: ethical awareness, ethical issues, the impact of religion on ethical decision-making, practical and theoretical resources for ethical decision-making, and challenges. While uncertainty was expressed about some aspects of Western approaches to ethics, participants strongly supported adoption of a range of Western bioethical principles, including cultural and ethical diversity, along with adherence to Islamic religious norms. A range of serious ethical challenges facing the Jordanian health system were identified, covering social, legal, managerial, and technical issues. Ethical decision-making in Jordan is complex, having to accommodate the needs of patients, the opinions of doctors and their families, the views of religious authorities, managerial considerations, and both local norms and international standards. Health professionals struggle with three sets of tensions that emerge out of the struggle between traditional, community-embedded forms of social organization and the demands generated by globalization and the influence of Western culture: the tensions between tradition and modernity, conservatism and pragmatism, and religion and secularism. Doctors in Jordan prefer approaches to ethical decision-making that realize a balance between the extremes, although the exact nature of where that balance should lie remains uncertain. (shrink)

Pragmatism emphasizes practical consequences and empirical explanations rather than introspective contemplations. However, the arguments of pragmatists are not uniform, as shown by the four prominent pragmatists presented in this article. The major difference between them is that Peirce and Haack acknowledge an objective truth, whereas James and Rorty do not. Thus, for a fuller understanding of the pragmatist view of our knowledge, both camps must be consulted. In the nursing field, pragmatism is occasionally referred to as a guiding (...) philosophy. However, the influence of James and Rorty has been greater than that of Peirce and Haack on pragmatists, which may risk leading to a skewed understanding of pragmatism by nursing scholars. Still, the four pragmatists share naturalism, which rejects a metaphysics that defines the nature of knowledge before our enquiry and emphasizes experience and practice. Pragmatic naturalism can help ensure that nursing theory does not deviate from clinical practice. This article also explores the broad adaptability of the ideas of all four pragmatists to philosophical issues in nursing, such as mixed‐methods research, epistemic relativism and realism. By showing that pragmatism can be relevant and stimulating to each of these topics, the article demonstrates that the different approaches to pragmatism can provide more inspiration for nurses and nursing researchers in the future. (shrink)

The singular expertise of family physicians is the ability to manage complexity with pragmatism, both clinically and ethically. Telemedicine raises multiple questions about the nature of the patient‐physician relationship as manifested in clinical encounters. Some of these questions are concerning, underscoring the need to assess whether medical care is better with this new technology—or if it is just different or maybe even worse. It seems clear, however, that, regardless of its limitations, telemedicine is here to stay. The pragmatic (...) complex ethical question, then, is how all of us together—both medical professionals and society at large—will manage it. (shrink)

Although moral case deliberation (MCD) is evaluated positively as a form of clinical ethics support (CES), it has limitations. To address these limitations our research objective was to develop a thematic CES tool. In order to assess the philosophical characteristics of a CES tool based on MCDs, we drew on hermeneutic ethics and pragmatism. We distinguished four core characteristics of a CES tool: (a) focusing on an actual situation that is experienced as morally challenging by the user; (b) (...) stimulating moral inquiry into the moral concepts, questions and routines in the lived experience of the CES tool user; (c) stimulating moral learning by exploring other perspectives; and (d) incorporating contextual details. We provide an example of a CES tool developed for moral dilemmas over client autonomy. Our article ends with some reflections on the normativity of the CES tool, other application areas and the importance of evaluation studies of CES tools. (shrink)

Like other Arab countries, Jordan must find ways of responding to the rapid processes of change affecting many aspects of social life. This is particularly urgent in healthcare, where social and technical change is often manifested in tensions about ethical decision-making in the clinic. To explore the attitudes, beliefs and concerns relating to ethical decision-making among health professionals in Jordanian hospitals, a qualitative study was conducted involving face-to-face interviews with medical personnel in four hospitals in Amman, the capital of Jordan. (...) Data were analysed thematically in relation to a pre-existing set of ethical categories. Interviews were conducted with thirty-eight doctors covering most medical specialities. Five major themes emerged from the interviews: ethical awareness, ethical issues, the impact of religion on ethical decision-making, practical and theoretical resources for ethical decision-making, and challenges. While uncertainty was expressed about some aspects of Western approaches to ethics, participants strongly supported adoption of a range of Western bioethical principles, including cultural and ethical diversity, along with adherence to Islamic religious norms. A range of serious ethical challenges facing the Jordanian health system were identified, covering social, legal, managerial, and technical issues. Ethical decision-making in Jordan is complex, having to accommodate the needs of patients, the opinions of doctors and their families, the views of religious authorities, managerial considerations, and both local norms and international standards. Health professionals struggle with three sets of tensions that emerge out of the struggle between traditional, community-embedded forms of social organization and the demands generated by globalization and the influence of Western culture: the tensions between tradition and modernity, conservatism and pragmatism, and religion and secularism. Doctors in Jordan prefer approaches to ethical decision-making that realize a balance between the extremes, although the exact nature of where that balance should lie remains uncertain. (shrink)

Machine Learning (ML) is on the rise in medicine, promising improved diagnostic, therapeutic and prognostic clinical tools. While these technological innovations are bound to transform health care, they also bring new ethical concerns to the forefront. One particularly elusive challenge regards discriminatory algorithmic judgements based on biases inherent in the training data. A common line of reasoning distinguishes between justified differential treatments that mirror true disparities between socially salient groups, and unjustified biases which do not, leading to misdiagnosis and (...) erroneous treatment. In the curation of training data this strategy runs into severe problems though, since distinguishing between the two can be next to impossible. We thus plead for a pragmatist dealing with algorithmic bias in healthcare environments. By recurring to a recent reformulation of William James’s pragmatist understanding of truth, we recommend that, instead of aiming at a supposedly objective truth, outcome-based therapeutic usefulness should serve as the guiding principle for assessing ML applications in medicine. (shrink)

: Fins, Bacchetta, and Miller's clinical pragmatism has several appealing features: an emphasis on dialogue, a commitment to consensus, a focus on particular individuals rather than persons in general, and a strong interest in the process as well as the product of moral decision making. Nevertheless, for all its protests to the contrary, clinical pragmatism has a tendency to privilege medical facts over nonmedical values, to conflate appropriate medical decisions with right moral decisions, and to conceive (...) problems at the bedside in terms of "getting" patients and families to "go along" with the treatment plans of clinicians. In sum, there is within clinical pragmatism the potential for physicians to take back some of the power they ceded to patients during the height of the patients' rights and autonomy movement. Provided that clinicians guard against the temptation to use clinical pragmatism manipulatively, however, the method promises, more than most other methods of moral problem solving, to help increasingly diverse individuals make good moral decisions about patients' care under conditions of enormous uncertainty. (shrink)

Brain death or determination of death based on the neurological criterion has been an enduring source of controversy in academic and clinical circles. The controversy chiefly concerns how death is defined, and it also bears on the justification of the proposed criteria for death determination and their interpretation. Part of the controversy on brain death and death determination stems from disputed crucial medical facts, but in this paper I formulate another hypothesis about the nature of ongoing controversies. At stake (...) is a misunderstood relationship between, on the one hand, the nature of our lay views about death and, on the other hand, the nature of scientific insights into death and its determination. The misunderstanding of this relationship has partly anchored the controversy and continues to fuel it. Based on a perspective inspired by pragmatism, which stresses the positive contribution of science to ethical and policy debates but also challenges different forms of scientism in science and philosophy found in foundationalist interpretations, I scrutinize three different stances regarding the relationship between lay and scientific perspectives about the definition of death: foundational lay views, foundational expert views, and co-evolving views. I argue that only the latter is sustainable given recent challenges to foundationalist interpretations. (shrink)

Often lurking below the surface of many clinical ethical issues are questions regarding background metaphysical, epistemological, meta-ethical, and political beliefs. In this issue, authors critically examine the effects of background beliefs on conscientious objection, explore ethical issues through the lenses of particular theoretical approaches like pragmatism and intersectional theory, rigorously explore the basic concepts at play within the patient safety movement, offer new theoretical approaches to old problems involving decision making for patients with dementia, explicate and explore the (...) problems and promises of machine learning in medicine, and offer us a non-rights-based argument for the just distribution of healthcare resources. (shrink)

The contribution of healthcare ethics committee (HEC) members to HECs is fundamental. However, little is known about how HEC members view clinical ethics. We report results from a qualitative study of the moral psychology of HEC members. We found that contrary to the existing Kohlberg-based studies, HEC members hold a pragmatic non-expert view of clinical ethics based mainly on respect for persons and a commitment to the patient’s good. In general, HEC members hold deflationary views regarding moral theory. (...) Ethical principles are not abstract foundations but the expression of moral commitments to patients that pre-exist awareness of moral theory. Emotions and proximity to patient sufferance fundamentally shape the views of HEC members on clinical ethics. Further work at the intersection of clinical ethics and qualitative research could bring to the foreground lay perspectives on moral problems that may differ from bioethics expert views. (shrink)

The issue of surrogacy has received a great deal of attention in the West ever since the famous Baby M case in the latter part of the 1980s. Ethicists, psychologists, and legal experts have struggled with the meanings and implications of this practice, especially in its commercial form. In contemporary times, however, the phenomenon of surrogacy has assumed new dimensions as it travels across national borders in the context of globalization. As a transnational phenomenon, it is now marketed as an (...) attractive part of "Reproductive Tourism," for the most part, by various clinics and organizations located in the global south to some of the so-called "First World nations."Until now, most of the philosophical literature. (shrink)

This article discusses the place of sedation in the care of the terminally ill, as used in the practice of palliative care using case studies, clinical pragmatism forms the theoretical framework from which to elucidate the varying part that sedation plays in the overall management of a person facing the end of life. We contend that when used appropriately, sedation is an ethical and legitimate intervention that enhances comfort at the end of life and ought not sedate the (...) person onto “oblivion”. (shrink)

BackgroundClinical ethics support aims to support health care professionals in dealing with ethical issues in clinical practice. Although the prevalence of CES is increasing, it does meet challenges and pressing questions regarding implementation and organization. In this paper we present a specific way of organizing CES, which we have called integrative CES, and argue that this approach meets some of the challenges regarding implementation and organization.MethodsThis integrative approach was developed in an iterative process, combining actual experiences in a case (...) study in which we offered CES to a team that provides transgender health care and reflecting on the theoretical underpinnings of our work stemming from pragmatism, hermeneutics and organizational and educational sciences.ResultsIn this paper we describe five key characteristics of an integrative approach to CES; 1. Positioning CES more within care practices, 2. Involving new perspectives, 3. Creating co-ownership of CES, 4. Paying attention to follow up, and 5. Developing innovative CES activities through an emerging design.ConclusionsIn the discussion we compare this approach to the integrated approach to CES developed in the US and the hub and spokes strategy developed in Canada. Furthermore, we reflect on how an integrative approach to CES can help to handle some of the challenges of current CES. (shrink)

The cognitive basis of utterance interpretation is an area that continues to provoke intense theoretical debate among pragmatists. That utterance interpretation involves some type of mind-reading or theory of mind (ToM) is indisputable. However, theorists are divided on the exact nature of this ToM-based mechanism. In this paper, it is argued that the only type of ToM-based mechanism that can adequately represent the cognitive basis of utterance interpretation is one which reflects the rational, intentional, holistic character of interpretation. Such a (...) ToM-based mechanism is supported on conceptual and empirical grounds. Empirical support for this view derives from the study of children and adults with pragmatic disorders. Specifically, three types of clinical case are considered. In the first case, evidence is advanced which indicates that individuals with pragmatic disorders exhibit deficits in reasoning and the use of inferences. These deficits compromise the ability of children and adults with pragmatic disorders to comply with the rational dimension of utterance interpretation. In the second case, evidence is presented which suggests that subjects with pragmatic disorders struggle with the intentional dimension of utterance interpretation. This dimension extends beyond the recognition of communicative intentions to include the attribution of a range of cognitive and affective mental states that play a role in utterance interpretation. In the third case, evidence is presented that children and adults with pragmatic disorders struggle with the holistic character of utterance interpretation. This serves to distort the contexts in which utterances are processed for their implicated meanings. The paper concludes with some thoughts about the role of theorizing in relation to utterance interpretation. (shrink)

This article discusses an approach to translational bioethics (TB) that is concerned with the adaptation—or ‘translation’—of concepts, theories and methods from bioethics to practical contexts, in order to support ‘non-bioethicists’, such as researchers and healthcare practitioners, in dealing with their ethical issues themselves. Specifically, it goes into the participatory development of clinical ethics support (CES) instruments that respond to the needs and wishes of healthcare practitioners and that are tailored to the specific care contexts in which they are to (...) be used. The theoretical underpinnings of this participatory approach to TB are found in hermeneutic ethics and pragmatism. As an example, the development of CURA, a low-threshold CES instrument for healthcare professionals in palliative care, is discussed. From this example, it becomes clear that TB is a two-way street. Practice may be improved by means of CES that is effectively tailored to specific end users and care contexts. The other way around, ethical theory may be enriched by means of the insights gained from engaging with practice in developing CES in a process of co-creation. TB is also a two-way street in the sense that it requires collaboration and commitment of both bioethicists and practitioners, who engage in a process of mutual learning. However, substantial challenges remain. For instance, is there a limit to the extent to which a method of moral reasoning can be adapted in order to meet the constraints of a given healthcare setting? Who is to decide, the bioethicist or the practitioners? (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Toward a Non-Cartesian Psychotherapeutic Framework: Radical Pragmatism as an AlternativeLouis S. Berger (bio)AbstractPostmodern criticism has identified important impoverishments that necessarily follow from the use of Cartesian frameworks. This criticism is reviewed and its implications for psychotherapy are explored in a psychoanalytic context. The ubiquitous presence of Cartesianism (equivalently, representationism) in psychoanalytic frameworks—even in some that are considered postmodern—is demonstrated and criticized. The postmodern convergence on praxis as a (...) desirable alternative to Cartesianism is reported, and its relevance for psychoanalysis is considered. The severe conceptual difficulties entailed in formulating such an alternative are discussed, as are those difficulties that would be encountered were psychoanalysis to attempt the shift from explanatory mental science to praxis. The principal psychoanalytic problematics explored are: the paradoxical relationships between theory and therapeutic technique; the therapeutic action; and validation of clinical practices. Initial, nontraditional suggestions for addressing these problems are offered.Keywordspsychoanalysis, therapeutic action, representation, state space, praxis, hermeneutics, Descartes, Heidegger, Wittgenstein“But the inability to bring one’s subject under conceptual control, fixing it propositionally, is not the end of thinking; on the contrary, it were better to say that the breakdown of concepts and the failure of words is an opening that takes us out of the realm where representation and calculation are all that matter to thinking.... [T]his is what happens in the Socratic dialogue where the negativity in which one ends up at a loss for words is at the same time that which sets thinking free.”Bruns 1989, 9“To evolve theory as though our methods and processes of study were essentially the same, or could be the same, as those of other sciences, or could be disregarded when it comes to theory, implies a view of reality that is no longer tenable, least of all in that ambiguous area which we call psychic reality. Nevertheless, all of us are still more or less captives of an erroneous understanding of objectivity and objective reality....”Loewald 1970, 45 [End Page 169]CartesianismCartesianism still underlies and dominates much of today’s thought. It is the label for a network of interrelated ideas and themes:the ontological duality of mind and body; the subjective individualism implicit in the ultimate appeal to direct personal verification; the method of universal doubt which was supposed to lead us to indubitable truths; the doctrine that language and signs are an external disguise for thought; the doctrine that vagueness is unreal and that the philosophic endeavor is one of knowing clearly and distinctly a completely determinate reality; and most fundamentally, the doctrine that we can break out of the miasma of our language or system of signs and have direct intuitive knowledge of objects. (Bernstein 1971, 5–6)[The Cartesian assumptions] constitute a picture of science and the world somewhat as follows: there is an external world which can in principle be exhaustively described in scientific language. The scientist, as both observer and language-user, can capture the external facts of the world in propositions that are true if they correspond to the facts and false if they do not. Science is ideally a linguistic system in which true propositions are in one-to-one relation to facts, including facts that are not directly observed because they involve hidden entities or properties, or past events or far distant events. These hidden events are described in theories, and theories can be inferred from observation, that is, the hidden explanatory mechanism of the world can be discovered from what is open to observation. Man as scientist is regarded as standing apart from the world and able to experiment and theorize about it objectively and dispassionately.(Hesse 1980, vii)Hesse goes on to say that “almost every assumption underlying this account has been subjected to damaging criticism,” a view echoed by others: “Most contemporary philosophers have been in revolt against the Cartesian framework” (Bernstein 1971, 5); “A rejection of the Cartesian view is a central theme for both of the giants of twentieth-century philosophy, Heidegger and Wittgenstein” (Sass 1992, 444n 77); and “The notion of alternative conceptual frameworks has been a commonplace of our culture since Hegel” (Rorty 1982, 3).These criticisms arise... (shrink)

Psychologists and neuroscientists often struggle to integrate findings in their respective domains, a problem due partly to implicitly and explicitly held philosophical positions on issues of reduction and autonomy across these domains. The present article reviews how reduction and autonomy have been used in philosophical arguments regarding how macro-scale findings relate to micro-scale findings across various scientific disciplines. The present article demonstrates how macro findings are indispensable to explanations of phenomena of interest by (a) providing information regarding higher levels of (...) organization in mechanisms, (b) including information not contained within certain micro explanations that (c) provides more general and stable causal explanations relative to micro explanations in certain situations. The purpose of presenting these analyses and recommendations is to disabuse psychologists and neuroscientists of pervasive assumptions that psychology is reducible to biology and that lower level phenomena (molecular) should be prioritized as somehow more explanatory than higher level phenomena (behavioral). The article concludes with 3 hypothetical scenarios from clinical psychology and psychiatry illustrating this critique and providing a pragmatic approach to clarify the relative roles, and importance, of biological and psychological data in service of general and stable explanations that are tailored to the kind of intervention desired. (shrink)

In this 25-year retrospective on the state of clinical ethics, and the anniversary of the founding of The Journal of Clinical Ethics, the author comments on the state of the field. He argues that the language of bioethics, as used in practice, seems dated and out of touch with a clinical reality marked by emerging technologies and the advent of new fields like palliative medicine.Reflecting on his experiences as a clinician and clinical ethicist, the author worries (...) about the emergence of a shallow bioethics, which is the product of a lingua franca. This linguistic amalgam is a weak composite in which concepts are simplified and nuance is overlooked, leading to interpretative errors. The best of ethical reasoning or clinical decision making can be lost in translation. Instead of the well-worn arguments over the relative worth of modes of ethical analysis, like principlism or pragmatism, the author argues that the emphasis should be on the cultivation of the “linguistic” skills necessary for translating any critical method in order to replace the lingua franca of clinical ethics with a more substantial discourse worthy of the complexity of the clinic. Through the emergence of such a shared language, at the interface of the sciences and the humanities, this multidisciplinary field can evolve towards more authentic interdisciplinarity. (shrink)

This article gives an overview of the development, remit, structure and working of the British Medical Association's Medical Ethics Committee. It situates it within a brief history of the Association and gives examples of current work.

The objective of this article is to analyse and compare four methods of ethical case deliberation. These include Clinical Pragmatism, The Nijmegen Method of ethical case deliberation, Hermeneutic dialogue, and Socratic dialogue. The origin of each method will be briefly sketched. Furthermore, the methods as well as the related protocols will be presented. Each method will then be evaluated against the background of those situations in which it is being used. The article aims to show that there is (...) not one ideal method of ethical case deliberation, which fits to all possible kinds of moral problems. Rather, as each of the methods highlights a limited number of morally relevant aspects, each method has its strengths and weaknesses as well. These strengths and weaknesses should be evaluated in relation to different types of situations, for instance moral problems in treatment decisions, moral uneasiness and residue, and the like. The suggestion arrived at on the basis of the findings of this paper is a reasonable methodological plurality. This means that a method can be chosen depending on the type of moral problem to be deliberated upon. At the same time it means, that by means of a method, deliberation should be facilitated. (shrink)

American Academy of Pediatrics (AAP) and American College of Medical Genetics (ACMG) recently provided two recommendations about predictive genetic testing of children. The Clinical Sequencing Exploratory Research Consortium's Pediatrics Working Group compared these recommendations, focusing on operational and ethical issues specific to decision making for children. Content analysis of the statements addresses two issues: (1) how these recommendations characterize and analyze locus of decision making, as well as the risks and benefits of testing, and (2) whether the guidelines conflict (...) or come to different but compatible conclusions because they consider different testing scenarios. These statements differ in ethically significant ways. AAP/ACMG analyzes risks and benefits using best interests of the child and recommends that, absent ameliorative interventions available during childhood, clinicians should generally decline to order testing. Parents authorize focused tests. ACMG analyzes risks and benefits using the interests of the child and other family members and recommends that sequencing results be examined for additional variants that can lead to ameliorative interventions, regardless of age, which laboratories should report to clinicians who should contextualize the results. Parents must accept additional analysis. The ethical arguments in these statements appear to be in tension with each other. (shrink)

Research question and aimClinical Ethics Committees (CECs) aim to support healthcare professionals (HPs) and healthcare organizations to deal with the ethical issues of clinical practice. In 2020,...