If medical complicity is understood as compliance with a directive to act against the professional's best medical judgment, the question arises whether it can ever be justified. This paper will trace the contours of what would legitimate a directive to act against a professional's best medical judgment (and in possible contravention of her oath) using Joseph Raz's service conception of authority. The service conception is useful for basing the legitimacy of authoritative directives on the ability of (...) the putative authority to enable subjects to comply better with reasons that already apply to them. Hence, the service conception bases the legitimacy of practical authority on a certain kind of greater knowledge or expertise. This helps to focus the conundrum regarding complicity on the clash of expertise between the medical expert and the governing body tasked with coordinating behaviour and otherwise devising rules for the social good. The ethical dilemma presented by a hypothetically legitimate directive to act against a professional's best medical judgment also serves to highlight the moral dimension of one's duty to obey a legitimate authority. (shrink)

Gebhardt in his brief report1 pleads for patient organisations to establish databanks on medical complications. Given the references and the lack of argumentation, there is substantial danger of misinterpretation of the current situation, which in turn may frustrate the process of increased transparency. We would therefore like to respond to this by giving background information and reasons for some of the choices that were made with respect to the registry of complications mentioned by Gebhardt.First, a distinction needs to be (...) made between an error and an adverse outcome, which are often confused. From Gebhardt’s reference to the journalist’s article which discusses the same registry of adverse outcomes, but with the title referring to errors, both Gebhardt and the journalist think errors and adverse outcomes are the same thing. However, an error refers to the process in which something has gone wrong, a substandard performance, regardless of the outcome. It has been explained by others that such a judgement may have a degree of subjectivity.2 An adverse outcome refers to the outcome which is unwanted but does not necessarily imply that an error has been made. This is why the term “adverse outcomes” is used rather than …. (shrink)

This is the account of an ongoing appeal initiated in 2009 by 725 doctors from 43 countries concerning medical complicity with torture in Israel. It has been underpinned by a voluminous and still accumulating evidence base from reputable international and regional human rights organisations, quoted below, and has spanned the terms of office of four World Medical Association presidencies and two UN special rapporteurs on torture. This campaign has been a litmus test of whether international medical (...) codes regarding doctors and torture actually matter, and are applied rigorously and even-handededly, particularly when compelling evidence incriminates a WMA member association. Our findings in the case of Israel suggest that this is not true, and that impunity largely operates. The WMA seems in partisan violation of its mandate to be the official international watchdog on the ethical behaviour of doctors. And as the IMA case demonstrates, by their inaction national medical associations or other regulatory bodies appear to function at base as buttresses and shields of the state. All data relevant to the study are included in the article. (shrink)

In 1998 a lawyer working for the Dutch consumer organisation, Consumentenbond, suggested that hospitals, like hotels, should be classified according to the quality of service they provide.1 For the establishment of such a register it would of course be necessary to determine various parameters, including the incidence of complications occurring in each hospital. It did not take long before this proposal was rejected by van Herk2 on the grounds that it would promote defensive medicine, which would not improve the ….

Paragraph 12 of the revised International Code of Medical Ethics (ICoME) states that ‘the physician should strive to practise medicine in ways that are environmentally sustainable with a view to minimising environmental health risks to current and future generations.’ 1 This emphasis on environmental sustainability is in line with popular discourse as well growing scholarly attention in medical ethics for healthcare’s contribution to climate change. Recent research analyses, for instance, the ‘greening’ of informed consent and related bioethical principles. (...) 2 3 It is unclear what the duty of practising sustainable healthcare means at the level of doctor–patient interaction. Parsa-Parsi _et al_ flag the potential conflict in the ICoME’s provisions if ‘the actions of physicians are influenced by environmental considerations to the detriment of patients’ (p. 2), noting that the ICoME does not provide a handhold to improve understanding of such tensions. The code ‘does not... (shrink)

Imprisonment may sometimes be a justified form of punishment. Yet the U.S. carceral system suffers from appalling problems of justice—in who is put into prisons, in how imprisoned people are treated, and in downstream personal and community health impacts. Medical personnel working in prisons and jails take on risky work for highly vulnerable and underserved patients. They are to be lauded for their professional commitments. Yet at the same time, prison care undercuts the ability of medical personnel to (...) uphold their own professional standards and sometimes fails in even basic health protection. Doctors in prisons are stuck between their commitment to vulnerable patients and complicity in a system that requires their participation to uphold its constitutionality. Medical ethics is frayed in prisons, and the problem deserves our attention. (shrink)

Shortly before and during the Second World War, Japanese doctors and medical researchers conducted large-scale human experiments in occupied China that were at least as gruesome as those conducted by Nazi doctors. Japan never officially acknowledged the occurrence of the experiments, never tried any of the perpetrators, and never provided compensation to the victims or issued an apology. Building on work by Jing-Bao Nie, this article argues that the U.S. government is heavily complicit in this grave injustice, and should (...) respond in an appropriate way in order to reduce this complicity, as well as to avoid complicity in future unethical medical experiments. It also calls on other U.S. institutions, in particular the Presidential Commission for the Study of Bioethical Issues, to urge the government to respond, or to at least inform the public and initiate a debate about this dark page of American and Japanese history. (shrink)

This essay reviews and defines avoidable medical error, malpractice and complication. The relevant ethical principles pertaining to unanticipated medical outcomes are identified. In light of these principles I critically review the moral culpability of the agents in each circumstance and the resulting obligations to patients, their families, and the health care system in general. While I touch on some legal implications, a full discussion of legal obligations and liability issues is beyond the scope of this paper.

Drawing on philosophy, law and political science, and on a wealth of practical experience delivering emergency medical services in conflict-ridden settings, Lepora and Goodin untangle the complexities surrounding compromise and complicity.

Medical complicity in torture is prohibited by international law and codes of professional ethics. But in the many countries in which torture is common, doctors frequently are expected to assist unethical acts that they are unable to prevent. Sometimes these doctors face a dilemma: they are asked to provide diagnoses or treatments that respond to genuine health needs but that also make further torture more likely or more effective. The duty to avoid complicity in torture then comes (...) into conflict with the doctor’s duty to care for patients. Sometimes the right thing for a doctor to do requires complicity in torture. Whether this is the case depends on: the expected consequences of the doctor’s actions; the wishes of the patient; and the extent of the doctor’s complicity with wrongdoing. Medical associations can support physicians who face this dilemma while maintaining a commitment to clear principles denouncing torture. (shrink)

To monopolize the scientific data gained by Japanese physicians and researchers from vivisections and other barbarous experiments performed on living humans in biological warfare programs such as Unit 731, immediately after the war the United States government secretly granted those involved immunity from war crimes prosecution, withdrew vital information from the International Military Tribunal for the Far East, and publicly denounced otherwise irrefutable evidence from other sources such as the Russian Khabarovsk trial. Acting in “the national interest” and for the (...) security of the US, authorities in the US tramped justice and morality, and engaged in what the English common law tradition clearly defines as “complicity after the fact.” To repair this historical injustice, the US government should issue an official apology and offer appropriate compensation for having covered up Japanese medical war crimes for six decades. To help prevent similar acts of aiding principal offender in the future, international declarations or codes of human rights and medical ethics should include a clause banning any kind of complicity in any unethical medicine—whether before or after the fact—by any state or group for whatever reasons. (shrink)

Objective: To study the preferences of patients for information related to elective procedures.Methods: A survey was carried out using a sample of 187 women. The majority of whom were on a low-income, who obtained obstetric or gynaecological services at St Joseph Regional Medical Center in Milwaukee, Wisconsin, while they were in a waiting room.Results: Many of the complications, including those that are uncommon and less serious, were considered to be relevant to the medical decisions of most patients. Average (...) seriousness ratings associated with complications of various elective procedures were in the range of moderate to high. A frequency of complications of 1:100 or higher would factor into most women’s elective treatment decisions. Women indicated a preference for receiving as much or more information pertaining to complications associated with particular elective obstetric or gynaecological procedures as other elective procedures.Conclusion: Most women wish to be informed of risks and treatment alternatives, rate many complications as serious, and are likely to use information provided to make elective treatment decisions. (shrink)

Background -/- Innovative neurosurgical treatments present a number of known risks, the natures and probabilities of which can be adequately communicated to patients via the standard procedures governing obtaining informed consent. However, due to their novelty, these treatments also come with unknown risks, which require an augmented approach to obtaining informed consent. -/- Objective -/- This paper aims to discuss and provide concrete procedural guidance on the ethical issues raised by serious unexpected complications of novel deep brain stimulation treatments. -/- (...) Approach -/- We illustrate our analysis using a case study of the unexpected development of recurrent stereotyped events in patients following the use of deep brain stimulation (DBS) to treat severe chronic pain. Examining these unexpected complications in light of medical ethical principles, we argue that serious complications of novel DBS treatments do not necessarily make it unethical to offer the intervention to eligible patients. However, the difficulty the clinician faces in determining whether the intervention is in the patient's best interests generates reasons to take extra steps to promote the autonomous decision making of these patients. -/- Conclusion and recommendations -/- We conclude with clinical recommendations, including details of an augmented consent process for novel DBS treatment. (shrink)

Recently, there have been a number of lawsuits in the United States in which families objected to performance of apnoea testing for determination of brain death. The courts reached conflicting determinations in these cases. We discuss the medicolegal complications associated with apnoea testing that are highlighted by these cases and our position that the decision to perform apnoea testing should be made by clinicians, not families, judges, or juries.

Apology is arguably the central act of the reparative work required after wrongdoing. Claudia Card’s (1940-2015) analysis of complicity in collectively perpetrated evils moves one to ask whether apology ought to be requested of persons culpably complicit in institutional evils. To better appreciate the benefits of and barriers to apologies offered by culpably complicit wrongdoers, this article examines doctors’ complicity in a practice that meets Card’s definition of an evil, namely, the non-medically necessary, nonconsensual “normalizing” interventions performed on (...) babies born with intersex anatomies. It argues that in this instance, the complicity of doctors is culpable on Card’s terms, and that their culpable complicity grounds rightful demands for them to apologize. (shrink)

Cooperation in wrongdoing is an everyday matter for all of us, though we need to discern when such cooperation is morally excluded as constituting formal cooperation, as opposed to material (unintended) cooperation whether justified or otherwise. In this paper, I offer examples of formal cooperation such as referral of patients for certain procedures where the cooperating doctor intends an intrinsically wrongful plan of action on the part of the patient and a medical colleague. I also consider a case of (...) formal cooperation where the cooperator intends a choice on the part of another person that is not intrinsically wrong, but wrong in the circumstances because the person believes it will cause serious uncompensated harm. (shrink)

Complicity consists in one person contributing to someone else's wrongdoing. But there is a diverse cluster ways of being involved in another’s wrongdoing. For a ‘diagnosis by exclusion’, we first fix the meaning of complicity in contrast to that with which it is often wrongly conflated. Literally cooperating in wrongdoing with others, for instance, is more than complicity. Each and every cooperator is actually a co-principal in the wrong jointly committed; and each bears the full responsibility, shared (...) with all co-principals, for the outcomes of that wrongdoing. Other sorts of involvement with wrongs committed by others amount to less than complicity because the involvement there is causally inert and hence does not actually contribute to the other’s wrongdoing at all. Pardoning wrongs wholly in the past may be like that. So too may be some cases of wilfully overlooking wrongs that others commit under one's very nose. Complicity is a very precise way of being involved in wrongdoing. Complicity consists in a secondary contribution of a causal (or potentially causal) sort to a wrong committed by someone else. That ‘contribution factor’ can be graded on many axes, in terms of how proximate, reversible or frequent the contribution was. Other things being equal, one is more complicit the …. (shrink)

This book explores the concept of and cases of complicity in an interdisciplinary context. It in part covers cases of direct complicity, where an agent or set of agents facilitates an identifiable act of wrongdoing. The book also draws attention to the manner in which agents become complicit in the reproduction of wider practices of wrongdoing. It goes on to explore the notion of complicity through a series of cases emerging from a variety of academic disciplines and (...) professional practice, including the complicity of politicians, medical practitioners, and the wider public in forms of state violence, protest movements and secret‐keeping. (shrink)

The cautions of our commentators are all well taken, and we are grateful for them. When we say that physicians should respect the wishes of their patients for medical treatment, even if that would make them complicit in torture being inflicted on their patients, Henry Shue reminds us that that assumes that the patients undergoing torture retain minimally adequate decision-making capacity. Insofar as the torture aims at, and succeeds in, producing ‘regression to an infantile state’, patients who are victims (...) of such torture would likely fail standard tests of that. True though that observation may be, it leaves us with no solution to our initial problem. Were we to assume that the victim does not have decision-making capacity, and reject his request for treatment on that basis, we would victimise him further by abandoning him to his fate leaving him with no alternatives and no support whatsoever. Furthermore, in regimes of psychologically sophisticated torture of the sort Shue discusses, there may be an even stronger reason for a physician to comply with a victim-patient's request for her to treat him. For a physician to refuse a would-be patient's request for treatment, on grounds he lacks adequate decision-making capacity, might further reinforce the infantilising message of the torturers. If so, that would amount to complicity in his torture, insofar as it furthers the wrong done by perpetrators. In the absence of victim's consent, doctors typically use criteria like family's advice, patient's best interest or heuristics identifying what most patients would prefer in similar situations. None of these options is available to doctors caring for torture survivors during the course of their torture, however. The first is obviously not. The second is not because the physician cannot be altogether sure what is in her victim-patient's best interests, given that treating him will …. (shrink)

One of the great merits ofOn Complicity and Compromiseis that it wades into specific swamps where ordinary theorists fear to slog. It is persuasive that in general it can be right sometimes to be complicit in wrongdoing by others through causally contributing to the wrongdoing, but not sharing its purpose, if by being involved one can reasonably expect to lessen the extent of the wrong that would otherwise be suffered by the victims. I focus on whether the book's general (...) thesis is applicable to torture, which depends on what torture and the torture situation are in fact like. I focus on the case to which the chapter several times refers: the innovative CIA paradigm of torture. First, to the extent that the paradigm, which is predominantly mental, or psychological, torture succeeds in its goal of producing regression to a compliant state, the physician would be unable to rely on the torture victim's expressions of preferences or interests as authentically his own. Second, since disorientation plays such a large role in the CIA's style of torture (adopted at Guantanamo by the military), the authorities would refuse to allow a stable relationship to be built up with any one doctor by any victim, making comprehension of the victim's preferences difficult. Third, even if the doctor could somehow judge what the victim's genuine interests were, the control of the situation is much too totalistic to allow the physician any action independent of what the torture regime requires. (shrink)

This book explores the concept of and cases of complicity in an interdisciplinary context. It in part covers cases of direct complicity, where an agent or set of agents facilitates an identifiable act of wrongdoing. The book also draws attention to the manner in which agents become complicit in the reproduction of wider practices of wrongdoing. It goes on to explore the notion of complicity through a series of cases emerging from a variety of academic disciplines and (...) professional practice, including the complicity of politicians, medical practitioners, and the wider public in forms of state violence, protest movements and secret‐keeping. (shrink)

Chasing Medical Miracles" is the first book to give readers a behind-the-scenes look at the complicated world of clinical trials, revealing how a multibillion-dollar industry of private companies conducting them with little oversight has taken root and quietly become a major part of the American medical establishment.

Medical professionals providing humanitarian aid in times of crisis face complicated ethical and clinical challenges. Today, humanitarian aid is given in accordance with existing guidelines developed by international humanitarian organizations and defined by international law. This paper considers the ethical aspects and frameworks of an atypical humanitarian project, namely one that provides medical support through an Israeli civilian hospital to Syrian Civil War casualties. We explore new ethical questions in this unique situation that pose a serious challenge for (...) the medical community and conventional ethical norms, a challenge Israeli medical staff meet on a daily basis. Before discussing the ethical challenges, we give a description of the project and its unique status. (shrink)

This volume of original work comprises a modest challenge, sometimes direct, sometimes implicit, to the mainstream Anglo-American conception of the discipline of medical ethics. It does so not by trying to fill the gaps with exotic minority interest topics, but by re-examining some of the fundamental assumptions of the familiar philosophical arguments, and some of the basic situations that generate the issues. The most important such situation is the encounter between the doctor and the suffering patient, which forms one (...) of the themes of the book. The authors show that concepts such as the body, suffering and consent - and the role such concepts play within patients' lives - are much more complicated than the Anglo-American mainstream appreciates. Some of these concepts have been discussed with subtlety by Continental philosophers, and a secondary purpose of the volume is to apply their ideas to medical ethics. Designed for upper-level undergraduates and graduate students with some philosophical background in ethics, Reconceiving Medical Ethics opens up new avenues for discussion in this ever-developing field. (shrink)

Medicine is facing wide-ranging challenges concerning the so-called medically unexplained disorders. The epidemiology is confusing, different medical specialties claim ownership of their unexplained territory and the unexplained conditions are themselves promoted through a highly complicated and sophisticated use of language. Confronting the outcome, i.e. numerous medical acronyms, we reflect upon principles of systematizing, contextual and social considerations and ways of thinking about these phenomena. Finally we address what we consider to be crucial dimensions concerning the landscape of unexplained (...) “matters”; fatigued being, pain-full being and dys-ordered being, all expressive momentums of an aesthetic of resistance. (shrink)

Ghostwriting in its various forms has received critical scrutiny from medical ethicists, journal editors, and science studies scholars trying to explain where ghostwriting goes wrong and ascertain how to counter it. Recent analyses have characterized ghostwriting as plagiarism or fraud, and have urged that it be deterred through stricter compliance with journal submission requirements, conflict of interest disclosures, author-institutional censure, legal remedies, and journals' refusal to publish commercially sponsored articles. As a supplement to such efforts, this paper offers a (...) critical assessment of medical ghostwriting as contrary to good patient care, on the grounds that it contradicts established general principles guiding clinical ethics. Specifically, I argue that ghostwriting undermines trust relationships between authors and their readers, and between these readers and their trusting patients, and in so doing contradicts the duty of respect for patient autonomy by obstructing informed consent. For this reason, complicity in ghostwriting practices should be understood as a violation of the professional ethical duties of physicians and other healthcare workers. (shrink)

Torture is unethical and usually counterproductive. It is prohibited by international and national laws. Yet it persists: according to Amnesty International, torture is widespread in more than a third of countries. Physicians and other medical professionals are frequently asked to assist with torture. -/- Medical complicity in torture, like other forms of involvement, is prohibited both by international law and by codes of professional ethics. However, when the victims of torture are also patients in need of treatment, (...) doctors can find themselves torn. To accede to the requests of the torturers may entail assisting or condoning terrible acts. But to refuse care to someone in medical need may seem like abandoning a patient and thereby fail to exhibit the beneficence expected of physicians. -/- In this paper, we argue that this dilemma is real and that sometimes the right thing for a doctor to do, overall, is to be complicit in torture. Though complicity in a wrongful act is itself prima facie wrongful, this judgment may be outweighed by other factors. We propose three criteria for analyzing how those factors apply to particular cases of medical complicity in torture. (shrink)

Complicity as toleration of wrong is deeply rooted in Western language and narratives. It is based on assumptions about the self, our relationship to the world and personal accountability that differ from the Common Law's and moral theology's standard doctrines. How we blame others for tolerating wrong depends upon the moral force of public discourse and upon the meaning of censure as exhortation. Censure as blame is usually retrospective, while censure as exhortation is forward-looking and stresses moral maturity and (...) flourishing. (shrink)

Cooperation in wrongdoing is an everyday matter for all of us, though we need to discern when such cooperation is morally excluded as constituting formal cooperation, as opposed to material (unintended) cooperation whether justified or otherwise. In this paper, I offer examples of formal cooperation such as referral of patients for certain procedures where the cooperating doctor intends an intrinsically wrongful plan of action on the part of the patient and a medical colleague. I also consider a case of (...) formal cooperation where the cooperator intends a choice on the part of another person that is not intrinsically wrong, but wrong in the circumstances because the person believes it will cause serious uncompensated harm. (shrink)

One limitation of medical ethics modeled on ideal moral theory is its relative silence on the aftermath of medical error: not just on the recognition and avoidance of malpractice, wrongdoing, or other such failures of medical ethics, but on how to respond given medical wrongdoing. Ideally, we would never do each other wrong; but given that inevitably we do, as fallible, imperfect agents we require non-ideal ethical guidance. For such non-ideal contexts, Nancy Berlinger’s analysis of (...) class='Hi'>medical error and Margaret Walker’s account of moral repair present powerful hermeneutical and practical tools toward understanding and enacting what is needed to restore relationships, trust, and moral standing in the aftermath of medical error and wrongdoing. Where restitutive justice aims to make injured parties whole and retributive justice to mete out punishment, reparative justice, as Walker describes it, “involves the restoration or reconstruction of confidence, trust, and hope in the reality of shared moral standards and of our reliability in meeting and enforcing them.” Medical moral repair is not without its challenges, however, in both theory and practice; the standard ways of holding medical professionals and institutions responsible for medical mistakes or malpractice function retributively and restitutively, either impeding or giving benign inattention to patient-practitioner relationship repair. This paper argues for the value of medical moral repair, while considering some complications of extending and synthesizing Berlinger’s and Walker’s respective accounts on medical error and moral repair. (shrink)

Apology is arguably the central act of the reparative work required after wrongdoing. The analysis by Claudia Card of complicity in collectively perpetrated evils moves one to ask whether apology ought to be requested of persons culpably complicit in institutional evils. To better appreciate the benefits of and barriers to apologies offered by culpably complicit wrongdoers, this article examines doctors’ complicity in a practice that meets Card's definition of an evil, namely, the non-medically necessary, nonconsensual “normalizing” interventions performed (...) on babies born with intersex anatomies. It argues that in this instance the complicity of doctors is culpable on Card's terms, and that their culpable complicity grounds rightful demands for them to apologize. (shrink)

The UN Convention against Torture defines torture as “any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person” by someone acting in an official capacity for purposes such as obtaining a confession or punishing or intimidating that person.1 It is unethical for healthcare professionals to participate in torture, including any use of medical knowledge or skill to facilitate torture or allow it to continue, or to be present during torture.2-7 Yet (...) class='Hi'>medical participation in torture has taken place throughout the world and was a prominent feature of the US interrogation practice in military and Central Intelligence Agency (CIA) detention facilities in the years after the attacks of 11 September 2001.8-11 Little attention has been paid, however, to how a regime of torture affects the ability of health professionals to meet their obligations regarding routine clinical care for detainees. -/- The 2016 release of previously classified portions of guideline from the CIA regarding medical practice in its secret detention facilities sheds light on that question. These show that the CIA instructed healthcare professions to subordinate their fundamental ethical obligations regarding professional standards of care to further the objectives of the torturers. (shrink)

It has been argued that some unremitting forms of grief, commonly labeled as complicated grief, pose a serious threat to the well-being and life of the mourner and may require clinical attention (Lichtenthal et al., 2004; Zisook et al., 2010). One central issue in this debate is whether and how we could draw a divide between uncomplicated and complicated grief to avoid, on the one hand, the medicalization of appropriate grief responses, and on the other hand, to provide help to (...) those who suffer from complicated grief. In this paper I show that a phenomenological approach can help with this task. First, I present Ratcliffe’s (2017) and Fuchs’ (2018) phenomenological analyses of typical grief responses. Then I argue that a promising way to draw a divide between uncomplicated and complicated grief is to look for the presence of reintegration processes geared towards establishing a new relation with the deceased. (shrink)

After his father passed away, James Nolan's mother gave him a box of materials that his dad had kept private. To Nolan's complete surprise, the contents revealed the role his grandfather had played as a doctor in the Manhattan Project. Dr. Nolan, it turned out, had been a significant figure. A talented radiologist, he cared for the scientists on the Project, helped organize the safety and evacuation plans for the Trinity Test at Alamogordo, escorted the "Little Boy" bomb from Los (...) Alamos to Japan, and was one of the first Americans to enter the irradiated ruins of Hiroshima and Nagasaki. The documents set Nolan on a hunt for more information about his grandfather and more generally about the conflicted role that medical personnel played in the early years of atomic testing. The result is a compelling history of the dawn of the atomic age as seen through the eyes of men and women torn between their duty and desire to win the war and their oath to protect life. Nolan follows his grandfather and medical colleagues as they seek to maximize safety while serving leaders determined to minimize delays, and as they consider the ethics of ending the deadliest of all wars with the most lethal of all weapons. The result, Nolan shows, was a very human pattern of caution, co-optation, and complicity. A vital and vivid account of a largely unknown chapter in atomic history, Delivering Little Boy is also a profound meditation on the professional and moral dilemmas that ordinary people face in extraordinary times. (shrink)

A difficult task for politicians who want to fight injustice without doing wrong themselves is identifying where it is permissible to vote for and/or promote so-called “imperfect laws” which somewhat improve existing unjust legal situations but leave closely related injustices intact. One approach is to seek a “selective ban” on some injustices which are politically preventable. This approach is acceptable at least in principle, unlike the approach of “regulation”—i.e., permitting or instructing others to do, or prepare to do, the unjust (...) act in specified ways. The latter necessarily involves us in formal cooperation with evil: wrongly intending that others choose wrongly; for example, that abortion doctors deliberately prepare for abortion, albeit in ways that make an abortion less risky or less likely. In relation to parental consent or parental notification, and to pregnancy counselling and provision of information to pregnant women, while there may be ways of requiring these without complicity in others’ wrongful choices, this is at least more difficult than is often recognised. There can also be problems of principle in seeking consensus with fellow-legislators who may positively intend and even promote the continuation of remaining injustices even as they collaborate with more consistent reformers in passing laws which mitigate injustice overall. (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)

Medical diagnosis has been traditionally recognized as a privileged field of application for so called probabilistic induction. Consequently, the Bayesian theorem, which mathematically formalizes this form of inference, has been seen as the most adequate tool for quantifying the uncertainty surrounding the diagnosis by providing probabilities of different diagnostic hypotheses, given symptomatic or laboratory data. On the other side, it has also been remarked that differential diagnosis rather works by exclusion, e.g. by modus tollens, i.e. deductively. By drawing on (...) a case history, this paper aims at clarifying some points on the issue. Namely: 1) Medical diagnosis does not represent, strictly speaking, a form of induction, but a type, of what in Peircean terms should be called ‘abduction’ (identifying a case as the token of a specific type); 2) in performing the single diagnostic steps, however, different inferential methods are used for both inductive and deductive nature: modus tollens, hypothetical-deductive method, abduction; 3) Bayes’ theorem is a probabilized form of abduction which uses mathematics in order to justify the degree of confidence which can be entertained on a hypothesis given the available evidence; 4) although theoretically irreconcilable, in practice, both the hypothetical- deductive method and the Bayesian one, are used in the same diagnosis with no serious compromise for its correctness; 5) Medical diagnosis, especially differential diagnosis, also uses a kind of “probabilistic modus tollens”, in that, signs (symptoms or laboratory data) are taken as strong evidence for a given hypothesis not to be true: the focus is not on hypothesis confirmation, but instead on its refutation [Pr (¬ H/E1, E2, …, En)]. Especially at the beginning of a complicated case, odds are between the hypothesis that is potentially being excluded and a vague “other”. This procedure has the advantage of providing a clue of what evidence to look for and to eventually reduce the set of candidate hypotheses if conclusive negative evidence is found. 6) Bayes’ theorem in the hypothesis-confirmation form can more faithfully, although idealistically, represent the medical diagnosis when the diagnostic itinerary has come to a reduced set of plausible hypotheses after a process of progressive elimination of candidate hypotheses; 7) Bayes’ theorem is however indispensable in the case of litigation in order to assess doctor’s responsibility for medical error by taking into account the weight of the evidence at his disposal. (shrink)

Medical classification systems aim to provide a manageable taxonomy for sorting diagnoses into their proper classes. The question, this paper wants to critically examine, is how to correctly systematise diseases within classification systems that are applied in a variety of different settings. ICD and DSM , the two major classification systems in medicine and psychiatry, will be the main subjects of this paper; however, the arguments are not restricted to these classification systems but point out general methodological and epistemological (...) challenges of classifying diseases for differing purposes. Deciding what qualifies as a disease to be included into a classification system as well as choosing a specific validator for correctly systematising diseases is complicated because the broad applicability of medical classification systems simultaneously appears as aim and challenge. Drawing upon the case study of classifying Alzheimer’s disease, this paper will address three dilemmas in designing ‘good’ medical classification systems. They are due to general epistemological problems of medicine, such as the relationship between individual manifestations of diseases and the necessity of building groups in order to scientifically elucidate causes of diseases. Moreover, they involve pragmatic issues of designing usable classifications that allow for easily discriminating between classes of diseases, restricting, however, the completeness of disease representations. This paper wants to trace how the choice of certain validators is unavoidably value-laden and deeply intertwined with epistemological assumptions of how different uses relate to each other, resulting either in a prioritisation of (constrained) coherence or of (vague) pluralistic connectibility. (shrink)

I will argue that there are difficulties with the application of the four principles approach to incompetent children. The most important principle – respect for autonomy – is not directly applicable to incompetent children and the most appropriate modification of the principle for them is not clear. The principle of beneficence – that one should act in the child’s interests – is complicated by difficulties in assessing what a child’s interests are and to which standard of interests those choosing for (...) children should be held. A further problem with the four principles approach is that parental authority does not follow clearly from the four principles. (shrink)

In many countries where human embryo commercialization is banned, and no profit is allowed to be made directly from the transaction of frozen embryos between donor and recipient, there is still considerable opportunity for profiteering in medical fees arising from laboratory and clinical services rendered to the recipient. It is easy to disguise the 'sale' of altruistically donated human embryos through substantially increased medical fees, particularly in a private practice setting. The pertinent question that arises is what would (...) constitute a fair and honest profit margin for the medical professional and health institution in question? A suitable benchmark would obviously be the level of medical fees normally charged to patients for a self-freeze/thaw embryo transfer cycle, after initial failure at their first attempt in ART. This is because the level of medical expertise, clinical and laboratory services required for a donor- and self-freeze/thaw embryo transfer cycle should, in theory, be about the same, although slight variation in treatment can be expected owing to patients' respective medical histories, which results in varying predisposition to medical complications. In any case, the health authority should ensure that there is no gross disparity in the medical fees for both donor- and self-freeze/thaw embryo transfer cycle, as this could mask opportunistic profiteering by medical professionals and, in fact, be a covert form of embryo commercialization. (shrink)

ObjectiveCochlear explantation for purely elective (e.g. psychological and emotional) reasons is not well studied. Herein, we aim to provide data and expert commentary about elective cochlear implant (CI) removal that may help to guide clinical decision-making and formulate guidelines related to CI explantation.Data sourcesWe address these objectives via three approaches: case report of a patient who desired elective CI removal; review of literature and expert discussion by surgeon, audiologist, bioethicist, CI user and member of Deaf community.Review methodsA systematic review using (...) three scientific online databases was performed. Included articles addressed the benefits and/or complications of cochlear implantation in young children, CI explantation with or without revision surgery and the ethical debate between the medical and Deaf communities on cochlear implantation and explantation.ConclusionsThe medical and audiological perspectives identify a host of risks related to implant removal without reimplantation, including risk from surgery, general anaesthesia, cochlear ossification and poor audiometric outcomes. The member of the deaf community and bioethicist argue that physicians need to guide the principles of beneficence, non-maleficence and patient autonomy. Taken together, patient desires should be seen as paramount, if the patient is otherwise fit for surgery and well informed.Implications for practiceSimilar to the case of device implantation, device explantation should be a multidisciplinary and collaborative decision with the patient and the family’s desires at the centre. While every case is different, we offer a CI explantation discussion to assist in clinical decision-making, patient counselling and education. (shrink)

Chiara Lepora and Robert Goodin invite us to join their insightful ‘conversation’ on complicity and compromise. Their book makes a dense, utterly precise and rewarding reading, as one proceeds stepwise through the logic of their philosophical arguments. For those unfamiliar with the relatively new discipline of ‘humanitarian ethics’, it might be disconcerting at first to see humanitarian actions brought to illustrate theories on complicity, with the Rwandan refugees crisis of 1994 and the tortured patient taken as two exemplary (...) cases. Actually, this connects with an increasing body of research and reflexions, showing that humanitarian workers face frequent ethical challenges, some of them amounting to a distressful sense of complicity. Lepora and Goodin carefully elaborate on definitions, arguing that complicity stricto sensu implies both causality with morally wrong actions and knowledge thereof. Nothing else. Perhaps controversially but in any case convincingly, in their strict definition of complicity they leave out of account a ‘shared …. (shrink)

Vesicovaginal fistula was a catastrophic complication of childbirth among 19th century American women. The first consistently successful operation for this condition was developed by Dr J Marion Sims, an Alabama surgeon who carried out a series of experimental operations on black slave women between 1845 and 1849. Numerous modern authors have attacked Sims’s medical ethics, arguing that he manipulated the institution of slavery to perform ethically unacceptable human experiments on powerless, unconsenting women. This article reviews these allegations using primary (...) historical source material and concludes that the charges that have been made against Sims are largely without merit. Sims’s modern critics have discounted the enormous suffering experienced by fistula victims, have ignored the controversies that surrounded the introduction of anaesthesia into surgical practice in the middle of the 19th century, and have consistently misrepresented the historical record in their attacks on Sims. Although enslaved African American women certainly represented a “vulnerable population” in the 19th century American South, the evidence suggests that Sims’s original patients were willing participants in his surgical attempts to cure their affliction—a condition for which no other viable therapy existed at that time. (shrink)

There are serious concerns about the commercialization of healthcare and adoption of the business approach in medicine. As market dynamics endanger established professional values, healthcare workers face more complicated ethical dilemmas in their daily practice. The aim of this study was to investigate the willingness of medical students to accept the assertions of commercialized healthcare and the factors affecting their level of agreement, factors which could influence their moral stance when market demands conflict with professional values. A cross-sectional study (...) was conducted in three medical schools in Turkey. The study population consisted of first-, third-, and sixth-year students, and 1,781 students participated in total. Students were asked to state if they agreed with the assertions of commercialized healthcare. Of all students, 87.2 per cent agreed with at least one of the assertions, and one-fifth of them agreed with more than half of the assertions. First-year students significantly agreed more with some assertions than third- and sixth-year students. Being female, having mid-level family income, choosing medicine due to idealistic reasons, and being in the third or sixth years of medical study increased the probability of disagreement. Also, studying in a medical school that included integrated lectures on health policies, rights related to health, and health inequities, along with early field visits, increased the probability of disagreement. This study suggests that agreement with the assertions of commercialized healthcare might be prevalent among students at a considerable level. We argue that this level of agreement is not compatible with best practice in professional ethics and indicates the need for an educational intervention in order to have physicians who give priority to patients’ best interests in the face of market demands. (shrink)

In recent times, daily, ordinary medical practices have incontrovertibly been developing under the condition of complexity. Complexity jeopardizes the moral core of practicing medicine: helping people, with their illnesses and suffering, in a medically competent way. Practical wisdom has been proposed as part of the solution to navigate complexity, aiming at the provision of morally good care. Practical wisdom should help practitioners to maneuver in complexity, where the presupposed linear ways of operating prove to be insufficient. However, this solution (...) is unsatisfactory, because the proposed versions of practical wisdom are too individualistic of nature, while physicians are continuously operating in varying teams, and dealing with complicated technologies and pressing structures. A second point of critique is, that these versions are theory based, and thus insufficiently attuned to the actual context of everyday medical practices. Now, our proposal is to use an approach of practical wisdom that enables medical practices to counter the complexity issue and to re-invent the moral core of medical practicing as well. This implies a practice oriented approach, as thematized by practice theory, qualitative empirical research from the inside, and abduction from actual performed practical wisdom towards an apt understanding of phronèsis. (shrink)