Ethics and Analysis: Philosophical Perspectives and Their Application in Therapy

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She is joint series editor of the Routledge series on Professional Ethics. Written by an international roster of philosophers, practitioners in numerous fields, and academics from disciplines such as law and economics, this is a resource of value to an equally diverse audience. The second edition is a substantial revision and expansion of the first edition, both in terms of ongoing thinking about older topics and in terms of new topics introduced by events and developments of the intervening years.

Entries are fully developed, well-structured, signed articles, each enhanced with a brief glossary, a bibliography, website references, and brief bios of the contributing authors. A subject classification in the front matter lists entries under the following broad themes: applied ethics, bioethics, computers and information management, economics and business, environment, politics, education, law, medicine, philosophical theories, social, and media.

A more specific sampling of topics: reality TV, biometric technologies, race and genomics, electronic surveillance, land use issues, tourism, religion in schools, victimless crimes, obesity, rights theory, gender roles, and social services, among many, many others. The second edition of this encyclopedia reflects these changes, touching on developments in medicine, information technology, and privacy among others…The scope of the content and the quality of the articles especially the discussions of the relationship of hermeneutics to applied ethics will appeal to the full range of students, specialists, and interested readers.

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Thanks in advance for your time. Skip to content. Search for books, journals or webpages All Pages Books Journals. View on ScienceDirect. Editors: Dan Callahan Peter Singer. Editor-in-Chiefs: Ruth Chadwick. Hardcover ISBN: Imprint: Academic Press. Published Date: 20th December Page Count: For regional delivery times, please check When will I receive my book? Sorry, this product is currently unavailable. Sorry, this product is currently out of stock. Institutional Subscription.

In other words, according to this imperative, such a worldview must 1 be comprehensive, 2 be internally coherent, 3 connect to a normative ethical theory, and 4 be, at a minimum, aspirational and acted upon. This personal worldview imperative is designed as an independent and objective means of assessment in order to avoid some of the inherent flaws of the well-being approach. While this would take us back to primitive cultures at the time of the origin of human life as we know it, the first known evidence of ethical concerns in the practice of medicine in Western cultures is what has been handed down as the Corpus Hippocraticum , which is a compilation of writings by a number of authors, including a physician known as Hippocrates, over at least a few centuries, beginning in the 5 th century, B.

According to these authors, medical care should be practiced in such a way as to diminish the severity of the suffering that illness and disease bring in their wake, and the physician should be acutely aware of the limitations concerning the practical art of medicine and refrain from any attempt to go beyond such limitations accordingly. The Oath of Hippocrates includes explicit prohibitions against both abortion and euthanasia but includes an equally explicit endorsement of an obligation of confidentiality concerning the personal information of the patient.

Additional codes of ethics concerning the practice of medicine have also come down to us: from the 1 st century A. The founding of the American Medical Association in was the occasion for the immediate formulation of standards for an education in medicine and for a code of ethics for practicing physicians.

A good number of medical codes of ethics were formulated and adopted by national and international medical associations during the middle part of the 20 th century. In an effort to modernize the Oath of Hippocrates for practical application, in the World Medical Association adopted the Declaration of Geneva , followed the very next year by its adoption of the International Code of Medical Ethics.

Since then, virtually every professional occupation that is health care-oriented in the U. Methods of moral decision-making are concerned, in a variety of ways, not only with moral decision-making but also with the people who make such decisions. Some such methods focus on the actions that result from the choices that are made in moral decision-making situations in order to determine which of such actions are right, or morally correct, and which of such actions are wrong, or morally incorrect. Other methods of moral decision-making concentrate on the persons who commit actions in moral decision-making situations that is, the agents in order to determine those whose character is good, or morally praiseworthy, and those whose character is bad, or morally condemnable.

The theorists of such methods deal with such questions as: Of all of the available options in a particular moral decision-making situation, which is the morally correct one to choose? What follows is a look at some of the most influential methods of moral decision-making that have been offered by proponents of such methods and that have been applied to ethical issues in the field of health care. Moral virtues include but would not be limited to courage, temperance, compassion, generosity, honesty, and justice.

The person in whom these moral virtues are to be found as steadfast dispositions can be relied on to exhibit a good character and thereby to commit morally correct actions in moral decision-making situations. The former soldier has chosen to be rash during the heat of battle while the latter soldier has chosen to be a coward. By contrast, the courageous soldier holds his position on the battlefield and chooses to fight when he is ordered to do so.

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The fundamental difference between the courageous soldier on the one hand and the rash and cowardly soldiers on the other is that, of the three, only the courageous soldier actually knows why he is on the battlefield and chooses to do his duty to defend his comrades, his country, and his family while recognizing, at the same time, the realistic possibility that he might be injured, or even killed, on the battlefield Aristotle, Virtue ethics is directly applicable to health care ethics in that, traditionally, health care professionals have been expected to exhibit at least some of the moral virtues, not the least of which are compassion and honesty.

The preeminent proponent of utilitarianism as an ethical theory in the 19 th century was John Stuart Mill. As a normative ethical theorist, Mill articulated and defended a theory of morality that was designed to prescribe moral behavior for all of humankind. Conversely, human actions, which are committed in moral decision-making situations, are determined to be morally incorrect to the extent to which they, on balance, produce more unhappiness rather than happiness for those who are affected by such actions.

However, unlike virtually all of his utilitarian predecessors, Mill offered a version of utilitarian ethics that was designed to accommodate many, if not most, of the same ethical concerns that Aristotle had expressed in his version of virtue ethics. In other words, even after it is determined that the utilitarian calculation of the ratio of happiness to unhappiness, in a particular moral decision-making situation, might result in an option that is deemed to be morally correct, an additional calculation might be in order to determine the ratio of happiness to unhappiness in the event that such an option, in future like cases, would consistently be deemed the appropriate one such that if this latter calculation would likely result in a ratio of unhappiness over happiness, then the option in the original case might be rejected despite its having been recommended by the utilitarian calculation for the original moral decision-making situation.

For example, in a moral decision-making situation in which an employed blue-collar worker witnesses a homeless person dropping a twenty-dollar bill on the sidewalk, the utilitarian calculation would recommend, as the morally correct option, to return the twenty-dollar bill to the homeless person rather than to keep it for oneself. However, given the same exact moral decision-making situation except that rather than a homeless person dropping a twenty-dollar bill on the sidewalk, the twenty-dollar bill is dropped by a universally known and easily recognizable multi-billionaire.

Another possible reason to reject an otherwise recommended option, based on the utilitarian calculation, would be if the same option were to be repeatedly chosen routinely by others in society, as influenced by the action in the original case in question. To the extent that the action in question, if repeated routinely by others in society, would result in unfavorable consequences for the society as a whole, that is, it would run counter to the maintenance of social utility, then the agent in the original moral decision-making situation in which this action was an option should choose to refrain from committing this action.

For example, if a prominent citizen of a small town, upon learning that the local community bank was having financial problems due to an unusually bad economy decided to withdraw all of the money that he had deposited in his accounts with this bank, the utilitarian calculation would, presumably, sanction such an action. However, precisely because this man is a well-known citizen of this small town, it can be predicted, reasonably, that word of his bank withdrawal would spread throughout the town and would likely cause many, if not most, of his fellow citizens to follow suit.

The problem is that if the vast majority of the townspeople did follow suit, then the bank would fail, and everyone in this town would be worse off than before. In other words, this would serve to undermine social utility, and so, the original action would not be recommended by the utilitarian calculation. As applicable to health care ethics, utilitarian considerations have become fairly standard procedure for large percentages of health care professionals over the past several generations.

It is not at all uncommon for decisions to be made, by health care professionals at all levels of health care, on the basis of what is in the best interest of a particular collectivity of patients.

Illness and disease: an empirical-ethical viewpoint

For example, officials at the U. Centers for Disease Control CDC learn of an outbreak of a serious, potentially fatal communicable disease. These officials decide to quarantine hundreds of people in the geographic area in which the outbreak occurred and to mandate that health care professionals across the country who diagnose patients with this same communicable disease must not only take similar measures but also must report the names and other personal information of the affected patients to the CDC. These decisions are, themselves, decisions of moral if not also legal decision-making, and these decisions raise additional moral issues.

At any rate, the fundamental reason for taking such measures, under the specified circumstances, is for the protection of the health of the citizens in those areas where the outbreaks occurred, but, ultimately, such measures are taken for the protection of the health of American citizens in general, that is, to promote social utility Mill, A deontological normative ethical theory is one according to which human actions are evaluated in accordance with principles of obligation, or duty.

If this attempt to universalize the maxim were to result in a contradiction, such a contradiction would dictate that the maxim in question cannot be universalized; and if the maxim cannot be universalized, then one ought not to commit the action. Kant asks his reader to consider the case of a man who stands in need of a loan of money but who also knows well that he will not be able to repay such a loan in the appropriate amount of time. The maxim of his action would be: Whenever I find myself in need of a loan of money but know that I am unable to repay it, I shall deceitfully promise to repay the loan in order to obtain the money.

To attempt to universalize this maxim, this man would need to entertain a future course of events in which all rational beings would also routinely attempt to act on this same maxim whenever they might find themselves in relevantly similar circumstances. However, as a rational being, this man would come to realize that this maxim could not be universalized because to attempt to do so would result in a contradiction. Thus, the loaning of money would, at least temporarily, come to a halt.

As Kant points out to his reader, because of the contradiction involved in attempting to universalize this maxim, neither the promise deceitful as it is itself nor the end to be achieved by the promise that is, the loan of money would be realizable. So, the fact that a contradiction results from the attempt to universalize the maxim reveals the impossibility of the maxim being able to be universalized, and because the maxim cannot be universalized, then the man ought not to commit the action. In application to any specific moral decision-making situation, the agent is being asked to respect rational beings as valuable in, and for, themselves, or as ends in themselves, and, thereby, to commit to the principle to never treat a person either oneself or any other as merely a means to some other end.

To apply this formulation of the categorical imperative to the same example as before is to realize that, once again, one ought not to make a deceitful promise. For, to make a deceitful promise to repay a loan of money in an effort to obtain such a loan is to treat the person to whom such a promise is made as a means only to the end of obtaining the money. To be faithful to this formulation of the categorical imperative is to never commit any action that treats any person as a means only to some other end Kant, For example, if a patient who had been prescribed an opioid for only a short period of time, post-surgery, were to contemplate whether to feign the continued experience of pain during the follow-up visit with the surgeon in an effort to obtain a new prescription for the same opioid in order to abet the opioid addiction of a friend, then the patient would be attempting to treat the surgeon as a means only to another end.

Central to their approach are the following four ethical principles: 1 respect for autonomy, 2 nonmaleficence, 3 beneficence, and 4 justice. However, given the abstract nature of these ethical principles, it is necessary to instantiate them with sufficient content so as to be able to be practically applicable to particular cases of moral decision-making. This is what is referred to as an application of the method of specification, which is designed to restrict the range and the scope of the ethical principle in question. In addition, each ethical principle, again, in order to be practically applicable, needs to be subjected to another methodological procedure, namely that of balancing according to which the principle, as a moral norm that is competing with others, and in order to be eligible for application to a particular case of moral decision-making, needs to be deemed to be of sufficient weight or strength, as compared to its competitors Beauchamp and Childress, None of the four ethical principles has been designated as enjoying superiority over the others; in fact, it is explicitly acknowledged that any of the four principles can, and would, reasonably be expected to conflict with any other.

Because of this, it has been pointed out that this method of moral decision-making is subject to the problem of having no means by which to adjudicate such conflicts. Moreover, to the extent that, in practice, the application of principlism can be reduced to a mere checklist of ethical considerations, it is not sufficiently nuanced to be, ultimately, effective Gert and Clouser, In other words, like the method of decision-making that is used by judges who must render decisions in the law, casuists insist that the best way in which to make decisions on specific cases as they arise in the field of health care, and which raise significant moral issues, is to use prior cases that have come to be viewed as paradigmatic, if not precedent setting, in order to serve as benchmarks for analogical reasoning concerning the new case in question.

For example, if a new case were to come about in the field of health care that raised the moral issue of how the health care professionals of a hospice organization should treat a woman who is five months into her pregnancy but who also has been diagnosed with stage four pancreatic cancer and has a life expectancy between two and three months, the casuist would advise that the moral decisions concerning the treatment of this woman should be made by seeking out as large a number as possible of cases that had occurred prior to this one and that exhibited as many as possible relevantly similar salient characteristics in addition to as many as possible of the same moral issues.

To render moral assessments concerning how these previous cases were handled some more morally acceptable and others not, or even more instructive would be at least one that stands out as reflective of either decisions determined to have been obviously morally correct or decisions determined to have been blatantly morally objectionable is to have established guideposts for moral decision-making in the present case under consideration Jonsen and Toulmin, According to the proponents of casuistry, normative ethical theories and ethical principles can take moral decision-making only so far because, first, the abstract nature of such theories and principles is such that they fail to adequately accommodate the particular details of the cases to which they are applied, and second, there will always be some cases that serve to confound them, either by failure of the theory or principle to be practically applicable or by suggesting an action that is found to be morally unsatisfying in some way.

However, casuistry, as a method of moral decision-making, seems to make use of various sorts of moral norms or rules, if only in a subconscious or nonconscious way. Furthermore, this moral norm or rule, itself, will almost certainly turn out to have been reflective of either popular societal or cultural bias because of the conscious methodology to refrain from the use of normative ethical theories and ethical principles, both of which carry with them standards of objectivity Beauchamp and Childress, For example, even though, theoretically and even legally, women, by a particular point in time during the first half of the 20 th century, were eligible for admission to medical schools should they have chosen to exercise their autonomous rights to apply for such admission, in practice and in fact, both the social conditioning of women and the gender bias of the men who administered medical schools, and who made decisions on which applicants would satisfy the requirements for admission, ensured that medical schools would graduate, almost exclusively, men with only single digit exceptions in America.

The point is that the concept of autonomy, in its theoretical sense, is too abstract to have had any practical application to women, in this case, whose eligibility for acceptance to medical schools was denied on the basis of gender. Thus, in addition to this concept of relational autonomy, concepts of responsibility and compassion as well as those of freedom and equality are essential to the majority of the proponents of feminist ethics Holmes and Purdy, and Sherwin, While among those who consider themselves to be proponents of feminist ethics there exists a range of perspectives concerning not only some of the most important ethical issues within the framework of this school of thought but also concerning the very nature of this school of thought, agreement can be found in the need to reflect on both the oppression and the suppression of women that has been inherent in most every culture throughout human history.

Yet another method of moral decision-making, which is sometimes thought of as a sub-field of feminist ethics but in the early 21 st century has come to be seen in its own right as a methodology and was given birth by feminist ethics, is usually referred to as the ethics of care. Like the proponents of feminist ethics, the proponents of the ethics of care have decided that any methodology of moral decision-making that is based on abstract theories or principles, rights or duties, or even objective decision-making turns out to be unsatisfying in terms of interacting with others in moral decision-making situations.

Nursing, as a profession, has been, traditionally, a profession of the nurturing of, as well as the caring for, the patient. Until the latter part of the 20 th century, nursing was also, historically, a profession for women. In no way is this to suggest that this ethics of care would, either intentionally or in practice, preclude men from identifying with it also.


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It should go without saying that many are the health care professionals who would choose to nurture, and to care for, their own patients in this same way, with or without the existence of any such accrediting agencies Kuhse, In addition to the application of a variety of methods of moral decision-making to the practice of health care, ethical principles are also so applicable, but not procedurally in the same way as in the method of moral decision-making identified above as principlism. In other words, ethical principles operate on a different level of moral decision-making than do normative ethical theories or other methods of moral decision-making; nonetheless, ethical principles, like normative ethical theories and these other methods of moral decision-making, are prescriptive, that is, they offer recommendations for moral action.

In theory, ethical principles can be used as one measure of how effective normative ethical theories are in their application to moral decision-making situations. For, any proposed normative ethical theory that is incapable of accommodating the requirements of the most fundamental ethical principles can be called into question on that very basis. In practice, autonomy, on the part of the patient, and paternalism, on the part of the health care professional represent mutually exclusive events, that is, to the extent that one of these two is present, in decision-making and their attendant actions within the clinical relationship of the patient and the health care professional, to that same extent is the other one absent.

Some health care professionals continue to profess their own personal beliefs that patient autonomy is over-rated because, in their own clinical experience, patients continue to make poor decisions concerning what is in the best interest of their own health care. Certainly, this is a realistic concern, and it probably always will be.

That is, not every adult patient has the ability to comprehend medical explanations even if such explanations are cast in the language of the native tongue of the patient and even if the ability of comprehension that is necessary for a proper understanding is at the level of, say, an average high school graduate. Reasons for these so-called exceptional cases vary from cultural or religious differences between the health care professional, on the one hand, and the patient, on the other, to the patient in question being a close relative, or friend, of the health care professional even in a clinical situation in which the health care professional has no part in the practice of health care for this close relative or friend.

In either of these types of cases and many like ones , these so-called exceptional cases are not exceptional cases at all. At its most fundamental level, a true respect for autonomous decision-making on the part of the patient demands that it be honored, objectively, even in the tough cases.

To the extent to which health care professionals serve their patients by helping them to maintain or improve their health status, health care professionals can be said, to the same extent, to be acting beneficently toward the patients they serve. In theory, every action performed by a health care professional, in a professional relationship with a patient, can be expected to be guided by the ethical principle of beneficence.


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Moreover, the respect for patient autonomy and the practice of beneficent medical care can be considered to be mutually complementary. However, despite the complementary nature of the ethical principle of autonomy and that of beneficence, it is not uncommon for these two ethical principles to conflict one with the other. For example, a young adult patient who has only recently suffered a ruptured appendix such that it is still early in the progression of pain might refuse to undergo an appendectomy for the reasons that the patient has never undergone surgery before and claims to be deathly afraid of hospitals.

Such cases of conflict between these two ethical principles would normally be adjudicated according to which right that is, that of autonomy or that of beneficence can reasonably, and objectively, be determined to supersede the other in importance. In the former example, the patient, after recovering from the life-saving appendectomy, might be appreciative of the fact that the principle of beneficence was allowed to prevail over the principle of autonomy. Of course, many are the occasions on which the principle of respect for autonomy might take precedence over the principle of beneficence.

Take, for example, a patient who is similar to the one in the above-mentioned case of a ruptured appendix in that the patient is, once again, deathly afraid of hospitals, but this time is elderly and has had only one surgery, although a major one. Acts of maleficence can be intentional or unintentional, and a large percentage of the latter kind happen as a result of either negligence or ignorance on the part of the health care professional.

An example of the former would be a surgeon who fails to exercise due diligence in scrubbing prior to surgery, the result of such negligence being that the surgical patient contracts an infection. An example of the latter would be a primary care physician who fails to scrutinize sufficiently the recent medication history of a patient prior to prescribing a new medication, the result of such ignorance being that the patient suffers a new health issue due to the adverse interaction of the newly prescribed medication with a previously prescribed one that is still being taken by the patient.

Because of the intimate relationship between the principle of nonmaleficence and that of beneficence, it is possible at least in some cases to construe the violation of either as a violation of the other. In other words, it might be possible to construe the failure to act in such a way as to benefit someone not only as a violation of the principle of beneficence but also as a violation of the principle of nonmaleficence. Conversely, it might be possible to construe the committing of an action that, reasonably, would be expected to actually cause harm to someone, not only as a violation of the principle of nonmaleficence but also as a violation of the principle of beneficence.


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Raising the question of whether the principle of nonmaleficence has been violated would also include clinical situations in which it can be determined, objectively, that the potential risks of the recommended treatment option, be it a procedure or a medication, actually outweigh the expected benefits, all things considered. To avoid this possibility, a calculation of the ratio of potential risks to expected benefits sometimes referred to as a risk-benefit analysis in the case of both medical procedures and the prescribing of medications is always necessary.

For a health care professional to fail to render such a calculation is, at least in theory, to violate the principle of nonmaleficence. In the clinical context, the ethical principle of justice dictates the extent to which the delivery of health care is provided in an equitable fashion. Consequently, the hallmarks of the concept of justice are fairness and impartiality.

In the context of health care, the question of justice is concerned with the degree to which patients are treated in a fair and impartial manner. Justice, as an ethical principle, demands that the actions taken by health care professionals, in their professional relationships with patients, be motivated by a consistent set of standards concerning the relevance of the variety of factors that are taken into consideration for such actions. For example, the recommendation, on the part of a health care professional, of two different primary treatment options for two different patients, each of whom having presented with the exact same symptoms to approximately the same extent, and with no known other relevant differences between the two patients except for one demographic distinction say, age, gender, or race , would, when taken together, appear to be unjust.

Of course, it is possible for a health care professional to be the subject of an unsubstantiated and erroneous charge of injustice concerning two, or more, clinical cases that might appear to be relevantly the same. Typically, the reason for such an accusation, should the accusation be inaccurate, is that the accuser is lacking the requisite knowledge of the cases in question in order to be able to determine that, although these two, or more, cases do, indeed, appear to be relevantly similar, in fact, they are not.

For example, a physician assistant might prescribe two different antibiotics one of which has been proven to be highly effective but the other of which has an inconsistent success rate, each for the same medical malady to two different patients who have been diagnosed with the medical malady in question. Learning of these facts, someone might accuse the physician assistant of being unfair, that is, unjust, in the treatment of these two patients.

However, what this accuser does not know is that the patient for whom the less effective antibiotic was prescribed is deathly allergic that is, subject to anaphylactic shock to the antibiotic with the higher success rate. In the final analysis, the ethical principle of justice demands that cases, which are relevantly similar, be treated the same and that cases, which are relevantly different, be treated in appropriately distinct ways in recognition of such differences.

The practice of every profession reveals ethical issues that are endemic to the professional field in question. The practice of health care is no different. What follows is a look at some of the most pervasive ethical issues that are encountered in the practice of health care. Any ethical issues that can arise within the clinical relationship between the health care professional and the patient are of the utmost importance if only because this relationship represents the front line of the provision of health care.

The most important part of this relationship is trust on the part of each of the participants in this relationship. This is why the issues of truth-telling, informed consent, and confidentiality are essential to the success of any relationship between a patient and a health care professional. True, or genuine, autonomous decision-making is possible only if the beliefs on which such decisions are made are accurate; in other words, any decision that is based on an inaccurate belief even if the belief is not recognized as such , cannot be a true autonomous decision.

Thus, every person can be said to be under a moral obligation to tell the truth, especially on topics the claims about which are important and relevant to the lives of their recipients. For, in such cases, the recipients of such claims, who choose to accept them, will, eventually, hold them as beliefs, and will act on them in order to pursue what they take to be interests of their own, and, perhaps, too, the interests of others.

Not only can the moral right to autonomy be said to be the most important right of a patient, in a clinical setting, it also can be said to be the foundational right for all of the other rights that a patient can be said to have. For example, a physician might choose to knowingly, and intentionally, refrain from informing a patient of the potential risks of a certain procedure that has been recommended, up to and including a realistic risk of death.

Other examples would include specific anesthetics that have a risk, small though it might be, of causing the death of the patient. This would provide the patient with the opportunity to make a more informed decision in consultation with the physician. Julian Savulescu and Richard W.

Savulescu and Momeyer recognize, and advise against, the exercise of paternalism, if not coercion, when it comes to both the providing of important and relevant information and the guiding of the patient through a process of, theoretically, rational deliberation because, as they say, to compel the patient either to accept medically justified information or to engage in practical rational deliberation concerning such information would be counter-productive in many respects Savulescu and Momeyer, and Savulescu In the case of any non-emergency medical procedure of any significance, there is a moral obligation to obtain the informed consent of the patient by written signature authorization of an informed consent document.

In the case of any emergency medical procedure of any significance, there is a moral obligation to make every reasonable effort to obtain the informed consent of the patient, in like manner. Failing that for example, due to the mental incapacity, or incompetence, of the patient , every reasonable effort should be made to obtain the informed consent, in like manner, of either a patient surrogate if the patient has a durable power of attorney for health care decisions or a patient advocate in the absence of such an advance directive.

Only in cases of an emergency medical procedure of any significance in which the nature of the illness, or injury, of the patient is such that proper treatment requires urgent medical attention, in addition to which it is not possible again, due to the mental incapacity, or incompetence, of the patient to obtain the written signature authorization of the patient, and there is insufficient time to secure the written signature authorization of either a patient surrogate or a patient advocate, would it be morally justified to proceed with such a medical procedure in the absence of any written signature authorization.

Adolescent patients represent a special case in that while, in many cases, the cognitive ability of the adolescent patient is sufficient to comprehend most, if not all, of the important and relevant information concerning their own health care needs as well as the recommended options for treatment, normally, they are not recognized as competent medical decision-makers in the law.

To accommodate both of these facts, and in addition to the written signature authorization by a parent or guardian, every reasonable effort should be made to inform adolescent patients of all of the important and relevant information concerning their own health care needs and the recommended treatment options, including the approved one, in order to obtain their assent to the latter. An exception to this is the case of emancipated minors, that is, minors who are in the military, married, pregnant, already a parent, self-supporting, or who have been declared to be emancipated by a court; emancipated minors, in most legal jurisdictions, are granted the same legal standing as adults for health care decision-making.

There is a moral obligation to protect from dissemination any and all personal information, of any type, that has been obtained on the patient by any and all health care professionals at any medical facility. The justification for the protection of this right is integral to the very provision of health care itself. It is essential that there exist a relationship of trust between the patient and any health care professional. This is so because there is a direct correlation between the trust that a patient places in a health care professional to keep in confidence any and all information of a personal nature that surfaces within the context of their clinical relationship and the extent to which that patient can be expected to be forthcoming with full and accurate information about oneself, which is necessary in order for the proper diagnosis and treatment of the patient to even be possible.

In fact, the absence of such trust, either well-founded or not, in the mind of a person who is considering whether to enter a patient-health care professional relationship can be sufficient to keep that person from entering such a relationship at all. Adding to the concern that a patient in any medical facility has, with respect to the extent to which personal information about oneself can reasonably be expected to be kept in confidence, is the number of employees of such a facility especially a hospital who have access to such information.

For example, it is not atypical for the personal information on a surgical patient in a hospital to be accessed by attending physicians as well as physicians who are specialists and who serve as case consultants, nurses for example, in the operating room, in the post-anesthesia care unit, in a step-down unit, on a medical-surgical floor, and perhaps, in other clinical areas , therapists respiratory, physical, and other types , laboratory technicians of a variety of kinds , dieticians, pharmacists, and others, including, but not limited to, patient chart reviewers for example, for quality assurance , and health insurance auditors.

Moreover, the greater the number of people who have access to the personal information on a patient, the greater is the possibility that such information might be compromised in any of a number of ways. Furthermore, patients, themselves, have the right to request access to their own medical records in any medical facility including medical offices as well as hospitals and long-term care facilities and should be allowed to the extent to which it is reasonably possible a voice in who else has access to such information. Such a communication imposes on the health care professional not only a moral, but also a legal, obligation to notify the proper authorities.

In such a case, the right of another to not be harmed supersedes the otherwise obligatory moral right to confidentiality on the part of the patient. Regents of the University of California case held that mental health professionals have a legal obligation to warn anyone who is threatened, in a serious way, by a patient. Given that the primary goals of such organizations are to foster and to protect the health of the members of entire populations, or societies, of people, the fundamental means by which to accomplish these goals are policies and programs the intent of which is either to prevent illness and injury or to provide health care services.

Depending on the severity of the particular type of sexually transmitted infection, and the degree to which it is wide-spread in the population in question, the fact that this spouse has contracted this particular sexually transmitted infection might reasonably be not only a matter of individual concern but also, properly, a public health matter. Of all of the ethical issues that can be encountered in the practice of health care, none has been more controversial than those of abortion, euthanasia, and physician-assisted suicide.

Despite the debates that are waged, with an abundance of passion concerning the specific moral aspects of each of these ethical issues, a reasoned analysis of each of these ethical issues might be expected to provide new opportunities for a better appreciation of the complexities of each. At least since the time of the Oath of Hippocrates , with its explicit prohibition against abortion, there have been admonishments against the practice of the aborting of a human fetus together with arguments on both sides of this issue.

Abortion is a perennial moral issue in most societies that ebbs and flows in its importance as an issue that serves to inform, if not incite, social debate and social action. However, over the late 20 th century and early 21 st century in America, stark differences between the opinions on each fundamental side of this issue have been voiced by people in the society at large, as compared to the reasoned debates waged by philosophers as a result of their attempts to bring clarity to the relevant moral issues, to the concepts that are inherent in such issues, and to the language that is used to express such issues and concepts.

The U. Supreme Court decision in the case of Roe v. From the end of the second trimester to the time of delivery, that is, after viability, state governments were granted the authority not only to limit but also to prohibit abortions. Despite the fact that those who adopt what are usually referred to as conservative positions and those who adopt what are usually referred to as liberal positions on the issue of abortion sometimes take the same position on related moral issues, for example, that murder is morally unacceptable and that people have a moral right to their own lives, many disagree, fundamentally, on the question of whether the act of abortion is also an act of murder and on the question of whether a fetus has a right to life.

Since the Roe v. Mary Anne Warren, in an influential essay in which she responds to many of the significant arguments in the literature to that point in time, makes an important distinction between what it is to be a human being as compared to what it is to be a person. According to Warren, the classic argument against abortion relies on a logical argument that depends on the fallacy of equivocation in order to attempt to be successful. The argument is as follows: since it is morally incorrect to kill innocent human beings, and since fetuses are innocent human beings, then it follows that it is morally incorrect to kill fetuses.

Consequently, the moral community consists of all, but only, persons. She then entertains the question concerning what characteristics an entity must have in order to be considered a person and launches a search for what might constitute the criteria necessary for personhood. Warren acknowledges that it should not be required of an entity that it must exhibit all five criteria in order to qualify as a person, nor should any particular one of these criteria be deemed necessary for personhood.

However, she does identify the first two criteria, followed closely by the third, as the most important. Finally, she insists that any entity that fails to exhibit any of these five criteria is, definitely, not a person, and that a human fetus is just such an entity. That is, if a fetus is allowed to develop, over the course of a normal pregnancy, its potential to become a person becomes more and more likely the closer that it gets to its time of delivery.

The question is whether this potentiality for personhood should be considered to guarantee the fetus some rights akin to the rights of a person, for example, a right to life. Warren takes up this issue and concludes that while the fact that the human fetus is a potential person, which, on moral grounds, might entail that women ought not to wantonly have abortions, in the final analysis, whenever the question comes down to the right to life of the fetus as opposed to the right of a woman to have an abortion, the right of the woman must always supersede the claimed right on behalf of the fetus because the rights of actual persons always outweigh the rights of potential persons.

Don Marquis takes on the question of the morality of abortion in a way that is separate and apart from any considerations of whether a fetus can be a determined to be a person and even whether a fetus can be considered to be potentially a person. It is, says Marquis, this loss that makes the taking of a human life morally incorrect. This argument against the taking of a human life would apply not only to adults but also to young children and babies who, arguably, also have a future of value concerning life experiences, activities, projects, and enjoyments to which to look forward.

In the same way, a human fetus has a similar future such that, if aborted, would never be able to come to pass Marquis, At least since the Roe v. Wade U. Supreme Court decision, the spectrum of positions on the issue of the moral status of abortion has been represented by an extreme conservative position, namely, that, without any exception, abortions of human fetuses ought never to be allowed; by an extreme liberal position, namely, that abortions of human fetuses ought always to be allowed, and for any reason whatsoever; and by more moderate positions, like, for example, that abortions of human fetuses ought not to be allowed, in general, but ought to be allowed in cases in which the following circumstances serve as the exceptions: in cases in which pregnancies have occurred as a result of the act of rape or the act of incest, or in cases in which the life of the expectant mother is seriously jeopardized by the pregnancy itself.

Euthanasia is an intervention in the standard medical course of treatment of a patient who is reasonably considered to be terminally, or irreversibly, ill or injured for the express purpose of causing the imminent death of that patient, normally for reasons of mercy. This distinction between active and passive euthanasia has been, historically, the focal point of the most controversy concerning the practice of euthanasia.

Traditionally, all health care-related professional codes of ethics find passive euthanasia to be morally allowable but active euthanasia to be tantamount to murder; the relevant laws in all of the legal jurisdictions in America follow suit. James Rachels, in a famous article on this very question Rachels, , attempts to demonstrate that this controversy represents a distinction without a difference.

For example, a cancer patient, with a prognosis of only a matter of days to live, continues on a regimen of the sedative lorazepam and the opioid morphine. With increasing frequency, the patient has complained of the worsening of the pain and has repeatedly requested ever-higher doses of the morphine drip. In response to each of these requests, the physician has complied, knowing full well that there will be a threshold beyond which the dosage of morphine will be sufficient in conjunction with a myriad of other causal factors that are idiosyncratic to this patient to kill the patient.

This, then, comes to pass. The key factor in the doctrine of double effect is the intention on the part of the medical professional in question. However, the most fundamental criticism of the application of the doctrine of double effect to such cases is that there is no relevant moral distinction between the action in question and an instance of active euthanasia. Palliative sedation, as the monitored use of medications, including sedatives and opioids, among others, to provide relief from otherwise unmitigated and excruciating physiological, among other types of, pain or distress by inducing any of a number of degrees of unconsciousness, can be similarly problematic depending on whether and to what extent the pain or distress of the patient in question is managed appropriately.

If managed well, palliative sedation need not be a causal factor in hastening the death of the patient; however, if it is not managed well, in theory, palliative care can be such a causal factor. Jack Kevorkian who, throughout the final decade of the 20 th century, as a retired pathologist, offered to help fatally ill patients to end their lives prematurely.

Prior to his fifth, and final, prosecution, which was for second degree murder, and for which he was convicted having avoided this fate the first four times , he claimed to have assisted approximately patients to end their lives, which he had claimed, throughout his entire medical career, that patients ought to have a right both morally and legally to do. Despite the fact that all health care-related professional codes of ethics have consistently, and still do, condemn physician-assisted suicide, currently, at least five of the fifty states in America have legalized physician-assisted suicide.

Among those European nations that had legalized both active euthanasia and physician-assisted suicide by the early 21 st century, the Netherlands has led the way Kevorkian, Theoretically, the most fundamental reason to conduct research involving human subjects is to add to our existing knowledge concerning the physiological and the psychological constitution of the human body and the human mind, respectively, in an effort to improve the quality of life of people as determined by the status of their bodily and mental health.

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Thus, the principle of beneficence should lie at the heart of all research that is conducted with human subjects. The history of such research is one of major achievements, typically incremental and over time, each of which has played a part in the extension of not only the duration of human life but also the quality of the day-to-day existence of members of the human race, virtually all over the planet.

However, many are the moral issues that have arisen due to the mistreatment to which many such human subjects have been subjected, and which have occurred in any of a number of important ways, from physiological abuse to mental and emotional abuse to the abuse of human rights. The history of human subject research is replete with examples of such abuses. By the middle of the 20 th century, enough people in sufficiently important roles in Western societies began to codify what they took to be some of the most basic moral rights that would need to be respected in order for human subject research to be recognized as morally acceptable.

Over many decades throughout the second half of the 20 th century, a variety of codes of ethics were developed for the protection of the rights of people who serve as human research subjects. In virtually every case, those codes, that were of the most importance, were formulated in response to specific cases of human subject research during the course of which at least some of the people who served as participants had some of their fundamental rights abused.

A few examples follow. The Nuremberg Code was formulated in response to experiments that were performed on people who were members of demographic groups that were targeted for extinction by Hitler in Nazi Germany and that were conducted by medical doctors and biomedical researchers some of whom had little to no expertise or experience in either the practice of medicine or the conducting of biomedical research.

Of the ten principles in the Code, the emphasis, in general, was on the need for biomedical researchers to obtain the voluntary informed consent of the prospective human subjects prior to the commencement of any such experimentation. Despite having no legal force, The Nuremberg Code has had profound effects on the ethics of human experimentation and has spawned a good number of other such codes since its formulation.

The participants in this study, begun during the throes of the Great Depression and in one of the economically poorest regions of America, were promised free food and free medical care for their participation. The Public Health Services Act established and mandated that every research facility in America that conducts either biomedical or behavioral research on human subjects have an Institutional Review Board IRB for the protection of the rights of human research subjects.

This requirement for each such research institution academic or otherwise to have IRB approval for each and every biomedical or behavioral research study was a result of many instances of research protocols that, for a variety of reasons, were thought, at least in retrospect, to have violated the human rights of their human participants. As for biomedical research, the famous case of Henrietta Lacks and her HeLa cells allowed for at least dozens and dozens of medical breakthroughs in the curing of diseases in the latter half of the twentieth century, making large amounts of money for some people and some institutions in the research process, while most of her descendants, including some of her own children, lived their entire lives without health insurance, some of whom were, even if temporarily, homeless.

Only recently has attention been brought to her story, and to this situation, by her biographer Skloot, The composition of the membership of all Institutional Review Boards IRBs is mandated to be reflective of diversity with respect to gender, race, and culture or heritage as well as a diversity of social experiences and an appreciation for issues relevant to the research involving human subjects that reflect the standards and values of society, if not also of the local community.

Moreover, IRBs are obligated to ensure that all proper procedures are followed for the voluntary informed consent of all of the subjects of all research projects. The moral issues that have arisen, over decades, concerning human subjects in both biomedical and behavioral research are many and varied.

In biomedical research, such issues include the exclusion of the members of specific demographic groups from even being considered to be eligible to become participants in such research. For example, until the latter part of the 20 th century in America, biomedical research on breast cancer was almost nonexistent. Not until women, in decent numbers, had entered the field of medicine and the field of biomedical research did research proposals into various aspects of breast cancer begin to compete for funding with research proposals into various aspects of prostate cancer.

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Furthermore, even biomedical research into, for example, the correlative, if not causal, factors involved in heart disease solicited only Caucasian males as prospective research participants. Examples of appropriate exclusionary practices would be biomedical research into testicular cancer, which would properly exclude women, just as biomedical research into sickle-cell anemia would properly exclude Caucasians. One of the most popularly known moral issues concerning both biomedical and behavioral research is the use of placebos.

The classic case of the use of placebos is the clinical drug trial, in which researchers are attempting to determine, first, the effectiveness of the experimental drug, and second, the extent to which potential adverse side-effects of the experimental drug are significant, if not fatal. In order to attempt to ensure credibility concerning the use of a placebo, the participants in both groups are intentionally deceived as to which group of participants is receiving the experimental drug and which is receiving the placebo. The main reason for a blind study is to attempt to avoid any possibility of what we might refer to as suggestive bias on the part of the participant concerning the possible effectiveness of the experimental drug.

The main reason for a double-blind study is to attempt to avoid any possibility of what we might call expectation bias on the part of the researchers themselves concerning either the effectiveness, or the lack thereof, of the experimental drug.



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