Barry Hoffmaster

The OHRP and SUPPORT - Another view

A group of physicians, bioethicists, and scholars in allied fields agrees with the Office for Human Research Protections about the informed-consent documents in SUPPORT.

What empirical research can do for bioethics.

other fields, editors, and database indexers to add ethicsrelated keywords whenever data are highly relevant to an ethical debate. Second, ethicists and institutional review board members should be trained to search for relevant data using non-ethics terms. Third, the prevalence of ethicallyrelevant data in health journals reinforces the need for ethics committees and institutional review boards to be composed of a diverse cross-section of health professionals who are familiar with literature in their disciplines and specialties.

From Applied Ethics to Narrative Ethics: The Rationality and Morality of Telling Stories in Bioethics

A commentary on a special report, titled Narrative Ethics: The Role of Stories in Bioethics, that appeared with the January-February 2014 issue.

Anatomy of a Clinical Ethics Consultation

Theoretical accounts of the nature and purposes of clinical ethics consultation are disappointingly superficial and diffuse. Attempts to illuminate the goals, the forms, the substance, and the criteria for the success of ethics consultations need to focus on detailed reports of cases and the contexts in which they occur. The uncommonly rich description of the consultation surrounding Mrs. Roses plight provides a splendid opportunity to explore such matters. The ethics consultant pursues a number of ventures providing and clarifying information, improving communication, educating and counseling, and being a friend with variable degrees of success. What the ethics consultant can do and how well he can do it are in large part constrained by three features of the hospital context in which this consultation unfolds: pervasive, perhaps ineliminable, uncertainty; communication failures; and firmly entrenched power. A fundamental issue for an ethics consultant is whether structural and institutional constraints should be accepted or challenged. Should an ethics consultant be a peacemaker or a reformer?

What Reason Can Do for Clinical Moral Perception

The need for expansive, generous clinical moral perception and for mutual regard and respect in physician-patient and physician–physician relationships is the central lesson of the valuable target article by Rentmeester and George (2009). But their approach—how they discern and frame problems, how they analyse and argue about problems, and how they develop recommendations for handling problems and for institutional responses to prevent problems—evinces an equally important lesson about the nature of method and reason in bioethics in particular and medicine and morality in general (and, indeed, elsewhere). That lesson concerns the need for a more open, experiential orientation to people and problems, including moral problems, and for a supporting enriched, non-formal conception of reason to design, direct, and develop bioethical positions. The approach of Rentmeester and George (2009) emphasizes that physicians as well as patients are vulnerable human beings who experience emotions that can either support or hinder doctor-patient relationships. In particular, emotional distress can distort judgement and corrode, if not block, relationships. Their aim is to help physicians recognize their emotional distress and manage it in ways that prevent or at least mitigate its deleterious consequences. That goal is a dramatic contrast and corrective to narrow bioethical analyses of the physician–patient relationship that confine it to a locus of decision-making authority, where doctors engage in expert deliberation based on applying general principles such as ‘do no harm’ and ‘respect autonomy’ with the outcomes of rational diagnosis and patients apply rational analysis within the constraints of what they learn and comprehend to reach their decisions. That kind of analysis reduces patient and physician to ciphers in a grand theoretical exercise. Underpinning that exercise and rendering it rational is a conception of applied ethics in which the conclusions of both patients and physicians are deduced from general principles combined with local clinical conditions. Rationality here is understood formally and identified with logic or utility maximisation. This hegemonic conception of ratio-

The Patient in the Family and the Family in the Patient

The notion that the family is “the unit of care” for family doctors has been enigmatic and controversial. Yet systems theory and the biopsychosocial model that results when it is imported into medicine make the family system an indispensable and important component of family medicine. The challenge, therefore, is to provide a coherent, plausible account of the role of the family in family practice. Through an extended case presentation and commentary, we elaborate two views of the family in family medicine — treating the patient in the family and treating the family in the patient — and defend both as appropriate foci for care by family doctors. The practical problem that arises when the family is introduced into health care is deciding when to concentrate on the family system. The moral problems that arise concern how extensively doctors may become involved in the personal lives of their patients and families. The patient-centered clinical method provides a strategy for handling both problems. Thus, making the family a focus of care in family medicine can be justified on theoretical, practical, and moral grounds.

Understanding judicial discretion

The main aim of this paper is to clarify the dispute over judicial discretion by distinguishing the different senses in which claims about judicial discretion can be understood and by examining the arguments for these various interpretations. Three different levels of dispute need to be recognized. The first concerns whether judges actually do exercise discretion, the second involves whether judges are entitled to exercise discretion, and the third is about the proper institutional role of judges. In this context, the views of Dworkin, Raz, Perry, Greenawalt, and Sartorius are examined. Finally, it is suggested that a resolution of the judicial discretion controversy requires a satisfactory theory of the justification of judicial decisions.

From applied ethics to empirical ethics to contextual ethics

Bioethics became applied ethics when it was assimilated to moral philosophy. Because deduction is the rationality of moral philosophy, subsuming facts under moral principles to deduce conclusions about what ought to be done became the prescribed reasoning of bioethics, and bioethics became a theory comprised of moral principles. Bioethicists now realize that applied ethics is too abstract and spare to apprehend the specificity, particularity, complexity and contingency of real moral issues. Empirical ethics and contextual ethics are needed to incorporate these features into morality, not just bioethics. The relevant facts and features of problems have to be identified, investigated and framed coherently, and potential resolutions have to be constructed and assessed. Moreover, these tasks are pursued and melded within manifold contexts, for example, families, work and health care systems, as well as societal, economic, legal and political backgrounds and encompassing worldviews. This naturalist orientation and both empirical ethics and contextual ethics require judgment, but how can judgment be rational? Rationality, fortunately, is more expansive than deductive reasoning. Judgment is rational when it emanates from a rational process of deliberation, and a process of deliberation is rational when it uses the resources of non-formal reason: observation, creative construction, formal and informal reasoning methods and systematic critical assessment. Empirical ethics and contextual ethics recognize that finite, fallible human beings live in complex, dynamic, contingent worlds, and they foster creative, critical deliberation and employ non-formal reason to make rational moral judgments.

The Humanity of Genetics Practices

Read together, historian Alexandra Minna Sterns Telling Genes: The Story of Genetic Counseling in America and bioethicist Michael Parkers Ethical Problems and Genetics Practice convey a rich understanding of genetic practices and their implicit moralities. The books are methodologically similar in that both authors examine genetics practices empirically, and the resulting perspectives are complementary, Sterns from outside genetics practices and Parkers from inside.

Comments on “Legalism and Medical Ethics”

Professor Ladd’s paper is an important and much needed investigation into the theoretical underpinnings of medical ethics. I agree wholeheartedly with his criticisms of a general ethics of rights. My remarks, therefore, will focus on three issues: the connection between legalism and an ethics of rights, Professor Ladd’s criticisms of a particular version of an ethics of rights, and the adequacy of the alternative ethics of responsibility that is offered in its place.