A fifty-four-year-old woman who had diabetes mellitus was involved in a motor-vehicle accident. She was taken to the emergency department of a small community hospital in a rural town, where it was determined that she had sustained a... more
A fifty-four-year-old woman who had diabetes mellitus was involved in a motor-vehicle accident. She was taken to the emergency department of a small community hospital in a rural town, where it was determined that she had sustained a comminuted fracture of the proximal portion of the femur. She underwent an open reduction and internal fixation of the femoral fracture, which was followed by the development of a deep wound infection that required multiple operative debridements and removal of the fixation device. The wound tissue appeared healthy, and there was no histological evidence of infection. However, the patient was left with a large soft-tissue defect and a 3-in (7.62 cm) bone deficiency. The surgeons at the community hospital were not trained in microvascular reconstructive surgery and attempted to transfer the patient to a larger, urban teaching institution for further care. Four separate institutions were contacted. All declined to accept the patient. The patient was eventually cared for by a trauma surgeon at a local private hospital. This case raises several important ethical issues, but we would like to concentrate on two in particular. One involves the responsibilities of physicians to a specific patient. The other involves the responsibilities of physicians to one another, to society, and to the community of patients. After the motor vehicle accident, the patient was taken to a local community hospital, where the femoral fracture was diagnosed and treated. The patient was known to have diabetes mellitus, and a subsequent deep wound infection developed that required multiple operative procedures. When she was left with a large soft-tissue defect and bone deficiency, the surgeons at …
Research Interests: Surgery, Ethics, Biomedical Engineering, Treatment, Medical Ethics, and 15 moreMedicine, Complication, Humans, Female, Transfer, Clinical Sciences, Middle Aged, Diabetes complications, Patient Advocacy, Teaching Hospitals, Emergency Department, Internal Fixation, Surgical wound infection, Patient transfer, and Femoral Fractures
A forty-three-year-old woman presented with problems following ankle surgery. The initial diagnosis was idiopathic avascular necrosis of the talus. An arthrodesis of the ankle was performed with external fixation and an iliac crest bone... more
A forty-three-year-old woman presented with problems following ankle surgery. The initial diagnosis was idiopathic avascular necrosis of the talus. An arthrodesis of the ankle was performed with external fixation and an iliac crest bone graft. A nonunion developed at the fusion site, and the patient reported persistent pain and an inability to bear weight. She sought a second opinion and was told that the attempt at fusion had failed. The treatment options were explained to her. She underwent debridement of the nonunion and a tibiocalcaneal arthrodesis with internal fixation. Postoperatively, the patient had a solid fusion and was able to bear full weight without pain. Although ultimately satisfied with the result, she repeatedly expressed anger about the original care and asked if malpractice had been committed. Two ethical questions are raised by this case. What should the orthopaedic surgeon who provides the second opinion do with respect to the surgeon who performed the surgery with the poor result, and what should the surgeon providing the second opinion do with respect to the patient who had the poor result? To consider the first question, imagine that Dr. S is a senior resident and Dr. J is her junior resident. In that situation, Dr. S’s two main concerns would be protecting future patients and instructing Dr. J. With these goals in mind, it is easy to see that it would be ethical for Dr. S to promptly raise questions with Dr. J about what had transpired in an attempt to instruct and correct. To the extent that Dr. J could put defensiveness and embarrassment aside, and to the extent that the problem was caused by ignorance, Dr. J should appreciate the instruction and be relieved that other patients will not suffer. To the degree that the problem was caused by a lack …
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Historians in the field have identified the 1960s–1970s with the birth of bioethics (Baker and McCullough 2009; Jonsen 1998), noting that this period was marked by dramatic advances in biomedical t...
Research Interests: Sociology, Applied Ethics, Bioethics, Research Design, Genomics, and 15 moreSocial Justice, Informed Consent, Population Dynamics, Accreditation, Medicine, Brain Death, Humans, Genetic research, Health Care Rationing, Public health systems and services research, Ethics Research, Bioethical Issues, Metagenome, Personal autonomy, and Health Services Accessibility
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ABSTRACT This chapter argues for appreciating the distinctiveness of medical ethics. If the ethics of medicine is different from the ethics of everyday life, it follows that the character of physicians is and should be different from the... more
ABSTRACT This chapter argues for appreciating the distinctiveness of medical ethics. If the ethics of medicine is different from the ethics of everyday life, it follows that the character of physicians is and should be different from the character of others. Molding the character of future physicians therefore becomes an important matter for the attention of medical educators. In that light, this chapter explains the appropriate goals for such an educational program and discusses the means for teaching and inculcating the principles, attitudes, and behaviors that physicians need to embrace in order to fulfill their special social role and professional obligations.
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This paper addresses the ethical acceptability of a proposed placebo controlled trial of a new intervention as a possible relapse prevention treatment for Neuromyelitis Optica (NMO). In the analysis of this controversial ethical issue,... more
This paper addresses the ethical acceptability of a proposed placebo controlled trial of a new intervention as a possible relapse prevention treatment for Neuromyelitis Optica (NMO). In the analysis of this controversial ethical issue, the author points out significant factors that are often overlooked or ignored, such as the life-long implications for study participants and others living with the disease, and also addresses commonly noted issues, such as vulnerability, benefits, harms, and justice that always require attention in research review.
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Dr. A is an orthopaedic surgeon who specializes in joint replacement. His local detail representative tells him of a hip and knee course with an excellent faculty and a hands-on workshop. The representative offers to pay Dr. A's... more
Dr. A is an orthopaedic surgeon who specializes in joint replacement. His local detail representative tells him of a hip and knee course with an excellent faculty and a hands-on workshop. The representative offers to pay Dr. A's travel and lodging expenses as well as a $1000 stipend to compensate him for the time away from his practice. The local detail representative offers to buy Drs. B and C lunch at a nearby restaurant in order to discuss her company's new fracture-fixation system. Dr. D is invited by a detail representative to a dinner lecture given by a prominent physician. The representative offers to donate $100 to Dr. D's medical school if she attends the dinner. A representative for a spinal instrumentation manufacturer offers Dr. E a trip, with all expenses paid, to attend a course on fixation techniques for the treatment of unstable spinal fractures if the physician will use the company's fixation system.
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ABSTRACT The American Journal of Bioethics 4.2 (2004) 20-22 The broad goal of medical education is to provide students with professional training; that is, to produce graduates with the knowledge and skills they will need to be good... more
ABSTRACT The American Journal of Bioethics 4.2 (2004) 20-22 The broad goal of medical education is to provide students with professional training; that is, to produce graduates with the knowledge and skills they will need to be good physicians. This entails helping students (including residents) to understand the content and the justification of their special responsibilities as physicians as well as to accept their professional responsibilities as important and overriding. It also involves promoting the development of habits of disposition and attitude that are essential to performance as a good physician; that is, the character (i.e., virtues) of a good physician and the development of skills to communicate competence, caring, and respect in their interaction with patients. In other words, medical education must acknowledge that its mission includes nurturing and evaluating medical professionalism and integrating ethics into clinical skills development (Moros and Rhodes 2002; Pellegrino 2002). In that light, we agree with several of the points made by Delese Wear and Mark G. Kuczewski (2004). They are correct to note that reports arising out of the au courant interest in professionalism have produced lists of abstract characteristics that "have failed to create pedagogical practices" that are effective in promoting professionalism. Also, the reports do not provide "a curricular theory of professional development," and they do not address the importance of "the learning environment for professional development." Nevertheless, we take issue with Wear and Kuczewski's view of how to identify an appropriate theory and how to use it to guide medical education. Wear and Kuczewski start by criticizing the ad hoc approach of distinguished medical societies in developing lists "of attitudes, values, and behaviors" that are essential components of professionalism. Specifically, they complain that these lists include "too many abstractions." To remedy these shortcomings, they suggest enlisting medical students and residents in the development of new ad hoc lists. We see no reason to expect novices to have greater insight than the experienced leaders in the field or any reason to expect a theory to emerge from a process designed to elicit a list. Even though the lists developed by expert physicians do capture important and traditional values of the profession, we share Wear and Kuczewski's doubts about the experts' approach to articulating the content of professionalism. The reports by the learned medical societies inadequately explain the moral necessity of the attitudes and behaviors they identify. A theory is needed to provide an account of which characteristics are essential and why. The coherence conferred by theory also provides a means for resolving inevitable conflicts between principles and serves as a guide for nurturing professionalism. We take the core of Wear and Kuczewski's complaint about "abstractions" to be that the lists fail to distinguish general characteristics (i.e., virtues) that are ethically crucial for everyone from virtues that are particularly related to the ethical practice of medicine. Virtue is the inclination to feel and act as one should. Some virtues are necessary for moral action in general; others are special responsibilities for some, such as those in a profession (Pellegrino and Thomasma 1993). For example, everyone with enough understanding of the world to appreciate its inherent dangers can recognize that some degree of courage is required to do almost anything. Courage is needed by ordinary citizens (e.g., to fly in an airplane), by patients (e.g., to submit to endoscopy), and by physicians (e.g., to treat patients with SARS). Similarly, integrity, the virtue of abiding by one's moral commitments, is the mark of every morally upright individual. Integrity supports the person who donates blood, the patient who abides by disease-containment measures, and the physician who resists pressure to discharge patients prematurely. We certainly want doctors, like everyone else, to be courageous people of integrity. Yet, without some special justification, there is no reason to count courage and integrity as special features of medical professionalism. Wear and Kuczewski's crucial point is that a theoretical framework...
Research Interests: Psychology, Applied Ethics, Medical Education, Medical Ethics, Ethical Theory, and 14 moreMoral Development, Medicine, Teaching, Social Responsibility, Learning, Curriculum, Humans, United States, Physicians, Professional Practice, Public health systems and services research, Virtues, internship and residency, and Schools Medical
D.B. presents to the orthopaedic surgeon's office with a knee injury. He informs the surgeon that he injured the knee at work. The physical examination is consistent with a torn medial meniscus. The surgeon requests a magnetic... more
D.B. presents to the orthopaedic surgeon's office with a knee injury. He informs the surgeon that he injured the knee at work. The physical examination is consistent with a torn medial meniscus. The surgeon requests a magnetic resonance imaging study and tells the patient that, depending on the results of the scan, arthroscopic surgery may be necessary. D.B. then explains that he no longer has health insurance, but, by saying that the injury occurred at work, his treatment will be covered by Workers' Compensation insurance. On further questioning, it seems unlikely that the injury did occur on the job. D.B. asks the surgeon to report the injury as work-related; otherwise, he will have to pay for the surgery himself and he cannot afford the expense. All of us are well aware of our ethical commitment to act for the good of our patients. But how far does the scope of that dictum extend? The case above raises the question of whether doctors should be concerned only with patients' health and medical well-being or whether they should also take an interest in other things that are of importance and value to their patients. Although in most circumstances it may seem very clear that doctors are not obligated to improve the financial situation of their patients, in some circumstances the extent of the physician's responsibility is not so obvious. The health-insurance structure in the United States leaves approximately 40,000,000 patients and their doctors facing difficult dilemmas about what they will sacrifice to be able to obtain or provide needed medical treatment. In the case above, the doctor and the patient confront the question of whether truth, health, or money should be relinquished. In this particular case, and in other similar situations that we …
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Volumes have been written arguing the morality of abortion. A crucial premise in many of these arguments concerns the status of the fetus; specifically, that the fetus has or does not have a right to life. Opponents of abortion typically... more
Volumes have been written arguing the morality of abortion. A crucial premise in many of these arguments concerns the status of the fetus; specifically, that the fetus has or does not have a right to life. Opponents of abortion typically argue that fetuses are persons and hence have an inviolable right to life. Advocates of the right to abortion typically maintain that fetuses are not persons and hence have no right to life.
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T.D. is a sixty-three-year-old woman who fell and fractured her wrist. She underwent a closed reduction and application of a short arm cast. Following removal of the cast, she was enrolled in a physical therapy program. She progressed... more
T.D. is a sixty-three-year-old woman who fell and fractured her wrist. She underwent a closed reduction and application of a short arm cast. Following removal of the cast, she was enrolled in a physical therapy program. She progressed slowly but eventually did well. Upon completion of treatment, she sent two bottles of wine to her physician. Two weeks later, T.D. made several requests of her physician. Despite nearly normal functioning of the wrist, she asked her doctor to prescribe additional physical therapy and to complete forms that would justify additional time off from work. She also asked for letters supporting suspension of her gym membership and alteration of her vacation plans. Patients often demonstrate their gratitude for the medical care that they have received by bringing gifts to the treating physicians. Usually, these tokens are cards, baked goods, articles of clothing, or handcrafted items—modest items given to physicians as gestures from appreciative patients or their families. As the above scenario illustrates, however, gifts can raise ethical issues of which we need to be aware. The potential problems usually involve the nature of the gift and the expectations of the patient. Certain gifts can create problems in and of themselves. Gifts of an exceedingly personal nature are usually inappropriate. Gifts of intimate items may be inconsistent with the maintenance of the doctor-patient relationship. They can certainly make the treating physician feel uncomfortable and interfere with the requisite boundaries of professionalism. Furthermore, the acceptance of such a gift by the physician may signal a departure from professionalism as well as the professional relationship. Similarly, gifts of excessive monetary value or cash gifts are usually improper. These types of gifts can be interpreted as payoffs or “tips” …
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Do-not-resuscitate (DNR) orders are typically signed by physicians in conjunction with patients or their surrogate decision makers in order to instruct healthcare providers not to perform cardiopulmonary resuscitation (CPR). Both the... more
Do-not-resuscitate (DNR) orders are typically signed by physicians in conjunction with patients or their surrogate decision makers in order to instruct healthcare providers not to perform cardiopulmonary resuscitation (CPR). Both the medical literature and CPR guidelines fail to address when it is appropriate for physicians to sign DNR orders without any knowledge of a patient's wishes. We explore the ethical issues surrounding instituting a two-physician DNR for a dying patient with multiple comorbidities and no medical record on file, no advance directives, and no surrogate decision maker. Through this case we also highlight the issues of poor prognostication and the reversal of a DNR in such circumstances.
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The Trusted Doctor: Medical Ethics and Professionalism rejects the well-entrenched views of medical ethics as everyday ethics or common morality applied to medicine. This chapter lays the foundation for the original account of medical... more
The Trusted Doctor: Medical Ethics and Professionalism rejects the well-entrenched views of medical ethics as everyday ethics or common morality applied to medicine. This chapter lays the foundation for the original account of medical ethics that follows in the book’s succeeding chapters. By presenting vivid examples and general arguments the author demonstrates ways in which the ethics of medicine is distinct and different from common morality. The chapter discusses the most popular common morality views, namely, the four principles approach expounded by Tom Beauchamp and James Childress in Principles of Biomedical Ethics and the ten rules approach presented by Bernard Gert, Charles Culver, and K. Danner Clouser in Bioethics: A Systematic Approach by presenting arguments that challenge their applicability to medical practice. A chart identifies some stark differences between the common morality approach and good medical practice and shows how everyday ethics is incompatible with me...
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Debates in the abortion literature typically rely upon crude versions of ethical naturalism. Pro-choice advocates invoke the absence of psychological characteristics such as the capacity to reason to support the claim that fetuses do not... more
Debates in the abortion literature typically rely upon crude versions of ethical naturalism. Pro-choice advocates invoke the absence of psychological characteristics such as the capacity to reason to support the claim that fetuses do not have a right to life; pro-life advocates invoke biological characteristics such as the human genome to support the claim that the fetus does have that right. Yet such arguments notoriously transition from claims of fact to moral claims. In contrast, constructivism offers a novel and useful approach to the abortion debate. In this chapter, I provide a constructivist account of the ethics of abortion. On this account, the fetus’s right to life derives from parents taking on the obligation to care for and nourish their future child. This constructivist account of the right to life as a special personal obligation offers a dramatic challenge to natural rights theorists’ paradigmatic example.
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LANGUAGE NOTE | Document text in Chinese目前，涉及遺傳聯繫的一些意義重大的道德問題與遺傳知識有關。在這篇文章中，... more
LANGUAGE NOTE | Document text in Chinese目前，涉及遺傳聯繫的一些意義重大的道德問題與遺傳知識有關。在這篇文章中， 我沒有著眼於通常提到的專業或公共機構對個人負責的問題，而是著手談論就遺傳知識而言，個人應相互負有的責任。我提出：個人在不提供社會的群體遺傳學知識、不增加他們家族的遺傳歷史知識、不發現關於他們自己和他們後代的遺傳信息的情況下，是否具有追求自己目標的道德權利。這些問題引導我們考察對遺傳不知的推定權利並探究各種各樣的社會紐帶。根據上述考慮我分析了幾個案例，從而導致了一些意想不到的結論，觸及了廣為人們接受的遺傳諮詢規則，也獲得了對典型問題的倫理學洞察力，並且進一步引發了未被答覆的面對遺傳知識個人所負何種責任的問題。DOWNLOAD HISTORY | This article has been downloaded 11 times in Digital Commons before migrating into this platform.
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Due to the extensive nature of the trauma, the surgical reconstruction took several hours. In the middle of the operation, one member of the operating-room staff began to complain about the late hour and commented that the surgeon need... more
Due to the extensive nature of the trauma, the surgical reconstruction took several hours. In the middle of the operation, one member of the operating-room staff began to complain about the late hour and commented that the surgeon need not be so meticulous as the patient was not going to use the hand to play piano; he would likely be using it to shoot a gun. The attending physician replied that we could not know whether or not the patient played piano, nor whether he might take it up after surgery. The surgery was completed, and the patient was brought to the intensive care unit for postoperative monitoring of his other injuries.
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The need for organs to transplant is clear. Due to the lack of transplants, people suffer, they die, and the cost of taking care of them until they die is huge. There is general agreement that it would be good to increase the supply of... more
The need for organs to transplant is clear. Due to the lack of transplants, people suffer, they die, and the cost of taking care of them until they die is huge. There is general agreement that it would be good to increase the supply of organs in order to meet the demand for organ transplantation.
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The association of medicine with science is at the core of the profession’s expertise. This chapter explains that doctors are duty-bound to base their diagnoses and treatment decisions on scientific evidence because patients rely on that... more
The association of medicine with science is at the core of the profession’s expertise. This chapter explains that doctors are duty-bound to base their diagnoses and treatment decisions on scientific evidence because patients rely on that commitment when seeking treatment and advice. Thus, the commitment to science is a core duty of medical ethics. The chapter argues that doctors should be committed to advancing biomedical knowledge and supporting medicine’s research agenda. In that light, the chapter opposes two widely accepted views. One is the World Medical Association’s position that physicians should focus exclusively on the good of their individual patient. The other is the US Common Rule’s distinction between clinical innovation and research, which has the effect of driving a wedge between medical ethics and research ethics. The chapter also addresses challenging issues of how human subject research should be conducted, research oversight, consent, vulnerable subjects, and pla...
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"Due to the COVID-19 pandemic, many courses that were once in person are now online. In our new “physically distanced” world, bioethics faculty has had to adapt quickly. To bridge the gap created by eliminating... more
"Due to the COVID-19 pandemic, many courses that were once in person are now online. In our new “physically distanced” world, bioethics faculty has had to adapt quickly. To bridge the gap created by eliminating face-to-face interaction for two cohorts of international bioethics students, we combined them and created five four-week online bioethics mini-courses: “Justice and Pandemic Diseases,” “Reproduction,” “Pediatrics,” “Organ Transplantation,” and “Death and Dying.” Each mini-course involved required readings, weekly lectures, discussion board participation, and a final paper. Our study evaluates the comparative effectiveness of synchronous and asynchronous lecture delivery on student learning as evidenced in online discussion board posts in the mini-courses. Students from both cohorts received the same educational materials but were divided into two groups for alternating synchronous and asynchronous Zoom lectures. We developed a standardized rubric, and raters have been using it to score each student’s initial posts. We hypothesized that, for the same discussion board question, students’ scores on posts following synchronous lectures will on average be higher than those following asynchronous lectures. We will finalize our data analysis at the conclusion of the final mini-course in late March and learn if the data support our hypothesis. There are many challenges in determining the comparative effectiveness of synchronous and asynchronous teaching on overall student learning. Our study addresses a modest yet worthwhile question, whether and to what degree these different lecture modalities impact student learning evidenced in discussion board posts. Our findings will contribute to bioethics pedagogical research during these challenging times. "
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This paper challenges the long-standing and widely accepted view that medical ethics is nothing more than common morality applied to clinical matters. It argues against Tom Beauchamp and James Childress’s four principles; Bernard Gert, K.... more
This paper challenges the long-standing and widely accepted view that medical ethics is nothing more than common morality applied to clinical matters. It argues against Tom Beauchamp and James Childress’s four principles; Bernard Gert, K. Danner Clouser and Charles Culver’s ten rules; and Albert Jonsen, Mark Siegler, and William Winslade’s four topics approaches to medical ethics. First, a negative argument shows that common morality does not provide an account of medical ethics and then a positive argument demonstrates why the medical profession requires its own distinctive ethics. The paper also provides a way to distinguish roles and professions and an account of the distinctive duties of medical ethics. It concludes by emphasizing ways in which the uncommon morality approach to medical ethics is markedly different from the common morality approach.
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In this paper I argue for recognizing the moral duty to participate in research. I base my argument on the need for biomedical research and the fact that at some point studies require human participants, what I call collaborative... more
In this paper I argue for recognizing the moral duty to participate in research. I base my argument on the need for biomedical research and the fact that at some point studies require human participants, what I call collaborative necessity. In presenting my position, I argue against the widely accepted views of Han Jonas and all of those who have accepted his declarations without challenge. I go on to show why it is both just and fair to invite and encourage people to participate in studies. It is just because research participation is the necessary means to achieve the broadly shared goals of preventing and curing disease and alleviating disease symptoms. Mutual love requires us to be willing to do for others what we would want them to do for us. It is fair because the approach treats similarly situated people in the same way. Research participation is morally required because failing to do one's part in the collaborative project of advancing biomedical science would be free-ri...
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This article provides a critique of the monolithic accounts that define justice in terms of a single and often inappropriate goal. By providing an array of real examples, I argue that there is no simple definition of justice, because... more
This article provides a critique of the monolithic accounts that define justice in terms of a single and often inappropriate goal. By providing an array of real examples, I argue that there is no simple definition of justice, because allocations that express justice are governed by a variety of reasons that reasonable people endorse for their saliency. In making difficult choices about ranking priorities, different considerations have different importance in different kinds of situations. In this sense, justice is a conclusion about whether an allocation reflects the human interests and priorities that are at stake. The article describes how several principles of justice have a legitimate place in medical allocations. To achieve justice within medical practice, professionals should focus on the human interests and compelling reasons for prioritizing specific principles within their specific medical domain.
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To promote justice in research practice and rectify health disparities, greater diversity in research participation is needed. Lack of trust in medical research is one of the most significant obstacles to research participation. Multiple... more
To promote justice in research practice and rectify health disparities, greater diversity in research participation is needed. Lack of trust in medical research is one of the most significant obstacles to research participation. Multiple variables have been identified as factors associated with research participant trust/mistrust. A conceptual model that provides meaningful insight into the interplay of factors impacting trust may promote more ethical research practice and provide an enhanced, actionable understanding of participant mistrust. A structured survey was developed to capture attitudes toward research conducted in emergency situations; this article focuses on items designed to assess respondents' level of trust or mistrust in medical research in general. Community-based interviews were conducted in English or Spanish with 355 New York City residents (white 42%, African American 29%, Latino 22%). Generally favorable attitudes toward research were expressed by a majorit...
Research Interests: Psychology, Research Design, Social Justice, Medicine, Humans, and 15 moreBiomedical Research, New York City, Female, Male, Physicians, Conceptual Framework, Attitude, African Americans, Aged, Middle Aged, Adult, European Continental Ancestry Group, Surveys and Questionnaires, Patient selection, and Residence Characteristics
Palliative care has had a long-standing commitment to teaching medical students and other medical professionals about pain management, communication, supporting patients in their decisions, and providing compassionate end-of-life care.... more
Palliative care has had a long-standing commitment to teaching medical students and other medical professionals about pain management, communication, supporting patients in their decisions, and providing compassionate end-of-life care. Palliative care programs also have a critical role in helping patients understand medical conditions, and in supporting them in dealing with pain, fear of dying, and the experiences of the terminal phase of their lives. We applaud their efforts to provide that critical training and fully support their continued important work in meeting the needs of patients and families. Although we appreciate the contributions of palliative care services, we have noted a problem involving some palliative care professionals' attitudes, methods of decisionmaking, and use of language. In this article we explain these problems by discussing two cases that we encountered.
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In their article, “The job of ‘ethics committees’”, Andrew Moore and Andrew Donnelly argue that current guidance documents provide that institutional research review committees (hereafter, institutional review boards (IRBs)) perform two... more
In their article, “The job of ‘ethics committees’”, Andrew Moore and Andrew Donnelly argue that current guidance documents provide that institutional research review committees (hereafter, institutional review boards (IRBs)) perform two different and distinct functions, namely, a regulative review and an ethical review. They argue for separating those functions and for eliminating the ethics review role from IRBs. Instead, they want IRBs to focus exclusively on determining whether research proposals conform to governing regulations. In their argument, Moore and Donnelly correctly note that regulatory requirements and ethical requirements can conflict. That point is correct, but hardly surprising. After all, regulations are general and the research proposals are specific, so an individual proposal may not conform to the general formulation of the rule and yet be consistent with ethics. Thus, a rule may generally be regarded as expressing a relevant moral consideration while providing a conclusion that does not appropriately reflect an ethical determination in the specific case. This inconsistency need not amount to what Moore and Donelly characterise as a ‘repellent’ or an ‘unconscionable’ review decision (p. 13). Moore and Donnelly are also concerned that IRB decisions may differ from each other in their review of the same proposal. Again, they are correct in recognising that such inconsistent outcomes would be less likely if IRBs were to focus exclusively on whether proposals conformed to the regulations. That said, I reach the opposite conclusion. As I see it, IRBs present us with a good example of when the possibility of inconsistency is a relatively small consideration in comparison to the important values that are served by IRBs considering their protocol reviews in light of ethics and conforming to regulations. Allow me to explain. The authors and endorsers of research ethics …
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cell transplantation in patients with Primary Immune Regulatory Disorders (PIRD): A Primary Immune Deficiency Treatment Consortium (PIDTC) Survey. Frontiers in Immunology 11:239. doi:10.3389/fimmu.2020. 00239. Foster, L. W., L. J.... more
cell transplantation in patients with Primary Immune Regulatory Disorders (PIRD): A Primary Immune Deficiency Treatment Consortium (PIDTC) Survey. Frontiers in Immunology 11:239. doi:10.3389/fimmu.2020. 00239. Foster, L. W., L. J. McLellan, L. A. Rybicki, J. Dabney, E. Welsh, and B. J. Bolwell. 2006. Allogeneic BMT and patient eligibility based on psychosocial criteria: A survey of BMT professionals. Bone Marrow Transplant 37 (2): 223–8. doi:10.1038/sj.bmt.1705219. Ifversen, M., R. Meisel, P. Sedlacek, K. Kalwak, L. Sisinni, D. Hutt, T. Lehrnbecher, et al. 2021. Supportive care during pediatric hematopoietic stem cell transplantation: Prevention of infections. a report from workshops on supportive care of the Paediatric Diseases Working Party (PDWP) of the European Society for Blood and Marrow Transplantation (EBMT). Frontiers in Pediatrics 9:705179. doi:10.3389/fped.2021.705179. Iltis, A. S. 2013. Parents, adolescents, and consent for research participation. The Journal of Medicine and Philosophy 38 (3):332–46. doi:10.1093/jmp/jht012. Kanate, A. S., M.-A. Perales, and M. Hamadani. 2020. Eligibility criteria for patients undergoing allogeneic hematopoietic cell transplantation. Journal of the National Comprehensive Cancer Network 18 (5):635–43. doi:10. 6004/jnccn.2020.7559. Lefkowitz, D. S., C. J. Fitzgerald, N. Zelikovsky, K. Barlow, and J. Wray. 2014. Best practices in the pediatric pretransplant psychosocial evaluation. Pediatric Transplantation 18 (4):327–35. doi:10.1111/petr.12260. Pai, A. L. H., J. Rausch, S. Drake, C. F. Morrison, J. L. Lee, A. Nelson, A. Tackett, S. Berger, L. Szulczewski, C. Mara, et al. 2018. Poor adherence is associated with more infections after pediatric hematopoietic stem cell transplant. Biology of Blood and Marrow Transplantation 24 (2): 381–5. doi:10.1016/j.bbmt.2017.10.033. Preussler, J. M., L.-W. Mau, N. S. Majhail, M. Bevans, E. Clancy, C. Messner, L. Parran, K. A. Pederson, S. Stickney Ferguson, K. Walters, et al. 2019. Caregiver availability and patient access to hematopoietic cell transplantation: Social worker perspectives inform practice. Supportive Care in Cancer 27 (11): 4253–64. doi:10.1007/ s00520-019-04696-2. Seltzer, R. R., C. M. Henderson, and R. D. Boss. 2016. Medical foster care: What happens when children with medical complexity cannot be cared for by their families? Pediatric Research 79 (1–2): 191–6. doi:10.1038/pr.2015. 196. Sharma, A., and L.-M. Johnson. 2019. Should poor social support be an exclusion criterion in bone marrow transplantation? American Journal of Bioethics 19 (11): 39–41. doi:10.1080/15265161.2019.1665736. Varma, S. D. Wendler. 2008. Research involving wards of the state: Protecting particularly vulnerable children. The Journal of Pediatrics 152 (1): 9–14. doi:10.1016/j.jpeds. 2007.07.039.
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Despite apparent disagreement in the scholarly literature on standards of pediatric decision making, a recognition that similar norms underpin many of the dominant frameworks motivated a June 2022 symposium “Best Interests and Beyond:... more
Despite apparent disagreement in the scholarly literature on standards of pediatric decision making, a recognition that similar norms underpin many of the dominant frameworks motivated a June 2022 symposium “Best Interests and Beyond: Standards of Decision Making in Pediatrics” in St Louis, MO. Over the course of this 3-day symposium, 17 expert scholars (see author list) deliberated on the question “In the context of US pediatric care, what moral precepts ought to guide parents and clinicians in medical decision making for children?” The symposium and subsequent discussion generated 6 consensus recommendations for pediatric decision making, constructed with the primary goals of accessibility, teachability, and feasibility for practicing clinicians, parents, and legal guardians. In this article, we summarize these recommendations, including their justification, limitations, and remaining concerns.
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An amendment to this paper has been published and can be accessed via the original article.
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To The Editor: In the Ethics in Practice article "Assessing a Patient's Capacity to Refuse Treatment" (2002;84:691-3), by Capozzi and Rhodes, the authors concluded that the "patient's insistence on her ability to... more
To The Editor: In the Ethics in Practice article "Assessing a Patient's Capacity to Refuse Treatment" (2002;84:691-3), by Capozzi and Rhodes, the authors concluded that the "patient's insistence on her ability to function independently at home with a hip fracture demonstrates her lack of decisional capacity." I disagree with the authors' conclusion. The role of a physician includes both advocating for and educating patients. Through this interaction, individuals are permitted to make autonomous decisions. Unfortunately, patients will often make choices that the physician believes are foolhardy, but a physician who overrides the choice of a patient with decisional capacity would be robbing that patient of his or her autonomy. The authors apparently believe that the patient in their case doesn't have decisional capacity because she "denies the indisputable facts." In addition, they do not accept the psychiatrist's assessment of capacity apparently because neither the patient nor the psychiatrist had a background in musculoskeletal medicine and therefore are not able to understand the implications of the refusal of surgery. I believe that the authors have overstated the "facts" in an altruistic …
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This article seeks to place the study of British government in a broader context by exploring the potential contribution of an anti-foundational epistemology. We seek to ‘reinvent’ a self-conscious, sceptical and tentative approach rooted... more
This article seeks to place the study of British government in a broader context by exploring the potential contribution of an anti-foundational epistemology. We seek to ‘reinvent’ a self-conscious, sceptical and tentative approach rooted in philosophy and history. The first section defines the Westminster model and the family of linked narratives: traditional sceptics, social science, radical theory, new public management. The second section outlines an anti-foundational epistemology, focusing on the notions of traditions, narratives, de-centering and dilemmas. The third section applies this approach to one prominent school of thought about British government: policy networks. We argue that an anti-foundational approach will decenter networks, shifting the locus of analysis from the institutions to individuals, and focus on dilemmas to explain how networks change. Finally, we conclude there is no essentialist account of British government, only complex and diverse narratives, and n...