Sweden: growing interest in ethics

Lindahl's bibliographic essay highlights five books, two doctoral theses, and several journal articles that are Sweden's major contributions to the bioethics literature. The books are H. Fagerberg's edited work on medical ethics (1984), widely used as a textbook in Sweden's medical and nursing schools; G. Wretmark, A. Wretmark, and J. Ludvigsson's co-authored text on ethics in medical care (1983); physician A. Andrén-Sandberg's case book (1986); theologian B. Hanson's collection of essays (1988); and Fagerberg's edited work on the ethics of prenatal diagnosis (1980). The theses are C. Blomquist's (1971), the first in Sweden on medical ethics, and C. Kjellstrand's 1988 work on high technology medicine. The articles include two on medical ethics in Sweden written by Lindahl and published in issues of Theoretical Medicine, the only cited works in English.     

The Federal Republic of Germany: a new forum for medical ethics

This bibliographic essay introduces recently-published German-language titles exemplifying current concerns in West German medical ethics. First mentioned are the Akademie für Ethik in der Medizin's new journal, Ethik in der Medezin, and its recommendations for including ethical content in medical education. Five other titles are discussed briefly: R. Peter's study on the protection of newborn life; geneticist T. Schroeder-Kurth and theologian S. Wehowski's book on the legal, ethical, and societal problems arising in reproductive medicine; internist F. Anschütz's critical reflection on medical practice from a clinician's perspective; physician and psychotherapist C. Schmeling-Kluda's practice-orientated study of the physician patient relationship, and philosopher H-M. Sass's edited work on health care, resource allocation, and public policy.     

A critique of clinical equipoise. Therapeutic misconception in the ethics of clinical trials

A predominant ethical view holds that physician-investigators should conduct their research with therapeutic intent. And since a physician offering a therapy wouldn't prescribe second-rate treatments, the experimental intervention and the best proven therapy should appear equally effective. "Clinical equipoise" is necessary. But this perspective is flawed. The ethics of research and of therapy are fundamentally different, and clinical equipoise should be abandoned.     

Poland: biomedical ethics in a socialist state

In one of a Hastings Center Report series of four country reports, a professor of ethics discusses the Polish approach to ethical issues in health care. Szawarski begins by outlining five factors that influence the practice of medicine in Poland: a socialist form of government, the influence of the Roman Catholic Church, an ongoing economic crisis, the legacy of the Nazi death camps, and a lack of formal instruction in biomedical ethics. He then discusses three current ethical concerns of physicians, patients, and the public: regulation of physician conduct, abortion, and in vitro fertilization. There is little formal public debate of the issues, however, and physicians seem committed to upholding traditional medical codes of ethics without analyzing underlying moral principles and justifications.     

Business ethics and health care: the re-emerging institution-patient relationship

Managed care poses a challenge to the traditional conceptualization of medicine and of the physician-patient relationship. People have evaluated the merits of managed care by focusing upon the way its incentives alter the relationship between physician and patient. However, this misses the key to rightly evaluating MCOs. To address the ethics of MCOs one should focus on the institution-patient relationship, and this has not been sufficiently addressed in the literature. I will address this relationship here and show how the institution-patient relationship has evolved, why it has become increasingly prominent, and why we must move beyond business ethics for rightly understanding it.     

The theologic ethics of euthanasia

The implications of a system of theological ethics are explored in relation to passive euthanasia, "double effect euthanasia," and active euthanasia. A religio-moral ethos anchored in beliefs of radical ethical freedom; the sacred origin and destiny of the human soul; persistent sin; and the drama of suffering, death, and transfiguration as a paradigm for difficult choices condones passive euthanasia and counsels the compassionate offer of relief from pain, even with the "double-edged intention" that the analgesia might end the patient's life. Active euthanasia must be proscribed in principle, but the technological advances that have postponed death also create the need for greater physician participation in offering a point of release in the barricade against death that we have erected.     

Undocumented patients. Commentary

Mr. A's physician recommends immediate dialysis. However, Mr. A is in the United States illegally, has no family living in the area, and is unemployed. The Emergency Medical Treatment and Labor Act requires the hospital not only to examine Mr. A, but to provide him with any needed stabilizing treatment without considering his lack of insurance coverage or ability to pay. The needed treatment to stabilize Mr. A is dialysis. Therefore, the physician admits him and starts dialysis. But Mr. A will need to continue dialysis indefinitely. Because he has no insurance and is an illegal immigrant, he is not eligible for any outpatient dialysis units. He is also unable to afford any medical treatments. Once Mr. A is stabilized, should he be discharged? His physician and social worker turn to the hospital ethics committee for help. What should Mercy Hospital do?     

OK,Boomer, MD: The Rights of Aging Physicians and the Health of Our Communities

How do we balance the rights of aging physicians against the right of the public to competent health care? This version of a classic public health ethics dilemma is here now and likely to increase as the population ages. Peer review has long been the standard mechanism for assessing physician competence, but it is subjective and too easily subverted. New options are needed, both in medicine and throughout the professions, but they are challenging to implement. Physicians have an ethical obligation to protect the health of the public by acknowledging, assessing, and addressing the cognitive effects of aging on medical competence.     

Limits on patient responsibility

The medical profession and medical ethics currently place a greater emphasis on physician responsibility than patient responsibility. This imbalance is not due to accident or a mistake but, rather is motivated by strong moral reasons. As we debate the nature and extent of patient responsibility it is important to keep in mind the reasons for giving a relatively minimal role to patient responsibility in medical ethics. It is argued that the medical profession ought to be characterized by two moral asymmetries: (1) Even if some degree of responsible behavior from patients is called for, placing the dominant emphasis on professional responsibility over patient responsibility is largely correct. The value of protecting the right to refuse treatment and arguments against paternalism block a more expansive account of patient responsibility and support a strong notion of professional responsibility. (2) Insofar as we do want to encourage an increase in patient responsibility, we have good reasons to emphasize prospective rather than retrospective notions of responsibility in clinical practice. Concerns about patient vulnerability along with the determined factors in disease leave little room for blame at the bedside. These two asymmetries generate normative limits on any positive account of patient responsibility.     

The honesty effect

Anne Barnhill focuses her article in this issue on the American Medical Association's ethics policy governing clinical use of placebos, but the implications of her analysis are deeper, touching on how physicians should make judgments about which interventions to offer patients in the process of shared decision‐making. The bottom line is that, even if an undisclosed placebo might be marginally more effective for a particular patient in the short term, over the long haul the integrity of the patient‐physician relationship relies on doctors being honest with their patients. Even when it comes to placebos, honesty remains the best policy.     

Healing Relationships

In a 2015 Hastings Center Report essay, Robert Truog and his coauthors argued that the clinical ethics portion of medical education should cast both a wider and a finer net than is sometimes realized. Many of the morally important moments in patient care are missed if we teach only general moral principles, they held; we also need to give attention to an indefinite stream of “microethical” decisions in everyday clinical practice. In the current issue, Truog plays out a similar theme as he discusses the moral significance of touching a patient and asks how artificial intelligence and other emerging technologies may change this ancient part of the physician‐patient relationship. And one of the articles in this issue examines the significance of clinicians’ relationships with other clinicians. Donna Chen and colleagues propose, in effect, that “teamwork” has become part of the ethics of everyday clinical practice—a new addition to what Larry Churchill and David Schenck called the “healing skills.”     

Truth telling in medicine: the Confucian view

Truth-telling to competent patients is widely affirmed as a cardinal moral and biomedical obligation in contemporary Western medical practice. In contrast, Chinese medical ethics remains committed to hiding the truth as well as to lying when necessary to achieve the family's view of the best interests of the patient. This essay intends to provide an account of the framing commitments that would both justify physician deception and have it function in a way authentically grounded in the familist moral concerns of Confucianism. It reflects on the moral conditions and possibilities for sustaining a Confucian understanding of truth-telling and consent in mainland China.     

“I am not interested in talking with you.”

Mr. M is an eighty‐five‐year‐old who presented to the hospital with congestive heart failure exacerbation, pneumonia, altered mental status, and sepsis. A physician determines that he lacks capacity, and the team in the intensive care unit looks to the patient's daughter, Celia, as his surrogate decision‐maker because she is named as an agent in his medical power of attorney form. While in the ICU, Mr. M suffers acute respiratory distress secondary to pneumonia and thus requires intubation. Celia accepts several life‐sustaining interventions, but she sporadically refuses other medically indicated therapies. Although providers explain the importance of the ICU insulin regimen for glucose control, she either refuses the insulin or requests a lower dose. The health care team believes that it is providing substandard care and that Celia's medical decisions are not in the patient's best interests, so they request an ethics consultation. When the clinical ethicist attempts to talk with Celia, she refuses to speak with him, saying flatly, “I am not interested in talking with you.” The clinical ethicist meets with Celia on a couple of occasions, but she consistently refuses to have a conversation with him. He wonders if the patient's surrogate decision‐maker can refuse a clinical ethics consultation and is unsure what his next steps should be.     

Nursing ethics: current state of the art

... The essays in this issue of the Journal highlight the types of insights that nursing ethics brings to health care ethics, in general, and attempt to address questions about the adequacy of the conceptual and theoretical foundations of bioethics for a practice discipline like nursing. The essays are written by nurses and non-nurses and bring a surprising balance to the discussion of important issues in nursing ethics from several perspectives. The essays do not represent the full scope of philosophical thought and normative judgements in nursing ethics at the present time, but they do provide a view of nursing ethics through the lens of nursing ethics research, past and present. [Introductions follow to essays by Joy H. Penticuff, Joan Liaschenko and Anne J. Davis, Nancy S. Jecker and Donnie J. Self, Betty J. Winslow and Gerald R. Winslow, Robert J. Connelly, Patricia A. Roth and Janet K. Harrison, and Kevin Wildes].     

The meanings of professional life: teaching across the health professions

Most of professional ethics is grounded on the assumption that we can speak meaningfully about particular, insulated professions with aims and goals, that conceptually there exists a clear "inside and outside" to any given profession. Professional ethics has also inherited the two-part assumption from mainstream moral philosophy that we can speak meaningfully about agent-relative versus agent-neutral moral perspectives, and further, that it is only from the agent-neutral perspective that we can truly evaluate our professional moral aims, rules, and practices. Several important changes that have occurred, or are currently taking place, in the structure of the health care professions, challenge those assumptions and signal the need for teachers of professional ethics to rethink the content of what we teach as well as our teaching methods. The changes include: influences and critique from other professions and from those who are served by the health professions, and influences and critique from professionals themselves, including increased activism and dissent from within the professions. The discussion focuses on changes that have occurred in the health-related fields, but insofar as similar changes are occurring in other professions such as law and business, these arguments will have broader conceptual implications for the way we ought to think about professional ethics more generally.     

Doctor does not know best: why in the new century physicians must stop trying to benefit patients

While twentieth-century medical ethics has focused on the duty of physicians to benefit their patients, the next century will see that duty challenged in three ways. First, we will increasingly recognize that it is unrealistic to expect physicians to be able to determine what will benefit their patients. Either they limit their attention to medical well-being when total well-being is the proper end of the patient or they strive for total well-being, which takes them beyond their expertise. Even within the medical sphere, they have no basis for choosing among the proper medical goals for medicine. Also, there are many plausible strategies for relating predicted benefits to harms, and physicians cannot be expert in picking among these strategies. Second, increasingly plausible ethical systems recognize that in some cases, patient benefit must be sacrificed to protect patient rights including the right to the truth, to have promises kept, to have autonomy respected, and to not be killed. Third, ethics of the next century will increasingly recognize that some patient benefits must be sacrificed to fulfill duties to others - either the duty to serve the interests of others or other duties such as keeping promises, telling the truth, and, particularly, promoting justice. Physicians in the twenty-first century will be seen as having a new, more limited duty to assist the patient in pursuing the patient's understanding of the patient's interest within the constraints of deontological ethical principles and externally imposed duties to promote justice. The result will be a duty to be loyal to the consumer of health care with the recognition that often this will mean that the physician is not permitted to pursue the physician's understanding of the patient's well-being.     

Philosophical challenges in teaching bioethics: the importance of professional medical ethics and its history for bioethics

The papers in this number of the Journal originated in a session sponsored by the American Philosophical Association's Committee on Philosophy and Medicine in 1999. The four papers and two commentaries identify and address philosophical challenges of how we should understand and teach bioethics in the liberal arts and health professions settings. In the course of introducing the six papers, this article explores themes these papers raise, especially the relationship among professional medical ethics, the "long history" of medical ethics, and bioethics. The tendency of bioethics to deprofessionalize medical ethics is rejected, in favor of an historically informed professional medical ethics. It is suggested that bioethics should be critically reconsidered from the perspective of medical ethics as professional ethics.     

Japan: a new field emerges

In Japan, bioethics is emerging as a discipline in which traditional Japanese values are being compared with ethical insights from scholars around the world. Kajikawa's bibliographic essay discusses recent publications on biomedical ethics by Japanese scholars that reflect topics of current interest and the public context in which they are debated. Works cited include books, conference proceedings, collaborative, multidisciplinary titles, seminar papers, an overview for the general public, and an annual bibliography of medical ethics references prepared by Tokai University. Topics include brain death and organ transplantation, nursing ethics, medical research, and bioethics and medical ethics in general. All titles are cited in English, with their Japanese publishers and dates of publication.     

Holding the present and future accountable to the past: history and the maturation of clinical ethics as a field of the humanities

Clinical ethics, like bioethics more generally, until recently has tended to focus on the present and future, with little attention to the history of moral thought about health care that preceded bioethics. As a consequence, clinical ethics and bioethics lack maturity as fields of the humanities. The papers in this year's clinical ethics issue of the Journal put contemporary clinical ethics in critical dialogue with the past, making the former accountable to the latter. The six papers in this issue of the Journal are briefly described, with an emphasis on how they contribute to the maturation of clinical ethics as a field of the humanities.