Processes and Pitfalls of Dialogical Bioethics

Bioethics uses various theories, methods and institutions for its decision-making. Lately, a dialogical, i.e., dialogue-based, approach has been argued for in bioethics. The aim of this paper is to explore some of the decision-making processes that may be involved in this dialogical approach, as well as related pitfalls that may have to be addressed in order for this approach to be helpful, particularly in clinical ethics. Using informal logic, an analysis is presented of the notion of dialogue and of the stages of dialogical decision-making, and then processes and related pitfalls associated with these stages in the context of clinical ethics are examined. The results of this exploration are expected to facilitate the implementation and empirical testing of dialogical bioethics.     

Constructing Critical Bioethics by Deconstructing Culture/nature Dualism

This paper seeks to respond to some of the recent criticisms directed toward bioethics by offering a contribution to a “critical bioethics”. Here this concept is principally defined in terms of the three features of interdisciplinarity, self-reflexivity and the avoidance of uncritical complicity. In a partial reclamation of the ideas of V.R. Potter, it is argued that a critical bioethics requires a meaningful challenge to culture/nature dualism, expressed in bioethics as the distinction between medical ethics and ecological ethics. Such a contesting of the “bio” in bioethics arrests its ethical bracketing of environmental and animal ethics. Taken together, the triadic definition of a critical bioethics offered here provides a potential framework with which to fend off critiques of commercial capture or of being “too close to science” commonly directed toward bioethics.     

Theological discourse and the postmodern condition: The case of bioethics

Bioethic reflects — like many other disciplines — the cultural fragmentation and the complexity of what has come to be known as the postmodern condition. The case of bioethics is particularly acute because of its epistemological indeterminacy and the moral pluralism characterizing post liberal societies. A provisional solution to this situation is the retrieval of a neo-Kantian version of ethical formalism in which concern for a consensus on rules replaces universal dialogue on moral content. The article analyzes the possible consequences of this solution with reference to theological ethics. In particular, the reduction of ethical rationality to a function of political regulation on the one hand, and the implicit legitimization of ethical relativism on the other, push any theological contribution to bioethics to the margins. The central methodological issue for the articulation of theological discourse in bioethics is how to avoid the pitfall of privatism while creating the conditions for ethical dialogue across different traditions. This revised version was published online in July 2006 with corrections to the Cover Date.     

Ethics in American health 1: ethical approaches to health policy

I trace the evolution of ethical approaches to health policy in the United States and examine a number of critical unresolved issues pertaining to the current set of frameworks. Several themes emerge. First, fair procedures claim more attention than substantive and procedural principles. Second, in the case of public deliberation, more focus has been placed on factors such as procedural mechanisms than on understanding how individuals and groups value different aspects of health and agree on health-related decisions. Third, the nation needs workable frameworks to guide collective choices about valuable social ends and their trade-offs; purely procedural strategies are limited in illuminating overarching health policy and ethics questions. There is a need to integrate consequential and procedural approaches to health ethics and policy.     

Fair Process and the Redundancy of Bioethics: A Polemic

Recent doctrine in both national and international organisationsconcerned with public health planning and resource allocationhas it that direct ethical justification of substantive decisionsis so difficult as to be impossible. Instead, we should agreeon criteria of procedural justice and reach decisions whosejustification lies in how they are arrived at, rather than anydirect ethical justification on the ground of substantive moralprinciples. In this polemical article, I argue that this amountsto a serious dereliction of intellectual duty on the part ofthe bioethics community. Our role in these settings is to produceand defend the best substantive arguments we can. Failing todo this makes bioethicists at best redundant and at worst leadsus to seriously defective conclusions. The argument is illustratedby analysis of the ethical frameworks for resource allocationunder the UNAIDS ‘3 by 5’ programme and for pandemicinfluenza planning.     

Fetal conditions and fatal decisions: ethical dilemmas in ultrasound screening in Vietnam

This paper situates discussion of the ethics of ethnographic research against the background of a theoretical and methodological debate about the relationship between ethics and method, and about the relationships between research methods and their objects. In particular, the paper investigates the implications of folding together the ethical and the empirical in research and argues that this requires the development of new ethico-ethnographic methods for the investigation of ethico-moral objects. The paper falls into three main parts. The first considers calls for what has come to be known as empirical ethics, that is, for a more empirically informed bioethics, by way of an exploration of the integration of ethnographic methods in bioethics, and concludes that approaches which see the ethical and the empirical as 'complementary' do not do justice to the methodological implications of enfolding the ethical and the ethnographic. The second part juxtaposes this with calls for the integration of ethics in ethnography and, similarly, argues that the enfolding of the ethical and the empirical in ethnography calls for the development of new methods. The paper goes on to problematise the 'negotiational' approaches to informed consent preferred by many ethnographers, arguing that the concept of negotiation, rather than offering a solution to the problem of consent, is itself ethically complex and in need of analysis. The paper argues that, in the context of ethnographic research, the possibility of negotiational forms of consent depends upon engagement between researchers and researched, with unavoidably 'ethical' concepts such as 'respect', 'recognition', 'dignity', 'justice' and so on, and that this poses methodological challenges to ethnography. The paper's third section explores the implications of these arguments for research practice, using The Genethics Club as an example.     

Richtig gute epidemiologische Praxis

Objective/methods

The need for public health ethics and ethics in epidemiology has recently become more obvious. In this article a methodological and normative framework for public health ethics is discussed.

Results

Some of the prevalent approaches of public health ethics and ethics in epidemiology are missing a systematic philosophical account and/or norms that are relevant and enlightening for the ethical discussion in public health. For an approach of public health ethics one can learn from bioethics and adopt methodologies that have been applied and elaborated in this field. However, there is a need for a set of principles in public health ethics that differs from the bioethical principles. Ethical codes and guidelines are already applied in the practice of epidemiology and public health without relating these to ethical principles. This is a deficit for goal-oriented ethical reasoning in public health and epidemiology.

Conclusion

An applied ethical discourse in public health can be helpful for public health and epidemiology. Ethical principles facilitate coherent reasoning that enriches the discussion of ethical problems as opposed to only relying on very specific moral rules as in codes and guidelines.     

Wanted: A New Ethics Field for Health Policy Analysis

Ethics guidance and ethical frameworks are becoming more explicit and prevalent in health policy proposals. However, little attention has been given to evaluating their roles and impacts in the policy arena. Before this can be investigated, fundamental questions must be asked about the nature of ethics in relation to policy, and about the nexus of the fields of applied ethical analysis and health policy analysis. This paper examines the interdisciplinary stretch between bioethics and health policy analysis. In particular, it highlights areas of scholarship where a health policy ethicsspecialization—as distinctive from bioethics—might develop to address health policy concerns. If policy and ethics both ask the same question, that question is: “What is the good, and how do we achieve (create, protect, cultivate) it?” To answer this question, the new field of “health policy ethics” requires development. First, we should develop a full set of ethical principles and complementary ethical theories germane to public policy per se. Second, we must understand better how explicit attention to ethical concerns affects policy dynamics. Third, we require new policy and ethical analytic approaches that contribute to constructive (not obstructive) policy making. Finally, we need indicators of robust, high quality ethical analysis for the purpose public policy making.     

Context in medical education: the informal ethics curriculum

As some formal bioethics instruction has become the norm in American medical schools, a trend has emerged toward increased attention to context in both bioethics education and bioethical decision-making. A focus on classical dilemmas and a textbook knowledge of principles is yielding its previous dominance to permit a more detailed examination of ethical behaviour in actual practice in medicine. After documenting and analysing this emerging trend in bioethics education and its parallel in bioethics theory and research, we turn to the context of medical education itself to look beyond formal bioethics instruction to the ' informal curriculum ' that is so central to the moral development of medical students and residents.
A qualitative research strategy is being used to study the informal curriculum through analysing tape-recorded informal conversations students and residents have with their friends and colleagues at work about issues bearing on their professional development. Data presented are documenting 'the unwritten code' for medical students on a surgical clerkship and the senior residents' informal ways of producing a ' practical ethics of conduct ' that shapes understanding of what is good, skilful, and right on that surgical service. How conceptions of appropriate conduct are conveyed, rewarded and sanctioned also reveals how professional demeanour is taught, permitting discussion about what should be retained and what changed. The context in which ethical issues arise enhances understanding of ethical practice in medicine.     

A pluralist view of nursing ethics

Abstract  This paper makes the case for a pluralist, contextualist view of nursing ethics. In defending this view, I briefly outline two current perspectives of nursing ethics – the Traditional View and the Theory View. I argue that the Traditional View, which casts nursing ethics as a subcategory of healthcare ethics, is problematic because it (1) fails to sufficiently acknowledge the unique nature of nursing practice; and (2) applies standard ethical frameworks such as principlism to moral problems which tend to alienate or undermine nursing ethical concerns. Alternatively, the Theory View, which aims to build an independent and comprehensive theory of nursing ethics, is also found wanting because it (1) fails to sufficiently acknowledge the heterogeneous nature of nursing practices; (2) overemphasizes the differences and undervalues the similarities between nurses and other health professionals; and (3) assumes that one ethical framework can be meaningfully applied across diverse moral problems and contexts.
My alternative, is to argue that nursing ethics inquiry should take a pluralist and critical stance towards available ethical frameworks and the negotiation of the ethical realm. On this view, the search for moral consensus or a unique ethical framework for nursing is replaced by the task of working strategically with multiple frameworks in order to expand the moral agency of nurses and empower them to positively engage with moral uncertainty as an inevitable feature of living a moral life. I conclude by indicating some of the implications that this has for the teaching of nursing ethics.     

Research on clinical ethics and consultation. Introduction to the theme

Clinical ethics consultation has developed from local pioneer projects into a field of growing interest among both clinicians and ethicists. What is needed are more systematic studies on the ethical challenges faced in clinical practice and problem solving through ethics consultation from interdisciplinary perspectives. The Thematic Issue covers a range of topics and includes five recent studies from various European countries and the USA, focusing on issues such as the ethical difficulties of end of life decisions, experiences with newly developed or well established ethics consultation services, and the expectations of physicians in various clinical fields who are still unfamiliar with clinical ethics consultation. The papers included illustrate the interface between different socio-cultural contexts and their ways of dealing with clinical ethics consultation. They deepen the dialogue on clinical ethics consultation that has emerged at the European and International level.     

Supererogation in clinical research

'Supererogation' is the notion of going beyond the call of duty. The concept of supererogation has received scrutiny in ethical theory, as well as clinical bioethics. Yet, there has been little attention paid to supererogation in research ethics. Supererogation is examined in this paper from three perspectives: (1) a summary of two analyses of 'supererogation' in moral theory, as well as an examination as to whether acts of supererogation exist; (2) a discussion of supererogation in clinical practice, including arguments that both physicians and patients can practice acts of supererogation; (3) a discussion as to why researchers, qua researchers, are not routinely recognized to perform acts of supererogation, while at the same time the very nature of research subject participation involves supererogation. The article concludes by considering three examples of supererogation on the part of researchers, with a plea that researchers' supererogatory actions be recognized as such.     

"Stuck in the middle with you": the ethics and process of qualitative research with two people in an intimate relationship

In this article, the authors discuss their experiences of two separate research projects involving interviews with both partners in care relationships that pushed the ethics of research methods along unfamiliar routes. The desire to understand the relationship from both sides was seen to outweigh the perils of accessing both stories but only when the ethical and procedural elements had been sufficiently worked through. It is those ethical and procedural elements that they share in this article, which is offered as a provocative nudge toward a continued critical appraisal of ethical standards within qualitative research and begins with the authors' reflection on their processes for such research through the examination of a fictionalized vignette.     

Managing ethical uncertainty: implicit normativity and the sociology of ethics

This article illustrates and discusses the idea of ‘implicit normativity’, and specifically its relevance to the management of ethical uncertainty. In particular I consider (i) the role implicit normativity plays in masking and containing potential ethical uncertainty and (ii) the contrast and boundary between implicit normativity and ‘overt ethics’ where ethical contestation – as well as particular processes and agents – are highlighted as salient. Using examples I show how the idea of implicit normativity can be applied not only to specific practices but also to whole fields of practice. The notion of ‘moral settlements’ – along with the explanatory role of the threat of ‘chaos’ – is introduced and elucidated to develop these points. I argue that attention to the management of ethical uncertainty shows the critically important contribution that an ambitious sociology of ethics can make to clinical ethics, including by helping to formulate and drive home questions about the ‘ethics of ethics’. The account presented here has resonances with work that seeks to use sociological lenses to move beyond conventional bioethics, including Petersen's (2013) call for a ‘normative sociology’.     

The Socratic method in teaching medical ethics: Potentials and limitations

The Socratic method has a long history in teaching philosophy and mathematics, marked by such names as Karl Weierstrass, Leonard Nelson and Gustav Heckmann. Its basic idea is to encourage the participants of a learning group (of pupils, students, or practitioners) to work on a conceptual, ethical or psychological problem by their own collective intellectual effort, without a textual basis and without substantial help from the teacher whose part it is mainly to enforce the rigid procedural rules designed to ensure a fruitful, diversified, open and consensus-oriented thought process. Several features of the Socratic procedure, especially in the canonical form given to it by Heckmann, are highly attractive for the teaching of medical ethics in small groups: the strategy of starting from relevant singular individual experiences, interpreting and cautiously generalizing them in a process of inter-subjective confrontation and confirmation, the duty of non-directivity on the part of the teacher in regard to the contents of the discussion, the necessity, on the part of the participants, to make explicit both their own thinking and the way they understand the thought of others, the strict separation of content level and meta level discussion and, not least, the wise use made of the emotional and motivational resources developing in the group process. Experience shows, however, that the canonical form of the Socratic group suffers from a number of drawbacks which may be overcome by loosening the rigidity of some of the rules. These concern mainly the injunction against substantial interventions on the part of the teacher and the insistence on consensus formation rooted in Leonard Nelson's Neo-Kantian Apriorism.     

Ethical Issues in the Economic Assessment of Health Care Technologies

This paper challenges traditional views which oppose health economics and medical ethics by arguing that economic assessment is a necessary complement to medical ethics and can help to improve public participation and democratic processes in choices about resource allocation for health care technologies. In support of this argument, four points are emphasized: (1) Most current biomedical ethical debates implicitly deal with economic issues of resource allocation. (2) Clinical decisions, which usually respect the Hippocratic code of ethics, are nevertheless influenced by economic incentives and constraints. (3) Economic assessment is concerned with both efficiency and equity and potential trade-offs between the two, which means that ethical judgements are always embedded in welfare economics. (4) The real debate is not between economics on the one side and medical ethics on the other. Rather it is between different ethical conceptions of social justice and the contrasting approaches they entail to reconciling individual interests and preferences with collective goods and welfare. This revised version was published online in August 2006 with corrections to the Cover Date.     

Good Care in Ongoing Dialogue. Improving the Quality of Care Through Moral Deliberation and Responsive Evaluation

Recently, moral deliberation within care institutions is gaining more attention in medical ethics. Ongoing dialogues about ethical issues are considered as a vehicle for quality improvement of health care practices. The rise of ethical conversation methods can be understood against the broader development within medical ethics in which interaction and dialogue are seen as alternatives for both theoretical or individual reflection on ethical questions. In other disciplines, intersubjectivity is also seen as a way to handle practical problems, and methodologies have emerged to deal with dynamic processes of practice improvement. An example is responsive evaluation. In this article we investigate the relationship between moral deliberation and responsive evaluation, describe their common basis in dialogical ethics and pragmatic hermeneutics, and explore the relevance of both for improving the quality of care. The synergy between the approaches is illustrated by a case example in which both play a distinct and complementary role. It concerns the implementation of quality criteria for coercion in Dutch psychiatry.

Beyond procedural ethics: Foregrounding questions of justice in global health research ethics training for students

Interest in global health is growing among students across many disciplines and fields of study. In response, an increasing number of academic programmes integrate and promote opportunities for international research, service or clinical placements. These activities raise a range of ethical issues and are associated with important training needs for those who participate. In this paper, we focus on research fieldwork conducted in lower income nations by students from more affluent countries and the ethics preparation they would benefit from receiving prior to embarking on these projects. Global health research is closely associated with questions of justice and equity that extend beyond concerns of procedural ethics. Research takes place in and is shaped by matrices of political, social and cultural contexts and concerns. These realities warrant analysis and discussion during research ethics training. Training activities present an opportunity to encourage students to link global health research to questions of global justice, account for issues of justice in planning their own research, and prepare for ‘ethics-in-practice’ issues when conducting research in contexts of widespread inequality. Sustained engagement with questions of justice and equity during research ethics training will help support students for involvement in global health research.