Laurence McCullough

The clinical ethics literature is striking for the absence of an important genre of scholarship that is common to the literature of clinical medicine: systematic reviews. As a consequence, the field of clinical ethics lacks the internal, corrective effect of review articles that are designed to reduce potential bias. This article inaugurates a new section of the annual "Clinical Ethics" issue of the Journal of Medicine and Philosophy on systematic reviews. Using recently articulated standards for argument-based normative ethics, we provide a systematic review of the literature on concealed medication for the management of psychiatric disorders. Four steps are completed: identify a focused question; conduct a literature search using key terms relevant to the focused question; assess the adequacy of the argument-based methods of the papers identified; and identify conclusions drawn in each paper and whether they apply to the focused question. We identified seven papers and provide an assessment of them. While none of the papers fully meet the standards of argument-based ethics, they did provide rationales for the use of concealed medications, with the important requirement such a practice be accountable in explicit organizational policy to prevent abuse of patients with mental illness or dementia.

Managed care employs two business tools of managed practice that raise important ethical issues: paying physicians in ways that impose conflicts of interest on them; and regulating physicians' clinical judgment, decision making, and behavior. The literature on the clinical ethics of managed care has begun to develop rapidly in the past several years. Professional organizations of physicians have made important contributions to this literature. The statements on ethical issues in managed care of four such organizations are considered here, the American Medical Association, the American College of Physicians, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics. Three themes common to these statements are identified and critically assessed: the primacy of meeting the medical needs of each individual patient; disclosure of conflicts of interest in how physicians are paid; and opposition to gag orders. The paper concludes with an argument for a basic concept in the clinical ethics of managed care: physicians and institutions as economically disciplined moral co-fiduciaries of populations of patients.

In lieu of an abstract, here is a brief excerpt of the content:Laying Medicine Open: Understanding Major Turning Points in the History of Medical EthicsLaurence B. McCullough (bio)AbstractAt different times during its history medicine has been laid open to accountability for its scientific and moral quality. This phenomenon of laying medicine open has sometimes resulted in major turning points in the history medical ethics. In this paper, I examine two examples of when the laying open of medicine has generated such turning points: eighteenth-century British medicine and late twentieth-century American medicine. In the eighteenth century, the Scottish physician-philosopher, John Gregory (1724–1773), concerned with the unscientific, entrepreneurial, self-interested nature of then current medical practice, laid medicine open to accountability using the tools of ethics and philosophy of medicine. In the process, Gregory wrote the first professional ethics of medicine in the English-language literature, based on the physician’s fiduciary responsibility to the patient. In the late twentieth century, the managed practice of medicine has laid medicine open to accountability for its scientific quality and economic cost. This current laying open of medicine creates the challenge of developing medical ethics and bioethics for population-based medical science and practice.Reading the Histories of Medicine, Bioethics, and Medical EthicsThere are many ways in which to read the history of medi-cine and therefore of medical ethics and bioethics. For example, the history of medicine can be usefully understood in terms of successive advances or revolutions in biomedical science and its clinical applications, with medical ethics understood as a moral response to scientific and technological change. On this reading, which has been common in the history of bioethics for the past three decades, moral response is required to address scientific and technological changes that are unprecedented and therefore threaten to outstrip society’s moral capacities [End Page 7] to understand and manage those changes well. Much recent work on the ethical, legal, and social issues raised by the genome project appeals to this reading. The history of medicine can also be read in social terms, with medicine understood as a major social institution shaped by various factors, not limited to science. In this perspective, medicine and society are understood in terms of a complex and dynamic synergy. Bioethics and medical ethics become part of this synergy and are to be explained—perhaps even explained away—by social historical factors. There are, of course, other ways to read the history of medicine and therefore of bio-ethics and medical ethics—e.g., in terms of key figures and movements that are thought to have shaped developments in crucial ways.I want to suggest another way to read these histories, namely, the successive laying open of medicine to accountability that sometimes results in key turning points in the development of medical ethics and bioethics. On this reading, ethics is understood as an intellectual and practical discipline that makes medicine as a social institution and its practitioners, physicians, morally accountable for their clinical judgment, decision making, and behavior. This differs from Robert Veatch’s (1981) reading of the history of medical ethics either as particular—informed by intellectual, moral, and experiential resources thought to be available only to physicians—or universal—informed by intellectual, moral, and experiential resources generally available in the culture (present and past). Veatch sees medical ethics as open when it is universal and closed, and unacceptable, when it is particular. I read the history of medical ethics as always universal and medicine as a social institution and practice as sometimes closed—i.e, not accountable for its scientific and moral integrity—and sometimes as open, accountable for such integrity. When medicine is “laid open,” medical ethics itself is sometimes transformed. The same may well be the case for the other health care professions. The histories of medical ethics and bioethics, therefore, can be usefully read as responses to the laying open of medicine and the health care professions generally at various times in their histories. In what follows, I examine two important examples of laying medicine open that create key turning points in the history of medical ethics—Scottish medicine from the eighteenth century and American medicine from the end of the twentieth century.The...

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.

The gathering of power unto themselves by physicians, a process supported by evidence-based practice, clinical guidelines, licensure, organizational culture, and other social factors, makes the ethics of power—the legitimation of physicians’ power—a core concept of clinical ethics. In the absence of legitimation, the physician’s power over patients becomes problematic, even predatory. As has occurred in previous issues of the Journal, the papers in the 2016 clinical ethics issue bear on the professionally responsible deployment of power by physicians. This introduction explores themes of physicians’ power in papers from an international group of authors who address autonomy and trust, the virtues of perinatal hospice, conjoined twins in ethics and law, addiction and autonomy in clinical research on addicting substances, euthanasia of patients with dementia in Belgium, and a pragmatic approach to clinical futility

Physicians make some medical decisions without disclosure to their patients. Nondisclosure is possible because these are silent decisions to refrain from screening, diagnostic or therapeutic interventions. Nondisclosure is ethically permissible when the usual presumption that the patient should be involved in decisions is defeated by considerations of clinical utility or patient emotional and physical well-being. Some silent decisions—not all—are ethically justified by this standard. Justified silent decisions are typically dependent on the physician's professional judgment, experience and knowledge, and are not likely to be changed by patient preferences. We condemn the inappropriate exclusion of the patient from the decision-making process. However, if a test or treatment is unlikely to yield a net benefit, disclosure and discussion are at times unnecessary. Appropriate silent decisions are ethically justified by such considerations as patient benefit or economy of time.

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.

This article comments on the treatment of critical-care ethics in four preceding articles about critical-care medicine and its ethical challenges in mainland China, Hong Kong, Japan, and the Philippines. These articles show how cultural values can be in both synchrony and conflict in generating these ethical challenges and in the constraints that they place on the response of critical-care ethics to them. To prevent ethical conflict in critical care the author proposes a two-step approach to the ethical jus tification of critical-care management: (1) the decision to resuscitate and initiate critical-care management, which is based on the obligation to prevent imminent mortality without permanent loss of consciousness; and (2) the decision to continue critical-care management, which is based on the obligation both to prevent imminent death without permanent loss of consciousness and to avoid unnecessary, significant iatrogenic costs to the patient and psychosocial costs to the family when the reduction of morta lity risk is marginal. Physicians and hospitals should restore the critical-care physician's authority and power - against prevailing cultural values, if necessary - to control when critical-care intervention is offered, when it is recommended to continue, and when it is recommended to be discontinued and the patient allowed to die.

Albert Jonsen in The Birth of Bioethics notes that his career in bioethics began with a phone call to him from soon-to-be colleagues at the University of California at San Francisco Medical Center. Bioethics didn't begin with a bang but as an accident in the root sense—something that happened, not by necessity, but rather by chance. Indeed, the opening chapters of Jonsen's book chronicle a series of accidents that helped to create the field of bioethics. Principal among these was the fact that physicians and biomedical scientists who became puzzled about the moral dimensions of their work and began to think about these puzzles sought help in doing so from moral theologians and philosophers. These physicians and scientists, for the most part, were university people. They thought broadly, not just deeply, about their work, but they just as well could have defined themselves by their academic discipline and departments and not reached beyond these familiar and comfortable intellectual confines to the “culture” of the humanities disciplines and departments. The theologians and philosophers whom these physicians and scientists sought out were also university people who also happened to have generous views of the intellectual life in their disciplines—atypical of the time, especially in philosophy. If C. P. Snow had been altogether right and if ungenerous self-understanding of their work by physicians, scientists, philosophers, and theologians had prevailed, bioethics might not have happened at all

In diesem Aufsatz zeige ich, wie Leibniz' spätere Philosophie auf seine frühen Arbeiten und auf die spätscholastische Philosophie, insbesondere den Nominalismus von Suarez, zurückgreift. Zunächst behaupte ich, daß Leibniz Suarez' Ontologie der Relationen ebenso wie seine Auffassung der Begriffe, des Besonderen und des Allgemeinen übernommen hat. Ich verwende die Ergebnisse dieser Untersuchung, um einige Hauptthemen der Leibnizschen Philosophie (die Theorie der Monaden und ihrer individuellen Begriffe, die Kategorienlehre, die Wahrheitstheorie, die unendliche Analyse und das principium indiscernibilium) zu erklären. Dieser Aufsatz soll die traditionelle Prägung von einem großen Teil des Leibnizschen Denkens aufzeigen und die Frage neu stellen: In welchem Sinne ist Leibniz ein Philosoph der modernen Tradition?

Research to improve the health of pregnant and fetal patients presents ethical challenges to clinical investigators, institutional review boards, funding agencies, and data safety and monitoring boards. The Common Rule sets out requirements that such research must satisfy but no ethical framework to guide their application. We provide such an ethical framework, based on the ethical concept of the fetus as a patient. We offer criteria for innovation and for Phase I and II and then for Phase III clinical trials to improve the health of pregnant patients and of fetal patients and also criteria to responsibly manage the transition from investigation to clinical practice. Basing ethical criteria for research involving pregnant women on the ethical concept of the fetus as a patient insulates the proposed ethical framework and therefore research on pregnant women from the divisive and politicized concepts and discourses of personhood, fetal rights, and unborn child.

Sildenafil citrate (Viagra) and other newly released pharmaceuticals that assist erectile dysfunction may be one of the most important categories of drugs released in the past decade. Sildenafil is distinctive because it creates a new therapeutic relationship not only between patient and physician, but also with sexual partner(s). Physicians must first evaluate the patient comprehensively, addressing not only erectile function and sexual performance, but overall physical and mental health. Since the drug does impact others, an expanded model for informed consent needs to be considered. Three models to consider include the public health one, ethically justified limits on confidentiality, and a biopsychosocial one. The biopsychosocial model may be preferred because it expands the patient-physician dyad to directly include others. Physicians also need to distinguish between professional, role-related obligations and personal conscience when treating patients whose sexual beliefs and practices differ from their own. Other ethical issues include inappropriate prescribing over the Internet, dealing with unrealistic patient expectations, and fairness in paying for treatment for sexual conditions in both men and women. With these proposed guidelines, physicians can continue to provide steady, reliable guidance for patients while working with yet another scientific advance in medicine.

Contrarian ways of thinking are generally good for the intellectual life and clinical ethics is no exception. This essay introduces the papers in the 2003 issue on clinical ethics of the Journal of Medicine and Philosophy , each of which goes against the grain in interesting and important ways. Considerations of identity predominate, in discussions of cloning, separation of conjoined twins, and the coming into existence of human beings. Whether viewing organ donation as admirable sacrifice is an altogether good thing is considered, as is the justification of fetal craniotomy. Finally, there is a review essay about From Chance to Choice , an important new book for the philosophy and ethics of molecular medicine.

Bioethics as a field began some years before it was finally named in the early 1970s. In many ways, bioethics originated in response to urgent matters of the moment, including the controversy over disconnecting Karen Quinlan's respirator, the egregious paternalism of Donald Cowart's doctors in the famous “Dax” case, the abuse of research subjects in the notorious Tuskegee Syphilis Study, and the need to devise an intellectual framework for the development of federal regulations to protect human subjects of research. The phrase “new and unprecedented” became a common description of the topics and issues to which people who later came to be called “bioethicists” responded. It should come as no surprise that bioethics and its practitioners soon came to the self-understanding that their work was new and unprecedented, much as the innovations of biomedical science and their clinical applications were thought to be.

Moral distress is one of the core topics of clinical ethics. Although there is a large and growing empirical literature on the psychological aspects of moral distress, scholars, and empirical investigators of moral distress have recently called for greater conceptual clarity. To meet this recognized need, we provide a philosophical taxonomy of the categories of what we call ethically significant moral distress: the judgment that one is not able, to differing degrees, to act on one’s moral knowledge about what one ought to do. We begin by unpacking the philosophical components of Andrew Jameton’s original formulation from his landmark 1984 work and identify two key respects in which that formulation remains unclear: the origins of moral knowledge and impediments to acting on that moral knowledge. We then selectively review subsequent literature that shows that there is more than one concept of moral distress and that explores the origin of the values implicated in moral distress and impediments to acting on those values. This review sets the stage for identifying the elements of a philosophical taxonomy of ethically significant moral distress. The taxonomy uses these elements to create six categories of ethically significant moral distress: challenges to, threats to, and violations of professional integrity; and challenges to, threats to, and violations of individual integrity. We close with suggestions about how the proposed philosophical taxonomy of ethically significant moral distress sheds light on the concepts of moral residue and crescendo effect of moral distress and how the proposed taxonomy might usefully guide prevention of and future qualitative and quantitative empirical research on ethically significant moral distress