Laurence McCullough

The ethics of managing obstetric patients in medical disasters poses ethical challenges that are unique in comparison to other disaster patients, because the medical needs of two patients—the pregnant patient and the fetal patient—must be considered. We provide an ethical framework for doing so. We base the framework on the justice-based prevention of exploitation of populations of patients, both obstetric and non-obstetric, in medical disasters. We use the concept of exploitation to identify a spectrum from ethically acceptable, to ethically challenging, to ethically unacceptable, management of obstetric patients in medical disasters. We also address the ethics of the care of obstetric and neonatal patients when the resources of a hospital are completely overwhelmed in a large-scale medical disaster.

The concept of medicine as a profession in the English-language literature of medical ethics is of recent vintage, invented by the Scottish physician and medical ethicist, John Gregory (1724-1773). Gregory wrote the first secular, philosophical, clinical, and feminine medical ethics and bioethics in the English language and did so on the basis of Hume's principle of sympathy. This paper provides a brief account of Gregory's invention and the role that Humean sympathy plays in that invention, with reference to key texts in Gregory's work. The paper also considers two interesting and perhaps provocative ways in which Hume can be read through Gregory: first, sympathy as a principle of scientific discovery in Hume's science of man and moral physiology; and sympathy as gendered feminine in Hume's moral philosophy. Hume's principle of sympathy is at the core of Gregory's medical ethics and the histories of Western medical ethics and bioethics pivot on Gregory - and, therefore, on Hume - as it does on few other figures.

Some problems that arise in the account given by Thomasma and Pellegrino [6] of the foundations of medical ethics in a philosophy of medicine are addressed, in particular questions of a conceptual character about treating therelatum of medicine as health. Which concept of health is appropriate and which will bear the burden of the position thomasma and Pellegrino advance? It is argued that the proper relationship of medicine is one between a healer and developing embodied minds. As a consequence, the project of providing a univocal account of the nature of medicine fails. Instead, pluralism infects philosophy and medicine, resulting in different philosophies of medicine. From these philosophies of medicine will follow not a single medical ethics but a variety.

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 six papers in the 2014 clinical ethics number of the Journal get us back to the basics in the work of clinical ethics and clinical ethicists: getting clear about concepts that should be used in achieving deliberative clinical ethics. The papers explore the concepts of the best interests of the patient, health and disease understood in their proper relationship to autonomy in our species, the therapeutic obligation, and the therapeutic imperative. The final paper appraises the systematic review, a scholarly tool for tracking the basic concepts of clinical ethics in the literature

The pluralism of methodologies and severe time constraints pose important challenges to pedagogy in clinical ethics. We designed a step-by-step student handbook to operate within such constraints and to respect the methodological pluralism of bioethics and clinical ethics. The handbook comprises six steps: Step 1: What are the facts of the case?; Step 2: What are your obligations to your patient?; Step 3: What are your obligations to third parties to your relationship with the patient?; Step 4: Do your obligations converge or conflict?; Step 5: What is the strongest objection that could be made to the identification of convergence in step 4 or the arguments in step 4? How can this objection be effectively countered?; and Step 6: How could the ethical conflict, or perceived ethical conflict, have been prevented?

On February 3, 2010, a “Letter of Concern from Bioethicists,” organized by fetaldex.org, was sent to report suspected violations of the ethics of human subjects research in the off-label use of dexamethasone during pregnancy by Dr. Maria New. Copies of this letter were submitted to the FDA Office of Pediatric Therapeutics, the Department of Health and Human Services Office for Human Research Protections, and three universities where Dr. New has held or holds appointments. We provide a critical appraisal of the Letter of Concern and show that it makes false claims, misrepresents scientific publications and websites, fails to meet standards of evidence-based reasoning, makes undocumented claims, treats as settled matters what are, instead, ongoing controversies, offers “mere opinion” as a substitute for argument, and makes contradictory claims. The Letter of Concern is a case study in unethical transgressive bioethics. We call on fetaldex.org to withdraw the letter and for co-signatories to withdraw their approval of it.

An orthodoxy has arisen which claims that there is a crisis in the United States health care system such that the system needs to be reformed. This essay challenges that orthodoxy by showing that we do not have a health care system in the United States. We have a non-system of health care, just as we do for virtually all basic social institutions. Challenging the current orthodoxy surfaces two ethical issues that have been ignored: creating a health care system will (a) cause resurgent paternalism and (b) pose a threat to moral pluralism. Keywords: Health care policy, managed care, paternalism, moral pluralism, institutional integrity, total quality management, continuous quality improvement CiteULike Connotea Del.icio.us What's this?

The Cambridge World History of Medical Ethics is the first comprehensive scholarly account of the global history of medical ethics. Offering original interpretations of the field by leading bioethicists and historians of medicine, it will serve as the essential point of departure for future scholarship in the field. The volumes reconceptualize the history of medical ethics through the creation of new categories, including the life cycle; discourses of religion, philosophy, and bioethics; and the relationship between medical ethics and the state, which includes a historical reexamination of the ethics of apartheid, colonialism, communism, health policy, imperialism, militarism, Nazi medicine, Nazi "medical ethics," and research ethics. Also included are the first global chronology of persons and texts; the first concise biographies of major figures in medical ethics; and the first comprehensive bibliography of the history of medical ethics. An extensive index guides readers to topics, texts, and proper names

Making finely crafted distinctions and deploying them in intellectually rigorous and clinically applicable judgments define, to a considerable degree, the art of clinical ethics. The papers in this Clinical Ethics number of the Journal of Medicine and Philosophy demonstrate the art of clinical ethics in their consideration of respect for autonomy vs. respect for persons, the role of risk in triggering assessment of decisional capacity vs. the role of risk in the concept and assessment of decisional capacity, intention vs. foresight in the clinical management of ectopic pregnancy, preserving life vs. relieving suffering in physician-assisted suicide, and what is essential vs. non-essential in defining the core areas of ethics education for members of hospital ethics committees.

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

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...