Allen Buchanan

This essay demonstrates that the management and contestability of power is central to Dewey's understanding of democracy and provides a middle ground between two opposite poles within democratic theory: Either the masses become the genuine danger to democratic governance (à la Lippmann) or elites are described as bent on controlling the masses (à la Wolin). Yet, the answer to managing the relationship between them and the demos is never forthcoming. I argue that Dewey's response to Lippmann for how we ought to conceive of the relationship between citizens and elites if power is not to become arbitrary is located within a larger framework that avoids the problematic distinction Wolin draws between the demos and representative government. For Dewey, the legitimacy of decision-making, and, indeed, the security of freedom, is determined not merely by our actual involvement, but the extent to which non-participation does not preclude the future contestability of power.

This essay articulates a crucial and neglected element of a general theory of the ethics of bureaucratic organizations, both private andpublic. The key to the approach developed here is the thesis that the distinctive ethical principles applicable to bureaucratic organizations are responses to the distinctive agency-risks that arise from the nature of bureaucratic organizations as complex webs of principal/agent relationships. It is argued that the most important and distinctive ethical principles for bureaucratic organizations express commitments on the part of bureaucrats that function to reduce the agency risks that are inherent in such organizations. This approach to the ethics of bureaucratic organizations is shown to be more illuminating than those that concentrate exclusively or primarily on determining the conditions for corporate responsibility or on the idea that the ethical obligations distinctive of bureaucracies are role-derived.

This chapter first identifies what is extremely valuable and distinctive in the approach to Ethics Glover takes in Humanity. It then goes on to argue that Glover's approach is incomplete, because it is insufficiently empirical and, more importantly because it lacks a conceptual framework capable of identifying the full range of topics for empirically informed Ethics research. The needed conceptual framework must incorporate social moral epistemology, which focuses on the interaction between the moral‐epistemic virtues and vices of individuals and the moral‐epistemic functions of institutions. Through the use of historical examples of the sort Glover appeals to in Humanity, this chapter shows that work in Ethics must pay more attention to the ethics of believing and to the role that institutions play in the formation of systems of belief.

abstract Part 1 of this essay argues that one of the most important contributions of philosophers to sound public policy may be to combat the influence of bad Philosophy (which includes, but is not limited to, bad Philosophy produced by accredited academic philosophers). Part 2 argues that the conventional conception of Practical Ethics (CPE) that philosophers bring to issues of public policy is defective because it fails to take seriously the phenomenon of the subversion of morality, the role of false factual beliefs in this subversion, and the vulnerability to the exploitation of our moral powers that our social-epistemic dependency entails. Given the serious risks of the subversion of morality through the propagation of false factual beliefs, CPE's near exclusive emphasis on identifying sound moral principles greatly constrains its potential contribution to the Negative Task of Practical Ethics, the endeavour to reduce the incidence of the most grievously wrong behaviour. Practical ethicists should focus more on the ethics of believing, and develop a more sophisticated conception of the moral and epistemic virtues of individuals and of institutions, one that includes protective meta-virtues, whose function it is to guard us against the more frequent and predictable subversions of morality, including those subversions that are facilitated by the processes of belief-formation that our social institutions and practices foster.

Appeals to the idea of human nature are frequent in the voluminous literature on the ethics of enhancing human beings through biotechnology. Two chief concerns about the impact of enhancements on human nature have been voiced. The first is that enhancement may alter or destroy human nature. The second is that if enhancement alters or destroys human nature, this will undercut our ability to ascertain the good because, for us, the good is determined by our nature. The first concern assumes that altering or destroying human nature is in itself a bad thing. The second concern assumes that human nature provides a standard without which we cannot make coherent, defensible judgments about what is good. I will argue (1) that there is nothing wrong, per se, with altering or destroying human nature, because, on a plausible understanding of what human nature is, it contains bad as well as good characteristics and there is no reason to believe that eliminating some of the bad would so imperil the good as to make the elimination of the bad impermissible, and (2) that altering or destroying human nature need not result in the loss of our ability to make judgments about the good, because we possess a conception of the good by which we can and do evaluate human nature. I will argue that appeals to human nature tend to obscure rather than illuminate the debate over the ethics of enhancement and can be eliminated in favor of more cogent considerations.

This book is the most comprehensive treatment available of one of the most urgent - and yet in some respects most neglected - problems in bioethics: decision-making for incompetents. Part I develops a general theory for making treatment and care decisions for patients who are not competent to decide for themselves. It provides an in-depth analysis of competence, articulates and defends a coherent set of principles to specify suitable surrogate decisionmakers and to guide their choices, examines the value of advance directives, and investigates the role that considerations of cost ought to play in decisions concerning incompetents. Part II applies this theoretical framework to the distinctive problems of three important classes of individuals, many of whom are incompetent: minors, the elderly and psychiatric patients. The authors' approach combines a probing analysis of fundamental issues in ethical theory with a sensitive awareness of the concrete realities of health care institutions and the highly personal and individual character of difficult practical problems. Its broad scope will appeal to health professionals, moral philosophers and lawyers alike.

Our society has long sanctioned, at least tacitly, a degree of conflict of interest in medical practice and clinical research as an unavoidable consequence of the different interests of the physician or clinical investigator, the patient or clinical research subject, third party payers or research sponsors, the government, and society as a whole, to name a few. In the past, resolution of these conflicts has been left to the conscience of the individual physician or clinical investigator and to professional organizations. The public is no longer willing to allow health care providers to wholly govern their own conflicts of interest for several reasons. These include: new forms of health care financing and delivery that provide innovative and lucrative opportunities for physician or insurer enrichment at patient expense; the increased importance of commercial research support as peer-reviewed governmental research support has decreased; evidence that physicians and clinical investigators too frequently resolve conflicts of interest in their own favor; and a general societal mistrust of authority. This volume represents a multidisciplinary effort, drawing from philosophy, medicine, law, economics and public policy to identify and categorize conflicts of interest in medical practice and clinical research, and, where possible, to offer a mechanism for resolving them. Part I addresses conflicts of interest from a theoretical perspective, offering basic concepts and analytical frameworks. The second part discusses two topics prominent in current health care policy debates--self-referral and financial incentives to limit care. Part III examines conflicts of interest generated by pharmaceutical industry involvement in clinical practice and research. The final section deals with conflicts of interest in clinical research in several contexts, including institutional reviews boards, clinical trials, Cooperative Research and Development Agreements between government and private researchers, brokerage of research subjects by Contract Research Organizations, and cost-effectiveness studies.

: Two basic criticisms of managed care are that it erodes patient trust in physicians and subjects physicians to incentives and pressures that compromise the physician's fiduciary obligation to the patient. In this article, I first distinguish between status trust and merit trust, and then argue (1) that the value of status trust in physicians is probably over-rated and certainly underdocumented; (2) that erosion of status trust may not be detrimental if accompanied by an increase in well-founded merit trust; and (3) that under conditions of managed care the physician's commitment to traditional medical ethics cannot serve as an adequate basis for merit trust. Next, drawing on an analogy between managed care organizations and polities, I argue that (4) the most appropriate basis for merit trust in managed care is a conception of organizational legitimacy that includes procedural justice, empowerment of constructive criticism within the organization, and organizational accommodation of the noninstrumental commitment to patient well-being that is distinctive of medical professionalism. I then explore the conditions necessary for robust competition for merit trust among managed care organizations and indicate the kinds of public policies needed to facilitate such competition. Finally, I show how the account of organization-based merit trust can accommodate the special fiduciary obligation of medical professionals, without indulging in the delusion that it is the physician's fiduciary obligation always to provide all care that is expected to be of any net benefit to the patient.