Tom Beauchamp

In the relatively short time since 2006—when Theoretical Medicine and Bioethics published an issue on moral issues relevant to the use of nonhuman animals in research [1]—significant changes have occurred for nonhuman animals in many quarters. Public sentiment, new policy initiatives, and scientific studies of nonhuman animals’ capacities have all influenced the ways in which nonhuman animals are perceived and treated in research. Today, a large body of information is available for use in decision making about the acceptability of using nonhuman animals in research. The articles in this issue assess how moral argument and empirical studies stand to guide animal research policies and practices in future years.Many in bioethics have come to regard issues of animal research as a subfield of research ethics, bringing it closer to human research ethics. Animal ethics, like public health ethics, has struggled for recognition in bioethics. As the contributions to this issue show, some in bioe.

In defense of anarchism Robert Paul Wolff contends that the moral autonomy of individuals cannot be made compatible with legitimate political authority. A state is legitimate, he maintains, if authorities in the state have a right to command where subjects correlatively have an obligation to obey. However, he also holds both that all autonomous individuals have a primary obligation to refuse to be ruled by all authorities and that all men are normally obliged to remain autonomous. It allegedly follows that anarchism is the only political theory consistent with autonomy. We propose to show that his arguments concerning legitimacy contain a crucial inconsistency and that his conclusions concerning the incompatibility of authority and autonomy fail.

This is the first new scholarly edition since the nineteenth century of one of the greatest works in the history of philosophy: David Hume's Enquiry concerning the Principles of Morals. It is the fourth volume of the Clarendon Hume Edition, which will be the definitive edition for the foreseeable future. In this elegant and lucid Enquiry Hume gives an accessible presentation of his fully developed ethical theory, that is to say his theory of the foundation of morality in human nature. He considered this work to be `of all my writings, historical, philosophical, or literary, incomparably the best'. The distinguished Hume scholar Tom Beauchamp presents an authoritative text accompanied by introduction, annotation, glossary, biographical sketches, bibliographies, and indexes.

The distinction between clinical research and clinical practice directs how we partition medicine and biomedical science. Reasons for a sharp distinction date historically to the work of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, especially to its analysis of the “boundaries” between research and practice in the Belmont Report (1978). Belmont presents a segregation model of the research-practice distinction, according to which research and practice form conceptually exclusive sets of activities and interventions. This model is still the standard in federal regulations today. However, the Commission’s deliberations and conclusions about the boundaries are more complicated, nuanced, and instructive than has generally been appreciated. The National Commission did not conclude that practice needs no oversight comparable to the regulation of research. It debated the matter and inclined to the view that the oversight of practice needed to be upgraded, though the Commission stopped short of proposing new regulations for its oversight, largely for prudential political reasons.

Calls are increasing for American health care to be organized as a learning health care system, defined by the Institute of Medicine as a health care system “in which knowledge generation is so embedded into the core of the practice of medicine that it is a natural outgrowth and product of the healthcare delivery process and leads to continual improvement in care.” We applaud this conception, and in this paper, we put forward a new ethics framework for it. No such framework has previously been articulated. The goals of our framework are twofold: to support the transformation to a learning health care system and to help ensure that learning activities carried out within such a system are conducted in an ethically acceptable fashion.

What grounds and justifies conclusions in medical ethics? Is the source external or internal to medicine? Thee influential types of answer have appeared in recent literature: an internal account, an external account, and a mixed internal / external account. The first defends an ethic derived from either the ends of medicine or professional practice standards. The second maintains that precepts in medical ethics rely upon and require justification by external standards such as those of public opinion, law, religious ethics, or philosophical ethics. The third claims that distinct medical ethics have emerged from distinct cultural frameworks, each with norms that govern physicians. There is merit in each perspective, but each overreaches its supporting arguments and fails to appreciate what is legitimate in the theses of its competitors. I propose a fourth account that offers a way to escape limitations of the other three, while retaining their most attractive features

In lieu of an abstract, here is a brief excerpt of the content:36. A DISCUSSION ON PERSONAL IDENTITY Jane L. Mclntyre's original paper "Is Hume's Self Consistent?" was presented at the MoGiIl Hume Conference; it will be published in the forthcoming volume devoted to those preceedings. Tom Beauchamp" s paper is presented here as delivered. John Biro's paper has been revised since its original presentation. 37. SELF INCONSISTENCY OR MERE SELF PERPLEXITY? Professor Mclntyre's imaginative and constructive paper has three primary parts (despite its division into six sections). First, she offers an interpretation of Hume's view of the self in Book I of the Treatise. Second, she explains why his own reservations in the Appendix create problems not only for this theory of self identity but for other parts of his philosophy as well. Finally, she tries to ease him out of these difficulties with her overlap interpretation of the bundle theory. My comments follow exactly this outline, though my conclusions, for the most part, do not coincide with hers. My reservations do not derive from her attempt to render Hume consistent. Rather, I question the foundations of the entire enterprise in which she, Robison, Nathanson, et. al. are engaged. That is, I remain unconvinced that the alleged problem, as presently framed, is more than a pseudo-problem. I. Hume's Theory in Book I In Book I Hume offers a variety of arguments about the nature of the self, most of which rely on other theories, such as those of causation, the association of ideas, and substance. Whatever the exact arguments and positions he may be advancing, at least the following six propositions are integral to his theory of personal identity: 1)The self is entirely reducible to a collection of perceptions. 2)The self is not characterized by strict identity. 3)There is nothing simple in which the collection of perceptions inheres. 4)Both identity and simplicity are attributed to the self because of relations between perceptions--the relations of causation and resemblance. 5)The relations of resemblance and causation unite these perceptions. 38. 6) There are no real (non-associational) connections or relations among these perceptions which unite them. Half of these six claims are critical denials of other philosophical claims; the other half are constructive philosophical theories. Hume's entire philosophical program in Book I is tied up with these claims. The criticisms are directed at numerous metaphysical theories of mind, substance and causation; and the constructive account of personai identity requires his theories of perception and association of ideas. I mention these obvious points only because it is so important to note that if_ the interpretation is correct which Professor Mclntyre and others give to (roughly) five sentences in the Appendix, where Hume mentions a possible inconsistency, then Hume is not only questioning his theory of personal identity in Book I, he is calling Book I itself into question. To be convinced that this strikingly implausible turnabout occurs in five sentences of the Appendix, we must be given a most compelling argument—one which I doubt is forthcoming. II. Hume's Alleged Inconsistency The alleged problem of inconsistency arises because Hume says in the Appendix that he does not know how to render his own former opinions consistent (T633, 636). However, when he comes to a formal statement of the inconsistency, as everyone is agreed, the propositions said to be inconsistent are not inconsistent. In the attempt to grasp Hume's meaning, a general consensus has emerged in recent Hume scholarship, including Professor Mclntyre in its company, that we ought both to move backward and forward a sentence or two in Hume's text. Hume says in those passages that his hopes for his theory are diminished because he is unable to explain the principles, that unite our successive perceptions in our thought or consciousness (T636) ; and he then indicates that i_f perceptions could be shown to inhere in something simple or to be really connected, these prob- 39. lems would vanish. It is this textual setting which Robison, Nathanson, and Professor Mclntyre turn into the claim that "the concept of a self which is affected by experience, and therefore must persist through experience— is precisely the concept of the self that...

Tom Beauchamp presents a new edition, designed especially for the student reader, of An Enquiry concerning Human Understanding, the classic work in which David Hume gave a general exposition of his philosophy to a broad educated readership. An authoritative new version of the text is preceded by a substantial introduction explaining the historical and intellectual background to the work and surveying its main themes. The volume also includes detailed explanatory notes on the text, a glossary of terms, and a section of supplementary readings.

Calls are increasing for American health care to be organized as a learning health care system, defined by the Institute of Medicine as a health care system “in which knowledge generation is so embedded into the core of the practice of medicine that it is a natural outgrowth and product of the healthcare delivery process and leads to continual improvement in care.” We applaud this conception, and in this paper, we put forward a new ethics framework for it. No such framework has previously been articulated. The goals of our framework are twofold: to support the transformation to a learning health care system and to help ensure that learning activities carried out within such a system are conducted in an ethically acceptable fashion.

Hume notoriously maintains that contiguity, succession, and constant conjunction are individually necessary and jointly sufficient conditions of causation. While his arguments for the necessity of constant conjunction have been thoroughly dissected, his arguments for contiguity and succession have generally been either ignored or misstated. I hope both to correct this unfortunate state of affairs and to show some fatal defects in Hume's account.The pertinent passages in Hume's writings acknowledge three conceivable ways in which the temporal relation between causes and effects might be construed: as separated by some interval; as perfectly contiguous, so that the effect succeeds the cause in the very next moment; as perfectly contemporaneous, existing at the same moment. Hume defends the correctness of and denies the tenability of both and.

In lieu of an abstract, here is a brief excerpt of the content:Refusals of Treatment and Requests for DeathTom L. Beauchamp (bio)It would be hard to overestimate the importance of two decisions on physician-assisted suicide delivered recently by the Ninth and Second Circuit Courts (Compassion in Dying v. State of Washington, 79 F.3d 790 (9th Cir. 1996) (en banc), aff’g 850 F.Supp. 1454 (W.D. Wash. 1994), rev’g 49 F.3d 586 (9th Cir. 1995); Quill v. Vacco, 80 F.3d 716 (2nd Cir. 1996). They are the highest courts yet to render an opinion on this subject, and their decisions have set the stage for the U.S. Supreme Court to take one of two paths: It will either say that (1) all citizens have a liberty interest in physician-assisted suicide, or that (2) each state may set its own policy on such matters. Whichever path is elected, a right to request physician-assisted suicide is a virtual certainty, at least in some states.These opinions are later segments of an evolving legal history in which courts have held that no criminal liability exists for withholding or withdrawing a life-sustaining treatment when physicians are directed to do so by a patient or an authorized surrogate (see Alan Meisel 1992). The decriminalization of suicide and the right to refuse a life-sustaining treatment now appear to be evolving into a rule that a patient has a legal right to control his or her death, or at least to obtain a lethal prescription. We are at a delicate point in this evolving history. Neither in law nor in bioethics is the justification of physician assistance in suicide the received opinion at the present time, but support for physician assistance in dying could soon become the received opinion in both disciplines.The leading edge of the wedge producing these changes has been widespread acceptance of an extensive right to refuse treatment. This right is today axiomatic in even conservative quarters of bioethics, but 20 years ago it was far from axiomatic that all patients have a right to refuse treatment. Few at that time judged that it would be both immoral and illegal for a physician not to forgo treatment in the face of a competent, authoritative refusal of any form of medical service or treatment.The justification for assistance in bringing about death in medicine is an extension of the justification for letting patients die. Letting a patient die by accepting a valid refusal to continue in life is directly analogous to helping a patient die by accepting a valid request for help. The high value we place on [End Page 371] rights of autonomy thereby spills over from the right to refuse to the underexplored right to request active assistance. 1 As the autonomy interest in this choice increases, denial of help to the patient becomes more burdensome.Those who defend the view that euthanasia and physician-assisted suicide are morally prohibited typically assume that assistance involves an act of killing, that acts of killing are impermissible, and that a defensible distinction exists between killing and letting die. However, this distinction has proved difficult to explicate, and the category of killing often seems distant from the problem at hand. For example, it is an eccentric view that a physician who prescribes a lethal medication to a patient thereby kills the patient (or, for that matter, lets the patient die) when the patient voluntarily ingests the medication and dies. So poor are the conceptual understandings of “killing” and “letting die” that conceptual confusion abounds as to which term to use in almost all morally difficult and controversial cases.A common view is that “letting die” is a matter of “ceasing useless treatments” after which patients die (Gaylin, Kass, Pellegrino, and Siegler 1988). This account is attractive, but too narrow. “Letting die” occurs in medicine under at least two circumstances: cessation of treatment because it is useless and cessation of treatment because it has been refused (which can occur even with useful treatments). Neither conceptually nor morally is “ceasing useless treatment” the proper way to state the condition under which many “letting-die” cases occur. It follows that the type of action—killing or letting...

Principles that provide general normative frameworks in bioethics have been criticized since the late 1980s, when several different methods and types of moral philosophy began to be proposed as alternatives or substitutes. Several accounts have emerged in recent years, including: (1) Impartial Rule Theory (supported in this issue by K. Danner Clouser), (2) Casuistry (supported in this issue by Albert Jonsen), and (3) Virtue Ethics (supported in this issue by Edmund D. Pellegrino). Although often presented as rival methods or theories, these approaches are consistent with and should not be considered adversaries of a principle-based account.

Our primary focus is on analysis of the concept of voluntariness, with a secondary focus on the implications of our analysis for the concept and the requirements of voluntary informed consent. We propose that two necessary and jointly sufficient conditions must be satisfied for an action to be voluntary: intentionality, and substantial freedom from controlling influences. We reject authenticity as a necessary condition of voluntary action, and we note that constraining situations may or may not undermine voluntariness, depending on the circumstances and the psychological capacities of agents. We compare and evaluate several accounts of voluntariness and argue that our view, unlike other treatments in bioethics, is not a value-laden theory. We also discuss the empirical assessment of individuals? perceptions of the degrees of noncontrol and self-control. We propose use of a particular Decision Making Control Instrument. Empirical research using this instrument can provide data that will help establish appropriate policies and procedures for obtaining voluntary consent to research