Bryan Pilkington

This issue of the Journal of Medicine and Philosophy brings together five articles, each of which highlights, in distinct ways, the benefit of philosophical reflection for the practices of modern medicine. In so doing, it is a fitting issue to appear in 2025, as the Journal marks its fiftieth year. The practices of modern medicine, and indeed the practices of the health professions generally, place practitioners—physicians, nurses, psychologists, and others—in situations in which inconsistent, unclear, or insufficiently rigorous thought can lead to challenges for providing optimal care for patients and for theorizing about that care. In some situations, more information is needed. In other situations, competing complexities must be resolved. In still others, logistical and bureaucratic hurdles must be overcome. Philosophical reflection can lead both to better and more fitting care for patients, potentially reduce the burdens on health professionals and the related instances of moral distress, and aid in the ethical practice of the health professions.

Clarke’s arguments in favour of permitting conscientious objection (CO) in healthcare and setting up registries are not new, but the consequentialist basis for them and the careful attention to seemingly deontological claims from prominent consequentialists about CO are novel. Though many of the arguments are persuasive, at least among those who already accept consequentialism of the form Clarke articulates, the analysis misses an important feature of CO (and a central point in debates about it): professionalism. Clarke is mistaken in dismissing the role of professions and, in turn, professionalism in consequentialist cases for CO. He writes, “It’s not clear why a consequentialist should fuss over…the proper conception of healthcare professionalism.”1 To the contrary, I argue in this short commentary that even consequentialists should care about professionalism when thinking about the ethics of CO. This is for (at least) two reasons. First, in the complex arena of health, accurately assessing utility and disutility requires knowledge which (in many sociocultural contexts) is housed in, and put into practice through, professions. Self-conceptions of persons associated with the proper execution of their work tasks, understandings and effects of burnout on healthcare workers and compensation models that individuate and reward members …

En nous appuyant sur les fondements historiques de la bioéthique, nous soutenons que les bioéthiciens, avec leurs approches et leurs parcours intrinsèquement interdisciplinaires, sont bien placés pour promouvoir l’équité, la diversité et l’inclusion (EDI) dans le milieu des soins de santé grâce à la pratique de l’éthique clinique. Dans le climat culturel et politique actuel, les bioéthiciens ne peuvent rester silencieux tout en restant fidèles aux principes de leur domaine. Les dispositions du code de déontologie de l’American Society for Bioethics and Humanities (ASBH) et l’expérience vécue par les bioéthiciens canadiens offrent des orientations pertinentes. Nous soutenons que la compétence en éthique clinique oblige les bioéthiciens à identifier et à chercher à éliminer les obstacles systémiques auxquels sont confrontés ceux que les éthiciens cliniques ont le privilège de servir. En adoptant une approche intersectionnelle de la bioéthique clinique, les bioéthiciens peuvent devenir les défenseurs de la promotion de soins de santé équitables.

Building on the historical foundation of bioethics, we argue that bioethicists, with inherently interdisciplinary approaches and backgrounds, are well positioned to promote Diversity Equity and Inclusion (DEI) in the healthcare setting through the practice of clinical ethics. In the current cultural and political climate, bioethicists cannot remain silent while staying true to the tenets of the field. Provisions in the American Society for Bioethics and Humanities (ASBH) Code of Ethics and the lived experience of Canadian bioethicists offer relevant guidance. We argue that competence in clinical ethics obliges bioethicists to identify and seek to remove systemic barriers facing those whom clinical ethicists are privileged to serve. By adopting an intersectional approach to clinical bioethics, bioethicists can become advocates for the promotion of just healthcare.

Michael Parker’s novel recommendation 1 for bioethicists to embrace adversarial cooperation (AC) to address deep value disagreements is both welcome and refreshing. However, the prerequisites for the success of such a model (even with its noted variability of form, context sensitivity and the author’s attention to shortcomings) are too robust to reasonably anticipate that they would be met in contexts where the model is most needed. There are (at least) three such prerequisites connected to virtues of potential actors and facilitators involved in AC, which are unlikely to be realised in contexts of deep disagreement: good faith acting, a philosophical sensibility and commitments connected to deliberative processes (not only first-order considerations of values). If such virtues are already possessed, then the model is unnecessary. Consider each in turn. First, the author makes the importance of acting in good faith for AC to work clear; however, even a cursory...

This book takes a step back from the usual debates over conscience in medicine and asks whether the conscientious practice of individual healthcare practitioners is coherent and acceptable on its own. This book argues in the affirmative and describes how we move forward in light of the deep moral and professional disagreement that exists. The book explains why the current framing within the debate is mistaken and offers an alternative framing. In so doing, the author discusses disagreement within healthcare professions, the distinction between conscience protectors and conscience dissenters, and how to properly understand the role of religious and personal philosophical reasons in practicing conscientiously. The book articulates the key confusion in much of the current debate – that disagreement over conscience in medicine is due to religious or personal philosophical beliefs – and rejects it. The book then, positively, argues that differing accounts of moral responsibility are at the root of this disagreement, opening up new avenues for dialogue and potentially fruitful collaborations. The book concludes with a much needed and basic discussion of what is going on when practical judgements are made in healthcare: the medical act. This book is of great interest to both advanced undergraduate and graduate students in philosophy, bioethics, and medicine, as well as researchers, physicians, and health professionals.

In this article, we focus on questions of agency in emerging technologies related to decision-making in medicine. We discuss three principles that were subsumed when bioethics embraced principlism: consent, confidentiality, and veracity. We argue that the advent of artificial intelligence and its employment within health care, impacts the physician-patient relationship in a way that its inclusion in other areas does not. In particular, we take up ethical dilemmas caused by AI related to trust, and illustrate how reflection on these subsumed principles helps to critique accurately policies related to the use of AI in health care and to navigate dilemmas associated with a loss of trust. We conclude by contrasting these principles with the proposed “five principles” system for AI, highlighting some areas of agreement, but also showing where consent, confidentiality, and veracity are necessary additions for ethically employing AI.

An essential element of determining surgical candidacy is an accurate understanding of the risks to a given patient. While surgeons remain largely responsible for the selection of their patients, and surgeons’ intuition has been shown to be a good indicator of postoperative outcomes, the recent focus in medicine towards minimizing the impact of physician bias has spurred a push towards prioritizing risk assessment tools in candidacy decisions. This has rekindled the debate surrounding what should determine surgical candidacy. Risk assessment tools are proven to be moderately to highly accurate at assessing the risk due to objective and proven risk factors, such as the impact of age or comorbidities. However, they fail to account for the humanity of both the surgeon and the patient and do not measure less easily quantifiable risk factors, such as a surgeon’s comfort with a procedure or a patient’s health beliefs, when determining risk. In this project, we offer an ethical analysis that highlights these less acknowledged factors. We argue that these factors need to be given greater consideration in risk assessment and surgical candidacy decisions, as they too can affect postoperative risks and outcomes.

This issue introduces or reintroduces readers to a discussion of bioethics, moral responsibility, and sin. A discussion around similar topics engaged readers of this journal two decades ago, and so this issue provides an opportunity to revisit those—many now classic—papers on the subject. This issue offers diverse perspectives on ethical considerations at the nexus of three (potentially) overlapping ideas: sin, bioethics, and moral responsibility. The description of ideas is intentional, leaving open sufficient space for authors to share interpretations of how they understand each without prejudicing one conception over another. To describe bioethics as a field of inquiry that began in the late 1960s, moral responsibility is an understanding of what one might be held accountable in light of the fact that one performed or failed to perform certain actions when one possessed the ability to do otherwise, or sin as a privation of a particular kind would have yielded an undoubtedly interesting but different set of papers and a much more narrow discussion. The reader finds here four articles that comprise this issue, engaging different Christian traditions and different bioethical topics.

Discussions of the proper role of conscience and practitioner judgement within medicine have increased of late, and with good reason. The cost of allowing practitioners the space to exercise their best judgement and act according to their conscience is significant. Misuse of such protections carve out societal space in which abuse, discrimination, abandonment of patients, and simple malpractice might occur. These concerns are offered amid a backdrop of increased societal polarization and are about a profession which has historically fought for such privileged space. There is a great deal that has been and might yet be said about these topics, but in this paper I aim to address one recent thread of this discussion: justification of conscience protection rooted in autonomy. In particular, I respond to an argument from Greenblum and Kasperbaur and clarify a critique I offered of an autonomy-based conscience protection argument which Greenblum and Kasperbaur seek to improve and defend. To this end, I briefly recap the central contention of that argument, briefly describe Greenblum and Kasperbaur’s analysis of autonomy and of my critique, and correct what appears to be a mistake in interpretation of both my work and of autonomy-based defenses of conscience protection in general.

Chat Generative Pre-Trained Transformer (ChatGPT) has been a growing point of interest in medical education yet has not been assessed in the field of bioethics. This study evaluated the accuracy of ChatGPT-3.5 (April 2023 version) in answering text-based, multiple choice bioethics questions at the level of US third-year and fourth-year medical students. A total of 114 bioethical questions were identified from the widely utilised question banks UWorld and AMBOSS. Accuracy, bioethical categories, difficulty levels, specialty data, error analysis and character count were analysed. We found that ChatGPT had an accuracy of 59.6%, with greater accuracy in topics surrounding death and patient–physician relationships and performed poorly on questions pertaining to informed consent. Of all the specialties, it performed best in paediatrics. Yet, certain specialties and bioethical categories were under-represented. Among the errors made, it tended towards content errors and application errors. There were no significant associations between character count and accuracy. Nevertheless, this investigation contributes to the ongoing dialogue on artificial intelligence’s (AI) role in healthcare and medical education, advocating for further research to fully understand AI systems’ capabilities and constraints in the nuanced field of medical bioethics.

The question of whether nursing ethics is a distinct entity within bioethics is an important and thought-provoking one. Though fundamental bioethical principles are appreciated and applied within the practice of nursing ethics, there exist distinct considerations which make nursing ethics a unique subfield of bioethics. In this article, we focus on the importance of relationships as a distinguishing feature of the foundation of nursing ethics, evidenced in its education, practice, and science. Next, we consider two objections to our claim of distinctiveness: first, that nursing ethics is merely an application of bioethical principles; second, that many bioethical subfields emphasize relationships. We respond by highlighting that throughout nursing education and generally in every career path that follows, the creation and nurturing of relationships is emphasized. Compassion and respect for the dignity of every patient is the framework upon which these therapeutic relationships are built. Much of the focus of nursing science rests on creating meaningful interpersonal experiences and human connection. After responding to each objection, we turn to the implications of this distinctiveness on clinical ethics practice, arguing that the strengths of our approach outweigh the limitations. The deep emphasis on creating meaningful interpersonal experiences and human connection supports a greater integration of relationships and social contexts into the evaluation of whether an action is ethically permissible, which is an important benefit in addressing the challenging human situations that patients face. Moreover, this perspective allows nurse ethicists to account for diverse and complex social structures and their influence in making ethical determinations. These strengths outweigh the limitations of potential inconsistencies between nurse and non-nurse clinical ethicists on the same service, a result we attribute to nursing ethics—and, in turn, the practice of the nurse ethicist—being framed by relationships to a larger extent than other bioethical subfields.

One of the perplexing features of an infectious disease is the damage it causes, not only to physical health, but to mental health and to social relationships. This tension between the separation that is required for safety and the human need for contact is especially felt by institutions of higher education. Many such institutions not only educate students but seek to foster the kinds of communities which have thrived on personal interaction and shared physical space. Different institutions have responded to COVID-19 and its impacts on their members differently. Given that the spring semester will begin months before COVID-19 vaccines are widely available, we offer seven recommendations and argue that for a university, college, or other similarly situated educational institution to ethically respond to the pandemic, it must follow these recommendations. These recommendations are grounded in both scientific research and ethical analysis. Proper ethical analysis, which is necessary for the implementation of good policies, cannot be accomplished without an evidence-based grounding. After describing features of the virus and the situation that faces higher education institutions, in general, we turn to a detailed discussion of transmission. We discuss interventions available to institutions, including masking, hygiene, barriers, and testing and surveillance. Our recommendations are supported by an ethical analysis reliant on four themes: expertise, planning, stewardship, and dignity.

This essay serves as an introduction to this issue of the Journal of Medicine and Philosophy. The five articles in this issue address a range of topics from the human embryo and substantial change to conceptions of disability. They engage claims of moral status, defense of our humanity, and argue for an accurate and just classification of persons of different communities within a healthcare system. I argue in this essay that though their concerns are diverse, the authors in this issue help to answer a common question: “Who counts as one of us?” Reading these articles through the lens of membership and the themes of dignity illustrates this commonality and bears fruit for further reflection on many of the challenging issues addressed in the subsequent papers

The authors, one a trained geneticist and the other a trained ethicist, designed and team-taught a bioethics course where nineteen third- and fourth-year undergraduate students were enrolled at Aquinas College in Grand Rapids, Michigan, during the fall 2016 semester. The syllabus, including democratically-chosen ethical debate topics, peer-led student working groups, and varied assessment methods were novel aspects of the course. The students, being either philosophy or biology majors or minors, successfully completed the course and indicated being highly satisfied with the course at its completion. Although there were limitations to a course such as this one, educators at similar small liberal arts institutions could offer a bioethics course by following our suggestions, including collaborative teaching and assessment and incorporating students’ preferences into the scheduled curriculum.