George Agich

This paper discusses the importance of Richard M. Zaners work on clinical ethics for answering the question: what kind of doing is ethics consultation? The paper argues first, that four common approaches to clinical ethics – applied ethics, casuistry, principlism, and conflict resolution – cannot adequately address the nature of the activity that makes up clinical ethics; second, that understanding the practical character of clinical ethics is critically important for the field; and third, that the practice of clinical ethics is bound up with the normative commitments of medicine as a therapeutic enterprise

Free and informed consent is generally acknowledged as the legal andethical basis for living organ donation, but assessments of livingdonors are not always an easy matter. Sometimes it is necessary toinvolve psychosomatics or ethics consultation to evaluate a prospectivedonor to make certain that the requirements for a voluntary andautonomous decision are met. The paper focuses on the conceptualquestions underlying this evaluation process. In order to illustrate howdifferent views of autonomy influence the decision if a donor's offer isethically acceptable, three cases are presented – from Germany, theUnited States, and India. Each case features a person with questionabledecision-making capacity who offered to donate a kidney for a siblingwith severe renal insufficiency. Although the normative framework issimilar in the three countries, different or sometimes even contraryarguments for and against accepting the offer were brought forward. Thesubsequent analysis offers two explanations for the differences inargumentation and outcome in spite of the shared reference to autonomyas the guiding principle: (1) Decisions on the acceptability of a livingdonor cannot simply be deducted from the principle of autonomy but needto integrate contextual information; (2) understandings of the wayautonomy should be contextualized have an important influence on theevaluation of individual cases. Conclusion: Analyzing the conceptualassumptions about autonomy and its relationship to contextual factorscan help in working towards more transparent and better justifieddecisions in the assessment of living organ donors.

The realities and myths of long-term care and the challenges it poses for the ethics of autonomy are analyzed in this perceptive work. The book defends the concept of autonomy, but argues that the standard view of autonomy as non-interference and independence has only a limited applicability for long term care. The treatment of actual autonomy stresses the developmental and social nature of human persons and the priority of identification over autonomous choice. The work balances analysis of the ethical concepts associated with autonomy with discussion of the implications of the ethical analysis for long term care. A central chapter involves a phenomenological analysis of four general features of everyday experience (space, time, communication, and affectivity) and explores their practical implications for long term care. This work concludes with a discussion of the advantages associated with a phenomenologically-inspired treatment of actual autonomy for the ethics of long-term care.

This article is an attempt to clarify a confusion in the brain death literature between logical sufficiency/necessity and natural sufficiency/necessity. We focus on arguments that draw conclusions regarding empirical matters of fact from conceptual or ontological definitions. Specifically, we critically analyze arguments by Tom Tomlinson and Michael B. Green and Daniel Wikler. which, respectively, confuse logical and natural sufficiency and logical and natural necessity. Our own conclusion is that it is especially important in discussing the brain death issue to observe the distinction between logical and natural sufficiency/necessity in a strict fashion

In lieu of an abstract, here is a brief excerpt of the content:Seeking the Everyday Meaning of Autonomy in Neurologic DisordersGeorge J. Agich (bio)The Socratic aphorism that the unexamined life is not worth living and dictums like "Know thyself" remind us of the centrality of self-understanding in the history of philosophical reflections on autonomy. These traditional concerns with autonomy may seem far removed from the neurologic impairments to which Joel Anderson and Warren Lux draw our attention. Nonetheless, Anderson and Lux have provided an important discussion that links the traditional philosophical commitment to self-knowledge with an account that parses these concepts in the context of neurologic disorders. Theirs is a potentially productive approach for improving our understanding of autonomy, one that Emilio Mordini and I advocated in a paper entitled, "Autonomy and the Ethics of Neurosurgery" (Agich and Mordini 1998, 54). We argued that the focus of bioethics on issues such as informed consent misses the more challenging and potentially fruitful collaboration that neurosurgery and neurology affords for advancing the philosophical understanding of the conditions of autonomy. The challenge is in the integration of concepts used in one context of meaning with other domains of discourse. A good example of the challenges embedded in pursuing this kind of project can be found in Anderson and Lux's discussion of the concept of accurate self-assessment.Anderson and Lux argue that accurate self-assessment is a requirement for one to act autonomously. On first hearing, this phrase sounds unsurprising and consistent with standard approaches that assume a higher degree of awareness of one's capacities. Their characterization, however, derives from their observations of cases involving severe neurologic impairments, which point to more basic processes than the reflective awareness or knowledge that is often assumed. Paradoxically, the language of accurate self-assessment sounds remarkably like an intellectual function. It appears to fall squarely within the traditional philosophical tendency to define autonomy in terms of ego-centered, intellectual functions involving relatively high-level reflective capacities. Despite their terminology, Anderson and Lux stress that their account requires a type of reflexivity that is not the same as self-conscious reflection understood in the highest degree. They stress this in a number of places. For example, they see the neurologic concept of executive function as involving basic feedback mechanisms that are "broadly isomorphic with capacities associated [End Page 295] with autonomy;" these include anticipation, goal seeking, planning, initiation, sequencing, monitoring, error detection, self-correction, as well as initiation of novel responses, a clearly heterogenous set of capacities (Anderson and Lux 2004, 285). These capacities are not capacities of the "mind," but basic neurologic functions of the intact embodied agent who is actively engaged in the world. Thus, these concepts capture or express a practical (or clinical) as opposed to a theoretical understanding of the basic conditions or capacities defining autonomy. Similarly, their talk of "self-assessment" does not need to be understood as explicit or conscious; rather, it typically operates in the background (Anderson and Lux 2004). They term this character of self-assessment "mundane" (Anderson and Lux 2004, 289), which strikes me as exactly the right way to characterize this key feature of autonomy (Agich 1995). Their phenomenological and clinically based insights are quite sound, but the reader struggles with a terminology that seems to run in a different direction. To be sure, they stress that they intend their language of "autonomy" and "accurate self-assessment" to involve ordinary, background, and everyday functions that do not require high levels or significant capacities for reflective self-assessment, but their very insistence underscores the problem inherent in this terminology.Anderson and Lux argue that the capacity for self-assessment has a task-relative dimension that requires a degree of "accuracy." They characterize accuracy in a way that may promote rather than forestall misunderstanding. They state that "an adequate degree of precision" (281) is required in such assessment. For example, in assessing whether one is able to jump a hurdle, they say "one must accurately estimate not only the strength of one's legs but also the height of the hurdle" (Anderson and Lux 2004, 281). They further characterize their account of "accuracy" as involving an epistemological externalism, which might lead some readers to assume...

Thomasma and Pellegrino''s [3] focus on the healing relationship as the way to give medical ethics a philosophical foundation contains a number of difficulties. Most importantly, their approach focuses philosophical analysis on an idealized view of the healing relationship in which the ideal of health is seen as an uncontroversial norm in the individual case. medical ethics is then characterized as an intrinsic part of the medical act itself. Philosophical inquiry seems limited to a description of the practice of medicine in which ethical norms are embodied. Insufficient attention to methodology leaves unclear how this vision is to be achieved in philosophical reflection

The bioethics literature on managed care has devoted significant attention to a broad range of conflicts that managed care is perceived to have introduced into the practice of medicine. In the first part of this paper we discuss three kinds of conflict of interest: conflicts of economic incentives, conflicts with patient and physician autonomy, and conflicts with the fiduciary character of the physician–patient relationship. We argue that the conflicts are either not as serious as they are often alleged to be or not unique to managed care. In part two we argue that managed care represents a new paradigm for medical care that features a new concept of management. We discuss three types or levels of management that managed care highlights, namely, administrative, clinical, and resource, which together offer a more sophisticated vantage point from which to assess patient care. We do not endorse managed care, but attempt to highlight some of the positive changes brought by managed care that were difficult to attain under traditional reimbursement systems

This article accepts the proposition that old people want to be treated with dignity and that statements about dignity point to ethical duties that, if not independent of rights, at least enhance rights in ethically important ways. In contexts of policy and law, dignity can certainly have a substantive as well as rhetorical function. However, the article questions whether the concept of dignity can provide practical guidance for choosing among alternative approaches to the care of old people. The article explores the paradoxical relationship between the apparent lack of specific content in many conceptions of dignity and the broad utility that dignity appears to have as a concept expressive of shared social understandings about the status of old people

In March 1997, 60 Minutes, a nationally syndicated news magazine program, featured a story in which it was claimed that The Cleveland Clinic Foundation had in place a non-heart-beating donor protocol that involved killing patients for their organs. These charges were brought by a philosopher from a local university. A student who worked at LifeBanc, the northeastern Ohio organ procurement agency where the organ donation protocol originated, was given the protocol by LifeBanc with the understanding that it was to be used in class; the student and professor charged that the protocol involved killing patients for their organs. These claims were advanced without noting that the protocol was a draft that was being reviewed and revised and had not been implemented.

The DSM-IV, like its predecessors, will be a major influence on American psychiatry. As a consequence, continuing analysis of its assumptions is essential. Review of the manuals as well as conceptually-oriented literature on DSM-III, DSM-III-R, and DSM-IV reveals that the authors of these classifications have paid little attention to the explicit and implicit value commitments made by the classifications. The response to DSM criticisms and controversy has often been to incorporate more scientific diversity into the classification, instead of careful inquiry and assessment of the principal values that drive the nosologic process. Implications for psychiatric science and future DSM classifications are discussed

In a practice like ethics consultation, quality and accountability are intertwined. Critics of ethics consultation have complained that clinical ethics consultants exercise power or influence in patient care without sufficient external oversight. Without oversight or external accountability, ethics consultation is seen as more sophistical than philosophical. Although there has been more discussion of accountability, concern for quality in ethics consultation is arguably more important, because it represents a central challenge for the field, namely, how to structure a responsible practice of ethics consultation

Ethics consultation is the most engaged aspect of clinical ethics, a field focused on ethical issues, questions, and conflicts arising in the course of patient care and delivery of healthcare services. Despite the skepticism of some academic bioethicists and criticism expressed by social commentators, clinical ethics, which began in North America, has expanded to Europe and many other parts of the world with the proliferation of healthcare institution ethics and ethics consultation support services. Along with the development and implementation of ethics policies and guidelines for patient care through work on hospital ethics committees, clinical ethicists are increasingly involved in the ethics of healthcare organizational structures and processes and the day to day provision of ethics consultative services to health professionals, patients, and families

While there is no denying the relevance of ethical knowledge and analytical and cognitive skills in ethics consultation, such knowledge and skills can be overemphasized. They can be effectively put into practice only by an ethics consultant, who has a broad range of other skills, including interpretive and communicative capacities as well as the capacity effectively to address the psychosocial needs of patients, family members, and healthcare professionals in the context of an ethics consultation case. In this paper, I discuss how emotion can play an important interpretive role in clinical ethics consultation and why attention to the role of defense mechanisms can be helpful. I concentrate on defense mechanisms, arguing first, that the presence of these mechanisms is understandable given the emotional stresses and communicative occlusions that occur between the families of patients and critical care professionals in the circumstances of critical care; second, that identifying these mechanisms is essential for interpreting and managing how these factors influence the way that the “facts” of the case are understood by family members; and, third, that effectively addressing these mechanisms is an important component for effectively doing ethics consultation. Recognizing defense mechanisms, understanding how and why they operate, and knowing how to deal with these defense mechanisms when they pose problems for communication or decision making are thus essential prerequisites for effective ethics consultation, especially in critical care

Frank Koughan and Walt Bogdanich's response to my article, reminds me of the Shakespearean line, My article was not about the specifics of the 60Minutes April 13, 1997, story on NHBD at the Cleveland Clinic Foundation (CCF), even though the story formed the basis for the reflection. I did not attack the critics, though I do believe that bioethicists are accountable for their scholarly and public pronouncements. Although I do not see why the 60Minutes' story should be treated with deference, my article was designed to raise questions for a primarily bioethics audience about the involvement of bioethicists in media coverage of bioethics topics. I am flattered that they took notice of my piece, but think their efforts to set the record straight only obfuscate matters further

Authority is an uneasy, political notion. Heard with modern ears, it calls forth images of oppression and power. In institutional settings, authority is everywhere present, and its use poses problems for the exercise both of individual autonomy and of responsibility. In medical ethics, the exercise of authority has been located on the side of the physician or the health care institution, and it has usually been opposed by appeal to patient autonomy and rights. So, it is not surprising, though still ironic, that ethics consultation, which develops from this patient rights-dominated ethic, should itself bring forth questions of authority. Nonetheless, it does.Insofar as authority has been discussed in ethics consultations, it has been understandably approached from the broad perspective of legitimation and power, which are common themes in social and political treatments of authority. These treatments have dominated twentieth-century discussions of authority, which primarily view authority as legitimate power.

Dr Agich takes up a previous difficult case related by Dr Kottow in an earlier issue of the Journal. He analyses the three ethical problems as presented in the case and offers his own opinion of it as well as his own conclusions with regard to the medical ethical aspects of it. Unlike Dr Kottow, Dr Agich's reading of the case indicates that the application of the principle of informed consent does not rule out ethical decisions for the physician, but emphasizes the relevance of ethical analysis beyond the issue of informed consent

This paper offers an exposition of what the question of method in ethics consultation involves under two conditions: when ethics consultation is regarded as a practice and when the question of method is treated systematically. It discusses the concept of the practice and the importance of rules in constituting the actions, cognition, and perceptions of practitioners. The main body of the paper focuses on three elements of the question of method: canon, discipline, and history, which are treated heuristically to outline what the question of method in ethics consultation fully involves

Central to much medical ethical analysis is the concept of the role of the physician. While this concept plays an important role in medical ethics, its function is largely tacit. The present paper attempts to bring the concept of a social role to prominence by focusing on an historically recent and rather richly contextured role, namely, that of consultation liaison psychiatry. Since my intention is primarily theoretical, I largely ignore the empirical studies which purport to develop the detailed functioning of the role. My limited intent is to draw attention to the theoretical complexity of the consultation liaison role as an example of the general relevance of role concepts to medical ethics. For this reason, consultation liaison psychiatry will function as an illustration of fundamental concepts of medical ethics rather than as a subject of analysis in its own right. Similarly, the concept of the social role will be developed only as is necessary to explore the general relationship between the consultation liaison role and ethical analysis. Keywords: medical ethics, consultation liaison psychiatry, social role, autonomy, institution CiteULike Connotea Del.icio.us What's this?

In this paper I analyze the alleged conflict between economic incentives to efficiently utilize health care resources and the obligation to provide patients with the best possible medical care. My analysis is developed in four stages. First, I discuss briefly the nature of prospective payment systems and economic incentives as well as the issue of professional autonomy. Second, I disscuss the notion of an incentive for action both as an economic incentive and as a concept of moral psychology. Third, I analyze several definitions of the physician's professional obligation and discuss four conditions that morally qualify the obligation. And fourth, I explore why the views of economists and physicians differ so strikingly on the question of economic incentives. In the process of this analysis, I argue that criticisms of prospective payment systems which are premised primarily on the conflict between economic incentives to contain cost and the professional obligation of beneficence are probably as much a matter of rhetoric as serious argumentation. Keywords: autonomy, beneficence, cost containment, economic incentives, moral obligation, prospective payment CiteULike Connotea Del.icio.us What's this?

This paper argues that the concept of management is critically important for understanding managed care. A proper interpretation of management is needed before a positive account of the ethics of managed care can be constructed. The paper discusses three aspects of management: administrative, clinical, and resource management, and compares the central commitments of traditional medical practice with those of managed care for each of these aspects. In so doing, the distinctive conceptual features of the managed care paradigm are discussed. The paper concludes by arguing that the concept of management implicit in the managed care paradigm affords a basis for building a more adequate ethic of managed care.