Steve Edwards

Struggling to understand ethics? Feeling lost when trying to handle moral dilemmas in professional practice? Worried about helping patients to make decisions in an ethical way? Nursing Ethics is an introductory text which enables you to consider, understand and tackle difficult moral problems. It takes a principle-based approach, which provides a practical and easy-to-apply framework for addressing ethical dilemmas. The book includes clear descriptions of moral theories and concepts and is packed with case examples – giving it immediate relevance to everyday nursing situations. As well as being significantly revised and updated, this new edition includes discussion of the Nursing and Midwifery Code (2008) and an entire chapter dedicated to genetics and the related complex ethical issues. Simple, clear and accessible – Nursing Ethics is an essential purchase for all students and practitioners of nursing and health care.

In this paper the need for valid evidence of the cost-effectiveness of treatments that have not been properly evaluated, yet are already available, albeit in short supply, are examined. Such treatments cannot be withdrawn, pending proper evaluation, nor can they be made more widely available until they have been shown to be cost-effective. As a solution to this impasse the argument put forward recently by Toroyan et al is discussed. They say that randomised controlled trials of such resources could be done but only if resources are randomly allocated independently of a research context. Relevant outcome data could then be collected for research, given this opportunity. We agree. We disagree with Toroyan et al on a number of points. First, they claim that no ethical issue relating to equipoise arises. We disagree and this disagreement depends on our showing that equipoise should be maintained in a relationship that they do not consider. Secondly, they say that consent to data collection is always needed. Again we disagree. Thirdly, they claim that the previous two issues are the only possible ethical issues that could arise. We argue, instead, that there is a further conflict of interests that has ethical import

In this paper the authors argue that research ethics committees should not be paternalistic by rejecting research that poses risk to people competent to decide for themselves. However it is important they help to ensure valid consent is sought from potential recruits and protect vulnerable people who cannot look after their own best interests. The authors first describe the tragic deaths of Jesse Gelsinger and Ellen Roche. They then discuss the following claims to support their case: competent individuals are epistemologically and ethically in the best position to say which risks are reasonable for them, so RECs should be no more restrictive than the “normal” constraints on people taking risks with themselves; RECs do not judge individual competence ; individual liberty is mostly limited by what serves the public interest, and RECs do not determine public interest; RECs may have a paternalistic role in preventing exploitation of competent people vulnerable to the use of incentives, and in protecting the interests of incompetent people; however, the moral and political authority of RECs has not been established in this respect

In this paper, we respond to Andrew Avins's recent review of methods whose use he advocates in clinical trials, to make them more ethical. He recommends in particular, “unbalanced randomisation”. However, we argue that, before such a recommendation can be made, it is important to establish why unequal randomisation might offer ethical advantages over equal randomisation, other things being equal. It is important to make a pragmatic distinction between trials of treatments that are already routinely available and trials of restricted treatments. We conclude that unequal randomisation could, indeed, be an ethical compromise between protecting the interests of participants and those of society

Tom Shakespeare’s important new book includes, among other topics, a persuasive critique of the social model of disability. A key component in his case against that model consists in an argument against the impairment/disability distinction as this is understood within the social model. The present paper focuses on the case Shakespeare makes against that distinction. Three arguments mounted by Shakespeare are summarised and responded to. It is argued that the responses adequately rebut Shakespeare’s case on this specific issue. Moreover, as the engagement with Shakespeare’s argument illustrates, his claim to employ a critical realist perspective appears to be in considerable tension with the case he offers against the impairment/disability distinction

In this article we examine ethical aspects of the involvement of children in clinical research, specifically those who are incapable of giving informed consent to participate. The topic is, of course, not a new one in medical ethics but there are some tensions in current guidelines that, in our view, need to be made explicit and which need to be responded to by the relevant official bodies. In particular, we focus on tensions between the World Medical Association Declaration of Helsinki, and the guidance offered by the British Medical Association, the Royal College of Paediatrics and Child Health , and the Council for International Organizations of Medical Sciences. We conclude with a call for these organisations to make their guidance explicit in relation to the World Medical Association Declaration

Tom Shakepeare is an eminent, and somewhat controversial, contributor to disability studies. As he outlines, part of the explanation for his controversial status within that field stems from his engagement with disciplines outside it, including genetics and bioethics. For many in the field of disability studies, no genuine engagement should be sought with scholars in genetics or bioethics because—so the party line goes—these areas of study are inherently opposed to disability rights and otherwise pose genuine threats to the status of disabled people. The present volume is unlikely to do much to reduce his controversial status.The book is divided into three parts. The first presents a detailed criticism of the social model with some, more positive, proposals concerning how disability is best conceived. The second part—perhaps the one that will be of most interest to JME readers—concerns bioethical issues in disability . The final part focuses on themes such as care, charity, intimacy and the role of the non-disabled in “the world of disability”.The main reason why this book is unlikely to reduce Shakespeare’s controversial status is that its central theme is a sustained attack on the so-called and widely held “social model” of disability. According to this model, the causes of disability lie in the social environment, not within the individual. So, change the social environment in appropriate ways, and disability disappears. Shakespeare illustrates the various ways in which this model is analytically flawed and has had a negative effect upon disability studies, research and the lives of disabled people. …

The ethics of care still appeals to many in spite of penetrating criticisms of it which have been presented over the past 15 years or so. This paper tries to offer an explanation for this, and then to critically engage with three versions of an ethics of care. The explanation consists firstly in the close affinities between nursing and care. The three versions identified below are by Gilligan (1982 ), a second by Tronto (1993 ), and a third by Gastmans (2006 ), see also Little (1998 ). Each version is described and then subjected to criticism. It is concluded that where the ethics of care is presented in a distinctive way, it is at its least plausible; where it is stated in more plausible forms, it is not sufficiently distinct from nor superior to at least one other common approach to nursing ethics, namely the much-maligned 'four principles' approach. What is added by this paper to what is already known: as the article tries to explain, in spite of its being subjected to sustained criticism the ethics of care retains its appeal to many scholars. The paper tries to explain why, partly by distinguishing three different versions of an ethics of care. It is also shown that all three versions are beset with problems the least serious of which is distinctiveness from other approaches to moral problems in health care.

Current UK guidelines regarding clinical research on children permit research that is non-therapeutic from the perspective of that particular child. The guidelines permit research interventions that cause temporary pain, bruises or scars. It is argued here that such research conflicts with the Declaration of Helsinki according to which the interests of the research subject outweigh all other interests. Given this, in the context of clinical research, who is best placed to protect the child from this kind of exploitation? Is it the medical researcher, the child’s parents or the nurse advocate? This article describes the problem, possible responses to it, and closes with a consideration of, and rejection of, a defence of current guidelines that claims moral parity between clinical research and clinical education

For more than 15 years Professor Per Nortvedt has been arguing the case for moral realism in nursing and the health‐care context more generally. His arguments focus on the clinical contexts of nursing and medicine and are supplemented by a series of persuasive examples. Following a description of moral realism, and the kinds of considerations that support it, criticisms of it are developed that seem persuasive. It is argued that our moral responses are explained by our beliefs as opposed to moral realities. In particular, two key arguments presented by Nortvedt are challenged: the so‐called argument from convergence and the argument from clinical sensitivity. Both of these key planks in the case for moral realism are rejected, and an alternative ‘social conditioning’ account briefly sketched, which, it is claimed, has the same explanatory power as Nortvedt's thesis but does not rest on an appeal to independently existing moral properties.

Is it true that an ethics of care offers something distinct from other approaches to ethical problems in nursing, especially principlism? In this article an attempt is made to clarify an ethics of care and then to argue that there need be no substantial difference between principlism and an ethics of care when the latter is considered in the context of nursing. The article begins by considering the question of how one could in fact differentiate moral theories. As is explained, this cannot be done merely in light of the moral judgements they defend, nor their ontological commitments (e.g. their view of the nature of persons). Following these methodological beginnings, care-based ethics is described and critically discussed. It is shown that ontological commitments embraced within care ethics do not themselves show that care ethics is distinct from other approaches. The idea of ‘psychological care’ is also discussed, which stems from the work of Margaret Little. Her claim that the ‘gestalts’ of justice and care cannot be combined is rejected in favour of an approach that does just that and which has been developed by Joan Tronto. It is then claimed that the moral commitments of principlism are certainly not incompatible with those of an ethics of care in the nursing context. A challenge to the idea that principlism and ethics of care might be compatible is anticipated in the work of Eva Feder Kittay. This challenge is responded to and it is concluded that care considered as a moral orientation and the moral values embedded in principlism are best combined in the nursing context. Care provides a moral orientation over which the obligations referred to in principlism can be laid