Abstract: Modern medicine is built on a long history of medical experimentation. Experiments in the past often exploited more vulnerable patients. Questionable ethics litter the history of medicine. Without such experiments, however, millions of lives would be forfeited. This paper asks whether all the “unethical” experiments of the past were unjustifiable, and do we still exploit the poorer members of the community today? It concludes by wondering if Harris is right in his advocacy of a moral duty to participate in medical research.
The Limits of Confidentiality
Introduction: Doctors, lawyers, and priests have traditionally recog nized the duty of professional secrecy regarding what individuals confide to them: personal matters such as alcoholism or depression, marital difficulties, corporate or political problems, and indeed most concerns that patients or clients want to share with someone, yet keep from all others.’ Accountants, bankers, social workers, and growing numbers of professionals now invoke a similar duty to guard confidences. As codes of ethics take form in old and new professions, the duty of confidentiality serves in part to reinforce their claim to professional status, and in part to strengthen their capacity to offer help to clients.
Mental disorder and the value(s) of ‘autonomy’
Summary (from Introduction of Autonomy and Mental Disorder, Radoilska ed.): In ‘Mental disorder and the value(s) of autonomy’, Jane Heal identifies and critically examines a form of thought which is implicit in discussions about what we, as a society, owe to people with mental disorder. This form of thought builds upon intuitions which link respect for a person with respect for a person’s autonomy. In light of these intuitions, the issue of how to treat a person with mental disorder may seem to revolve around the question whether or not this person has the capacity for autonomy. However, Heal argues, inquiries that share this logical form are methodologically inappropriate and potentially unhelpful in answering either of the questions they put together: what we owe to people with mental disorder and what is involved in autonomy as a capacity. The reason for this is twofold.
Firstly, the apparent consensus about autonomy as a capacity for self-determination that ought to be protected from interference by a corresponding right to self-determination is too shallow to ground a coherent course of action in terms of respect for autonomy. Even if we work with the assumption that autonomy is part of the Enlightenment project, we face an important dilemma since we have to choose between a Kantian or rationality oriented and a Millian or well-being oriented take on the nature and significance of autonomy. Secondly, even if we were to reach a substantive consensus on the concept of autonomy, it would arguably require an intricate array of mental capacities, outside the reach of at least some people with mental disorder. Getting clearer on what autonomy is will not help us find out what it means to treat these people respectfully.
When Caring Is Just and Justice is Caring: Justice and Mental Retardation
Summary: In this paper, Kittay advances a conception of justice that ‘begins with an acknowledgement of dependency and seeks to organise society so that our well-being is not inversely related to our need for care or to care’ (576). Her motivation for advancing this view is that ideals of citizenship in liberal society, including independence and productivity, perpetuate the victimisation, social exclusion, or stigmatisation of people with mental retardation and their carers. This is because liberal definitions of personhood do not provide resources for responding in a morally adequate way to the mutual dependence of people with mental retardation and their carers/advocates. People with mental retardation are inescapably dependent because of their central need for attentive care. And, carers’ work is so deeply other-directed that they also do not fit the liberal model of the rationally self-interested actor. Thus, both carers and their charges are vulnerable and need to be advocated for so that they can be seen as having important entitlements to public resources and claims to justice. To this end, Kittay proposes a conception of personhood that is based on relationships. Although those with mental retardation are inherently dependent, they still count as persons because they are able to participate in relationships. This makes them entitled to the satisfactions that make life worth living. To achieve the twin goal of achieving justice for familial or paid carers, Kittay advances a new principle of justice, doulia, which calls for larger society to support those who care for the inexorably dependent. Kittay takes her relational conception of personhood and her principle of doulia to ensure that appropriate forms of social organization exist to support all those who become dependent. She claims her view is needed because principles of charity and beneficence are not adequate since they are consistent with the continued stigmatization of mental retardation and care work, and ground only low-priority social obligations.
Autonomy and Trust in Bioethics
Publisher’s Note: Onora O’Neill suggests that the conceptions of individual autonomy (so widely relied on in bioethics) are philosophically and ethically inadequate; they undermine rather than support relationships based on trust. Her arguments are illustrated by issues raised by such practices as the use of genetic information by the police, research using human tissues, new reproductive technologies, and media practices for reporting on science, medicine, and technology. The study appeals to a wide range of readers in ethics, bioethics, and related disciplines.
Ethics in medicine: Virtue, Vice and Medicine
Publisher: How, in a secular world, should we resolve ethically controversial and troubling issues relating to health care? Should we, as some argue, make a clean sweep, getting rid of the Hippocratic ethic, such vestiges of it as remain? Jennifer Jackson seeks to answer these significant questions, establishing new foundations for a traditional and secular ethic which would not require a radical and problematic overhaul of the old.
These new foundations rest on familiar observations of human nature and human needs. Jackson presents morality as a loose anatomy of constituent virtues that are related in different ways to how we fare in life, and suggests that in order to address problems in medical ethics, a virtues–based approach is needed. Throughout, attention is paid to the role of philosophy in medical ethics, and how it can be used to clarify key notions and distinctions that underlie current debates and controversial issues. By reinstating such concepts as justice, cardinal virtue, and moral duty, Jackson lays the groundwork for an ethics of health care that makes headway toward resolving seeming dilemmas in medical ethics today.
This penetrating and accessible book will be invaluable to students of sociology and health care, as well as those who are interested in the ethical uncertainties faced by the medical world.
Respecting the Margins of Agency: Alzheimer’s Patients and the Capacity to Value
Introduction: Dworkin puts forth two main arguments to justify adhering to the wishes the patient expressed before becoming demented. As he sees it, this course of action both promotes the patient’s well-being and is required in order to respect the patient’s autonomy. In each argument, while I consider most of the ideas well-founded, I challenge the crucial premise. In the argument focused on the patient’s well-being, I dispute the claim that demented patients are no longer capable of generating what Dworkin calls “critical interests.” In the argument concerning autonomy, I question the premise that demented patients no longer possess the “capacity for autonomy.”7 In each case, I will trace how the problematic premise arises within Dworkin’s argument and then develop an alternative account of the relevant capacity.
From Nuremberg to Guantánamo: Medical Ethics Then and Now
Abstract: On October 25, 1946, three weeks after the International Military Tribunal at Nuremberg entered its verdicts, the United States established Military Tribunal I for the trial of twenty-three Nazi physicians. The charges, delivered by Brigadier General Telford Taylor on December 9, 1946, form a seminal chapter in the history of medical ethics and, specifically, medical ethics in war. The list of noxious experiments conducted on civilians and prisons of war, and condemned by the Tribunal as war crimes and as crimes against humanity, is by now more or less familiar. That list included: high-altitude experiments; freezing experiments; malaria experiments; sulfanilamide experiments; bone, muscle, and nerve regeneration and bone transplantation experiments; sea water experiments; jaundice and spotted fever experiments; sterilization experiments; experiments with poison and with incendiary bombs. What remains less familiar is the moral mindset of doctors and health care workers who plied their medical skill for morally questionable uses in war. In his 1981 work, The Nazi Doctors, Robert Jay Lifton took up that question, interviewing doctors, many of whom for forty years continued to distance themselves psychologically from their deeds. The questions about moral distancing Lifton raised (though not the questions about criminal experiments) have immediate urgency for us now. Military medical doctors, psychiatrists and psychologists serve in U.S. military prisons in Guantánamo, Abu Ghraib, Kandahar, and, until very recently, in undisclosed CIA operated facilities around the world where medical ethics are again at issue. Moreover, they serve in top positions in the Pentagon, as civilian and military heads of command, who pass orders and regulations to military doctors in the field, and who are in charge of the health of enemy combatants, as well as U.S. soldiers. Because we recently marked the sixtieth anniversary of the judgment at Nuremberg, I want to awaken our collective memory to the ways in which doctors in war, even in a war very different from the one the Nazis fought, can insulate themselves from their moral and professional consciences.
Anorexia Nervosa: Psychopathology as the Crystallization of Culture
Diversifying Syllabi: Bordo claims that the recent increase in women with Anorexia is a symptom of the “central ills” of our culture. Bordo discusses three sources of this “cultural illness” which leads to anorexia: the dualist axis, the control axis, and the gender/power axis. She spends the bulk of the paper discussing each “axis” or problematic component of society which is reflected back to us in the increasing diagnosis of anorexia. These “psychopathogolgies” are expressions of the culture, she claims.
Medical Ethics Needs a New View of Autonomy
Abstract: The notion of autonomy commonly employed in medical ethics literature and practices is inadequate on three fronts: it fails to properly identify nonautonomous actions and choices, it gives a false account of which features of actions and choices makes them autonomous or nonautonomous, and it provides no grounds for the moral requirement to respect autonomy. In this paper I offer a more adequate framework for how to think about autonomy, but this framework does not lend itself to the kinds of practical application assumed in medical ethics. A general problem then arises: the notion of autonomy used in medical ethics is conceptually inadequate, but conceptually adequate notions of autonomy do not have the practical applications that are the central concern of medical ethics. Thus, a revision both of the view of autonomy and the practice of “respect for autonomy” are in order.