We often consider medical practitioners to be epistemic authorities: “Doctor knows best,” as the saying goes. The place of expert judgment in evidence-based medicine hierarchies, and the crucial role of patient preferences and values in medical decision-making, however, pose problems for making sense of such authority. I argue that there is an account of such medical epistemic authority that does justice to the complexities of the doctor–patient relationship, while maintaining that medical practitioners hold an epistemically privileged (...) position. Such a view can better inform medical practice by clearly illuminating the distinct roles of patients and doctors in decision-making processes. (shrink)

Vor dem Hintergrund, dass in den Medien und der Öffentlichkeit thematisierte und dargestellte Arztbilder stets auch auf die öffentliche Meinung und die Vorstellungen der Menschen von Ärzten wirken, spürt der Artikel der Frage nach, welches Arztbild die amerikanische TV-KrankenhausserieDr. House transportiert und welche Ausprägung das dargestellte Arzt-Patienten-Verhältnis einnimmt. Hierbei werden die medizinethischen Reflexionen durch eine detaillierte medienwissenschaftliche Genre-Einordnung und dramaturgische Analyse eingerahmt und unterstützt. Zudem werden als Analyseinstrumentarium die vier Modelle des Arzt-Patienten-Verhältnisses nach Emanuel/Emanuel herangezogen. Dieser interdisziplinäre Forschungsansatz zeigt, dass (...) die Hauptfigur der Serie, der Arzt Dr. Gregory House, durchaus als Gegenentwurf einesmodernen Arztes, der fürsorglich, nicht-direktiv und stets im Sinne desinformed consent handelt, konzipiert und präsentiert wird. Doch ist daraus nicht zu schließen, dass die Figur des Dr. House einseitig als Paternalist gezeichnet ist. Die Kategorisierung und Einordnung des Dr. House und der von ihm repräsentierten Arzttugenden ist vielmehr entlangaller Elemente des gesellschaftlichen Arztideals vorzunehmen, zu denen eine entsprechende wissenschaftlich-medizinische Kompetenz, die Orientierung an objektivierbaren Indizien, die Verpflichtung auf das naturwissenschaftliche, evidenzbasierte Ideal, eine angenehme Kommunikation mit dem Patienten sowie die nötige, gebotene Aufklärung zählen. So wird in der Analyse deutlich, dass die Darstellung von Dr. House vielschichtiger ist und immer wieder auf ethische Dilemma-Situationen in der Medizin verweist. Diese wirkmächtige dramatisch-filmische Darstellung von Konfliktsituationen im diagnostisch-therapeutischen Kontext sollte daher auch in der kommunikationswissenschaftlichen Wirkungsforschung vertieft werden. (shrink)

The late Robert Veatch, one of the United States’ founders of bioethics, never tired of reminding us that the paradigm-shifting contribution that bioethics made to patient care was to liberate patients out of the hands of doctors, who were traditionally seen to know best, even when they decidedly did not know best. It seems to us that with the advent of COVID-19, health policy has come full-circle on this. COVID-19 gave rise to a large number of purportedly “ethical” (...) guidance documents aiming to assist health care providers and practitioners with responding to the ethical challenges that might arise in their response to the pandemic. Ethics has two primary functions: provide clear action guidance, and provide clear action justification. The documents in question arguably reflect the ultimate policy triumph of bioethical “principlism”, and, perhaps surprisingly, as a corollary, the ultimate triumph of “doctor-knows-best”. (shrink)

When a gynecologist asks a twenty-one-year-old patient about her use of contraception, he is surprised that she would like to have a tubal ligation. The patient says that she would “never want to bring a child into this screwed up world.” She has discussed tubal ligation with her boyfriend of one year, and he has told her that he accepts her decision. She asks her doctor if she can schedule the procedure as soon as possible. Her gynecologist mentions that (...) he is concerned that she is very young and may eventually change her mind about having children. She insists that she has thought about it carefully and is certain that she wants the procedure. Her doctor feels very uncomfortable about this request. He consults the hospital ethics committee. Should he do as the patient asks or suggest that she wait at least six months and reconsider? (shrink)

Since at least the Karen Ann Quinlan case, the idea of autonomy has always been central to the discussion about whether to given life-prolonging treatment. Those on different sides of the debate may disagree strongly about some of the issues, but the importance of the patient's autonomy has been accepted by people of widely different points of view.

While twentieth-century medical ethics has focused on the duty of physicians to benefit their patients, the next century will see that duty challenged in three ways. First, we will increasingly recognize that it is unrealistic to expect physicians to be able to determine what will benefit their patients. Either they limit their attention to medical well-being when total well-being is the proper end of the patient or they strive for total well-being, which takes them beyond their expertise. Even within the (...) medical sphere, they have no basis for choosing among the proper medical goals for medicine. Also, there are many plausible strategies for relating predicted benefits to harms, and physicians cannot be expert in picking among these strategies. Second, increasingly plausible ethical systems recognize that in some cases, patient benefit must be sacrificed to protect patient rights including the right to the truth, to have promises kept, to have autonomy respected, and to not be killed. Third, ethics of the next century will increasingly recognize that some patient benefits must be sacrificed to fulfill duties to others - either the duty to serve the interests of others or other duties such as keeping promises, telling the truth, and, particularly, promoting justice. Physicians in the twenty-first century will be seen as having a new, more limited duty to assist the patient in pursuing the patient's understanding of the patient's interest within the constraints of deontological ethical principles and externally imposed duties to promote justice. The result will be a duty to be loyal to the consumer of health care with the recognition that often this will mean that the physician is not permitted to pursue the physician's understanding of the patient's well-being. (shrink)

The questions and dilemmas of bioethics touch everyone. Should people who refuse to be vaccinated be treated for COVID-19, even if that displaces vaccinated patients with other serious conditions? What restrictions on abortion should there be, if any? Should women be paid to donate eggs? Bioethics: What Everyone Needs to Know ® discusses these and other similar questions facing the public today--as well as providing a way for thinking deeply about them. Steinbock and Menzel first examine major moral theories and (...) how they can be used to analyze bioethical issues. They then provide historical background to the birth of bioethics and explain how it shifted from a paternalistic doctor knows best approach to respect for autonomy, a fundamental value in contemporary bioethics. Subsequent chapters cover advance directives, experimentation on human subjects, the definition of death, physician-assisted dying, abortion, disability, just healthcare systems, the allocation of scarce resources, pharmaceutical drug pricing, assisted reproductive technology, egg donation, surrogate motherhood, sex selection, and the genetic modification of humans. Race and gender are considered throughout, as are the ethical issues raised by pandemics. Steinbock and Menzel consider the controversial questions that surface in the public sphere, explaining the facts, and then evaluating different approaches to resolving them. (shrink)

BackgroundThe Mental Capacity Act was enacted in 2007 in England and Wales, but the assessment of mental capacity still remains an area of professional concern. Doctors’ compliance with legal and professional standards is inconsistent, but the reasons for poor compliance are not well understood. This preliminary study investigates doctors’ experiences of and attitudes toward mental capacity assessment.MethodsThis is a descriptive, cross-sectional study where a two-domain, study-specific structured questionnaire was developed, piloted and digitally disseminated to doctors at differing career stages employed (...) in a large, multi-site National Health Service Trust in London over 4 months in 2018. Descriptive statistics and frequency tables adjusted for missing data were generated and secondary analysis was conducted.ResultsParticipants were predominantly UK trained, female and between the ages of 30 and 44 years. Less than half of the participants reported receiving formal MCAx training. Only one-third of the participants self-rated themselves as very competent or extremely competent. Self-reported MCA confidence was significantly affected by career stage with Consultants with over 10 years of experience reporting lowest confidence.ConclusionsThis study describes significant variation in practice by doctors and low self-confidence in the practice of MCAx. These results raise concerns that MCAx continues to be inconsistently performed by doctors despite appropriate awareness of the law and professional guidance on best practice. (shrink)

Cooperation between doctors of various specialties and other medical specialists is the standard of care in the treatment of patients. Due to the variety of diseases and the dynamic development of medicine in general, it is difficult to be an expert in every field and know all the recommended treatments. An example of such cooperation is the joint treatment of patients with the problem of ingrown toenails. The article contains an analysis of patients who received treatment in a doctor’s (...) office in cooperation with podiatrists. A conservative approach towards the treatment of this condition sees the patient being initially diagnosed and treated by a podiatrist and then later, if necessary, being referred to a doctor for surgical treatment. The exchange of experiences and information on patients treated by interdisciplinary teams allows doctors and podiatrists to find the best possible treatment and improve the quality of life of patients. The follow-up of patients after surgery can be performed later in podiatry offices. Owing to modern electronic communication, it is possible for a doctor to constantly monitor the patient’s condition without the need for direct visits to the doctor’s office. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Scholars of Bonaventure's thought labor under the difficulty that the Seraphic Doctor is more widely admired than read. Yet there is one advantage they may claim: the immense popularity down through the centuries of his magnum opus: the Itinerarium mentis in Deum, "The Journey of the Mind to God." The text is poetic, concise, and dense. It summarizes many points in Bonaventure's philosophy, theology, and spirituality – indeed, (...) it has sometimes been called a summa of his spiritual theology.In the present essay, I offer a proposal for reading the Itinerarium. I do so with two types of readers in mind. One is the Bonaventure scholar, for whom I make certain arguments concerning the logic of the text and its relationship to other works of Bonaventure. The other is the non-specialist who wishes to teach the Itinerarium as a significant part of the Christian theological patrimony. To the latter, I offer a schematic to understand the different elements of the text in their relationship to each other. This guided reading will, I hope, help the teacher to present the scientific power of Bonaventure's theology.I. Preliminary NoteMy preliminary claim is that the Itinerarium is best understood as divided into two trajectories: one involves the three stages of seeing God through the visible world, the soul, and what is above the soul; the other involves the three stages of seeing God in the visible world, the soul, and what is above the soul. This claim might be criticized by readers of the text. Bonaventure gives several possibilities for understanding the structure of the text in the first part of chapter 1, and does not state that one should be privileged above the others. However, as he goes on to explain each stage, the division that keeps reappearing is that of seeing God through and in the visible world, the soul, and what is above the soul. I therefore regard that division as the most significant. In what follows, I first examine certain antecedents to the Itinerarium's structural argument in earlier works of Bonaventure. I then outline the first trajectory, highlighting its similarities and differences with those earlier works, and then the second trajectory, highlighting its uniqueness and proposing a key by which it may be understood. I close with a brief statement of the significance of my reading in light of some recent scholarship.For reference, one may use the following chart, delineating the trajectories.Knowing God through Knowing God inwhat is below the soul chap. 1: the consideration of God through his vestiges in the universe chap. 2: the consideration of God in his vestiges in this visible worldthe soul chap. 3: the consideration of God through his image imprinted on our natural powers chap. 4: the consideration of God in his image reformed through the gifts of gracewhat is above the soul chap. 5: the consideration of the divine unity through its primary name which is Being chap. 6: the consideration of the most blessed Trinity in its name which is the GoodII. Antecedents to This Kind of Consideration of GodA) Knowing God through and inThe distinction between seeing God through and in is not unique to the Itinerarium. It occurs earlier, in the Commentary on the Sentences, in two places. Though the contexts and the language are slightly different, the content of the distinction is the same. To know God through creatures is "to be raised from the knowledge of the creature to the knowledge of God as by way of a intermediate ladder." To know God in creatures is rather to know "his presence and influence in the creature." Bonaventure says further that knowing God through creatures is characteristic of wayfarers, and is a knowledge that is.. (shrink)

Most people know precious little about the risks and benefits of participating in a clinical trial--a medical research study involving some innovative treatment for a medical problem. Yet millions of people each year participate anyway. Patients at Risk explains the reality: that our current system intentionally hides much of the information people need to make the right choice about whether to participate. Witness the following scenarios: -Hundreds of patients with colon cancer undergo a new form of keyhole surgery at leading (...) cancer centersnever -Tens of thousands of women at high risk of developing breast cancer are asked to participate in a major research study. They are told about the option of having both breasts surgically removed but not told about the option of taking a standard osteoporosis pill that might cut the risk of getting breast cancer by one-half or more. Patients at Risk written by two nationally prominent experts, is the first book to reveal the secrets that many in the research establishment have fought long and hard to keep from patients. It shows why options not commonly knownincluding getting a new treatment outside of a research studycan often be the best choice. It explains how patients can make good decisions even if there is only limited information about a treatments effect. And it does this through the eye-opening stories of what is happening daily to thousands of people. Day after day, we are learning how little we know about what really works. Headlines regularly announce that a previously unquestioned treatmenthormone replacement therapy, drugs such as Vioxx or Celebrexmay now be much riskier than we thought. The latest book in a surge of recent books criticizing the medical establishment (but the first to look at clinical trials specifically), Patients at Risk helps to empower patients to survive in a world of medical uncertainty, and makes positive recommendations for systemic reform. (shrink)

The claim that skeptical theism induces moral paralysis or aporia (known as the moral paralysis objection) has been extensively discussed. In this context, Stephen Maitzen has introduced the Alien Doctor Analogy, an intriguing case that he employs to advance the moral paralysis objection. Michael Rea, however, has criticized the analogy for portraying the skeptical theist uncharitably. In this essay, I argue that Maitzen and Rea are both incorrect: the Alien Doctor Analogy is flawed indeed, but because it portrays (...) the skeptical theist too charitably. I modify the analogy to remedy this flaw. I then use the analogy to advance an original version of the moral paralysis objection. Specifically, I contend that skeptical theists, whenever they encounter apparently gratuitous evil that they could prevent, should be convinced by what I call the “God-Knows-Best Argument,” which always concludes that they should refrain from intervening. Thus, skeptical theism does induce moral paralysis. (shrink)

As a third-year medical student, I have the job of being the first person from the medical team to check in on patients in the morning, follow up on consults that they may need, and communicate with people from other services who are involved with patients’ care. Because third-year medical students have the most time of anyone on the medical team, we are encouraged to get to know our patients. We are encouraged to take time to understand our patients’ conditions (...) on both a medical and personal level, that is, both to read about their complex diseases and to talk about their preferences, goals, families, and lives outside the hospital. As best we can, we then communicate their personal needs and preferences to the medical team of doctors, nurses, social workers and others. What could be wrong with that? (shrink)

Medical paternalism has long been a common medical practice. However, patient autonomy in healthcare has been recently adopted by doctors and patients alike. This study explored whether doctors and patients in a tertiary care hospital in Saudi Arabia preferred autonomy or paternalism in shared decision‐making. A total of 118 participants (51 patients requiring total knee replacement, owing to stages 3–4 of osteoarthritis, and 67 doctors) from the Eastern province, Saudi Arabia. responded to a 17‐question category‐based questionnaire involving four scales of (...) autonomy. Descriptive statistics and chi‐square test results revealed that in this hospital, patients preferred a paternalistic approach toward their medical care along with a full disclosure of the risks related to surgical procedures. We recommend health education regarding the specific autonomy subscales (doctor knows best, patient should decide, right to non‐participation, and obligatory risk information), and the implementation of protocols that protect patients' rights and enhance personal autonomy. (shrink)

Objectivism is the view that how an agent ought to act depends on all kinds of facts, regardless of the agent’s epistemic position with respect to them. One of the most important challenges to this view is constituted by certain cases involving specific conditions of uncertainty—so-called three-options cases. In these cases it seems overwhelmingly plausible that an agent ought to do what is recommendable given her limited perspective, even though the agent knows that this is not objectively the (...) class='Hi'>best course of action. The standard objectivist response to this challenge relies on a distinction between what one ought to do and what would be blameworthy or unreasonable to do. This response is affected by several problems. In this paper I introduce and defend an alternative objectivist response to the challenge. My proposal admits that in the relevant cases the agent ought to do what is recommendable given her perspective, but maintains that this diagnosis of the cases is fully compatible with objectivism. I argue that this proposal has several advantages over alternative accounts of the cases. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Tincture of the Doctor's TimeHolland KaplanI first thought of Mr. H as a "difficult patient" while reading the written hand-off I received on him as I was preparing to take over an inpatient general medicine service—"He leaves all the time to smoke." I don't think the statement was meant to imply anything about the patient; if anything, it may have been included for context to prepare me (...) for the patient's intermittent absence. But, reading this, I felt a familiar sense of annoyance rising in my chest. Every few months, I take care of a patient who seems to never be in his room. The patient is consistently out smoking, in the cafeteria, or in another unknown location, seemingly doing an undisclosed activity. This is frustrating because it means I have to work around the patient's schedule of smoke breaks and jaunts to the cafeteria to evaluate the patient on a daily basis. The thoughts inevitably cross my mind: Does this patient even want care in the hospital if he's never in his room? Is he actually sick enough to need to be in the hospital if he's able to spend so much time outside of the hospital? Why is he leaving so frequently—is he doing drugs?This particular patient had been in perfect health until two months before I met him when he was shot multiple times during an encounter at a gas station. One of the bullets had lodged in his back, shattering a vertebra. Another had decimated the bones in his right upper arm, which were now held in place by screws and plates. Several had landed in his abdomen, necessitating the removal of part of his bowel. Finally, a bullet had sliced through the lower part of his right kidney, shredding his ureter and mandating surgical reconstruction of his urinary system. After over a month in the intensive care unit with multiple reparative surgeries, he was discharged to a rehabilitation facility. But he started having fevers and fast heart rates; ultimately, he was admitted to the hospital again for multiple infected fluid collections that had formed at the sites of his surgeries. He left the hospital prior to getting treated for these infections, purportedly "against medical [End Page 12] advice." And now, several weeks later, he was here in the hospital for the same reason.The first time I went to see Mr. H, he was, of course, not in his room. I went to the nursing station to ask if the clerk knew where he was. She knowingly said, "Oh yeah, he goes out a lot. I can give him a call to let him know the doctor is here to see him if you'd like." I assented, thanked the clerk for calling him, and proceeded, annoyed, in seeing the rest of my patients. I considered how I would address Mr. H's behavior when I was finally able to talk to him. I had seen others take many different approaches—negotiation about the timing and frequency of these extramural expeditions, ultimatums about getting discharged, mandating urine drug screens upon return, and silent, frustrated tolerance. I resolved to wait to speak to him to determine which approach might be most suitable. An hour later, I received a call from the clerk that Mr. H had returned to his room to see me.The first time I met Mr. H, he informed me he had taken the bus to midtown to make a run to the grocery store. I was internally incredulous. He felt well enough to go to the grocery store? Why was he in the hospital then? At that moment, I opted not to discuss his frequent departures yet, as I was frustrated and realized I wouldn't be able to identify the best way to address them. I reviewed his medical issues with him, asked specific questions about how he was feeling, performed a physical exam, and reiterated his current plan of care. Mr. H made it very clear that he would like to get out of the hospital as soon as possible. I tried to set the expectation that he... (shrink)

Patient choice, we might think, is the popular version of the ideas of informed consent and the principle of respect for autonomy and intimately connected to the politics of liberal individualism. There are various accounts to be given for why patient choice, in all its forms, has dominated thinking in bioethics and popular culture. All of them, I suggest, will make reference to the decline of paternalism. The bad old days of ‘doctor knows best’ are gone and (...) were replaced by the primacy of patient choice and informed consent.The response to the dominance of the principle of patient choice has been slow in building but it has come in a number of ways. Two sets of papers in this issue of the Journal of Medical Ethics show just how far this response has come and the degree to which the pendulum is swinging back in the other direction. Neil Levy's Feature article, ‘Forced to be free? Increasing patient autonomy by constraining it’, argues that we should go to greater lengths to correct patients' mistaken decisions . In the ‘Author meets critics’ section, Sarah Conly's book, Against Autonomy: Justifying Coercive Paternalism is the focus of comment . Both authors draw on a similar range of empirical evidence to undermine the sanctity of patient and individual choice. An array of commentators draw on these target pieces to give a clear picture of the ways in which the popular view can justifiably be undermined.Levy's paper focuses on the process of informed consent in clinical contexts. He argues that, while this process is crucially important, it systematically fails because of well-documented frailties of human reason. The evidence of these frailties comes from cognitive and social psychology, on biases and heuristics. The key question is how …. (shrink)

The more we know about medicine, the more we realize that many health questions have no one true answer. Realizing this, and thinking carefully about how medicine asks patients to treat their conditions, leads us to some questions. How reliable are the guidelines that might form the basis of doctors’ advice? Is it wrong, after all, to base an approach to medicine on patients’ preferences? And, given that there is often a distance between the treatment a doctor advises and (...) what a patient would like to do, how do we bridge the gap—especially in a health culture of inequality, technical proficiency, and increasing costs? In practical, engaging, narrative-driven chapters about common health conditions that millions of Americans are familiar with—depression and high blood pressure, arthritis and diabetes—Dr. Zackary Berger of Johns Hopkins demystifies the often bewildering disconnect between patients and doctors and asks us all to think more clearly about how best to protect and cure the human body. (shrink)

There are ethical guidelines that form the foundation of the traditional doctor–patient relationship in medicine. Health care providers are under special obligations to their patients. These include obligations to disclose information, to propose alternative treatments that allow patients to make decisions based on their own values, and to have special concern for patients’ best interests. Furthermore, patients know that these obligations exist and so come to their physicians with a significant level of trust. In this sense, therapeutic medicine (...) significantly differs from straightforward business practices such as the buying and selling of houses, cars, cell phones, etc. However, we argue that this relationship differs when medicine is used for enhancement rather than therapy. When patients seek enhancements they are not as vulnerable as when they are ill. And in an enhancement setting, physicians have little role outside of medical risks to discuss motivation and alternatives. Therefore, we conclude that a more reasonable alternative may be for doctors and patients to use ethical norms associated more with straightforward business practices, specifically sales. We believe that full disclosure of this different set of norms will benefit both physicians and patients. (shrink)

It took nearly two thousand years for society to recognize the Hippocratic insistence that “the doctor knows best”1 was an inadequate approach to medical decisionmaking. Today, patient-centered medicine has come to understand that the individual patient has a significant role in the decisionmaking process.2.

Patients have not been entirely ignored in medical ethics. There has been a shift from the general presumption that ‘doctor knows best’ to a heightened respect for patient autonomy. Medical ethics remains one–sided, however. It tends (incorrectly) to interpret patient autonomy as mere participation in decisions, rather than a willingness to take the consequences. In this respect, medical ethics remains largely paternalistic, requiring doctors to protect patients from the consequences of their decisions. This is reflected in a (...) one–sided account of duties in medical ethics. Duties fall mainly on doctors and only exceptionally on patients. Medical ethics may exempt patients from obligations because they are the weaker or more vulnerable party in the doctor–patient relationship. We argue that vulnerability does not exclude obligation. We also look at others ways in which patient responsibilities flow from general ethics: for instance, from responsibilities to others and to the self, from duties of citizens, and from the responsibilities of those who solicit advice. Finally, we argue that certain duties of patients counterbalance an otherwise unfair captivity of doctors as helpers. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Hermeneutical Injustice and Best PracticeAlasdair Coles, PhD, MRCP (bio)To a doctor who routinely sees people with psychosis and neurological conditions causing strange experiences, José Porcher’s paper is challenging and troubling.Challenging, because the accusation of hermeneutical injustice is accurate. In the hurly burly of the emergency department or a government outpatient clinic, doctors resort to reductionism, for the sake of urgent efficiency. A person becomes a “case of (...) psychosis” and the immediate questions are: “Should they be admitted? Are they fit to make their own decisions? What medication should we prescribe?” In that context, spending time on analyzing the contents of the delusions, and acknowledging their meaning to the individual, is a luxury. Most doctors, burnt out by COVID and struggling to get people basic healthcare, will probably be unconcerned about hermeneutical injustice. But, disdain for the experience of psychosis leads to loss of trust between patient and doctor, as nicely illustrated by Heriot-Maitland, Knight, and Peters’ first patient. One consequence is that patients withhold information they imagine will not be well received by the medical profession. In my experience, of studying the rare entity of people with epilepsy that causes pleasurable or even religious experience, the patients have usually not discussed this with their doctor (Coles & Collicut, 2019) A tangible medical consequence is that their doctors are not aware of the risk of non-compliance with anticonvulsant drugs, so that they are at risk of serial seizures or even sudden death.Porcher’s uncritical appreciation of the Avraham case worries me. Although one of the two therapists is described as “particularly well-versed in Jewish custom and lore” (Bilu et al., 1990), they are not believers. Yet, they take on priestly roles. For instance, after identifying Avraham’s “the Black” as a demon (“which the patient did not belie” [Bilu et al., p. 110]), they prescribe incantations based on Jewish exorcism rites. And, once Avraham was better, he and his wife attributed his “miraculous cure” to the therapists who they regarded as “pious and pure hearted” (Bilu et al., p. 116). Not only are Avraham’s secular therapists being disingenuous, it is dangerous for seculars to appropriate religious language, concepts, and customs. In particular, clumsy use of exorcism rituals can lead to long-term spiritual distress. Those ministers of religion who practice deliverance [exorcism] are highly trained, not least to respect the importance of asking for psychiatric [End Page 239] help. It is unwise not to return the professional favor. Avraham’s therapists should have called in a Jewish minister, trained in clinical pastoral care, to assist them.Key issues are raised by Porcher’s analysis of the Femi case. Femi presented with a psychosis that included religious content. This is common (Sofou et al., 2021): religious imagery is present in 5% to 50% of cases of psychosis, assessed by repeated studies across multiple cultures. The medical team concluded Femi had a psychosis, because his symptoms caused him harm (social isolation, absence from work). Porcher rightly condemns Femi’s therapists because they undermined his dignity, by invalidating his experience of God. And Porcher goes on to state the “both–and” view, that something can be psychopathology and a religious experience. So far so good. But what Porcher does not allow is that some people experience psychoses with very harmful and dark religious imagery, invalidation of which is therapeutic. So, when Porcher asks “what could ever justify someone in the judgment that someone’s religious experiences are illegitimate?” the answer is: compassion. Schizophrenia is not fun. And the disease causes hallucinations that have no relation to reality; to the person I saw recently who believed her clothes were eating her, how helpful would it be to validate the nonsense of clothes with teeth? It follows that some religious delusions may be just that. And people are helped by knowing that. That is the reality of care of the deluded patient. For those therapists who just assume all religious content is inauthentic, Porcher’s article stands as a useful corrective. But assuming the opposite may be as harmful or more. There has to be judgement somewhere along the line. Best practice is that this is done... (shrink)

Efforts to build research capacity and capability in low and middle income countries (LMIC) has progressed over the last three decades, yet it confronts many challenges including issues with communicating or even negotiating across different cultures. Implementing global research requires a broader understanding of community engagement and participatory research approaches. There is a considerable amount of guidance available on community engagement in clinical trials, especially for studies for HIV/aids, even culturally specific codes for recruiting vulnerable populations such as the San (...) or Maori people. However, the same cannot be said for implementing research in global health. In an effort to build on this work, the Pakistan Institute of Living and Learning and University College London in the UK sought to better understand differences in beliefs, values and norms of local communities in Pakistan. In particular, they have sought to help researchers from high income countries (HIC) understand how their values are perceived and understood by the local indigenous researchers in Pakistan. To achieve this end, a group discussion was organised with indigenous researchers at Pakistan Institute of Living and Learning. The discussion will ultimately help inform the development of a cultural protocol for researchers from HIC engaging with communities in LMIC. This discussion revealed five common themes; (1) religious principles and rules, (2) differing concepts of and moral emphasis on autonomy and privacy, (3) importance of respect and trust; (4) cultural differences (etiquette); (5) custom and tradition (gift giving and hospitality). Based on the above themes, we present a preliminary cultural analysis to raise awareness and to prepare researchers from HIC conducting cross cultural research in Pakistan. This is likely to be particularly relevant in collectivistic cultures where social interconnectedness, family and community is valued above individual autonomy and the self is not considered central to moral thinking. In certain cultures, HIC ideas of individual autonomy, the notion of informed consent may be regarded as a collective family decision. In addition, there may still be acceptance of traditional professional roles such as ‘doctor knows best’, while respect and privacy may have very different meanings. (shrink)

Shared decision-making involves health professionals and patients/clients working together to achieve true person-centred health care. However, this goal is infrequently realized, and most barriers are unknown. Discussion between philosophers, clinicians, and researchers can assist in confronting the epistemic and moral basis of health care, with benefits to all. The aim of this paper is to describe what shared decision-making is, discuss its necessary conditions, and develop a definition that can be used in practice to support excellence in maternity care. Discussion (...) between the authors, with backgrounds in philosophy, clinical maternity care, health care management, and maternity care research, assisted the team to confront established norms in maternity care and challenge the epistemic and moral basis of decision-making for caesarean section. The team concluded that shared decision-making must start in pregnancy and continue throughout labour and birth, with equality in discourse facilitated by the clinician. Clinicians have a duty of care for the adequacy of women's knowledge, which can only be fulfilled when relevant knowledge is offered freely and when personal beliefs and biases that may impinge on decision-making (defeaters) are disclosed. Informed consent is not shared decision-making. Key barriers include existing cultural norms of “the doctor knows best” and “patient acquiescence” that prevent defeaters being acknowledged and discussed and can lead to legal challenges, overuse of medical intervention and, in some areas, obstetric violence. Shared decision-making in maternity care can thus be defined as an enquiry by clinician and expectant woman aimed at deciding upon a course of care or none, which takes the form of a dialogue within which the clinician fulfils their duty of care to the client's knowledge by making available their complete knowledge (based on all types of evidence) and expertise, including an exposition of any relevant and recognized potential defeaters. Research to develop measurement tools is required. (shrink)

abstract Is it permissible for a doctor or nurse to knowingly administer a placebo in a clinical setting? There is certainly something suspicious about it: placebos are typically said to be ‘sham’ treatments, with no ‘active’ properties and so giving a placebo is usually thought to involve tricking or deceiving the patient who expects a genuine treatment. Nonetheless, some physicians have recently suggested that placebo treatments are sometimes the best way to help their patients and can be administered (...) in an honest way. These physicians conclude that placebo treatments are a perfectly acceptable, and ethically unproblematic, mode of treatment. While I grant the common idea that placebos are deceptive is correct, I argue that widespread misunderstandings concerning why this is so has led proponents of placebo treatments to respond to the charge of deception in a way that misses the mark entirely. My goal in this paper, then, is to develop a precise conception of what makes something a placebo, which in turn will clarify the central charge concerning the ethics of placebo treatment, viz. that it is deceptive. (shrink)

Since the 1960s we have moved rapidly from a “doctor-knows-best” society which in which medical paternalism -- such as withholding information from patients “for their benefit” -- was common, towards a society which celebrates patients’ rights to make informed decisions about their care. In Choosing Life, Choosing Death, Charles Foster mounts a polemic against the current enthusiasm for respect for autonomy in medical ethics and law.

In this commentary on the previous paper it is explained that screen-detected Duct Carcinoma In Situ is effectively a new disease of unknown natural history. It is therefore impossible that 'the doctor knows best' and it is therefore both in the patient and the public's best interests that such cases are submitted to the rigours of the randomised controlled trial. Inevitably this brings the ethical dilemma of how to explain to patients the uncertainty and how to (...) involve them in a rational decision to take part in the randomised controlled trial. It is argued that as well as there being a collective benefit for future generations of women, that we should resolve this problem now, the individual woman is likely to benefit from being treated according to a strict protocol. Nevertheless the time of diagnosis is paradoxically not the best time for a patient to become aware of these matters and it is about time that the lay public and the opinion formers recognized their responsibility to become acquainted with the benefits and the needs of the randomised controlled trial in anticipation of the day when they themselves will be patients. (shrink)

This baseline study was conducted to find out the knowledge, attitudes and practices of medical ethics among the undergraduate medical interns who did not have structured ethics curriculum in their course. A descriptive, cross-sectional study was carried out using a self-administered structured questionnaire among the medical undergraduate interns of Maharajgunj Medical Campus, the pioneer medical college of Nepal which enrols 60 students in a year. A total of 46 interns participated in the study. The most common source of knowledge on (...) ethics was lectures/seminars (35.7%) followed by experience at work (24.5%), training (21.4%) and own reading (17.3%). The main contents of Hippocratic Oath were known to 98.8% while 60.9% knew the main contents of Nepal Medical Council (NMC) code of ethics. Great majority (91.3%) regard ethics as very important in medical profession. “Doctors know the best irrespective of patients’ opinion” was disagreed by only 39.1% indicating the paternalistic attitude. However, 78.3% were in favour of adhering to the patient’s wish. None of the participant agreed to abandon confidentiality. Only about one-fourth (26.1%) claim to encounter ethical dilemma every day while the highest number (43.5%) had once in a month. To deal with the situation of ethical dilemma, majority approached to immediate supervisor followed by head of the department and colleagues. Eighty-seven percent of participating interns were involved in research activities involving human subjects. Only one of the participants had encountered the ethical issue on end-of-life and it was do-not-resuscitate consent in a terminally ill patient. On implementation of the curriculum on medical ethics focus should be - principles of biomedical ethics, sensitive ethical dilemmas like end-of-life care and practical experiences with participation in deliberations of the ethics committee. (shrink)

This chapter contains sections titled: The Clinical Encounter Medical Paternalism Re‐examined Ethical Frameworks The Temptation to Deceive Different Forms of Deception Communicating Outside Medicine Character, Context, and Care References Further reading.

Dear Readers,Welcome to this issue of our beloved Bangladesh Journal of Bioethics! In this sweltering heat we are all seeking for some cool and comfort. We bring this issue of BJB on different ethical practices and bring up related questions. Are we respecting the rights of every human being when we are either doing research or practicing health service provision? What are the minimum norms and standards to be maintained or are we circumventing those? The issue looks into different issues (...) and provides us with indepth information, queries, fears and reservations.In the article on Knowledge, attitude and practice of medical ethics among medical intern students in a Medical College in Kathmandu, Ramesh P Aacharyaand Yagya L Shakya, report on a Knowledge Attitude and Practice survey of 46 medical undergraduate interns of Maharajgunj Medical Campus. The result of the survey is quite interesting. ‘Doctors know the best irrespective of patients’ opinion was agreed upon by 35 %, ‘Confidentiality cannot be kept in modern era and should be abandoned’ was strongly disagreed by 34.8% and disagreed by 60.9%. The Authors hope that the findings will assist the faculties to strengthen the teaching of medical ethics and guiding the interns for ethical professional conduct. In the article titled Organizational Justice and Employee’s Service Behavior in the Healthcare Organizations in Bangladesh is an agenda for Research, Md. Nuruzzaman and Md. Humayun Kabir Talukder present a conceptual framework and a set of hypotheses regarding the relationships among distributive justice, procedural justice, interactional justice, employee’s citizenship behaviour, role prescribed behaviour and counterproductive behavior in the healthcare organizations in Bangladesh. The authors state that the purpose is to assist the policy makers and service providers in identifying desirable and undesirable HRM practices in order to maintain optimum level of employee commitment for ensuring quality and efficient service delivery to the communities. Though the article is theoretical it may be useful for the policy makers and service providers. If an operational research could be carried out to test the hypothesis the practical utility of the concept could be tested in Bangladesh.Zoheb Rafique in the article Ethical Justification of Conducting Research Trials in Lower and Middle Income Countries Including Pakistan: The Responsibilities of Research Enterprises explores the ethical aspects of research sponsored by commercial agencies. He looks into the factors that influence selection of a study site for a sponsored trial particularly in traditional countries like Pakistan where cultural values add to the problem in assuring that research is conducted in an ethical manner. In this paper, the Author discusses the responsibilities of researchers and funders in low and middle income countries like Pakistan and the ethical justifications of doing research trials in developing countries. He concludes that research participants should be fully informed about the research trial and their participation and it is their right to know all risks and benefits so that they have the option of rejecting participation.The article on Ethical aspects of Dhaka University Tele-medicine System by Ahmed Raihan Abir provides and analysis of the tele- medicine system in Dhaka University. The Author is a member of an extended group at Dhaka University (DU) which has been developing telemedicine equipment and data acquisition software to promote telemedicine practice in Bangladesh. Recently the Telemedicine group of DU and a local NGO named SAMAMA with support from Service innovation fund (SIF) of the Prime Minister Office (PMO) of Bangladesh took the initiative to establish eight rural telemedicine centers and one expert center for the field trial of telemedicine in Bangladesh. The aim of this paper is to examine the ethical challenges of such health care system and the effort to overcome these problems before starting the field trial. The author looks into the details of Data confidentiality and security, Responsibilities of Doctor and Rural Technician, Quality of service and Implications of telemedicine in Bangladesh. He concludes that DU telemedicine project will essentially bring the services of qualified medical experts to the doorsteps of the common people throughout the country, even in the remote rural areas. Although a telemedicine cannot match a face to face consultation, DU tele-medicine system is much better than no consultation at all.Sifat Rahman in the article on Ethical Issues of Fair Subject Selection in Research provides an overview of the criterion for maintaining ethical standards for conducting research. The Author reviews the three fundamental conditions to be met for adhering to strict ethical standards which are: Respect for Persons by protecting the autonomy of people, treating them with courtesy and respect and obtaining informed consent.; Beneficence which incorporates the philosophy of "Do no harm" while maximizing benefits for the research project and minimizing risks to the research subjects; and Justice by ensuring that reasonable, non-exploitative, and well-considered procedures are administered fairly. Finally the Author concludes that Researchers must be truthful and conduct no deception.Dear Readers, as you can see from the above ethics and maintaining the values in research and services are of utmost importance in the improvement of the quality of life. Through our queries, questions and sense of respect for every living being can our endeavors to ensure ethics in all spheres of development be successful.Dear Readers, please keep on sending your articles, notes or thoughts to us. Your participation will make a difference in the quality of our lives.Best regardsTahera AhmedEditor. (shrink)

OBJECTIVES: To study and report the attitudes of patients and general practitioners (GPs) concerning the obligation of doctors to act for the good of their patients, and to provide a practical account of beneficence in general practice. DESIGN: Semi-structured interviews administered to GPs and patients. SETTING AND SAMPLE: Participants randomly recruited from an age and gender stratified list of GPs in a geographically defined region of South Australia. The sample comprised twenty-one general practitioners and seventeen patients recruited by participating GPs. (...) RESULTS: In practice, acting for the good of the patient not only accommodates the views of patients and GPs on expertise and knowing best, but also responds to the particular details of the clinical situation. Patients had a complex understanding of the expertise necessary for medical practice, describing a contextual domain in which they were expert, and which complemented the scientific expertise of their GPs. General practitioners identified multiple sources for their expertise, of which experience was the most significant. The role of the GP included responding to individual patients and particular clinical problems and ranged from the assumption of responsibility through to the proffering of medical advice. CONCLUSION: This study found that GPs acting for the good of their patients covered a variety of GP actions and patient preferences. Beneficence was not justified by presumed patient vulnerability or the inability of patients to understand medical problems, but furthered through a recognition of the different areas of expertise contributed by both parties to the consultation. (shrink)

In our recent article ‘The Ethics of the Algorithmic Prediction of Goal of Care Preferences: From Theory to Practice’1, we aimed to ignite a critical discussion on why and how to design artificial intelligence (AI) systems assisting clinicians and next-of-kin by predicting goal of care preferences for incapacitated patients. Here, we would like to thank the commentators for their valuable responses to our work. We identified three core themes in their commentaries: (1) the risks of AI paternalism, (2) worries about (...) attacks to our humanity stemming from the use of AI and (3) the possibility of designing AI systems for more relevant use cases than the one we consider in our work. We shall focus on these themes, leaving aside some other interesting suggestions, given the limited space available for our response. Diaz Milian and Bhattacharyya discuss the risks of AI paternalism highlighting how the use of an AI to predict goal of care preferences may incentivise clinicians and surrogates to shift the burden of decision making to the machine.2 In particular, ‘[i]f the AI-generated response is given priority above the other agents’2 and the AI makes decisions autonomously, then ‘AI paternalism’ would emerge.2 Against this possibility, the authors suggest four safeguards to be implemented in the AI life-cycle.2 These are procedures that may improve the trustworthiness of the AI and human control over it.3 We agree that it is important …. (shrink)

A friend of mine recently lent me a little book entitled What a Young Wife Ought to Know, by Mrs. Emma F. Angell Drake, M.D., of Denver, Colorado. It was published in 1902 and is one of the Self and Sex series of “pure books on avoided subjects.” Its premise is that “Woman [is] fitted by the creator for wifehood and motherhood,” and it has chapters entitled “Home and Dress,” “Marital Relations,” “The Mother the Teacher,” and so on. My friend (...) had come across it in, of all places, the library of a mental hospital where his wife was being treated for postpartum depression. He stole it as a matter of principle. What a Young Wife Ought to Know has its late-medieval equivalent in a poem of around two hundred lines known as “What the Goodwife Taught Her Daughter,” which has been used quite often by medieval historians as evidence for aspects of female behavior in the fourteenth and fifteenth centuries. There are problems with this, though, as a comparison with Mrs. Emma F. Angell Drake's book shows. Historians of the early twentieth century would not, I assume, use What a Young Wife Ought to Know as evidence of social practice; rather, its interest is ideological. The same is true of “What the Goodwife Taught Her Daughter”: it is a poem that speaks for the special interests that have shaped its form and content. (shrink)

Artificial intelligence (AI) is increasingly being developed for use in medicine, including for diagnosis and in treatment decision making. The use of AI in medical treatment raises many ethical issues that are yet to be explored in depth by bioethicists. In this paper, I focus specifically on the relationship between the ethical ideal of shared decision making and AI systems that generate treatment recommendations, using the example of IBM’s Watson for Oncology. I argue that use of this type of system (...) creates both important risks and significant opportunities for promoting shared decision making. If value judgements are fixed and covert in AI systems, then we risk a shift back to more paternalistic medical care. However, if designed and used in an ethically informed way, AI could offer a potentially powerful way of supporting shared decision making. It could be used to incorporate explicit value reflection, promoting patient autonomy. In the context of medical treatment, we need value-flexible AI that can both respond to the values and treatment goals of individual patients and support clinicians to engage in shared decision making. (shrink)

L.A. Paul argues that interesting issues for rational choice theory are raised by epistemically transformative experiences: experiences which provide access to knowledge that could not be known without the experience. Consideration of the epistemic effects of pregnancy has important implications for our understanding of epistemically transformative experiences and for debate about the ethics of abortion and applied ethics more generally. Pregnancy is epistemically transformative both in Paul’s narrow sense and in a wider sense: those who have not been pregnant face (...) significant barriers to acquiring the knowledge made accessible through pregnancy. This knowledge is crucial for engaging with the ethics of abortion. The epistemically transformativeWIDE nature of pregnancy may require us to use new methods to try to partially grasp what pregnancy is like such as for example, significant engagement with narrative literature. Because pregnancy is also epistemically transformative in a narrow sense, we need to work out how to engage in ethical reasoning when relevant knowledge is not fully accessible to all. This argument has implications beyond the debate about abortion. Philosophers in many areas of applied ethics will need to work out how to respond appropriately to epistemically transformative experiences. (shrink)

The Case of Archie Battersbee in the United Kingdom (UK) is a tragic one: a 12-year-old otherwise healthy boy who suffered a cardiac arrest at home on April 7, 2022, and was subsequently diagnosed...

This essay reviews current work in conversation analysis with an eye to what it might contribute to the study of evidentiality and epistemic asymmetry. After a brief review of some aspects of the interactional organization of conversation, I turn to consider the way in which participants negotiate relative epistemic positioning through the use of particular practices of speaking. The analytic focus here is on agreements and confirmations especially in assessment sequences. In conclusion, I consider a single case in which various (...) practices are employed to convey a delicate balance of knowledge and simultaneously to attend to a range of other, non-epistemic, interactional issues. (shrink)

In a time when conservatives believe that the traditional family is under increasing fire, some think an appeal to Darwinian science may be the answer. I argue that these conservatives are wrong to maintain that Darwinian theory can serve as the intellectual foundation for the traditional conception of the family. Contra Larry Arnhart and James Q. Wilson, a Darwinian philosophy of nature simply lacks the stability the traditional family requires; it cannot support the traditional conception of human nature and the (...) normativity it was thought to contain. If conservatives are to maintain these traditional ideas, the theoretical foundation must lie elsewhere. (shrink)

This paper uses a non-ideal theory approach advocated for by Alison Jaggar to show that practices involved with the medicalization of serious mental disorders can subject people who have these disorders to a cycle of vulnerability that keeps them trapped within systems of injustice. When medicalization locates mental disorders solely as problems of individual biology, without regard to social factors, and when it treats mental disorders as personal defects, it perpetuates injustice in several ways: by enabling biased diagnoses through stereotyping, (...) by exploiting and coercing people who are seen as insufficiently competent, and by perpetuating idealized conceptions of choice and control that do not take into account people’s real limitations and the social context of health. Through practices of diagnosis, treatment, and recovery, medicalization can perpetuate injustices toward people who have serious mental disorders. (shrink)

This paper examines two realisations of the television talk show in North America: The Oprah Winfrey Show and Dr. Phil, looking specifically at how they function within the sub-genre of ‘therapeutic talk show’ in keeping with Livingstone and Lunt’s (1994) classification of talk shows. Talk shows are defined by Ilie (2001) as “semi-institutional discourse” having features of a given setting (TV studio), topic- and goal-oriented talk, high degree of topic control, as well as restrictions on time and turn-taking. Theorists examining (...) this sub-genre of therapeutic talk show have argued that it provides a valuable means by which stories otherwise unrecognized have a forum, or that values of truth and honesty can be conveyed (Livingstone & Lunt 1994; Masciarotte 1991; Carbaugh 1988). However, theorists such as Abt and Seesholtz (1994) view therapeutic talk shows as potentially demeaning to guests who appear on them as well as a means by which suffering can be trivialized. Through an examination and analysis of requests for information, both direct and indirect, which are the principal features of all interviews, I look at how Oprah Winfrey and Dr. Phil problematize the narratives told by their guests. Both hosts rely heavily on one type of request, B-Event assertions functioning as indirect requests for information, to provoke specific response. My findings indicate that these talk shows do not in fact provide a forum for talk that would otherwise not be considered as suggested by Livingstone and Lunt (1994). Both Oprah Winfrey and Dr. Phil appropriate the stories provided by their guests; they also participate in their own overarching meta-narrative whereby as ‘heroes’ they solve their guests’ problems within a given time frame. Guests’ narrative responses share more with the speech act of confession than with free self-expression. The speech act of confession encouraged by these therapeutic talk shows serves in turn to reinforce conservatively-held values on the part of the at-home audience for whom such confession is also entertainment. (shrink)

In a time when conservatives believe that the traditional family is under increasing fire, some think an appeal to Darwinian science may be the answer. I argue that these conservatives are wrong to maintain that Darwinian theory can serve as the intellectual foundation for the traditional conception of the family. Contra Larry Arnhart and James Q. Wilson, a Darwinian philosophy of nature simply lacks the stability the traditional family requires; it cannot support the traditional conception of human nature and the (...) normativity it was thought to contain. If conservatives are to maintain these traditional ideas, the theoretical foundation must lie elsewhere. (shrink)

We find the idea that infant crying arises from thermoregulation more consistent with a coregulatory account of its evolutionary history than it is with the informational account advocated in the target article.

Best known for his contributions to the development of contemporary intersubjectivity theory, Bernard Brandchaft has dedicated a career to the advancement of psychoanalytic theory and practice. Continually searching for a theoretical viewpoint that would satisfactorily explain the clinical phenomena he was encountering, his curiosity eventually led him to the work of Heinz Kohut and the then-emerging school of self psychology. However, seemingly always one step ahead of the crowd, Brandchaft constantly reformulated his ideas about and investigations into the intersubjective (...) nature of human experiences. Many of the chapters in this volume have never before been published. Together, they articulate the evolution of Brandchaft's thinking along the road toward an emancipatory psychoanalysis. Moreover, commentary from Shelley Doctors and Dorienne Sorter – in addition to Bernard Brandchaft himself – examines the clinical implications of the theoretical shifts that he advocated and provides a contemporary context for the case material and conclusions each paper presents. These theoretical shifts, both clear and subtle, are thereby elucidated to form the grand narrative of a truly visionary psychoanalytic thinker. (shrink)

The advent of social networking sites has changed the face of the information society Mason wrote of 23 years ago necessitating a reevaluation of the social contracts designed to protect the members of the society. Despite the technological and societal changes that have happened over the years, the information society is still based on the exchange of information. This paper examines various historical events involving social networking sites through the lens of the PAPA framework (Mason 1986 ) to highlight select (...) ethical issues regarding the sharing of information in the social-networking age. Four preliminary principles are developed to guide the ethical use of social networking sites (SNS). (shrink)