: The "difference position" holds that clinical research and therapeutic medical practice are sufficiently distinct activities to require different ethical rules and principles. The "similarity position" holds instead that clinical investigators ought to be bound by the same fundamental principles that govern therapeutic medicine—specifically, a duty to provide the optimal therapeutic benefit to each patient or subject. Some defenders of the similarity position defend it because of the overlap between the role of attending physician and the role of investigator in (...) a research trial. This overlap is maximal when the same physician occupies both roles with respect to a particular patient-subject. We address the ethical tensions inherent in that role conflict and argue that the tensions are real but manageable. The difference position provides a sound ethical framework within which to manage those tensions, while the similarity position is unsatisfactory because it seeks to deny the existence of the tensions. (shrink)

A special report of The Hastings Center and the Association of American Medical Colleges addressed the ethical oversight of learning health systems, which seek to combine high‐quality patient care with routine data collection aimed at improving patient outcomes. The report contained two position papers, authored by a number of distinguished bioethicists, and several commentaries. The position papers urged two changes. First, they urged a rethinking of our approach to the regulation of human subjects research, so as to make it easier (...) in the future for learning health systems to function well. Second, they argued that the rethinking required dispensing with a strict distinction between research and therapy, which has been a major tenet of bioethics since the Belmont Report, which explicated basic ethical principles governing human subjects research. We fully support the objectives of the authors, and we agree that the learning health system is an important advance that serves patients well. Unnecessary regulatory burden ought not impede this progress. We disagree, however, that the best way to bring about these needed changes in the regulatory environment is to reject the basic distinction between research and treatment. Unfortunately, we find the arguments in favor of that strategy to be, in places, reminiscent of what we take to be basic conceptual errors that hampered the ethical understanding of human subjects research prior to adoption of the Belmont Report. To see why one need not reject the research‐treatment distinction in order to promote learning health systems, we first investigate in some detail the arguments offered for eliminating the distinction. We next turn to an issue not addressed by those authors, namely, the relationship between the physician or investigator and the patient or subject, to illustrate why the distinction is important and what is lost if it is jettisoned. (shrink)

Some ethical issues facing contemporary medicine cannot be fully understood without addressing medicine's internal morality. Medicine as a profession is characterized by certain moral goals and morally acceptable means for achieving those goals. The list of appropriate goals and means allows some medical actions to be classified as clear violations of the internal morality, and others as borderline or controversial cases. Replies are available for common objections, including the superfluity of internal morality for ethical analysis, the argument that internal morality (...) is merely an apology for medicine's traditional power and authority, and the claim that there is no single, "core" internal morality. The value of addressing the internal morality of medicine may be illustrated by a detailed investigation of ethical issues posed by managed care. Managed care poses some fundamental challenges for medicine's internal morality, but also calls for thoughtful reflection and reconsideration of some traditionally held moral views on patient fidelity in particular. (shrink)

Cosmetic surgery is a fast-growing medical practice. In 1997 surgeons in the United States performed the four most common cosmetic procedures443,728 times, an increase of 150% over the comparable total for 1992. Estimated total expenditures for cosmetic surgery range from $1 to $2 billion. As managed care cuts into physicians' income and autonomy, cosmetic surgery, which is not covered by health insurance, offers a financially attractive medical specialty.

The leading ethical position on placebo-controlled clinical trials is that whenever proven effective treatment exists for a given condition, it is unethical to test a new treatment for that condition against placebo. Invoking the principle of clinical equipoise, opponents of placebo-controlled trials in the face of proven effective treatment argue that they (1) violate the therapeutic obligation of physicians to offer optimal medical care and (2) lack both scientific and clinical merit. We contend that both of these arguments are mistaken. (...) Clinical equipoise provides erroneous ethical guidance in the case of placebo-controlled trials, because it ignores the ethically relevant distinction between clinical trials and treatment in the context of clinical medicine and the methodological limitations of active-controlled trials. Placebo controls are ethically justifiable when they are supported by sound methodological considerations and their use does not expose research participants to excessive risks of harm. (shrink)

A basic question of medical ethics is whether the norms governing medical practice should be understood as the application of principles and rules of the common morality to medicine or whether some of these norms are internal or proper to medicine. In this article we describe and defend an evolutionary perspective on the internal morality of medicine that is defined in terms of the goals of clinical medicine and a set of duties that constrain medical practice in pursuit of these (...) goals. This perspective is developed by means of a critical examination of the essentialist conception of the internal morality of medicine advocated by Edmund Pellegrino and the critique of internal morality approaches by Robert Veatch and Tom Beauchamp. (shrink)

A predominant ethical view holds that physician‐investigators should conduct their research with therapeutic intent. And since a physician offering a therapy wouldn't prescribe second‐rate treatments, the experimental intervention and the best proven therapy should appear equally effective. "Clinical equipoise" is necessary. But this perspective is flawed. The ethics of research and of therapy are fundamentally different, and clinical equipoise should be abandoned.

The practice of voluntary physician‐assisted death as a last resort is compatible with doctors' duties to practice competently, to avoid harming patients unduly, to refrain from medical fraud, and to preserve patients' trust. It therefore does not violate physicians' professional integrity.

The doctrine of clinical equipoise is appealing because it appears to permit physicians to maintain their therapeutic obligation to offer optimal medical care to patients while conducting randomized controlled trials (RCTs). The appearance, however, is deceptive. In this article we argue that clinical equipoise is defective and incoherent in multiple ways. First, it conflates the sound methodological principle that RCTs should begin with an honest null hypothesis with the questionable ethical norm that participants in these trials should never be randomized (...) to an intervention known to be inferior to standard treatment. Second, the claim that RCTs preserve the therapeutic obligation of physicians misrepresents the patient-centered orientation of medical care. Third, the appeal to clinical equipoise as a basic principle of risk-benefit assessment for RCTs is incoherent. Finally, the difficulties with clinical equipoise cannot be resolved by viewing it as a presumptive principle subject to exceptions. In the final sections of the article, we elaborate on the non-exploitation framework for the ethics clinical research and indicate issues that warrant further inquiry. (shrink)

"Unlike most photographs of Eads Bridge, which are taken from a distance, Quinta Scott's intimate photographic essay shows the subtleties of form and texture that give this structure its remarkable aesthetic impact. Howard Miller's text complements the photos, explaining the place of James Eads's unorthodox design in the history of American architecture and aesthetics. Miller also explains the bridge's place in local and national economic history, describes its innovative engineering, and brings to life its unique creator."--Jacket.

With breathtalung speed, traditional criminal prohibitions against assisted suicide have been declared unconstitutional in twelve states, including California and New York. This poses great promise and great peril. The promise is that competent terminally ill patients, as a compassionate measure of last resort, will have the option of putting an end to their suffering by physician-assisted suicide. More sigmficant, legally permitting this controversial option may be a catalyst for doctors, health care institutions, and society to improve the care of the (...) dying. PAS should be limited only to those relatively few competent patients who continue to suffer intolerably despite unrestrained efforts to palliate and who face a continued existence that they regard as worse than death. When dying patients know they will not be abandoned to miserable and pointless suffering if palliative care fails, they will be fortified to cope better with the process of dying.The immediate peril is that PAS will become a quick fix, available on demand to any patient diagnosed as terminally ill, thus bypassing palliative care and producing premature deaths. (shrink)

*The opinions expressed are the views of the author and do not necessarily reflect the policy of the National Institutes of Health, the Public Health Service, or the U.S. Department of Health and Human Services.

Realism in international relations theory is frequently understood to entail the abandonment or cynical manipulation of moral rules and principles. But realism has always been more than an amoral or immoral doctrine. More interesting versions of realism offer moral justifications for limiting the role of morality. We argue for a version of realism that flows from the function of the liberal democratic state as an indispensable condition of value. After setting out its central characteristics, we also argue that this liberal (...) democratic realism can adequately address four severe criticisms typically raised against realism in general. (shrink)

We are drowning in information, while starving for wisdom.Are the smartest people also the wisest? Not necessarily. While traditional intellectual reasoning and procedural knowledge have helped build the communities we live in, there is a growing scientific understanding that we need emotionally balanced and better-fitting prosocial frameworks for coping with the uncertainties and complexities of life and addressing new challenges of the modern world. We are now poised on the edge of a new science of wisdom.The concept of wisdom, long (...) considered the “pinnacle of insight into the human condition”, has been that of an intangible, subjective, culturally specific entity—an unscientific... (shrink)

CHAPTER I POLITICAL FAITH AND UTOPIAN THOUGHT In the three and a half centuries since Bacon and the miller prayed for peace among the willows, countless men ...

Like Henry Harris, I began doing intensive research on Hegel's Phenomenology of Spirit in the mid-sixties. I recall going through all the chapters as a graduate student during one academic year, and looking around for commentaries. The only English-language commentary available was Loewenberg's Hegel's Phenomenology: Dialogues in the Life of Mind, which was suggestive of the dialectic taking place in the book, but not much help in getting over the “rough spots”. This gave me an incentive to work through Jean (...) Hyppolite's commentary, not yet translated into English, with my basic reading-knowledge of French. My 1976 Hegel's Phenomenology, Part I: Analysis and Commentary was one of the first in a long line of Anglophone commentaries. Harris in his introduction to Vol. I. mentions this effort at “analysis”, along with Findlay's “analysis” accompanying the 1977 Miller translation of the Phenomenology, as incentives for the inclusion of his own improved running analysis in the present commentary. I have included discussions of numerous partial or complete commentaries on Hegel's Phenomenology in review articles published in 1971 in the American Philosophical Quarterly and Teorema, in 1979 in the American Philosophical Quarterly, and in 1981 in Hegel-Studien. Harris has the advantage of producing the most recent of all these commentaries, and in a way offers us a compendium of everything that has been done on the Phenomenology. His analysis and commentary includes a survey of the literature, in which almost all previous laborers in the field can find themselves commended or criticized in the endnotes. Thus I find comments like “Kainz has completely misunderstood the argument here”, “This is a point which Kainz has grasped more definitely than most commentators”, “[Kainz] does not deserve the brickbat Flay hurls at him”, and so forth. Other commentators, living and dead – Flay, Pöggeler, Navickas, Kenneth and Merold Westphal, Heidegger, Lauer, Werner Becker, Kojève, Wahl, Hyppolite, Labarrière, Bonsiepen, Forster, Shklar, Solomon, Werner Marx, and Robert Williams — are similarly discussed and critiqued. For some of us Anglophone commentators, such remarks may seem like red marks on essays from a patient professor. But certainly no one will mind, since Harris has spent more time and energy on this very specialized project than any of us. In fact, some former commentators almost have a “conflict of interest” in reviewing Harris' work, since so many of us have benefited at various points in our research from Harris' personal support and criticism. But in academics, as in life, mentors cannot always be assured of loyalty. (shrink)

After critiquing some earlier attempts (including those of Marcus Singer and Frances Howard–Snyder) to ground objections to actual–consequence act utilitarianism (ACAU) on human cognitive limitations, I present two new objections with this same foundation. Both start with the observation that, because human cognitive abilities are not up to the task of reliably recognizing utility–maximizing actions, any agents who are recognizably human – including the best possible humans, morally speaking – are certain to perform many actions every day that ACAU (...) says are immoral, and to perform some actions over the course of their lives that it says are highly immoral. The first objection is that, if Mill's analysis of what it means to call an action wrong is accurate, then ACAU entails a conclusion that no one will accept, viz., that the morally–best humans possible ought to undergo constant punishment. The second objection is that ACAU entails that even the morally–best humans possible are bad moral agents in some respect. This conclusion, while unpalatable, is not so obviously unacceptable as the first. However, I do briefly consider some ways in which it might be possible to demonstrate that it is false and thereby complete a reductio of ACAU. (shrink)

In The Healer's Power, Howard Brody placed the concept of power at the heart of medicine's moral discourse. Struck by the absence of “power” in the prevailing vocabulary of medical ethics, yet aware of peripheral allusions to power in the writings of some medical ethicists, he intuited the importance of power from the silence surrounding it. He formulated the problem of the healer's power and its responsible use as “the central ethical problem in medicine.” Through the prism of power (...) he refracted a wide range of ethical problems, from informed consent to truth-telling, from confidentiality to futility, from the physician's fantasies to the physician's virtues. At times this prism shed new light on old problems, enabling us to see from an unexpected angle the elements of which the problem was composed. At other times it exposed issues of ethical significance that had been neglected in the bioethics literature. (shrink)

A letter to the editor from Howard Brody, David Buchanan, and Franklin G. Miller in response to the recent article by Erik Malmqvist Understanding Exploitation," March-April 2011).

The Vatican’s position on in vitro fertilization (IVG), found in the ’Instruction on Bioethics’ (1987), is that all IVF is immoral, for it violates the normative procreative act of married spouses. The dilemma created is, if all instances of IVF are immoral, then God’s act in the Incarnation (granting the traditional doctrine) must also have been immoral. Conversely, if God’s act in the Incarnation was not immoral, then at least some cases of human IVF are not immoral either. A resolution (...) is offered. Two diagrams are employed. (shrink)

After briefly presenting Ronald Giere's (1979, 1980) recent counterfactual characterization of population-level causation, I present two counterexamples to the characterization. The difficulty discussed stems from nonaccidental correlations that can obtain between causally effective and causally neutral factors.

Ellen Furlong and Laurie Santos helpfully summarize a number of fascinating studies of certain influences on both human and monkey behavior. As someone who works primarily in philosophy, I am not in a position to dispute the details of the studies themselves. But in this brief commentary I do want to raise some questions about the inferences Furlong and Santos make on the basis of those studies. In general, I worry that they may be overreaching beyond what their own data (...) suggests. (shrink)

THE LIMITS OF NATURALISM Brand Blanshard I The Issue The purpose of this paper is to consider whether science, as currently conceived, is adequate to the ...

Across mammals, when fathers matter, as they did for hunter-gatherers, sex-similar pair-bonding mechanisms evolve. Attachment fertility theory can explain Schmitt's and other findings as resulting from a system of mechanisms affording pair-bonding in which promiscuous seeking is part. Departures from hunter-gatherer environments (e.g., early menarche, delayed marriage) can alter dating trajectories, thereby impacting mating outside of pair-bonds.

Conventional medical ethics and the law draw a bright line distinguishing the permitted practice of withdrawing life-sustaining treatment from the forbidden practice of active euthanasia by means of a lethal injection. When clinicians justifiably withdraw life-sustaining treatment, they allow patients to die but do not cause, intend, or have moral responsibility for, the patient's death. In contrast, physicians unjustifiably kill patients whenever they intentionally administer a lethal dose of medication. We argue that the differential moral assessment of these two practices (...) is based on a series of moral fictions – motivated false beliefs that erroneously characterize withdrawing life-sustaining treatment in order to bring accepted end-of-life practices in line with the prevailing moral norm that doctors must never kill patients. When these moral fictions are exposed, it becomes apparent that conventional medical ethics relating to end-of-life decisions is radically mistaken. (shrink)

Ofrezco una exposición, tanto apreciativa como crítica, de la interpretaciónpropensista de la probabilidad que Karl Popper introdujo en 1957 y desarrollóen numerosas publicaciones durante los 35 años siguientes.