A formal Ethics Consultation Service (ECS) can provide significant help to patients, families and hospital staff. As with any other form of clinical consultation, documentation of the process and the advice rendered is very important. Upon review of the published consult documentation practices of other ECSs, we judged that none of them were sufficiently detailed or structured to meet the needs and purposes of a clinical ethics consultation. Thus, we decided to share our method in order to advance the practice (...) of ethics consultation. Here, we describe a method of ECS documentation practice, including use of a formal consult report template, as well as a log for maintaining a chronological record of the consultations performed. These two documents facilitate order and organisation of the ECS. They also enable the ECS to keep an account of professional time and experience, enable quick consult trend assessments (by consult theme or ward, for example) and establish a potential registry of consults for future research study. This method of documentation, we believe, not only contributes significantly to the primary purpose of the consultation—namely, the evincing and sharing of ethical opinion about a case—but also enables consultants to improve their practice and to pursue research on clinical ethics consultation. (shrink)

In 1982, Jonsen, Siegler and Winslade published Clinical Ethics, in which they described the “four quadrants” approach, a new method of analysing clinical ethics cases. Although the book is now in its 6th edition, a literature search has revealed only one academic paper demonstrating the method at work. This paper is an attempt to start filling this gap. As a way of describing and testing the approach, I apply the four quadrants method to a detailed clinical ethics case. The (...) analysis is interspersed with reflections on the method itself. It is hoped that this experiment will encourage ethicists and clinicians to devote more attention to this neglected approach. (shrink)

The American Medical Association enacted its Code of Ethics in 1847, the first such national codification. In this volume, a distinguished group of experts from the fields of medicine, bioethics, and history of medicine reflect on the development of medical ethics in the United States, using historical analyses as a springboard for discussions of the problems of the present, including what the editors call "a sense of moral crisis precipitated by the shift from a system of fee-for-service medicine to a (...) system of fee-for-system medicine, better known as 'managed care.'" The authors begin with a look at how the medical profession began to consider ethical issues in the 1800s and subsequent developments in the 1900s. They then address the sociological, historical, ethical, and legal aspects of the practice of medicine. Later chapters discuss current and future challenges to medical ethics and professional values. Appendixes display various versions of the AMA's Code of Ethics as it has evolved over time. Contributors: George J. Annas, J.D., M.P.H., Arthur Isak Applbaum, Ph.D., Robert B. Baker, Ph.D., Chester R. Burns, M.D., Ph.D., Arthur L. Caplan, Ph.D., Alexander Morgan Capron, J.D., Christine K. Cassel, M.D., Linda L. Emanuel, M.D., Ph.D., Eliot L. Freidson, Ph.D., Albert R. Jonsen, Ph.D., Stephen R. Latham, J.D., Ph.D., Susan E. Lederer, Ph.D., Florencia Luna, Ph.D., Edmund D. Pellegrino, M.D., Charles E. Rosenberg, Ph.D., Mark Siegler, M.D., Rosemary A. Stevens, Ph.D., Robert M. Tenery, Jr., M.D., Robert M. Veatch, Ph.D., John Harley Warner, Ph.D., Paul Root Wolpe, Ph.D. (shrink)

Principles that provide general normative frameworks in bioethics have been criticized since the late 1980s, when several different methods and types of moral philosophy began to be proposed as alternatives or substitutes. Several accounts have emerged in recent years, including: (1) Impartial Rule Theory (supported in this issue by K. Danner Clouser), (2) Casuistry (supported in this issue by Albert Jonsen), and (3) Virtue Ethics (supported in this issue by Edmund D. Pellegrino). Although often presented as rival methods or (...) theories, these approaches are consistent with and should not be considered adversaries of a principle-based account. (shrink)

This paper challenges the long-standing and widely accepted view that medical ethics is nothing more than common morality applied to clinical matters. It argues against Tom Beauchamp and James Childress’s four principles; Bernard Gert, K. Danner Clouser and Charles Culver’s ten rules; and Albert Jonsen, Mark Siegler, and William Winslade’s four topics approaches to medical ethics. First, a negative argument shows that common morality does not provide an account of medical ethics and then a positive argument demonstrates why the (...) medical profession requires its own distinctive ethics. The paper also provides a way to distinguish roles and professions and an account of the distinctive duties of medical ethics. It concludes by emphasizing ways in which the uncommon morality approach to medical ethics is markedly different from the common morality approach. (shrink)

In this engaging study, the authors put casuistry into its historical context, tracing the origin of moral reasoning in antiquity, its peak during the sixteenth and early seventeenth century, and its subsequent fall into disrepute from the mid-seventeenth century.

A physician says, "I have an ethical obligation never to cause the death of a patient," another responds, "My ethical obligation is to relieve pain even if the patient dies." The current argument over the role of physicians in assisting patients to die constantly refers to the ethical duties of the profession. References to the Hippocratic Oath are often heard. Many modern problems, from assisted suicide to accessible health care, raise questions about the traditional ethics of medicine and the medical (...) profession. However, few know what the traditional ethics are and how they came into being. This book provides a brief tour of the complex story of medical ethics evolved over centuries in both Western and Eastern culture. It sets this story in the social and cultural contexts in which the work of healing was practiced and suggests that, behind the many different perceptions about the ethical duties of physicians, certain themes appear constantly, and may be relevant to modern debates. The book begins with the Hippocratic medicine of ancient Greece, moves through the Middle Ages, Renaissance and Enlightenment in Europe, and the long history of Indian and Chinese medicine, ending as the problems raised modern medical science and technology challenge the settled ethics of the long tradition. (shrink)

Casuistry is a traditional method of interpreting and resolving moral problems. It focuses on the circumstances of particular cases rather than on the application of ethical theories and principles. After a brief history of casuistry, the method is explained and its relation to theory and principles is discussed.

This essay focuses on how casuistry can become a useful technique of practical reasoning for the clinical ethicist or ethics consultant. Casuistry is defined, its relationship to rhetorical reasoning and its interpretation of cases, by employing three terms that, while they are not employed by the classical rhetoricians and casuists, conform, in a general way, to the features of their work. Those terms are (1) morphology, (2) taxonomy, (3) kinetics. The morphology of a case reveals the invariant structure of the (...) particular case whatever its contingent features, and also the invariant forms of argument relevant to any case of the same sort: these invariant features can be called topics. Taxonomy situates the instant case in a series of similar cases, allowing the similarities and differences between an instant case and a paradigm case to dictate the moral judgment about the instant case. This judgment is based, not merely on application of an ethical theory or principle, but upon the way in which circumstances and maxims appear in the morphology of the case itself and in comparison with other cases. Kinetics is an understanding of the way in which one case imparts a kind of moral movement to other cases, that is, different and sometimes unprecedented circumstances may move certain marginal or exceptional cases to the level of paradigm cases. In conclusion, casuistry is the exercise of prudential or practical reasoning in recognition of the relationship between maxims, circumstances and topics, as well as the relationship of paradigms to analogous cases. (shrink)

Introduction Watching the Doctor In some cultures, it is said, villagers cluster around a healer and a patient, eagerly listening to their conversation and ...

What has moral theory to do with practical judgment? The practical ethicist can move by analogy from case to case, saying of most new cases, “Oh, I think I've been here before.” Theory, ascending to a broader view, can provide directions when the ethicist finds herself in unfamiliar territory.

For the last century, moral philosophy has stressed theory for the analysis of moral argument and concepts. In the last decade, interest in the ethical issues of health care has stimulated attention to cases and particular instances. This has revealed the gap between ethical theory and practice. This article reviews the history and method of casuistry which for many centuries provided an approach to practical ethics. Its strengths and weaknesses are noted and its potential for contemporary use explored.

This is the God Squad. It is faceless, impersonal, unmoved by tragedy, almost terrorist in aspect. The photo appeared in LIFE magazine on November 9, 1962, and it depicted the Admissions and Policy Committee of the Seattle Artificial Kidney Center. The Committee had been established in 1962 to select those few persons who would be admitted to the new and tiny dialysis unit that was created by Dr. Belding Scribner, inventor of the arteriovenous shunt. It consisted of seven anonymous members (...) – a minister, a lawyer, a businessman, a homemaker, a labor leader, and two physicians. Each month they received a pile of charts about persons with end-stage renal disease. A prior medical evaluation had rated them all medically suitable for dialysis. The Committee’s task was to select one or two out of a dozen or so to take the available spots. The others were left to die. After several years of this agonizing work, the amendments to the Social Security Act provided financial support for renal dialysis and transplant, allowing the Admission Committee some peace of mind. (shrink)

The theology of John Calvin has deeply affected the American mentality through two streams of thought, Puritanism and Jansenism. These traditions formulate moral problems in terms of absolute, clear principles and avoid casuistic analysis of moral problems. This approach is designated American moralism. This article suggests that the bioethics movement in the United States was stimulated by the moralistic mentality but that the work of the bioethics has departed from this viewpoint. Keywords: bioethics, Calvinism, casuistry, Jansenism, moralism, moral principle, Puritanism (...) CiteULike Connotea Del.icio.us What's this? (shrink)

“Bioethics began in religion, but religion has faded from bioethics.” This interpretation is commonplace among many who have an opinion on bioethics. This chapter examines this.

Covering the period from 1947 to 1987, Jonsen examines the history of bioethics. He discusses human experimentation, genetic engineering and organ transplantation as well as the philosophical, legal and social policy implications.

Book reviewed in this article: Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. By Albert R. Jonsen, Mark Siegler, and William J. Winslade.

A member of the two federal advisory panels on artificial hearts reflects that the nuclear‐powered artificial heart, had it been developed, would have posed a physical threat to others. Today's artificial heart poses a different threat. Because of the high costs, many people may be deprived of access to other forms of medical care and other social goods.

Book reviewed in this article: The Abuse of Casuistry: A History of Moral Reasoning. By Albert R. Jonsen and Stephen Toulmin.

“Strangers at the Benchside: Research Ethics Consulation” (Cho et al. 2008) proposes what is probably a good idea. Early scrutiny of the ethical dimensions of emerging science seems sensible—at lea...

The essays in this Special Section are about the ethics of Commercialism in Medicine. They are written, for the most part, by bioethicists, with the support of several prominent physicians and a health policy lawyer. This journal is, of course, devoted to ethics. Thus, our intent is to subject the question of commercialism in medicine to ethical scrutiny. Much has been written about commercialism in healthcare but very little about the ethics of commercialism in healthcare. One of our authors, Dr. (...) Jerome Kassirer, has encouraged a national dialogue about these issues. We hope to start that dialogue in the bioethical community and, through that community, into the nation. (shrink)

Many years ago, the esteemed patriarch of bioethics, Joseph Fletcher, spoke loud and clear in favor of rationality in reproduction. By rationality, he meant not merely limiting population growth, which he certainly favored, but bringing to bear human analytic and creative intelligence on the random and instinctive activities of sexual intercourse and procreation that we share with all mammals. In his 1974 book, The Ethics of Genetic Control: Ending Reproductive Roulette, he foresaw most of the issues that we are facing (...) today. He reflected on artificial insemination, prenatal diagnosis, cloning, eugenics, ectogenesis, ovum transfers, and genetic engineering. He examined these innovations to the extent that he felt that each of them represents a way of exercising rational and responsible control over life and reproduction. The subtitle of his book, “Ending Reproductive Roulette,” proclaims his faith. Dr. Fletcher's dedication to rationality led him to make the astonishing statement, “Man is a maker and the more rationally contrived and deliberate anything is, the more human it is. Therefore, laboratory reproduction is radically human compared to conception by ordinary heterosexual intercourse.”. (shrink)

Bioethics Beyond the Headlines is a primer in bioethics. You will not find convoluted philosophical arguments in this volume. Rather, you will find an engaging sampling of the key questions in bioethics, including euthanasia, assisted reproduction, cloning and stem cells, neuroscience, access to healthcare, and even research on animals and questions of environmental ethics—areas typically overlooked in general introductions to bioethics.

Although this case raises what are commonly called “cultural issues,” it does so in two rather different ways: first, an explicit question of what Shari’a, or Islamic law, teaches regarding bodily mutilation and, second, the most appropriate manner of conveying information in the idiom of the culture. It is necessary for an ethics committee or consultant who is dealing with such a case to obtain accurate information and, if possible, to ascertain how best to communicate that information.

This book is about the ethical issues that clinicians encounter in caring for patients. In order to practice excellent clinical care, clinicians and those studying to become clinicians must understand ethical issues such as informed consent, truth telling, confidentiality, privacy, the distinction between research and clinical care, and end-of-life care. Our audience also includes families and other persons close to patients, who may participate in decisions about their care"--Provided by publisher.

Ethics consultation, while often a process of negotiation between diverse opinions, sometimes requires deeper moral inquiry. The form of such inquiry is suggested by classical casuistry and its attendant doctrine of probabilism.

If I were the organizer of a conference on brain imaging, consciousness, and ethics, I would give it the name encephaloethics, the ethics of the brain. I know well that many commentators disdain th...