Money plays a powerful role in modern medicine, both in terms of how health services are organized and delivered and increasingly in how physicians understand themselves and their work. The phrase “the hegemony of money” is intended to capture that power.

The Covid‐19 pandemic has concentrated bioethics attention on the “lifeboat ethics” of rationing and fair allocation of scarce medical resources, such as testing, intensive care unit beds, and ventilators. This focus drives ethics resources away from persistent and systemic problems—in particular, the structural injustices that give rise to health disparities affecting disadvantaged communities of color. Bioethics, long allied with academic medicine and highly attentive to individual decision‐making, has largely neglected its responsibility to address these difficult “upstream” issues. It is time (...) to broaden our teaching, research, and practice to match the breadth of the field in order to help address these significant societal inequities and unmet health needs. (shrink)

In March 1996, the General Accounting Office issued the report Scientific Research: Continued Vigilance Critical to Protecting Human Subjects. It stated that “an inherent conflict of interest exists when physician-researchers include their patients in research protocols. If the physicians do not clearly distinguish between research and treatment in their attempt to inform subjects, the possible benefits of a study can be overemphasized and the risks minimized.” The report also acknowledged that “the line between research and treatment is not always clear (...) to clinicians. Controversy exists regarding whether certain medical procedures should be categorized as research.”This problem currently plagues gene transfer research. A few months prior to the GAO report, an ad hoc committee appointed by National Institutes of Health Director Harold Varmus expressed similar concerns in its assessment of NIH investment in research on gene therapy. (shrink)

Many international business training programs present a viewpoint of cultural relativism that encourages business people to adapt to the host country's culture. This paper presents an argument that cultural relativism is not always appropriate for business ethics; rather, a code of conduct must be adapted which presents guidelines for core ethical business conduct across cultures. Both moral and economic evidence is provided to support the argument for a universal code of ethics. Also, four steps are presented that will help ensure (...) that company ethical standards are followed internationally. (shrink)

In March 1996, the General Accounting Office (GAO) issued the reportScientific Research: Continued Vigilance Critical to Protecting Human Subjects.It stated that “an inherent conflict of interest exists when physician-researchers include their patients in research protocols. If the physicians do not clearly distinguish between research and treatment in their attempt to inform subjects, the possible benefits of a study can be overemphasized and the risks minimized.” The report also acknowledged that “the line between research and treatment is not always cleartoclinicians. Controversy (...) exists regarding whether certain medical procedures should be categorized as research.”This problem currently plagues gene transfer research. A few months prior to the GAO report, an ad hoc committee appointed by National Institutes of Health (NIH) Director Harold Varmus expressed similar concerns in its assessment of NIH investment in research on gene therapy. (shrink)

Our culture is well on its way to reducing medical ethics to legal requirements, general citizen ethics, or personal values. A distinctive ethic for medicine provides critical distance and moral meaning for the profession and an enriched societal ethic.

Two decades ago, I wrote an essay expressing my skepticism about the nascent movement to certify bioethics consultants. My concerns were numerous. For example, I worried that the move toward certification would give too much weight to moral theory and neglect the importance of the less formal moral reasoning of patients and their families. I was also concerned that the effort to certify competence, complete with standardized testing, would be largely self-promotional and make unfounded claims about who has the capacity (...) to do this work. My worries were prescient. Notice, for example, the way that the American Society for Bioethics and Humanities was advertising its new Healthcare Ethics... (shrink)

Images of the future are usually only caricatures of the present. Perhaps this picture of the future of medical care will also prove to be a caricature. Whether it does depends on choices that Americans have still to make. —Paul Starr The Social Transformation of American Medicine.

Book reviewed in this article: The Needs of Strangers. By Michael Ignatieff. The Health Economy. By Victor Fuchs. Just Health Care. By Norman Daniels.

This essay is an exploration of the transformative possibilities open to us through aging. Transformative openings are described using psychologist Abraham Maslow's notion of "peak-experiences," which are both normal and common for humans. Popular cultural stereotypes of aging are examined and discarded. The experiences of loss, especially diminishments of mobility, dexterity, and mental acuity, are characteristic of aging. It is argued that these losses present novel transformative openings, especially when death and aging are viewed in dialectical relationship.

Schneiderman, Jecker, and Jonsen have written an eloquent essay that both defends the concept of medical futility and describes their own candidate for a practical, working definition. Whether they have provided the best such definition I cannot say, but they are surely right to claim that some such concept is needed—for doctors to practice, for patients to receive good care, for family and friends of the patient to understand and prepare for what is happening, and for society to trust what (...) doctors say and do in delivering care. In brief, futility—or something like it—is a concept with important personal and social value, and more than simple prognostic meaning. One of the... (shrink)

The American Journal of Bioethics, Volume 11, Issue 7, Page 15-16, July 2011.

Feldman and Goldsmith sought an evolutionary explanation of the child prodigy phenomenon. Following in this vein, a theory involving the evolution and development of the collaboration of working memory and the cognitive functions of the cerebellum is presented with commentary on Edmunds and Noel’s report on a child’s literary precocity. It is argued that the evolution of working memory and the cerebellum within the increasing rule-governed complexity of culture may have produced the child prodigy within agricultural villages as early as (...) 10,000 years ago, in child prodigies, heightened emotional–attentional control in the central executive of working memory and modeled in the cerebellum is acquired in infancy through perceptual analysis , and this heightened emotional–attentional control begins in visuospatial processing, links visuospatial and language processing in working memory , and initiates and accelerates a positive feedback loop with the cerebellum in a specific knowledge domain. It is concluded that the working memory– cerebellar approach provides an evolutionary and developmental explanation of the child prodigy and strongly supports Edmunds and Noel’s visuospatial–high verbal ability explanation. (shrink)

AIDS and the responses and attitudes it evokes surpass the analytic abilities of standard bioethics. These responses and attitudes are explored in terms of literary and anthropological categories, such as dirt, disorder, pollution and ritual cleanliness. Implications for medical education are suggested.

Being a patient and living a life -- Clinical space and traits of healing -- False starts and frequent failures -- Three journeys : A.'Ibuprofen and love', B. 'Staying tuned up', C. 'We all want the same things' -- Being a patient : the moral field -- Rethinking healthcare ethics : the patient's moral authority.

Edmund Pellegrino claims that medical ethics must be derived from a perception of the patient's damaged humanity, rather than from the self-imposed duties of professionals. This essay explores the meaning and examines the challenges to this patient-centered ethic. Social scientific and bioethical interpretations of medicine constitute one kind of challenge. A more pervasive challenge is the ascendancy of managed care, and especially investor-owned, for-profit managed care. A list of questions addressed to patients, physicians and organizations is offered as one means (...) of assessing this threat and moving toward morally trustworthy relationships. (shrink)

For more than a half-century, evidence scholars have been exploring whether the criminal standard of proof can be grounded in decision theory. Such grounding would require the emergence of a social consensus about the utilities to be assigned to the four outcomes at trial. Significant disagreement remains, even among legal scholars, about the relative desirability of those outcomes and even about the formalisms for manipulating their respective utilities. We attempt to diagnose the principal reasons for this dissensus and to suggest (...) ways in which a broadly shared evaluation might be forged, both with respect to the appropriate equations for defining the standard of proof and with respect to the appropriate utilities to associate with the various trial outcomes. Where consensus cannot be forged, we hold that remaining differences can probably be finessed. We also suggest ways to elicit the utilities of individuals on these matters so as to avoid the usual flaws of such surveys. Along the way, we note a). the disproportionate role that the Blackstone ratio of errors continues to play in appraisals of the utilities of trial outcomes (despite its unintelligibility in the context of utilities) and b). the persisting belief -for which there is no theoretical basis-that every plausible assignment of utilities will inevitably result in a very high standard of proof. Finally, we examine some of the technical features associated with a proposed rank ordering of the utilities of trial outcomes. (shrink)

This essay argues that Hume's theory of justice can be useful in framing a more persuasive case for universal access in health care. Theories of justice derived from a Rawlsian social contract tradition tend to make the conditions for deliberation on justice remote from the lives of most persons, while religiously-inspired views require superhuman levels of benevolence. By contrast, Hume's theory derives justice from the prudent reflections of socially-encumbered selves. This provides a more accessible moral theory and a more realistic (...) path to the establishment of universal access. (shrink)

"This book maps the moral terrain in the grounded reality of human experience without relying on theories or systems of ethics as the primary orienting strategy. Moral awareness needs first to be appreciated for what it is before it is made to conform to theories or systems. And moral consciousness is not a steady or stable set of perceptions; as we change so do the moral challenges that most concern us"--.

Lauris Kaldjian makes a strong case for respecting the role of conscience in the practice of medicine. His excellent book, Practicing Medicine and Ethics, presents an historically informed and carefully crafted explication of the role of conscience in Western ethics and its relevance for medical practitioners. The essay that initiates the discussion in this issue of Perspectives in Biology and Medicine is an equally well-written and lucid account of this important component of morality. But it is also worrisome in its (...) implications for insulating conscience from the other facets of moral thinking and feeling. The reasons Kaldjian's account is not finally compelling stem from his tethering conscience too... (shrink)

Weaknesses in Roger Sperry's "Defense of Mentalism" that appeared in the Spring issue of JMB are described. Sperry's clarification of his mentalist position still appears to lack a plausible mechanism of interaction. The wheel rolling down hill analogy is described as "a ghost in the subcircuitry." Neurological Positivism's energetic mechanism of brain-mind interaction is summarized. The relatioship of systems theory to reductionism is described briefly in terms of NP.

Drew Leder's Clinical Interpretation: The Hermeneutics of Medicine [1] is an essay which understates its case and thereby opens itself to misinterpretation. This response to Leder argues for a more thorough-going hermeneutic for both medicine and science. At the conceptual as well as the practical level, modern medicine and its scientific foundations are hermeneutic enterprises. The purpose of this essay is to argue that we should not back away from this more radical thesis. Embracing it will result in less alienation (...) of physicians from patients, and of physicians from the tasks of medicine. (shrink)

Kuttner and Rosenblum's presentation of the "only objective evidence for consciousness" is criticized for not adequately defining consciousness , not providing at the outset an explanation of the philosophical-theoretical interpretation of quantum theory that would lead to a direct rationale for their "impossible" quantum experiments, and suggesting that data from their impossible experiments could be treated as non-theoretical "facts." It is concluded that Kuttner and Rosenblum fail to objectify consciousness.

The age-rationing debate of fifteen years ago will inevitably reemerge as health care costs escalate. All age-rationing proposals should be judged in light of the current system of rationing health care by price in the U.S., and the resulting pattern of excess and deprivation. Age-rationing should be rejected as public policy, but recognized as a personal virtue of stewardship among the elderly.

The ethicist's role in the clinical context is not presently well defined. Ethicists can be thought of as moralists, technicians, Sophists, or as teachers and learners. Each of these roles is examined in turn. An argument is made for the ethicist as a teacher who must also learn a great deal about the clinical setting in order to encourage an effective critical examination of basic values. Four specific tasks of this teaching role are discussed: describing moral experience, eliciting assumptions, considering (...) multiple alternatives and justifying choices. (shrink)