Medical Ethics Research Between Theory and Practice

The main object of criticism of present-day medical ethics is the standard view of the relationship between theory and practice. Medical ethics is more than the application of moral theories and principles, and health care is more than the domain of application of moral theories. Moral theories and principles are necessarily abstract, and therefore fail to take account of the sometimes idiosyncratic reality of clinical work and the actual experiences of practitioners. Suggestions to remedy the illnesses of contemporary medical ethics focus on re-establishing the connection between the internal and external morality of medicine. This article discusses the question how to develop a theoretical perspective on medical ethical issues that connects philosophical reflection with the everyday realities of medical practice. Four steps in a comprehensive approach of medical ethics research are distinguished: (1) examine health care contexts in order to obtain a better understanding of the internal morality of these practices; this requires empirical research; (2) analyze and interpret the external morality governing health care practices; sociological study of prevalent values, norms, and attitudes concerning medical-ethical issues is required; (3) creation of new theoretical perspectives on health care practices; Jensen's theory of healthcare practices will be useful here; (4) develop a new conception of bioethics that illuminates and clarifies the complex interaction between the internal and external morality of health care practices. Hermeneutical ethics can be helpful for integrating the experiences disclosed in the empirical ethical studies, as well as utilizing the insights gained from describing the value-contexts of health care practices. For a critical and normative perspective, hermeneutical ethics has to examine and explain the moral experiences uncovered, in order to understand what they tell us.     

Integrating justice and care in animal ethics

In this paper I argue that the standoff between justice and care approaches to animal ethics presents us with a false dilemma. We should take justice's focus on reasoning from principles, and care's use of sympathetic awareness, as two integrated deliberative capacities necessary for the consideration of arguments for extending moral concern to animals. Such an integrated approach rests on a plausible account of the psychology of moral deliberation. I develop my argument as follows. Section I summarizes the nature of the debate between justice and care approaches to animal ethics, focusing on Brian Luke's arguments against justice approaches. Section II provides pro-justice rebuttals to Luke's objections. These rebuttals, while largely successful against Luke's objections, do not account for the intuition that sympathy does play a central epistemological role in animal ethics. Section III explains how sympathy cognitively simulates the perspective of the other, and thus can play an epistemological role in animal ethics. I argue that the abilities to simulate the perspective of the other and to reason from moral principles can complement each other. In section IV, I argue that though it may not be desirable to use both sympathy and reasoning from principles in all moral deliberation, it is a desirable aim when offering, and considering, moral arguments for what I will term the "extensionist project" of extending over moral concern to animals. I make this idea plausible by elucidating the claim that arguments for this project are best thought of as second-order deliberations about our first-order deliberative life.     

Modernity and Morality in Habermas's Discourse Ethics

Discourse ethics is originally conceived as a programme of philosophicaljustification of morality. This depends on the formal derivation of the moral principle (U) from non-moral principles. The moral theory is supposed to fall out of a pragmatic theory of meaning. The original programme plays a central role in Habermas's social theory: the moral theory, if true, provides good evidence for the more general theory of modernization. But neither Habermas nor his followers have succeeded in providing a formal derivation. This essay shows how and why Habermas's proposed derivation is impossible. As if aware of the lacuna, Habermas has recently suggested that (U) can be derived by 'abduction' rather than deduction. The proposal draws heavily on modernization theory; hence the only justification for (U) now available to him rests on premises drawn from that theory. The original programme of the justificationof morality has thus given way to the weaker programme of the philosophical elucidationof morality. Further, since Habermas's moral theory is no longer justified independently of modernization theory, but at least partly by it, the moral theory cannot without circularity provide evidence for the modernization theory.     

I. Kant after Virtue 1

Maclntyre's refurbishing of Aristotelian ethics aims to restore both intelligibility and rationality to moral discourse. In After Virtue he concentrates on showing how intelligible action requires that lives be led within institutional and cultural traditions. But he does not offer a developed account of practical reason which could provide grounds for seeking some rather than other intelligible continuations of lives and traditions. Despite Maclntyre's criticisms of Kant's ethics, a Kantian account of practical reasoning may complement his account of intelligibility. An appropriate interpretation of Kantian ethics is outlined, which escapes Maclntyre's criticisms, allows both for the universal character of basic moral principles and for the historical variability of intelligible action, and which makes moral worth or virtue the centre of the moral life. The refurbishing of Aristotelian ethics may be achieved by a Kantian completion.     

A Synthetic Approach to Bioethical Inquiry

This paper attempts to sort out some of the current tensions and ambiguities inherent in the field of bioethics as it continues to mature. In particular it focuses on the question of the methodological relevance of theory or ethical principles to the domain of clinical ethics. I offer an approach to reasoning about moral conflict that combines the insights of contemporary moral theorists, the philosophy of American pragmatism, and the skills of rhetorical deliberation. This synthetic approach locates a proper role for moral theory in the practice of clinical ethics, thus linking abstract philosophical ideas about morality, humanity, suffering, and health to specific deeds, actions, and decisions in the concrete lives of particular individuals. The aim of this synthetic approach of bioethical inquiry is a rapprochement between theoretical knowledge in moral philosophy and the contextualized, relational, and practical understanding of what morality demands of us in our daily lives. I argue for a conception of bioethical inquiry that takes morality to be a study of certain practical, socially embedded concerns about matters of right and wrong, good and evil, as well as a study of the moral theories by which these actual concerns can be explored and critically evaluated.     

Understanding the Trusted Doctor and Constructing a Theory of Bioethics

This paper offers a constructivist account of bioethics as an alternative to previous discussions that explained the ethics of medicine by an extrapolation of principles or virtues from ordinary morality. Taking medicine as a higher and special calling, I argue that the practice of medicine would be impossible without the trust of patients. Because trust is a necessary condition for medical practice, the ethics of the profession must provide the principles for guiding physician behavior and the profession toward promoting trust and being trustworthy. In a phrase, that principle is “seek trust and deserve it.” I sketch out how the concept of trust provides a different justification for common sense principles of bioethics and explain how the concept of trust provides reasonable guidance for resolving moral conflicts within medicine. The trust-seeking approach provides a new and unexpected ordering of some traditional medical values, it reveals the weightiness of previously undervalued bioethical precepts, and illuminates the centrality of some largely ignored obligations of medicine. It also has the power to guide clinical practice and to inform the profession about standards for medical institutions. This revised version was published online in August 2006 with corrections to the Cover Date.     

Distributive justice and the minnesota health access initiative

As I have suggested, from the perspective of distributive justice MinnesotaCare's reforms are inadequate. But to coin (and alter slightly) a phrase of Kant's, if its authors do not deserve our moral esteem, perhaps they do merit our encouragement, and it is on a note of the latter that I will conclude. MinnesotaCare is an experiment in systemic incremental change being performed in a complex health care system, the only true laboratory for such an experiment. For this reason, it will provide us important information concerning the ethics, economics, [and] the politics of health care reform while improving the position of some Minnesotans in a significant way. Thus, while MinnesotaCare is susceptible to forceful moral criticism, as an experiment in reform it holds out the promise of providing us some of the data necessary for discovering a just solution.     

Accepting Fallibility: A Model for Personal Responsibility for Nonegregious Ethics Infractions

The profession's ethics standards require counselors to self‐monitor their professional actions and take responsibility for misconduct. However, the professional literature has focused on preventing misconduct and on response to serious violations and has offered little guidance regarding the minor infractions that all professionals are vulnerable to committing during their careers. The author presents a 4‐element model to guide counselors in ethically repairing damage when they recognize they have violated ethics codes or ethical principles in minor ways. The model uses the ethical principles that underlie the American Counseling Association's (1995) Code of Ethics and Standards of Practice and J. R. Rest's (1983, 1994) model of moral behavior as a foundation.     

Practical judgment as reflective judgment: On moral salience and Kantian particularist universalism

Moral particularists and generalists alike have struggled over how to incorporate the role of moral salience in ethical reasoning. In this paper, I point to neglected resources in Kant to account for the role of moral salience in maxim formation: Kant's theory of reflective judgment. Kant tasks reflective judgment with picking out salient empirical particulars for formation into maxims, associating it with purposiveness, or intentional activity (action on ends). The unexpected resources in Kantian reflective judgment suggest the possibility of a particularist universalism, where recalcitrant particulars directly inform, and in some cases revise, moral principles. Such an account improves on particularist accounts of moral salience and moral perception: rather than deriving moral sensitivity solely from an agent's upbringing or cultural resources, the reflective dimension is situated alongside the universalist dimension of moral principles typically identified with Kantian ethics, allowing for a critical approach both to moral universals and to the reception of moral particulars.     

A Meta-Ethical Critique of Care Ethics

A meta-ethical analysis demonstrates that care ethics is a grounded in a distinct mode of moral reasoning. This is comprised primarily of the rejection of principles such as impartiality, and the endorsement of emotional or moral virtues such as compassion, as well as the notion that the preservation of relations may override the interests of the individuals involved in them. The main conclusion of such a meta-ethical analysis is that such meta-ethical foundations of care ethics are not sound. Reasonable alternatives for care ethics may be its formulation as an additional principle within an established principlist framework, or the move to a dialogical ethics, where the good to be acted upon is not decided in advance but rather critically discussed and established within the encounter of the parties involved. This revised version was published online in August 2006 with corrections to the Cover Date.     

Ethics in Long-Term Care: Are the Principles Different?

It has become common in medical ethics to discuss difficult cases in terms of the principles of respect for autonomy, beneficence, nonmaleficence, and justice. These moral concepts or principles serve as maxims that are suggestive of appropriate clinical behavior. Because this language evolved primarily in the acute care setting, I consider whether it is in need of supplementation in order to be useful in the long-term care setting. Through analysis of two typical cases involving residents of long-term care facilities, I argue for the additional principles of candor and responsibility for narrative integrity.     

启新、拓新与创新——论生态伦理学对伦理学的贡献

构建和谐社会,必须弘扬生态伦理,繁荣生态伦理学。生态伦理学对伦理学的贡献功不可没,主要体现为：开辟了伦理学研究的新领域,确立了处理人与自然关系的新原则,培育了人对自然的新态度,对传统思想展开了新的系统批判,明确了人类在自然生活中扮演的新角色,对伦理学基本观念进行了新阐释,制定了人类行为新规范。     

Which Teacher Should I Choose?: A Xunzian Approach to Distinguishing Moral Experts from Fanatics

This essay examines whether an invocation of an epistemological privilege on the part of supposed moral experts prevents potential students from being able to evaluate among potential candidates for the role of plausible moral teacher. Throughout, it works to demonstrate that it is possible for even the untutored student to distinguish between a fanatic and a moral expert. In particular, this essay focuses on the version of virtue ethics espoused by the early Chinese philosopher Xunzi. It argues that by reflecting on the attributes of fanatics, as well as on Xunzi's ideas and arguments about students and teachers, it is possible to arrive at a general set of principles that provide beginners with the tools necessary to distinguish dangerous fanatics from plausible moral teachers, even given the fact that both claim for themselves an epistemological privilege.     

Different Voices, Still Lives: Problems in the Ethics of Care

ABSTRACT Recent writings in feminist ethics have urged that the activity of caring is more central to women's lives than are considerations of justice and equality. This paper argues that an ethics of care, so understood, is difficult to extend beyond the local and familiar, and is therefore of limited use in addressing the political problems of the modern world. However, the ethics of care does contain an important insight: if references to care are understood not as claims about women's nature, but as reflections on the extent to which moral obligations are both unchosen and conflicting, then an ethics of care can supplement an ethics of justice, and can also provide a more realistic account of both men's and women's moral life.     

John Finnis on Aquinas 'The Philosopher'

In the ten dense chapters of his new book, John Finnis examines and sometimes amends what he takes to be the key moral, legal, social and political doctrines of Thomas Aquinas. Finnis correctly stresses that neither ethics nor politics, in the Arstotelian tradition to which Aquinas belonged, are theoretical sciences. They are 'practical' or action-guiding sciences. Since societal order originates in free choice, it is subject to moral norms. The latter are more firmly grounded by Aquinas than Aristotle because the former unlike the latter has an explicit and coherent account of universal or exceptionless moral principles.
Finnis natural law ethics derives from a set of self-evident precepts that focus practical reason on the pursuit and protection of basic human goods. Finnis expanding list of the latter now include marriage. Finnis equates – implausibly, in my view – attaining the ensemble of basic human goods ('integral human fulfilment') with Aquina's notion of beatitudo imperfecta or this-worldly happiness.
Throughout the book, Finnis' exegesis of Aquinas is slanted towards bolstering Finnis' own Thomist philosophical ethics. Accordingly, Thomistic historical scholarship, which carefully traced Aquinas' biblical and patristic sources and which locate Aquinas' theological ethics within the conditions of his own life and times, has little weight in Finnis' interpretation. Overall, Finnis shows little concern for the internal logic of the Summa theologiae and, consequently, he does not adequately clarify how Aquinas' own ethics, according to its proper principles, can be both integrally theological and rational without thereby becoming a philosophical ethics.     

Organizational ethics in Catholic health care: honoring stewardship and the work environment.

Organizational ethics refers to the integration of values into decision making, policies, and behavior throughout the multi-disciplinary environment of a health care organization. Based upon Catholic social ethics, stewardship is at the heart of organizational ethics in health care in this sense: stewardship provides the hermeneutic filter that enables basic ethical principles to be realized practically, within the context of the Catholic theology of work, to concerns in health care. This general argument can shed light on the specific topic of non-executive compensation programs as an illustration of organizational ethics in health care.     

Religion and Public Health: Moral Tradition as Both Problem and Solution

Despite strong religious influence in the development of medicine and medical ethics, religion has been relatively absent in the rise of preventive medicine and population health. Episodic, clinical medicine has a powerful hold on the religious imagination in health care. Nevertheless, Hebrew Scripture, elements of rabbinical teaching, and modern concepts of social justice all can be used to inspire action in health care that goes beyond clinical medicine. The Christian tradition can call upon the corporal works of mercy, virtue ethics, and Catholic social teaching, as well as the modern history Catholic sisters in the U.S. to do the same. By considering the moral imperative for public health, Jewish and Christian individuals and organizations reaffirm the notion that the human person is both sacred and social. This article suggests a need for religious traditions to consider their moral traditions anew with an eye toward prevention and population health.

     

Care Ethics and Confucianism: Caring through Li

The role of li, or ritual, in Confucianism is a perceived impediment to interpreting Confucianism to share a similar ethical framework with care ethics because care ethics is a form of moral particularism. I argue that this perception is false. The form of moral particularism promoted by care ethicists does not entail the abandonment of social conventions such as li. On the contrary, providing good care often requires employing systems of readily recognizable norms in order to ensure that care is successfully communicated and completed through one's care‐giving practices. I argue that li performs this communicative function well and that the early Confucians recommend breaching li precisely when its efficacy in performing this function is compromised.