Response: Clinical wisdom and evidence-based medicine are complementary

A long-debated question in the philosophy of health, and contingent disciplines, is the extent to which wise clinical practice ("clinical wisdom") is, or could be, compatible with empirically validated medicine ("evidence-based medicine"--EBM). Here we respond to Baum-Baicker and Sisti, who not only suggest that these two types of knowledge are divided due to their differing sources, but also that EBM can sometimes even hurt wise clinical practice. We argue that the distinction between EBM and clinical wisdom is poorly defined, unsupported by the methodology employed, and ultimately incorrect; crucial differences exist, we argue, not in the source of a particular piece of clinical knowledge, but in its dependability. In light of this subtle but fundamental revision, we explain how clinical wisdom and EBM are--by necessity--complementary, rather than in conflict. We elaborate on how recognizing this relationship can have far-reaching implications for the domains of clinical practice, medical education, and health policy.     

Love,Power and Consistency: Scotus’ Doctrines of God’s Power,Contingent Creation,Induction and Natural Law

I first examine John Duns Scotus’ view of contingency, pure possibility, and created possibilities, and his version of the celebrated distinction between ordained and absolute power. Scotus’ views on ethical natural law and his account of induction are characterised, and their dependence on the preceding doctrines detailed. I argue that there is an inconsistency in his treatments of the problem of induction and ethical natural law. Both proceed with God’s contingently willed creation of a given order of laws, which can be revoked and replaced with a new order of laws. In the case of ethical natural law God promulgated the Decalogue, for example; in the case of nature, there are physical laws that can be known by induction. Scotus exalts the freedom of God and the mutability of ethical natural law in order to explain exceptions to it disclosed by revelation (for example, the Old Testament command to Abraham to kill Isaac). Yet he treats ethical natural laws as (mostly) not universal and immutable. In contrast, he holds that we can arrive at knowledge of the universal and immutable laws of nature, except for those regularities that result from free will. Finally, I present several ways of characterising this tension between Scotus’ doctrines.     

The Courage of Conviction: Andreia as Precondition for Philosophic Examination in Plato's Protagoras and Republic

There are at least two apparently conflicting views of courage found in Plato's dialogues: the intellectualist view exemplified by Socrates’s identification of courage with wisdom as found in the Protagoras; and the dispositional view of courage as a natural temperament to overcome fear in situations of danger, the necessary qualification for the auxiliary class in the Republic. In this paper I argue that these views are complementary, dispositional courage being a necessary precondition for the pursuit of the proper human excellence of wisdom. I demonstrate this by considering the role opinion plays in each understanding of courage, showing both that dispositional courage is necessary to ensure that proper opinions be retained in the pursuit of wisdom and that wisdom is necessary to guarantee these opinions are the proper ones. Finally, I argue that not only is this relationship of the two understandings of courage present in the Republic, but even in the Protagoras Socrates’s method of conducting the elenchus betrays awareness on his part of the importance of dispositional courage in the pursuit of wisdom     

Nanoethics: From utopian dreams and apocalyptic nightmares towards a more balanced view

Nanotechnology is a swiftly developing field of technology that is believed to have the potential of great upsides and excessive downsides. In the ethical debate there has been a strong tendency to strongly focus on either the first or the latter. As a consequence ethical assessments of nanotechnology tend to radically diverge. Optimistic visionaries predict truly utopian states of affairs. Pessimistic thinkers present all manner of apocalyptic visions. Whereas the utopian views follow from one-sidedly focusing on the potential benefits of nanotechnology, the apocalyptic perspectives result from giving exclusive attention to possible worst-case scenarios. These radically opposing evaluations hold the risk of conflicts and unwanted backlashes. Furthermore, many of these drastic views are based on simplified and outdated visions of a nanotechnology dominated by self-replicating assemblers and nanomachines. Hence, the present state of the ethical debate on nanotechnology calls for the development of more balanced and better-informed assessments. As a first step in this direction this contribution presents a new method of framing the ethical debate on nanotechnology. Thus, the focus of this paper is on methodology, not on normative analysis.     

Treating fetuses: The patient as person

The medical treatment in utero of human beings raises several ethical questions. I argue that treatment is sufficient to establish the fetus as person; and consider how conflicts between the interests of the fetus and mother are to be resolved when such treatment is proposed. My arguments rest upon a 'relational model' of ethical discourse derived from H. Richard Niebuhr's "ethics of the fitting." I conclude that the limitation of personal autonomy is rarely justified, but may be when direct, grave, harm to others is imminent; and that educative rather than punitive measures are the best prospect for protecting fetal life.     

真实性及其伦理边界——对新闻真实性原则的伦理反思

真实是新闻的生命 ,追求并维护新闻的真实性是新闻工作者的伦理准则。然而和任何准则都不可能是绝对的一样 ,真实性同样不是一条绝对性原则。在具体的新闻传播活动中 ,由真实性引发的伦理冲突是经常存在的。新闻从业人员的职责之一 ,就是如何运用自己的道德智慧来解决这些伦理冲突。     

The role of the clinical ethics consultant in "unsettled" cases

In this article I take up a central question posed by the article jointly authored with Bill Winslade in this issue of JCE: What should be the role of clinical ethics consultants (CECs) in (what we call) an unsettled case: that is, a situation in which the range of allowable choices, among which the parties to a bioethical disagreement must select, cannot be clearly or completely specified? I argue here that CECs should, in such cases, guide the parties by presenting their own reasoned conclusions about what the scope of allowable choices should be taken to include. Since this position challenges the received view that CECs must not express their own moral positions or conclusions in their role as ethicists, I try to defend my view of the CEC's role in unsettled cases against several objections.     

Ethical issues in field research: balancing competing values.

An ethical issue becomes a dilemma when the psychologist is pulled in different directions by competing values. This paper will focus on the conflict between experimental and ethical values inherent in field research. The problem has special significance in community psychology, which gives priority to studying, in natural settings, those affected by social problems. An example is given of research that required observation of family interaction in the homes of convicted child abusers. The case demonstrates that the value of ecological validity often conflicts with the need to protect privacy and obtain uncoerced consent. Other ethical constraints, including the duty to report lawbreaking and to protect the public from harm, may threaten research validity.     

Ethical issues in research on preventing HIV infection among injecting drug users

The ethical issues in conducting research on preventing HIV infection are among the most complex of any area of human subjects research. This article is an update of a 1987 article that addressed potential conflicts between research design and ethics with respect to AIDS prevention among injecting drug users. The present article reviews current ethical issues that arise in the design and conduct of HIV/AIDS prevention research focused on injecting drug users. Disclaimer: The content of this publication is solely the responsibility of the authors and does not necessarily represent the views of the Beth Israel Medical Center or Johns Hopkins University.     

The best interest standard: both guide and limit to medical decision making on behalf of incapacitated patients

In this issue of JCE, Douglas Diekema argues that the best interest standard (BIS) has been misemployed to serve two materially different functions. On the one hand, clinicians and parents use the BIS to recommend and to make treatment decisions on behalf of children. On the other hand, clinicians and state authorities use the BIS to determine when the government should interfere with parental decision-making authority. Diekema concedes that the BIS is appropriately used to "guide" parents in making medical treatment decisions for their children. But he argues that the BIS is inappropriately used as a "limiting" standard to determine when to override those decisions. Specifically, Diekema contends that the BIS "does not represent the best means for determining when one must turn to the state to limit parental action." He argues that this limiting function should be served by the harm principle instead of by the BIS. I contend that we should not reassign the BIS's limiting function to the harm principle. In this article I make two arguments to support my position. First, the BIS has effectively served, and can serve, both guiding and limiting functions. Second, the harm principle would be an inadequate substitute. It cannot serve the limiting function as well as the more robust BIS.     

Two Virtuous Actions Cannot both be Completed

This essay highlights an alternative tradition of understanding value conflicts in early Confucian thought. In contrast to a prominent position among interpreters that argues for the resolvability or harmonization of conflicting values, I argue that some early Confucians conceptualized value conflicts as irresolvable. In other words, when meaningful aspects of a situation come into tension with each other and values are threatened to be either left unfulfilled or harmed, early Confucians put forth a variety of views. Some believed that all values could be tended to as long as one had the moral imagination of a sage, whereas others saw the world as a place where irreconcilable conflicts between values could occur for even the most profound people. Within this diversity, I take up a view about irresolvable value conflicts where the confrontation with a deep value conflict leaves behind a moral remainder that can mar even the character of a sage.     

BOOK REVIEW

In this brief note, we respond to Gottlieb and Lasser's (2001/this issue) critical commentary on our work on narrative research ethics. We argue that their concern for privileging voices needs to be balanced against the risk of exploiting some research participants, that conflicts of interest are best resolved through appropriately prioritizing ethical principles and in consultation with others, and that the researcher's ability to protect participants from harm can be enhanced through appropriate clinical training and access to clinical expertise. We welcome Gottlieb and Lasser's specific recommendations for ethical practice in narrative research and encourage further ethical reflection by other researchers in this area.     

Ontology for an Uncompromising Ethical Realism

I begin by distinguishing two general approaches to metaethics and ontology. One in effect puts our experience as engaged ethical agents on hold while independent metaphysical and epistemological inquiries, operating by their own lights, deliver metaethical verdicts on acceptable interpretations of our ethical lives; the other instead keeps engaged ethical experience in focus and allows our reflective interpretation of it to shape our metaphysical and epistemological views, including our ontology. While the former approach often leads to deflationary views, the latter may lead us to enrich our metaethical picture as needed to capture robust objectivity and categorical normative authority for ethics. Assuming, as I have argued elsewhere, that this requires positing irreducibly evaluative or normative properties and facts, the question I take up here is what ontological implications this has. I argue against quietist (or nonmetaphysical) non-naturalist views, which maintain that positing such properties and facts either has no ontological implications (Parfit) or has only domain-specific ontological implications that likewise imply nothing about what the world contains (Scanlon). Against these views, I advocate a worldly, dual-aspect view, locating irreducibly evaluative or normative properties as features of relevant worldly things. But while I have previously defended this view as a form of non-naturalism, I here explore the possibility of instead seeing it as a new, more expansive form of naturalism—what might be called “Non-Scientistic Naturalism”—inspired by parallel attempts in the philosophy of mind to accommodate irreducibly phenomenal properties within a more expansive physicalism.     

Toward Honest Ethical Pluralism

I give the label “ethical pluralism” to the meta-ethical view that competing moral views are valid. I assume that validity is conferred on a moral view by its satisfying the relevant meta-ethical criteria in a maximally satisfactory way. If the relevant meta-ethical criteria are based on something roughly like the wide reflective equilibrium model, then ethical pluralism is likely to be correct. Traditional moral views do not grant exemptions from their own binding rules or principles to agents – should any exist – who adhere to a competing valid moral view. Given the usual conception of accepting a moral view, an ethical pluralist cannot honestly accept a traditional moral view. Consequently, I argue, an ethical pluralist is committed to the view that all traditional moral views are invalid. Given the likelihood of ethical pluralism, this conclusion is alarming. I set forth a weak conception of accepting a moral view that is designed to allow an ethical pluralist honestly to accept a traditional moral view. In particular, my conception is designed to explain how someone can (a) be guided by the view that she accepts; (b) accept her own moral view while rationally not accepting competing views that she thinks are equally valid; and (c) not be prepared to prescribe morally to those who are following other valid views. Central to my formulation are what I call a stance of modest respectful disapproval toward other people’s wrong behavior, together with acceptance of decisive moral reasons for oneself that are generated by the valid moral view that one accepts.     

The Influence of Conflict Issue Importance on the Co‐occurrence of Task and Relationship Conflict in Teams

Task conflicts may be beneficial for team performance whereas relationship conflicts are associated with negative team outcomes. Because the two conflict types are typically correlated within teams, it is difficult to enhance task conflicts and simultaneously avoid relationship conflicts. This study examines how importance of the conflict issue moderates the association between task and relationship conflict. In addition, the hypothesis was tested that the interaction between task conflict and issue importance on relationship conflict is mediated by task conflict emotionality. A sample of 50 teams provided data for this study. Results confirmed the buffering effect of conflict issue importance. When teams fight about important task issues, no association between task conflict and relationship conflict was found. This effect could be partially attributed to the decrease in negative emotions present in teams during important task conflicts. The implications of this study are described and directions for future research are indicated.     

Bocheński on the human condition: is a long and happy life the whole story?

Following his retirement from teaching in 1972 J. M. Bocheński entered into a creative phase of his scholarly career characterized by, among other things, a marked shift to ‘naturalism’ to the detriment of philosophical ‘speculation’ of any kind (comprising much of classical metaphysics, ‘world views’, ‘ideologies, ‘moralizing’—for him so many nefarious ‘superstitions’). During this period he examined issues which bear on the human condition in a way that was at once constructive and critical—constructive by virtue of the logical analyses of such concepts as authority, critical by dint of his refusal to take seriously any so-called ‘anthropocentric’/‘humanist’ thinking attempting to secure a special standing for ‘Man’ in the world. These attitudes come to expression in his last work devoted to worldly wisdom, the practical rationality required to ensure a long and happy life. I examine, first, some of the background of this work, with an eye to the naturalism it is based on, provide a schematic overview of the contents of the study, and concentrate on a couple of key issues related to the question as Bocheński understood it. The salient issue concerns his insistence that whatever else it may be the wisdom that is conducive to the long and happy life is not to be confused, conceptually, with any sort of morality: worldly wisdom and the categorical commands of morality stand in no essential relation to each other and may indeed be contradictory … to the detriment of morality, according to Bocheński. Throughout, but especially in the concluding section, I express some doubts about the cogency of this position.     

Love and Benevolence in Hutcheson's and Hume's Theories of the Passions

In this paper I consider two related issues raised by Aristotle's treatment of hearing and sounds. The first concerns the kinds of changes Aristotle takes to occur, in both perceptual medium and sense organs, when a perceiver hears a sounding object. The second issue concerns Aristotle's views on the nature and location of the proper objects of auditory perception. I argue that Aristotle's views on these topics are not what they have sometimes been taken to be, and that when rightly understood they compare favourably in many respects with leading contemporary accounts.     

Confucian Ethics and the Critique of Ideology

The debate between Hans-Georg Gadamer and Jürgen Habermas provides a fresh perspective from which Confucian philosophy may be approached. In this paper, focusing on the Lunyu (Analects), I argue that the sayings of Confucius reflect an essentially 'conservative' orientation, finding in tradition a reservoir of insight and truth. There is a critical dimension to it in that ethical reflection and self-cultivation would enable the individual to challenge particular claims of tradition. However, can self-cultivation transcend tradition as a whole and enable the individual to effect radical change? Following the strategy of Habermas' critique of Gadamer, what happens if tradition is systemically corrupt? In this discussion, rather than taking tradition generally I will focus on the concept of ritual (li) to suggest how the Lunyu seeks to crystallise the wisdom of the past into an ethical guide. The conclusion I draw is in the main a Gadamerian one. Committed to a critical appropriation of tradition, Confucian philosophy seeks ethical renewal from within, on the premise that through incremental change self-cultivation can make a real difference in the quest for moral excellence.     

How mediation (and other) approaches may improve ethics consultants' outcomes

Articles in this issue of JCE recommend a number of approaches to clinical ethics consultation. Given these various approaches, how should ethics consultants proceed?