Before the rules are written: navigating moral ambiguity in performance enhancement

In 1984, a number of US cyclists used blood transfusions to boost their performance at the Los Angeles Olympic Games. The cyclists broke no rules and dominated the Games, yet were later maligned as cheaters and dopers—they had, it seemed, violated some important norm, albeit one which was neither an official rule nor otherwise easily identifiable. Their case illustrates the moral ambiguity that arises when a performance enhancement is employed in a sport that has not addressed it. This article takes up the crucial question posed by such moral ambiguity: is it ethical to enhance performance through a substance or technology when no rules exist to prohibit it? We first examine ordinary ethical obligations that athletes carry based on their status as moral agents. We conclude that such obligations provide some guidance, but cannot resolve the issue. We then examine arguments that take sport as a unique social practice that presents its own moral obligation not to use performance enhancers. We argue that these ‘spirit of sport’ arguments, developed by McNamee and Loland and Hoppeler cannot resolve the issue either. We conclude that when the rules governing sport are silent on the issue of performance enhancement the constraints on its ethical use are limited at best.     

From Therapy and Enhancement to Assistive Technologies: An Attempt to Clarify the Role of the Sports Physician

Sports physicians are continuously confronted with new biotechnological innovations. This applies not only to doping in sports, but to all kinds of so-called enhancement methods. One fundamental problem regarding the sports physician's self-image consists in a blurred distinction between therapeutic treatment and non-therapeutic performance enhancement. After a brief inventory of the sports physician's work environment I reject as insufficient the attempts to resolve the conflict of the sports physician by making it a classificatory problem. Followed by a critical assessment of some ideas from the US President's Council on Bioethics, the formulation of ethical codes and attempts regarding a moral topography, it is argued that the sports physician's conflict cannot be resolved by the distinction between therapy and enhancement. Instead, we also have to consider the possibility that the therapy-based paradigm of medicine cannot do justice to the challenges of the continuously increasing technical manipulability of the human body and even our cognitive functions as well. At the same time we should not adhere to transhumanist ideas, because non-therapeutic interventions require clear criteria. Based on assistive technologies an alternative framework can be sketched that allows for the integration of therapeutic and non-therapeutic purposes. After a thorough definition of standards and criteria, the role of the sports physician might be defined as that of an assistant for enhancement. Yet the process of defining such an alternative framework is a societal and political task that cannot be accomplished by the sports physicians themselves. Until these questions are answered sports physicians continue to find themselves in a structural dilemma that they partially can come to terms with through personal integrity.     

Ethical and legal aspects in teaching students of medicine

Due to the rapid advances in medical technology, medical students are now being faced with increasingly complex and unparalleled ethical and practical dilemmas during their training. The new and future challenges of high-tech medicine demand improvements in current medical education, not only by meeting the needs of students through humanized training programs, but also by involving them in finding solutions to the ethical and legal quandaries they encounter. Today’s students of medical universities must acquire knowledge and understanding of the ethical and legal issues relevant to the practice of medicine, and we have to do everything possible to introduce these students to the current discussions on more or less controversial ethical and legal topics. Although final answers may not be found, the very discussion, argumentation, and awakening of students’ interest should become an essential part of the core curriculum of every doctor. An earlier version of this paper was presented at an international conference, “The Ethics of Intellectual Property Rights and Patents,” held in Warsaw, Poland on 23–24 April, 2004. The author is a student and member of the Senate Committee on Teaching.     

谈《疏五过论》的五种过错对当今医生的教育意义

传统的医学道德观认为：“医乃仁术”、“生命至贵”等就是“‘大医精诚”。医者要做到“大医精诚”,就要避免《疏五过论》中医者的五种过错,使患者保持健康的生命。所以,医生要以严谨认真的工作态度,充分了解患者的病情;以生物心理社会医学模式来处理患者;不能急功近利,追求名誉,应常怀仁爱之心建立和谐的医惠关系。医生处理患者的态度及自身的道德修养直接影响患者的健康和生命,这种理念应该成为医生终生追求的目标,这样才能顺应新医改的要求。     

MEDICAL MANAGEMENT OF INFANT INTERSEX: THE JURIDICO‐ETHICAL DILEMMA OF CONTEMPORARY ISLAMIC LEGAL RESPONSE

Technological advances in the field of medicine and health sciences not only manipulate the normal human body and sex but also provide for surgical and hormonal management of hermaphroditism (intersexuality). Consequently, sex assignment surgery has not only become a standard care for babies born with genital abnormalities in the West but even in some Muslim states. On the positive side, it goes a long way in saving children born with abnormal genitalia from numerous legal interdictions of the pre‐sex corrective surgery. Nevertheless, the larger ethical and legal questions that medical management of genital abnormality raises to some extent have not been adequately appreciated by contemporary Muslim responses. This article, therefore, in principle argues against surgical management of intersexuality during early infancy from the Islamic legal perspective.     

Enhancement and ethics

Now suppose we could use genetic engineering, regenerative medicine or drugs --chemical enhancers, or reproductive technology or nanotechnology to produce healthier, fitter and more intelligent individuals, what should our reaction be? Would it be unethical to do so? Would it be ethical not to do so? Our question is this: If the goal of enhanced intelligence, increased powers and capacities and better health is something that we might strive to produce through education, including of course the more general health education of the community; why should we not produce these goals, if we can do so safely, through enhancement technologies or procedures? If these are legitimate aims of education could they be illegitimate as the aims of medical or life science, as opposed to educational science?     

Ethical reflections on the status of the preimplantation embryo leading to the German embryo protection act

Ethical conflicts have always been connected with new techniques of reproductive medicine such as in-vitro fertilization. The fundamental question is: When does human life begin and from which stage of development should the embryo be protected? This question cannot be solved by scientific findings only. In prenatal ontogenesis there is no moment during the development from the fertilized oocyte to a human being which could be recognized as an orientation point for all ethical problems connected with the question of the right to dispose of prenatal life (interruption of pregnancy, research on embryos). The protection of an individual human life must be valid for all in the same manner and from the very beginning on. It must not depend on value judgments or on stages of development, so-called grades of humanity, because these would then become selection criteria. Procreated life must have the right to be born. These were the essential ethical arguments which led to the German Embryo Protection Law.     

The Naked Spirit of Sport: A Framework for Revisiting the System of Bans and Justifications in the World Anti-Doping Code

As the World Anti-Doping Code is up for revision, the paper proposes a framework for reading the Code based on a relatively literal approach and an almost exclusive focus on the ‘spirit of sport’ as a key element of the Code. The author argues that this single element can contribute to revealing the underlying rationale of the Code, as it serves to justify bans of doping substances and methods, in some cases without recurring to evidence sustaining the claims made. For a substance/method to be banned, the Code requires that two out of three criteria be met: performance enhancement, health risk and the spirit of sport. The paper demonstrates how these provisions link to other parts of the Code, (under the rules of the Code 2009) in the absence of performance-enhancing properties combined with a health risk. The paper draws implications from these findings regarding terminological (im)precision, legal certainty/predictability, transparency/accountability, limits to arbitrary exercise of power and internal/external validity.     

A League of Their Own? Evaluating Justifications for The Division of Sport into ‘Enhanced’ and ‘Unenhanced’ Leagues

Cheating through the use of illegal performance enhancements (such as doping) is a persistent problem in sport. It has been suggested that one response to this problem is to separate sport into two parallel leagues. One league would resemble sport as it is currently practised – i.e. with restrictions on use of particular enhancements – and the other would not possess these restrictions, allowing those that wish to use currently illegal enhancements to do so. In this paper I articulate the ‘two leagues’ proposal further and subject it to critical scrutiny. The proposal fails. It does so by failing to address conceptual confusion regarding enhancement use in sport; by replicating in the new league the current problems associated with enhancement-based cheating; and by creating new problems. In an attempt to revive it I describe other possible justifications for the proposal, based on its promotion of personal autonomy, and rights-based justifications. These fail, with the exception of a group right claiming provision of the enhanced league as a participatory good. I conclude that this latter use of the proposal is the only sensible one, but it nevertheless faces significant obstacles.     

The relationship between medicine's internal morality and religion.

In the face of managed care and market economies infringing on the practice of medicine, reducing its autonomy and determining the moral guidelines for medical practice, many physicians are calling out for a return to what is perceived as a traditional medical ethic. Many religiously motivated critics of certain modern developments in medicine have made similar appeals. These calls are best understood as an attempt to define medicine as a practice that is necessarily ethical in nature, a practice the moral basis of which is internal to that practice. This article examines and assesses this definition of medicine in reference to Aristotle's division of human undertakings into three distinct categories: theory, poieisis (i.e., production), and praxis. It is concluded that medicine can be understood as a praxis (as opposed to a theory or production, both of which are morally neutral), because the practice of medicine, and all of its constitutive acts, can only be explained and assessed in reference to health, which is itself a final good and hence of moral value. Such an understanding would immunize medicine against usurpation by the free market. However, by the same token it would also dissociate medicine from all other moralities external to it, including those grounded in faith and religion.     

和谐伦理精神探析

和谐社会是一种和而不同的动态的理性社会,它需要一种全新的和谐伦理精神来支撑。这种和谐伦理精神主要体现在公平正义、诚信友爱、尊重自然等三个方面。公平正义是构建社会主义和谐社会制度的首要美德;诚信友爱是协调和谐人际关系的道德基石;尊重自然是实现人与自然和谐相处的生态伦理精神。这三种伦理精神的统一体现了社会、人和自然的统一。     

WHEN BETTER IS WORSE. On the therapy/enhancement distinction in sports

The standard therapy/enhancement distinction is usually related to health purposes and some sense of normality. In this paper, I will challenge the basis of the distinction arguing that only the first part of it is related to health and, consequently, the distinction should be better understood as differentiating between qualitative and quantitative consequences of interventions. As health and normality are broad concepts inside of which it is possible to make some ulterior distinctions, I will propose three different senses of normality in order to more easily grasp the therapy/enhancement distinction. As with the distinction between therapy and enhancement, the difference between sports- and non-sports-persons is usually stated in terms of health and normality. I will challenge this assumption, too. In my opinion, the main difference between people, sportspeople and athletes should be related to the practice itself. Once the practice of a sport is taken seriously, along with its tough and demanding lifestyle, it is possible to properly analyse the distinction between people who practice and do not practice sport; the different levels at which they participate—quite obviously—have little to do with health purposes. Finally, I will revisit the standard therapy/enhancement distinction in sport in order to provide a way to easily reformulate this distinction allowing embarrassing blunders to be avoided and athletes’ health to be adequately cared for. I will conclude this paper with two open questions related to the use of the therapy/enhancement distinction for sport purposes and the challenge that it represents for some basic values of sport.     

Measuring the quality of life: Why,how and what?

In this paper three questions concerning quality of life in medicine and health care are analysed and discussed: the motives for measuring the quality of life, the methods used in assessing it, and the definition of the concept. The purposes of the study are to find an ethically acceptable motive for measuring the quality of life; to identify the methodological advantages and disadvantages of the most prevalent current methods of measurement; and to present an approach towards measuring and defining the quality of life which evades the difficulties encountered and discussed. The analysis comprises measurements both in the clinical situation concerning individual patients and in research concerning whole populations. Three motives are found for evaluating the quality of human life: allocation of scarce medical resources, facilitating clinical decision making, and assisting patients towards autonomous decision making. It is argued that the third alternative is the only one which does not evoke ethical problems. As for the methods of evaluation, several prevalent alternatives are presented, ranging from scales of physical performance to more subtle psychological questionnaires. Clinical questionnaires are found to fail to provide a scientific foundation for universally measuring the quality of life. Finally, the question of definition is tackled. The classical distinction between need-based and want-based theories of human happiness is presented and discussed. The view is introduced and defended that neither of these approaches can be universally preferred to the other. The difficulty with the need approach is that it denies the subjective aspects of human life; whereas the problem of the want approach is that it tends to ignore some of the objective realities of the human existence. In conclusion, it is argued that the choice of methods as well as definitions should be left to the competent patients themselves — who are entitled, if they so wish, to surrender the judgement to the medical personnel. Technical factors as well as the requirements of respect for autonomy and informed consent support this conclusion.     

An Alternative Solution to Lifting the Ban on Doping: Breaking the Payoff Matrix of Professional Sport by Shifting Liability Away from Athletes

The persistence of doping in professional sports—either by individuals on an isolated basis and by whole teams as part of a systematic doping programme—means that professional sport today is rarely if ever untainted. There are financial incentives in place that incentivise doping and there are data that show that doping is often a systematic, organised enterprise (either at team-level, or at state-level). The main question to be answered today in professional sports is whether doping’s repressive anti-doping policies do not have greater negative consequences for society. Whilst some have suggested legitimising safe doping under medical control, in this paper, I argue that doing so will do little to prevent clandestine use of dangerous performance-enhancing substances, and suggest an alternative solution to lifting the ban on doping, i.e. starting from extending liability for doping in sport beyond athletes to those holding power and authority over athletes, to changing winning incentives for doping, to making sport sustainable in the longer time by devising ways of providing athletes with a steady income which is not linked to record breaking or sponsorships.     

A study of the foundations of ethical decision making of clinical medical ethicists

A study of clinical medical ethicists was conducted to determine the various philosophical positions they hold with respect to ethical decision making in medicine and their various positions' relationship to the subjective-objective controversy in value theory. The study consisted of analyzing and interpreting data gathered from questionnaires from 52 clinical medical ethicists at 28 major health care centers in the United States. The study revealed that most clinical medical ethicists tend to be objectivists in value theory, i.e., believe that value judgments are knowledge claims capable of being true or false and therefore expressions of moral requirements and normative imperatives emanating from an external value structure or moral order in the world. In addition, the study revealed that most clinical medical ethicists are consistent in the philosophical foundations of their ethical decision making, i.e., in decision making regarding values they tend not to hold beliefs which are incompatible with other beliefs they hold about values.     

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.     

Philosophy of medicine as the source for medical ethics

The article offers an approach to inquiry about, the foundation of medical ethics by addressing three areas of conceptual presupposition basic to medical ethical theory. First, medical ethics must presuppose a view about the nature of medicine. it is argued that the view required by a cogent medical morality entails that medicine be seen both as a healing relationship and as a practical art. Three ways in which medicine inherently involves values and valuation are presented as important, i.e., in being aimed at the good of health, in being a cognitive art evaluating towards that good, and as a manifestation of a virtuous disposition concerning that good. Finally, a value ontology drawn from these considerations is seen as necessarily underlying medical ethics. A set of three such basic values are promoted as crucial: the value of health; the value of the individual patient; and the value of altruism that mediates the class of potential patients.     

The Ethics of Smart Pills and Self-Acting Devices: Autonomy,Truth-Telling,and Trust at the Dawn of Digital Medicine

Digital medicine is a medical treatment that combines technology with drug delivery. The promises of this combination are continuous and remote monitoring, better disease management, self-tracking, self-management of diseases, and improved treatment adherence. These devices pose ethical challenges for patients, providers, and the social practice of medicine. For patients, having both informed consent and a user agreement raises questions of understanding for autonomy and informed consent, therapeutic misconception, external influences on decision making, confidentiality and privacy, and device dependability. For providers, digital medicine changes the relationship where trust can be verified, clinicians can be monitored, expectations must be managed, and new liability risks may be assumed. Other ethical questions include direct third-party monitoring of health treatment, affordability, and planning for adverse events in the case of device malfunction. This article seeks to lay out the ethical landscape for the implementation of such devices in patient care.     

Ethics in medicine: Are we blind? In support of teaching medical ethics at the bedside

The ability to recognize and respond to the ethical dimension of medicine is integral to providing health care that is comprehensive and humane. However, this aspect of medical practice is underemphasized in clinical and academic medicine, despite attempts to devise curricula in this field. This paper examines the origins and consequences of this deficiency through a case history of a Jehovah's Witness who reluctantly accepted a blood transfusion. It emphasizes the ubiquity of the ethical context in medicine and argues that blindness to this context stems from the prevailing scientific and technological paradigm in medicine. Innovations in medical education are called for to enhance health care providers' abilities to appreciate and cope with these complex situations.