Accounting for context: Future directions in bioethics theory and research

Many physicians have found that the traditional approach to bioethics fails to account for important aspects of their moral experience in practice. New approaches to bioethics theory are challenging the traditional application of universal moral principles based in liberal moral theory. At the same time, a shift in both the goals and methods of bioethics education has accompanied its “coming of age” in the medical school curriculum. Taken together, these changes challenge both bioethics educators and theorists to come closer to the details and nuances of real clinical encounters. The emerging trend emphasizes the importance of context in bioethics education and in the moral theory and research under-girding it. This article introduces one research approach examining the practical life contexts of medical students' ethical experiences and learning. It calls for increased attention to research and theory in bioethics that more adequately accounts for the ways different contexts produce significant changes in meaning and understanding in medical encounters.     

The ethics of clinical innovation in psychopharmacology: Challenging traditional bioethics

Objective  

To assess the scientific and ethical basis for clinical innovation in psychopharmacology.     

The ethics of clinical innovation in psychopharmacology: Challenging traditional bioethics

Advance health care directives and informed consent remain the cornerstones of patients' right to self-determination regarding medical care and preferences at the end-of-life. However, the effectiveness and clinical applicability of advance health care directives to decision-making on the use of life support systems at the end-of-life is questionable. The Uniform Anatomical Gift Act (UAGA) has been revised in 2006 to permit the use of life support systems at or near death for the purpose of maximizing procurement opportunities of organs medically suitable for transplantation. Some states have enacted the Revised UAGA (2006) and a few of those have included amendments while attempting to preserve the uniformity of the revised Act. Other states have introduced the Revised UAGA (2006) for legislation and remaining states are likely to follow soon. The Revised UAGA (2006) poses challenges to the Patient Self Determination Act (PSDA) embodied in advance health care directives and individual expression about the use of life support systems at the end-of-life. The challenges are predicated on the UAGA revising the default choice to presumption of donation intent and the use of life support systems to ensure medical suitability of organs for transplantation. The default choice trumps the expressed intent in an individual's advance health care directive to withhold and/or withdraw life support systems at the end-of-life. The Revised UAGA (2006) overrides advance directives on utilitarian grounds, which is a serious ethical challenge to society. The subtle progression of the Revised UAGA (2006) towards the presumption about how to dispose of one's organs at death can pave the way for an affirmative "duty to donate". There are at least two steps required to resolve these challenges. First, physicians and hospitals must fulfill their responsibilities to educate patients on the new legislations and document their preferences about the use of life support systems for organ donation at the end-of-life. Second, a broad based societal discussion must be initiated to decide if the Revised UAGA (2006) infringes on the PSDA and the individual's right of autonomy. The discussion should also address other ethical concerns raised by the Revised UAGA (2006), including the moral stance on 1) the interpretation of the refusal of life support systems as not applicable to organ donation and 2) the disregarding of the diversity of cultural beliefs about end-of-life in a pluralistic society.     

Cultural context in medical ethics: lessons from Japan

This paper examines two topics in Japanese medical ethics: non-disclosure of medical information by Japanese physicians, and the history of human rights abuses by Japanese physicians during World War II. These contrasting issues show how culture shapes our view of ethically appropriate behavior in medicine. An understanding of cultural context reveals that certain practices, such as withholding diagnostic information from patients, may represent ethical behavior in that context. In contrast, nonconsensual human experimentation designed to harm the patient is inherently unethical irrespective of cultural context. Attempts to define moral consensus in bioethics, and to distinguish between acceptable and unacceptable variation across different cultural contexts, remain central challenges in articulating international, culturally sensitive norms in medical ethics.     

Movement nulling: for heterochromatic photometry and isolating channels for 'real' and 'apparent' motion

Null measurements given by cancelling forces, voltages, or whatever, are used in physics for gaining 'objectivity'--by avoiding 'subjective' perceptions; but, somewhat paradoxically, null methods can be useful for studying perception itself. Here we consider cancelling opposed movements for photometry with coloured lights, and some recent experiments, carried out with John Harris, on nulling 'real' against opposed 'apparent' motion for teasing out some neural movement channels.     

Prevention ethics: explicating the context of prevention activities

Research and intervention involving primary prevention [related to mental health and psychology] have grown dramatically in the past 10 years. However, little attention has been paid to ethical issues in primary prevention. This article proposes a framework for increasing awareness of such issues. The framework centers on explicating the contexts where prevention activities occur and the roles adopted by interventionists engaging in these activities. Several assumptions underlying primary prevention are stated, and ways of clarifying ethical issues are proposed.     

Hard-to-manage preschool boys: Family context and the stability of externalizing behavior

Preschool boys identified by their teachers as active, inattentive, and impulsive (N=42) were compared with matched classroom controls (N=43) and with parentidentified problem boys (N=27) on measures of family functioning often associated with children's problem behaviors, including family history of psychopalhology, stressful life events, and family composition. Teacher-identified and parent-identified problem boys did not differ on measures of family adversity, and both groups came from less well functioning families than comparison boys. Mothers of problem boys, regardless of referral source, were more negative and controlling toward their sons when observed in a compliance task. Children's problem behaviors were moderately stable over a oneyear follow-up period; initial symptom levels, maternal self-reported depression, and negative maternal control predicted follow-up ratings of externalizing problems.Thanks are expressed to Clea Angell, Clare Flanagan, Julie Hunt, Patricia Huszar, Andrea Lurier, Sarah McAuliffe, Jasmine Sardessai, and Teri Sobolik for help with data collection, coding, and analysis. We are grateful to the staff of the many preschools in the Pittsburgh area who facilitated our work. Special appreciation is expressed to the children and parents who participated in this study.Portions of these data were presented at the Rochester Symposium on Developmental Psychopathology, Rochester, New York, October 1988, and at the Society for Research in Child and Adolescent Psychopathology, Costa Mesa, California, February, 1990. This work was supported by grant R0I MH32735 from the National Institute of Mental Health to Dr. Campbell.     

Creating space for preferred identities: narrative practice conversations about gender and culture in the context of trauma

This paper describes a narrative approach to work with the effects of extreme trauma and forced migration. It describes an approach to work across cultures in cases in which the culturally informed dominant discourses have shaped the effects of the trauma on those that survived them. The paper sets out the stories of two women as exemplars of the complexities of such practice. Examples of the main forms of narrative practice conversations are given and the work is developed through considerations of ways in which therapists can work respectfully between cultures.     

Social context and historical emergence: The underlying dimension of medical ethics

I argue that work in medical ethics which attempts to humanize medicine without examining hidden assumptions (about medicine's ontology, explanations, goals, relationships) has the dehumanizing effect of legitimating practices which treat persons as abstractions. After illustrating the need to reexamine the field of medical ethics and the doctor-patient relationship in particular, I use Foucault's work to provide a social, historical framework for discussion. This background begins to demonstrate that doctor-patient relationships cannot be made satisfactory by new hospital policies or interpersonal skills, but have deep-rooted problems due to medicine's place in social history. Real progress requires social or structural change.     

The context as a moral rule in medical ethics

A purely deductive medical ethics cannot properly account for the varieties of circumstances which arise in medical practice. By contrast, a purely inductive medical ethics lacks sufficient guidance from ethical principles. In resolving ethical dilemmas in medicine, most often an appeal is made to middle-level axioms and methodological rules to mediate between theory and practice. I argue that this appeal must be augmented by considerations of context, such considerations, in effect, constituting a moral rule based on the social structure of medical practice. A contextual grid is proposed which assists the process of weighing values in resolving cases.     

Disability: an agenda for bioethics

Contemporary bioethics has been somewhat skewed by its focus on high-tech medicine and the resulting development of ethical frameworks based on an acute-care model of healthcare. Research and scholarship in bioethics have payed only cursory attention to ethical issues related to disability. I argue that bioethics should concern itself with the full range of theoretical and practical issues related to disability. This encounter with the disability community will enrich bioethics and, potentially, society as well. I suggest a number of items that the bioethics agenda should include, such as the development of a casuistry of the right to healthcare and to community integration and an advocacy role in fostering an understanding among the public and policy makers of the need to reform research and treatment related to disability.