Training in clinical ethics consultation: the Washington Hospital Center course

How can one be trained to enter the evolving field of clinical ethics consultation? The classroom is not the proper place to teach clinical ethics consultation; it is best done in a clinical setting. The author maps the elements that might be included in an apprenticeship, and sets out propositions for debate regarding the training needed for clinical ethics consultants and directors of clinical ethics consultation services. I was invited to be an observer of the first Intensive Course in Clinical Ethics at the Washington Hospital Center (WHC). I had no input into the planning. Having been present at a meeting of the Clinical Ethics Consultation Affinity Group of the American Society of Bioethics and Humanities (ASBH) when the issue of a lack of training programs was discussed, I was acutely aware of the need. Knowing how popular the various four-day intensive courses in bioethics have been, held at Georgetown University first, and then in Seattle and locations in the Midwest, it seemed time to have a four-day intensive course that was devoted to clinical ethics. The differences between bioethics and clinical ethics is substantial and largely unappreciated by those in bioethics. So when the WHC team agreed to take on the task of offering an intensive in clinical ethics, it was an important step for the field.     

Rethink "Affirmative Agreement," but Abandon "Assent"

Training in ethics and professionalism is a fundamental component of residency education, yet there is little empirical information to guide curricula. The objective of this study is to describe empirically derived ethics objectives for ethics and professionalism training for multiple specialties. Study design is a thematic analysis of documents, semi-structured interviews, and focus groups conducted in a setting of an academic medical center, Veterans Administration, and community hospital training more than 1000 residents. Participants were 84 informants in 13 specialties including residents, program directors, faculty, practicing physicians, and ethics committees. Thematic analysis identified commonalities across informants and specialties. Resident and nonresident informants identified consent, interprofessional relationships, family interactions, communication skills, and end-of-life care as essential components of training. Nonresidents also emphasized formal ethics instruction, resource allocation, and self-monitoring, whereas residents emphasized the learning environment and resident-attending interactions. Conclusions are that empirically derived learning needs for ethics and professionalism included many topics, such as informed consent and resource allocation, relevant for most specialties, providing opportunities for shared curricula and resources.     

History and theory in "applied ethics"

Robert Baker and Laurence McCullough argue that the "applied ethics model" is deficient and in need of a replacement model. However, they supply no clear meaning to "applied ethics" and miss most of what is important in the literature on methodology that treats this question. The Baker-McCullough account of medical and applied ethics is a straw man that has had no influence in these fields or in philosophical ethics. The authors are also on shaky historical grounds in dealing with two problems: (1) the historical source of the notion of "practical ethics" and (2) the historical source of and the assimilation of the term "autonomy" into applied philosophy and professional ethics. They mistakenly hold (1) that the expression "practical ethics" was first used in a publication by Thomas Percival and (2) that Kant is the primary historical source of the notion of autonomy as that notion is used in contemporary applied ethics.     

Ethics, theism and metaphysics: An analysis of the theocentric ethics of James Gustafson

Modern ethics has been shaped by two dominant philosophical assumptions: (1) that there can be no theoretical knowledge of God, i.e., denial of metaphysics, and (2) that moral claims can be redeemed independently of theistic affirmations, i.e., morality does not require theism. These assumptions have influenced much of modern theological ethics. Yet, insofar as theological ethics accepts that morality does not require any explicit or implicit religious beliefs, it affirms that a secularistic morality is possible. But this affirmation is directly at odds with the essence of theism, namely, that God is the source and end of all things, including the moral life. By accepting the dominant consensus, therefore, theological ethics undermines its fundamental theistic claim. Focusing on James Gustafson's theocentric ethics, I seek to show the price that theological ethics pays for subscribing to the dominant consensus. I argue that: (1) Gustafson embraces an inconsistent self-understanding, which undermines his theocentric claim, (2) this is due to his dismissal of metaphysics, and (3) his theocentric ethic would be more compelling if formulated in terms of Whitehead's process metaphysics.     

"伦理"与"道德"概念的三重比较义

“伦理”与“道德”是伦理学或道德哲学中的两个核心概念,但二者长期处于概念模糊和逻辑混乱状态,导致伦理学和道德教育“名不正而言不顺”。通过对这两个概念进行以词源学为基础的三重比较:汉语言文化中的比较、英语文化中的比较、中西文化中的比较,我们可以得出的结论是:当代“伦理”概念蕴含着西方文化的理性、科学、公共意志等属性,“道德”概念蕴含着更多的东方文化的情性、人文、个人修养等色彩。“西学东渐”以来,中西“伦理”与“道德”概念经过碰撞、竞争和融合的过程,目前二者划界与范畴日益清晰,即“伦理”是伦理学中的一级概念,而“道德”是“伦理”概念下的二级概念。二者不能相互替代,它们有着各自的概念范畴和使用区域。     

A Code of Ethics for Health Care Ethics Consultants: Journey to the Present and Implications for the Field

For decades a debate has played out in the literature about who bioethicists are, what they do, whether they can be considered professionals qua bioethicists, and, if so, what professional responsibilities they are called to uphold. Health care ethics consultants are bioethicists who work in health care settings. They have been seeking guidance documents that speak to their special relationships/duties toward those they serve. By approving a Code of Ethics and Professional Responsibilities for Health Care Ethics Consultants, the American Society for Bioethics and Humanities (ASBH) has moved the professionalization debate forward in a significant way. This first code of ethics focuses on individuals who provide health care ethics consultation (HCEC) in clinical settings. The evolution of the code's development, implications for the field of HCEC and bioethics, and considerations for future directions are presented here.     

The role of information about "convention," "design," and "goal" in representing artificial kinds

In this chapter, we have considered the nature and development of our capacities for the representation of artificial kinds. We have presented a range of evidence collected using varying methods and from our own laboratories and those of others that speaks to the question of the kinds of information that might be central to knowledge of artifacts and their functions in human semantic memory. One key argument here has been that despite the fact that information about shared convention has been argued to play an important role in understanding of the "proper" uses of artifacts, just as it does in the case of the use of linguistic symbols within language communities, there are important differences between the two cases, and indeed across development, decisions about categories and functions dissociate. We have argued here that the nonarbitrary relationship between the material kind and mechanical structure of artifacts and the functions that can be supported undercuts the force of information about convention as important to determining proper artifact function. Shared convention appears less important for determining this facet of our semantic memory for artifacts than it does in supporting the proper relationship between linguistic symbols and the categories of artifact to which they refer.     

Communitarians and medical ethicists: or "why I am none of the above"

Recent medical ethics has been shaped by liberal presuppositions, but in challenging those assumptions, Christians must be careful not to adopt communitarian assumptions instead, which tend to promote community as a good in itself. Rather, argues Stanley Hauerwas, Christians should attend to the virtues of their own tradition, regarding community as an instrumental good in fostering that tradition.     

ON "HUXLEYS EVOLUTION AND ETHICS IN SOCIOBIOLOGICAL PERSPECTIVE" BY GEORGE C. WILLIAMS

Abstract. I concur with Williams that improving human ethics requires full consideration of the biogenetic facts; but I argue that the understanding of biogenetic facts, and of ethics also, can be improved by a fuller view of nature's mechanism for selecting what is fit, a view recently generated by physical scientists. For me ethics necessarily must fit the evolved genotype, but ethics does not emerge until the rise of cultural evolution, where nature selects a culturetype symbiotic with the genotype. I outline my integrated dynamics of the relation of culturetypes to genotypes and to the laws governing physical systems. The biologist's finding that a living organism is of transient significance compared with its lines of heritage and their consequences, I argue, is constructively important for ethical and theological understanding.     

The hippocampus as a "stupid," domain-specific module: Implications for theories of recent and remote memory, and of imagination.

The hippocampus and surrounding regions of the medial temporal lobe play a central role in all neuropsychological theories of memory. It is still a matter of debate, however, how best to characterise the functions of these regions, the hippocampus in particular. In this article, I examine the proposal that the hippocampus is a "stupid" module whose specific domain is consciously apprehended information. A number of interesting consequences for the organisation of memory and the brain follow from this proposal and the assumptions it entails. These, in turn, have important implications for neuropsychological theories of recent and remote episodic, semantic, and spatial memory and for the functions that episodic memory may serve in perception, comprehension, planning, imagination, and problem solving. I consider these implications by selectively reviewing the literature and primarily drawing on research my collaborators and I have conducted.     

Reflections of a reluctant clinical ethicist: Ethics consultation and the collapse of critical distance

The obvious appeal and growing momentum of clinical ethics in academic medical centers should not blind us to a potential danger: the collapse of critical distance. The very integration into the clinical milieu and the processes of clinical decision making, that clinical ethics claims as its greatest success, carries the seeds of a dilution of ethics' critical stance toward medicine and medical education. The purpose of this paper is to suggest how this might occur, and what potential contributions of ethics to medicine might be sacrificed as a result. Medical sociology will be used for comparison. Sociologists have found that they may function either as students and critics of established medical practices and educational philosophies, or as collaborative participants in them — but rarely both. It may be that professional ethics is most effective when it plays the role of stranger rather than insider, and is continually able to question the most basic assumptions and values of the enterprise with which it is associated. As with medical sociology, ethics and humanities must ask to what extent their desire for acceptance in the clinic requires their acceptance of the clinic: specifically, acceptance of basic assumptions about optimal ways of organizing medical education, socializing physicians-in-training, providing care, and even of defining medical ethics itself. The paper concludes by recommending that ethics reassert its strangeness in the medical milieu even as it assumes a more prominent role within the medical center.     

The Cultural Context of the American Counseling Association Code of Ethics

The American Counseling Association code of ethics was constructed in a particular cultural context and reflects the assumptions of that context. Beginning with a discussion of the purposes served by ethical codes, I review 3 patterns of implicit assumptions: (a) examples of implicit cultural bias, (b) examples of cultural encapsulation, and (c) examples favoring the dominant culture. Positive recommendations for developing more inclusionary ethical guidelines are discussed on the basis of case examples and the consequences of good or bad ethical practice. The need to make underlying philosophical and cultural assumptions explicit in the Preamble to the code of ethics is clarified.     

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.     

The hippocampus and memory for "what," "where," and "when"

Previous studies have indicated that nonhuman animals might have a capacity for episodic-like recall reflected in memory for "what" events that happened "where" and "when". These studies did not identify the brain structures that are critical to this capacity. Here we trained rats to remember single training episodes, each composed of a series of odors presented in different places on an open field. Additional assessments examined the individual contributions of odor and spatial cues to judgments about the order of events. The results indicated that normal rats used a combination of spatial ("where") and olfactory ("what") cues to distinguish "when" events occurred. Rats with lesions of the hippocampus failed in using combinations of spatial and olfactory cues, even as evidence from probe tests and initial sampling behavior indicated spared capacities for perception of spatial and odor cues, as well as some form of memory for those individual cues. These findings indicate that rats integrate "what," "where," and "when" information in memory for single experiences, and that the hippocampus is critical to this capacity.     

Women's neuroethics? Why sex matters for neuroethics

The Neuroethics Affinity Group of the American Society for Bioethics and Humanities (ASBH) met for the third time in October 2007 to review progress in the field of neuroethics and consider high-impact priorities for the future. Closely aligned with ASBH's own goals of recruiting junior scholars to bioethics and mentoring them to successful careers, the Neuroethics Affinity Group placed a call for new ideas to be presented at the Group meeting, specifically by junior attendees. One group responded with the idea to probe a new direction for neuroethics focused on the neuroscience of gender differences. In the spirit of full disclosure, two of the authors are a student (Chalfin) and fellow (Murphy) of the program I formerly directed at Stanford University. The third (Karkazis) is junior faculty there. The intellectual ownership of the ideas in the report below, however, are entirely theirs. Like lit torches in a juggling act, there are many directions this project can go. The report is a snapshot of these authors' first iteration of the concept of women's neuroethics. Many thanks are extended to participants of the ASBH Neuroethics Affinity Group meeting whose enthusiasm and feedback was immensely helpful in shaping the concept and moving it ahead.     

THE PHILOSOPHY OF JOSEPH MARGOLIS

Abstract: In this article I focus on some of Joseph Margolis's contributions to medical ethics. I first discuss some of Margolis's normative and metaphysical views on death and abortion, particularly in his early work Negativities , as well as some of his metaphysical assumptions. Then these views and assumptions are related to his theory of persons and, by implication, his theory of culture, set forth in a number of later works. In the course of the discussion, I call attention to some controversial issues of today, such as embryonic stem cell research and the creation of embryos for the sole purpose of research, and ask for Margolis's views on them, given his earlier contributions and assumptions. Finally, I comment on his relativism and his program for research in aesthetics and ethics.     

Making Pacifism Plausible

The ethics of war is a minefield. It is a morass of conceptual unclarity, contentious assumptions, impassioned arguments, unexploded myths, and the injured defenders of indistinct positions. My aim is to help to make the minefield (conceptually) safe, and to assist that most vulnerable party to the dispute, the pacifist. In this paper I explore the possibility that, farfrom being naïve or outlandish, pacifism might follow from a widely-held and fundamental intuition about the moral status of persons [hereafter MSP]. In Section 1 I describe MSP, and suggest how we might draw implications from it about the ethics of war. In Section 2, I argue that a ‘presumption of war-ism’ has distorted debate in the ethics of war: to arrive at a balanced view, we need distinguish two sets of moral questions. First, can the development and maintenance of the means to make war be justified? Second, can the use of those means ever be justified? I sketch some strategies which might be developed in addressing the first question, concentrating on what MSP suggests might be wrong with setting up a war-machine, and with being or employing a soldier. In Section 3 I argue that even if considerations from Section 2 are insufficient to establish that we must dismantle our war-machines, facts about war which conflict with MSP do establish that we must never use them.     

The Dharma of Ethics, the Ethics of Dharma: Quizzing the Ideals of Hinduism

This paper is divided into six parts. The first presents a rudimentary definition of ethics based on Western philosophical theories, particularly their concern for articulating universal moral principles. The second examines the assumptions anchoring Western moral philosophies, and raises the question: are the philosophical presuppositions of modern Western philosophy consistent with the presuppositions of Hinduism? It concludes that the two are not entirely in agreement, particularly on the issue of personal and social identity. The third section locates areas in Hinduism that discursively concur with the concerns of Western ethicists, and explores the limits of the semblance. The fourth identifies problematic areas, and raises the question: should the idea of universal ethics be abandoned for Hinduism? The fifth section concludes that such abandonment would be hasty, and initiates a searching look into the Hindu epics for concepts that, while not identical with may still be parallel to some Western notions of ethics. The sixth looks at the content of normative Hindu morality, and generalizes on the basis of this content about the nature of “Hindu ethics”.