Cambridge Quarterly of Healthcare Ethics最新文献

Pragmatism gained considerable attention in bioethical discussions in the early 21st century. However, some dimensions and contributions of pragmatism to bioethics remain underexplored in both research and practice. It is argued that pragmatism can make a distinctive contribution to bioethics through its concept, developed by Charles S. Peirce and John Dewey, that ethical issues can be resolved through experimental inquiry. Dewey's proposal that policies can be confirmed or disconfirmed through experimentation is developed by comparing it to the confirmation of scientific hypotheses, with a focus on the objection that the consequences of following a moral view or policy do not provide guidance on choosing among competing ethical perspectives. As confirmation of scientific hypotheses typically relies on evidence gathered from observation, the possibility of ethically relevant observation is then explored based on Peirce's views on feelings as emotional interpretants. Finally, the connection between Dewey's experimental ethics and democracy is outlined and compared to unfettered ethical progressivism.

The model for capacity assessment in the United States and much of the Western world relies upon the demonstration of four skills including the ability to communicate a clear, consistent choice. Yet such assessments often occur at only one moment in time, which may result in the patient expressing a choice to the evaluator that is highly inconsistent with the patient's underlying values and goals, especially if a short-term factor (such as frustration with the hospital staff) distorts the patient's preferences momentarily. These challenges are particularly concerning in cases, which arise frequently in hospital settings, in which patients demand immediate self-discharge, often during off-hours, while faced with life-threatening risks. This paper examines the distinctive elements that shape such cases and explores their ethical implications, ultimately offering a model for such situations that can be operationalized.

It took nearly two thousand years for society to recognize the Hippocratic insistence that "the doctor knows best"¹ was an inadequate approach to medical decisionmaking. Today, patient-centered medicine has come to understand that the individual patient has a significant role in the decisionmaking process.².

Based on Nathan Goldstein's case report, "But I have a pacer…there is no point in engaging in hypothetical scenarios": A Non-imminently Dying Patient's Request for Pacemaker Deactivation, it is reasonable to conclude that it was, all-things-considered, ethically appropriate to grant the patient's request to deactivate her pacemaker. Philosophically, and as a clinical bioethicist, I support the team's decision to honor the patient's request for pacemaker deactivation. However, it is worth exploring a bit further whether the distress on the part of the outside hospital's ethics committee and providers-who declined to honor the patient's request for pacemaker deactivation-may actually track something of moral significance. Might their discomfort around deactivation be "truth-tracking" in moral terms?

This article raises the question of whether bioethics qualifies as a discipline. According to a standard definition of discipline as "a field of study following specific and well-established methodological rules" bioethics is not a specific discipline as there are no explicit "well-established methodological rules." The article investigates whether the methodological rules can be implicit, and whether bioethics can follow specific methodological rules within subdisciplines or for specific tasks. As this does not appear to be the case, the article examines whether bioethics' adherence to specific quality criteria (instead of methodological rules) or pursuing of a common goal can make it qualify as a discipline. Unfortunately, the result is negative. Then, the article scrutinizes whether referring to bioethics institutions and professional qualifications can ascertain bioethics as a discipline. However, this makes the definition of bioethics circular. The article ends by admitting that bioethics can qualify as a discipline according to broader definitions of discipline, for example, as an "area of knowledge, research and education." However, this would reduce bioethics' potential for demarcation and identity-building. Thus, to consolidate the discipline of bioethics and increase its impact, we should explicate and elaborate on its methodology.

Physicians place significant weight on the distinction between acts and omissions. Most believe that autonomous refusals for procedures, such as blood transfusions and resuscitation, ought to be respected, but they feel no similar obligation to accede to requests for treatment that will, in the physician's opinion, harm the patient (e.g., assisted death). Thus, there is an asymmetry. In this paper, we challenge the strength of this distinction by arguing that the ordering of values should be the same in both cases. The reason for respecting refusals is that, in such cases, autonomy outweighs well-being. We argue that the same should be true in request cases, which means that requests should not be denied only due to the treatment being too harmful in the physician's opinion. Our strategy is to consider and reject a number of arguments for the asymmetrical view, including an appeal to the doing-allowing distinction and positive and negative rights. The duty to respect refusals is still greater than the duty to grant requests on our view, but, by arguing that the ordering of values is the same in both cases, we show that there is less of a distinction in healthcare between requests and refusals than many currently believe.

Bioethicists aim to provide moral guidance in policy, research, and clinical contexts using methods of moral analysis (e.g., principlism, casuistry, and narrative ethics) that aim to satisfy the constraints of public reason. Among other objections, some critics have argued that public reason lacks the moral content needed to resolve bioethical controversies because discursive reason simply cannot justify any substantive moral claims in a pluralistic society. In this paper, the authors defend public reason from this criticism by showing that it contains sufficient content to address one of the perennial controversies in bioethics-the permissibility and limits of clinician conscientious objection. They develop a "reasonability view" grounded in public reason and apply it to some recent examples of conscientious objection.

Can Rawlsian public reason sufficiently justify public policies that regulate or restrain controversial medical and technological interventions in bioethics (and the broader social world), such as abortion, physician aid-in-dying, CRISPER-cas9 gene editing of embryos, surrogate mothers, pre-implantation genetic diagnosis of eight-cell embryos, and so on? The first part of this essay briefly explicates the central concepts that define Rawlsian political liberalism. The latter half of this essay then demonstrates how a commitment to Rawlsian public reason can ameliorate (not completely resolve) many of the policy disagreements related to bioethically controversial medical interventions today. The goal of public reason is to reduce the size of the disagreement by eliminating features of the disagreement that violate the norms of public reason. The norms of public reason are those norms that are politically necessary to preserve the liberal, pluralistic, democratic character of this society. What remains is reasonable disagreement to be addressed through normal democratic deliberative processes. Specific issues addressed from a public reason perspective include personal responsibility for excessive health costs, the utility of a metaphysical definition of death for organ transplantation, and the moral status of excess embryos generated through IVF and/or their use in medical research.