Medical Ethics

How work gets done in complex health care systems is ethically important. When health care professionals and other staff experience moral uncertainty or distress in their own work and improvise remedies to manage these problems, this has potential consequences for patients, families, colleagues, and the system itself. This book argues that health care ethics in complex and changing health care systems should reflect the moral complexity of health care work, analyze common ethical challenges with reference to behaviors and pressures driven by the system itself, and support opportunities for health care workers at all levels to reflect on the problems they face and to take part in social change. The book’s chapters include frameworks for looking at ethical challenges in health care as problems of safety and harm with consequences for patients. The book is designed to support clinician education in medicine, nursing, and interdisciplinary contexts and to be accessible to readers without formal training in health care ethics. It includes extensive practical suggestions, including a full chapter on recommended practices, and is supported by an index.Less

This book brings together some of the leading scholars in the fields of public health ethics and bioethics to discuss disaster or emergency ethics and ethical aspects of preparedness and response with specific application to public health policy and practice. The book fills a gap in the existing public health ethics literature by providing a comprehensive ethical conception of emergency preparedness as a distinctive form of civic “practice” brought about by the interrelationships and coordination of many groups, disciplines, and interests and drawing on numerous bodies of knowledge and expertise. It addresses particular aspects of preparedness and response plans and particular decisions that planners and communities have to make, decisions that require balancing many diverse and sometimes conflicting values while identifying and applying a framework of basic ethical principles for preparedness planning, emergency response, and post-disaster recovery. It also explores the relationship between emergency preparedness and other facets of public health practice. The book begins with a broad and synthetic overview of emergency ethics that addresses the central components and ethically significant issues arising in public health preparedness planning, disaster response, and recovery. Following that overview are five chapters that delve deeply into important and problematic issues and discuss these in a philosophically innovative and detailed way. These issues include the allocation of scarce resources, the conduct of ethical research in the context of public health emergencies, the obligations of public health professionals, communication and engagement with the public, and special moral obligations surrounding vulnerable populations.Less

Psychiatry and religious/spiritual share an interest in human flourishing, a concern with beliefs and values, and an appreciation for community. Yet historical tensions between science and religion have often reinforced disciplinary boundaries and obstructed dialogue, leaving clinicians uncertain about how to approach ethical dilemmas arising between them. Common questions concern conflicting values, the ways that religion/spirituality informs the value commitments of patients and their clinicians, and what principles should guide the interaction between clinicians’ own professional and personal commitments.This volume aims to help readers think more clearly about these issues as they present to psychiatrists and other mental health professionals, religious professionals working in mental health settings, bioethicists and trainees in these disciplines. Rather than philosophical arguments or practice guidelines, chapter authors offer a conceptual framework for understanding the role of religion/spirituality in ethical decision-making, as well as pragmatic guidance for approaching challenging cases. Authors in Part One explore several dimensions of the ethical challenges presented by religious/spiritual related to diagnosis, integrated treatment, harmful religion, and the work of ethics committees and religious professionals. Those in Part Two consider ways of approaching these issues as they arise in different clinical contexts, such as forensic, consultation-liaison, geriatric, child, international and community psychiatry, as well as in psychiatric research and teaching.Less

This volume brings together original essays exploring the intersections of clinical practice, policy, and bioethics in women’s healthcare. Including but moving beyond the familiar theme of reproduction, it aims to both broaden areas of scholarship in feminist bioethics and to respond to ethical challenges that many women experience in accessing healthcare. Some of the contributions overlap with concerns that feminist scholars have voiced in the past, such as the medicalization of women’s bodies, but address new procedures (e.g., female cosmetic genital surgery). Other chapters expand into new fields that are underexplored in the bioethics literature, such as ethical issues concerning the care of Indigenous women, uninsured refugees and immigrants, women engaged in sex work, and those with HIV and perinatal mental health disorders. The richness of the collection lies in the multitude of disciplines represented. Contributors range from those who are in active clinical practice—medicine, nursing, and ethics—to philosophers contemplating new conceptual issues. Topical and contemporary, this book provides a valuable resource for physicians, nurses, clinical ethicists, and researchers working in the areas of women’s health and applied ethics.Less

No specialty faces more diverse and challenging ethical dilemmas than palliative medicine. What is the best way to plan ahead for the end of life? How should physicians respond when patients refuse treatments likely to be beneficial or demand treatments not likely to be? Who makes medical decisions for patients who are too ill to decide for themselves? Do patients have the “right to die” (and, if so, what exactly does that mean)? Other ethics texts have explored these issues but often from an academic perspective that overlooks the practical realities of clinical medicine. Conversely, medical textbooks frequently lack sufficient philosophical depth to fully explore the complexities of these issues. This complete guide to the ethics of palliative care combines clinical experience with philosophical rigor to provide a comprehensive analysis of this fascinating field. Using relevant case studies, core subjects such as intensive symptom management at the end of life, physician-assisted dying, and palliative sedation are examined from historical, legal, clinical, and ethical perspectives. Whereas pediatric issues are often an afterthought in palliative care textbooks, this guide explores the unique nature of ethical dilemmas in the prenatal, neonatal, and adolescent age groups. Other important topics such as neuro-palliative care, organ donation, research, and moral distress are also covered in detail. Written with clinical nuance for medical professionals—and clear language as well as a glossary for lay readers—this guide offers all readers an opportunity to explore and understand the fascinating ethical issues facing patients suffering from life-threatening illness.Less

Raising a child with multiple special needs or disabilities is a time-consuming and difficult task that exceeds the usual parameters of parenting. This book examines all the facets of that task, from the better-known physical, financial, and emotional burdens to the previously invisible moral work involved. Drawing from narratives written by parents of children with a variety of special needs, academic research in ethics and disability, and personal experience in pediatrics, this book begins to recognize the moral consequences of providing long-term care for a child with complex needs. Using a virtue ethic framework based on Joan Tronto’s phases of care, it isolates the various tasks involved and evaluates the moral demands placed on the parent performing them. Raising a child with special needs requires an excess of attentiveness, responsibility, competence, and responsiveness, and demands from the parent a reassessment of their personal and social lives. In each phase, moral work must be done to become the sort of person who can perform the necessary caregiving. Some of the consequences are predictable, such as the emotional and physical burden of constant attentiveness and numerous unexpected responsibilities. But the need for competence, which drives an acquisition of medical knowledge, has not previously been analyzed. Nor has there been recognition of the enormous moral task of encouraging identity formation in a child with intellectual delays or autism. For a child who cannot attain independence, parents must continue to provide care and support into an uncertain future.Less

Hippocrates’ Oath and Asclepius’ Snake: The Birth of the Medical Profession articulates the Oath as establishing the medical profession—a practice incorporating an internal, uniquely medical ethic that particularly prohibits doctors from killing. In its most basic and least controvertible form, this ethic mandates that physicians try to help while not trying to harm the sick. Relying on Greek myth, drama, and medical experience (e.g., homeopathy), the book shows how this medical code arises from reflection on the most vexing medical-ethical problem: iatrogenic harm, injury caused by a physician. The book argues that deliberate iatrogenic harm—especially the harm of a doctor choosing to kill (physician-assisted suicide, euthanasia, abortion, and involvement in capital punishment)—amounts to an abandonment of medicine as an exclusively therapeutic profession. Since electively killing a patient always injures (even when done at the patient’s request), the Oath excludes killing (along with other salient harms such as sexual exploitation and the violation of patient confidentiality) from medicine as a profession. The work argues that medicine as a profession necessarily involves stating before others what one stands for: the goods one seeks and the bads one seeks to avoid on behalf of the sick. The book considers and rejects the view that medicine is purely a technique lacking its own unique internal ethic. It concludes by noting that medical promising (as found in the White Coat Ceremony by which US medical students matriculate) implicates medical autonomy, which merits respect, including the honoring of professional conscientious objection.Less

Spiritual sickness troubles American medicine. Through a death-denying culture, medicine has gained enormous power—an influence it maintains by distancing itself from religion and spirituality, which too often remind us of our mortality. As a result of this separation of medicine from spiritual traditions, patients facing serious illness infrequently receive adequate spiritual care despite the large body of empirical data demonstrating its import to patient meaning-making, quality of life, and medical utilization. This secular–sacred divide also unleashes depersonalizing social forces through the market, technology, and legal-bureaucratic powers that reduce clinicians to tiny cogs in an unstoppable machine. Hostility to Hospitality is one of the first books of its kind to explore these hostilities threatening medicine and offer a path forward for the partnership of modern medicine and spirituality. Drawing from interdisciplinary scholarship including empirical studies, interviews, history and sociology, theology, and public policy, the authors argue for structural pluralism as the missing piece to changing hostility to hospitality.Less

Illness narratives, patients’ stories about their experiences of illness, have gained a reputation as a scientific domain in medicine in the last thirty years. Patients’ stories about living with an illness, diagnostic procedures and treatments, encounters with medical institutions and its impact on their private and social life have been considered as an important access to their meaning-making and coping endeavours. They also play an important role in doctor-patient communication and the development of a healing relationship. This book aims at sensitizing professionals who use illness narratives in the field of medicine for their problems, challenges, and chances. In what ways should scholars of narratives respond to such uses? We argue that the use of narratives in applied contexts raises many questions about what kind of tools they are and what epistemological foundations, communicational properties and pragmatic effects they comprise when they are shifted from research material to clinical or educational and instructive instruments in various domains. This raises ethical concern and reflections. The book brings together scholars from various disciplines across clinical and theoretical fields. They give impressive examples how illness narratives can be used in many practical domains, and reflect on the chances as well as on the methodological or epistemological assumptions and challenges which are inevitably connected with the use of narratives as clinical, educational, or informative tools.Less

Rated as one of the top 15 breakthroughs in medicine over the last 150 years, evidence-based medicine (EBM) has become highly influential in medicine, and promotes the seemingly irrefutable principle that decision-making in medical practice should be based, as much as possible, on the most up-to-date research findings. EBM has been particularly popular within psychiatry, a field that is haunted by a legacy of controversial interventions. For advocates, anchoring psychiatric practice in research data makes psychiatry more scientific valid and ethically legitimate. Few, however, have questioned whether EBM, a concept pioneered by those working in other areas of medicine, can be applied to psychiatric disorders. This resource analyzes the basic assumptions of EBM, and critically examines their applicability to psychiatry. By highlighting the basic ethical tensions between psychiatry and EBM, the author addresses the fundamental and controversial question of whether psychiatrists should practice evidence-based medicine at all.Less

Patient expectations for immediate, risk-free healthcare have never been greater; the scrutiny that the medical profession face to deliver this perfect care has also never been greater; the complexity of the law under which we work and practise is ever-increasing, yet clinicians are meant to have an up-to-date understanding of all these matters. Many legal texts are written in ‘legalese’ language, which may be off-putting or confusing to the medical professional, especially in times of urgency and stress. This book has been written in an attempt to overcome these concerns while specifically aimed at the non-legally trained healthcare practitioner. It offers pragmatic easy-to-access information and guidance for the busy clinician needing to check the legal landscape before, during, or after treatments and consultations. This book is designed to be your number one reference for all medicolegal matters that demand an immediate answer. Each chapter details pertinent case law, statutes and legislation, and professional guidance, before considering specific aspects of medicolegal importance. Sections of text are complimented with a ‘key points’ summary box to act as a reminder or revision aid. Further reading is suggested at the end of each chapter, including links to websites that can provide up-to-date advice as the law changes and evolves. An alphabetical glossary of legal terms at the end of the book offers a rapid and easy reference that supports every chapter.Less

Charles Fried’s 1974 treatise is a classic statement of the moral relationship between doctor and patient as expressed in the concept of personal care. This concept is then tested in the context of medical experimentation and specifically the randomized clinical trial (RCT). Regularly referred to as a point of departure for ethical and legal discussions of the RCT, it has long been out of print. This second edition is introduced by former National Institutes of Health ethicists Frank Miller and the late Alan Wertheimer, followed by a reprint of the 1974 text, a lengthy essay by Harvard Law School scholars Glenn Cohen and James Greiner discussing the extension of RCTs to social science and public policy contexts, and a concluding essay by Charles Fried reflecting on the original text and its application to the changed circumstances in the intervening years of the practice of medicine and of medical experimentation.Less

Suffering is an unavoidable reality in healthcare. Not only are patients and families suffering but also the clinicians who care for them. Commonly the suffering experienced by clinicians is moral in nature, in part a reflection of the increasing complexity of health care, their roles within it, and the expanding range of available interventions that challenge their moral foundations. Moral suffering is the anguish that arises occurs in response to moral adversity that challenges clinicians’ integrity: the inner harmony that arises when their essential values and commitments are aligned with their choices and actions. The sources and sequelae of moral distress, one type of moral suffering, have been documented among clinicians across specialties. Transforming their suffering will require solutions that expanded individual and system strategies. Moral resilience, the capacity of an individual to restore or sustain integrity in response to moral adversity, offers a path forward. It encompasses capacities aimed at developing self- regulation and self-awareness, buoyancy, moral efficacy, self-stewardship and ultimately personal and relational integrity. Whether it involves gradual or profound radical change clinicians have the potential to transform themselves and their clinical practice in ways that more authentically reflect their character, intentions and values. The burden of healing our healthcare system is not the sole responsibility of individuals. Clinicians and healthcare organizations must work together to transform moral suffering by cultivating the individual capacities for moral resilience and designing a new architecture to support ethical practice. Used worldwide for scalable and sustainable change, the Conscious Full Spectrum approach, offers a method to solve problems to support integrity, shift patterns that undermine moral resilience and ethical practice, and leverage the inner potential of clinicians and leaders to produce meaningful and sustainable results that benefit all.Less

Written by international experts, this resource lays out the moral, legal and ethical restraints to using donors after cardiac death for organ transplant, together with the techniques that have been adopted to improve their outcome. The different approaches and results of renal transplant according to country are covered along with the procedures and outcomes adopted to use other organs, notably the liver and lungs.Less

In the 21st century, the primary challenge for health care is chronic illness. To meet this challenge, we need to think anew about the role of the patient in health and health care. There have been widespread calls for patient-centered care, but this model of care does not question deeply enough the goals of health care, the nature of the clinical problem, and the definition of health itself. We must instead pursue patient-centered health, which is a health perceived and produced by patients. We should not only respect, but promote patient autonomy as an essential component of this health. Objective health measures cannot capture the burden of chronic illness, so we need to draw on the patient's perspective to help define the clinical problem. We require a new definition of health as the capacity for meaningful action. It is recognized that patients play a central role in chronic illness care, but the concept of health behavior retards innovation. We seek not just an activated patient, but an autonomous patient who sets and pursues her own vital goals. To fully enlist patients, we must bridge the gap between impersonal disease processes and personal processes. This requires understanding how the roots of patient autonomy lie in the biological autonomy that allows organisms to carve their biological niche. It is time for us to recognize the patient as the primary customer for health care and the primary producer of health. Patient agency is both the primary means and primary end of health care.Less

The aim of this collection is to develop new theoretical and practical approaches to address the responsibilities created by new forms of healthcare practice. In particular, the authors examine the significance of people’s key relationships, such as family and community, and how they deliberate and make decisions about their responsibilities. Each chapter of the collection works through a set of questions that provide a framework for understanding the problematic behind the book and the broader debates it is part of: why families matter, what counts as family, how families track responsibilities, how treatment decisions ought to work in families, and what justice requires of families.Less