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Topic: Philosophy
November 13, 2014 | Posted By Michael Brannigan, PhD

Reminders of our finitude always lurk close by, like Ezekiel Emanuel's article in last month's Atlantic, "Why I Hope to Die at 75." The head of the Clinical Bioethics Department at the National Institutes of Health gives reasons for not living beyond 75: inevitable decline, disability, incapacity, and diminishment of "creativity, originality, and productivity." According to Emanuel, we wish to be remembered for our good years, prior to decline.

There are grains of truth here. Many of us "die" well before we are officially declared dead. I've seen patients kept alive for far too long in permanent vegetative states, while family dynamics, emotions, finances and scarce medical resources are depleted. We pay a high price for medical "progress." I also know thriving, vibrant elderly, themselves significantly disabled and incapacitated.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

October 13, 2014 | Posted By Wayne Shelton, PhD

As I have been saying in recent blogs, most of what we do in clinical ethics, but also in most areas of bioethics, is procedural ethics. That is when we are faced with an ethical dilemma, our approach, whether consciously or unconsciously is usually to try to reach a reasonable compromise or consensus among the key participants that are in conflict consistent with well-established values and principles. This tendency reflects an obvious reality about the nature of contemporary ethics that we often ignore: in the current Western moral setting, our only viable methodology for resolving value laden disputes, whether at the micro level in clinical ethics or macro level in healthcare policy, is to attempt to craft an agreement or consensus among those with a say. Whether we are dealing with patients and families at odds with their physician on how to define the goals of care in the hospital setting or trying to build a consensus of opinion among voters in the political arena, we assume there are no final, authoritative moral answers that avail themselves to us. Whether we like it or not, we humans must figure out ethical dilemmas for ourselves and learn to get along.

Yet the idea of procedural ethics remains very worrisome for many people, including such bioethicists and Tristram Engelhardt, Jr. He believes that procedural ethics, such much of what we do in clinical ethics, is not really ethics in because it is based on convention and legalistic type standards. For him ethics worthy of the name must flow from a content-rich, canonical moral tradition that provides moral authority to our everyday ethical and moral judgments. The prototype ethical tradition was the medieval Christian Natural Law perspective grounded in Aristotelian philosophy. Aristotle assumed the inherent order and intelligibility of the cosmos, which also permeated his understanding of ethics. Humans, like all natural things, had a natural function, which was to be rational. But rational did not mean to that ethics was about finding intellectual or theoretical basis for right action according to rational rules in order to know and perform one’s duty—this was Kant’s (1724-1804) ethics during the 18th century following the rise of modern science. For Aristotle, the question was, how can one live and embody the good life; so rationality in this sense meant internal harmony between emotions and decision-making that resulted in well-established habits or states of character. This means finding in all of one’s activities the balance between excess and deficiency, or what he called the “mean”. Over time, forming the right habits according to the mean in all areas of life lead to excellence and happiness or what he called the good life. This was the natural fulfillment of the human function in practical terms consistent with the ancient Aristotelian.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website

September 16, 2014 | Posted By Wayne Shelton, PhD

Ok, I realize I am being somewhat provocative. But there is a real and very serious issue, which I am groping to address in a more precise manner.

In my last blog I described the contemporary moral setting from a philosophical perspective as one in which no single substantive normative moral perspective can resolve moral questions, such as the boundaries of human life and the scope of individual rights, with final moral authority. This is just to say, more simply and obviously when we reflect upon it, that in democratic, secular America, ethics, both philosophically and practically, becomes inextricably linked to public discourse in politics and public policy.

When bioethicists ask questions and make arguments about abortion, physician assisted suicide, stem cell research and cloning, and many other similar issues that pertain to questions about the value of human life in relation to both individual rights and societal goals, we have no privileged moral authority from which to draw. As bioethicists we engage in procedural, persuasive discourse, based on conventional moral principles that most often conflict, which is why there is moral dilemma or problem requiring analysis and prioritization. Our purpose in defending a particular moral position is to win assent from others. In short, for a bioethicist to promote a moral position, it is implicitly an attempt to build a consensus among readers and listeners that will hopefully impact public opinion about a particular moral problem or question. Moreover, to the extent these questions have public policy ramifications, and practically all do, it means that moral discourse is also oriented to effect change and function as a medium in which bioethicists often speak as advocates about how moral options should be framed as public policy positions in a democratic society. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website. 

September 4, 2014 | Posted By Luke Gelinas, PhD

There has been a good bit of debate lately in bioethics circles over the concept and proper definition of death.   The disagreement is between those who think that the cessation of brain activity or ‘brain-death’ is sufficient for death, on the one hand, and those who think that brain-dead patients whose circulatory systems continue to function are still alive, on the other.  Consider, for example, the recent tragic case of Jahi McMath.  McMath suffered complications from a surgery to correct sleep apnea which resulted in cardiac arrest and her being placed on a ventilator.  Shortly after physicians at Oakland Children’s Hospital pronounced her brain-dead and so legally dead.  Her family, however, disagreed, and appealed to the courts for Jahi to be maintained via mechanical ventilation and PEG tube.

Although Jahi’s family disagrees with the claim that she is brain-dead (insisting that she is merely ‘brain-damaged’), suppose the Oakland physicians are correct in their diagnosis of brain death.  Nonetheless, even after the pronouncement of brain-death Jahi’s body continued to exhibit the sort of homeodynamic equilibrium—at least for the time being, and with assistance from mechanical ventilation and other life-sustaining interventions—characteristic of living organisms.  It was warm to the touch; her heart continued to pump blood through her veins; and so on.  Indeed the bodies of brain dead patients have in some cases remained functional for weeks and even months, performing such surprising feats as undergoing puberty and even gestating fetuses. This has led certain physicians and philosophers to question whether brain death is really sufficient for death.  Patients who are truly dead, after all, could not be warm to the touch or gestate fetuses.  Could they?  

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website. 

August 11, 2014 | Posted By Wayne Shelton, PhD

In my last blog I asked the question, “What is ethics doing?” where I contrasted the armchair, academic ethics that I knew as a graduate student with the clinical ethics cases in which I am now involved in clinical ethics consultations. I alluded to the famous paper by Stephen Toulmin (1922-2009), “How medicine saved the life of ethics” by providing ethics with many practical value laden problems to address. The very process of becoming involved with applied ethics and ethical problems of practicing physicians in the healthcare system was itself as, or perhaps more, transformational for ethics than it was for medicine. Even though medicine needed a serious study of its value-laden issues, which has evolved into bioethics and clinical ethics, the very activity of doing applied ethics has evolved into a better defined field of inquiry with a clearer purpose. But what about the armchair, academic pursuits of philosophical ethics of old? Is there anything left for it to do? This is the question I will attempt to answer in this blog.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website. 

July 22, 2014 | Posted By Wayne Shelton, PhD

I recall being a PhD candidate in philosophy in the 1970’s, I often pondered the subject matter of my graduate courses in ethics. I would ask myself, what does any of this have to do with ethics? What are we doing?

As our courses went from Kant to Mill to G.E. Moore to the Emotivists and others, I couldn’t help but have a sense of unreality about the content of what I was learning.

How can we use reason to find a basis for knowing right action? What are the ways we can define right action based on a normative moral theory?

What is the meaning of good? Right? And obligation? Can these terms be defined within a theoretical, substantive moral framework or are they just expressions of feelings and emotions without any cognitive content? If they are more than the latter, what do they mean?

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

April 11, 2014 | Posted By Wayne Shelton, PhD

In my last blog I alluded to the effect of an assumed point of view, particularly a set of ideological set of assumptions around which a community is organized, has on the way we interpret data about how we perceive risks and benefits and make decisions about a range of issues.  I was applying this perspective to public health perspectives such as the risks of gun ownership and forgoing vaccinations. In this blog, I will sketch out a theoretical approach for how humans process and understand information a bit more and conclude with some questions for my next blog about how to understand the obligations of those who are in the best positions to understand public health data, such as the better educated and healthcare workers.

We often assume that most people are capable of coming to objective and fair beliefs and reasonable decisions about various empirical topics, e.g. the effects of climate change, if only we have access to valid, scientific information.  Thus, we often further assume that the goal of having more enlightened people to make more enlightened decisions about public health issues, or for that matter political issues and most other issues of public interest, is simply a matter of bringing to bear more complete and clear knowledge for people to understand. This is the assumption that Dan Kahan (a law and psychology professor from Yale Law School) and his research team calls the “More Information Hypothesis”. However recent research shows that this hypothesis is simply not true—in fact the more information people on opposite sides of an issue get, the more divided and intractable the conflict becomes. The simple fact of making more information accessible clearly does not resolve most public issues that are connected to well-established ideological and philosophical perspectives.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

March 3, 2014 | Posted By Marleen Eijkholt, PhD

If someone asked me: What is my philosophy of clinical ethics? I would initially be dumbstruck for an answer. In response, I would probably try to define an answer from my background in bioethics and philosophy. I would pick frameworks in philosophy that represent my approach. For example, I would be inclined to refer to pragmatism and casuistry, as frameworks that determine my clinical ethics approach. My last blogpost about Marlise Munoz, the brain dead woman in Texas is a good example of this. My philosophy as a clinical ethicist is based on the facts of the case, a subsequent calculation of rights and wrongs. The outcome of this sum guides my ethics advice about what is practically possible, conform short-handed pragmatism. In responding to a case, I start with the specifics of a case and formulate answers that may be acceptable by multiple stakeholders, instead of relying on general theoretical outcomes, as a short-handed casuist. Finally, I reason along the lines of several relevant principles, such as autonomy, beneficence, non-maleficence, justice and dignity, and seek to apply these principles to the specifics of a case.

However, given that the background of clinical ethicists lies over a broad spectrum, I doubt that this answer would be satisfactory.  If I hadn’t had a background in bioethics, what would I have answered to this question? Does the fact that I am an ethicist in the clinic mean that I have to frame my answers along philosophical and ethical theories? Would a social worker, an accountant or an attorney equally have a philosophy in their work? Asking myself this latter question, I think that those professions do have a professional philosophy, but that they would be less likely to phrase it in philosophical language. Instead, probably they would describe their philosophy in more layman’s terms and would narrate about their approach in the different cases they see. So how do I approach my cases as a clinical ethicist?

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

May 1, 2013 | Posted By Paul Burcher, MD, PhD

When Beauchamp and Childress wrote their first edition of Principles of Biomedical Ethics, Immanuel Kant figured prominently in their discussion of the principle of autonomy.  Now he warrants barely a mention in the same, much revised chapter of the sixth edition.  Why the substantial de-emphasizing of Kant’s philosophy, when he wrote such important ethical treatises in which the human ability to make free and autonomous choice is so central?  Isn’t his philosophy the basis for our biomedical principle of autonomy?  The surprising answer is no, it cannot be. One reason is that Kant’s philosophical use of the principle of autonomy is actually quite different than the biomedical principle.  The other answer is that Kant’s principle does not provide a philosophical justification for the protection of patient’s rights.  I will explain both of these perhaps surprising claims.  But I do believe there is still a role for Kantian autonomy in the discipline of bioethics:  it remains a valid criterion (or yardstick) for when physicians should accede to patient requests for treatment.

Autonomous choice for Kant is ethical choice.  When we choose a course of action because it is consistent with the Categorical Imperative, we are choosing autonomously because we are freely choosing to obey an ethical law rather than being a slave to our passions and desires—we are not being pushed along by the world, we are initiating a new action for reasons that are somewhat “otherworldly” because they are neither empirical nor material, the ethical law is a priori and therefore “above the fray”.  But patients choose a course of action in healthcare for many reasons, and most of these reasons are amoral, and some may even violate Kant’s Categorical Imperative, such as refusing treatment for a non-terminal condition.  Kant saw any “suicide” as a violation of the second statement of the Categorical Imperative because human life must never be treated as a means to an end, and suicide abandons life for some reason (intractable pain, depression, despair), thereby treating it as a means, not an end in itself.  The point of this is that most decisions in a healthcare setting do not qualify as autonomous under Kant’s framework, because they are not ethical decisions in a strict sense.  They are done for personal reasons, which need not conform to moral law.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

April 11, 2013 | Posted By Wayne Shelton, PhD

Much of the history of philosophy, including the history of philosophical ethics, can be summarized as the quest for a basis in an objective, rational truth. My sense is that many ethicists, both philosophers and non-philosophers, today have not let go of this quest entirely. The purpose of this short blog to is sketch briefly the philosophical landscape of our tradition and what I think is the proper response to it in terms of how we should view ethics.

Early Greek philosophers, such as Thales, Democritus, Parmenides and Heraclitus were seeking an understanding of the natural phenomena independent from traditional mythology. Their goal was to find an explanation that accounted for both diversity and change in nature, but also the unity and continuity. A basic question became, what is the ultimate source or the most basic element of the universe that helps us understand the universe, as well as what we know and how we should live? Plato, through his dialogues using Socrates as his mouthpiece, postulated that ultimate Truth or Good is to be found in the Forms, which were in a separate, higher realm from everyday human experience. For Plato, what we come to know in the realm of earthly experience is always an approximation of their ultimate counterparts in the Forms. Of course a special realm of truth requires a special understanding, which not surprisingly he believed was accessible only to the Philosopher King, whose understanding was oriented to such a level.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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