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Tue, 12 Jan 2010 23:32:00 PST

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Tue, 12 Jan 2010 23:32:00 PST

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Tue, 12 Jan 2010 23:32:00 PST

La Frontera: Responsibly Managing Borders and Boundaries in Clinical Ethics

Mccullough, L. B. — Tue, 12 Jan 2010 23:32:00 PST

The papers in the 2010 "Clinical Ethics" number of the Journal of Medicine and Philosophy explore issues along La Frontera, the borders and boundaries of clinical ethics. The first three papers in this "Clinical Ethics" number of the Journal explore borders and boundaries drawn within clinical ethics, concerning the moral standing of complementary and alternative medicine, palliative sedation, and induced abortion and feticide. The fourth and fifth papers explore the borders and boundaries between research ethics and clinical ethics.

The Proper Role of Evidence in Complementary/Alternative Medicine

Hansen, K., Kappel, K. — Tue, 12 Jan 2010 23:32:00 PST

In this article we explore the role evidence ought to play in complementary and alternative medicine (CAM). First, we consider the claim that evidence in the form of randomized controlled trials (RCTs) cannot be obtained for CAMs. Second, we consider various claims to the effect that there are ways of obtaining evidence that do not make use of RCTs. We argue that there is no good reason why CAM should be exempted from the general requirement that treatments undergo evaluation by RCT. Third, we consider two implications for health care policy. First, many activities in conventional medicine have never been rigorously evaluated and are widely in use nonetheless. We argue that this fails to provide a reason for exempting CAM from a demand for evidence. Second, CAM use may be compared to a choice of lifestyle, and this has a significant impact on which requirements of evidence can reasonably be imposed.

Disambiguating Clinical Intentions: The Ethics of Palliative Sedation

Jansen, L. A. — Tue, 12 Jan 2010 23:32:00 PST

It is often claimed that the intentions of physicians are multiple, ambiguous, and uncertain—at least with respect to end-of-life care. This claim provides support for the conclusion that the principle of double effect is of little or no value as a guide to end-of-life pain management. This paper critically discusses this claim. It argues that proponents of the claim fail to distinguish two different senses of "intention," and that, as a result, they are led to exaggerate the extent to which clinical intentions in end-of-life contexts are ambiguous and uncertain. It argues further that physicians, like others who make life and death decisions, have a duty to get clear on what their intentions are. Finally, it argues that even if the principle of double effect should be rejected, clinical intentions remain ethically significant because they condition the meaning of extraordinary clinical interventions, such as that of palliative sedation.

Selective Terminations and Respect for the Disabled

Stangl, R. — Tue, 12 Jan 2010 23:32:00 PST

It is widely thought that abortion on the grounds of fetal abnormality is morally justified. More controversially, Peter Singer has argued that some infants with severe disabilities ought to be killed. Many disability rights activists object that such claims and practices express disrespect toward disabled persons, even if fetuses and infants are only potentially persons. This can seem puzzling. If disabled fetuses are not members of the community of disabled persons, how can our treatment of the former express disrespect toward the latter? In what follows, I shall argue for two claims: first, the he puzzle is only apparent because whether we respect someone depends not only on how we do treat him but also on how we would treat him were circumstances different, and secondly, "substitutionary arguments" for selective terminations of disabled fetuses or infants do express disrespect toward disabled persons, even if fetuses and infants are only potentially persons.

Clinical Research in Context: Reexamining the Distinction between Research and Practice

Anderson, J. A. — Tue, 12 Jan 2010 23:32:00 PST

At least since the seminal work of the (US) National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research in the 1970s, a fundamental distinction between research and practice has underwritten both conceptual work in research ethics and regulations governing research involving human subjects. Notwithstanding its undoubted historical importance, I believe the distinction is problematic because it misrepresents clinical inquiry. In this essay, I aim to clarify the character of clinical inquiry by identifying crucial contextual constraints on justification constitutive of clinical science. This analysis shows that, from an epistemological point of view, clinical research and clinical practice are not sharply distinct but intimately intertwined. This result is important in its own right—an enriched understanding of the epistemology of clinical research is valuable in and of itself. But this result is also important because it has profound implications for the ethics of human subjects research.

The Exceptional Ethics of the Investigator-Subject Relationship

Sachs, B. — Tue, 12 Jan 2010 23:32:01 PST

This article concerns the validity of six canonical rules that institutional review boards use to constrain the behavior of investigators. These rules require investigators to design their studies in a scientifically valid way, not pay their subjects to take risks, minimize risks to their subjects, secure for their subjects access to effective interventions post-trial, not pay their subjects too much and allow their subjects to withdraw from the study unconditionally. Enforcement of these rules is problematic because there are other relationships that seem to be like the investigator-subject relationship in all ethically relevant respects, such as the employer-employee and volunteer organizer-volunteer relationships, to which we would not dream of applying these same rules. Applying these rules in one context but not the others is a violation of ethical consistency I label "exceptionalism." We should conclude that it is time to reexamine the validity of the six rules.

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Tue, 17 Nov 2009 09:52:21 PST

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Tue, 17 Nov 2009 09:52:21 PST

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Tue, 17 Nov 2009 09:52:21 PST

Introduction: Symposium on a Regulated Market in Transplantable Organs

Hippen, B. E. — Tue, 17 Nov 2009 09:52:21 PST

A Litmus Test for Exploitation: James Stacey Taylor's Stakes and Kidneys

Kuntz, J. R. — Tue, 17 Nov 2009 09:52:21 PST

James Stacy Taylor advances a thorough argument for the legalization of markets in current (live) human kidneys. The market is seemly the most abhorrent type of market, a market where the least well-off sell part of their body to the most well off. Though rigorously defended overall, his arguments concerning exploitation are thin. I examine a number of prominent bioethicists’ account of exploitation: most importantly, Ruth Sample's exploitation as degradation. I do so in the context of Taylor's argument, with the aim of buttressing Taylor's position that a regulated kidney market is morally allowable. I argue that Sample fails to provide normative grounds consistent with her claim that exploitation is wrong. I then reformulate her account for consistency and plausibility. Still, this seemingly more plausible view does not show that Taylor's regulated kidney market is prohibitively exploitative of impoverished persons. I tack into place one more piece of support for Taylor's conclusion. (wc. 148)

Autonomy, Moral Constraints, and Markets in Kidneys

Kerstein, S. J. — Tue, 17 Nov 2009 09:52:21 PST

This article concerns the morality of establishing regulated kidney markets in an effort to reduce the chronic shortage of kidneys for transplant. The article tries to rebut the view, recently defended by James Taylor, that if we hold autonomy to be intrinsically valuable, then we should be in favor of such markets. The article then argues that, under current conditions, the buying and selling of organs in regulated markets would sometimes violate two Kantian principles that are seen as moral constraints. One principle forbids expressing disrespect for the dignity of humanity; the other forbids treating others merely as means. In light of the moral danger posed by regulated markets, the article advocates an alternative way of diminishing the current organ shortage, namely opt-out systems of cadaveric organ donation.

Organ Markets and the Ends of Medicine

Davis, F. D., Crowe, S. J. — Tue, 17 Nov 2009 09:52:21 PST

As the gap between the need for and supply of human organs continues to widen, the aim of securing additional sources of these "gifts of the body" has become a seemingly overriding moral imperative, one that could—and some argue, should—override the widespread ban on organ markets. As a medical practice, organ transplantation entails the inherent risk that one human being, a donor, will become little more than a means to the end of healing for another human being and that he or she will come to have a purely instrumental value. With the establishment of organ markets, not only will the harms of instrumentalization be a reality—the ends of medicine will be further compromised and confused.

Constraint, Consent, and Well-Being in Human Kidney Sales

Hughes, P. M. — Tue, 17 Nov 2009 09:52:21 PST

This paper canvasses recent arguments in favor of commercial markets in human transplant kidneys, raising objections to those arguments on grounds of the role of injustice, exploitation, and coercion in compromising the autonomy of those most likely to sell a kidney, namely, the least well off members of society.

Autonomy and Organ Sales, Revisited

Taylor, J. S. — Tue, 17 Nov 2009 09:52:21 PST

In this paper I develop and defend my arguments in favor of the moral permissibility of a legal market for human body parts in response to the criticisms that have been leveled at them by Paul M. Hughes and Samuel J. Kerstein.

Why Should We Compensate Organ Donors When We Can Continue to Take Organs for Free? A Response to Some of My Critics

Cherry, M. J. — Tue, 17 Nov 2009 09:52:21 PST

In Kidney for Sale by Owner: Human Organs, Transplantation, and the Market, I argued that the market is the most efficient and effective—and morally justified—means of procuring and allocating human organs for transplantation. This special issue of The Journal of Medicine and Philosophy publishes several articles critical of this position and of my arguments mustered in its support. In this essay, I explore the core criticisms these authors raise against my conclusions. I argue that clinging to comfortable, but unfounded, notions that human body parts are not commodities, that the physician-patient relationship transcends commercial practices, and that medicine rises above market-place morality (where "market-place morality" is presented rhetorically as a criticism) leads to a real failure adequately to appreciate the complex reality of modern medicine. Denying the illicit moral intuitions that commodification of body parts is immoral or that it necessarily violates human dignity would benefit donors and recipients alike, while also reinforcing virtuous transplantation practice and policy. Honestly acknowledging the medical marketplace would shed light on what is often a hazy and shrouded policy setting. At stake is not solely the efficiency of procuring human organs for transplantation but also the recognition of the moral authority of persons over themselves.

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Tue, 01 Sep 2009 08:25:57 PDT

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Tue, 01 Sep 2009 08:25:57 PDT

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Tue, 01 Sep 2009 08:25:57 PDT

Animal-Human Chimeras, Sexually Deviant Behavior, and Embryonic Stem Cell Research: An Introduction

Hinkley, A. E. — Tue, 01 Sep 2009 08:25:57 PDT

The Search for Reasons in a Unified Relationship

Koppelman-White, E. R. — Tue, 01 Sep 2009 08:25:57 PDT

The paternalism, autonomy debate was influenced by traditional ideas that reasons are either objective (based on values existing independent of any particular person) or subjective (based on values tied to individual's personal histories). This dichotomy has been rewarding for the health care community. However, the tenets of this debate have influenced the nature of deliberation in a way that seriously compromises the ability of health care professionals and patients to bring reflection (the search for justified reasons) to a successful end. It sets up the moral landscape not as one of unity and reciprocity, but as one of divisiveness and distance-where one person (the physician) does something to another (paternalism) or for another (patient autonomy), rather than with another. This distance and divisiveness undermines the unity of wills and genuine reciprocity that I argue is indispensable for genuinely good relationships and necessary for successfully establishing what reasons there are to act. It has created an abyss in communication that even recent suggestions for change cannot bridge. In this paper, I discuss the nature of this abyss and the problems it has created by demonstrating that traditional theoretical ideas about the nature of reasons have influenced the nature of deliberation in health care. I argue that recent suggestions for "justified paternalism" fail to bridge the abyss. Finally, I suggest that to be successful, we must change the framework; we must reject the ideas of objective and subjective value and embrace instead the idea that values are intersubjective.

Metaphysical and Ethical Perspectives on Creating Animal-Human Chimeras

Eberl, J. T., Ballard, R. A. — Tue, 01 Sep 2009 08:25:57 PDT

This paper addresses several questions related to the nature, production, and use of animal-human (a-h) chimeras. At the heart of the issue is whether certain types of a-h chimeras should be brought into existence, and, if they are, how we should treat such creatures. In our current research environment, we recognize a dichotomy between research involving nonhuman animal subjects and research involving human subjects, and the classification of a research protocol into one of these categories will trigger different ethical standards as to the moral permissibility of the research in question. Are a-h chimeras entitled to the more restrictive and protective ethical standards applied to human research subjects? We elucidate an Aristotelian-Thomistic metaphysical framework in which to argue how such chimeras ought to be defined ontologically. We then examine when the creation of, and experimentation upon, certain types of a-h chimeras may be morally permissible.

Sex, Immorality, and Mental Disorders

Gert, B., Culver, C. M. — Tue, 01 Sep 2009 08:25:57 PDT

Although the definition of a mental disorder has remained essentially the same from Diagnostic and Statistical Manual of Mental Disorder, Third Edition, Revised (DSM-III-R) through DSM-IV to DSM-IV-TR, the account of the paraphilias has changed continually. Although the definition in all the DSMs explicitly rules out deviant sexual behavior as sufficient for labeling someone as having a mental disorder, deviant sexual behavior counts as sufficient for all the paraphilias in DSM-III-R. In DSM-IV, the account of all the paraphilias is made consistent with the definition. In DSM-IV-TR, mere deviant sexual behavior is not sufficient for being classified as having a paraphilia, but immoral deviant sexual behavior is. Thus, in DSM-IV-TR, only those paraphilias that involve immoral deviant sexual behavior are inconsistent with the definition, but deviant sexual behavior by itself does not count as a mental disorder.

A Regulatory Argument Against Human Embryonic Stem Cell Research

Napier, S. — Tue, 01 Sep 2009 08:25:57 PDT

This article explores the plausibility of an argument against embryonic stem cell research based on what the regulations already say about research on pregnant women and fetuses. The center of the argument is the notion of vulnerability and whether such a concept is applicable to human embryos. It is argued that such an argument can be made plausible. The article concludes by responding to several important objections.

Evidence-Based Medicine Must Be ...

La Caze, A. — Tue, 01 Sep 2009 08:25:57 PDT

Proponents of evidence-based medicine (EBM) provide the "hierarchy of evidence" as a criterion for judging the reliability of therapeutic decisions. EBM's hierarchy places randomized interventional studies (and systematic reviews of such studies) higher in the hierarchy than observational studies, unsystematic clinical experience, and basic science. Recent philosophical work has questioned whether EBM's special emphasis on evidence from randomized interventional studies can be justified. Following the critical literature, and in particular the work of John Worrall, I agree that many of the arguments put forward by advocates of EBM do not justify the ambitious claims that are often made on behalf of randomization. However, in contrast to the recent philosophical work, I argue that a justification for EBM's hierarchy of evidence can be provided. The hierarchy should be viewed as a hierarchy of comparative internal validity. Although this justification is defensible, the claims that EBM's hierarchy substantiates when viewed in this way are considerably more circumscribed than some claims found in the EBM literature.

What They Mean by "Good Science': The Medical Community's Response to Boutique Fetal Ultrasounds

Raucher, M. S. — Tue, 01 Sep 2009 08:25:57 PDT

Since 1994, when the first fetal imaging boutique appeared in Texas, many sites have been established around the country for parents to receive nonmedical fetal imaging using three- and four-dimensional ultrasound machines. These businesses boast the benefits they offer to parental-fetal bonding, but the medical community objects to the use of ultrasound machines for nonmedical purposes. In this article, I present the statements released by the medical community, highlighting the alarmist strategies used to paint boutique ultrasounds as bad science and elevate the medical use of ultrasounds. Through a close reading of the statements, it is shown that the medical community's primary concern is not the health of the fetus or the woman but rather their place as the sole users of fetal ultrasounds. This detailed analysis reveals a medical community fearful that its authority is being usurped and is therefore responding with statements meant to denigrate boutique fetal ultrasounds