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PubMed1990

Interpretive bioethics: the way of discernment.

This paper critically appraises the applied action-guide approach to bioethics and finds it wanting in two ways: it is tethered to a social contract view of the doctor-patient relationship that is largely incompatible with experiences of illness and care; and, as a formalist doctrine, it lacks critical edge and tends toward accommodationism. An alternative approach is recommended that involves interpreting moral experience by means once associated with the rhetorical arts--practical reasoning, hermeneutics, casuistry, and thick description.

Bioethics↗
PubMed2004

Medical ethics and double effect: the case of terminal sedation.

The use of terminal sedation to control the intense discomfort of dying patients appears both to be an established practice in palliative care and to run counter to the moral and legal norm that forbids health care professionals from intentionally killing patients. This raises the worry that the requirements of established palliative care are incompatible with moral and legal opposition to euthanasia. This paper explains how the doctrine of double effect can be relied on to distinguish terminal sedation from euthanasia. The doctrine of double effect is rooted in Catholic moral casuistry, but its application in law and morality need not depend on the particular framework in which it was developed. The paper further explains how the moral weight of the distinction between intended harms and merely foreseen harms in the doctrine of double effect can be justified by appeal to a limitation on the human capacity to pursue good.

Casuistry↗
PubMed2004

Does empirical research make bioethics more relevant? "The embedded researcher" as a methodological approach.

What is the status of empirical contributions to bioethics, especially to clinical bioethics? Where is the empirical approach discussed in bioethics related to the ongoing debate about principlism versus casuistry? Can we consider an integrative model of research in medical ethics and which empirical methodology could then be valuable, the quantitative or the qualitative? These issues will be addressed in the first, theoretical part of the paper. The concept of the "embedded researcher" presented in this article was stimulated by the two questions, (1) how can we safeguard that our research will yield valid and meaningful results to practice? and (2), how can we convince clinical colleagues that medical ethics offers relevant contributions to the analysis and solution of problems? One tentative answer has been our effort to elaborate a coherent methodological research approach in the field of end-of-life issues integrating qualitative and quantitative as well as casuistic methodologies. This development is characterized in the second part describing the ECOPE Study (short title) "Ethical Conditions Of Passive Euthanasia." The achievements and limitations of the suggested approach of the "embedded researcher" are discussed referring to 3 examples of our joint studies about ethical issues concerning (1) critical decision-making in neonatology (2) limitation of treatment in intensive care (3) problems with doctor-patient conversation at the end-of life in oncology. Conclusions from our studies are put to discussion in the final part of the paper about how to further develop research in the field of end-of-life care and, maybe, clinical bioethics as a whole.

Bioethical Issues↗
PubMed2002

Defending principlism well understood.

After presenting the current version of principlism, in the process repudiating a widespread deductivist misinterpretation, a fundamental metaethical disagreement is developed by outlining the deductivistic critique of principlism. Once the grounds for this critique have been understood, the dispute between casuistry, deductivism and principlism can be restructured, and the model of "application" proven to be the central difference. In the concluding section it is argued that principlism is the most attractive position, if the perceptual model of weak intuitionism is made more explicit.

Bioethics↗
PubMed2006

Bioethics as a second-order discipline: who is not a bioethicist?

A dispute exists about whether bioethics should become a new discipline with its own methods, competency standards, duties, honored texts, and core curriculum. Unique expertise is a necessary condition for disciplines. Using the current literature, different views about the sort of expertise that might be unique to bioethicists are critically examined to determine if there is an expertise that might meet this requirement. Candidates include analyses of expertise based in "philosophical ethics," "casuistry," "atheoretical or situation ethics," "conventionalist relativism," "institutional guidance," "regulatory guidance and compliance," "political advocacy," "functionalism," and "principlism." None succeed in identifying a unique area of expertise for successful bioethicists that could serve as a basis for making it a new discipline. Rather expertise in bioethics is rooted in many professions, disciplines and fields and best understood as a second-order discipline.

Bioethics↗
PubMed1991

Who is entitled to double effect?

The doctrine of double effect continues to be an important tool in bioethical casuistry. Its role within the Catholic moral tradition continues, and there is considerable interest in it by contemporary moral philosophers. But problems of justification and correct application remain. I argue that if the traditional Catholic conviction that there are exceptionless norms prohibiting inflicting some kinds of harms on people is correct, then double effect is justified and necessary. The objection that double effect is superfluous is a rejection of that normative conviction, not a refutation of double effect itself. This justification suggests the correct way of applying double effect to controversial cases. But versions of double effect which dispense with the absolutism of the Catholic tradition lack justification and fall to the objection that double effect is an unnecessary complication.

Bioethical Issues↗
PubMed1992

Moving forward in bioethical theory: theories, cases, and specified principlism.

The field of bioethics has deployed different models of justification for particular moral judgments. The best known models are those of deductivism, casuistry, and principlism (under one, rather limited interpretation). Each of these models, however, has significant difficulties that are explored in this essay. An alternative model, suggested by the work of Henry Richardson, is presented. It is argued that specified principlism is the most promising model of justification in bioethics.

Casuistry↗
PubMed1996

Four approaches to doing ethics.

Within the field of medical ethics there is a startling amount of diversity regarding which issues and relationships are deemed relevant for ethical inquiry and analysis, what strategies are appropriate for examining and resolving ethical conflict, what should be the goals for medical ethics, even who should participate in that project. What I will try to make clear in this paper is that how we go about this process of doing medical ethics, of examining, reflecting, decisionmaking, and behaving, makes a practical difference, and not just a philosophical one, in terms of the understandings we will reach about ethical matters. Without attempting to resolve any of the conflicts within or between different conceptions of doing ethics, I will try to articulate the differences in orientation, and particularly the tone and educational emphasis, that attend four major contemporary approaches to ethical inquiry and analysis: deductivism, principlism, modern casuistry, and feminist/relationist ethics.

Beneficence↗
PubMed1998

An anthropological exploration of contemporary bioethics: the varieties of common sense.

Patients and physicians can inhabit distinctive social worlds where they are guided by diverse understandings of moral practice. Despite the contemporary presence of multiple moral traditions, religious communities and ethnic backgrounds, two of the major methodological approaches in bioethics, casuistry and principlism, rely upon the notion of a common morality. However, the heterogeneity of ethnic, moral, and religious traditions raises questions concerning the singularity of common sense. Indeed, it might be more appropriate to consider plural traditions of moral reasoning. This poses a considerable challenge for bioethicists because the existence of plural moral traditions can lead to difficulties regarding "closure" in moral reasoning. The topics of truth-telling, informed consent, euthanasia, and brain death and organ transplantation reveal the presence of different understandings of common sense. With regard to these subjects, plural accounts of "common sense" moral reasoning exist.

Bioethical Issues↗
PubMed1995

Principlism and its alleged competitors.

Principles that provide general normative frameworks in bioethics have been criticized since the late 1980s, when several different methods and types of moral philosophy began to be proposed as alternatives or substitutes. Several accounts have emerged in recent years, including: (1) Impartial Rule Theory (supported in this issue by K. Danner Clouser), (2) Casuistry (supported in this issue by Albert Jonsen), and (3) Virtue Ethics (supported in this issue by Edmund D. Pellegrino). Although often presented as rival methods or theories, these approaches are consistent with and should not be considered adversaries of a principle-based account.

Altruism↗
PubMed1997

New paths of medical ethics.

The author of this essay comments on the thematic block "New Medical Ethics," which appeared in the journal Drustvena istrazivanja (23-24, vol. 5, 3-4/1996), and enters upon an extended discussion on the methodological and philosophical aspects of bioethics (also called biomedical ethics and new medical ethics). The essay represents an attempt to explain the origins of the new medical ethics that is arising out of the new medical situation due to scientific-technological progress. The author distinguishes between positive and negative aspects of bioethics and reconstructs (taking into account the suppositions of Peter Singer) the structure of bioethical methods. He defines bioethics--based on the claim that it is necessarily affiliated with philosophy--as a specific, relational and multiperspectival ethics. Such an approach is formulated as an alternative to deductivist conceptions which consider bioethics as a part of applied ethics, but also as an alternative to bioethical trends (casuistry, principles of biomedical ethics, etc.) that do not permit openness to ethical and philosophical theory.

Bioethics↗
PubMed1990

Methodologies for clinical ethics.

Truly professional medical ethics requires a methodology that generates both moral discernment and consistently right judgments. In this article the author briefly reviews difficulties involved in ethical decision-making, the historical development of casuistry, and four ethical methodologies employed in clinical medicine today. These latter, which are outlined and compared, are as follows: the methodology developed by David Thomasma in the 1960s and 1970s; one created by Jonsen, Siegler, and Winslade; another developed by the author; and the Bochum Protocol authored by Hans-Martin Sass et al. of the Bochum Center for Medical Ethics in the Federal Republic of Germany.

Casuistry↗
PubMed1978

[The therapy for pyogenic coxitis and its stabilisation with the fixateur externe (tubular system) (author's transl)].

The treatment of the destructive, unstable state of infection on the hip often takes an unfavourable course, because alloarthroplastic techniques are ruled out on principle, while the hip arthrodesis itself creates biomechanical problems under the incomparably more favourable aseptic conditions. The protracted trimming arthrodesis with immobilisation by pelvic plaster cast remains precarious with regard to the painful stress and the sedation of the infection, and it always includes the danger a damage causing immobilisation of the knee joint. The jointparts destructed by the infection are equivalent to an infected pseudarthrosis; for its stabilisation the fixateur externe is indicated, by analogy to the approach used on the extremities. The biomechanical problems are similar to those occuring with the internal fixation of hip arthrodesis: neutralisation of dislodging forces on the long leg lever, reliable anchorage of the means of osteosynthesis on the pelvis and axial compression on the broadest possible contact surfaces of the anthrodesis. A special installation of the fixateur externe (tubular system of the ASIF) is pointed out, which meets almost all requirements. The external osteosynthesis joins lateral ilium and femur shaft, compressing the hip area. For securing the stability it is necessary to include both of the iliac crests and a diagonal brace in the outer construction. The external fixation for stabilising the hip represents a large-scale technique which, by its nature, is inferior to internal osteosynthesis. But for the treatment of active pyogenic coxitis neither the arthrodesis by copra-head-plate nor the screw joint in connection with intertrochanteric osteotomy is suited. The advantages in contrast to the classical therapy with pelvic plaster cast are obvious. The operating method is explained on a model and presented in a casuistry on 3 people operated on so far. If the head-neck-segment is lost completely after septic head necrosis, a careful debridement and the Girdlestone-plastic usually lead to an infection sanitation, but mostly at the cost of an unstable hip on the considerably shortened leg.

Adult↗
PubMed1990

[Isolated dislocation in the distal radio-ulnar joint].

Anatomy, injury-mechanism and classification will be illustrated with a casuistry of the rate isolated luxation of the ulnar head. Diagnosis is established clinically and with comparative X-rays. In our case the luxation was irresponsible in general anaesthesia and had to be succeeded by open reposition with temporary pin-fixation. Postoperatively a cast up to the upper arm is necessary for six weeks. With the removal of the plaster the wire pins also must be immediately withdrawn, as to evade complications like fatigue-breakage of the implanted material. With adherence to this therapeutic scheme operative treatment is not problematic and - by means of posttraumatic physical therapy - shows a good functional result.

Bone Nails↗
PubMed2000

[Patellar tendon rupture after anterior cruciate ligament reconstruction with autologous patellar tendon-bone transplant. A case report].

Patellar ligament ruptures due to a complication after usage of bone-tendon autograft for an anterior cruciate ligament reconstruction happens seldom. During surgeries to restore continuity a fascia-lata-strip may be wrapped in and fixated to secure the primary tendon suture. This may be done in addition to the usually employed patella-tibial wiring cerclage. Whether a matrix for the scarred healing tendon will be created in addition to the construction of a support for the primary tendon seam without a foreign body reaction has to be left to further histological clarifications that cannot be implemented in the present casuistry.

Adult↗
PubMed1997

[Reduction of the left ventricular outflow tract gradient in hypertrophic, obstructive cardiomyopathy after myocardial infarct].

A 73-year old female patient is known to have hypertrophic obstructive cardiomyopathy (HOCM) since 1989. After a transmural anterolateral myocardial infarction with the development of a large apical aneurysms of the anterior wall, a previously measured gradient of 110 mm Hg in the LVOT is no longer detected. As a consequence of this casuistry, "pseudomyectomy" caused by myocardial infarction is described as an example of an uncommon spontaneous course of HOCM.

Aged↗
PubMed2005

What kind of doing is clinical ethics?

This paper discusses the importance of Richard M. Zaner's work on clinical ethics for answering the question: what kind of doing is ethics consultation? The paper argues first, that four common approaches to clinical ethics -- applied ethics, casuistry, principlism, and conflict resolution cannot adequately address the nature of the activity that makes up clinical ethics; second, that understanding the practical character of clinical ethics is critically important for the field; and third, that the practice of clinical ethics is bound up with the normative commitments of medicine as a therapeutic enterprise.

Ethical Theory↗
PubMed2006

An argument for the use of Aristotelian method in bioethics.

The main claim of this paper is that the method outlined and used in Aristotle's Ethics is an appropriate and credible one to use in bioethics. Here "appropriate" means that the method is capable of establishing claims and developing concepts in bioethics and "credible" that the method has some plausibility, it is not open to obvious and immediate objection. It begins by suggesting why this claim matters and then gives a brief outline of Aristotle's method. The main argument is made in three stages. First, it is argued that Aristotelian method is credible because it compares favourably with alternatives. In this section it is shown that Aristotelian method is not vulnerable to criticisms that are made both of methods that give a primary place to moral theory (such as utilitarianism) and those that eschew moral theory (such as casuistry and social science approaches). As such, it compares favourably with these other approaches that are vulnerable to at least some of these criticisms. Second, the appropriateness of Aristotelian method is indicated through outlining how it would deal with a particular case. Finally, it is argued that the success of Aristotle's philosophy is suggestive of both the credibility and appropriateness of his method.

Bioethics↗