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PubMed2000

Winding roads and faded signs: ethical decision making in a postmodern world.

We are living in an era, sometimes referred to as "postmodern," exemplified by complex change related to vast increases in information and technology and exposure to diverse people and ideas. Society as a whole is experiencing dissonance in solving ethical dilemmas, and nurses' ethical dilemmas are never far removed from the social context in which nurses practice. This article explores aspects of postmodernism that complicate ethical decision making. It is hoped that this discussion may aid nurses in understanding how world values, especially those of postmodernism, complicate ethical decision making in health care. Suggestions melding aspects of the postmodern with traditional approaches to ethical decision making are presented.

Bioethics↗
PubMedDate not supplied

Ethical drift: when good people do bad things.

There are many factors in today's healthcare environment which challenge nurses and nursing administration in adhering to ethical values. This article discusses the phenomenon of ethical drift, a gradual erosion of ethical behavior that occurs in individuals below their level of awareness. It is imperative for nurse managers and executives to be aware of the danger that workplace pressures pose in encouraging ethical drift at all levels of nursing, and to take steps to prevent this phenomena from occurring in their facilities.

Attitude of Health Personnel↗
PubMedDate not supplied

Self-determination vs. family-determination: two incommensurable principles of autonomy: a report from East Asia.

Most contemporary bioethicists believe that Western bioethical principles, such as the principle of autonomy, are universally binding wherever bioethics is found. According to these bioethicists, these principles may be subject to culturally-conditioned further interpretations for their application in different nations or regions, but an 'abstract content' of each principle remains unchanged, which provides 'an objective basis for moral judgment and international law'. This essay intends to demonstrate that this is not the case. Taking the principle of autonomy as an example, this essay argues that there is no such shared 'abstract content' between the Western bioethical principle of autonomy and the East Asian bioethical principle of autonomy. Other things being equal, the Western principle of autonomy demands self-determination, assumes a subjective conception of the good and promotes the value of individual independence, whilst the East Asian principle of autonomy requires family-determination, presupposes an objective conception of the good and upholds the value of harmonious dependence. They differ from each other in the most general sense and basic moral requirement.

Asia↗
PubMed1998

The ethics of HIV research in developing nations.

This paper discusses a dispute concerning the ethics of research on preventing the perinatal transmission of HIV in developing nations. Critics of this research argue that it is unethical because it denies a proven treatment to placebo-control groups. Since studies conducted in developed nations would not deny this treatment to subjects, the critics maintain that these experiments manifest a double standard for ethical research and that a single standard of ethics should apply to all research on human subjects. Proponents of the research, however, argue that these charges fail to understand the ethical complexities of research in developing nations, and that study designs can vary according to the social, economic, and scientific conditions of research. This essay explores some of the ethical issues raised by this controversial case in order to shed some light on the deeper, meta-ethical questions. The paper argues that standards of ethical research on human subjects are universal but not absolute: there are some general ethical principles that apply to all cases of human subjects research but the application of these principles must take into account factors inherent in particular situations.

Acquired Immunodeficiency Syndrome↗
PubMed1999

Is there an Asian bioethics?

Is there an Asian bioethics? Some people might consider it blasphemous even to ask this question. But this paper asks it not so much to seek an answer as to clarify what it could actually mean. The idea is to sort out the presuppositions and possible implications of asserting the existence of an Asian bioethics. In the end, this paper makes the following points: (1) In the attempt to assert an Asian identity, one must be careful not to commit the mistake of universalizing (among Asians) a single Asian perspective; and (2) In the face of pluralism and multi-culturalism, there is some room for a kind of universalist ethics that is founded on a collage of culturally inspired perspectives rather than on a single standard of morality.

Asia↗
PubMed1999

Corruption and research.

Last year there was a heated debate regarding clinical trials with AZT carried out in developing countries. AIDS vaccine trials also posed various dilemmas and ethical problems. In this paper I will consider the possibility of corruption in bioethics, and international multi-centre research will be taken as an example. International clinical trials will be seen from another perspective. I will try to show that the possibility of systemic corruption should be considered when designing an international multi-centre research trial which may involve countries in very different situations regarding corruption. I will analyze three different approaches to this problem and suggest some strategies regarding their capacity to exclude the possibility of corruption.

Biomedical Research↗
PubMed2000

Conscientious objection in medicine.

Recognition of conscientious objection seems reasonable in relation to controversial and contentious issues, such as physician assisted suicide and abortion. However, physicians also advance conscience-based objections to actions and practices that are sanctioned by established norms of medical ethics, and an account of their moral force can be more elusive in such contexts. Several possible ethical justifications for recognizing appeals to conscience in medicine are examined, and it is argued that the most promising one is respect for moral integrity. It is also argued that an appeal to conscience has significant moral weight only if the core ethical values on which it is based correspond to one or more core values in medicine. Finally, several guidelines pertaining to appeals to conscience and their ethical evaluation are presented.

Conscience↗
PubMed2001

Is 'best proven' a useless criterion?

In this article, I examine some proposals for modification of ethical documents regulating research, particularly, the problems that introducing certain economic clauses may pose. I evaluate suggestions that reject the notion of providing the 'best proven diagnostic and therapeutic method' in favor of 'the highest attainable therapeutic method' or 'the proven effective prophylactic, diagnostic and therapeutic methods.' I analyze the plausibility and problems of introducing a double standard and the consequences it may have in developing countries. Finally I highlight the impact these changes may imply for these countries.

Clinical Trials as Topic↗
PubMed2001

How rational should bioethics be? The value of empirical approaches.

Rational justification of claims with empirical content calls for empirical and not only normative philosophical investigation. Empirical approaches to bioethics are epistemically valuable, i.e., such methods may be necessary in providing and verifying basic knowledge about cultural values and norms. Our assumptions in moral reasoning can be verified or corrected using these methods. Moral arguments can be initiated or adjudicated by data drawn from empirical investigation. One may argue that individualistic informed consent, for example, is not compatible with the Asian communitarian orientation. But this normative claim uses an empirical assumption that may be contrary to the fact that some Asians do value and argue for informed consent. Is it necessary and factual to neatly characterize some cultures as individualistic and some as communitarian? Empirical investigation can provide a reasonable way to inform such generalizations. In a multi-cultural context, such as in the Philippines, there is a need to investigate the nature of the local ethos before making any appeal to authenticity. Otherwise we may succumb to the same ethical imperialism we are trying hard to resist. Normative claims that involve empirical premises cannot be reasonable verified or evaluated without utilizing empirical methods along with philosophical reflection. The integration of empirical methods to the standard normative approach to moral reasoning should be reasonably guided by the epistemic demands of claims arising from cross-cultural discourse in bioethics.

Anthropology, Cultural↗
PubMed2001

The moral foundation of the clinical duties of care: needs, duties and human rights.

It has become fashionable to question attempts to derive internationally agreed duties of clinical care from more general theories of human rights. For example, some argue that such attempts risk moral abstraction through their neglect for the importance of culture and community in shaping moral consciousness and thus often unhelpful in the resolution of concrete moral dilemmas within medicine. Others denounce the importance of general moral principles altogether in bioethics and attempt to articulate what are claimed to be more practical approaches to resolving moral conflict. This paper challenges such arguments. It does so through arguing that: i) all humans everywhere have the same basic human needs; ii) the satisfaction of these needs varies with culture; iii) the imputation of moral duties on others entails respect for their right to basic need satisfaction, including the right to choose between presumptions about the duties and rights of patients which follow from these more general principles and v) problems of moral indeterminancy that arise from putting these principles into practice can be resolved through associated procedural policies of rational negotiation and compromise. The moral importance and practicality of respect for individual human rights within the practice of medicine is thus defended. Indeed, the paper concludes by arguing that without belief in human rights linked to a theory of basic human needs, communitarian theories of morality are incoherent.

Cultural Diversity↗
PubMed2003

The conjoined twins and the limits of rationality in applied ethics.

In this article I consider the case of the surgical separation of conjoined twins resulting in the immediate and predictable death of the weaker one. The case was submitted to English law by the hospital, and the operation permitted against the parents' wishes. I consider the relationship between the legal decision and the moral reasons adduced in its support, reasons gaining their force against the framework of much mainstream normative ethical theory. I argue that in a few morally dilemmatic situations, such a legalistic-theoretical approach cannot plausibly accommodate certain irreducible and ineliminable features of the ethical experience of any concrete individual implicated in the situation, and that this failure partly undermines its self-appointed role of guiding such an individual's conduct. For example, the problem as experienced by the judge and by the parents might not be the same problem at all, and some of their respective reasons may be mutually unintelligible or impotent. I certainly do not argue for a rejection of law or of moral theory; I merely challenge their implicit claim to comprehensiveness and their fixation with an idealised and putatively universal rationality modelled on converging scientific enquiry. Finally, I claim that at least in the twins' case there may be insufficient normative robustness to the conclusions reached, or indeed reachable, by the court in a situation where intuitions and moral reasons pull in fundamentally incommensurable directions; as such, there may be room for an acknowledgement of the spiritual, through a humble abstention from making a decision--which is not to be confused with deciding to do nothing.

Bioethical Issues↗
PubMed2001

Ethics committees. Research ethics: beyond the guidelines.

There is international recognition of the need for sustainable research ethics committees to provide ethical review of human subjects research in developing countries, but many developing countries do not have such committees (often called 'IRBs'). Theoretical and practical uncertainties encountered by an IRB on the Caribbean island of Grenada offer insight into ethical review of research in developing countries. Theoretical uncertainties include questions about whether means of ensuring confidentiality and obtaining informed consent will be effective in local settings, and whether deviations from Western norms are justifiable. International guidelines are helpful in addressing these concerns, but are subject to interpretation. Guidelines are less helpful in practical areas like selecting members or chairs. They do not address what sort of procedures and paperwork will work in a developing country, or IRBs' relationships to governments that have no mandate for them. Experiences presented here show that IRBs in developing countries can sustainably adhere to international standards. Sustainability requires knowledge, personal commitment, and an official mandate to uphold international standards. Capacity building must therefore focus on educational programs to make developing country leaders knowledgeable about the value of international guidelines to their nations. Such knowledge is needed before people will become motivated to promote, implement, and uphold their guidelines. People in developing countries must help design bridges to help their nations put international standards into practice. The structure of such bridges may, of necessity, very in different settings.

Committee Membership↗
PubMed2001

From human wrongs to universal rights: communication and feminist challenges for the promotion of women's health in the Third World.

This article argues that in the quest for global bioethics in its relation to the promotion of women's health and women's rights, the main challenge is to, first, rise above the relativist trap and second, to solve the false dilemma between individualism and collectivism. Particularly in order to improve women's position and advance their well-being in many developing countries with patriarchal cultural practices, there is an urgent need to introduce modern medicine and to share more evenly and efficiently the health care resources of the industrialized societies. This presumes that we can find a normative bioethical approach that promotes the rights of individuals without striving for cultural assimilation and disrespect. From the philosophical point of view this means that we have to overcome the debate between the rival views of justice, and rather find the shared features of the various approaches, thus diminishing the exaggerated polarizations between them. The author claims that despite its importance in women's rights protection, feminist bioethics cannot remain as a normative alternative that can replace either liberal or communitarian approaches. Instead feminism needs to be part of both liberal and communitarian ethical thinking. Communitarianism, for its part, cannot offer an alternative to either liberalism or feminism, but it can function as an essential critical balancing force within these approaches. Individualist liberalism, on the other hand, has to find its way into collective social structures and accept their maintenance, instead of exhausting itself in its attempts to lift individuals above or beyond their social contexts. All in all, the article shows that in finding the global bioethical norms the incompatibility between universalist and relativist reasoning or between individualist and collective ethical positions per se is not the main problem. Rather the problem is in our persistent tendency to believe that such an incompatibility exists. However, if we overcome the debate on whether one cultural background is superior to another, we can find a way to agree on some common norms that are based on shared values of very different traditions. Finding globally acceptable values, however, is not enough unless we pay more attention to their promotion in practice, in very different economic, social and political circumstances.

Bioethics↗
PubMed2001

Moral agency, moral worth and the question of double standards in medical research in developing countries.

International regulations governing medical research, healthcare and medical practice, are, obviously, meant to be guidelines and not detailed procedural rules of thumb that can be applied unreflectively without any danger of doing moral wrong. Moreover, such regulations are meant to apply internationally, and no set of straight-jacketed rules of thumb can conceivably apply to all societies and communities of the world, extremely diverse and differently situated as they are. The mark of a good international guideline or regulation, in my view, is that it should provide a clear principle of action that applies equally to all global communities and societies without seeking to foist the particular or momentary moral dilemmas, quandaries, obsessions and preoccupations of some on all. In this paper, I propose to argue that, because moral obligations are obligations only from the point of view of a particular moral agent, we should avoid making the peculiar problems of any particular moral agent(s) the obsessive concern of all moral agents, and that we need, in particular, to make appropriate distinctions between the ethics of developed world research in the developing world, collaborative or cooperative research between the developed and developing worlds, developed world research in the developed world and developing world research in the developing world. A consequence of looking at things this way is that, while it should be clear that there are ethical concerns, imperatives and obligations at all levels, different standards may and, in fact, cannot but be applied in different contexts at different levels, without resorting to the use of double standards, which can never be morally justified. Finally, I venture to propose a formula for a solemn pledge of moral integrity and noble intent, from the perspective of the agent, that is to say, the investigator, sponsor and funder of any research, to complement and balance the widely accepted informed consent requirement, from the perspective of the patient, the subject of any biomedical research.

Biomedical Research↗
PubMed2004

Challenging the bioethical application of the autonomy principle within multicultural societies.

This article critically re-examines the application of the principle of patient autonomy within bioethics. In complex societies such as those found in North America and Europe health care professionals are increasingly confronted by patients from diverse ethnic, cultural, and religious backgrounds. This affects the relationship between clinicians and patients to the extent that patients' deliberations upon the proposed courses of treatment can, in various ways and to varying extents, be influenced by their ethnic, cultural, and religious commitments. The principle of patient autonomy is the main normative constraint imposed upon medical treatment. Bioethicists typically appeal to the principle of patient autonomy as a means for generally attempting to resolve conflict between patients and clinicians. In recent years a number of bioethicists have responded to the condition of multiculturalism by arguing that the autonomy principle provides the basis for a common moral discourse capable of regulating the relationship between clinicians and patients in those situations where patients' beliefs and commitments do or may contradict the ethos of biomedicine. This article challenges that claim. I argue that the precise manner in which the autonomy principle is philosophically formulated within such accounts prohibits bioethicists' deployment of autonomy as a core ideal for a common moral discourse within multicultural societies. The formulation of autonomy underlying such accounts cannot be extended to simply assimilate individuals' most fundamental religious and cultural commitments and affiliations per se. I challenge the assumption that respecting prospective patients' fundamental religious and cultural commitments is necessarily always compatible with respecting their autonomy. I argue that the character of some peoples' relationship with their cultural or religious community acts to significantly constrain the possibilities for acting autonomously. The implication is clear. The autonomy principle may be presently invalidly applied in certain circumstances because the conditions for the exercise of autonomy have not been fully or even adequately satisfied. This is a controversial claim. The precise terms of my argument, while addressing the specific application of the autonomy principle within bioethics, will resonate beyond this sphere and raises questions for attempts to establish a common moral discourse upon the ideal of personal autonomy within multicultural societies generally.

Bioethics↗