Abstract There seem to be two clearly-defined camps in the debate over the problem of moral expertise. On the one hand are the “Professionals”, who reject the possibility entirely, usually because of the intractable diversity of ethical beliefs. On the other hand are the “Ethicists”, who criticise the Professionals for merely stipulating science as the most appropriate paradigm for discussions of expertise. While the subject matter and methodology of good ethical thinking is certainly different from that of good clinical thinking, they argue, this is no reason for rejecting the possibility of a distinctive kind of expertise in ethics, usually based on the idea of good justification. I want to argue that both are incorrect, partly because of the reasons given by one group against the other, but more importantly because both neglect what is most distinctive about ethics: that it is personal in a very specific way, without collapsing into relativism.
Abstract Background: Physicians face ethical difficulties daily, yet they seek ethics consultation infrequently. To date, no systematic data have been collected on the strategies they use to resolve such difficulties when they do so without the help of ethics consultation. Thus, our understanding of ethical decision making in day to day medical practice is poor. We report findings from the qualitative analysis of 310 ethically difficult situations described to us by physicians who encountered them in their practice. When facing such situations, the physicians sought to avoid conflict, obtain assistance, and protect the integrity of their conscience and reputation, as well as the integrity of the group of people who participated in the decisions. These goals could conflict with each other, or with ethical goals, in problematic ways. Being aware of these potentially conflicting goals may help physicians to resolve ethical difficulties more effectively. This awareness should also contribute to informing the practice of ethics consultation. . . .
Results: When faced with ethical difficulties, the physicians avoided conflict and looked for assistance, which contributed to protecting, or attempting to protect, the integrity of their conscience and reputation, as well as be integrity of the group of people who participated in the decisions. These efforts sometimes reinforced ethical goals, such as following patients’ wishes or their best interests, but they sometimes competed with them. The goals of avoiding conflict, obtaining assistance, and protecting the respondent’s integrity and that of the group of decision makers could also compete with each other.
Conclusion: In resolving ethical difficulties in medical practice, internists entertained competing goals that they did not always successfully achieve. Additionally, the means employed were not always the most likely to achieve those aims. Understanding these aspects of ethical decision making in medical practice is important both for physicians themselves as they struggle with ethical difficulties and for the ethics consultants who wish to help them in this process.
Extract I was intrigued by her argument that an “autonomous” medical decision can sometimes involve simple deference to medical authority, but I’m still unclear what she means when she says that such decisions can be construed as conscientiously autonomous if derived from a patient’s “self trust.” This seems precisely the paradox at the heart of debates over the existence of free will, or in Kukla’s rubric, autonomous choice: is there a “space” outside of social life constituting individual desires where choices derive from what one “really” wants?
Extract With regard to Dr. Lee’s comment that the proposed Wisconsin legislation does not eliminate a health care provider’s duty to provide a referral after refusing to perform a service, I would note that Assembly Bill 207 . . . specifically permits health care providers’ refusals to “participate in” services they find personally objectionable, with “participate in” specifically defined . . . as “to perform; practice; engage in; assist in; recommend; counsel in favor of; make referrals for; prescribe, dispense or administer drugs”.
Extract If pharmacists object to particular prescriptions, they should only be allowed to refuse to fill the prescription if meaningful and logistically feasible alternatives are in place. As an alternative, either another pharmacist must be on duty with the refusing pharmacist, or alternative ways of providing service must be in place. A woman should not have to travel to other pharmacies in search of a pharmacist that serves all patients, nor should she have to wait an unreasonable amount of time to have her prescription filled.
Oswaldo Castro, Frederic A Lombardo, Victor R Gordeuk
New England Journal of Medicine
Extract Real medical care and services always respect human life. No one should be forced to collaborate in abortion (even when it is achieved through the prevention of implantation), lethal research on embryos, euthanasia, or assisted suicide.
Extract To bring out what I see as the most plausible interpretation of Kukla’s article, I recast her main point as follows (though I am not optimistic that she would accept this restatement): The received view in bioethics is commonly interpreted so that autonomy occurs exclusively through discrete informed consents to medical procedures. However, this vision of autonomy is too narrow. Autonomy is also expressed through stable, enduring, and committed acceptance of medical practices. Kukla rightly points out that this account must be rounded by a rich understanding of medical practices together with a model of the virtue of conscientiousness in upholding the practices, principles, regimes, and values adopted.
Extract Someone might want to argue that this strict adherence to promise keeping justifies a person being forced, coerced, compelled, into performing actions that are unjust or morally impermissible if they are members of an organization/profession that begins to engage in performing unjust, or morally unjustifiable actions. . . .By utilizing our moral beliefs at the appropriate time when first we make our promise to provide competent professional service to our clients, we can avoid placing ourselves in situations that compromise our deeply held moral beliefs later on. If later on we are confronted by a change in the professional setting that did not exist in the original decision making situation, then we are rationally compelled to reassess our professional position relative to the requirements of our moral beliefs and perform the appropriate action, either comply, persuade others that they are wrong or leave the professional setting.
Extract Conclusion Offering legal protection to pharmacists comes at too great a cost to women’s health and legal rights. The pill is a viable and effective method of birth control for many women and, as Congress has noted, it can be used to prevent other social, economic, and medical problems. The Supreme Court has clearly established that a state cannot interfere with a woman’s right to access contraceptives, including the pill. While pharmacists should be free to practice their religion, that practice cannot interfere with their professional duty to dispense valid prescriptions free of moral judgment. Furthermore, the vague wording in most conscience clause statutes does not restrict objections to those of a religious nature. A pharmacist can use any personal moral objection as an excuse not to dispense a prescription. The result of a pharmacist’s objection can be quite severe for the patient (an unintended pregnancy or health problems), and the duties imposed under tort law should apply. A pharmacist should not be able to escape the legal consequences of his or her actions. States that allow pharmacists to do so are clearly protecting the rights of a small segment of their citizens at the expense of others. If these statutes are challenged in court, it is likely that the statutes will be found to be unconstitutional. While this is a serious consequence, it is appropriate given the rights at stake.
Extract L.L. deVeber and Ian Gentles imply that termination of pregnancy causes psychological problems. However, pre-existing differences between women who seek abortion and those who carry pregnancies to term are considerable and may account for differences in psychological status after abortion or delivery. A relevant comparison would assess psychological distress experienced by women seeking and obtaining an abortion and those seeking but denied pregnancy termination. . . The research cited by deVeber and Gentles, however, fails to meet this standard. . . . There is no causal evidence that abortion alone elevates the risk of psychiatric admission. Observational evidence of such an association may be readily interpreted as resulting from confounding pre-existing factors.
