In defence of moral imperialism: four equal and universal prima facie principles

Global bioethics and respect for cultural diversity: how do we avoid moral relativism and moral imperialism?

One of the major concerns of advocates of common morality is that respect for cultural diversity may result in moral relativism. On their part, proponents of culturally responsive bioethics are concerned that common morality may result in moral imperialism because of the asymmetry of power in the world. It is in this context that critics argue that global bioethics is impossible because of the difficulties to address these two theoretical concerns. In this paper, I argue that global bioethics is possible if we adopt a culturally responsive and self-critical attitude towards our moral values and those of others. I use the example of women's reproductive autonomy in indigenous African culture to show that the difference between the leading Euro-American and indigenous African construal of autonomy is that the former ascribes greater weight on individual self-determination while the latter emphasizes responsibilities towards the community. One develops dignity in virtue of their capacity for communing with others. Hence, women have rights, but as members of the community, they also have obligations including the duty to procreate. The involvement of the family in reproductive decisions does not contravene women's dignity and human rights. In applying the principle of autonomy in this communitarian context, one has to be sensitive to these ontological and moral specificities. The aim of global bioethics should not be to reach common grounds at all costs; any common norms should be the result of a negotiated democratic dialogue between cultures and not the result of imposition by the preponderant culture(s).

A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology

Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes "normal" or "good" kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1-2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage "non-ideal" situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial "third element".

Does the English Law on Abortion Affront Human Dignity?

The English law on abortion is examined through four lenses manufactured by the principle of dignity. Those lenses are embodiment, relationality, story and a transactional, rather than an atomistic, approach to the ascertaining of the relevant interests. It is contended that this approach gives more nuanced, humane, intellectually satisfactory and pastorally satisfactory answers than those generated by the existing law. It is further argued that only this dignity-based approach is compatible with that mandated by Article 8 of the ECHR.

Ethics teaching in a medical education environment: preferences for diversity of learning and assessment methods

BACKGROUND

Ethics and professionalism are an integral part of medical school curricula; however, medical students' views on these topics have not been assessed in many countries.

OBJECTIVE

 The study aimed to examine medical students' perceptions toward ethics and professionalism teaching, and its learning and assessment methods.

DESIGN

A self-administered questionnaire eliciting views on professionalism and ethics education was distributed to a total of 128 final-year medical students.

RESULTS

A total of 108 students completed the survey, with an 84% response rate. Medical students reported frequently encountering ethical conflicts during training but stated only a moderate level of ethics training at medical school (mean = 5.14 ± 1.8). They noted that their education had helped somewhat to deal with ethical conflicts (mean = 5.39 ± 2.0). Students strongly affirmed the importance of ethics education (mean = 7.63 ± 1.03) and endorsed the value of positive role models (mean = 7.45 ± 1.5) as the preferred learning method. The cohort voiced interest in direct faculty supervision as an approach to assessment of knowledge and skills (mean = 7.62 ± 1.26). Female students perceived greater need for more ethics education compared to males (p = < 0.05). Students who claimed that they had experienced some unprofessional treatment had a more limited view of the importance of ethics as a subject (P = 0.001).

CONCLUSION

Medical students viewed ethics education positively and preferred clinically attuned methods for learning.

Doctor can I buy a new kidney? I've heard it isn't forbidden: what is the role of the nephrologist when dealing with a patient who wants to buy a kidney?

Organ trafficking is officially banned in several countries and by the main Nephrology Societies. However, this practice is widespread and is allowed or tolerated in many countries, hence, in the absence of a universal law, the caregiver may be asked for advice, placing him/her in a difficult balance between legal aspects, moral principles and ethical judgments.In spite of the Istanbul declaration, which is a widely shared position statement against organ trafficking, the controversy on mercenary organ donation is still open and some experts argue against taking a negative stance. In the absence of clear evidence showing the clinical disadvantages of mercenary transplantation compared to chronic dialysis, self-determination of the patient (and, with several caveats, of the donor) may conflict with other ethical principles, first of all non-maleficence. The present paper was drawn up with the participation of the students, as part of the ethics course at our medical school. It discusses the situation in which the physician acts as a counselor for the patient in the way of a sort of "reverse" informed consent, in which the patient asks advice regarding a complex personal decision, and includes a peculiar application of the four principles (beneficence, non-maleficence, justice and autonomy) to the donor and recipient parties.

Information, choice and the ends of health promotion

In this paper I provide a critique of a set of assumptions relating to agency, choice and the legitimacy of actions impacting health that can be seen in some approaches to health promotion. After a brief discussion about the definition of health promotion, I outline two contrasting approaches to this area of health care practice. The first is focused on the provision of information and the second is concerned with seeking to change people's preferences in a particular way. It has been argued by a number of critics of health promotion that only the first approach is ethical, as it is for individuals to make their own lifestyle choices and adopt their own conception of the good life. I argue against this 'information' approach to health promotion on two grounds. First, I suggest that given the aims of health promotion, the provision of information is, as a matter of fact, of limited effectiveness in achieving these aims (and it may worsen health inequalities). Second, I argue that we have good reasons to question the appropriateness of respecting many of the preferences that individuals happen to have, given the origins and quality of such preferences. I then go on to argue, that by contrast we have good reasons to focus on changing at least some of the preferences that people have related to their lifestyle choices. This involves a commitment to both paternalism and a defence of a certain conception of the good life, but both can be defended. I use the example of potential responses to the growing problem of obesity to illustrate my argument, arguing that only policy that, at least sometimes, aims at preference change will be both effective and ethical.

Tuskegee University experience challenges conventional wisdom: is integrative bioethics practice the new ethics for the public's health?

The Tuskegee University National Center for Bioethics in Research and Health Care was established in 1999 in partial response to the Presidential Apology for the United States Public Health Service's Study of Untreated Syphilis in the Negro Male conducted in Macon County, Alabama, from 1932 to 1972. The Center's mission of promoting equity and justice in health and health care for African Americans and other underserved populations employs an integrative bioethics approach informed by moral vision. Etymological and historical analyses are used to delineate the meaning and evolution of bioethics and to provide a basis for Tuskegee's integrative bioethics niche. Unlike mainstream bioethics, integrative bioethics practice is holistic in orientation, and more robust for understanding the epistemic realities of minority life, health disparities, and population health. The conclusion is that integrative bioethics is relevant to the survival of all people, not just a privileged few; it could be the new ethics for the public's health.

Patient autonomy and choice in healthcare: self-testing devices as a case in point

This paper aims to critique the phenomenon of advanced patient autonomy and choice in healthcare within the specific context of self-testing devices. A growing number of self-testing medical devices are currently available for home use. The premise underpinning many of these devices is that they assist individuals to be more autonomous in the assessment and management of their health. Increased patient autonomy is assumed to be a good thing. We take issue with this assumption and argue that self-testing provides a specific example how increased patient autonomy and choice within healthcare might not best serve the patient population. We propose that current interpretations of autonomy in healthcare are based on negative accounts of liberty to the detriment of a more relational understanding. We also propose that Kantian philosophy is often applied to the healthcare arena in an inappropriate manner. We draw on the philosophical literature and examples from the self-testing process to support these claims. We conclude by offering an alternative account of autonomy based on the interrelated concepts of relationality, care and responsibility.

The four principles: can they be measured and do they predict ethical decision making?

BACKGROUND

The four principles of Beauchamp and Childress--autonomy, non-maleficence, beneficence and justice--have been extremely influential in the field of medical ethics, and are fundamental for understanding the current approach to ethical assessment in health care. This study tests whether these principles can be quantitatively measured on an individual level, and then subsequently if they are used in the decision making process when individuals are faced with ethical dilemmas.

METHODS

The Analytic Hierarchy Process was used as a tool for the measurement of the principles. Four scenarios, which involved conflicts between the medical ethical principles, were presented to participants who then made judgments about the ethicality of the action in the scenario, and their intentions to act in the same manner if they were in the situation.

RESULTS

Individual preferences for these medical ethical principles can be measured using the Analytic Hierarchy Process. This technique provides a useful tool in which to highlight individual medical ethical values. On average, individuals have a significant preference for non-maleficence over the other principles, however, and perhaps counter-intuitively, this preference does not seem to relate to applied ethical judgements in specific ethical dilemmas.

CONCLUSIONS

People state they value these medical ethical principles but they do not actually seem to use them directly in the decision making process. The reasons for this are explained through the lack of a behavioural model to account for the relevant situational factors not captured by the principles. The limitations of the principles in predicting ethical decision making are discussed.

Informed consent and cluster-randomized trials

We argue that cluster-randomized trials are an important methodology, essential to the evaluation of many public health interventions. However, in the case of at least some cluster-randomized trials, it is not possible, or is incompatible with the aims of the study, to obtain individual informed consent. This should not necessarily be seen as an impediment to ethical approval, providing that sufficient justification is given for this omission. We further argue that it should be the institutional review board's task to evaluate whether the protocol is sufficiently justified to proceed without consent and that this is preferable to any reliance on community consent or other means of proxy consent.

When Ethics Survive Where People Do Not

The provision of health care service in resource-poor settings is associated with a broad set of ethical issues. Devakumar's case discusses the ethical issues related to the inability to treat in a cholera clinic patients who do not have cholera. This paper gives a closer look on the context in which Devakumar's case took place. It also analyses the potential local and organizational factors that gives rise to ethical dilemmas and aggravate them. It also proposes a framework to help in the proactive handling of the factors that leads to ethical dilemmas and resolving the ethical issues as they appear. It adopts the four principles of autonomy, beneficence, non-maleficence and justice as universal and prima facie principles, but with the inclusion of a local understanding of what of each of these principles means. It is based on a collaborative approach that involves the beneficiaries and other partners in the field to help share information and resources, as well as adopting the provision of a wider service to the whole community. This is done by asking three basic questions: (a) who are the relevant stakeholders? (b) what ought to be the ethical principles in place? and (c) how should we take, implement and follow the decision about service provision?

Moral imperialism and multi-centric clinical trials in peripheral countries

Moral imperialism is expressed in attempts to impose moral standards from one particular culture, geopolitical region or culture onto other cultures, regions or countries. Examples of Direct Moral Imperialism can be seen in various recurrent events involving multi-centric clinical trials promoted by developed (central) countries in poor and developing (peripheral) countries, particularly projects related to the theory of double standards in research. After the WMA General Assembly refused to change the Helsinki Declaration - which would have given moral recognition to the above mentioned theory - the USA abandoned the declaration and began to promote regional seminars in peripheral countries with the aim of "training" researchers on ethical perspectives that reflect America's best interests. Individuals who received such training became transmitters of these central countries' ideas across the peripheral countries, representing a form of Indirect Moral Imperialism. The paper proposes the establishment of regulatory and social control systems for clinical trials implemented in peripheral countries, through the formulation of ethical norms that reflect the specific contexts of these countries, along with the drawing up and validation of their own national norms.

Bioethical concerns are global, bioethics is Western

Modern bioethics was born in the West and thus reflects, not surprisingly, the traditions of Western moral philosophy and political and social theory. When the work of bioethics was confined to the West, this background of socio-political theory and moral tradition posed few problems, but as bioethics has moved into other cultures - inside and outside of the Western world - it has become an agent of moral imperialism. We describe the moral imperialism of bioethics, discuss its dangers, and suggest that global bioethics will succeed only to the extent that it is local.

Cesarean delivery on maternal request: can the ethical problem be solved by the principlist approach?

In this article, we use the principlist approach to identify, analyse and attempt to solve the ethical problem raised by a pregnant woman's request for cesarean delivery in absence of medical indications. We use two different types of premises: factual (facts about cesarean delivery and specifically attitudes of obstetricians as derived from the EUROBS European study) and value premises (principles of beneficence and non-maleficence, respect for autonomy and justice).Beneficence/non-maleficence entails physicians' responsibility to minimise harms and maximise benefits. Avoiding its inherent risks makes a prima facie case against cesarean section without medical indication. However, as vaginal delivery can have unintended consequences, there is a need to balance the somewhat dissimilar risks and benefits. The principle of autonomy poses a challenge in case of disagreement between the pregnant woman and the physician. Improved communication aimed to enable better informed choice may overcome some instances of disagreement. The principle of justice prohibits unfair discrimination, and broadly favours optimising resource utilisation. Available evidence supports vaginal birth in uncomplicated term pregnancies as the standard of care. The principlist approach offered a useful framework for ethical analysis of cesarean delivery on maternal request, identified the rights and duties of those involved, and helped reach a conclusion, although conflict at the individual level may remain challenging.

Overview of psychiatric ethics III: principles-based ethics

OBJECTIVE

The aim of this paper is to consider the application of principle-based medical ethics to psychiatry.

CONCLUSIONS

Principles-based medical ethics is a useful tool for resolving ethical dilemmas in psychiatry in that clinical aspects of ethical dilemmas can be better articulated then in other methods . The ethical dilemmas unique to psychiatry, such as those related to impairment of autonomy, present a challenge to the method. After considering a case example, we conclude that psychiatrists can best utilise a principles based approach to ethical dilemmas when they combine this with a level of critical reflection in the light of other ethical theories, such as virtue ethics, as well as close consideration of the clinical and social context of the ethical dilemma.

Waiver of individual patient consent in research: when do potential benefits to the community outweigh private rights?

Health services research is important to ensure continued best quality of care, but often uses data obtained without explicit consent for this purpose. Obtaining consent may be difficult for many reasons, but excluding individuals may introduce biases that alter the significance of studies. Approval by ethics committees of a waiver of the need for consent allowed our study to proceed and provide evidence that has led to the implementation of a population-based screening policy for the prospective detection of hereditary non-polyposis colorectal cancer. This screening policy has resulted in more cases being detected routinely with better management for affected patients and their at-risk families. A need for consent would have prohibited this study, and the development of a more efficient screening policy could have been delayed for several more years. Ethics committees can effectively manage the need to uphold basic ethical principles without unnecessarily impeding socially useful research. Committees need to be familiar with the guidelines approved under sections 95 and 95A of the Privacy Act 1988 (Cwlth) in addition to the National Health and Medical Research Council National statement on ethical conduct in research involving humans.

Global bioethics -- myth or reality?

Background

There has been debate on whether a global or unified field of bioethics exists. If bioethics is a unified global field, or at the very least a closely shared way of thinking, then we should expect bioethicists to behave the same way in their academic activities anywhere in the world. This paper investigates whether there is a 'global bioethics' in the sense of a unified academic community.

Methods

To address this question, we study the web-linking patterns of bioethics institutions, the citation patterns of bioethics papers and the buying patterns of bioethics books.

Results

All three analyses indicate that there are geographical and institutional differences in the academic behavior of bioethicists and bioethics institutions.

Conclusion

These exploratory studies support the position that there is no unified global field of bioethics. This is a problem if the only reason is parochialism. But these regional differences are probably of less concern if one notices that bioethics comes in many not always mutually understandable dialects.

What are the moral obligations of the traveller in relation to vaccination?

More and more people each year are involved in international travel for reasons of business and pleasure. Such travel brings great economic and social benefits but it also has serious potential medical costs because it creates greater opportunities for the spread of infectious disease. In this paper, I discuss the ethical issues relating to a traveller's responsibility to be vaccinated against infectious diseases (where such vaccinations exist). What are the relevant moral obligations, in this situation? What are the boundaries of legitimate restrictions that can be placed upon an individual for the sake of protecting others from disease? Do we have extra special obligations to protect others from harm when we choose to travel abroad (beyond those we might have to other people in our own country)? I explore two different arguments suggesting that we do have an obligation to be vaccinated in this case. The first argument is built upon the potential harm to other people that might arise in the case of vaccination-refusal, and the second argument looks at the need to contribute to the preservation of public goods, such as herd protection.