The virtues (and vices) of the four principles

Human flourishing, the goals of medicine and integration of palliative care considerations into intensive care decision-making

Aristotle's ethical system was guided by his vision of human flourishing (also, but potentially misleadingly, translated as happiness). For Aristotle, human flourishing was a rich holistic concept about a life lived well until its ending. Both living a long life and dying well were integral to the Aristotelian ideal of human flourishing. Using Aristotle's concept of human flourishing to inform the goals of medicine has the potential to provide guidance to clinical decision-makers regarding the provision of burdensome treatments, such as intensive care treatment, where pursuing a chance of survival must be balanced against the risk of exposing patients to a negative dying experience. By conceptually uniting potentially competing goals of medicine, such as prolonging life and the promotion of peaceful deaths, Aristotle's understanding of human flourishing creates an argument for the integration of palliative care considerations into intensive care decision-making and for advanced care planning with healthy patients.

Parenteral Nutrition in Pediatric Patients with Neurodisability: Current Perspectives

Pediatric neurodisability describes functional limitations in children with varied severity and complexity often attributed to brain or neuromuscular abnormalities. The life expectancy of children with neurodisability is improving, but many will require significant medical support. The gastrointestinal tract is usually affected in children with neurodisability and can lead to a wide range of symptoms. In gastrointestinal (GI) dystonia, a newly coined term, feeding will trigger a distressing dystonia and symptoms can improve with cessation of feed. Parenteral nutrition (PN) is often viewed as a viable option in severe GI dystonia or when enteral feeding does not support sufficient nutrition. The use of PN in children with severe neurodisability is complex. It involves an intricate interplay between medical, psychological and ethical factors. In the absence of a universally agreed guidance on the use of PN in this cohort, paediatricians should maintain the individual need of the child at the centre of the decision-making process and work closely with families and other healthcare professionals before initiating or withholding PN in children with severe neurodisability. In this article, we discuss the complex and multifaceted approach to the use of PN in children with severe neurodisability and aimed to explore the medical, psychological and ethical aspect dilemmas facing clinicians looking after children with declining gut function who may require PN support.

Harming patients by provision of intensive care treatment: is it right to provide time-limited trials of intensive care to patients with a low chance of survival?

Time-limited trials of intensive care have arisen in response to the increasing demand for intensive care treatment for patients with a low chance of surviving their critical illness, and the clinical uncertainty inherent in intensive care decision-making. Intensive care treatment is reported by most patients to be a significantly unpleasant experience. Therefore, patients who do not survive intensive care treatment are exposed to a negative dying experience. Time-limited trials of intensive care treatment in patients with a low chance of surviving have both a small chance of benefiting this patient group and a high chance of harming them by depriving them of a good death. A 'rule of rescue' for the critically unwell does not justify time-limiting a trial of intensive care treatment and overlooks the experiential costs that intensive care patients face. Offering time-limited trials of intensive care to all patients, regardless of their chance of survival, overlooks the responsibility of resource-limited intensive care clinicians for suffering caused by their actions. A patient-specific risk-benefit analysis is vital when deciding whether to offer intensive care treatment, to ensure that time-limited trials of intensive care are not undertaken for patients who have a much higher chance of being harmed, rather than benefited by the treatment. The virtue ethics concept of human flourishing has the potential to offer additional ethical guidance to resource-limited clinicians facing these complex decisions, involving the balancing of a quantifiable survival benefit against the qualitative suffering that intensive care treatment may cause.

The movement of virtue from ethos to action

In this paper, we explore the concept of virtue in nursing care. We particularly examine the description of 'virtue' offered by Aristotle, who considers it the mental constitution that forms the basis for laudable social behaviour. We then turn to Katie Eriksson's work on caritative caring ethics and draw parallels between the Aristotelian concept of virtue and being a good nurse. Eriksson suggests that embracing an ethos, a set of basic values, affects nurses' attitudes as well as the way they speak and take on their responsibility for the patient. We discuss these ideas in relation to a tentative ideal model of the movement from ethos to action to understand and address nurses' ethical thinking and acting. Here, we focus on the catalytic role of virtue as a means for realizing a deliberate, intentional acting with the best of the patient in mind. As an outcome of our analysis, we suggest that the movement of virtue from ethos to action is most usefully conceptualized as knowledge about facts, habits of the heart, deeds of the hand and the power of words. Implications for nursing leadership are suggested, including incorporating organizational values through the means of ethical conversations.

Modeling Lay People's Ethical Attitudes to Organ Donation: A Q-Methodology Study

BACKGROUND

Organ donation is commonly evaluated by biomedical ethicists based largely on principlism with autonomy at the top of the "moral mountain." Lay people may differ in the way they invoke and balance the various ethical interests. We explored lay people's ethical attitudes to organ donation.

METHODS

Respondents (n=196) ranked 42 opinion-statements on organ donation according to a 9-category symmetrical distribution. Statements' scores were analyzed by averaging-analysis and Q-methodology.

RESULTS

Respondents' mean (SD) age was 34.5 (10.6) years, 53% were women, 69% Muslims (30% Christians), 29% Saudis (26% Filipinos), and 38% healthcare-related. The most-agreeable statements were "Acceptable if benefit to recipient large," "Explicit donor consent and family approval for live donation," "Acceptable if directed to family member," and "Explicit donor consent and family approval for postmortem donation." The most-disagreeable statements were "Donor consent and family approval not required for postmortem donation," "Acceptable with purely materialistic motivation," and "Only donor no-known objection for postmortem donation." Women, Christians, and healthcare respondents gave higher rank to "Explicit donor consent and family approval for live donation," "Only donor family consent required for postmortem donation," and "Acceptable if organ distribution equitable," respectively, and Muslims gave more weight to donor/family harm (p ≤0.001). Q-methodology identified various ethical resolution models that were associated with religious affiliation and included relatively "motives-concerned," "family-benefit-concerned," "familism-oriented," and "religious or non-religious altruism-concerned" models. Of 23 neutral statements on averaging-analysis, 48% and 65% received extreme ranks in ≥1 women and men Q-methodology models, respectively.

CONCLUSION

1) On average, recipient benefit, requirement of both explicit donor consent and family approval, donor-recipient relationship, and motives were predominant considerations; 2) ranking of some statements was associated with respondents' demographics; 3) Q-methodology identified various ethical resolution models that were partially masked by averaging-analysis; and 4) strong virtue and familism approaches in our respondents provide some empirical evidence against principlism adequacy.

Lay People's Ethical Attitudes To Placebo Treatment: A Q-Methodology Study

BACKGROUND

Placebo-treatment acceptability is debated among ethicists, mostly due to conflict between respect-to-autonomy and beneficence principles. It is not clear how lay people balance these and other ethical principles.

METHODS

One hundred and eighty-seven respondents rank-ordered 42 opinion statements covering various ethical aspects of placebo-treatment, according to a 9-category symmetrical distribution. We analyzed statements' scores using averaging-analysis and by-person factor analysis (Q-methodology).

RESULTS

Respondents' mean (SD) age was 34.6 (10.6) years, 54% were women, 40% healthcare-related, 68% Muslims (31% Christians), and 39% received general education in Saudi Arabia (24% in the Philippines). On averaging-analysis, the most-agreeable statements were "Acceptable if benefit to patient large" and "Acceptable with physician intent to benefit patient". The most-disagreeable statements were "Acceptable with physician self-benefit intent" and "Acceptable with large harm to other patients". Muslims gave a higher rank to "Giving no description is acceptable", "Acceptable with small benefit to patient", and "Acceptable with physician intent to benefit patient" and a lower rank to "Acceptable to describe as inactive drug", "Acceptable with physician intent to please patient caring relative", and "Acceptable with moderate harm to other patients" (p<0.01). Q-methodology detected several ethical attitude models that were mostly multi-principled and consequentialism-dominated. The majority of Christian and Philippines-educated women loaded on a "relatively family and deception-concerned" model, whereas the majority of Muslim and Saudi Arabia-educated women loaded on a "relatively common-good-concerned" model. The majority of Christian and healthcare men loaded on a "relatively deception-concerned" model, whereas the majority of Muslim and non-healthcare men loaded on a "relatively motives-concerned" model. Of nine intent-related statements, ≥2 received extreme rank on averaging-analysis and in 100% of women and men models.

CONCLUSION

1) On averaging-analysis, patient's beneficence (consequentialism) followed by physician's intent (virtue ethics) were more important than deception (respect-to-autonomy). 2) Q-methodology identified several ethical attitude models that were mostly multi-principled and associated with respondents' demographics.

Practising Virtue: A challenge to the view that a virtue centred approach to ethics lacks practical content

A virtue centred approach to ethics has been criticized for being vague owing to the nature of its central concept, the paradigm person. From the perspective of the practitioner the most damaging charge is that virtue ethics fails to be action guiding and, in addition to this, it does not offer any means of act appraisal. These criticisms leave virtue ethics in a weak position vis-à-vis traditional approaches to ethics. The criticism is, however, challenged by Hursthouse in her analysis of the accounts of right action offered by deontology, utilitarianism and virtue ethics. It is possible to defend the action guiding nature of virtue ethics: there are virtue rules and exemplars to guide action. Insights from Aristotle’s practical approach to ethics are considered alongside Hursthouse’s analysis and it is suggested that virtue ethics is also capable of facilitating action appraisal. It is at the same time acknowledged that approaches to virtue ethics vary widely and that the challenges offered here would be rejected by those who embrace a radical replacement virtue approach.

Role of the Nasogastric Tube and Lingzhi (Ganoderma lucidum) in Palliative Care

Decision-making on behalf of an incapacitated patient at the end of life is a complex process, particularly in family-centric societies. The situation is more complex when attempts are made to accommodate Eastern concepts of end-of-life care with more conventional Western approaches. In this case report of an incapacitated 74-year-old Singaporean man of Malay descent with relapsed Stage 4 diffuse large B cell lymphoma who was without an established lasting power of attorney, we highlight the difficult deliberations that ensue when the patient's family, acting as his proxy, elected to administer lingzhi through his nasogastric tube (NGT). Focusing on the questions pertaining to end-of-life decision-making in Asia, we consider the issues surrounding the use of NGT and lingzhi in palliative care (PC) and the implementation of NGT for administering lingzhi in a PC setting, particularly in light of a dearth of data on such treatment measures among PC patients.

Declining body, institutional life, and making home-are they at odds? The lived experiences of moving through staged care in long-term care settings

This study examines elderly residential life in long-term care settings, focusing on the ways residents interact with their physical and social environments. It further proposes that the residential environment is an important player for everyday ethics in long-term care settings, and is also an important factor in enhancing the quality of life for residents. By employing the theories of place identity and environmental meanings and listening to the voices of the elderly collected through an ethnographic field study in elderly homes of life care, the study reveals the residents' experiences of going through declining health and moving through the stages of care. Two major themes were identified. The first theme of liminal life portrays the elders' fears as they move through the stages of care. This theme includes four sub-themes: (1) the loss of home and the loss of autonomy; (2) impending loss and its constant reminders; (3) the social classification of "us" and "them"; (4) the irreversibility of moving. The second theme of relational life describes the keys to successful transitions as experienced and told by the residents. The second theme includes three sub-themes: (1) shifting identity and the acceptance of old age; (2) human interdependence and building trust; (3) an accompanied death. Study implications are further discussed, including specific suggestions for social programs and revisions to the physical environments. A more fundamental question about place-based staged care is also raised so as to serve as a point of departure for reflections and discussions amongst health professionals, planners and designers, and other decision-makers.

Defending the four principles approach as a good basis for good medical practice and therefore for good medical ethics

This paper argues that the four prima facie principles-beneficence, non-maleficence, respect for autonomy and justice-afford a good and widely acceptable basis for 'doing good medical ethics'. It confronts objections that the approach is simplistic, incompatible with a virtue-based approach to medicine, that it requires respect for autonomy always to have priority when the principles clash at the expense of clinical obligations to benefit patients and global justice. It agrees that the approach does not provide universalisable methods either for resolving such moral dilemmas arising from conflict between the principles or their derivatives, or universalisable methods for resolving disagreements about the scope of these principles-long acknowledged lacunae but arguably to be found, in practice, with all other approaches to medical ethics. The value of the approach, when properly understood, is to provide a universalisable though prima facie set of moral commitments which all doctors can accept, a basic moral language and a basic moral analytic framework. These can underpin an intercultural 'moral mission statement' for the goals and practice of medicine.

How "moral" are the principles of biomedical ethics?--a cross-domain evaluation of the common morality hypothesis

Background

The principles of biomedical ethics – autonomy, non-maleficence, beneficence, and justice – are of paradigmatic importance for framing ethical problems in medicine and for teaching ethics to medical students and professionals. In order to underline this significance, Tom L. Beauchamp and James F. Childress base the principles in the common morality, i.e. they claim that the principles represent basic moral values shared by all persons committed to morality and are thus grounded in human moral psychology. We empirically investigated the relationship of the principles to other moral and non-moral values that provide orientations in medicine. By way of comparison, we performed a similar analysis for the business & finance domain.

Methods

We evaluated the perceived degree of “morality” of 14 values relevant to medicine (n₁ = 317, students and professionals) and 14 values relevant to business & finance (n₂ = 247, students and professionals). Ratings were made along four dimensions intended to characterize different aspects of morality.

Results

We found that compared to other values, the principles-related values received lower ratings across several dimensions that characterize morality. By interpreting our finding using a clustering and a network analysis approach, we suggest that the principles can be understood as “bridge values” that are connected both to moral and non-moral aspects of ethical dilemmas in medicine. We also found that the social domain (medicine vs. business & finance) influences the degree of perceived morality of values.

Conclusions

Our results are in conflict with the common morality hypothesis of Beauchamp and Childress, which would imply domain-independent high morality ratings of the principles. Our findings support the suggestions by other scholars that the principles of biomedical ethics serve primarily as instruments in deliberated justifications, but lack grounding in a universal “common morality”. We propose that the specific manner in which the principles are taught and discussed in medicine – namely by referring to conflicts requiring a balancing of principles – may partly explain why the degree of perceived “morality” of the principles is lower compared to other moral values.

Towards Principles-Based Approaches to Governance of Health-related Research using Personal Data

Technological advances in the quality, availability and linkage potential of health data for research make the need to develop robust and effective information governance mechanisms more pressing than ever before; they also lead us to question the utility of governance devices used hitherto such as consent and anonymisation. This article assesses and advocates a principles-based approach, contrasting this with traditional rule-based approaches, and proposes a model of principled proportionate governance. It is suggested that the approach not only serves as the basis for good governance in contemporary data linkage but also that it provides a platform to assess legal reforms such as the draft Data Protection Regulation.

Meaning and value in medical school curricula

RATIONALE, AIMS AND OBJECTIVES

Bioethics and professionalism are standard subjects in medical training programmes, and these curricula reflect particular representations of meaning and practice. It is important that these curricula cohere with the actual concerns of practicing clinicians so that students are prepared for real-world practice. We aimed to identify ethical and professional concerns that do not appear to be adequately addressed in standard curricula by comparing ethics curricula with themes that emerged from a qualitative study of medical practitioners.

METHOD

Curriculum analysis: Thirty-two prominent ethics and professionalism curricula were identified through a database search and were analysed thematically. Qualitative study: In-depth, semi-structured interviews were conducted with 20 medical practitioners. Participants were invited to reflect upon their perceptions of the ways in which values matter in their practices and their educational experiences. The themes emerging from the two studies were compared and contrasted.

RESULTS

While representations of meaning and value in ethics and professionalism curricula overlap with the preoccupations of practicing clinicians, there are significant aspects of 'real-world' clinical practice that are largely ignored. These fell into two broad domains: (1) 'sociological' concerns about enculturation, bureaucracy, intra-professional relationships, and public perceptions of medicine; and (2) epistemic concerns about making good decisions, balancing different kinds of knowledge, and practising within the bounds of professional protocols.

CONCLUSIONS

Our findings support the view that philosophy and sociology should be included in medical school and specialty training curricula. Curricula should be reframed to introduce students to habits of thought that recognize the need for critical reflection on the social processes in which they are embedded, and on the philosophical assumptions that underpin their practice.

Virtuous acts as practical medical ethics: an empirical study

RATIONALE, AIMS AND OBJECTIVES

To examine the nature, scope and significance of virtues in the biographies of medical practitioners and to determine what kind of virtues are at play in their ethical behaviour and reflection.

METHODS

A case study involving 19 medical practitioners associated with the Sydney Medical School, using semi-structured narrative interviews. Narrative data were analysed using dialectical empiricism, constant comparison and iterative reformulation of research questions.

RESULTS

Participants represented virtuous acts as centrally important in their moral assessments of both themselves and others. Acts appeared to be contextually virtuous, rather than expressions of stable character traits, and virtue was linked to acts that served to protect or enhance fundamental values attached to ontological security and human flourishing. Virtue ethics, in this sense, was the single most important ethical system for each of the participants.

CONCLUSION

Virtue ethics, construed as the appraisal of acts in contexts of risk, danger or threat to foundational values, emerged as the 'natural' ethical approach for medical practitioners in this case study. Teaching medical ethics to students and graduates alike needs to accommodate the priority attached to virtuous acts.

Nasogastric feeding at the end of life: A virtue ethics approach

The use of Nasogastric (NG) feeding in the provision of artificial nutrition and hydration at the end of life has, for the most part, been regarded as futile by the medical community. This position has been led chiefly by prevailing medical data. In Singapore, however, there has been an increase in its utilization supported primarily by social, religious and cultural factors expressly to prolong life of the terminally ill patient. Here this article will seek to review the ethical and clinical impact of this treatment and provide some understanding for such decisions in the light of the Duty of Palliative Care [DoPC]. Complemented by virtue ethics theory, the DoPC highlights and seeks to realize the individual case specific goals of care that maximize comfort and quality of life of the patient in the face of rapid attenuation of treatment options and the eminence of the final outcome by considering each of these factors individually in order to provide the best outcome for the patient and the family.

Which medical error to disclose to patients and by whom? Public preference and perceptions of norm and current practice

Background

Disclosure of near miss medical error (ME) and who should disclose ME to patients continue to be controversial. Further, available recommendations on disclosure of ME have emerged largely in Western culture; their suitability to Islamic/Arabic culture is not known.

Methods

We surveyed 902 individuals attending the outpatient's clinics of a tertiary care hospital in Saudi Arabia. Personal preference and perceptions of norm and current practice regarding which ME to be disclosed (5 options: don't disclose; disclose if associated with major, moderate, or minor harm; disclose near miss) and by whom (6 options: any employee, any physician, at-fault-physician, manager of at-fault-physician, medical director, or chief executive director) were explored.

Results

Mean (SD) age of respondents was 33.9 (10) year, 47% were males, 90% Saudis, 37% patients, 49% employed, and 61% with college or higher education. The percentage (95% confidence interval) of respondents who preferred to be informed of harmful ME, of near miss ME, or by at-fault physician were 60.0% (56.8 to 63.2), 35.5% (32.4 to 38.6), and 59.7% (56.5 to 63.0), respectively. Respectively, 68.2% (65.2 to 71.2) and 17.3% (14.7 to 19.8) believed that as currently practiced, harmful ME and near miss ME are disclosed, and 34.0% (30.7 to 37.4) that ME are disclosed by at-fault-physician. Distributions of perception of norm and preference were similar but significantly different from the distribution of perception of current practice (P < 0.001). In a forward stepwise regression analysis, older age, female gender, and being healthy predicted preference of disclosure of near miss ME, while younger age and male gender predicted preference of no-disclosure of ME. Female gender also predicted preferring disclosure by the at-fault-physician.

Conclusions

We conclude that: 1) there is a considerable diversity in preferences and perceptions of norm and current practice among respondents regarding which ME to be disclosed and by whom, 2) Distributions of preference and perception of norm were similar but significantly different from the distribution of perception of current practice, 3) most respondents preferred to be informed of ME and by at-fault physician, and 4) one third of respondents preferred to be informed of near-miss ME, with a higher percentage among females, older, and healthy individuals.

The revised APTA code of ethics for the physical therapist and standards of ethical conduct for the physical therapist assistant: theory, purpose, process, and significance

INTRODUCTION

In June 2009, the House of Delegates (HOD) of the American Physical Therapy Association (APTA) passed a major revision of the APTA Code of Ethics for physical therapists and the Standards of Ethical Conduct for the Physical Therapist Assistant. The revised documents will be effective July 1, 2010.

PURPOSE

The purposes of this article are: (1) to provide a historical, professional, and theoretical context for this important revision; (2) to describe the 4-year revision process; (3) to examine major features of the documents; and (4) to discuss the significance of the revisions from the perspective of the maturation of physical therapy as a doctoring profession. PROCESS OF REVISION: The process for revision is delineated within the context of history and the Bylaws of APTA. FORMAT, STRUCTURE, AND CONTENT OF REVISED CORE ETHICS DOCUMENTS: The revised documents represent a significant change in format, level of detail, and scope of application. Previous APTA Codes of Ethics and Standards of Ethical Conduct for the Physical Therapist Assistant have delineated very broad general principles, with specific obligations spelled out in the Ethics and Judicial Committee's Guide for Professional Conduct and Guide for Conduct of the Physical Therapist Assistant. In contrast to the current documents, the revised documents address all 5 roles of the physical therapist, delineate ethical obligations in organizational and business contexts, and align with the tenets of Vision 2020.

SIGNIFICANCE

The significance of this revision is discussed within historical parameters, the implications for physical therapists and physical therapist assistants, the maturation of the profession, societal accountability and moral community, potential regulatory implications, and the inclusive and deliberative process of moral dialogue by which changes were developed, revised, and approved.

Experienced speech-language pathologists' responses to ethical dilemmas: an integrated approach to ethical reasoning

PURPOSE

To investigate the approaches of experienced speech-language pathologists (SLPs) to ethical reasoning and the processes they use to resolve ethical dilemmas.

METHOD

Ten experienced SLPs participated in in-depth interviews. A narrative approach was used to guide participants' descriptions of how they resolved ethical dilemmas. Individual narrative transcriptions were analyzed by using the participant's words to develop an ethical story that described and interpreted their responses to dilemmas. Key concepts from individual stories were then coded into group themes to reflect participants' reasoning processes.

RESULTS

Five major themes reflected participants' approaches to ethical reasoning: (a) focusing on the well-being of the client, (b) fulfilling professional roles and responsibilities, (c) attending to professional relationships, (d) managing resources, and (e) integrating personal and professional values. SLPs demonstrated a range of ethical reasoning processes: applying bioethical principles, casuistry, and narrative reasoning when managing ethical dilemmas in the workplace.

CONCLUSIONS

The results indicate that experienced SLPs adopted an integrated approach to ethical reasoning. They supported clients' rights to make health care choices. Bioethical principles, casuistry, and narrative reasoning provided useful frameworks for facilitating health professionals' application of codes of ethics to complex professional practice issues.

Redressing the balance in mental health nursing education: arguments for a values-based approach

Evidence-based practice (EBP) has become a dominant epistemology in nursing education, and has devalued the complex interpersonal components of mental health nursing. A curriculum for mental health nursing, which values the personhood of service users, should focus on those processes that promote recovery within a therapeutic relationship committed to collaboration and respect for diversity. These relationships become possible where the preparation of mental health nurses for practice includes an examination of self in terms of beliefs and values and their consequences on others. The combination of action and reflection in praxis provides a means by which self-examination and professional obligation can be examined in order to construct a moral identity, which is responsive to the needs of people with mental health problems. Praxis is more than a means of reflecting on practice: it draws together skill, practice knowledge, attitudinal style, and moral reasoning. For this reason, ethical values have a vital role to play in the development of contemporary nursing praxis.

Observational research in trauma radiology: should patients be informed?

The need for prospective studies in trauma radiology emerges as knowledge on the appropriate use of imaging becomes increasingly important in this field. Prospective observational studies enroll patients after research questions are articulated but only observe medical practice and should not compromise or change patient treatment. However, controversy exists regarding the requirement of informed consent from trauma patients in this type of study. This is reflected not only in differences in reporting informed consent in recent scientific publications on trauma radiology but also by the fact that policies regarding this topic vary in different parts of the world. The authors consider whether requesting informed consent is appropriate in prospective observational studies in trauma radiology from practical and different ethical perspectives.

Overview of psychiatric ethics V: utilitarianism and the ethics of duty

OBJECTIVE

The aim of this paper is to describe the ethical theories of utilitarianism and the ethics of duty (Kant's ethics) and to evaluate their value as theoretical bases of psychiatric ethics.

CONCLUSIONS

Utilitarianism is a well-established moral philosophy and has significant instrumental value in dealing with common ethical problems faced by psychiatrists. Despite its capacity to generate solutions to ethical problems, utilitarianism requires a process of what Rawls described as 'reflective equilibrium' to avoid morally repugnant choices, based on utility. The criticisms of utilitarianism, such as the problems of quantifying utility and the responsibility for consequences, are very relevant for psychiatry. Singer's model of utilitarian thinking is particularly problematic for our profession. Kant's ethics provides the pretext for duty bound codes of ethics for psychiatrists, but suffers from problems of flawed claims to the universalizability prescribed by Kant's 'categorical imperative'. Kant's valorization of reason as the core of the autonomy of persons is a valuable insight in understanding psychiatrists' ethical obligations to their patients.

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.

The ethics of cesarean section by choice

In responding to patient requests for cesarean section, physicians must consider ethical principles. Obstetricians have autonomy and beneficence-based obligations to the mother, and the mother and the obstetrician have beneficence-based obligations to the fetus. Maternal autonomy is usually accepted as the most compelling ethical canon. However, the physician has a right to refuse requests. Thus, when a patient requests surgery, the physician may attempt to dissuade her and failing that either acquiesce or, feeling that professional conscience would not allow him/her to honor that request, refuse. Which choice is made should reflect the provider's believe about the strength of the supporting data. Given the need to recognize patient autonomy, to respect patient values even as one tries to motivate patients to work toward the highest health values, and to acknowledge women's primacy as fetal champions, a physician should be loathe to refuse unless the data regarding cesarean section by choice are wholly tilted away from maternal-child interests. If the data are in the realm of equipoise, even if not at the tipping point, discussing options, attempting to dissuade patients but ultimately acquiescing to their judgment would not be incompatible with obstetrical ethics.

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

Raanan Gillon is a noted defender of the four principles approach to healthcare ethics. His general position has always been that these principles are to be considered to be both universal and prima facie in nature. In recent work, however, he has made two claims that seem to present difficulties for this view. His first claim is that one of these four principles, respect for autonomy, has a special position in relation to the others: he holds that it is first among equals. We argue that this claim makes little sense if the principles are to retain their prima facie nature. His second claim is that cultural variation can play an independent normative role in the construction of our moral judgments. This, he argues, enables us to occupy a middle ground between what he sees as the twin pitfalls of moral relativism and (what he calls) moral imperialism. We argue that there is no such middle ground, and while Gillon ultimately seems committed to relativism, it is some form of moral imperialism (in the form of moral objectivism) that will provide the only satisfactory construal of the four principles as prima facie universal moral principles.

The dangers of medical ethics

The dominant conception of medical ethics being taught in British and American medical schools is at best pointless and at worst dangerous, or so it will be argued. Although it is laudable that medical schools have now given medical ethics a secure place in the curriculum, they go wrong in treating it like a scientific body of knowledge. Ethics is a unique subject matter precisely because of its widespread familiarity in all areas of life, and any teaching has to start from this shared ethical understanding and from the familiar ethical concepts of ordinary language. Otherwise there is a real risk that spurious technocratic jargon will be deployed by teacher and student alike in the futile search for intellectual respectability, culminating in a misplaced sense of having "done" the ethics module. There are no better examples of such jargon than "consequentialism", "deontology", and the "Four Principles". At best, they cannot do the work they were designed to do and, at worst, they can lead student and practitioner into ignoring their own healthy ethical intuitions and vocabulary.