Asymmetry in judgments of moral blame and praise: the role of perceived metadesires

An important consideration in judging the blameworthiness (or praiseworthiness) of an action is whether the agent had sufficient control over it. In three experiments, we investigated judgments of moral blame and praise elicited when individuals were presented with vignettes describing actions that were performed either carefully and deliberately or impulsively and uncontrollably. Experiment 1 uncovered an asymmetry between judgments of positive versus negative actions--negative impulsive actions elicited a discounting of moral blame, but positive impulsive actions did not elicit a discounting of moral praise. Experiments 2 and 3 showed that this asymmetry arises because individuals judge agents on the basis of their metadesires (the degree to which the agents embrace or reject the impulses leading to their actions). Individuals assume that an agent would embrace an uncontrollable positive impulse, and reject an uncontrollable negative impulse.

Age-related differences in responses to thoughts of one's own death: mortality salience and judgments of moral transgressions

Two experiments explored age differences in response to reminders of death. Terror management research has shown that death reminders lead to increased adherence to and defense of one's cultural worldview. In Study 1, the effect of mortality salience (MS) on evaluations of moral transgressions made by younger and older adults was compared. Whereas younger adults showed the typical pattern of harsher judgments in response to MS, older adults did not. Study 2 compared younger and older adults' responses to both the typical MS induction and a more subtle death reminder. Whereas younger adults responded to both MS inductions with harsher evaluations, older adults made significantly less harsh evaluations after the subtle MS induction. Explanations for this developmental shift in responses to reminders of death are discussed.

Affective response to one's own moral violations

Morality depends on a set of cultural rules that regulate interpersonal behaviour and provide a basis for social cohesion. The interpretation of moral transgressions and their affective consequences depends on whether the action is intentional or accidental, and whether one is the agent of or witness to the action. We used event-related functional magnetic resonance imaging (fMRI) to investigate whether the amygdala is involved in judging one's own moral violation of social norms. In this study, participants (n = 12) were asked to make evaluations regarding the degree of inappropriateness of social behaviours described in stories in which they themselves, or someone else, transgressed social norms either intentionally or accidentally. Consistent with our hypothesis, the amygdala was activated when participants considered stories narrating their own intentional transgression of social norms. This result suggests the amygdala is important for affective responsiveness to moral transgressions.

A defense of the common morality

Phenomena of moral conflict and disagreement have led writers in ethics to two antithetical conclusions: Either valid moral distinctions hold universally or they hold relative to a particular and contingent moral framework, and so cannot be applied with universal validly. Responding to three articles in this issue of the Journal that criticize his previously published views on the common morality, the author maintains that one can consistently deny universality to some justified moral norms and claim universality for others. Universality is located on the common morality and nonuniversality in other parts of the moral life, called "particular moralities." The existence of universal moral standards is defended in terms of: (1) a theory of the objectives of morality, (2) an account of the norms that achieve those objectives, and (3) an account of normative justification (both pragmatic and coherentist).

Risk assessment in mental health care: values and costs

Risk assessment has assumed increasing salience in mental health care in a number of countries. The frequency of serious violent incidents perpetrated by people with a mental illness is an insufficient explanation. Understandings of mental illness and of the role of those charged with their care (or control) play a key role. "Moral outrage", associated with an implied culpability when certain types of tragedy occur, is very significant. This leads to tensions concerning the role of post-incident inquiries, and contributes to a flawed conception of what such inquiries can offer. At the same time, understanding of probability and prediction is generally very poor, among both professionals and the public. Unrealistic expectations for risk assessment and management in general psychiatric practice carry a variety of significant costs, taking a number forms, to those with a mental illness, to mental health professionals and to services. Especially important are changes in professional practice and accountabilities that are significantly divorced from traditional practice, implications for trust in patient-clinician relationships and the organisations in which mental health professionals work, and practices that often breach the ethical principle of justice (or fairness) and heighten discrimination against people with mental illness.

Are Patients With Self-Inflicted Injuries More Likely to Die?

BACKGROUND

Suicide represents one of the leading causes of trauma in industrialized countries. However, when compared with unintentional injury and assault, the outcome of self-inflicted injury has not been well described.

METHODS

All patients admitted to a French academic trauma center from January 2002 to December 2004 and listed in a trauma data bank were included in a prospective analysis. Variables including mortality, circumstances (unintentional vs. assault vs. self-inflicted), and mechanism of injury were recorded.

RESULTS

About 1,004 continuous trauma patients were analyzed: 151 (15%) with self-inflicted injuries, 761 (76%) with unintentional injuries, and 91 (9%) with injuries from assault. When compared with patients suffering from unintentional injuries and assault, self-inflicted injury patients presented more frequently after a fall from height (94 of 151 vs. 133 of 759 and 0 of 91, p < 0.05) and with a severe head injury (47 of 151 vs. 172 of 752 and 10 of 91, p < 0.05). They also had a more severe injury (Injury Severity Score, 28 +/- 21 vs. 22 +/- 16 and 12 +/- 10; p < 0.05), a lower probability of survival (Trauma Related Injury Severity Score, 0.71 +/- 0.37 vs. 0.83 +/- 0.28 and 0.92 +/- 0.19; p < 0.05), and survival rate (70% vs. 85% and 93%, p < 0.05). In multivariate analysis, Trauma Related Injury Severity Score (odds ratio, 0.54; 95% confidence interval, 0.45-0.59; p < 0.001), age (odds ratio, 1.17; confidence interval, 1.02-1.34; p < 0.05), and mechanism of trauma (p = 0.01) were independently correlated with the final mortality rate.

CONCLUSIONS

Self-inflicted injury patients presented with a higher mortality rate that was related to increased injury severity. The circumstances surrounding the trauma were not independently associated with an increased odds ratio of death after major trauma.

Dubious premises--evil conclusions: moral reasoning at the Nuremberg trials

Fifty years ago, 23 Nazi physicians were defendants before a military tribunal in Nuremberg, charged with crimes against humanity. During that trial, the world learned of their personal roles in human experimentation with political and military prisoners, mass eugenic sterilizations, state-ordered euthanasia of the “unfit,” and the program of genocide we now know as the Holocaust. These physicians, and their colleagues who did not stand trial, were universally condemned in the free world as ethical pariahs. The term “Nazi doctor” became the paradigm for total defection from the most rudimentary elements of medical morality. The caduceus literally became the instrument of the swastika.

A theory of international bioethics: multiculturalism, postmodernism, and the bankruptcy of fundamentalism

The first of two articles analyzing the justifiability of international bioethical codes and of cross-cultural moral judgments reviews "moral fundamentalism," the theory that cross-cultural moral judgments and international bioethical codes are justified by certain "basic" or "fundamental" moral priniciples that are universally accepted in all cultures and eras. Initially propounded by the judges at the 1947 Nuremberg Tribunal, moral fundamentalism has become the received justification of international bioethics, and of cross-temporal and cross-cultural moral judgments. Yet today we are said to live in a multicultural and postmodern world. This article assesses the challenges that multiculturalism and postmodernism pose to fundamentalism and concludes that these challenges render the position philosophically untenable, thereby undermining the received conception of the foundations of international bioethics. The second article, which follows, offers an alternative model -- a model of negotiated moral order -- as a viable justification for international bioethics and for transcultural and transtemporal moral judgments.

Zones of consensus and zones of conflict: questioning the "common morality" presumption in bioethics

Many bioethicists assume that morality is in a state of wide reflective equilibrium. According to this model of moral deliberation, public policymaking can build upon a core common morality that is pretheoretical and provides a basis for practical reasoning. Proponents of the common morality approach to moral deliberation make three assumptions that deserve to be viewed with skepticism. First, they commonly assume that there is a universal, transhistorical common morality that can serve as a normative baseline for judging various actions and practices. Second, advocates of the common morality approach assume that the common morality is in a state of relatively stable, ordered, wide reflective equilibrium. Third, casuists, principlists, and other proponents of common morality approaches assume that the common morality can serve as a basis for the specification of particular policies and practical recommendations. These three claims fail to recognize the plural moral traditions that are found in multicultural, multiethnic, multifaith societies such as the United States and Canada. A more realistic recognition of multiple moral traditions in pluralist societies would be considerable more skeptical about the contributions that common morality approaches in bioethics can make to resolving contentious moral issues.

Regret among primary care physicians: a survey of diagnostic decisions

BACKGROUND

Experienced and anticipated regret influence physicians' decision-making. In medicine, diagnostic decisions and diagnostic errors can have a severe impact on both patients and physicians. Little empirical research exists on regret experienced by physicians when they make diagnostic decisions in primary care that later prove inappropriate or incorrect. The aim of this study was to explore the experience of regret following diagnostic decisions in primary care.

METHODS

In this qualitative study, we used an online questionnaire on a sample of German primary care physicians. We asked participants to report on cases in which the final diagnosis differed from their original opinion, and in which treatment was at the very least delayed, possibly resulting in harm to the patient. We asked about original and final diagnoses, illness trajectories, and the reactions of other physicians, patients and relatives. We used thematic analysis to assess the data, supported by MAXQDA 11 and Microsoft Excel 2016.

RESULTS

29 GPs described one case each (14 female/15 male patients, aged 1.5-80 years, response rate < 1%). In 26 of 29 cases, the final diagnosis was more serious than the original diagnosis. In two cases, the diagnoses were equally serious, and in one case less serious. Clinical trajectories and the reactions of patients and relatives differed widely. Although only one third of cases involved preventable harm to patients, the vast majority (27 of 29) of physicians expressed deep feelings of regret.

CONCLUSION

Even if harm to patients is unavoidable, regret following diagnostic decisions can be devastating for clinicians, making them 'second victims'. Procedures and tools are needed to analyse cases involving undesirable diagnostic events, so that 'true' diagnostic errors, in which harm could have been prevented, can be distinguished from others. Further studies should also explore how physicians can be supported in dealing with such events in order to prevent them from practicing defensive medicine.

Health care quality in end-of-life care: promoting palliative care in the intensive care unit

Seminal articles published in the late 1990s instigated not only an intense interest in health care quality but also a new era of research into quality end-of-life care, particularly in intensive care units (ICUs). ICUs can improve health care quality at the end of life by better using palliative care services and palliative care-related principles. This article details how the interest in health care quality has spurred a similar interest in end-of-life and palliative care in ICUs, defines palliative care and describes how it improves health care quality, and highlights barriers to the incorporation of palliative care in ICUs.

A theory of international bioethics: the negotiable and the non-negotiable

The preceding article in this issue of the Kennedy Institute of Ethics Journal presents the argument that "moral fundamentalism," the position that international bioethics rests on "basic" or "fundamental" moral prinicples that are universally accepted in all eras and cultures, collapses under a variety of multicultural and postmodern critiques. The present article looks to the contractarian tradition of Hobbes and Locke -- as reinterpreted by David Gauthier, Robert Nozick, and John Rawls -- for an alternative justification for international bioethics. Drawing on the central themes of this tradition, it is argued that international bioethics can be rationally reconstructed as a negotiated moral order that respects culturally and individually defined areas of nonnegotiability. Further, the theory of a negotiated moral order is consistent with traditional ideals about human rights, is flexible enough to absorb the genuine insights of multiculturalism and postmodernism, and yet is strong enough to justify transcultural and transtemporal moral judgments, including the condemnation of the Nazi doctors at Nuremberg. This theory also is consistent with the history of the ethics of human subjects experimentation and offers insights into current controversies such as the controversy over changing the consent rule for experiments in emergency medicine and the controversy over exempting certain clinical trials of inexpensive treatments for preventing the perinatal transmission of AIDS from the ethical standards of the sponsoring country.

The Stateville penitentiary malaria experiments: a case study in retrospective ethical assessment

During World War II, malaria research was conducted in prisons. A notable example was the experiments at Stateville Penitentiary in Illinois, in which prisoner-subjects were infected with malaria for the purpose of testing the safety and efficacy of novel anti-malaria drugs. Over time, commentators have shifted from viewing the malaria research at Stateville as a model of ethical clinical research to seeing the experiments as paradigmatic of abusive human experimentation. This essay undertakes a retrospective ethical assessment of the Stateville malaria research during the 1940s in light of basic ethical principles and the Nuremberg Code, as well as contemporary malaria research. In addition to its historical interest, this case study provides a rich context for addressing basic issues of research ethics, including the voluntariness of consent, the justification of risks, and the exploitation of vulnerable subjects.

A defense of fundamental principles and human rights: a reply to Robert Baker

This article seeks to rebut Robert Baker's contention that attempts to ground international bioethics in fundamental principles cannot withstand the challenges posed by multiculturalism and postmodernism. First, several corrections are provided of Baker's account of the conclusions reached by the Advisory Committee on Human Radiation Experiments. Second, a rebuttal is offered to Baker's claim that an unbridgeable moral gap exists between Western individualism and non-Western communalism. In conclusion, this article argues that Baker's "nonnegotiable primary goods" cannot do the work of "classical human rights" and that the latter framework is preferable from both a practical and a theoretical standpoint.

Construction of a Scale for Measuring Development of Moral Judgement

The present research is a part of a study done to develop an objective measure of the development of moral judgement according to Kohlberg's theoretical construct. The Padua Scale of Moral Judgement and the relationship between empirical data and theory are presented. The scale was constructed from responses to the Sociomoral Reflection Measure–Short Form derived from Kohlberg's Moral Judgement Interview. Reliability and validity of the new scale as well as group age and sex differences were examined.

Distinguishing the Effects of Life Threat, Killing Enemy Combatants, and Unjust War Events in U.S. Service Members

Although previous studies have identified behavioral health risks associated with combat exposure, it is unclear which types of combat events are associated with these risks, particularly regarding contrasts among the risks associated with life-threatening experiences, killing combatants, and exposure to unjust war events, such as killing a noncombatant or being unable to help civilian women and children. In the present study, we examined surveys from 402 soldiers following deployment (i.e., baseline) and again 13 months later (i.e., Year 1). Regression analyses were conducted across a range of behavioral health (e.g., posttraumatic stress disorder, depression, suicide ideation, anxiety, somatic, insomnia, aggression) and benefit-finding measures, each controlling for two combat event categories while assessing the predictive utility of a third. The results suggested that life-threatening events were associated with poor behavioral health at baseline, relative risk (RR) = 10.00, but not at Year 1, RR = 2.67. At both baseline and Year 1, killing enemy combatants was not associated with behavioral health, RRs = 1.67-3.33, but was positively associated with benefit-finding, RRs = 26.67-40.00. Exposure to unjust war events was associated with a transdiagnostic pattern of behavioral health symptoms at baseline, RR = 40.00, and Year 1, RR = 23.33. Overall, the results suggest unjust war event exposure is particularly injurious, above and beyond exposure to other combat-related events. Future research can build on these findings to develop clearer descriptions of the combat events that might place service members at risk for moral injury and inform the development of assessment and treatment options.

Loathing the sinner, medicalizing the sin: why sexually violent predator statutes are unjust

In seventeen states, persons convicted of one or more sexually violent offenses may be involuntarily civilly committed at the end of their criminal terms if they suffer from a mental disorder that renders them likely to reoffend sexually. These statutes place the burden on states to show that the sex offender meets the United States Constitutional standard of dangerousness. The key to proving dangerousness is proof of a mental disorder. However, the United States Supreme Court recently found that the offender need not be mentally ill. He need only "suffer" from "mental abnormality" or "personality disorder" that affects his cognitive, emotional or volitional capacities such that he is highly likely to sexually reoffend. These statutes are expressions of disgust: a fear of contamination by persons who engage in sexual conduct that forces us to confront our dark impulses. We do not merely hate the sin; we hate the sinner, and we want the sinner to be removed from our presence. Moreover, the emotions these statutes express are the source of widespread moral panic not warranted by data about recidivism risk. Laws that express disgust are likely to result in the unjust treatment of sex offenders.

Looking back and judging our predecessors

The Advisory Committee on Human Radiation Experiments has correctly argued that persons and institutions can sometimes be held responsible for actions taken more than a half-century ago, when practices and policies on the use of research subjects were strikingly different. In reaching its conclusions, the Committee did not altogether adhere to the language and commitments of its own ethical framework. In its Final Report, the Committee emphasizes judgments of wrongdoing, to the relative neglect of culpability; it discusses mitigating conditions that are exculpatory, but does not provide a thoroughgoing assessment of either culpability or exculpation. However, the Committee's shortcomings are mild in comparison to the deficiencies in the "Report of the UCSF Ad Hoc Fact Finding Committee on World War II Human Radiation Experiments" of the University of California at San Francisco. The latter report reaches no significant judgments of either wrongdoing or culpability. The findings that should have been reached by both committees are discussed.

A multi-institutional report of peri-operative and functional outcomes after robot-assisted partial nephrectomy in patients with a solitary kidney

To evaluate peri- and post-operative outcomes after robotic partial nephrectomy (RPN) in patients with a solitary kidney. A multi-institutional database of 1868 patients was used to identify 35 patients with a solitary kidney who underwent RPN at six different centers from 2007 to 2016. Peri-operative outcomes were summarized with descriptive statistics. We assessed the change in eGFR over time with a linear mixed-effects model. Median operative time, ischemia time, and estimated blood loss were 172 min, 16 min, and 113 mL, respectively. There were no positive surgical margins. The median length of stay was 1 day (range 1-7), and over half (54.3%) of patients were discharged one post-operative day 1. Seven post-operative complications occurred in six patients (17.1%); of which four were Clavien I, two were Clavien II, and one was Clavien III. The linear decline in eGFR up to 24 month post-RPN was marginal and not significant (ß = - 0.14; 95% CI = - 0.51, 0.23; p = 0.453), with predicted mean eGFR decreasing from 59.2 to 55.8 mL/min/1.73 m² at 24 months. These results suggest that, in patients with a solitary kidney, RPN is a safe and feasible treatment option. In patients with a solitary kidney, RPN did not significantly compromise renal function for up to 2 years after surgery.