Bridging the Gap Between Theory and Practice: Philosophy Through a Wide-Angle Lens

Bridging the Gap Between Theory and Practice: Philosophy Through a Wide-Angle Lens Abstract Philosophers who specialize in bioethics (broadly defined to include health care ethics, clinical ethics, public health ethics, and research ethics among other applied fields) face a distinctive set of challenges in our work: to bring the theoretical insights of philosophical work and methodology to practical dilemmas affecting a diverse group of stakeholders every day. This article describes some of the key contributions that philosophy can make to the field of bioethics. It also identifies some of the pitfalls that can undermine the value of a philosophical approach when used to analyze questions arising in the real world. Recognition of the importance of individual context, practical implications, and social considerations can help successfully bridge the gap between theory and practice. Using this wide-angle lens to view bioethical problems can enable philosophers working in our field to offer insights that are both rigorous and relevant. bioethics, practical dilemmas, theoretical insights I. INTRODUCTION Philosophers who specialize in bioethics (broadly defined to include health care ethics, clinical ethics, public health ethics, and research ethics among other applied fields) face a distinctive set of challenges in our work. We seek to maintain the high standards of analytical rigor demanded by our home discipline but must do so in a way that is accessible to those without philosophical training. We attempt to be precise in terminology that is used in many different ways in many different contexts. We strive to identify and question assumptions that are considered self-evident by those with other experiences and backgrounds. In essence, our aim is to bring the theoretical insights of philosophical work and methodology to practical dilemmas affecting a diverse group of stakeholders every day. The challenge of bridging the gap between ideal and real worlds makes working in bioethics both difficult and rewarding to do well. II. PHILOSOPHY’S CONTRIBUTION TO CLINICAL PRACTICE Good philosophy has much to contribute to bioethics; philosophical tools are often used in our scholarly work and in practice. Over the last 50 years, our field has grown and developed into a multidisciplinary, interprofessional endeavor that draws on empirical data, normative analysis, artistic inspiration, legal guidelines, policy considerations, personal narrative, and spiritual insight. As we immerse ourselves in these varied approaches, we should keep in mind that many philosophers were among the founders of our field and it has been argued that philosophy remains essential to progress in bioethics (Savulescu, 2015). The following tools and others can be used in bioethics to help move our thinking forward in a rigorous way. While not unique to philosophy, the habit of defining key terms and distinguishing among similar concepts is a hallmark of good philosophical work. This can be particularly important when using theoretical ideas in practice; when patients and clinicians use the same term to refer to different things, the conversation is unlikely to go well. Paradigmatic examples of this type of work include clarification of the concept of medical futility (Tomlinson, 1988; Schneiderman, Jecker, and Jonsen, 1990) and articulation of varied definitions of brain death (Halevy and Brody, 1993). These pieces led the dialogue and debate on these controversial topics out of conceptual quagmire and into practical use. Philosophers are also trained to break down claims into their core components, identifying premises and assumptions that can be analyzed for their individual veracity and collective soundness. This technique has been particularly valuable for analyzing complex issues such a personal identity, societal well-being, and moral responsibility (Parfit, 1984). Such components can then be used as building blocks for discussion and negotiation among members of society with differing world-views (Engelhardt, 1996). We use thought experiments to test hypotheses and to illustrate the importance of relevant facts. A classic example of the use of this approach is James Rachels’ (1975) “Active and Passive Euthanasia” published in the New England Journal of Medicine. This piece demonstrated the now-widely-accepted moral equivalence between withholding and withdrawing medical treatment, dramatically impacting the ethical evaluation of decisions at the end of life. Thought experiments catch readers’ attention and invite them to reach their own conclusions, isolating the morally relevant pieces of information. The resulting insights can then be applied to challenges facing health care providers on a daily basis. The practice of intentionally assuming key premises or bracketing particular considerations can facilitate focused analysis of a question of special interest. In some cases, this technique can help to simplify an issue for discussion to bring the most important considerations to the forefront. In other cases, like that of “A Defense of Abortion” by Judith Jarvis Thomson (1971), an author grants to her critics a central, controversial premise that she may not hold with the intention of creating an argument that even those critics should find compelling. This technique could be particularly useful in resolving challenging questions that arise in the context of today’s pluralistic society. By anticipating objections that could be raised by a reader or interlocutor, we make our arguments stronger and avoid misunderstandings. Considering the views of others in a fair and robust way demonstrates respect for those who may hold different positions on controversial issues. Doing so may also make possible compromise positions that would not have otherwise been seen as viable by those entrenched on either side (Buchanan, 1988). III. PHILOSOPHY’S DRAWBACKS FOR CLINICAL PRACTICE There are, however, potential hazards of using a traditional philosophical approach to real-world questions of which we must remain aware. Scholars and educators may become so focused on conceptual distinctions, semantic differences, or nuanced details that we fail to demonstrate how those considerations matter in practice. Describing principled resolutions without taking the realities of their implementation into account can generate skepticism about the value a philosophical approach has to offer. Similarly, although the use of hypothetical scenarios can be helpful in illustrating key points, when those scenarios become too far removed from actual possible cases or events they may lose their intuitive force or educational value. We may at times be so interested in exploring the various facets of a question that our audiences could not be blamed for arriving at the conclusion that there are no “right” answers to problems in ethics. These pitfalls are avoidable, but bioethicists can only navigate around them if they are cognizant of their existence. Health care professionals, bench scientists, and policy-makers deal with messy realities, not with the cleaned-up, theoretical versions of problems that philosophers sometimes prefer to deal in. Simplifying and abstracting problems to the point that we can conduct clear and concise theoretical analyses risks making those analyses irrelevant unless we are willing and able to take our work a step further, showing clearly how our arguments and conclusions can inform daily practice. We need to take seriously the complexity of questions arising in the real world and offer adequately nuanced answers in response. We need to consider how context can shape both the way problems are defined and solutions are implemented. This is not to say that streamlined, theoretical analysis is never appropriate, only that it alone is rarely sufficient for resolving real-world issues. It is a necessary step for laying a solid foundation on which further work can be built. Bioethicists must maintain awareness of our audiences, have humility about the scope of the conclusions we draw, and appreciate the challenges of developing and offering guidance meant to have an impact on actual practice. IV. INCLUSIVE PHILOSOPHICAL APPROACHES TO PRACTICAL PROBLEMS The papers in this issue of Journal of Medicine and Philosophy accept these challenges head-on. They take a broad, inclusive perspective on problems that have often been viewed through a narrowly focused lens. The authors take into account the embedded nature of the issues they discuss, considering social, practical, and policy-related aspects of genomic screening, withdrawal of life-sustaining support, and research with human subjects. In doing so, they move the dialogue about these important issues forward. In “Chromosome Screening Using Non-Invasive Prenatal Testing Beyond Trisomy-21: What to Screen for and Why It Matters,” Hens (2018) considers public funding for NIPT. She does not limit her scope to parental reproductive autonomy, but compares specific characteristics of certain types of genetic conditions and the reasons for and against public coverage of each. The paper includes consideration of whether routinization of testing could impact individual decision-making and identifies variation in phenotype as a complicating factor. In particular, Hens first argues that if screening is covered for Down syndrome, screening for more serious conditions should also be covered. The second part of her paper addresses chromosomal abnormalities that do not have severe physiological consequences for children who have them. She makes the interesting argument that in such cases the ethical obligation to preserve the privacy of the future child outweighs the parental right to have information about a developing fetus. Although that genomic information might be relevant to parental decision-making, the fact that the associated phenotype is not severe makes the choice to terminate “unwarranted” and so makes parental autonomy a less weighty ethical consideration. As a result, NIPT for mild conditions should not be covered by public funds. Morrissey and Walker (2018) also take a look at genomic sequencing through a wide-angle lens in “The Ethics of General Population Preventive Genomic Sequencing: Rights and Social Justice,” considering the differences between using a public health framework and a preventive health care framework. They analyze two oft-cited rights: the right not to know one’s genetic information and a child’s right to an open future. Rather than stopping their investigation at an individual level, the authors thoughtfully discuss how those rights can be interpreted in the context of public health and competing social interests. Their conclusion that there is some ambiguity about which framework is more appropriate for analyzing genomic sequencing seems plausible given the multifaceted nature of these technologies. Morrissey and Walker then expand their analysis further to incorporate an even broader set of issues: those related to social justice. A rights-based approach, they argue, does not adequately attend to the value of ensuring that all members of society have minimally decent lives. It also fails to address concerns about injustices inherent in society, including systematic inequalities and compounding disadvantages. From the perspective of those lacking “cultural health capital,” rights not to have one’s genetic information and to have the ability to make decisions about knowing genetic information later in one’s life may seem like a problem of privilege that obscures other, more fundamental ethical issues. The authors argue that viewing these rights in context of the real world, full of social inequalities, offers a more complete and nuanced assessment and leads to different conclusions about their relative importance. “Two ways to kill a patient” by Ben Bronner (2018) offers a close analysis of the argument underlying the currently well-accepted moral distinction between killing and letting die. When removal of life support is viewed as allowing an otherwise-expected course of events to take place, it does not generate moral concern because the physician’s act is not judged to cause a patient’s death. In contrast, if the physician’s act of removing life support is considered to make the difference between the patient’s life and death, the claim that the act caused the patient’s death (in a morally concerning way) becomes plausible. These differing interpretations of causation, Bronner argues, are the source of disagreement among those who support the standard view that there is a moral distinction between killing and letting die and those who critique it. Beyond simply identifying this source of controversy, Bronner looks to a variety of other real-world scenarios to help develop a more nuanced argument about whether and when there is a moral distinction between killing and letting die. These include situations in which one member of the medical team puts a DNR order in place while others refrain from attempting CPR, cases in which members of a medical team refuse to honor the request of the patient and/or family to continue life support, and scenarios in which there is disagreement among the medical team about proper goals of care. Recognizing that a variety of individuals could be involved in the course of events that, in the end, result in the death of a patient, Bronner describes what he terms the “collectivist assumption.” This intriguing result of this assumption is that whether a physician’s act is judged to cause the patient’s death in a morally problematic way can depend on the actions of other members of the medical team. The arguments presented therefore are not limited to simplified, idealized cases but deal with complexities that arise in the context of medical practice. In “Schemata, CONSORT, and the Salk Polio Vaccine Trial,” Kowalski and Mrdjenovich (2018) question the widespread presumption that randomized controlled trials (RCTs) are the ethically preferable approach to research with human subjects in nearly all cases. They identify sources of resistance to the focus evidence-based medicine that holds RCTs as the appropriate gold standard. Using the case example of the Salk polio vaccine trial, they argue that in certain cases, particularly those involving large-scale public health interventions, other research designs may not be appropriate. In contrast to paradigm cases of human subjects’ research, questions in public health may take a variety of forms, including (but not limited to) the effectiveness of the intervention. As a result, different approaches may be required. The implication of the authors’ argument is that research designs falling outside of the RCT model should not be rejected out of hand, but should be evaluated within the context in which they are being considered. The practical limitations and challenges associated with conducting research should be taken into account, and therefore flexibility in trial design may be not only ethically acceptable but preferable. As with other articles in this issue, this paper critiques a simplified assumption (the universal superiority of RCTs) by examining carefully the results it produces in real world cases. The final article in this issue, “Serial Participation and the Ethics of Phase 1 Healthy Volunteer Research” by Walker, Cottingham, and Fisher (2018), describes the perspectives and experiences of five individuals who participate in phase 1 clinical trials to make ends meet. Rather than focusing exclusively on these individuals’ choices to participate in research, the authors explore their larger narratives and seek to understand these choices as they relate to other characteristics of the participants’ lives. The insights made possible by this approach both illustrate and complicate several well-recognized worries about using healthy volunteers in research: concerns about payment undermining consent, exploitation of disadvantaged individuals, and issues about data validity. The authors’ analysis brings to light ethical considerations relating to systematic involvement in the research enterprise that have been neglected by traditional research ethics. Rather than being worried about undue inducement, participants felt they would be better off if they received more compensation. Although the risks and benefits of individual trials were relevant to them, the cumulative effects of research participation were also on their minds. Participants reported types of exploitation beyond financial injustice, including access to and scheduling of trials. They described rules of serial research participation that encouraged departure from the activities required by research protocols. An understanding of these system-oriented problems enriches our understanding of challenging questions in research ethics and reveals a roadmap for future exploration. V. CONCLUSION The challenge for philosophers in bioethics is to maintain our standards of clarity and rigor while expanding the scope of our work to include real-world complexities. When applying arguments and conclusions to actual practice, it is necessary to see problems through a wide-angle lens that doesn’t leave concerns about the larger context in our peripheral vision. The papers in this issue of the Journal of Medicine and Philosophy take this challenge seriously and therefore contribute to their respective areas of inquiry. REFERENCES Bronner, B. 2018. Two ways to kill a patient. Journal of Medicine and Philosophy  43: 44–63. Buchanan, A. 1988. Advance directives and the personal identity problem. Philosophy and Public Affairs  17: 277– 302. Google Scholar PubMed  EngelhardtJr., H. T. 1996. The Foundations of Bioethics , 2nd ed. New York: Oxford University Press. Halevy, A., and B. Brody. 1993. Brain death: Reconciling definitions, criteria and tests. Annals of Internal Medicine  119: 519– 25. Google Scholar CrossRef Search ADS PubMed  Hens, K. 2018. Chromosome screening using non-invasive prenatal testing beyond trisomy-21: What to screen for and why it matters. Journal of Medicine and Philosophy  43: 8–21. Kowalski, C. J., and A. J. Mrdjenovich. 2018. Schemata, CONSORT and the Salk polio vaccine trial. Journal of Medicine and Philosophy  43: 64–82. Morrissey C. , and Walker R.. 2018. The ethics of general population preventive genomic sequencing: Rights and social justice. Journal of Medicine and Philosophy  43: 22–43. Parfit, D. 1984. Reasons and Persons . New York: Oxford University Press. Rachels, J. 1975. Active and passive euthanasia. New England Journal of Medicine  292: 78– 80. Google Scholar CrossRef Search ADS PubMed  Savulescu, J. 2015. Bioethics: Why philosophy is essential for progress. Journal of Medical Ethics  41: 28– 33. Google Scholar CrossRef Search ADS PubMed  Schneiderman, L. J., N. Jecker, and A. R. Jonsen. 1990. Medical futility: Its meaning and ethical implications. Annals of Internal Medicine  112: 949– 54. Google Scholar CrossRef Search ADS PubMed  Thomson, J. J. 1971. A defense of abortion. Philosophy and Public Affairs  1: 47– 66. Tomlinson, T., and H. Brody. 1988. Ethics and communication in do not resuscitate orders. New England Journal of Medicine  318: 43– 6. Google Scholar CrossRef Search ADS PubMed  Walker, R., M. Cottingham, and J. Fisher. 2018. Serial participation and the ethics of phase 1 healthy volunteer research. Journal of Medicine and Philosophy  43: 83–114. © The Author(s) 2018. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The Journal of Medicine and Philosophy Oxford University Press

Bridging the Gap Between Theory and Practice: Philosophy Through a Wide-Angle Lens

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Abstract

Abstract Philosophers who specialize in bioethics (broadly defined to include health care ethics, clinical ethics, public health ethics, and research ethics among other applied fields) face a distinctive set of challenges in our work: to bring the theoretical insights of philosophical work and methodology to practical dilemmas affecting a diverse group of stakeholders every day. This article describes some of the key contributions that philosophy can make to the field of bioethics. It also identifies some of the pitfalls that can undermine the value of a philosophical approach when used to analyze questions arising in the real world. Recognition of the importance of individual context, practical implications, and social considerations can help successfully bridge the gap between theory and practice. Using this wide-angle lens to view bioethical problems can enable philosophers working in our field to offer insights that are both rigorous and relevant. bioethics, practical dilemmas, theoretical insights I. INTRODUCTION Philosophers who specialize in bioethics (broadly defined to include health care ethics, clinical ethics, public health ethics, and research ethics among other applied fields) face a distinctive set of challenges in our work. We seek to maintain the high standards of analytical rigor demanded by our home discipline but must do so in a way that is accessible to those without philosophical training. We attempt to be precise in terminology that is used in many different ways in many different contexts. We strive to identify and question assumptions that are considered self-evident by those with other experiences and backgrounds. In essence, our aim is to bring the theoretical insights of philosophical work and methodology to practical dilemmas affecting a diverse group of stakeholders every day. The challenge of bridging the gap between ideal and real worlds makes working in bioethics both difficult and rewarding to do well. II. PHILOSOPHY’S CONTRIBUTION TO CLINICAL PRACTICE Good philosophy has much to contribute to bioethics; philosophical tools are often used in our scholarly work and in practice. Over the last 50 years, our field has grown and developed into a multidisciplinary, interprofessional endeavor that draws on empirical data, normative analysis, artistic inspiration, legal guidelines, policy considerations, personal narrative, and spiritual insight. As we immerse ourselves in these varied approaches, we should keep in mind that many philosophers were among the founders of our field and it has been argued that philosophy remains essential to progress in bioethics (Savulescu, 2015). The following tools and others can be used in bioethics to help move our thinking forward in a rigorous way. While not unique to philosophy, the habit of defining key terms and distinguishing among similar concepts is a hallmark of good philosophical work. This can be particularly important when using theoretical ideas in practice; when patients and clinicians use the same term to refer to different things, the conversation is unlikely to go well. Paradigmatic examples of this type of work include clarification of the concept of medical futility (Tomlinson, 1988; Schneiderman, Jecker, and Jonsen, 1990) and articulation of varied definitions of brain death (Halevy and Brody, 1993). These pieces led the dialogue and debate on these controversial topics out of conceptual quagmire and into practical use. Philosophers are also trained to break down claims into their core components, identifying premises and assumptions that can be analyzed for their individual veracity and collective soundness. This technique has been particularly valuable for analyzing complex issues such a personal identity, societal well-being, and moral responsibility (Parfit, 1984). Such components can then be used as building blocks for discussion and negotiation among members of society with differing world-views (Engelhardt, 1996). We use thought experiments to test hypotheses and to illustrate the importance of relevant facts. A classic example of the use of this approach is James Rachels’ (1975) “Active and Passive Euthanasia” published in the New England Journal of Medicine. This piece demonstrated the now-widely-accepted moral equivalence between withholding and withdrawing medical treatment, dramatically impacting the ethical evaluation of decisions at the end of life. Thought experiments catch readers’ attention and invite them to reach their own conclusions, isolating the morally relevant pieces of information. The resulting insights can then be applied to challenges facing health care providers on a daily basis. The practice of intentionally assuming key premises or bracketing particular considerations can facilitate focused analysis of a question of special interest. In some cases, this technique can help to simplify an issue for discussion to bring the most important considerations to the forefront. In other cases, like that of “A Defense of Abortion” by Judith Jarvis Thomson (1971), an author grants to her critics a central, controversial premise that she may not hold with the intention of creating an argument that even those critics should find compelling. This technique could be particularly useful in resolving challenging questions that arise in the context of today’s pluralistic society. By anticipating objections that could be raised by a reader or interlocutor, we make our arguments stronger and avoid misunderstandings. Considering the views of others in a fair and robust way demonstrates respect for those who may hold different positions on controversial issues. Doing so may also make possible compromise positions that would not have otherwise been seen as viable by those entrenched on either side (Buchanan, 1988). III. PHILOSOPHY’S DRAWBACKS FOR CLINICAL PRACTICE There are, however, potential hazards of using a traditional philosophical approach to real-world questions of which we must remain aware. Scholars and educators may become so focused on conceptual distinctions, semantic differences, or nuanced details that we fail to demonstrate how those considerations matter in practice. Describing principled resolutions without taking the realities of their implementation into account can generate skepticism about the value a philosophical approach has to offer. Similarly, although the use of hypothetical scenarios can be helpful in illustrating key points, when those scenarios become too far removed from actual possible cases or events they may lose their intuitive force or educational value. We may at times be so interested in exploring the various facets of a question that our audiences could not be blamed for arriving at the conclusion that there are no “right” answers to problems in ethics. These pitfalls are avoidable, but bioethicists can only navigate around them if they are cognizant of their existence. Health care professionals, bench scientists, and policy-makers deal with messy realities, not with the cleaned-up, theoretical versions of problems that philosophers sometimes prefer to deal in. Simplifying and abstracting problems to the point that we can conduct clear and concise theoretical analyses risks making those analyses irrelevant unless we are willing and able to take our work a step further, showing clearly how our arguments and conclusions can inform daily practice. We need to take seriously the complexity of questions arising in the real world and offer adequately nuanced answers in response. We need to consider how context can shape both the way problems are defined and solutions are implemented. This is not to say that streamlined, theoretical analysis is never appropriate, only that it alone is rarely sufficient for resolving real-world issues. It is a necessary step for laying a solid foundation on which further work can be built. Bioethicists must maintain awareness of our audiences, have humility about the scope of the conclusions we draw, and appreciate the challenges of developing and offering guidance meant to have an impact on actual practice. IV. INCLUSIVE PHILOSOPHICAL APPROACHES TO PRACTICAL PROBLEMS The papers in this issue of Journal of Medicine and Philosophy accept these challenges head-on. They take a broad, inclusive perspective on problems that have often been viewed through a narrowly focused lens. The authors take into account the embedded nature of the issues they discuss, considering social, practical, and policy-related aspects of genomic screening, withdrawal of life-sustaining support, and research with human subjects. In doing so, they move the dialogue about these important issues forward. In “Chromosome Screening Using Non-Invasive Prenatal Testing Beyond Trisomy-21: What to Screen for and Why It Matters,” Hens (2018) considers public funding for NIPT. She does not limit her scope to parental reproductive autonomy, but compares specific characteristics of certain types of genetic conditions and the reasons for and against public coverage of each. The paper includes consideration of whether routinization of testing could impact individual decision-making and identifies variation in phenotype as a complicating factor. In particular, Hens first argues that if screening is covered for Down syndrome, screening for more serious conditions should also be covered. The second part of her paper addresses chromosomal abnormalities that do not have severe physiological consequences for children who have them. She makes the interesting argument that in such cases the ethical obligation to preserve the privacy of the future child outweighs the parental right to have information about a developing fetus. Although that genomic information might be relevant to parental decision-making, the fact that the associated phenotype is not severe makes the choice to terminate “unwarranted” and so makes parental autonomy a less weighty ethical consideration. As a result, NIPT for mild conditions should not be covered by public funds. Morrissey and Walker (2018) also take a look at genomic sequencing through a wide-angle lens in “The Ethics of General Population Preventive Genomic Sequencing: Rights and Social Justice,” considering the differences between using a public health framework and a preventive health care framework. They analyze two oft-cited rights: the right not to know one’s genetic information and a child’s right to an open future. Rather than stopping their investigation at an individual level, the authors thoughtfully discuss how those rights can be interpreted in the context of public health and competing social interests. Their conclusion that there is some ambiguity about which framework is more appropriate for analyzing genomic sequencing seems plausible given the multifaceted nature of these technologies. Morrissey and Walker then expand their analysis further to incorporate an even broader set of issues: those related to social justice. A rights-based approach, they argue, does not adequately attend to the value of ensuring that all members of society have minimally decent lives. It also fails to address concerns about injustices inherent in society, including systematic inequalities and compounding disadvantages. From the perspective of those lacking “cultural health capital,” rights not to have one’s genetic information and to have the ability to make decisions about knowing genetic information later in one’s life may seem like a problem of privilege that obscures other, more fundamental ethical issues. The authors argue that viewing these rights in context of the real world, full of social inequalities, offers a more complete and nuanced assessment and leads to different conclusions about their relative importance. “Two ways to kill a patient” by Ben Bronner (2018) offers a close analysis of the argument underlying the currently well-accepted moral distinction between killing and letting die. When removal of life support is viewed as allowing an otherwise-expected course of events to take place, it does not generate moral concern because the physician’s act is not judged to cause a patient’s death. In contrast, if the physician’s act of removing life support is considered to make the difference between the patient’s life and death, the claim that the act caused the patient’s death (in a morally concerning way) becomes plausible. These differing interpretations of causation, Bronner argues, are the source of disagreement among those who support the standard view that there is a moral distinction between killing and letting die and those who critique it. Beyond simply identifying this source of controversy, Bronner looks to a variety of other real-world scenarios to help develop a more nuanced argument about whether and when there is a moral distinction between killing and letting die. These include situations in which one member of the medical team puts a DNR order in place while others refrain from attempting CPR, cases in which members of a medical team refuse to honor the request of the patient and/or family to continue life support, and scenarios in which there is disagreement among the medical team about proper goals of care. Recognizing that a variety of individuals could be involved in the course of events that, in the end, result in the death of a patient, Bronner describes what he terms the “collectivist assumption.” This intriguing result of this assumption is that whether a physician’s act is judged to cause the patient’s death in a morally problematic way can depend on the actions of other members of the medical team. The arguments presented therefore are not limited to simplified, idealized cases but deal with complexities that arise in the context of medical practice. In “Schemata, CONSORT, and the Salk Polio Vaccine Trial,” Kowalski and Mrdjenovich (2018) question the widespread presumption that randomized controlled trials (RCTs) are the ethically preferable approach to research with human subjects in nearly all cases. They identify sources of resistance to the focus evidence-based medicine that holds RCTs as the appropriate gold standard. Using the case example of the Salk polio vaccine trial, they argue that in certain cases, particularly those involving large-scale public health interventions, other research designs may not be appropriate. In contrast to paradigm cases of human subjects’ research, questions in public health may take a variety of forms, including (but not limited to) the effectiveness of the intervention. As a result, different approaches may be required. The implication of the authors’ argument is that research designs falling outside of the RCT model should not be rejected out of hand, but should be evaluated within the context in which they are being considered. The practical limitations and challenges associated with conducting research should be taken into account, and therefore flexibility in trial design may be not only ethically acceptable but preferable. As with other articles in this issue, this paper critiques a simplified assumption (the universal superiority of RCTs) by examining carefully the results it produces in real world cases. The final article in this issue, “Serial Participation and the Ethics of Phase 1 Healthy Volunteer Research” by Walker, Cottingham, and Fisher (2018), describes the perspectives and experiences of five individuals who participate in phase 1 clinical trials to make ends meet. Rather than focusing exclusively on these individuals’ choices to participate in research, the authors explore their larger narratives and seek to understand these choices as they relate to other characteristics of the participants’ lives. The insights made possible by this approach both illustrate and complicate several well-recognized worries about using healthy volunteers in research: concerns about payment undermining consent, exploitation of disadvantaged individuals, and issues about data validity. The authors’ analysis brings to light ethical considerations relating to systematic involvement in the research enterprise that have been neglected by traditional research ethics. Rather than being worried about undue inducement, participants felt they would be better off if they received more compensation. Although the risks and benefits of individual trials were relevant to them, the cumulative effects of research participation were also on their minds. Participants reported types of exploitation beyond financial injustice, including access to and scheduling of trials. They described rules of serial research participation that encouraged departure from the activities required by research protocols. An understanding of these system-oriented problems enriches our understanding of challenging questions in research ethics and reveals a roadmap for future exploration. V. CONCLUSION The challenge for philosophers in bioethics is to maintain our standards of clarity and rigor while expanding the scope of our work to include real-world complexities. When applying arguments and conclusions to actual practice, it is necessary to see problems through a wide-angle lens that doesn’t leave concerns about the larger context in our peripheral vision. The papers in this issue of the Journal of Medicine and Philosophy take this challenge seriously and therefore contribute to their respective areas of inquiry. REFERENCES Bronner, B. 2018. Two ways to kill a patient. Journal of Medicine and Philosophy  43: 44–63. Buchanan, A. 1988. Advance directives and the personal identity problem. Philosophy and Public Affairs  17: 277– 302. Google Scholar PubMed  EngelhardtJr., H. T. 1996. The Foundations of Bioethics , 2nd ed. New York: Oxford University Press. Halevy, A., and B. Brody. 1993. Brain death: Reconciling definitions, criteria and tests. Annals of Internal Medicine  119: 519– 25. Google Scholar CrossRef Search ADS PubMed  Hens, K. 2018. Chromosome screening using non-invasive prenatal testing beyond trisomy-21: What to screen for and why it matters. Journal of Medicine and Philosophy  43: 8–21. Kowalski, C. J., and A. J. Mrdjenovich. 2018. Schemata, CONSORT and the Salk polio vaccine trial. Journal of Medicine and Philosophy  43: 64–82. Morrissey C. , and Walker R.. 2018. The ethics of general population preventive genomic sequencing: Rights and social justice. Journal of Medicine and Philosophy  43: 22–43. Parfit, D. 1984. Reasons and Persons . New York: Oxford University Press. Rachels, J. 1975. Active and passive euthanasia. New England Journal of Medicine  292: 78– 80. Google Scholar CrossRef Search ADS PubMed  Savulescu, J. 2015. Bioethics: Why philosophy is essential for progress. Journal of Medical Ethics  41: 28– 33. Google Scholar CrossRef Search ADS PubMed  Schneiderman, L. J., N. Jecker, and A. R. Jonsen. 1990. Medical futility: Its meaning and ethical implications. Annals of Internal Medicine  112: 949– 54. Google Scholar CrossRef Search ADS PubMed  Thomson, J. J. 1971. A defense of abortion. Philosophy and Public Affairs  1: 47– 66. Tomlinson, T., and H. Brody. 1988. Ethics and communication in do not resuscitate orders. New England Journal of Medicine  318: 43– 6. Google Scholar CrossRef Search ADS PubMed  Walker, R., M. Cottingham, and J. Fisher. 2018. Serial participation and the ethics of phase 1 healthy volunteer research. Journal of Medicine and Philosophy  43: 83–114. © The Author(s) 2018. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

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Published: Feb 1, 2018

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