Theory and practice of clinical ethics support services: narrative and hermeneutical perspectives

In this paper we introduce narrative and hermeneutical perspectives to clinical ethics support services (CESS). We propose a threefold consideration of 'theory' and show how it is interwoven with 'practice' as we go along. First, we look at theory in its foundational role: in our case 'narrative ethics' and 'philosophical hermeneutics' provide a theoretical base for clinical ethics by focusing on human identities entangled in stories and on moral understanding as a dialogical process. Second, we consider the role of theoretical notions in helping practitioners to understand their situation in clinical ethics practice, by using notions like 'story', 'responsibility', or 'vulnerability' to make explicit and explain their practical experience. Such theoretical notions help us to interpret clinical situations from an ethical perspective and to foster moral awareness of practitioners. And, thirdly, we examine how new theoretical concepts are developed by interpreting practice, using practice to form and improve our ethical theory. In this paper, we discuss this threefold use of theory in clinical ethics support services by reflecting on our own theoretical assumptions, methodological steps and practical experiences as ethicists, and by providing examples from our daily work. In doing so, we illustrate that theory and practice are interwoven, as theoretical understanding is dependent upon practical experience, and vice-versa.     

REFLECTIVE EQUILIBRIUM AND EMPIRICAL DATA: THIRD PERSON MORAL EXPERIENCES IN EMPIRICAL MEDICAL ETHICS

In ethics, the use of empirical data has become more and more popular, leading to a distinct form of applied ethics, namely empirical ethics. This ‘empirical turn’ is especially visible in bioethics. There are various ways of combining empirical research and ethical reflection. In this paper we discuss the use of empirical data in a special form of Reflective Equilibrium (RE), namely the Network Model with Third Person Moral Experiences. In this model, the empirical data consist of the moral experiences of people in a practice. Although inclusion of these moral experiences in this specific model of RE can be well defended, their use in the application of the model still raises important questions. What precisely are moral experiences? How to determine relevance of experiences, in other words: should there be a selection of the moral experiences that are eventually used in the RE? How much weight should the empirical data have in the RE? And the key question: can the use of RE by empirical ethicists really produce answers to practical moral questions? In this paper we start to answer the above questions by giving examples taken from our research project on understanding the norm of informed consent in the field of pediatric oncology. We especially emphasize that incorporation of empirical data in a network model can reduce the risk of self‐justification and bias and can increase the credibility of the RE reached.     

生态文明时期道德观的新视角

道德和道德观念是随着人类社会历史发展以及社会实践活动的深化而不断发展变化的。人们依据不同发展阶段的特征,提出符合时代发展趋势的道德原则、道德规范和道德标准,以推动道德进步。现在人类社会开始进入由工业文明向生态文明迈进的发展新阶段,因而,时代要求转变以往支配人们行动的旧道德观,打破狭隘的视野局限,把原有道德观仅仅局限于人与人之间、人与社会之间扩展到人与自然之间,以人与自然和谐发展作为生态文明时期的道德准则。这种新的道德观要求树立崭新的生态意识,坚持公正和平等的原则。以约束人类行为,提高人的生态道德修养为宗旨。使人类的社会实践活动有利于资源的持续利用和环境保护,倡导过一种适度消费的文明生活。     

EMPIRICAL ETHICS AS DIALOGICAL PRACTICE

In this article, we present a dialogical approach to empirical ethics, based upon hermeneutic ethics and responsive evaluation. Hermeneutic ethics regards experience as the concrete source of moral wisdom. In order to gain a good understanding of moral issues, concrete detailed experiences and perspectives need to be exchanged. Within hermeneutic ethics dialogue is seen as a vehicle for moral learning and developing normative conclusions. Dialogue stands for a specific view on moral epistemology and methodological criteria for moral inquiry. Responsive evaluation involves a structured way of setting up dialogical learning processes, by eliciting stories of participants, exchanging experiences in (homogeneous and heterogeneous) groups and drawing normative conclusions for practice. By combining these traditions we develop both a theoretical and a practical approach to empirical ethics, in which ethical issues are addressed and shaped together with stakeholders in practice. Stakeholders' experiences are not only used as a source for reflection by the ethicist; stakeholders are involved in the process of reflection and analysis, which takes place in a dialogue between participants in practice, facilitated by the ethicist. This dialogical approach to empirical ethics may give rise to questions such as: What contribution does the ethicist make? What role does ethical theory play? What is the relationship between empirical research and ethical theory in the dialogical process? In this article, these questions will be addressed by reflecting upon a project in empirical ethics that was set up in a dialogical way. The aim of this project was to develop and implement normative guidelines with and within practice, in order to improve the practice concerning coercion and compulsion in psychiatry.     

生态文明时期道德观的新视角

道德和道德观念是随着人类社会历史发展以及社会实践活动的深化而不断发展变化的。人们依据不同发展阶段的特征,提出符合时代发展趋势的道德原则、道德规范和道德标准,以推动道德进步。现在人类社会开始进入由人工业文明向生态文明迈进的发展新阶段,因而,时代要求转变以往支配人们行动的旧道德观,打破狭隘的视野局限,把原有道德观仅仅局限于人与人之间、人与社会之间扩展到人与自然之间,以人与自然和谐发展作为生态文明时期的道德准则。这种新的道德观要求树立崭新的生态意识,坚持公正和平等的原则。以约束人类行为,提高人的生态道德修养为宗旨。使人类的社会实践活动有利于资源的持续利用和环境保护,倡导过一种适度消费的文明生活。     

Reciprocity and Ethical Tuberculosis Treatment and Control

This paper explores the notion of reciprocity in the context of active pulmonary and laryngeal tuberculosis (TB) treatment and related control policies and practices. We seek to do three things: First, we sketch the background to contemporary global TB care and suggest that poverty is a key feature when considering the treatment of TB patients. We use two examples from TB care to explore the role of reciprocity: isolation and the use of novel TB drugs. Second, we explore alternative means of justifying the use of reciprocity through appeal to different moral and political theoretical traditions (i.e., virtue ethics, deontology, and consequentialism). We suggest that each theory can be used to provide reasons to take reciprocity seriously as an independent moral concept, despite any other differences. Third, we explore general meanings and uses of the concept of reciprocity, with the primary intention of demonstrating that it cannot be simply reduced to other more frequently invoked moral concepts such as beneficence or justice. We argue that reciprocity can function as a mid-level principle in public health, and generally, captures a core social obligation arising once an individual or group is burdened as a result of acting for the benefit of others (even if they derive a benefit themselves). We conclude that while more needs to be explored in relation to the theoretical justification and application of reciprocity, sufficient arguments can be made for it to be taken more seriously as a key principle within public health ethics and bioethics more generally.     

TRIANGULAR REFLECTIVE EQUILIBRIUM: A CONSCIENCE‐BASED METHOD FOR BIOETHICAL DELIBERATION

Following a discussion of some historical roots of conscience, we offer a systematized version of reflective equilibrium. Aiming at a comprehensive methodology for bioethical deliberation, we develop an expanded variant of reflective equilibrium, which we call ‘triangular reflective equilibrium’ and which incorporates insights from hermeneutics, critical theory and narrative ethics. We focus on a few distinctions, mainly between methods of justification in ethics and the social practice of bioethical deliberation, between coherence in ethical reasoning, personal integrity and consensus formation, and between political and moral deliberation. The ideal of deliberation is explicated as a sharing of conscience within a special commitment to sincerity and openness to persuasion. Personal growth in wisdom is an indirect by‐product of the continuous practice of moral deliberation. This is explicated in the light of Sternberg's balance theory of wisdom and in the context of medicine as a profession embodying altruistic responsibilities of care in democratic and pluralistic societies.     

Evolutionary naturalism and the objectivity of morality

We propose an objective and justifiable ethics that is contingent on the truth of evolutionary theory. We do not argue for the truth of this position, which depends on the empirical question of whether moral functions form a natural class, but for its cogency and possibility. The position we propose combines the advantages of Kantian objectivity with the explanatory and motivational advantages of moral naturalism. It avoids problems with the epistemological inaccessibility of transcendent values, while avoiding the relativism or subjectivism often associated with moral naturalism. Our position emerges out of criticisms of the contemporary sociobiological views of morality found in the writings of Richard Alexander, Michael Ruse, and Robert Richards.     

Evolutionary ethics,Darwinian ethics and ethical naturalism

The relevance of evolutionary theory to ethics goes back to Darwin but until recently discussion employed evolutionary theory to justify ethical, social and political positions. Recently, evolutionary theory has been used to explain the existence of moral systems and moral propensities and, thereby, to provide a naturalistic basis for ethics. I argue that this approach has advanced our understanding of the basis of moral systems and moral propensities but does not as yet adequately incorporate the role of cognition in its account. Cognition has the effect of decoupling to some extent — though, of course, far from fully — human moral systems from their evolutionary origins. In an adequate account, evolutionary theory will play a crucial role but so also will our evolved cognitive abilities.     

Great Expectations: Teaching Ethics to Medical Students in South Africa

Many academic philosophers and ethicists are appointed to teach ethics to medical students. We explore exactly what this task entails. In South Africa the Health Professions Council's curriculum for training medical practitioners requires not only that students be taught to apply ethical theory to issues and be made aware of the legal and regulatory requirements of their profession, it also expects moral formation and the inculcation of professional virtue in students. We explore whether such expectations are reasonable. We defend the claim that physicians ought to be persons of virtuous character, on the grounds of the social contract between society and the profession. We further argue that since the expectations of virtue of health care professionals are reasonable, it is also sound reasoning to expect ethics teachers to try to inculcate such virtues in their students, so far as this is possible. Furthermore, this requires of such teachers that they be suitable role models of ethical practice and virtue, themselves. We claim that this applies to ethics teachers who are themselves not members of the medical profession, too, even though they are not bound by the same social contract as doctors. We conclude that those who accept employment as teachers of ethics to medical students, where as part of their contractual obligation they are expected to inculcate moral values in their students, ought to be prepared to accept their responsibility to be professionally ethical, themselves.     

Becoming "One Who Treats": A Case Study of a Luo Healer and Her Grandson in Western Kenya

Using a case study of a healer and her grandson, this article shows how learning to heal is embedded in the close relationship of reciprocity and care between grandmother and grandchild in Luo society. Through shared daily life with his grandmother, the child develops social sense, respect, and compassion for people, as well as practical skills. By showing that learning to heal is not only embedded in everyday practice and in social relations, but is also a moral and emotional process, this article contributes to sociocultural theories of learning and to ethnographic accounts of childhood in Africa.     

Neuroethics and fMRI: mapping a fledgling relationship

Human functional magnetic resonance imaging (fMRI) informs the understanding of the neural basis of mental function and is a key domain of ethical enquiry. It raises questions about the practice and implications of research, and reflexively informs ethics through the empirical investigation of moral judgments. It is at the centre of debate surrounding the importance of neuroscience findings for concepts such as personhood and free will, and the extent of their practical consequences. Here, we map the landscape of fMRI and neuroethics, using citation analysis to uncover salient topics. We find that this landscape is sparsely populated: despite previous calls for debate, there are few articles that discuss both fMRI and ethical, legal, or social implications (ELSI), and even fewer direct citations between the two literatures. Recognizing that practical barriers exist to integrating ELSI discussion into the research literature, we argue nonetheless that the ethical challenges of fMRI, and controversy over its conceptual and practical implications, make this essential.     

Aspects du care et de « l’éthique du care » en psychiatrie

The debate about care and its different forms has developed a lot in social sciences and in moral philosophy, since Carol Gilligan, arguing in a feminist perspective against the prejudices of moral development psychology, has defined an “ethics of care” and claimed that it should be recognized as of the same value as the dominant ethics (Kantian or utilitarian). Following this claim, a variety of researches have been carried out concerning the activity of caring that goes beyond the field of medical practice. However, in the medical field, in which “care” has to be distinguished from “cure,” the development of a theory of care has a strong impact on the conception of treatment (of its organization, its assessment, and the way it is taught). We will focus particularly on what is implied in psychiatry by such a characterization of care.     

Moral concerns across the United States: associations with life-history variables,pathogen prevalence,urbanization, cognitive ability,and social class

This study evaluated the extent to which predictions derived from several theories could account for variability in human moral values across US states. We investigated moral values as conceptualized by Moral Foundations Theory, which argues that morality evolved in response to adaptive challenges in at least five domains: Ingroup/loyalty, Authority/respect, Purity/sanctity ("binding" foundations) and Harm/care, Fairness/reciprocity ("individualizing" foundations). We report correlations for measures of cognitive ability, social class, urbanization, pathogen prevalence, life expectancy, and teenage birth rates. Social class and educational attainment had fairly consistent but small effects across moral foundations (social class: positively associated with Ingroup/loyalty, negatively with individualizing foundations and Purity/sanctity; education: positively associated with individualizing foundations, negatively with binding foundations). We conducted multilevel regressions that were stratified for ethnicity. The most consistent state-level predictor of moral values was teenage birth rates (negatively associated with individualizing foundations, positively with binding foundations). This suggests that life-history theory may provide an explanation for individual differences in moral values, although the directions of effects for teenage birth rates diverged from predictions of life-history theory. We conclude that none of the tested theories provides a good explanation for the observed variability in moral values in the USA. We discuss how a life-history approach might account for the findings, and note the need for improved measurement of pathogen stress to better distinguish its effects from those of life-history variables.     

转化医学研究中生命伦理学辩护的现况分析与前瞻思考

转化医学作为一门新兴学科,运用多学科交叉策略来推动医学发展,从临床实践中发现问题,将其凝练成科学问题进行基础医学研究,再将研究成果应用到疾病诊断、治疗和预防过程中,使其真正发挥作用,是一个从基础医学到临床应用的双向进程。转化医学已逐步融入各个学科,并在干细胞研究、生物标志物、细胞信号转导、药物及器具研发及个体化医学等各个领域发挥重要作用。随着转化医学研究深入,一些临床试验势必对人体存在一定伤害和潜在危险,存在各种伦理问题。虽说科学研究与伦理道德是一对相互冲击的矛盾,但两者在总体上又是一致的,共同决定着社会前进步伐。科研的重大进步必然会对伦理道德提出更高要求,而伦理道德的高标准又规范、引导、促进科学研究朝着正确方向迈进,两者相辅相成。鉴于伦理辩护对于转化医学研究强有力的支撑,建议在转化医学研究中能进一步完善伦理监管体系,发挥机构伦理委员会的功效,持续加大伦理培训的力度,强化研究人员的伦理道德修养,从而为转化医学的发展夯实人文基础。     

WHICH NATURALISM FOR BIOETHICS? A DEFENSE OF MODERATE (PRAGMATIC) NATURALISM

There is a growing interest in various forms of naturalism in bioethics, but there is a clear need for further clarification. In an effort to address this situation, I present three epistemological stances: anti-naturalism, strong naturalism, and moderate pragmatic naturalism. I argue that the dominant paradigm within philosophical ethics has been a form of anti-naturalism mainly supported by a strong 'is' and 'ought' distinction. This fundamental epistemological commitment has contributed to the estrangement of academic philosophical ethics from major social problems and explains partially why, in the early 1980s, 'medicine saved the life of ethics'. Rejection of anti-naturalism, however, is often associated with strong forms of naturalism that commit the naturalistic fallacy and threaten to reduce the normative dimensions of ethics to biological imperatives. This move is rightly dismissed as a pitfall since ethics is, in part, a struggle against the course of nature. Rejection of naturalism has drawbacks, however, such as deterring bioethicists from acknowledging the implicit naturalistic epistemological commitments of bioethics. I argue that a moderate pragmatic form of naturalism represents an epistemological position that best embraces the tension of anti-naturalism and strong naturalism: bioethics is neither disconnected from empirical knowledge nor subjugated to it. The discussion is based upon historical writings in philosophy and bioethics.     

Anthropology and politics: The logic of their interrelationship

Conclusion The thesis of value neutrality is logically untenable and anthropologically naive. It is logically untenable because it does not attend to contextual (i.e. historical, sociological and political) meaning. It is anthropologically naive because it does not take into account that values are culturally mediated and historically situated, i.e. it assumes that values are the result of arbitrary choices. And, one must add, it is morally objectionable because it eliminates the notion of responsibility, though it pretends to defend it.Rather than attacking the thesis of value neutrality by following the more usual procedure of unmasking specific substantive theories, I have dismantled the logic of value neutrality itself by concentrating on the insurmountable formal contradictions of the fact-value dichotomy. In neglecting social, economic and cultural constraints, while stressing the freedom of the individual, the thesis of value neutrality emerges as liberal ideology. Whatever the liberating effect of decisionism may have been, it has de facto become the ideology of a scientific establishment which was conditioned to sell its services to the highest bidder. Decisionism has promoted a division of labor between those who determine the ends and those who supply the technical means without being concerned about their application . Thus it supports the status quo, and becomes a means of repression and exploitation .Decisionism is an inherent aspect of positivism . The subjectivity of ethics is the counterpart of the objectivity of science. Both are the result of a subjective idealism which takes the individual subject as point of departure. It is the individual subject who constructs his world on the basis of sensory impressions and his reason and who chooses his values. This implies not only the autonomy of ethics vis-à-vis science, but also an autonomy of facts vis-à-vis theory, and an autonomy of both science and ethics vis-à-vis history. This epistemological position is, therefore, elementaristic, individualistic and ahistorical.A radical alternative has to take as point of departure that cognition in its diverse manifestations (scientific and epistemological paradigms, logic, etc.) and value systems are interrelated historical products. It has to reject the compartmentalization of fact and value, fact and theory , subject and object, and it must place these relations in a truly dialectical perspective. Such a perspective does not provide us with unshakable moral and political precepts, but — since it does not take what is historically given for the eternally valid nor confound history with mere arbitrariness — it does point to the possibility and necessity of transformation and emancipation, i.e., the historically ly possible.Cornelis J.J. Vermeulen is Professor of Anthropology at the University of Amsterdam.

---

     

医德视域下医学生医学精神的建构

近些年来,我国十分重视医学生职业道德教育,然而,在医德教学实践中仍存在着观念落后、内容失衡和方法单一等多方面问题。同时,随着我国多元结构社会的形成,医学生的思想状况和价值观趋于复杂化,从业时职业道德水平出现滑坡。针对目前医学生医德教育存在的种种问题,试图从加强和改进医学生医德教育的角度,探索医学生医德教育改革,增强医学生医德教育的实效性。