I am grateful to C Parker for his close reading and detailed
criticism of a paper of 2005 in which I suggested some possible advantages
of moving from controversy to conversation in medical ethics.1,2 His
arguments are incisive, but also illustrate what I was attempting to
articulate. In conversation of the kind I was commending, one’s aim is not
to defend or attack a thesis but to explore the possibilit...
I am grateful to C Parker for his close reading and detailed
criticism of a paper of 2005 in which I suggested some possible advantages
of moving from controversy to conversation in medical ethics.1,2 His
arguments are incisive, but also illustrate what I was attempting to
articulate. In conversation of the kind I was commending, one’s aim is not
to defend or attack a thesis but to explore the possibility of coming to a
shared understanding of agreement or disagreement on the subject under
discussion. To this end, a degree of negative capability about the
definition (and especially the stipulative definition) of one another’s
ideas may be necessary until, through the to-and-fro of conversation, each
has had confirmed by the other a clearer understanding of what these ideas
mean to them and of the contexts in which they find them meaningful.
Whether a commendation of the advantages of such an approach to medical
ethics can be successfully defended against the kind of skilful forensic
analysis employed by Mr Parker is doubtful however, not least because to
attempt such a defence would require abandoning the very approach one is
seeking to commend. Perhaps these advantages can only be shown, by
actually engaging in conversation.
These remarks should not be taken as indicating any lack of respect
for Mr Parker’s arguments, nor for what is a perfectly proper activity for
professional philosophers. In my paper I acknowledged that there are
occasions when the sharp edge of controversy is appropriate and that
controversies are unlikely to cease. Insofar as the aim of those engaged
in controversy is to mount a potentially successful attack or defence
however, this approach has some limitations in the multidisciplinary field
of medical ethics. Since ethics is not an exact science, and since
morality is essentially contestable, attempts to render moral arguments
invulnerable rarely succeed, and the consequent philosophical debates are
potentially interminable. In medical ethics however, awaiting the outcome
of all such debates sine die is not always possible or advisable. That is
not only because medical ethics is oriented to practice, but also because
a variety of different moral arguments, few of which in themselves are
conclusive or sufficient, often need to be considered before coming to a
fallible judgement. May I illustrate this last remark with reference to
two of Mr Parker’s criticisms of my paper.
First, Mr Parker dismisses my question about whether an in vitro
embryo is actually encountered “as a ‘you’ rather than an ‘it’” as a
‘test’ which is ‘vacuous’ and ‘not usable’. If that were the sole ‘test’
of whether or not an in vitro embryo is to be accorded the moral status of
a person, I would agree with him. But that was not the point of my
suggestion. I simply do not know whether any embryos in vitro are
persons, and I do not see how I could know, since to claim or deny that an
embryo is a person is to make a moral judgement. It is precisely because I
do not know, that I find the question of whether the embryo is actually
encountered “as a ‘you’ rather than an ‘it’” helpful. The point of my
question is not to elicit a knock-down argument about whether an embryo is
or is not a person, but rather to contribute to the formation of a
fallible moral judgement on the matter. In forming a moral judgement on a
matter about which there is no certainty, it is important to listen to
testimony, and allow it to question one’s own prejudices. If anyone can
testify that he or she actually encounters an embryo in vitro as ‘you’
rather than ‘it’, that is something that we must take very seriously
indeed in coming to a judgement.
Secondly, Mr Parker dismisses the appeal in my paper to the Golden
Rule, because it provides no ‘basis for a decision mechanism in moral
conflict’ and is ‘based on an assumption that one is comparing only
virtuous actions’. But in medical ethics that is an assumption which it
seems to me reasonable to make, namely that the Golden Rule is addressed
not to the ‘tough robber’ or ‘sadistic boxer’, but to the conscience of
responsible people of good will, called upon to make practical decisions,
and aware that whatever is decided may have a significant moral
opportunity cost. That, of course, may be yet another example of my
‘tendency to place exaggerated faith in individuals who do not deserve the
honour’, but where there is no agreed decision mechanism to take the place
of fallible judgement, as is commonly the case in medical ethics,
dispensing with the expectation of virtuous judges seems unwise.
K M Boyd
Professor of Medical Ethics University of Edinburgh
Medical School Teviot Place Edinburgh EH8 9AG
References:
1. Parker C. Perspectives on ethics. J Med Ethics 2007; 33:21-23.
2. Boyd KM. Medical ethics: principles, persons and perspectives: from
controversy to conversation. J Med Ethics 2005; 31:481-6.
The article by Kassirer outlines some of the inherent struggles
within the universal health care system of Canada (1). Additional
communications reinforce these struggles (2). Is the Canadian Medical
Association hiding behind the screen of autonomy while discussions of
private public health care are in the minds of the Canadian people and its
health care providers? (3).
The article by Kassirer outlines some of the inherent struggles
within the universal health care system of Canada (1). Additional
communications reinforce these struggles (2). Is the Canadian Medical
Association hiding behind the screen of autonomy while discussions of
private public health care are in the minds of the Canadian people and its
health care providers? (3).
References:
1. Kassirer JP. Assault on editorial independence: improprieties of
the Canadian Medical Association J Med Ethics 2007; 33: 63-66.
2. Tuohy CH. The costs of constraint and prospects for health care
reform in Canada. Health Aff (Millwood) 2002; 21(3):32-46 .
3. CBCnews (February 21, 2006). Canadian Medical Association Journal
fires 2 editors. Retrieved February 6, 2007, from
http://www.cbc.ca/health/story/2006/02/21/cmaj060221.html#skip300x250
In the article by Sokol and Car titled 'Patient confidentiality and telephone consultations: time for a password'(1), the authors express
their concerns re: access to a patients medical information and outline
a
strategy using passwords during telephone consultations to secure
patient
privacy and protect against the unauthorized access to private and
personal medical records/history. While we sympathize...
In the article by Sokol and Car titled 'Patient confidentiality and telephone consultations: time for a password'(1), the authors express
their concerns re: access to a patients medical information and outline
a
strategy using passwords during telephone consultations to secure
patient
privacy and protect against the unauthorized access to private and
personal medical records/history. While we sympathize with the author's
concerns these recommendations may only increase the access health care
personnel have to their patients, and furthermore increase the
frustration
patients incur during access to their personal information and
communication with their health care provider. Previous reports have
suggested a negative experience for nurses and their telephone
consultations with patients (2). It would appear that the addition of a
password system may increase patient dissatisfaction and decrease
overall
public perception in a medical system already plagued with inadequacies.
Perhaps a better alternative to telephone passwords would be
to directly involve patients and consumers of health care with regards
to
the access and distribution of patient information (3).
References:
1. Sokol DK, Car J. Patient confidentiality and telephone
consultations: time for a password J Med Ethics 2006; 32: 688-689.
2. Giesen P, Charante EM, Mokkink H, Bindels P, van den Bosch W,
Grol
R. Patients evaluate accessibility and nurse telephone consultations in
out-of-hours GP care: determinants of a negative evaluation. Patient
Educ
Couns. 2007; 65(1):131-6.
3. Nilsen ES, Myrhaug HT, Johansen M, Oliver S, Oxman AD. Methods
of
consumer involvement in developing healthcare policy and research,
clinical practice guidelines and patient information material. Cochrane
Database Syst Rev. 2006 Jul 19;3:CD004563.
The issue of transferring human research specimens across national
boundaries has become a hot issue especially for Developing Countries due
to fears of exploitation. Stories of "parachute, tourist and mosquito"
researchers are common in Africa and other Developing Countries. These
are researchers who come from Developed Countries to Developing Countries
just to collect specimens and then leave to go...
The issue of transferring human research specimens across national
boundaries has become a hot issue especially for Developing Countries due
to fears of exploitation. Stories of "parachute, tourist and mosquito"
researchers are common in Africa and other Developing Countries. These
are researchers who come from Developed Countries to Developing Countries
just to collect specimens and then leave to go back and work in their
laboratories. The next time one hears about these researchers is when
they are publishing. Researchers and institutions from Developing
Countries also complain of being "used" as specimen collection technicians
and specimen collection centres who are not in any way involved in the
analysis of data, writing, publication and sharing of other benefits.
In order to ensure that we minimise on the possibilities of
exploitation and promote partnership, material transfer agreements (MTAs)
are the way forward. We can no longer depend on trust alone since the
trust has been abused on so many occasions. A Material Transfer Agreement
(MTA) is a contract that governs the transfer of tangible research
materials between two institutions. It defines the rights of the provider
and the recipient with respect to the materials, and any derivatives. The
MTAs would have to spell out the exact specimens being transferred, the
quantities being transferred, the exact purpose for which they are being
transferred, issues relating to the maintenance of confidentiality, access
issues, continuation of partnership, publication and intellectual property
issues as well as the disposal of the specimens. The MTA would even
specify that no new study can be conducted using the stored specimens
without the involvement of the provider institution and without the
approval from the provider institution's ethics committee.
Because of some problems that have occured in the past, some
institutions in Developing Countries have been forced to upgrage their
storage facilities so as to be able to keep duplicates of specimens
transferred to other countries. Whilst this precautionary measure may make
sense to the institutions and researchers, to the research participant it
translates into "more of the specimen than is necessary for the specific
study".
Researchers are not the owners of human specimens that have been
kindly donated by research participants but are merely stewardes entrusted
with this resource on behalf of mankind. To this end, the Ethics
Committees in Developing Countries should review the MTAs on behalf of
communities and the "real" owners of the specimens so as to ensure that
the rights and welfare of research participants continue to be promoted
and protected. Instead of continuing to send specimens to other
countriues, international collaborative research should assist in building
the capacities of Developing Country institutions, laboratoties and
researchers so that in future they can conduct their own research
independently. That way local institutions and researchers can drive the
research agenda and conduct relevant and priority research.
Dear Editor,
I am grateful to C Parker for his close reading and detailed criticism of a paper of 2005 in which I suggested some possible advantages of moving from controversy to conversation in medical ethics.1,2 His arguments are incisive, but also illustrate what I was attempting to articulate. In conversation of the kind I was commending, one’s aim is not to defend or attack a thesis but to explore the possibilit...
Dear Editor,
The article by Kassirer outlines some of the inherent struggles within the universal health care system of Canada (1). Additional communications reinforce these struggles (2). Is the Canadian Medical Association hiding behind the screen of autonomy while discussions of private public health care are in the minds of the Canadian people and its health care providers? (3).
References:...
Dear Editor,
In the article by Sokol and Car titled 'Patient confidentiality and telephone consultations: time for a password'(1), the authors express their concerns re: access to a patients medical information and outline a strategy using passwords during telephone consultations to secure patient privacy and protect against the unauthorized access to private and personal medical records/history. While we sympathize...
Dear Editor,
The issue of transferring human research specimens across national boundaries has become a hot issue especially for Developing Countries due to fears of exploitation. Stories of "parachute, tourist and mosquito" researchers are common in Africa and other Developing Countries. These are researchers who come from Developed Countries to Developing Countries just to collect specimens and then leave to go...
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