This glossary has been prepared for use in PHIL 235 (Bioethics) at Manchester University, an introductory-level course on ethics. Mentions of "Veatch" refer to the textbook used in the course: Robert M. Veatch, Amy M. Haddad, and Dan C. English, Case Studies in Biomedical Ethics (Oxford University Press, 2010).
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ABIM Foundation: The American Board of Internal Medicine (ABIM) Foundation was created in 1999 to advance medical professionalism. They published a Physician Charter in 2002 in conjunction with the American College of Physicians (ACP) Foundation and the European Federation of Internal Medicine.
Resources on the Web: [ABIM (Physician Charter)] [ABIM (official website)]
Act Utilitarianism: See Utilitarianism, Act vs Rule.
Active Euthanasia: See Euthanasia.
ADA: The American Dental Association (ADA) was founded in 1859.
Resources on the Web: [ADA (Code of Ethics)] [ADA (official website)]
Advance Directive: A document prepared by the patient specifying how the patient should be treated medically, should the patient be unable to participate in those decisions. This might include a living will or instruction directive, that gives advance instructions on end-of-life treatment, or a proxy directive that specifies an individual to make healthcare decisions on the patient’s behalf, should the patient become incompetent (a Durable Power of Attorney for Health Care [see]).
Resources on the Web: [State of New Jersey, Dept. of Health and Senior Services (Advance Directive Forms)] [AMA Code, 2.225 (Advance Directives)] [AMA Virtual Mentor (case study)]
Agent, Moral: See Moral Agent and Moral Patient.
Allograft: The transplantation of living cells, tissues, or organs between individuals of the same species, e.g., from one human to another (from the Greek allos, other). Compare with xenograft.
AMA: The American Medical Association (AMA) was founded in 1847, and is the largest professional society of physicians (doctors of medicine [M.D.] and doctors of osteopathy [D.O.]). It has been publishing the weekly Journal of the American Medical Association (JAMA) since 1883. The first offical meeting of the society took place in Philadelphia in 1847, and the two principal items of business were to establish a Code of Ethics and to set the minimum professional requirements for medical education and training. See also the WMA.
Resources on the Web: [AMA (Code of Ethics)] [AMA (official website)]
ANA: The American Nurses Association (ANA) was founded in 1896. The Code of Ethics for Nurses, published in 1998, is a revision of the Code for Nurses (1985).
Resources on the Web: [ANA (Code of Ethics)] [ANA (official website)] [Pursuing a Nursing Career (LearnHowToBecome.org)]
Angiogram: An image of the blood vessels, normally obtained by injecting an opaque medium into the circulatory system and then using X-ray based imaging, although CT (computed tomography) and MR (magnetic resonance) imaging is also used.
Antinomianism: From the Greek anti- (against) and nomos (law), this is the view that there are no legitimate moral laws or principles, and that the rightness of our actions must always be determined by their context or situation (another term for this position is ‘situationalism’). The opposite position is legalism [see].
AOA: The American Osteopathic Association (AOA) was founded in 1897.
Resources on the Web: [AOA (official website)]
APhA: The American Pharmaceutical Association (APhA) was founded in 1852, and is the largest professional association of pharmacists in the United States.
Resources on the Web: [APhA (Code of Ethics)] [APhA (official website)]
Assisted Suicide: From the AMA Code of Medical Ethics...
Physician-assisted suicide occurs when a physician facilitates a patient’s death by providing the necessary means and/or information to enable the patient to perform the life-ending act (e.g., the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide).
Assisted-suicide is legal in Oregon, Washington, and Montana, as well as in several other countries (Belgium, Germany, Luxembourg, the Netherlands, and Switzerland). See also the related entry on Euthanasia.
Resources on the Web: [AMA Code, 2.211 (Physician-Assisted Suicide)] [PBS Frontline (The Kevorkian Verdict)] [Oregon’s Death with Dignity Act (see)] [Wikipedia]
Atresia: A condition, often congenital, where an opening or canal is abnormally closed or absent (e.g., esophageal atresia, intestinal atresia).
Attending Physician: ...
Autonomy, Principle of: (or “principle of respect for autonomy”) From the Greek autos (self) and nomos (law). Autonomy is a central moral principle today, having sprung from the Enlightenment culture of the past two centuries. It has not always enjoyed such a privileged status, however, and there are still cultures where it takes a back seat to communitarian concerns.
• “You should respect the capacity of individuals to choose their own vision of the good life and act accordingly.”
• “You shall not treat a patient without the informed consent of the patient or of a lawful surrogate, except in narrowly defined emergencies” [GBG, 29].
See also Paternalism, the Harm Principle, Informed Consent, and Confidentiality or Fidelty.
The principle of autonomy is captured in the second of three “Fundamental Principles” of the ABIM Physician Charter [see]:
Principle of primacy of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.
Autonomy is also discussed in the AMA Code of Ethics:
The principle of patient autonomy holds that an individual’s physical, emotional, and psychological integrity should be respected and upheld. This principle also recognizes the human capacity to self-govern and choose a course of action from among different alternative options. Autonomous, competent patients assert some control over the decisions which direct their health care. [Opinion 10.02 — Patient Responsibilities]
There are three basic senses of autonomy; to be completely autonomous is to be autonomous in all three of these senses:
Liberty of Action: Autonomy as the “lack of external coercion” (i.e., force or the threat of force).
Freedom of Choice: Autonomy as the “availability of options” (e.g., having the resources for some action).
Effective Deliberation: Autonomy as the possession of information and the ability to process it effectively (i.e., to understand it). Here autonomy requires that the agent act “rationally” both in choosing the best means to the desired end, and in choosing the most appropriate ends. Such effective deliberation can be foiled in any of three basic ways:
(1) constitutional irrationality: the agent may be immature, senile, etc.
(2) ephemeral irrationality: the agent is under the influence of extreme emotion (such as fear or anger) or pain, or is feverish, or under the influence of certain drugs.
(3) lack of information: here the agent may be acting rationally, but lacks the appropriate information or has been misinformed (intentionally or not) or in some manner deceived.
The principle of autonomy clearly must allow for the patient to disagree with his or her healthcare professionals and to choose a different course of action. As the American Hospital Association (1985) writes:
“Decision-making capacity is the patient’s ability to make choices that reflect an understanding and appreciation of the nature and consequences of one’s actions and of alternative actions, and to evaluate them in relation to the person’s preferences and priorities. A patient’s decision contrary to a physician’s recommendation does not in itself indicate incapacity.”
Resources on the Web: [AMA Code, 10.02 (Patient Responsibilities)] [ABIM (Physician Charter)]
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Belmont Report: “The current U.S. system of protection for human research subjects is heavily influenced by the Belmont Report, written in 1979 by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont Report outlines the basic ethical principles in research involving human subjects. In 1981, with this report as foundational background, HHS and the Food and Drug Administration revised, and made as compatible as possible under their respective statutory authorities, their existing human subjects regulations.” [HHS.gov] See also the Nuremberg Code and the Helsinki Declaration.
Resources on the Web: [U.S. Department of Health and Human Services, Code of Federal Regulations (The Belmont Report)]
Beneficence, Principle of: Doing or producing good, primarily with the thought of helping another person; commonly paired with nonmaleficence [see]. The principle of beneficence might be formulated as:
• “We should act in ways that promote the welfare of other people”
• “We should foster the interests and happiness of other persons and of society at large.”
Unlike the principle of non-maleficence, which also applies to the general population, this principle may well not apply to everyone. It is certainly a duty of professional caregivers, although what concrete actions the principle requires of them is not always clear, as there are countless ways in which a healthcare professional could benefit a patient, and not all can be required. In general, the professional must be willing to make “reasonable” sacrifices for the well-being of the patient (for example, working overtime if a complication arises that requires their attention).
Compare with the Principle of Utility, and see Principle (moral/ethical).
Resources on the Web: [Stanford Encycl. of Philosophy (The Principle of Beneficence in Applied Ethics)]
Brain Death, whole: The patient’s brainstem (necessary for basic physiologic activities like respiration) is destroyed, as well as the cerebellum (necessary for thinking and conscious experience), and the patient will die unless kept on a respirator. If you accept the “whole brain death” criterion as your criterion of death, of course, then euthanasia is not an issue here since there is no one to kill or let die. See Impaired States of Cognitive Being.
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Categorical Imperative: See Imperative, Categorical.
Classification of Actions: See Moral Classification of Actions.
Clinical Trials: Before being allowed by the Food and Drug Administration (FDA) to market a drug in the United States, pharmaceutical companies need to subject the drug to a three-stage review: (1) Investigational New Drug (IND) application, (2) Clinical Trials, and (3) New Drug Application (NDA). About 20% of the investigational new drugs (IND) filed with the FDA clear all three stages.
The clinical trials occur in four phases (and here I quote from Meadows 2002):
Phase 1 studies are usually conducted in healthy volunteers. The goal here is to determine what the drug’s most frequent side effects are and, often, how the drug is metabolized and excreted. The number of subjects typically ranges from 20 to 80.
Phase 2 studies begin if Phase 1 studies don’t reveal unacceptable toxicity. While the emphasis in Phase 1 is on safety, the emphasis in Phase 2 is on effectiveness. This phase aims to obtain preliminary data on whether the drug works in people who have a certain disease or condition. For controlled trials, patients receiving the drug are compared with similar patients receiving a different treatment — usually a placebo or a different drug. Safety continues to be evaluated, and short-term side effects are studied. Typically, the number of subjects in Phase 2 studies ranges from a few dozen to about 300.
Phase 3 studies begin if evidence of effectiveness is shown in Phase 2. These studies gather more information about safety and effectiveness, studying different populations and different dosages and using the drug in combination with other drugs. The number of subjects usually ranges from several hundred to about 3,000 people.
Phase 4 studies occur after a drug is approved. They may explore such areas as new uses or new populations, long-term effects, and how participants respond to different dosages.
Resources on the Web: [Michelle Meadows, “The FDA’s Drug Review Process” (2002) FDA.gov]
Coma/Comatose: See Permanently Unconscious.
Commission vs Omission: Is doing harm morally equivalent to failing to prevent the same sort of harm from occurring? This is the difference between committing an action (e.g., drowning someone) and omitting an action (e.g., failing to save a drowning person). Consequentialists [see] tend not to find a moral difference, while non-consequentialists [see] typically do. The moral irrelevance of this distinction was forcefully argued by James Rachels, who considers two drowning scenarios: in the first, Smith drowns a child in a bathtub; in the other, Jones plans to drown a child, but then finds the child already unconscious under water and refrains from saving him. These cases would appear to be morally identical, although the former is a killing (an act or commission) and the second a letting die (or omission); see also Withdrawing and Withholding Treatment. [James Rachels, “Active and Passive Euthanasia,” New England Journal of Medicine, 292 (1975): 78–86]
Another famous thought experiment touching on this distinction is the trolley problem [YouTube].
Resources on the Web: [Stanford Encycl. of Philosophy (Doing vs. Allowing Harm)]
Compassionate Use: (also known as Expanded Access) The American Cancer Society describes this as “the treatment of a seriously ill patient using a new, unapproved drug when no other treatments are available. Drugs that are being tested but have not yet been approved by the US Food and Drug Administration (FDA) are called investigational drugs. These drugs are generally available only to people who are taking part in a clinical trial (a research study that is testing the drug). Being able to use one of these drugs when you are not in a clinical trial has many names, but is most commonly referred to as compassionate use.”
Resources on the Web: [Amer. Cancer Society]
Confidentiality, Principle of: See Fidelity, Principle of.
Consent: See Informed Consent.
Consequences: Every action and every policy will result in various consequences, and these are of three morally-relevant sorts: (1) intended, (2) foreseen, but unintended, (3) unforeseen — and then a category that cuts across these three: (4) actual. Consequentialist moral theories typically weigh only those consequences that actually occur, while deontological moral theories will be concerned with the agent’s intentions (and thus, what is unintended or unforeseen will have little or no relevance). Of special interest are foreseen (but unintended) consequences that nevertheless do not occur; the relevance here is in the additional risk of harm imposed on others.
Examples
• intended: Administering morphine, with the intention of to lessen the pain in a patient.
• foreseen, but unintended: Administering morphine, and causing constipation in the patient.
• unforeseen: Administering morphine, and causing hives due to an unusual allergic reaction.
Consequentialism: Any moral theory that determines the rightness of an action by referring to the consequences of that action. Veatch discusses two kinds of consequentialism: Utilitiarianism [see] and Hippocratic ethics [see]. The principle difference between these concerns the scope of relevant consequences: utilitarianism is concerned with the well-being of all persons possibly affected by the action or policy, while Hippocratic ethics is concerned solely with the well-being of the patient.
Resources on the Web: [Stanford Encycl. of Philosophy (Consequentialism)]
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Death, Definition of: ...
• Pulmonary death: Cessation of breath (as seen in movies: the inability to fog a mirror).
• Cardiac death: See Pittsburgh Protocol
• Whole brain death: [see]
• Higher brain death:
The Uniform Declaration of Death Act was drafted in 1981, approved by the American Medical Association and the American Bar Association, and has since been adopted by all fifty states. It offers two criteria for legally declaring a person dead:
(1) Irreversible cessation of circulatory and respiratory functions; or
(2) Irreversible cessation of all functions of the entire brain, including the brain stem.
Resources on the Web: [Stanford Encycl. of Philosophy (The Definition of Death)] [healthcare.findlaw.com (What is the Uniform Declaration of Death Act?)]
Declaration of Geneva: See Geneva, Declaration of.
Dementia: Unlike a coma or a permanently vegetative state [see], which typically result from some accident (resulting, ultimately, in lack of oxygen to different parts of the brain), dementia involves a progressive loss of cerebral functions. A common and well-publicized form of dementia is Alzheimer’s. See Impaired States of Cognitive Being.
Deontologism: Any moral theory that is duty-based, such as Kant’s [see] moral theory — the term comes from the Greek word deon (“being necessary”). This is a non-consequential kind of moral theory in that the consequences of the action are considered either of secondary importance, or altogether irrelevant. What matters morally are features of the action itself, which is performed because of one’s duty to perform it (as opposed to acting from self-interest or some other inclination).
Veatch focuses on the following non-consequentialist duties, all of which can be understood as derived from a respect for persons [see]: the principles of autonomy [see], veracity [see], fidelity [see], and avoidance of killing [see].
Descriptive Science: See Normative Science.
Difference Principle: See Original Position.
Dilemma: See Moral Dilemma.
Disclosure of Information: See Informed Consent, Veracity.
Distributive Justice: The just allocation of benefits and burdens in society; see Justice.
Robert Nozick (1938-2002; Harvard) described two approaches to distributive justice. The historical approach looks to how a pattern of distribution came about. If the current pattern came about in a just manner from some previous pattern, and if the previous pattern was also just, then the current pattern is just. The end-state approach compares the current pattern of distribution against some standard to determine whether it is just. Nozick favored the historical approach, while Rawls [see] developed an important end-state model of distributive justice [Nozick, Anarchy, State, and Utopia, 1974]
Alternatively, one might distribute resources based on or more substantive principles of fairness: equality, need, contribution, or effort.
The ABIM [see] Physician Charter includes distributive justice as a central concern. The last of three “Fundamental Principles” reads:
Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.
And the set of “Professional Responsibilities” includes:
Commitment to a just distribution of finite resources. While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost effective care. The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one’s patients to avoidable harm and expense but also diminishes the resources available for others.
Resources on the Web: [Stanford Encycl. of Philosophy (Distributive Justice)]
Divine Command Theory of Morality: This is a form of ethical subjectivism [see] in which an action is morally right insofar as God has commanded us to perform that action, and wrong insofar as God has prohibited it. On this view, morality is determined by the will of God.
Resources on the Web: [Stanford Encycl. of Philosophy (Theological Voluntarism)]
DNR: Do not rescuscitate orders might be part of an advance directive [see] indicating that CPR should not be administered on a patient whose heart has stopped.
Resources on the Web: [AMA Code, 2.22 (Do-Not-Resuscitate Orders)]
Double-Effect, Principle of: A doctrine in the natural law [see] tradition that places the following restrictions on the permissibility of an action when some of the foreseeable consequences of the action are evil: (1) the act is good in itself or at least indifferent; (2) only the good consequences of the act are intended; (3) the good consequences are not the effect of the evil; and (4) the good consequences are commensurate with the evil consequences.
Resources on the Web: [Stanford Encycl. of Philosophy (Doctrine of Double Effect)]
DRG: Diagnosis-related group is a system, implemented in the 1983, to classify hospital procedures into various groups, in order to better regulate and standardize reimbursement for those procedures. For instance, “normal newborn” (DRG 391) is one DRG, “limb reattachment” (DRG 485) another; the 2006 list includes 579 distinct DRGs (some of which have been discontinued) [PDF].
Due Care: Healthcare providers are required to exercise due care, that is, “to be cautious, attentive, patient and thoughtful in their actions with patients, and to possess the knowledge and skills relevant for providing their kind of care.”
‘Due Care’ is defined by the context of the action, such as the current state of knowledge and the presence of alternative sources of help. For instance, primary care physicians routinely performed general surgery in the early part of the 20th century, but such behavior today would normally violate the standards of due care, in that it places unnecessary risks on the patient (see Nonmaleficence, Principle of).
Durable Power of Attorney for Health Care: “A Health Care Power of Attorney is a document that allows you to designate a person who will have the authority to make health care decisions on your behalf if you are unconscious, mentally incompetent, or otherwise unable to make such decisions.” See also Advance Directive.
Resources on the Web: [American Bar Association, “Giving Someone a Power of Attorney For Your Health Care” (pdf)] [LectLaw.com (Power of Attorney forms)]
Duty-Based Ethic: See Deontologism.
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End-State Model of Distributive Justice: See Distributive Justice.
Ethics: The science devoted to answering such questions as: “How shall we live?” “At what shall we aim with our lives?” And “how shall we get on with those around us?” Morality [see] is the body of possible answers. The words ‘ethics’ and ‘morality’ are closely related, stemming from Greek and Latin words that mean “custom” (Greek: ethos; Latin: mos). Ethics, as a science, is purely a matter of the understanding (theory), but morality will always involve our actions (practice).
Normative ethics is what people normally have in mind when they think of ethics. It is the normative science [see] that studies goodness (What is the best distribution of benefits and burdens in the world, and what counts as a benefit?), virtue (What traits of character do we value in people?), and right action (What rules or principles should we follow?). Each of these areas typically involves criteria for deciding when a situation is good or bad, when a person’s character is virtuous or vicious, and when an action is right or wrong. Theories of normative ethics discussed in this glossary include Natural Law [see], Kant’s deontological moral theory [see], and Mill’s utilitarianism [see].
Normative ethics contrasts with metaethics [see], that area of ethics concerned with the meaning and justification of ethical claims.
Ethical Objectivism vs Ethical Subjectivism: The metaethical [see] positions that understand the truth-value of moral judgments as based either on some objective (non-willful) state of affairs, or on some arbitrary will.
Objectivist normative theories include:
• Aquinas’s natural law theory [see], which grounds morality in the very nature of things.
• Kant’s deontological moral theory [see], which grounds morality in the nature of reason.
• Mill’s utilitarianism [see], which grounds morality in the experiencing of pleasure.
Subjectivist normative theories include:
• simple subjectivism [what Veatch calls "personal relativism"] — moral judgment is grounded on the arbitrary will or feelings of the individual,
• ethical relativism [see] [what Veatch calls "social relativism"] — moral judgment is grounded on the arbitrary will of the community, and
• divine command theory [see] — moral judgment is grounded on the arbitrary will of God) .
Equal Liberty Principle: See Original Position.
Eugenics: From the Greek eu- (good) and genos (clan, birth). The study (and implementation) of improving the human genome. What counts as an “improvement” is, of course, a point of considerable debate. Past eugenic programs have given the field a bad name, although matters of genetic compatibility and considerations of the likely characteristics of offspring are often part of individual reproductive decisions, and occasionally appear as matters of public health initiatives (e.g., the requirement in some states for a blood test prior to receiving a marriage licence).
Resources on the Web: [Stanford Encycl. of Philosophy (Pregnancy, Birth, and Medicine)]
Euthanasia: From the Greek eu- (good) and thanatos (death). The deliberate killing of a person, primarily because the person is suffering from an incurable and painful illness. It is useful to distinguish between killing someone (“active”) and letting them die (“passive”), and doing this either with their consent (“voluntary”), against their consent (“involuntary”), or where consent has been neither given nor refused (“non-voluntary”). Involuntary killings fall outside the scope of euthanasia, and all of these differ from the related issue of assisted suicide [see]. Important cases involving these different variations include the following:
Passive euthanasia: Euthanasia brought about by withholding some life-saving treatment (e.g., withholding a life-saving transplant, or hemodialysis, or failing to intubate, or give antibiotics, or administer CPR, or give food or water — the range here is quite wide, from the extraordinary to the ordinary).
voluntary: Satz v Perlmutter (Florida, 1978), Elizabeth Bouvier (California, 1983-).
non-voluntary: Karen Quinlan (New Jersey, 1975-85), Browning (Florida, 1990), Nancy Beth Cruzan (Missouri, 1983-90), Claire Conroy (New Jersey, 1983), Nancy Ellen Jobes (New Jersey, 1987), Paul Brophy (Massachusetts, 1983-86), Joseph Saikewicz (Massachusetts, 1976), Baby Doe (Indiana, 1982), Terry Schiavo (Florida, 1998-2005).
Active euthanasia: Euthanasia is brought about by actively killing the patient, most commonly by giving an overdose of a sedative.
voluntary: “Debbie” (Illinois, 1988), Thomas Youk (Michigan, 1998).
non-voluntary: Dr. Kadijk and Baby Doe (Holland 1994).
Resources on the Web: [AMA Code, 2.21 (Euthanasia)]
Expanded Access: See Compassionate Use.
Experimentation (on humans): See Nuremberg Code, Helsinki Declaration, Belmont Report, IRB, Clinical Trials.
Extraordinary Treatment: As articulated in Catholic moral theology, a treatment is extraordinary, and therefore not obligatory, if it involves great costs, pain, or inconvenience, and is a grave burden to oneself or others without a reasonable expectation that such treatment would be successful [Gerald Kelly, S.J., Medico-Moral Problems (St. Louis: The Catholic Hospital Association Press, 1958), pp. 128-41]. (Many of the terms used here, of course, are ambiguous; their precise meaning will vary from culture to culture.) See also Medical Futility and Proportionality.
Extrinsic Value: See Value, Intrinsic vs Extrinsic.
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Fidelity, Principle of: This is a commitment made to others with whom one stands in a special (fiduciary [see]) relationship. It involves a commitment to disclose all relevant information to the patient (and otherwise to practice honesty [see]), to keep promises, to keep the patient’s information confidential — and, in general, to make the patient’s interests of primary concern (much as a parent, while concerned for all children, is primarily concerned for one’s own children). See also Principle (moral/ethical).
The principle of fidelity is captured in the first of three “Fundamental Principles” of the ABIM Physician Charter [see]:
Principle of primacy of patient welfare. The principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.
Two aspects of the principle of fidelity are found in the Declaration of Geneva [see]:
The health of my patient will be my first consideration.
I will respect the secrets that are confided in me, even after the patient has died.
Resources on the Web: [AMA Code, 5.05 (Confidentiality)] [ABIM (Physician Charter)]
Fiduciary Relationship: A covenantal relationship based on trust (from the Latin fiducia, trust). Such relationships fall on a wide spectrum, but all will involve special rights and duties that arise as a result of the relationship.
Final Value: See Value, Final vs Instrumental.
Fistula: An opening, often resulting from illness or injury (e.g., ulcerative colitis can lead to a fistula in the small intestine) or a congenital abnormality (e.g., a tracheo-esophageal fistula is an opening between the trachea and the esophagus that is sometimes encountered in newborns).
Formalism: A moral theory that determines the rightness of an action by its form rather than its content, or its actual or intended consequences. Kant’s deontological moral theory, [see] is a kind of moral formalism.
Futility, Medical: See Medical Futility.
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Geneva, Declaration of: This professional oath, taken by medical students upon receiving their degrees, is a modernized version of the Oath of Hippocrates [see], and was adopted by the 2nd General Assembly of the WMA [see] in Geneva, Switzerland, in 1948.
AT THE TIME OF BEING ADMITTED AS A MEMBER OF THE MEDICAL PROFESSION:
I SOLEMNLY PLEDGE to consecrate my life to the service of humanity;
I WILL GIVE to my teachers the respect and gratitude that is their due;
I WILL PRACTISE my profession with conscience and dignity;
THE HEALTH OF MY PATIENT will be my first consideration;
I WILL RESPECT the secrets that are confided in me, even after the patient has died;
I WILL MAINTAIN by all the means in my power, the honour and the noble traditions of the medical profession;
MY COLLEAGUES will be my sisters and brothers;
I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;
I WILL MAINTAIN the utmost respect for human life;
I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;
I MAKE THESE PROMISES solemnly, freely and upon my honour. [from the WMA website]
Greatest Happiness Principle: The foundational principle for John Stuart Mill’s [see] Utilitarianism [see]. To quote Mill:
The creed which accepts as the foundation of morals, Utility, or the Greatest Happiness Principle, holds that actions are right in proportion as they tend to promote happiness, wrong as they tend to produce the reverse of happiness. By happiness is intended pleasure, and the absence of pain; by unhappiness, pain, and the privation of pleasure. [Utilitarianism, ch. 2 (1863)]
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Harm Principle: (or “harm to others” principle) Developed originally by J. S. Mill [see]:
[T]he sole end for which mankind are warranted, individually or collectively, in interfering with the liberty of action of any of their number, is self-protection. [On Liberty (1859), Ch. 1, §9]
The principle holds that liberty (autonomy in the sense of “liberty of action” [see]) is a fundamental good that must not be compromised without good reason; coercion is justified only when it prevents an evil greater than the coercion itself. Not to be confused with the principle of nonmaleficence [see].
Two versions of this principle:
• The private harm principle: this justifies the restriction of one person’s liberty to prevent injury to other specific individuals (e.g., this would disallow such actions as willful homicide, assault and battery, and robbery).
• The public harm principle: this justifies the restriction of one person’s liberty to prevent injury to institutional practices or regulatory systems that are in the public interest (e.g., this might disallow such actions as tax evasion, treason, smuggling, or contempt of court).
Hedonism: The ethical theory that holds that the good is pleasure (from the Greek hedone, pleasure). Hedonism has been argued for and against since the Ancient Greeks. Utilitarianism [see] is a modern form of hedonism.
Helsinki Declaration: A set of guidelines for experimenting on human subjects, developed in 1964 by the World Medical Association [see] at its General Assembly in Helsinki (thus the name). This declaration was intended to replace and expand upon the Nuremberg Code [see], and revised various times since (most recently at the Seoul General Assembly in 2008). See also the Belmont Report.
Resources on the Web: World Medical Association [Helsinki Declaration]; [AMA Code, 2.30 (Information from Unethical Experiments)] [AMA Code, 2.07-2.078 (Clinical Investigation)]
Hippocrates, Oath of: Hippocrates of Cos (c.450-c.380 BCE), an ancient Greek physician, wrote down what has become the most famous of the medical oaths in the West. A significant body of medical literature is associated with his name, although much of it may have originated with his followers rather than with him. See also the Oath of Maimonides and the Declaration of Geneva.
I swear by Apollo the physician, and Asclepius, and Hygieia and Panacea and all the gods and goddesses as my witnesses, that, according to my ability and judgement, I will keep this Oath and this contract:
To hold him who taught me this art equally dear to me as my parents, to be a partner in life with him, and to fulfill his needs when required; to look upon his offspring as equals to my own siblings, and to teach them this art, if they shall wish to learn it, without fee or contract; and that by the set rules, lectures, and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to students bound by this contract and having sworn this Oath to the law of medicine, but to no others.
I will use those dietary regimens which will benefit my patients according to my greatest ability and judgement, and I will do no harm or injustice to them.
I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.
In purity and according to divine law will I carry out my life and my art.
I will not use the knife, even upon those suffering from stones, but I will leave this to those who are trained in this craft.
Into whatever homes I go, I will enter them for the benefit of the sick, avoiding any voluntary act of impropriety or corruption, including the seduction of women or men, whether they are free men or slaves.
Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.
So long as I maintain this Oath faithfully and without corruption, may it be granted to me to partake of life fully and the practice of my art, gaining the respect of all men for all time. However, should I transgress this Oath and violate it, may the opposite be my fate. [Translated by Michael North, National Library of Medicine, 2002 (website)]
Hippocratic Ethics: A kind of consequentialist [see] moral theory based on the Oath of Hippocrates [see]. It is similar to utilitarianism [see], except that the health-care provider following this ethic is concerned solely with the well-being of the patient currently being treated, and not with the well-being of all other members of the moral community. Rather than relying on the principle of utility [see], the Hippocratic ethicist would rely more on the principles of nonmaleficence [see] and beneficence [see].
Historical Model of Distributive Justice: See Distributive Justice.
HMO: “A health maintenance organization (HMO) is an organization that provides managed care [see] for health insurance contracts in the United States as a liaison with health care providers (hospitals, doctors, etc.). The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options if the employer offers traditional healthcare options. Unlike traditional indemnity insurance, an HMO covers only care rendered by those doctors and other professionals who have agreed to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers.” [Wikipedia]
Resources on the Web: [Film clip from As Good as It Gets (1997) (YouTube)] [Film clip of Congressional testimony on HMOs from Sicko (2007) (YouTube)]
Honesty: See Veracity, Principle of.
Hospice Care: “Hospice care is end-of-life care provided by health professionals and volunteers. They give medical, psychological and spiritual support. The goal of the care is to help people who are dying have peace, comfort and dignity. The caregivers try to control pain and other symptoms so a person can remain as alert and comfortable as possible. Hospice programs also provide services to support a patient's family. Usually, a hospice patient is expected to live 6 months or less. Hospice care can take place at home, at a hospice center, in a hospital, or in a skilled nursing facility.” [MedlinePlus.gov Glossary (website)]
Hypothetical Imperative: See Imperative, Categorical vs Hypothetical.
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Iatrogenic: Caused, or brought about by the physician; from the Greek iatros (healer). This is generally used in the context of harmful effects stemming from the physician, such as the increased mortality documented in 18th and 19th century maternity wards caused by attending physicians who would perform post-mortem examinations between their intermitten inspections of laboring women — without washing their hands in between, thereby exposing the women to lethal bacteria.
Impaired States of Cognitive Being: Impaired states fall within a spectrum, and somewhere between the fully alert and the dead. The following have entries in this glossary: Whole Brain Death [see], Dementia [see], Locked-in Syndrome [see], Permanently Unconscious (including “comatose” and “persistent vegetative state”) [see].
Imperative, Categorical: A central concept of Immanuel Kant’s [see] deontological moral theory, and to be distinguished from the lower-level moral imperatives that Kant refers to by the same name. The categorical imperative is a principle or formula from which is to be derived all the commands of morality (the laws that practical reason gives for guiding our actions). As such, it is a second-order rule of action from which we derive our first-order rules (e.g., of promise keeping, or of benevolence). Kant also gives us three separate formulations of this imperative – the Universal Law, the End-in-Itself, and the Autonomy formulations – noting that these are three ways of thinking about the same thing, and not different moral principles:
• The Universal Law formulation (“Act only on that maxim that I can consistently will to become a universal law”) is a rule for telling us how to make rules of action (a rule for rule making), and doing this in an entirely formal way. At its heart is the prohibition against making a moral exception of oneself (there is to be “no double-standard” – one for me and another for everyone else).
• The End-in-Itself formulation (“Act so as to treat humanity, whether in your own person or in the person of another, always as an end, never merely as a means”) focuses on the nature of human beings, insofar as they act according to maxims (“have wills”) and so are persons. According to this formulation, I am not to use another in any way with which the other cannot in principle agree, since doing so would be to use that person merely as a means, as a mere tool or instrument of my own plans and desires. This forbids the use of deception or coercion, since either of these involve the other person in a scheme of action to which they would not consent if they knew all the details (were not deceived) or if they were not forced.
• The Autonomy formulation (“Act so that the will may regard itself as in its maxims laying down universal laws”) instructs us to act as autonomous agents legislating for all agents in the kingdom of ends. Everyone is legislating for themselves, and at the same time for everyone else, in that we are all using the same basic formula for deciding which of our maxims are moral, and which not.
Imperative, Categorical vs Hypothetical: An imperative is a command, and Kant [see] distinguishes between two general kinds: hypothetical (of which there are imperatives of skill and imperatives of prudence) and categorical. Only the latter are absolutely binding.
Hypothetical imperatives all have the logical form: “If you want E, then do A!”, where E is some particular end or goal, and A is some action. With imperatives of skill, the thing wanted might be any goal at all, while an imperative of prudence always posits happiness as the goal – a goal presumably shared by all human beings. Hypothetical imperatives oblige us (have power over us) only to the extent that we desire the goal mentioned in the “If”-clause.
Categorical imperatives, on the other hand, have the form: “Do A!”, and as a consequence bind us absolutely, since they are not based upon some goal that we might later decide to forego.
Kant argues that these categorical imperatives (or ‘moral imperatives’) are generated by a certain meta-rule that he also calls the ‘Categorical Imperative’ [see], and of which there are three formulations.
Informed Consent: The principle of autonomy [see] suggests that a patient may not be treated without that patient’s informed consent, and that this must meet the following criteria:
Disclosure of Information: the patient is told the risks, harms/benefits, and alternatives to the course of action (this is related to the principle of veracity [see]).
Understanding: the information is given in a way understandable by the relevant parties.
Mental Competence: the patient must be mentally competent.
Voluntary Consent: the consent is granted without coercion or fraud. (A person might also be coerced by a lack of practical choice, for instance, someone in desperate financial straits might agree to serve in a risky study because of the compensation.)
Resources on the Web: [Stanford Encycl. of Philosophy (Informed Consent)][AMA Code, 8.08 (Informed Consent)]
Instrumental Value: See Value, Final vs Instrumental.
Intending vs Permitting: Any action that we undertake will have multiple consequences [see], some of which we intend, while the rest are unintended. Of the unintended consequences, some are foreseen, but permitted, while others are unforeseen. Of the latter, some will nonetheless be found desirable, others undesirable, and the rest a matter of indifference. This distinction between intended and permitted consequences is generally considered morally relevant, although not to consequentialists, who (ultimately) care only about those consequences that actually come about, and not whether they were intended. When these consequences involve a killing, the distinction is made in terms of direct (intended) and indirect (merely permitted) killing [see].
Intrinsic Value: See Value, Intrinsic vs Extrinsic.
In Vitro Fertilization : ...
Resources on the Web: [AMA Code, 2.14 (In Vitro Fertilization)]
IRB: An Institutional Review Board is a committee for reviewing and monitoring research projects for compliance with the relevant code of ethics (primarily for ensuring the welfare and rights of human and non-human animal test subjects). For instance, all research funded by the Department of Health and Human Services must include an IRB.
Resources on the Web: [U.S. Department of Health and Human Services, Code of Federal Regulations (45 CFR 46: Protection of Human Subjects)] [IRB: Ethics and Human Research, a journal published by the Hastings Center (website)]
Ischema: ...
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Justice: In its most abstract sense, justice is fairness — giving each his due, and treating similar people similarly. Justice is traditionally divided into a number of concerns:
• Retributive justice: fairness in the meting out of punishment.
• Corrective justice: fairness of demands for civil damages.
• Commutative justice: fairness of wages, prices, and exchanges.
• Distributive justice [see]: fairness in the distribution of resources (benefits) as well as burdens. This is similar to commutative justice, but not the same; for example, distributive justice might involve a tax scheme for redistributing a pattern of wealth resulting from a commutatively just arrangement of wages.
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Kant, Immanuel: Immanuel Kant (1724-1804) was a German philosopher who wrote on a wide range of subjects, most famously on epistemology and the limits of human reason in his Critique of Pure Reason (1781). But he is also well known for his moral philosophy, where he developed a deontological theory [see]. Kant’s writings on ethics include the brief Foundations of the Metaphysics of Morals (1785), the Critique of Practical Reason (1788), and the Metaphysics of Morals (1797). The first of these, the Foundations, was written to exhibit moral reason in its purest form, showing that morality is grounded in reason itself, as expressed in the Categorical Imperative [see].
Killing, Direct vs Indirect: This distinction rests on the intention of the actor. Direct killing requires that the killing be an intended consequence of the action; indirect killing is where the death is either foreseen or unforeseen, but in any event not intended. See also the Principle of Double Effect, Consequences, and Intending vs Permitting.
Killing, Principle of Avoidance of: Veatch discusses this as one of four basic deontological [see] principles derived from our respect for persons [see].
Killing vs Letting Die: This is one example of a larger class of commission vs omission [see] and is what distinguishes active from passive euthanasia [see]. See also the closely related distinction between Withdrawing and Withholding Treatment.
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Legalism: The rigid application of moral principles, regardless of the circumstances; opposed to antinomianism [see].
Living Will: See Advance Directive.
Locked-In Syndrome: The level and content of consciousness may be normal, but the patient is so severely paralyzed that the patient may appear to have diminished or no consciousness. See Impaired States of Cognitive Being.
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Maimonides, Oath of: Moses Maimonides (1135-1204) was the greatest Jewish scholar of the middle ages. “Between Moses and Moses there are none greater than Moses” — a common saying about Maimonides suggesting the high regard in ß he was held.
Maimonides grew up in Muslim Spain, in Cordoba, but his family was forced into exile when he was thirteen, eventually settling in Cairo, where he and his brother became successful jewel merchants. After the death of both his brother and father, he took up the study of medicine, and his fame as a physician resulted in his appointment as court physician to the great Muslim ruler Saladin (1138-1193) — the same man who had defeated Richard the Lionhearted during the Third Crusade.
Maimonides’ fame in the history of philosophy rests squarely on his main work, The Guide for the Perplexed, written in Arabic, and in which he hoped to harmonize Greek philosophy with his Jewish faith — or, in more general terms, the claims of reason with the claims of faith. See also the Oath of Hippocrates and the Declaration of Geneva.
The Oath (in English translation):
The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.
May I never see in the patient anything but a fellow creature in pain.
Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.
Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.
Resources on the Web: [Oath of Maimonides] [Stanford Encycl. of Philosophy (Maimonides)]
Managed Care: “Managed care plans are health insurance plans that contract with health care providers and medical facilities to provide care for members at reduced costs. These providers make up the plan's network. How much of your care the plan will pay for depends on the network’s rules.
Restrictive plans generally cost you less. More flexible plans cost more. There are three types of managed care plans:
Health Maintenance Organizations (HMO) [see] usually only pay for care within the network. You choose a primary care doctor who coordinates most of your care.
Preferred Provider Organizations (PPO) [see] usually pay more if you get care within the network, but they still pay a portion if you go outside
Point of Service (POS) plans let you choose between an HMO or a PPO each time you need care” [MedlinePlus.gov Glossary (website)]
Maximin Principle: See Original Position.
Medical Futility: A medical intervention is futile when it offers the patient no clinical benefit. This could be either quantitative (the likelihood of success is poor) or qualitative (the improvement in quality of life, even given a sucessful intervention, is poor).
Resources on the Web: [AMA Code, 2.035 (Futile Care)]
Medicare and Medicaid: Medicare is a federal government-sponsored health insurance, funded by Social Security taxes, for individuals over 65, people under 65 with certain disabilities, and anyone with end-stage renal disease. Medicaid is a government-sponsored health insurance for financially-impoverished individuals, and is funded jointly by the federal government and individual states. Congress legislated both of these programs in 1965; Medicare funding of individuals with renal disease began in 1972.
In addition to these two programs, the Children’s Health Insurance Program (CHIP) provides health insurance for children in families whose income is too high to qualify for medicaid, but who otherwise cannot afford health insurance.
Resources on the Web: [Summary of Medicare and Medicaid (pdf)]
Medicine: Medicine and medical interventions might be classified functionally as one or more of the following:
Therapeutic medicine (or curative medicine) seeks to remove an illness or other physical ailment. This is what is most commonly understood by ‘medicine’.
Palliative medicine seeks to lessen the symptoms of an illness or other ailment. From the Latin palliare (to cloak), it aims to cover or hide a symptom, often in the form of pain management. Hospice care [see] is palliative medicine practiced on patients near the end of life, where the patient is kept comfortable and therapeutic efforts of curing the patient are abandoned (normally because they are seen as futile); but palliative medicine also has a role at other stages of life and with all sorts of disorders (e.g., taking an aspirin for a headache is palliative, addressing the symptom, but not the cause of the symptom).
Preventive medicine seeks to prevent the onset of a disease in the first place (“well baby” checks are a form of preventive medicine, as are public health measures such as proper sanitation).
Diagnostic medicine seeks to arrive at an understanding of a disease or disorder. Many medical interventions are aimed at diagnosis, rather than therapy, although the diagnosis is normally sought with the hope that a successful therapy might then follow.
Experimental medicine seeks knowledge, but not regarding any particular patient (and in this fashion differs from all of the above forms of medicine, whose focus is always the individual patient). Clinical trials [see] of a new pharmaceutical would be an example of experimental medicine, and this is often wholly separate from any therepeutic effects (especially in Phase One of the trials, which are normally conducted on healthy volunteers).
Metaethics: That area of ethics that is concerned with the meaning and justification of ethical claims. What is the scope or status of moral values? What does it mean to say that a situation is good, a person virtuous, or an action right? Here I’m not asking how I identify the good, the virtuous, and the right — this is what one does in normative ethics [see] — rather, I’m asking what it is that I’m doing when I make such an identification. Am I recognizing some property, like being red, that makes something good (the property of goodness)? Does moral value exist in the world independently of human beings and their interests, or does it depend on our existence? Do we create moral value or do we discover it? Is it simply a reflection of our interests, or of our emotional states and feelings? The study of these questions constitutes the field of metaethics.
Mill, John Stuart: John Stuart Mill (1806-73) was born in London as the first son of the Scottish philosopher James Mill. Among other things, he was an important expositor of utilitarianism [see].
Mill’s father personally undertook the education of John Stuart and, as a consequence of certain natural gifts, and perhaps also of the pedagogy employed, the young student was reading Latin by the age of three and Greek by the age of eight — and in general was well versed in the arts and sciences by the time he was in his teens.
Mill went to work for the British East India Company at the age of seventeen, and stayed in that employment for thirty-five years. In 1852 he married Harriet Taylor, a recently widowed woman with whom he had shared an intense, intellectual relationship for the previous twenty-one years. He was elected to Parliament for a term in 1865.
Both during and after his employment with the East India Company, Mill made important contributions to philosophy and social reform, writing such classics as A System of Logic (1843), Principles of Political Economy (1848), On Liberty (1859), Utilitarianism (1863), and The Subjection of Women (1869).
Moral Agent and Moral Patient: A moral agent is anyone capable of acting morally or immorally, which generally requires that they be rational and free, aware of one’s duties and the rights of others. A moral patient is anyone or anything capable of being benefitted or harmed (in other words, possessing moral considerability [see]).
While all moral agents will also be moral patients, not all patients will be agents, since there are morally considerable individuals constitutionally incapable of moral agency (e.g., very young children, the severely mentally incapacitated, and very likely all or most non-human living organisms).
Moral Classification of Actions: One traditional classification scheme sorts our actions into four groups — required, prohibited, supererogatory, and morally irrelevant — and the sorting is done in terms of our emotional response to the action — specifically, whether we feel the action is praiseworthy or blameworthy. This system of classification is clearly subjective, and is best considered as a first approximation for understanding the moral status of various actions.
Morally required: failure to do them merits blame, while doing them does not merit praise (except, perhaps in circumstances where an individual is in “remedial moral training,” such as a young child). For example, failure to keep a promise would normally be blameworthy.
Morally prohibited: doing them merits blame, while failure to do them does not merit praise (except in “remedial moral training,” as above). For example, killing an innocent person would normally be blameworthy.
Morally supererogatory: doing them merits praise, but failure to do them does not merit blame. They are morally relevant, but neither required nor prohibited. For example, saving the life of a stranger at considerable personal risk would normally be praiseworthy, while its omission would not be blameworthy.
Morally irrelevant: neither required, prohibited, nor supererogatory, and so doing them (or failure to do them) merits neither praise nor blame. For example, while dressing in the morning, pulling on your right sock first is morally irrelevant; no one would think to blame or praise you for such an action.
Moral Considerability and Moral Significance: A being is morally considerable (or has moral standing) if it can be benefitted or harmed; as such it merits some respect by moral agents [see]. To have moral considerability is to have one’s interests taken seriously, to enjoy a buffer-zone that prevents moral agents from treating one frivolously or without due respect. If something lacks this, then we are not forced to justify our actions towards it; it cannot complain of injury, and no one can complain on its behalf. One’s moral community will consist of all morally considerable individuals; determining the scope of one’s moral community is an important and an early task in moral reflection.
Moral significance concerns the level or extent of deferrence an individual enjoys in the moral community. The interests of individuals within the community will often collide; for instance, non-human animals often have their interests defeated by human interests (e.g., when eating them, or experimenting on them, or keeping them in captivity for human amusement), and the matter of moral significance helps us determine which interests may be overridden, and which may not. [Kenneth Goodpaster, “On Being Morally Considerable,” Journal of Philosophy (1978)]
Moral Dilemma: A situation in which two or more moral principles give conflicting advice on what to do, such that one or more of these principles must be violated. These dilemmas suggest the need for a ranking of one’s principles, perhaps by appealing to a more encompassing moral theory.
Morality: The body of beliefs that concern how we ought to conduct our lives and, in particular, our beliefs about right and wrong actions, good and bad states of affairs, and virtuous and vicious characters; morality is what ethics [see] studies.
It is difficult to offer a definition that captures the meaning of ‘morality’ without being circular. For instance, morality concerns the distinction we draw between right and wrong actions — how we should and should not act — but not in every sense of ‘right’ and ‘wrong’ or ‘should’ and ‘should not’, only in the moral sense.
The moral sense differs from the legal (e.g., You should not jaywalk), the prudential (e.g., You should not ignore your boss), the technical (e.g., You should not use that much torque while tightening that screw), or one based simply on etiquette (e.g., You should not chew with your mouth open).
Legal: what is required/prohibited by the state vs what is required/prohibited by ... one’s conscience? (... although many laws are reflections of moral concerns — e.g., laws prohibiting murder or theft — while other laws help coordinate group behavior, leading to a greater good for the whole, which might be considered morally relevant).
Prudential: what is good/bad for the self vs what is good/bad for the other (... although what happens to oneself might be morally significant as well. Can we draw a well-defined line between “self-regarding” and “other-regarding” actions?)
Technical: what is good/bad for reaching some goal (... although the goal, as well as the means to the goal, might be morally relevant).
Etiquette: what is done/not done in “polite society” (... although violating the norms of polite society might cause harms to others that are morally significant).
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Natural Law: Thomas Aquinas (1225-1274) is an important source of the natural law tradition, which is for him firmly situated in a Christian Aristotelianism, although its roots are in pre-Christian Greek and Roman law traditions. As Aristotle argued, there are natural capacities and ends for human beings that are defined by their nature as a rational animal. To excel in these natural capacities is to become virtuous. Natural law consists of those principles which, if followed, will best allow human beings to become virtuous.
Aquinas defines law as “a certain ordinance of reason for the comon good, made by whoever has care of the community, and that is promulgated” (Summa Theologicae, Ia-IIae.90.4), and he distinguishes four kinds of law:
• eternal: the foundation of all other law; identical to the mind of God as seen by God, and for the good of the entire created universe; this is the inherent order God established in the universe, and thus all creation participates in this law — water flowing down a hill, a plant growing towards the light, and so on;
• divine: derived from eternal law, as it appears to humans through revelation;
• natural: “nothing other than the participation in eternal law by rational creatures” (Summa Theologicae, Ia-IIae, q91, a2); as rational beings, humans are able to participate more fully in the eternal law than other creatures; and
• human: (also called civil or positive law) laws developed by human authorities, based upon natural law but reflecting the particularities of individual human communities.
The first principle of the natural law is “good is to be done and pursued, and evil avoided” (Summa Theologicae, Ia-IIae, q94, a2). All other precepts of natural law are derived from this, of which Aquinas mentions the following: (1) “Whatever is a means of preserving human life and of warding off its obstacles belongs to natural law” (insofar as we are living), (2) sexual intercourse and the education of offspring have a proper place in human life (insofar as we are animals), (3) we are to avoid ignorance (insofar as we are rational), and (4) we are to avoid offending those among whom we have to live (insofar as we are social). [Jason T. Eberl, Thomistic Principles and Bioethics (Routledge, 2006)]
Non-Cognitivism: The view that moral statements are neither true nor false.
Resources on the Web: [Stanford Encycl. of Philosophy (Moral Cognitivism vs. Non-Cognitivism)]
Nonmaleficence, Principle of: One must not cause harm, primarily with the thought of not harming another person; this is commonly paired with Beneficence [see]. This principle is often stated as the first duty of the physician: primum non nocere (“first of all, do no harm”) — or alternatively: “Avoid causing needless harm to others.” This principle can be violated in one of two ways: (1) through intentionally doing something either to harm another or to place them at unnecessary risk, and (2) through carelessness (e.g., in dispensing medications) or avoidable ignorance. Although typically understood as a recommendation not to act (“better to do nothing, than to cause harm”), this principle is sometimes used to indicate a requirement to act in order to protect a patient from some harm.
This principle requires, for instance, that healthcare providers exercise due care [see]. Compare with the Principle of Utility, and see Principle (moral/ethical).
Normative Ethics: what people normally have in mind when they think of ethics [see].
Normative Science: Normative and descriptive are paired opposites; normative concerns what ought to be while descriptive concerns what is. For example, psychology is a descriptive science that, among other things, explains how people think or reason; logic is a normative science that explains how people ought to think or reason. Anthropology is a descriptive science that explains how people do in fact behave, while ethics is a normative science that explains how people ought to behave.
Nuremberg Code: A set of guidelines developed in the aftermath of World War II and the discovery of inappropriate experimentation on human subjects by Nazi physicians and other scientists during the war crimes trials at Nuremberg. See also the Helsinki Declaration and the Belmont Report.
Resources on the Web: [Nuremberg Code]
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Oath of Hippocrates: See Hippocrates, Oath of.
Oath of Maimonides: See Maimonides, Oath of.
Obligation: From the Latin ob- (toward) and ligare (to bind). Generally used synonomously with ‘duty’.
Objectivism, Ethical: See Ethical Objectivism.
Omission: See Commission vs Omission.
Original Position: A thought experiment developed by John Rawls [see] for arriving at a just set of rules or principles. Rawls is interested in procedures that, if followed, guarantee a just outcome (a popular example of this is the procedure whereby the person who slices the pie takes the last piece).
In general, any principle or rule is just (fair) if it is (a) agreed to unanimously, and everyone’s decision to agree is (b) well-informed, and (c) uncoerced.
Arriving at such rules is difficult, since individuals have different interests and act to enhance or defend those interests. What we need, then, is some fiction that makes possible a well-informed, uncoerced unanimity regarding rules of justice. This fiction is what Rawls calls the veil of ignorance; once behind it, we are in the “original position.” Here we are ignorant of our social or economic class, our political affiliations, racial or ethnic background, educational background, gender, profession, and particular conception of the good. This veil is supposed to be “thick” enough to hide all knowledge that would make self-interested decisions unjust. We still know the general laws of the natural and social sciences and that we will all be members of the same generation, but we will remain ignorant of the culture that we will find ourselves in, the historical period, or the technological level. Given the veil of ignorance, moral principles are attained even while people use self-interest as their sole motivation.
Rawls claims that what we are interested in from the original position are primary goods: things that a person would want whatever her particular conception of the good turns out to be. In general terms, these primary goods are “rights and liberties, opportunities and powers, income and wealth.”
From the original position, people will not try to maximize their primary goods, according to Rawls; rather, they will try to minimize their losses or, more specifically, they will follow the maximin principle: favor principles of justice that make as good as possible the worst thing that could possibly befall yourself (that is, consider the person who is worst off, and make that person as well off as possible).
Finally, Rawls develops a special theory of justice that would be favored in a society such as our own. If we can assume, in the original position, that our society will enjoy the relative abundance of a contemporary industrial democracy, then Rawls feels that top priority will be given to preserving basic political and civil liberties. Because basic needs will be met in such a society, no one will be willing to trade their liberties for basic needs. This special theory is expressed in two principles:
The Equal Liberty Principle: “Each person is to have an equal right to the most extensive basic liberty compatible with a similar liberty for others.”
The Difference Principle: “Social and economic inequalities are to be arranged so that they are both (a) to the greatest benefit of the least advantaged and (b) attached to offices and positions open to all under conditions of fair equality of opportunity.”
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Palliative Medicine: See Medicine.
Paresis: From the Greek word parienei (let go). The condition of muscular weakness resulting from either nerve damage or disease. Stroke victims often suffer from a partial paresis or a hemiparesis (where one side of the body is paralyzed or weakened).
Passive Euthanasia: See Euthanasia.
Paternalism: From the Latin word pater (father), paternalism is to treat another as a child by restricting their freedom in various ways “for their own good.” More specifically, it is interfering with a person’s autonomy [see] (in the sense of their “liberty of action”) for the sake of promoting that person’s interests. Paternalism might occur at the level of the state, of an institution (such as a hospital), or of an individual, and the justification may differ depending on the actor involved.
Gerald Dworkin defines paternalism as “the interference with a person’s liberty of action justified by reasons referring exclusively to the welfare, good, happiness, needs, interests, or values of the person being coerced” [“Paternalism” The Monist, 56 (1972): 65].
A distinction is commonly drawn between weak and strong paternalism:
• Weak paternalism: if a person already lacks autonomy in the sense of effective deliberation (due to some constitutional or temporary impairment or lack of information) then it is permissible to interfere with that person’s liberty of action (e.g., restraining a confused or an inebriated person about to walk into heavy traffic, or restraining an otherwise competent person about to walk on an unsafe bridge); here the person’s goals or preferences are accepted (e.g., health, avoidance of harm), but the means they have chosen are irrational (i.e., the means are unlikely to promote the goal).
• Strong paternalism: a person’s goals or preferences are rejected as irrational, and thus it is permissible to interfere with that person’s liberty of action (Dworkin's example: a person who prefers to ride her motorcycle without a helmet, despite the added risks of injury, might be interfered with by the strong paternalist).
Paternalism is normally viewed as morally permissible in only two situations: when trying to prevent someone with a severely compromised autonomy (normally due to some incapacity for “effective deliberation”) from causing themselves harm, or when temporarily constraining a person who appears intent on self-harm until it can be determined whether he is acting autonomously.
Resources on the Web: [Stanford Encycl. of Philosophy (Paternalism)]
Patient, Moral: See Moral Agent and Moral Patient.
Permanently Unconscious: There are two forms of this state: comatose and persistent vegetative state. The comatose involves some brainstem damage resulting in permanently closed eyes and no or little gag and cough reflex; the latter makes long-term survival unlikely as it makes the patient highly susceptible to respiratory infections.
Coma is a state in which the cortex or higher brain areas of a person are damaged resulting in loss of consciousness, inability to be roused, and unresponsiveness to pain, sound, touch and light. If lower brain centers are damaged, a respirator may be required for the person to breathe. The damage may be reversible or irreversible. [American Hospice Foundation (see)]
Persistent vegetative state generally involves no brainstem damage, allowing the eyes to open and close in apparent sleep cycles. Because the patient’s gag and cough reflexes are intact, long-term survival is common.
A vegetative state exists when a person is able to be awake, but is totally unaware. A person in a vegetative state can no longer “think,” reason, relate meaningfully with his/her environment, recognize the presence of loved ones, or “feel” emotions or discomfort. The higher levels of the brain are no longer functional. A vegetative state is called “persistent” if it lasts for more than four weeks. [Ibid.]
See Impaired States of Cognitive Being.
Permitting vs Intending: See Intending vs Permitting.
Physician: See Attending Physician and Staff Physician.
Pittsburgh Protocol: A protocol designed to expand the pool of available organs for transplantation. Among other things, organ-harvesting can begin once the donor’s heart has been stopped for two minutes (the definition of cardiac death used here).
Resources on the Web: [AMA document (pdf)]
PPO: “In health insurance in the United States, a preferred provider organization (PPO) is a managed care [see] organization of medical doctors, hospitals, and other health care providers who have covenanted with an insurer or a third-party administrator to provide health care at reduced rates to the insurer’s or administrator’s clients.” [Wikipedia]
Primum non nocere: Latin for “first of all, do no harm” — traditionally viewed as the first moral principle of healthcare professionals, and referred to as the Principle of Nonmaleficence [see].
Principle (moral/ethical): A moral or ethical principle is a criterion that determines when an action is morally right or wrong; it is normally our first step in justifying or explaining a moral judgment, and are typically just verbal expressions of some right or duty. These principles might concern the consequences of the action (e.g., the principles of beneficence [see], nonmaleficence [see], and utility [see]) or some non-consequential (formal) feature of the action itself (e.g., the principles of autonomy [see], justice [see], veracity [see], or fidelity [see]).
See also: Distributive Justice; Double-Effect; Killing, Avoidance of
Profession: A profession traditionally includes the following features:
(1) A dedication to a particular way of life,
(2) that involves activities important to the functioning of society,
(3) and that puts service to society ahead of personal gain.
(4) There is controlled entrance into its membership (educational and licensing requirements).
(5) There is some ethical code governing the practice of the profession.
A number of professional societies are given entries in this glossary: ABIM [see], ADA [see], AMA [see], ANA [see], AOA [see], APhA [see], WMA [see].
Proportionality, Criterion of: Used as a criterion of whether a medical procedure or treatment is extraordinary [see], and therefore morally optional. In general if the burden equals or exceeds the benefits, the the treatment is morally optional. This is similar to the “grave burden” phrase found in Catholic moral theology:
One is held to use only ordinary means — according to circumstances of persons, places, times and culture — that is to say, means that do not involve any grave burden for oneself or another. [Pope Pius XII, “The Prolongation of Life.” The Pope Speaks 4 (1958): 395-96]
Proxy Directive: See Advance Directive.
PVS: Persistent Vegetative State. See Permanently Unconscious.
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QALY: Quality-adjusted life year (QALY, pronounced qwah-lee) is the unit of measurement for comparing the overall benefits of different healthcare expenditures, e.g., if you have $10 million to spend each year, will there be more benefits by spending it on kidney transplants to otherwise healthy individuals or on insulin-management of Type 2 diabetes (assuming more demand than supply with each of these)? The assumption with QALY is that we are interested not just in maximizing the number of lives saved (with our medical resources), but life-years (so, if forced to choose, a 15-yr-old should be saved instead of an 85-yr-old, since doing the former will win more life-years. Similarly, it assumes that we are interested in maximizing not just life-years, but also the quality of those years (for instance, 10 extra years living in full health is worth more than 10 extra years living as a bed-ridden invalid).
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Rationing and Resource Allocation: Rationing, or the allocation of resources, will occur in any situation where resources are scarce. There has always been, and likely always will be, a scarcity of medical resources.
This rationing can occur in any number of ways, both just and unjust — ranging from the laissez-faire approach of letting the strong take what they want, and the weak what they can, to a centrally-controlled rationing based on some principle of distributive justice [see]. Medical Triage [see] is a system of rationing in emergency situations; see also Medical Futility.
Resources on the Web: [AMA Code, 2.03 (Allocation of Limited Medical Resources)] [AMA Virtual Mentor journal issue on rationing (April 2011)]
Rawls, John: (1921-2002) a leading social and political philosopher of the 20th century, teaching at Harvard for the majority of his career. He is best known for A Theory of Justice (Harvard University Press, 1971), the publication of which marked a renaissance in normative ethics. This theory of justice mingles elements of the Kantian and utilitarian traditions. A central feature of Rawls’s theory of justice is his discussion of the original position [see].
Relativism (cultural): The claim that moral beliefs differ from culture to culture. This merely describes what people believe to be true, and not what actually is true, and so is contrasted with ethical relativism [see], which claims that the truth of moral beliefs will differ from culture to culture. (Veatch calls this “descriptive relativism.”)
Relativism (ethical): The claim that moral standards differ from culture to culture, so that the truth-value of a moral claim will depend upon the speaker and her context (what Veatch calls “normative relativism”). It is a kind of ethical subjectivism [see], opposed to ethical universalism [see], and contrasted with cultural relativism [see].
Rescue, Rule of: “The strong social tendency to help an identified individual [...] rather than unidentified, anonymous, or statistical people who are equally deserving and equally endangered” [Pence 340].
Respect for Persons: The Belmont Report [see] notes that the “respect for persons incorporates at least two ethical convictions: first, that individuals should be treated as autonomous agents, and second, that persons with diminished autonomy are entitled to protection.” See also Autonomy, Principle of.
Rights: All rights are always against someone and to something. These can be construed as either moral or legal (the primary difference is whether they are enforceable by the state).
Rights directed against a specific person or group are given the Latin name in personam, while rights directed against any person whatsoever are called in rem. Similarly, the right might be toward a person’s doing something for me (“positive”) or their not interfering with me (“negative”); these negative rights are further divided according to whether the interference is with my action (“active”) or simply with my being (“passive”):
• Positive in personam: “Rights of contract,” and arise through a contract or promise, either explicit or implicit. Some positive in personam rights are more accurately called “rights of reparation,” where an injured party has a right to be compensated by whomever caused the injury.
• Positive in rem: “Rights of beneficence.” It is common to attempt to base these rights in “natural law,” that is, to claim that we have by nature certain rights to the actions of others.
• Active in rem: “Rights of liberty” or the right of autonomy, the right to act in any way I see fit. This right received its classic defense in John Stuart Mill’s On Liberty (1859)
• Passive in rem: “Rights of security” amount to our basic right not to be touched. It may include rights against trespass, seizure of property, damage to property or body, torture, and killing.
Inalienable rights are those that cannot be given up or taken away; to forfeit a right is to give it up unwillingly (e.g., someone found guilty of a crime might be required to forfeit a certain sphere of their right to liberty for a certain period of legal confinement); we often waive various rights, which we do willingly, temporary, and always with the option of re-invoking them (e.g., we typically waive the right not to be touched with respect to our circle of acquaintances).
The right to life is notoriously ambiguous, and could plausibly be understood as either a negative in rem right, or as...
It might seem that rights and duties complement each other — that for every right there is a corresponding duty (e.g., a patient’s right against his physician that his case be kept confidential corresponds with the physician’s duty to maintain confidentiality). But ...
Resources on the Web: [Stanford Encycl. of Philosophy (Rights)]
Rule Utilitarianism: See Utilitarianism, Act vs Rule.
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Staff Physician: ...
Strong Paternalism: See Paternalism.
Subjectivism, Ethical: See Ethical Objectivism vs Ethical Subjectivism.
Supererogatory: An action morally good to perform, but not required of us. Charity is definitionally understood as supererogatory. See also the Moral Classification of Actions.
SurrogatePregnancy: ...
Resources on the Web: [AMA Code, 2.18 (Surrogate Mothers)]
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Teratogenic: Causing a deformation in an embryo.
Therapeutic Privilege: The allowance for a healthcare provider to withhold information from a patient on the grounds that the disclosure would somehow harm the patient. This was a traditionally invoked allowance — on paternalistic [see] grounds — but is at odds with a patient’s autonomy [see] and the requirements of informed consent [see].
Resources on the Web: [AMA Virtual Mentor (case study)]
Triage: The process of sorting people based on their need for immediate medical treatment as compared to their chance of benefiting from such care. Triage is done in emergency rooms, disasters and wars when limited medical resources must be allocated to maximize the number of survivors. [MedicineNet.com]
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Universalism (ethical): The claim that certain moral principles are true for all people, regardless of who the speaker is or what the context or cultural background might be; opposed to ethical relativism [see].
UNOS: United Network for Organ Sharing (UNOS) is a private, non-profit organization that manages the nation’s organ transplant system under contract with the federal government, maintaining a database for every transplant event (retrieval and implantation), managing the list for patients waiting a donor organ. It was established in 1968, and received the first (and only) federal contract in 1986.
Resources on the Web: [United Network for Organ Sharing (website)][UNOS transplantation history (website)]
Utilitarianism: A moral theory that considers an action morally right to the extent that it maximizes overall happiness; see the Greatest Happiness Principle. Jeremy Bentham (1748-1832) and John Stuart Mill [see] gave utilitarianism its modern form.
Utilitarianism is a consequentialist moral theory [see] in that it decides the moral worth of an action solely on the basis of its consequences. Motives, intentions, the character of the agent — none of this ultimately matters in morally evaluating an action. A world filled with virtuous people acting always with good intentions will likely be a better world (insofar as it contains more of what is good); but such virtue and such intentions are worthy or desirable only so far as they increase this good — according to utilitarianism.
Utilitarianism, Act vs Rule: Recent moral theorists have distinguished between two different kinds of utilitarianism: act utilitarianism and rule utilitarianism. Mill [see] does not distinguish between these two forms in his writing, and different passages suggest different interpretations (the difference probably wasn’t clear in his own mind).
Act utilitarianism is thought to be the “pure” utilitarian position, where each act is considered on its own merits. For any particular act, if performing it will maximize the good, then it should be performed; otherwise not. Act utilitarianism may lead to certain theoretical problems (such as urging us not to keep promises), for which reason some ethicists have promoted a modified version of utilitarianism called “rule utilitarianism.”
Rule utilitarianism evaluates the rule, rather than the individual action. If following a certain rule (instead of some other rule) maximizes the good, then that rule should be followed, even if it would turn out, with some instances, that happiness could be maximized by breaking the rule. This means, for instance, that certain applications of the rule might fail to maximize the good, but because that kind of act normally does maximize the good, then it is always right to so act. This form of utilitarianism has the advantage of being easier for human beings to follow: we have to evaluate only rules, rather than individual acts. It also has the advantage of avoiding certain problems of act utilitarianism, such as committing unjust (yet happiness-maximizing) acts. It has the intuitive disadvantage, however, of occasionally requiring us to perform acts even when doing so will fail to maximize the good.
Utility, Principle of: “We should act so as to bring about the greatest good and the least harm”; this is equivalent to John Stuart Mill’s [see] Greatest Happiness Principle [see], and lies at the heart of Utilitarianism [see].
Utility is quite similar to Beneficence [see] and Nonmaleficence [see], but is distinguished by its concern with the sum-total of well being in the world, while beneficence and nonmaleficence are always focused on the person in front of you (e.g., one’s patient). The principle of utility might require me to sacrifice one person to benefit others, which violates the principle of nonmaleficence that I, first of all, do no harm. This is the distinction between utilitarianism and Hippocratic ethics [see]. See also Principle (moral/ethical).
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Value, Final vs Instrumental: This distinction concerns the manner in which we value something, and was first made by Aristotle in the opening sentences of Book One of his Nicomachean Ethics. Something has final value if we value it for its own sake, while it has instrumental value if we value it for the sake of something else.
Aristotle also notes that some things might be valued for their own sake as well as for the sake of something else — a college education is, for many, valued for its own sake, but many also value it as a means to finding employment of some sort. This raises the question of whether there might be something that we value only for its own sake and never for the sake of another; this would be our ultimate value, and he notes that everyone agrees that this highest value is happiness.
Value, Intrinsic vs Extrinsic: This distinction concerns the source of value, and is of central importance in Kantian ethics. Kant famously claimed (Groundwork of the Metaphysics of Morals, 1785) that the good will is “good without qualification” (= intrinsically valuable). Something has intrinsic value if it is the source of value, and has extrinsic value if its value comes only through association with something with intrinsic value.
For instance, Kant understood the good will as the source of moral value, and while happiness was valued by human beings for its own sake (as of final value), it had value only extrinsically, namely, to the extent that it was appropriately associated with a good will — much as the moon is bright only extrinsically, and only to the exent that it receives light from the sun.
Veil of Ignorance: See Original Position.
Veracity, Principle of: The general ethical principle of truth-telling (or considered from the other side: not to tell lies). This duty not to lie was not part of healthcare ethics until the 1980 revision of the AMA Code of Ethics; prior to that, it was considered proper to lie to patients whenever that might spare them emotional pain or otherwise benefit them. To quote from the current AMA Code (8.12):
It is a fundamental ethical requirement that a physician should at all times deal honestly and openly with patients. Patients have a right to know their past and present medical status and to be free of any mistaken beliefs concerning their conditions.
See also Principle (moral/ethical).
Resources on the Web: [AMA Code, 8.12 (Patient Information)]
Voluntary Consent: See Informed Consent.
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Weak Paternalism: See Paternalism.
Withdrawing and Withholding Treatment: The AMA Code of Medical Ethics maintains that there is no moral difference between withdrawing and withholding life-sustaining treatment, and that competent patients must be allowed to choose either of these courses; see also Commission vs Omission.
Resources on the Web: [AMA Code, 2.20 (Withholding or Withdrawing Life-sustaining Medical Treatment)] [AMA Virtual Mentor (case study)]
WMA: The World Medical Association (WMA) was founded in 1947 in the aftermath of World War II, with funding from National Medical Associations from around the world (now numbering 100). The WMA is the sponsoring organization of the Declaration of Geneva [see] (the modernized version of the Oath of Hippocrates [see] that most or all medical students take upon receiving their degrees), and of the Helsinki Declaration [see] (regulating experimentation on human subjects). Its Medical Ethics Manual was first published in 2005. See also the AMA.
Resources on the Web: [WMA (Medical Ethics Manual)] [WMA (official website)]
Wrongful Life/Wrongful Birth: A child with severe medical ailments might sue (typically through a surrogate) a parent for being brought into an existence "not worth living", or a parent of such a child might sue a healthcare professional or hospital for wrongful birth, either because they refused to abort the fetus, or failed to provide proper genetic counseling or in some other way failed to properly inform the parents of known risks or complications for the child.
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Xenograft: The transplantation of living cells, tissues, or organs from one species to another (from the Greek xenos, foreign). Compare with allograft.
Resources on the Web: [Wikipedia]
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Bibliography
Meadows, Michelle, “The FDA’s Drug Review Process” (2002) [FDA.gov].
Pence, Gregory E., Classic Cases in Medical Ethics (McGraw Hill, 2004).
Veatch, Robert M., Amy M. Haddad, and Dan C. English, Case Studies in Biomedical Ethics (Oxford University Press, 2010).
Prepared by Steve Naragon [email]. Last update: 9 Dec 2015