Narrative Ethics, COVID-19, and Flawed Stories.

The bioethics literature has paid little attention to resistance to COVID-19 vaccination, despite the safety and effectiveness of vaccines and the heavy death toll of the virus. A narrative approach to the problem might begin with descriptions of good and bad narratives about vaccination. Bad stories about vaccination tend to be constructed backwards, starting with the desired conclusion (vaccination is dangerous or ineffective) and from that filling in needed "facts" to support the conclusion. Physicians need to act in more trustworthy ways in order to convince at least some patients to consider vaccination.

Meaning and an Overview of the Placebo Effect.

The placebo effect can be defined as a bodily change due to the symbolic effects of a treatment or treatment situation. It is further explained by the meaning model: a positive placebo response is most likely to occur when the meaning of the illness is altered for the patient in a positive direction. Moerman's suggestion that "placebo effect" be replaced by "meaning response" is based in part on dissatisfaction with the characterization of placebo, which is avoided when one focuses instead more comprehensively on placebo effect. The placebo effect can then be explained by the mental processes of expectancy or conditioning and their effect on specific neuro-chemical processes that bring about end-organ changes.

Futility: Definition and Goals.

Schneiderman, Jecker, and Jonsen (2017) correctly take issue with a recent multi-society statement that attempts to replace most uses of the term futility with "inappropriate treatment." However, they mistakenly categorize any treatment of permanent unconsciousness as futile. Futility can be readily defined as an intervention that will not work, and it is always an incomplete statement unless one specifies the goal one hopes to achieve.

Ethical issues in patient-centered outcomes research and comparative effectiveness research: a pilot study of community dialogue.

Community bioethics dialogues were held on the topic of patient-centered outcomes research (PCOR) and comparative effectiveness research (CER). Participants were 65 and older and represented either a lower income, African American group (A) or a higher income White group (B). Participants were presented with a variety of background reading and study materials. Meetings were held 2 hr per week for 6 weeks. The groups showed both independence in judgment from the investigators and diversity of opinion between the two groups. Group B addressed more topics than Group A and in some instances explored additional policy nuances. Members of Group A appeared more cognizant of issues of social justice that affect vulnerable populations and appeared leery of approaches that suggested possible disrespect for their own personal experiences. Future plans call for both repeating the dialogue with additional, diverse community groups and repeating community bioethics dialogues on new topics with the same groups.

Professionalism: a framework to guide medical education.

CONTEXT: Despite considerable advances in the incorporation of professionalism into the formal curriculum, medical students and residents are too often presented with a mechanical, unreflective version of the topic that fails to convey deeper ethical and humanistic aspirations. Some misunderstandings of professionalism are exacerbated by commonly used assessment tools that focus only on superficially observable behaviour and not on moral values and attitudes. METHODS: Following a selective literature review, we engaged in philosophical ethical analysis to identify the key precepts associated with professionalism that could best guide the development of an appropriately reflective curriculum. RESULTS: The key precepts needed for a robust presentation of professionalism can be grouped under two headings: 'Professionalism as a trust-generating promise' (representing commitment to patients' interests, more than a mere business, a social contract, a public and collective promise, and hard work), and 'Professionalism as application of virtue to practice' (based on virtue, deeper attitudes rather than mere behaviour, and requiring of practical wisdom). CONCLUSIONS: These key precepts help students to avoid many common, unreflective misunderstandings of professionalism, and guide faculty staff and students jointly to address the deeper issues required for successful professional identity formation.

Chauncey Leake and the development of bioethics in America.

Chauncey D. Leake (1896-1978) occupies a unique place in the history of American bioethics. A pharmacologist, he was largely an autodidact in both history and philosophy, and believed that ethics should ideally be taught to medical students by those with philosophical training. After pioneering work on medical ethics during the 1920s, he helped to lay the groundwork for important centers for bioethics and medical humanities at two institutions where he worked, the University of California-San Francisco and the University of Texas Medical Branch-Galveston. Understanding Leake's role in American bioethics requires navigating a number of paradoxes--why he was described respectfully in his time but largely forgotten today; how in the 1920s he could write forward-looking pieces that anticipated many of the themes taken up by bioethics a half-century later, yet played largely a reactionary role when the new bioethics actually arrived; and why he advocated turning to philosophy and philosophers for a proper understanding of ethics, yet appeared often to misunderstand philosophical ethics.

U.S. responses to Japanese wartime inhuman experimentation after World War II.

In 1945-46, representatives of the U.S. government made similar discoveries in both Germany and Japan, unearthing evidence of unethical experiments on human beings that could be viewed as war crimes. The outcomes in the two defeated nations, however, were strikingly different. In Germany, the United States, influenced by the Canadian physician John Thompson, played a key role in bringing Nazi physicians to trial and publicizing their misdeeds. In Japan, the United States played an equally key role in concealing information about the biological warfare experiments and in securing immunity from prosecution for the perpetrators. The greater force of appeals to national security and wartime exigency help to explain these different outcomes.

Binding and Hoche's "Life Unworthy of Life": A Historical and Ethical Analysis.

The 1920 essay by German attorney Karl Binding and psychiatrist Alfred Hoche, "Permitting the Destruction of Life Unworthy of Life," is often characterized as a stepping-stone toward the Nazi genocide policies. A careful review of Binding and Hoche's arguments does reveal elements that foreshadow Nazi thinking, but it also contains points that fail to parallel--or that directly contradict--Nazi death practices. A proper ethical and historical analysis of this work requires a more nuanced discussion than it often receives.

Economism and the commercialization of health care.

Those concerned over the excessive commercialization of health care, to the detriment of both professional and patient-centered values, commonly propose remedies that assume that meaningful change can occur largely within the health care sector. I argue instead that a major shift in the public culture and political discourse of the U.S. will be required if the commercialization of health care is to be adequately addressed. The notion that health and health care are commodities to be bought and sold in the market is encouraged by the ideology that is preferably called economism, though also today labeled neoliberalism, market fundamentalism, market triumphalism, and other terms. This ideology has been successful in pushing aside alternative accounts and policies over the past four decades, so that economism-inspired policies seem both commonsensical and inevitable. This dominance of the public political discourse hides two important facts about economism - it is a quasi-religious ideology that pretends to be a reflection of economic science; and it is shot through with internal contradictions that ultimately render it self-defeating as a guide to policy. Advocates for reduced commercialism in health care must directly address economism and attempt to educate the public and policymakers about its flaws.

Peabody's "Care of the Patient" and the Nature of Medical Science.

Francis W. Peabody's 1927 essay "The Care of the Patient" is widely quoted, yet few appreciate the subtlety of its interweaving of medical science with its more obvious humanistic elements. Understanding the essay in context requires a recapitulation of Peabody's life story, a review of earlier work that led up to the culminating lecture in 1926, and a detailed analysis of the thread of argument Peabody wove through the lecture. A better understanding of the essay shows how Peabody anticipated several important later developments in medical thought.

Revisiting "The maximin strategy in modern obstetrics".

Published in 1981, "The Maximin Strategy in Modern Obstetrics" offered two claims: first, that obstetrical interventions ought to be assessed not singly, but rather as packages of interconnected measures that could cumulatively increase risks of harm; and second, that many of these interventions, considered either singly or as a package, lacked a sound evidence base. The first claim has been well supported by later literature, although the term "cascade effect" has proven a more felicitous descriptor for the phenomenon of interventions that trigger the use of other interventions to monitor, prevent, or treat possible side-effects. The second claim was initially supported in a very inadequate way, since the "Maximin" article appeared before an understanding of the methods of systematic reviews of medical evidence had been widely promulgated. Despite these defects, subsequent, rigorously conducted systematic reviews have tended to confirm the impression first offered in 1981, that practices that support physiologic childbearing and the innate, hormonally driven capacities of childbearing women and their fetuses/newborns are much more in keeping with the available evidence than practices involving common or routine high-technology interference with physiologic processes. Harm may occur either directly, through high-technology interventions, or when such procedures distract attention and resources from safe, effective biological processes and lower-technology measures. Surveys indicate a lack of knowledge of this evidence among childbearing women, signaling a serious ethical deficiency in shared decision-making processes and perhaps the skills and knowledge of maternity care clinicians.

Religion and bioethics: toward an expanded understanding.

Before asking what U.S. bioethics might learn from a more comprehensive and more nuanced understanding of Islamic religion, history, and culture, a prior question is, how should bioethics think about religion? Two sets of commonly held assumptions impede further progress and insight. The first involves what "religion" means and how one should study it. The second is a prominent philosophical view of the role of religion in a diverse, democratic society. To move beyond these assumptions, it helps to view religion as lived experience as well as a body of doctrine and to see that religious differences and controversies should be welcomed in the public square of a diverse democratic society rather than merely tolerated.

How virtue ethics informs medical professionalism.

We argue that a turn toward virtue ethics as a way of understanding medical professionalism represents both a valuable corrective and a missed opportunity. We look at three ways in which a closer appeal to virtue ethics could help address current problems or issues in professionalism education-first, balancing professionalism training with demands for professional virtues as a prerequisite; second, preventing demands for the demonstrable achievement of competencies from working against ideal professionalism education as lifelong learning; and third, avoiding temptations to dismiss moral distress as a mere "hidden curriculum" problem. As a further demonstration of how best to approach a lifelong practice of medical virtue, we will examine altruism as a mean between the extremes of self-sacrifice and selfishness.