Common morality versus specified principlism: reply to Richardson.

In his article 'Specifying, balancing and interpreting bioethical principles' (Richardson, 2000), Henry Richardson claims that the two dominant theories in bioethics--principlism, put forward by Beauchamp and Childress in Principles of Bioethics, and common morality, put forward by Gert, Culver and Clouser in Bioethics: A Return to Fundamentals--are deficient because they employ balancing rather than specification to resolve disputes between principles or rules. We show that, contrary to Richardson's claim, the major problem with principlism, either the original version or the specified principlism of Richardson, is that it conceives of morality as being composed of free-standing principles, rather than as common morality conceives it, as being a complete public system, composed of rules, ideals, morally relevant features, and a procedure for determining when a rule can be justifiably violated.

Literature and medical ethics.

The essays in this Journal issue offer examples of how textual analysis, literary theory, and the reading and writing of literature can contribute to an understanding of ethical issues in medicine. The editors' purpose in such an issue is to stimulate discussion between philosopher-ethicists and literary scholars whose work concerns this topic. With the concluding essays by editors Clouser and Hawkins, this discussion begins.

Philosophy, literature, and ethics: let the engagement begin.

The goal is to isolate points of philosophical interest in the preceding articles on narrative medical ethics in order to focus subsequent dialogue between the two disciplines. Ethics is an enterprise that has over the centuries developed a somewhat malleable structure, comprising characteristics, methods, lines of reasoning, rules, principles, assumptions, and arguments. This structure provides the framework within which many disciplines contribute to ethics through the exercise of their particular interests, skills, and methods. Challenging or changing the structural components requires arguments of a traditional sort appropriate to the discipline of ethics. Three tenets are proposed as comprising the "received view" or credo of the literature and ethics movement. Each is examined. Then the individual articles in this issue are explored to the end of ferreting out points that would be fruitful points of discussion between philosophy and literature folks pursuing their mutual interest in ethics.

The method of public morality versus the method of principlism.

Two years ago in two articles in a thematic issue of this journal the three of us engaged in a critique of principlism. In a subsequent issue, B. Andrew Lustig defended aspects of principlism we had criticized and argued against our own account of morality. Our reply to Lustig's critique is also in two parts, corresponding with his own. Our first part shows how Lustig's criticisms are seriously misdirected. Our second and philosophically more important part picks up on Lustig's challenge to us to show that our account of mortality is more adequate than principlism. In particular we show that recognition of mortality as public and systematic enables us to provide a far better description of morality than does principlism. This explains why we adopt the label "Dartmouth Descriptivism."

The challenge for future debate on euthanasia.

There is a significant pattern emerging in the discourse about euthanasia and assisted suicide as exemplified in the other articles in this special issue of the Journal of Pain and Symptom Management. That pattern is a dynamic tension that should be nurtured in the best interests of our options at the end of life. On the one hand, there is general acceptance of the right to self-determination and (within debatable limits) of the rationality and mortality of suicide. And on the other hand, there has been emphasis on comfort care through appropriately chosen medications and through a wholesome doctor-patient relationship that fosters a view of life worth living. Thus the creative tension is between the freedom to be dispatched with a minimum of suffering and the efforts to make it more desirable to stay and fight. It is a variation of the "fight or flight" response. The tension must be maintained for the good of us all. Too much emphasis on either one would skew the balance, and a dangerous extreme could result.

Humanities in medical education: some contributions.

The author discusses the contribution of humanities teaching in medical education. Five "qualities of mind" specifically engendered by the humanistic disciplines are isolated, delineated, and illustrated: critical abilities, flexibility of perspective, nondogmatism, discernment of values, and empathy and self-knowledge.

A critique of principlism.

The authors use the term "principlism" to refer to the practice of using "principles" to replace both moral theory and particular moral rules and ideals in dealing with the moral problems that arise in medical practice. The authors argue that these "principles" do not function as claimed, and that their use is misleading both practically and theoretically. The "principles" are in fact not guides to action, but rather they are merely names for a collection of sometimes superficially related matters for consideration when dealing with a moral problem. The "principles" lack any systematic relationship to each other, and they often conflict with each other. These conflicts are unresolvable, since there is no unified moral theory from which they are all derived. For comparison the authors sketch the advantages of using a unified moral theory.

Teaching medical ethics in its contexts: Penn State College of Medicine.

Ethics teaching at The Pennsylvania State University College of Medicine began when the medical school accepted its first students in 1967. The ethics program co-evolved with the school and the Department of Humanities without guidelines or models, since neither medical ethics nor medical humanities had yet been invented as fields of study. The focus of the article is on two key differences between the Penn State ethics program and most other such programs: the teaching of medical ethics within the context of other issues of value and meaning in medicine, and the fact that the humanities faculty is involved in the activities and structures of the medical center of which the medical school is a part. The authors close with a description of successful factors in their program that they maintain could apply to other programs.

Rationality in medicine: an explication.

Various meanings of "rational" implicitly and explicitly suggested in this issue's articles are abstracted and stated. Two accounts of rationality are shown to be able to explain most uses of "rational": the "cool moment" account and a more objective account. The former is examined and modified, but still found inadequate. The objective account of rational is developed, taking "irrational" as the basic concept. "Irrational" is given content in terms of a list, and "rational" is subsequently defined as "not irrational". Reasons and motives are defined and distinguished. The advantages of the objective account are explored and some challenges to it are answered.

A covenant between physician and patient. An innovation by a graduating class.

A class of medical school seniors desired more than the traditional graduation ceremony. They planned and presented a "baccalaureate service" to give voice to deeply felt concerns. A part of this service was a covenant in the form of a responsive reading between the new physicians and the public. The covenant, written for the occasion, encompasses mutual understanding and agreement between physician and patient, thereby avoiding pitfalls and anachronisms associated with traditional oaths and codes.