Rules, practices and principles: Putting bioethical principles in their place.

Bioethics seems preoccupied with establishing, debating, promoting and sometimes debunking principles. While these tasks trade on the status of the word 'principle' in our ordinary language, scant attention is paid to the way principles operate in language. In this paper, we explore how principles relate to rules and practices so as to better understand their logic. We argue that principles gain their sense and power from the practices which give them sense. While general principles can be, and are, establishable in abstraction from specific practices, as they are in principlist bioethics, such principles are impotent as moral guides to action. We show that the purchase any principle has as a moral guide to action emerges from its indexical properties as a principle which has sense in a specific practice. The meaning of any principle is internal to the practice and context in which it is invoked and, therefore, principles are not kinds of master rule which dictate moral judgement in new contexts but rather chameleon-like rules which change with the contexture in which they are invoked.

Whose models? Which representations? A response to Wagner.

In Where the Ethical Action Is, we argued that medical and ethical modes of thought are not different in kind but different aspects of a situation. One of the consequences of this argument is that the requirement for or benefits of normative moral theorising in bioethics is undercut. In response, Wagner has argued that normative moral theories should be reconceived as models. Wagner's argument seems to be that once reconceived as models, the rationale for moral theorising, undercut by our arguments in Where the Ethical Action Is, will be re-established because we will see those moral-theories-now-rebranded-as-models as serving a role akin to the role models serve in some of the natural sciences. In this response to Wagner, we provide two arguments against Wagner's proposal. We call these arguments the Turner-Cicourel Challenge and the Question Begging Challenge.

Philosophy and the clinic: Stigma, respect and shame.

Since its foundation in 2010, the annual philosophy thematic edition of this journal has been a forum for authors from a wide range of disciplines and backgrounds, enabling contributors to raise questions of an urgent and fundamental nature regarding the most pressing problems facing the delivery and organization of healthcare. Authors have successfully exposed and challenged underlying assumptions that framed professional and policy discourse in diverse areas, generating productive and insightful dialogue regarding the relationship between evidence, value, clinical research and practice. These lively debates continue in this thematic edition, which includes a special section on stigma, shame and respect in healthcare. Authors address the problems with identifying and overcoming stigma in the clinic, interactional, structural and phenomenological accounts of stigma and the 'stigma-shame nexus'. Papers examine the lived experience of discreditation, discrimination and degradation in a range of contexts, from the labour room to mental healthcare and the treatment of 'deviancy' and 'looked-after children'. Authors raise challenging questions about the development of our uses of language in the context of care, and the relationship between stigma, disrespect and important analyses of power asymmetry and epistemic injustice. The relationship between respect, autonomy and personhood is explored with reference to contributions from an important conference series, which includes analyses of shame in the context of medically unexplained illness, humour, humiliation and obstetric violence.

Stigma respecified: Investigating HIV stigma as an interactional phenomenon.

In this paper, I discuss stigma, understood as a category which includes acknowledged, enacted degradation, discreditation and discrimination. My discussion begins with an analysis of HIV stigma, as discussed in a social media post on Twitter. I then analyse a fictionalized clinical stigma scenario. These two analyses are undertaken to highlight aspects of the conceptual anatomy and interactional dynamics of stigma and by extension shame. Brief social media declarations and short, fictionalized clinical interactions are rich with information which helps us understand how stigma-degradation, discreditation and discrimination-is operationalized in interaction.

Bioethics to the rescue! A response to Emmerich.

In our article, Where the ethical action is, we argue that medical and ethical modes of thought are not different in kind but merely different aspects of a clinical situation. In response, Emmerich argues that in so doing, we neglect several important features of healthcare and medical education. Although we applaud the spirit of Emmerich's response, we argue that his critique is an attempt at a general defence of the value of bioethical expertise in clinical practice, rather than a specific critique of our account.

Where the ethical action is.

It is common to think of medical and ethical modes of thought as different in kind. In such terms, some clinical situations are made more complicated by an additional ethical component. Against this picture, we propose that medical and ethical modes of thought are not different in kind, but merely different aspects of what it means to be human. We further propose that clinicians are uniquely positioned to synthesise these two aspects without prior knowledge of philosophical ethics.

Cultivating the dispositions to connect: an exploration of therapeutic empathy.

Empathy is a broad concept that involves the various ways in which we come to know and make connections with one another. As medical practice becomes progressively orientated towards a model of engaged partnership, empathy is increasingly important in healthcare. This is often conceived more specifically through the concept of therapeutic empathy, which has two aspects: interpersonal understanding and caring action. The question of how we make connections with one another was also central to the work of the novelist E.M. Forster. In this article we analyse Forster's interpretation of connection-particularly in the novel Howards End-in order to explore and advance current debates on therapeutic empathy. We argue that Forster conceived of connection as a socially embedded act, reminding us that we need to consider how social structures, cultural norms and institutional constraints serve to affect interpersonal connections. From this, we develop a dispositional account of therapeutic empathy in which connection is conceived as neither an instinctive occurrence nor a process of representational inference, but a dynamic process of embodied, embedded and actively engaged enquiry. Our account also suggests that therapeutic empathy is not merely an untrainable reflex but something that can be cultivated. We thus promote two key ideas. First, that empathy should be considered as much a social as an individual phenomenon, and second that empathy training can and should be given to clinicians.

The Meaning Response, "Placebo," and Methods.

In 2002, Dan Moerman outlined three candidate explanations for the "placebo response": the "conditioned stimulus-response," Irving Kirsch's "response-expectancy" explanation, and the "meaning response." The meaning response, Moerman argued, was the only one of the three candidate explanations that could cover all the data, gained from decades of RCTs and centuries of historical record. Moerman went so far as to propose replacing the term "placebo effect/response" with the term "meaning response," because people are not responding to placebos, since there is nothing to respond to; people are responding to meanings. There is evidence of medically significant meaning responses where there is no evidence for conditioning. Similarly, there is evidence for such responses where those subject to them lack the knowledge-epistemic capital-required to form the beliefs which might constitute an expectation. Something else, neither conditioning nor propositional attitudes, explained placebo responses, and Moerman proposed the meaning response. While the authors consider the meaning response to avoid the pitfalls of conditioning and response-expectancy, it has been subject to criticism. The criticisms have focused on what is seen as the explanation falling foul of the naturalistic demand and not fitting with prevalent predilections in the philosophy of mind and cognitive science. This article seeks to allay these worries and proposes the inclusion of ethnomethodological fieldwork in future research.

Shame and HIV: Strategies for addressing the negative impact shame has on public health and diagnosis and treatment of HIV.

There are five ways in which shame might negatively impact upon our attempts to combat and treat HIV. Shame can prevent an individual from disclosing all the relevant facts about their sexual history to the clinician. Shame can be a motivational factor in people living with HIV not engaging with or being retained in care. Shame can prevent individuals from presenting at clinics for STI and HIV testing. Shame can prevent an individual from disclosing their HIV (or STI) status to new sexual partners. Shame can serve to psychologically imprison people, it makes the task of living with HIV a far more negative experience than it should, or needs to, be. Drawing on recent philosophical work on shame, and more broadly on work in the philosophy and psychology of emotion, we (a.) propose a framework for understanding how shame operates upon those who experience the emotion, (b.) propose a strategy for combatting the negative role shame plays in the fight against HIV, and (c) suggest further study so as to identify the tactics that might be employed in pursuing the strategy here proposed.

Shame, stigma, HIV: philosophical reflections.

It is a distinctive feature of HIV that its pathology cannot be adequately grasped separate from a number of psychosocial factors, and stigma is widely seen as the most prominent. We argue that it is equally important to have an adequate understanding of shame, as the emotional response to stigma. We have identified five ways shame might negatively impact upon attempts to combat and treat HIV, which emerge from the stigma HIV carries and STI-stigma in general. In this paper, we draw out four insights from philosophical work on emotions and shame which we propose will improve understanding of shame and stigma. We conclude by briefly discussing how these insights might shed light on the negative role shame can play for a person living with HIV engaging with, or being retained in, care. We conclude by proposing further study.