No Need for Parental Involvement in the Vaccination Choice of Adolescents

Parental decision making is necessary for contracting medical interventions that require personal risk-benefit evaluation, and for overseeing matters of education. In the nineteenth century, exemptions from obligatory vaccination were granted for religious and conscientious reasons. Then and today, religion and moral values play marginal roles in vaccine hesitancy and denialism. Rather, the key values invoked by vaccine hesitants and denialists are liberty and pluralism. Neither is compatible with limiting adolescents' choice. Because vaccination does not require assessment of personal medical risks, because it does not need to occur within the sphere of the doctor-patient relationship, and because the risk involved is within the range of their daily activities, adolescents have the right to free access to vaccination without legal requirement of parental involvement. Drawing on the development of Common Law, and on the development of respect for personal conscience in the history of ideas, this paper does not promote an argument that grants public health an overriding moral power. Rather, this paper rejects the presumption that vaccination of adolescents might involve a conflict between parental authority and public health. Free access to vaccination is compatible with the law and ethics of adolescents' evolving autonomy in relation to healthcare.

Medicine as Grooming Behavior: Potlatch of Care and Distributive Justice

This article offers a conceptualization of medicine as based on the ethological term ‘grooming behavior’. This is a paradigm that frees medicine from strict dependence on definitions of health and disease. The paradigm is descriptive and it aims at a better understanding of our health – related habits and institutions. The article particularly tries to illuminate the beneficial aspects of ‘over-medicalization’ and wastefulness that allegedly characterize contemporary biomedicine, mainly the mitigation of social tensions and the provision of luring ethoses of human action as alternatives to individualism, militarism, and the like. ‘Medicine as grooming behavior’ balances the hegemonic vectors rampant in biomedicine. Moreover, contrary to the equilibrium concept of health, the article claims that each choice of grooming entails its own accord and discord with the human body. Therefore, desert for healthcare is not a unique right, nor can it be delineated naturally. The one desert people do have is the right to equal consideration of one’s subjective worldview. Medicine as grooming behavior enhances such consideration while it cultivates diversity and creativity, which are pivotal to human happiness and well being.

Deliberation at the hub of medical education: beyond virtue ethics and codes of practice

Although both codes of practice and virtue ethics are integral to the ethos and history of "medical professionalism", the two trends appear mutually incompatible. Hence, in the first part of the paper we explore and explicate this apparent conflict and seek a direction for medical education. The theoretical and empirical literature indicates that moral deliberation may transcend the incompatibilities between the formal and the virtuous, may enhance moral and other aspects of personal sensitivity, may help design and improve other parts of the curricula, and may foster self-awareness and clarification of the professional role. Not only are these goals essential for good and conscientious doctoring, but they may also reduce physicians' "burn-out". We argue that medical education should focus on the ubiquitous practice of deliberation in contemporary medicine, and especially the practice of moral deliberation.

Respect for personal autonomy, human dignity, and the problems of self-directedness and botched autonomy

This paper explores the value of respect for personal autonomy in relation to clearly immoral and irrational acts committed freely and intentionally by competent people. Following Berlin's distinction between two kinds of liberty and Darwall's two kinds of respect, it is argued that coercive suppression of nonautonomous, irrational, and self-harming acts of competent persons is offensive to their human dignity, but not disrespectful of personal autonomy. Irrational and immoral choices made by competent people may claim only the negative liberty to be left alone. Lives disposed to autonomy are worthy of solidarity and active support in addition to the right of free choice and action. Autonomous premeditated desires (distinguished from mere consent) may embody transcendental choices, which transcend consideration of physical and psychological well-being. Choices made by incompetent persons (e.g., children and the mentally disabled) are not related to autonomy, but to self-directedness. The value of human dignity confers protection to self-directedness, but not at the expense of other vital interests.

Triangular reflective equilibrium: a conscience-based method for bioethical deliberation

Following a discussion of some historical roots of conscience, we offer a systematized version of reflective equilibrium. Aiming at a comprehensive methodology for bioethical deliberation, we develop an expanded variant of reflective equilibrium, which we call 'triangular reflective equilibrium' and which incorporates insights from hermeneutics, critical theory and narrative ethics. We focus on a few distinctions, mainly between methods of justification in ethics and the social practice of bioethical deliberation, between coherence in ethical reasoning, personal integrity and consensus formation, and between political and moral deliberation. The ideal of deliberation is explicated as a sharing of conscience within a special commitment to sincerity and openness to persuasion. Personal growth in wisdom is an indirect by-product of the continuous practice of moral deliberation. This is explicated in the light of Sternberg's balance theory of wisdom and in the context of medicine as a profession embodying altruistic responsibilities of care in democratic and pluralistic societies.

Nozick's experience machine and palliative care: revisiting hedonism

In refutation of hedonism, Nozick offered a hypothetical thought experiment, known as the Experience Machine. This paper maintains that end-of-life-suffering of the kind that is resistant to state-of-the-art palliation provides a conceptually equal experiment which validates Nozick's observations and conclusions. The observation that very many terminal patients who suffer terribly do no wish for euthanasia or terminal sedation is incompatible with motivational hedonism. Although irreversible vegetative state and death are equivalently pain-free, very many people loath the former even at the price of the latter. This attitude cannot be accounted for by hedonism. Following these observations, the goals of palliative care are sketched along four circles. The first is mere removal or mitigation of noxious symptoms and suffering. The second targets sufferings that stymie patients' life-plans and do not allow them to be happy, the third targets sufferings that interfere with their pursuance of other goods (palliation as a primary good). The fourth is the control of sufferings that do not allow the person to benefit from any human good whatsoever ("total pain" or critical suffering). Only in the fourth circle are people hedonists.

Cultural circumcision in EU public hospitals--an ethical discussion

The paper explores the ethical aspects of introducing cultural circumcision of children into the EU public health system. We reject commonplace arguments against circumcision: considerations of good medical practice, justice, bodily integrity, autonomy and the analogy from female genital mutilation. From the unique structure of patient-medicine interaction, we argue that the incorporation of cultural circumcision into EU public health services is a kind of medicalization, which does not fit the ethos of universal healthcare. However, we support a utilitarian argument that finds hospital based circumcision safer than non-medicalized alternatives. The argument concerning medicalization and the utilitarian argument both rely on preliminary empirical data, which depend on future validation

From imago Dei in the Jewish-Christian traditions to human dignity in contemporary Jewish law

The article surveys and analyzes the roles in Judaism of the value of imago Dei/human dignity, especially in bioethical contexts. Two main topics are discussed. The first is a comparative analysis of imago Dei as an anthropological and ethical concept in Jewish and Western thought (Christianity and secular European values). The Jewish tradition highlights the human body and especially its procreative function and external appearance as central to imago Dei. The second is the role of imago Dei as a moral value relative to others. In rabbinic Judaism, respect for human dignity is not the primary moral maxim; it is secondary to the value of neighborly love and sometimes to other moral laws and values.

Responsibility as a meta-virtue: truth-telling, deliberation and wisdom in medical professionalism

The article examines the new discourse on medical professionalism and responsibility through the prism of conflicts among moral values, especially with regard to truth-telling. The discussion is anchored in the renaissance of English-language writing on medical ethics in the 18(th) century, which paralleled the rise of humanitarianism and the advent of the word "responsibility". Following an analysis of the meanings of the value of responsibility in general and in medical practice in particular, it is argued that, similarly to the Aristotelian notion of equity, responsibility of care is a second-order value, which corrects virtues, laws and norms in exceptional circumstances. Virtues and practices of the second order, such as responsibility and deliberation, bear especially on professional doctoring, which includes a commitment to give priority to the good of the patient over one's own good. It is argued that, in situations of conflict, and particularly conflicts between personal moral identity and the good of patients, the fundamental professional commitment is to critical and rational deliberation and to the cultivation of psycho-moral flexibility. This leads indirectly to moral growth and strengthening of professional character.

Human rights and bioethics

In the first part of this article we survey the concept of human rights from a philosophical perspective and especially in relation to the "right to healthcare". It is argued that regardless of meta-ethical debates on the nature of rights, the ethos and language of moral deliberation associated with human rights is indispensable to any ethics that places the victim and the sufferer in its centre. In the second part we discuss the rise of the "right to privacy", particularly in the USA, as an attempt to make the element of personal free will dominate over the element of basic human interest within the structure of rights and when different rights seem to conflict. We conclude by discussing the relationship of human rights with moral values beyond the realm of rights, mainly human dignity, free will, human rationality and response to basic human needs.

The Doctor by Luke Fildes: an icon in context

This paper discusses one of the most famous paintings on medical themes: The Doctor by Sir Luke Fildes (Fig. 1), which exemplifies how an ideal type of doctoring is construed from reality and from the views and expectations of both the public and doctors themselves. A close reading of The Doctor elucidates three fundamental conflicts in medicine: the first is between statistical efficiency in accordance with scales of morbidity and mortality and the personal devotion that every sick child or suffering individual wants to receive; the second is between the doctor-dominated market and the patient-dominated market; and the third is between influential and rich doctors ("consultants") and practitioners of family medicine (GPs).

The new Israeli law on the care of the terminally ill: conceptual innovations waiting for implementation

Israel has recently enacted a law on the care of terminally ill patients. This law, the Patient Nearing Death Act, is the first of its kind in the world. The law divides terminally ill patients--upon their own wishes--into two separate groups: "those who wish their lives be prolonged," and those who do not. Doctors will have to abide by elaborate advanced directives and take into account various sources of information on the presumed wishes of the patient. The law sanctions discontinuation of mechanical ventilation should it become a "cyclical" rather than "continuous" therapy, a provision that has implications for the use of the already available paraPAC ventilators. The law exposes gaps in modern Judaism between the religious law and the attitudes of the observant population with regard to medical ethics.

Contemporary art and the ethics of anatomy

The ethics of anatomy bears on the ways in which we present and behold human bodies and human remains, as well as on the duties we have with regard to the persons whose bodies or body parts are presented. Anatomy is also a mode of thought and of social organization. Following Merleau-Ponty's assertion that the human body belongs both to the particular and to the metaphysical, I contend that art's ways of rendering of the particular in human anatomy often bring into relief metaphysical and ethical insights relevant to clinical medicine. This paper discusses the art of Gideon Gechtman, Mary Ellen Mark, Shari Zolla, and Christine Borland. It considers the relationship of these artists to earlier artistic traditions and the implications of their work for contemporary medicine and the biopsychosocial paradigm. Andrew Wyeth, the Visible Male Project, the Isenheim Altarpiece by GrA(1/4)newald, and an anonymous Dutch Baroque portrait are also discussed.

Bodyworlds and the ethics of using human remains: a preliminary discussion

Accepting the claim that the living have some moral duties with regard to dead bodies, this paper explores those duties and how they bear on the popular travelling exhibition Bodyworlds. I argue that the concept of informed consent presupposes substantial duties to the dead, namely duties that reckon with the meaning of the act in question. An attitude of respect and not regarding human remains as mere raw material are non-alienable substantial duties. I found the ethos of Bodyworlds premature but full of promises such as public attitudes to organ donations. At the practical level I conclude that Bodyworlds should use only willed donations or unclaimed bodies for which dignified funerals are not available. In the case of live donations, Bodyworlds has a duty to participate in the medical care of needy donors. However, secrecy with regard to the source of cadavers seems to be the most troublesome aspect of Bodyworlds.

The story of the body and the story of the person: towards an ethics of representing human bodies and body-parts

Western culture has a few traditions of representing the human body - among them mortuary art (gisants), the freak show, the culture of the relics, renaissance art and pre-modern and modern anatomy. A historical analysis in the spirit of Norbert Elias is offered with regard to body - person relationship in anatomy. Modern anatomy is characterized by separating the story of the person from the story of the body, a strategy that is incompatible with the bio-psycho-social paradigm of clinical medicine. The paper discusses different aspects of the above traditions and how they might bear on this conflict and on contemporary bioethics and bedside practice.

Is the clock ticking for terminally ill patients in Israel? Preliminary comment on a proposal for a bill of rights for the terminally ill

This paper presents and discusses a recent Israeli proposal to legislate on the rights of the dying patient. A gap exists between elitist biases of the committee proposing the law, and popular values and sentiments. The proposed law divides the dying patients into two groups: "those who wish to go on living" and "those who wish to die". The former will have a right to life prolonging extraordinary care. It is not clear who would foot the bill for this care. Also it is hard to see how this munificence could fail to discriminate against all other patients. Both the secular ethicists and the rabbis involved in drawing up the proposal accepted the assumption that it is good for some terminal patients to die. The rabbis objected, however, to direct and active interventions that shorten life. The solution arrived at was to install timers in the ventilators so as to allow them to expire automatically unless the patient wishes for their resetting.

Speciesism as a precondition to justice

Over and above fairness, the concept of justice presupposes that in any community no one member's wellbeing or life plan is inexorably dependent on the consumption or exploitation of other members. Renunciation of such use of others constitutes moral sociability, without which moral considerability is useless and possibly meaningless. To know if a creature is morally sociable, we must know it in its community; we must know its ecological profile, its species. Justice can be blind to species no more than to circumstance. Speciesism, the recognition of rights on the basis of group membership rather than solely on the basis of moral considerations at the level of the individual creature, embodies this assertion but is often described as a variant of Nazi racism. I consider this description and find it unwarranted, most obviously because Nazi racism extolled the stronger and the abuser and condemned the weaker and the abused, be they species or individuals, humans or animals. To the contrary, I present an argument for speciesism as a precondition to justice.

Towards a dialogue between utilitarianism and medicine

Utilitarianism focuses on the optimization of personal well being in ways that seems to make the practice of medicine irrelevant to the well being of the practitioners, unless given external incentives such as money or honor. Care based on indirect incentives is considered inferior to care motivated internally. This leads to the paradox of utilitarian care. Following Nozick's conceptual Pleasure Machine it is argued that in addition to the promotion of personal well being, people care about fulfilling their well being in a world which is real, just, good, and beautiful. Complete mechanization of social and personal life in accordance with a strict utilitarian regime is also incompatible with the kind of world people desire, even if it promises more fulfillments in terms of personal well being. This explains the so-called Taurek-Parfit paradox, according to which sometimes ethics seems "to count the numbers" and sometimes not. The very pursuit of utilitarianism does not contribute to any personal life plan. The helping professions make the world a better place for us to live in, even though they do not necessarily bear directly on the well being of any individual other than the recipients of care. This resolves the paradox of utilitarian care.

Medicine through the artist's eyes: before, during, and after the Holocaust

Pre-Holocaust German art celebrates the doctor as a hero, triumphant over disease and poor hygiene. It emphasizes the ontological conception of disease and the ability of medicine to cure pathology or remove it. Some New Objectivity artists question this conceptualization by pushing it to the extreme of realistic representations. However, the clinical encounter has virtually disappeared from post-Holocaust art. Medicine is depicted in three main ways: as an ambiguous and alien Faustian craft; with a focus on holistic notions of healing, thus avoiding biomedicine altogether; or with a focus on the subjective experience of illness, thus ignoring the interaction between medicine and the diseased person.

[The terminal patient: Jewish religious law, the Steinberg report and the bioethical discourse in Israel]

This article surveys key texts in contemporary orthodox Jewish law (Halakha) with regard to end-of-life decision making. The author proposes twelve principles that govern Jewish law in that matter. The article proceeds to examine the Steinberg report in the light of Halakha. Orthodox Judaism regards human life as a prime value, which is always beyond consideration of economical means or quality of life. The avoidance of suffering is the only justification to shorten the life of the sufferer, provided that the acts performed do not fall within the Halakhic definition of murder, namely active and direct action that shortens life. It is argued that the main challenge of bioethics in Israel is the bridging between the positive law of Halakha whose fundamental value is submission to God's will as manifested in Halakha, and the rationalism, universalism, and egalitarianism which constitute naturalistic ethics. This challenge may produce ideas such as the "clock machine". It is too early to know if this is a trickery, or genuine ethical creativity.

Of doctor-patient sex and assisted suicide

The ethical chapter of the Israel Medical Association has recently issued guidelines with regard to sexual relationships between doctors and patients or past patients. This paper juxtaposes the paternalistic and severe attitude to doctor-patient sex with the relaxation and individualization of decisions regarding doctors' involvement in assisted suicide, passive and active euthanasia. The discussion bears on our concepts of palliative care and our expectations from it.

Revisiting the problem of Jewish bioethics: the case of terminal care

This paper examines the main Jewish sources relevant to end-of-life ethics, two Talmudic stories, the early modern code of law (Shulhan Aruch), and contemporary Halakhaic (religious law) responsa. Some Orthodox rabbis object to the use of artificial life support that prolongs the life of a dying patient and permit its active discontinuation when the patient is suffering. Other rabbis believe that every medical measure must be taken in order to prolong life. The context of the discussion is the most recent release of the "Steinberg Report," which proposes a law regulating end-of-life issues in Israel. It is argued that the Orthodox rabbis base their views on a strongly positivist concept of religious law. The rabbis deliberate the law as a manifestation of the will of God and try to stretch the law as much as possible in order to benefit the patient, even when it is good for the patient to die. Direct and active actions that kill are prohibited; certain forms of passive euthanasia and contrivances that terminate life support without needing direct human action are accepted.

One or two: an examination of the recent case of the conjoined twins from Malta

The article questions the assumption that conjoined twins are necessarily two people or persons by employing arguments based on different points of view: non-personal vitalism, the person as a sentient being, the person as an agent, the person as a locus of narrative and valuation, and the person as an embodied mind. Analogies employed from the cases of amputation, multiple personality disorder, abortion, split-brain patients and cloning. The article further questions the assumption that a conjoined twin's natural interest and wish is separation. I first contend that separation is such a radical procedure as to render the post-separation person different from the pre-separation one. Therefore, it is not possible to benefit the pre-separation twin by the act of separation. The article concludes with a critical evaluation of the tendency in bioethics to regard ethical challenges as rivalry between individuals competing for scarce resources.

Expressions of Holocaust experience and their relationship to mental symptoms and physical morbidity among Holocaust survivor patients

This study explores current expressions of past trauma among Holocaust survivors. Medical records and extensive interviews were analyzed for 38 Holocaust survivors who were hospitalized and/or under ambulatory care. The sample consisted of 55% women and 45% men whose mean age was 72 (SD = 9.2). Expressions of Holocaust experience yielded two factors: Holocaust-as-Present (e.g., feeling the Holocaust experience as continuing, Holocaust-related somatization) and Holocaust-as-Past (e.g., avoiding preoccupation with traumatic memories, feeling unduly stigmatized as a survivor). The results indicate that mental symptoms and the number of medical diagnoses are positively correlated with Holocaust-as-Present but negatively correlated with Holocaust-as-Past. However, scoring high on Holocaust-as-Past relates to a higher danger to life as a result of significant morbidity. The findings suggest two differential modes of either remaining enmeshed in the traumatic experience or attempting to contain the sequelae of the trauma. These modes differ in their implications for mental and physical health.

Head-counting vs. heart-counting: an examination of the recent case of the conjoined twins from Malta

This paper reexamines the recent case of the conjoined twins from Malta. Survival was said to be possible only through separation, which would actually leave only one twin alive. The parents refused to allow the killing of one to save the other, but the court ruled that this would amount to the neglect of innocent life. The article questions the assumption that the case is indeed a struggle between two people. Further, it questions the assumption that a conjoined twin's natural interest and wish is separation. Historical evidence shows that many conjoined twins do not wish for separation, even when it becomes a question of survival.The article concludes with a critical evaluation of the tendency in contemporary society and particularly in bioethics to regard ethical challenges as rivalry between individuals competing for scarce resources.

Pantagruelism: a Rabelaisian inspiration for understanding poisoning, euthanasia and abortion in the Hippocratic oath and in contemporary clinical practice

Contrary to the common view, this paper suggests that the Hippocratic oath does not directly refer to the controversial subjects of euthanasia and abortion. We interpret the oath in the context of establishing trust in medicine through departure from Pantagruelism. Pantagruelism is coined after Rabelais' classic novel Gargantua and Pantagruel. His satire about a wonder herb, Pantagruelion, is actually a sophisticated model of anti-medicine in which absence of independent moral values and of properly conducted research fashion a flagrant over-medicalization of human problems. Ultimately this undermines the therapeutic core of medicine itself. We contend that PAS is a case of such over-medicalization and that its institution creates medicophobia. This article does not express an opinion about euthanasia in general. Rather, we claim that physicians should learn from the oath and from Rabelais that they should keep their practice to medical care and not to exploit their expertise and social privileges for the sake of ulterior motives, even when their patients desire those goals.

Persuasion as respect for persons: an alternative view of autonomy and of the limits of discourse

The article calls for a departure from the common concept of autonomy in two significant ways: it argues for the supremacy of semantic understanding over procedure, and claims that clinicians are morally obliged to make a strong effort to persuade patients to accept medical advice. We interpret the value of autonomy as derived from the right persons have to respect, as agents who can argue, persuade and be persuaded in matters of utmost personal significance such as decisions about medical care. Hence, autonomy should and could be respected only after such an attempt has been made. Understanding suffering to a significant degree is a prerequisite to sincere efforts of persuasion. It is claimed that a modified and pragmatic form of discourse is the necessary framework for understanding suffering and for compassionately interacting with the frail.

The naturalness of the artificial and our concepts of health, disease and medicine

This article isolates ten prepositions, which constitute the undercurrent paradigm of contemporary discourse of health disease and medicine. Discussion of the interrelationship between those prepositions leads to a systematic refutation of this paradigm. An alternative set is being forwarded. The key notions of the existing paradigm are that health is the natural condition of humankind and that disease is a deviance from that nature. Natural things are harmonious and healthy while human made artifacts are coercive interference with natural balance. It is suggested that the current paradigm is influenced by the world of finances and by instrumental reason. The alternative model suggests that human nature cannot be delineated. Humans fashion their own selves and nature by artificial means, medicine among them. The article discusses the implications of the paradigm adapted in various scholarly and popular debates such as the use of sex hormones for contraception, the care of the elderly, holistic medicine and distributive justice in health care. Medicine is not an isolated or a privileged realm. There is no unique entitlement to healthcare. It is always part of a broader agenda of social values and institutions. A open view of human societies, values and practices as they are situated within concrete material conditions is the platform required for an integrative and creative discourse of health care.