Ewolucja strategii militarnej NATO, NATO
Estrada i Studio 04 2010, Do czytania, Estrada i Studio, 2010
Estrada i Studio 04 2008, Do czytania, Estrada i Studio, 2008
Estrada i Studio 04.2010, [◙◙◙◙◙ஜ۩۞۩ஜ◙◙◙◙◙ ☆E☆, Estrada I Studio
Evidence-Based Imaging - Optimizing Imaging in Patient Care, My collection of medical books, 208 Books (part 3 of 3)
Eskortowce typu Shoreham 1930, Encyklopedia militariów MarkaF - morskie
Eskortowce typu Bridgewater 1928, Encyklopedia militariów MarkaF - morskie
Eskortowiec Milford 1932, Encyklopedia militariów MarkaF - morskie
Eskortowiec Grimsby 1933, Encyklopedia militariów MarkaF - morskie
Eskortowiec Shoreham 1930, Encyklopedia militariów MarkaF - morskie
Ethics-ch-04, Med, Military Medical Ethics Volume 1
[ Pobierz całość w formacie PDF ]The Science Behind the Art: Empirical Research on Medical Ethics
Chapter 4
THE SCIENCE BEHIND THE ART:
EMPIRICAL RESEARCH ON MEDICAL
ETHICS
DANIEL P. SULMASY, OFM, MD, P
H
D
*
INTRODUCTION
TYPES OF ETHICAL INQUIRY
TYPES OF STUDIES IN DESCRIPTIVE ETHICS
Anthropology
Sociology
Epidemiology
Health Services Research
Psychology
THE RELATIONSHIP BETWEEN DESCRIPTIVE AND NORMATIVE BIOETHICS
Ethics and Opinion Surveys
The Fact/Value Distinction
Illicit Inferences
Empirical Studies and Normative Ethics
Normative and Descriptive Ethics: Two-Way Feedback
JUDGING GOOD DESCRIPTIVE ETHICS
Survey Research
Qualitative Research
Multimethod Research
Experimental Methods
Theoretical Framework
Biases in Empirical Research on Ethics
Detached Disinterest
RESOURCES IN ETHICS
National Reference Center for Bioethics Literature
Bioethicsline
Bioethics Journals
The Internet
DESCRIPTIVE BIOETHICS AND MILITARY MEDICINE
CONCLUSION
*
Professor of Medicine and Director of the Bioethics Institute, New York Medical College, Valhalla, New York; and Sisters of Charity Chair in
Ethics, John J. Conley Department of Ethics, Saint Vincent’s Hospital and Medical Center, 153 West 11th Street, New York, New York 10011;
formerly, Associate Professor of Medicine, Georgetown University; and Director, Center for Clinical Bioethics, Georgetown University Medi-
cal Center, Washington, DC
105
Military Medical Ethics, Volume 1
J.O. Chapin
Doctor’s Heritage
1944
The last of seven images from the series
The Seven Ages of a Physician.
The series depicts the life progression of a
doctor from birth to first encounter with suffering, through medical training, professional experience, service to
country during war, and research to further knowledge. In this final painting in the series, the doctor’s heritage is
that of passing along to the next generation his knowledge and vision regarding how to best be a physician. That
involves not just understanding the basics of medicine, as depicted in the right half of the painting, but also under-
standing medicine in a more complete context, which is symbolized in the left side of the painting with the globe, the
skull, and the book. The wisdom that he passes on includes understanding how doctors make decisions regarding
patients—the very essence of being a complete physician—and the focus of this chapter.
Art: Courtesy of Novartis Pharmaceuticals.
106
The Science Behind the Art: Empirical Research on Medical Ethics
INTRODUCTION
With characteristic elegance, Aristotle once said
that ethics is “about what to do.”
1(1103b.28–31)
If ethics
is truly as broad as that, then many sorts of ethical
questions will inevitably arise, even if one limits
the sphere of inquiry to biomedical ethics. A phi-
losopher might be inclined to ask, “How does a phy-
sician ever
know
the right thing to do in any given
situation?” A physician might be more inclined to
ask simply, “What ought I to do with this patient
now?” A government agency or a disinterested so-
cial scientist might be inclined to ask, “What do
physicians usually do in that situation?” And phy-
sicians might ask a health services researcher,
“What data can you give me to help me to decide
what I ought to do?”
The latter two questions are empirical questions.
And because contemporary Western medicine is based
upon empirical science, it was inevitable that physi-
cians should begin to engage in empirical research
in bioethics. In fact, empirical studies now constitute
the most prevalent form of articles on bioethics pub-
lished in the medical literature. But many readers re-
main puzzled by empirical research in bioethics.
This chapter addresses some of these questions.
The chapter begins by distinguishing empirical
ethics from other sorts of ethical inquiry, then pro-
vides an overview of the kinds of empirical studies
that count as empirical research in bioethics. The
chapter discusses criteria for quality in evaluating
empirical research in bioethics, and describes the
proper relationship between empirical bioethics and
philosophical bioethics.
The range of studies falling under the broad
canopy of “empirical bioethics” is truly astound-
ing. The disciplines of sociology, anthropology, so-
cial psychology, economics, epidemiology, and
health services research (to name just a few) all have
scholars who “do” bioethics, and all these disci-
plines have made enriching contributions to the
field. These types of research begin with empirical
observations, and take empirical observation as
their standard of validity. It is not always immedi-
ately clear, however, that these types of research
should have anything whatsoever to do with ethics.
And so it is necessary, at the outset, to understand the
nature of empirical research in ethics broadly.
TYPES OF ETHICAL INQUIRY
There are three basic types of ethical inquiry—
normative ethics, metaethics, and descriptive ethics.
2
Normative ethics
is the type of ethical study that
is most familiar. Normative ethics is the branch of
philosophical or theological study that sets out to
give answers to the questions, “What ought to be
done? What ought not to be done? What kinds of
persons ought we strive to become?” Normative
ethics sets out to answer these questions in a sys-
tematic, critical fashion, and to justify the answers
that are offered. In bioethics, normative ethics is
concerned with arguments about such topics as the
morality of physician-assisted suicide and whether
so-called partial birth abortions are ever morally
permissible. Normative ethics constitutes the core
of all ethical inquiry. It is because of the normative
questions at stake that other types of ethical inquiry
have their point.
Metaethics
is the branch of philosophical or theo-
logical inquiry that investigates the meaning of
moral terms, the logic and linguistics of moral rea-
soning, and the fundamental questions of the na-
ture of good and evil, how one knows what is right
or wrong, and what sorts of arguments can be used
to justify one’s moral positions. It is the most ab-
stract type of ethical inquiry, but it is vital to nor-
mative investigations. Whether or not it is explic-
itly acknowledged, all normative inquiry requires
some sort of a stand regarding metaethical ques-
tions. Metaethics asks, “What does ‘right’ mean?
What does ‘ought’ mean? What is implied by say-
ing ‘I ought to do X’? Is morality objective or sub-
jective? Are there any moral truths that transcend
particular cultures? If so, how does one know what
these truths are?” Stands regarding all of these ques-
tions lurk below the surface of most normative ethi-
cal discussions, whether in general normative eth-
ics, bioethics, or military bioethics. Sometimes it is
only possible to understand the grounds upon
which people disagree by investigating questions
at this level of abstraction. In most cases, however,
there is enough general agreement that normative
inquiry can proceed without explicitly engaging
metaethical questions.
The concern of this chapter, however, is the third
type of ethical inquiry,
descriptive
ethics
. Descriptive
ethics does not directly engage the questions of
what one ought to do or of how people use ethical
107
Military Medical Ethics, Volume 1
terms. Descriptive ethics asks empirical questions
such as, “How do people think they ought to act in
this particular area of normative concern? What
facts are relevant to this normative ethical inquiry?
How do people actually behave in this particular
circumstance of ethical concern?” In bioethics, the
literature is replete with descriptive ethics’ studies
such as surveys asking what patients and physicians
think about the morality of euthanasia and assisted
suicide, or about how much money might be saved
through the widespread use of advance directives,
or about what percentage of unwed women who
become pregnant choose to undergo elective abortion.
No descriptive ethics study ever answers a nor-
mative question about what should be done. That
is a matter for normative ethics. Yet, descriptive eth-
ics can be very helpful to normative inquiry, and
normative inquiry can be helpful to descriptive eth-
ics as well. I will return to these themes in more
detail later in this chapter.
TYPES OF STUDIES IN DESCRIPTIVE ETHICS
Because good ethics always depends upon good
facts, almost any empirical field might be able to
make a contribution to descriptive ethics. Nonethe-
less, there are certain techniques and certain disci-
plines that are especially well-suited to descriptive
research in bioethics. A comprehensive survey of
all empirical studies that have contributed to bio-
ethics would be well beyond what could be accom-
plished in a single chapter. This chapter will instead
briefly discuss those empirical fields most often
used. Readers interested in exploring this subject
further are encouraged to read
Methods in Medical
Ethics.
3
California.
7
Anthropological studies have explored
the distinctive culture of surgeons as well, examin-
ing how that culture affects selection, training, and
professional demeanor of surgeons.
8
Still other in-
vestigators have used conversational analysis of
transcripts of audiotapes of physician–patient in-
teractions to describe certain styles of physician
verbal behavior and how these relate to patient sat-
isfaction and malpractice risk.
9
All of these sorts of
studies help to broaden our understanding of mul-
tiple issues in contemporary bioethics. Anthropo-
logical studies have also raised troubling norma-
tive questions about such issues as the meaning of
the Western notion of informed consent in other
cultural settings. For example, anthropologists have
looked at the question of the meaning of informed
consent in vaccine trials in Africa in which individu-
als defer decision making to their tribal chief.
10
Anthropology provides fascinating insights into
the status quo of the physician–patient relationship
in the West as well, raising questions about whether
reform might be called for. Anthropologists will
continue to make contributions to bioethics as the
field enters the 21st century.
Anthropology
Perhaps the first empirical field to have made
contributions to descriptive ethics is anthropology.
Anthropology has made, and continues to make,
many significant scholarly contributions to bioeth-
ics. Questions about cultural variations in ap-
proaches to matters of moral concern have been of
interest since at least the time of Aristotle,
1(1148b.20–24)
challenging assumptions about the relationship
between morality and culture. Classical investigations
have included studies of child rearing in various
cultures by such preeminent figures as Margaret
Mead.
4
Studies in multiple cultures of the treatment
of infants born with various deformities have also
had an influence on contemporary bioethics, chal-
lenging contemporary Western prohibitions on
practices such as infanticide.
5
Contemporary eth-
nographic techniques have been used to study, for
instance, the difficulties involved in implementing
the federal government’s
Patient Self-Determination
Act
on Navajo Indian reservations.
6
Other studies
have attempted to use ethnographic analysis to
study differences in the role of the family vs au-
tonomous individuals in bioethical decision mak-
ing among Chinese and Latino cancer patients in
Sociology
Sociology has also played an important role in
descriptive bioethics. Renee Fox was among the
pioneers in the field, lending her expertise as a so-
ciologist to such questions as the Hopkins Baby
case,
11
dialysis, and organ transplants.
12
Sociologists
have also studied the training of physicians, with a
keen eye towards the ways in which the training
influences the style and the content of ethical deci-
sion making by physicians.
13
Still others have stud-
ied such phenomena as partial codes (ie, “chemical
code only,” or “CPR [cardiopulmonary resuscita-
tion] but no intubation”), noting how these often
arise in the setting of disputes between staff and
108
The Science Behind the Art: Empirical Research on Medical Ethics
family members.
14
In another important example,
the President’s Commission sponsored a sociologi-
cal study of informed consent in clinical practice.
15
The chief techniques employed by sociologists have
included both detailed interviews and participant-
observer studies. In participant-observer studies,
the investigator inserts himself or herself into the
routine of clinical practice, developing enough trust,
and blending well enough into the routine to mini-
mize the impact of his or her presence, while pre-
serving enough objectivity as an outside observer
to describe effectively and comment upon the pro-
cesses under observation.
16
These studies hold up
a mirror in which members of the healthcare pro-
fession can gain insight into their behaviors regard-
ing matters of bioethical concern.
veys, validated instruments regarding quality of
life, decision analysis, technology assessment, enor-
mous insurance claims’ data sets, chart reviews, and
even randomized controlled trials to study the de-
livery of healthcare services. These studies have
looked at questions of ethical concern such as the
care of the dying,
18
factors associated with the writ-
ing of orders not to resuscitate,
19
the implementa-
tion of euthanasia in the Netherlands,
20
the quality
of care delivered by managed care organizations,
21
patient perceptions of informed consent,
22
and
many other areas. The standards with which such
research is conducted have become quite high.
Psychology
Epidemiology
Finally, the field of psychology deserves special
mention as a discipline that has made, and contin-
ues to make, important contributions to the field of
descriptive bioethics. Kohlberg’s theories of moral
development have been used to conduct studies
charting the moral development of medical stu-
dents
23
and even of bioethicists.
24
Carol Gilligan and
other critics have charged that Kohlberg’s schema
is biased by the fact that he exclusively studied boys
and therefore overemphasizes the themes of justice
and autonomy in his theory of moral development.
They have launched a whole new school of thought
in philosophical and theological bioethics known
as care based ethics.
25
This school has had an espe-
cially strong influence on nursing ethics. Still oth-
ers have used Bandura’s social learning theory to
look at the impact of ethics education on the knowl-
edge, attitudes, and perceived self-efficacy (confi-
dence) of medical house officers and faculty.
26
Besides moral development and education, psy-
chological theories and techniques have been used
to look at morally important questions such as the
anxiety associated with genetic testing
27
and ways
to change sexual behavior among men at risk for
HIV (human immunodeficiency virus) infection.
28
Still others have looked at such interesting ques-
tions as the ability of surrogate decision makers to
predict what sorts of treatments their terminally ill
loved ones would want in the event that they were
to become unable to speak for themselves.
29
While by no means exhaustive, this brief survey
of empirical studies in bioethics from the fields of
anthropology, sociology, epidemiology, health ser-
vices research, and psychology serves to demon-
strate the incredible breadth and variety of disci-
plines and techniques that contribute to descriptive
bioethics. All are fascinating. All hold a definite
Another discipline that has made important con-
tributions in the field of descriptive bioethics has
been epidemiology, a branch of medical research
that counts the incidence and distribution of health
problems in a population. Beginning in the late
1970s, physician researchers trained in epidemiol-
ogy began to conduct empirical studies regarding
bioethics. As people who count, epidemiologists
began to sound a more quantitative note that had
not been evident in the bioethics studies of sociolo-
gists and anthropologists. Early studies were liter-
ally studies that counted the frequency of certain
clinical events of bioethics interest, such as the fre-
quency of ethical dilemmas on an internal medi-
cine service or the frequency with which DNR (do
not resuscitate) orders were written.
17
These stud-
ies began to appear in leading journals of clinical
medicine. Moral dilemmas had been encountered
for centuries in medical practice, and DNR orders
had been around for a long time, but these studies
brought new attention to bioethics by bringing these
issues to the attention of clinicians. Moreover, they
made irrefutable what had been argued by more
philosophically minded bioethicists before—the
practice of medicine is laced through and through
with bioethical decision making.
Health Services Research
Epidemiology, along with several other fields,
has contributed to the burgeoning field of health
services research. Many bioethical issues have been
addressed by studies in the field of health services
research. Investigators in this field use opinion sur-
109
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