Work Of Ethicists Research Articles

“Friendly to all beings”: Annie Besant as ethicist

ABSTRACT Annie Besant (1847–1933) has rarely been identified as a philosopher. Her work as an ethicist has been obscured by the reaction of critics to her abandonment of Anglican Christianity for serial engagements with theism, atheism, collectivist socialism, and Theosophy – often characterized as fickle and indecisive ‘conversions’. However, Besant saw these engagements as stages in a quest for a universally applicable system of morality and conduct founded on empirical principles, and as valid as any scientific law. This article positions Besant as an ethicist working in the virtue ethics tradition, as defined by Rosalind Hursthouse, first by examining Besant’s ethical evolution, driven by the philosophical problem of whether ethics can exist without metaphysics (which she sometimes phrased as ‘Can morals exist without religion?’), and second, by identifying an anonymously published Advanced Text Book of Hindu Religion and Ethics (1903) as the most complete expression of her syncretic ethical system.

Taking on the Taliban: Ethical issues at the frontline of academia.

This article reflects on the challenges of developing academic research that is undertaken to create social change. I describe the ways that my research has been generated and guided by activism. Even though the descriptor of my research interests is generally gender-based violence and mental health, my research is situated within an ongoing political discourse that fundamentally opposes and normatively challenges ideologies such as those implemented at a governmental level during the Taliban regime in Afghanistan that continue to have power over Afghan women's lives. I critique the emergence of two research projects that work with women survivors of violence and develop trauma therapeutic interventions using traditional storytelling. My positionality as a woman of Muslim origin and an academic in the U.K. resulted in inescapable juxtapositions and the necessary blurring of the boundaries between personal and professional viewpoints as well as highlighting the potency of traumatic stories in contexts of conflict, oppression, silencing and marginalization. I go on to explain why I have a moral obligation as an ethicist working in global health, with resources and expertise, to systematically develop my research questions and objectives in accordance with the end-goal of tackling and deconstructing harmful ideologies and practices towards women and girls in societies marred by the violent complexities of national and international conflicts.

Ethical issues in HIV prevention research with people who inject drugs.

Injection drug use continues to significantly contribute to new infections with HIV. Moreover, conducting HIV prevention research with people who inject drugs (PWIDs) can be complicated for an array of practical, social, legal, and ethical reasons. It is critical that these research efforts are sensitive to the particular vulnerabilities associated with injection drug use as well as those related to being at risk of acquiring HIV so as to minimize harm to participants in research. To describe how we addressed some of these ethical challenges during the course of a large-scale multinational randomized HIV prevention trial involving PWIDs, which was successfully completed. The ethical issues encountered during the life cycle of the trial were cataloged by the principal investigator, study coordinator, and ethicist working on the trial. Relevant study documents were then reviewed to provide pertinent details. The ethical issues unique to the trial were then described. Before implementation, the trial faced particularly complex challenges related to the vulnerability of PWIDs, where HIV seroincidence rates in the population were high and legal policies and stigma regarding injection drug use was severe. Accordingly, a rapid policy assessment was commissioned, and a series of community engagement activities were conducted. During the trial, in addition to using careful standard operating procedures regarding all aspects of trial conduct and extensive staff training, the trial standardized informed consent procedures and assessed them. Furthermore, social harms were monitored along with physical harms and adverse events. Following the decision to close the study, it was critical to develop an orderly and safe process for closing it. The issue of post-trial access to the study medication and a complex intervention also surfaced for consideration. The issues described in this article are necessarily limited to how they manifested themselves within the context of a particular trial that was conducted in two countries. In addition, other stakeholders may have divergent views on the ethical issues described and may also have identified additional ethical issues that would warrant examination. Adopting similar approaches to addressing ethical issues in future research promises to facilitate this work so that needed strategies to prevent HIV infection among PWIDs can be safely and appropriately tested. Future trials enrolling PWIDs who are at risk of detainment should identify ways of mapping closely their experiences and perceptions in order to better apprehend some of the ethical issues at stake. In addition, scholarly and policy work needs to address the ethical issues related to post-trial access to multi-modal interventions that may be desired by participants, but are not shown to be effective in achieving the primary outcomes of the study.

The Predictable Irrationality of Righteous Minds, and the Work of Ethicists

AbstractAs Jonathan Haidt explains in The Righteous Mind, it is often our moral intuitions that come first, rapidly or even automatically, with ethical reasoning coming later. Haidt's book is one of many that have come out in recent years highlighting the relevance of psychology (and its close cousin, neuroscience) for understanding human morality. As a behavioral scientist, I have devoured many of these books. I am fascinated by human nature and love trying to understand why all of us behave and think the way we do. But as a physician ethicist, I often find myself reading these books with a parallel agenda: not just to understand human nature, but also to see whether this line of research has relevance for my work as an ethicist. My bottom line: Understanding moral psychology ought to be a required component of ethics training, not because the science will help us to differentiate between right and wrong, but because it will better equip us to teach ethics in a way that promotes moral behavior in our students.

Field Workers at the Interface

This issue of Developing World Bioethics includes a collection of papers on intermediary staff and volunteers working at the interface between research institutions and researchers, and the communities from which research participants are recruited. ‘Field worker’ – a short hand commonly used in many research settings – refers here to those whose main role is face-to-face engagement with participants, who usually speak the participants’ first language, who are from or live in the study areas, and whose work entails moving around the study areas or health facilities. Field workers can be differentiated from medical or scientific staff for whom only part of their duties entail direct interaction with participants, and who are primarily based in the research institution or the clinic. In international research settings field workers are variously called research assistants, community interviewers, data collectors, fieldworkers, field assistants, assessors, follow up staff or defaulter tracers. Although some may hold first degrees or certificates, many are secondary school leavers without higher education opportunity; overall they are formally less qualified than clinical and research staff. Instead, field workers often have extensive informal training and experience from earlier volunteering and jobs in research centres or the NGO sector, which often require similar tasks and expertise.1 Their roles may include communicating about studies and mobilisation and follow-up of participants, conducting interviews, and carrying out relatively simple biomedical data-collection procedures such as taking temperatures and collecting finger prick blood samples.

Establishing HIV treatment as prevention in the HIV Prevention Trials Network 052 randomized trial: an ethical odyssey.

Obtaining the definitive data necessary to determine the safety and efficacy of using antiretroviral treatment (ART) to reduce the sexual transmission of HIV in heterosexual couples encountered an array of ethical challenges that threatened to compromise HIV Prevention Trials Network (HPTN) 052, the multinational clinical trial addressing this issue that has profound public health implications. To describe and analyze the major ethical challenges faced in HPTN 052. The ethical issues and modifications of HPTN 052 in response to these issues were cataloged by the principal investigator, the lead coordinator, and the ethicist working on the trial. The major ethical issues that were unique to the trial were then described and analyzed in light of the published literature as well as guidances and policies. The ethical challenges that must be addressed in many clinical trials, such as those related to obtaining informed consent and making provisions for ancillary care, are not described. When HPTN 052 was being designed, ethical questions emerged related to the relevance of the research question itself given data from observational research and a range of beliefs about the appropriate means of preventing and treating HIV infection and AIDS. Furthermore, ethical challenges were faced regarding site selection since there was a scientific need to conduct the research in settings where HIV incidence was high, but alternatives to study participation should be available. As in most HIV-prevention research, ethical questions surrounded the determination of the appropriate prevention package for all of those enrolled. During the course of the trial, guidance documents and policies emerged that were of direct relevance to the research questions, calling for a balancing of concerns for the research subjects and trial integrity. When the study results were made public, there was a need to ensure access to the treatment shown to be effective that in some cases differed from the guidelines used at the sites where the research was being conducted. In addition, questions were raised about whether there was an obligation to notify subjects about 'unlinked' transmissions of HIV, that is, infections acquired from someone other than the designated sexual partner enrolled in the study. The ethical issues described are limited to those discerned by the authors and not those of other stakeholders who may have identified additional issues or had a different perspective in analyzing them. Understanding the ethical challenges faced in HPTN 052 promises to inform the design and conduct of future complex, long-term clinical trials aimed at addressing critical scientific and public health questions, where data and practice patterns emerge over the course of the trial.

Studying and Advocating

Studying and Advocating

Avoiding Cheap Grace: Medical Harm, Patient Safety, and the Culture(s) of Forgiveness

Dena Davis defines the job of the ethicist working on clinical issues as describing what real people really believe and how they really act. (2) If so, then insights from religion and related aspects of culture may help hospital administrators charged with meeting new standards for patient safety to recognize the restorative role that has long played between individuals and within communities and to incorporate into their systems for dealing with medical mistakes that lead to injury, death, or other trauma) What follows is a broad religious studies rather than a strictly theological or doctrinal perspective on forgiveness, one that incorporates insights from Jewish and Christian social ethics, ritual studies, sociology of medicine, and medical anthropology, as well as from clinicians themselves. That said, several concepts borrowed from Christian theologian Dietrich Bonhoeffer--cheap among them--are integral to my argument against what might be termed as self-interpreting principle. What mean here is a way of formulating so that its relational character--the actions that various actors undertake in relation to one another so can take place--is forgotten. This relational understanding of may be replaced by a cheap grace that, in formulating as automatic, either acknowledges no role for the injured person as agent of forgiveness, or assumes that this person should offer in the absence of disclosure, apology, accountability, compensation, or other goods that we might place under the principle of justice. In cases of medical harm, a cheap grace approach on the part of professional caregivers, including clinicians, chaplains, social workers, or pastors, may also place pressure on a patient and family to forgive automatically--by reminding them that good people are forgiving, or by assuring them that offering will bring them closure, or by telling them that, after all, nobody meant to harm them--even as the patient's and family's distress is prolonged because they do not know what really happened, or because there is no acknowledgment of their suffering by those directly responsible for it. In avoiding non-relational approaches to forgiveness, we must keep in mind that forgiveness is a Janus-faced word. It holds contradictory meanings--to engage and to detach--that are often conflated or insufficiently distinguished in everyday conversation as well as scholarly discourse. In the Jewish and Christian traditions, the deepest meaning of is detachment. Forgiveness as cheap grace, as entitlement rather than outcome, ignores this deep meaning by refusing to ask what those harmed through medical mistakes may need in order to achieve detachment, or by pressuring them into engagement or acquiescence, even into a divine, salvific role, instead of allowing detachment to take place over time--in what the Christian Bible refers to as kairos, the appropriate time, as opposed to chronos, chronological time--once justice has been secured. (4) Arguing for a definition of after medical harm that holds detachment as the ultimate goal of the process does not mean that injured patients--or clinicians who have made errors--should simply be encouraged to detach from incidents of medical harm, and from their feelings concerning these incidents. Forgiveness entails more than detachment. Even in mundane interpersonal situations, forgiveness-as-detachment can be unsatisfying: after we have succeeded in emotionally detaching ourselves from a painful situation, we may still hesitate to say I forgive you if we believe that, by doing so, we are excusing bad behavior rather than affirming changed behavior. One caution about the Jewish and Christian traditions is in order: while they are powerful if not always acknowledged influences upon Western culture and Western medicine, they are not universal. …

Ethicists and health care reform: an indecent proposal?

The Clinton Administration stated that the list of values and moral principles generated by the Ethics group reflects "fundamental national beliefs about community, equality, and liberty" and that "these convictions anchor health reform in shared moral traditions." However, these statements are difficult to justify. There is not a moral consensus in America that would justify through-going health care reform. In such a context of pluralism, ethicists should seek to move society in the direction of solidarity. The participation of ethicists on the Clinton Task Force was valuable because it showed that health reform is an exercise in social ethics, disseminated the work of ethicists to the entire Task Force, and expanded the experience of the ethicists involved. It may also have accelerated the moral transformation of Americans, which is needed before radical reform can take place.