Common Morality Principles in Biomedical Ethics: Responses to Critics.

After briefly sketching common-morality principlism, as presented in Principles of Biomedical Ethics, this paper responds to two recent sets of challenges to this framework. The first challenge claims that medical ethics is autonomous and unique and thus not a form of, or justified or guided by, a common morality or by any external morality or moral theory. The second challenge denies that there is a common morality and insists that futile efforts to develop common-morality approaches to bioethics limit diversity and prevent needed moral change. This paper argues that these two critiques fundamentally fail because they significantly misunderstand their target and because their proposed alternatives have major deficiencies and encounter insurmountable problems.

Never Solo: Gratitude for My Academic Journey.

Tom Beauchamp and I were asked by the editors of The Journal of Medicine and Philosophy to prepare "intellectual autobiographies," with particular attention to sources and influences on our work, including but not limited to Principles of Biomedical Ethics. Of course, it is artificial and even impossible to try fully to separate the "intellectual" from other aspects of our lives. So, while emphasizing the "intellectual" aspects of my autobiography, I have attended to other aspects, too. The huge debts of gratitude I owe also mix the "intellectual" and other aspects of life.

Response to Commentaries.

After expressing our gratitude to the commentators for their valuable analyses and assessments of Principles of Biomedical Ethics, we respond to several particular critiques raised by the commentators under the following rubrics: the compatibility of different sets of principles and rules; challenges to the principle of respect for autonomy; connecting principles to cases and resolving their conflicts; the value of and compatibility of virtues and principles; common morality theory; and moral status. We point to areas where we see common agreement with our commentators and respond to their critical evaluations.

Robert Veatch's transplantation ethics: obtaining and allocating organs from deceased persons.

This essay appreciatively and critically engages the late Robert Veatch's extensive and important contributions to transplantation ethics, in the context of his overall ethical theory and his methods for resolving conflicts among ethical principles. It focuses mainly on ways to obtain and allocate organs from deceased persons, with particular attention to express donation, mandated choice, and presumed consent/routine salvaging in organ procurement and to conflicts between medical utility and egalitarian justice in organ allocation. It concludes by examining the unclear relations between Veatch's ideal moral theory and his nonideal moral theory, especially in organ allocation.

The circulatory-respiratory determination of death in organ donation.

OBJECTIVE: Death statutes permit physicians to declare death on the basis of irreversible cessation of circulatory-respiratory or brain functions. The growing practice of organ donation after circulatory determination of death now requires physicians to exercise greater specificity in circulatory-respiratory death determination. We studied circulatory-respiratory death determination to clarify its concept, practice, and application to innovative circulatory determination of death protocols. RESULTS: It is ethically and legally appropriate to procure organs when permanent cessation (will not return) of circulation and respiration has occurred but before irreversible cessation (cannot return) has occurred because permanent cessation: 1) is an established medical practice standard for determining death; 2) is the meaning of "irreversible" in the Uniform Determination of Death Act; and 3) does not violate the "Dead Donor Rule." CONCLUSIONS: The use of unmodified extracorporeal membrane oxygenation in the circulatory determination of death donor after death is declared should be abandoned because, by restoring brain circulation, it retroactively negates the previous death determination. Modifications of extracorporeal membrane oxygenation that avoid this problem by excluding brain circulation are contrived, invasive, and, if used, should require consent of surrogates. Heart donation in circulatory determination of death is acceptable if proper standards are followed to declare donor death after establishing the permanent cessation of circulation. Pending additional data on "auto-resuscitation," we recommend that all circulatory determination of death programs should utilize the prevailing standard of 2 to 5 mins of demonstrated mechanical asystole before declaring death.

What Does the Evolution From Informed Consent to Shared Decision Making Teach Us About Authority in Health Care?

This article examines the legal doctrine and ethical norm of informed consent and its deficiencies, particularly its concentration on physician disclosure of information rather than on patient understanding, which led to the development of shared decision making as a way to enhance informed consent. As a vague and imprecise rubric, shared decision making encompasses several different approaches. Narrower approaches presuppose an individualistic account of autonomy, while broader approaches view autonomy as relational and hold that clinician-patient relationships grounded in good communication can assist decision making and foster autonomous choices. Shared decision making faces conceptual, normative, and practical challenges, but, with its goal of respecting, protecting, and promoting patients' autonomous choices, it represents an important cultural change in medicine.

COVID-19 and Religious Ethics.

The editors of the JRE solicited short essays on the COVID-19 pandemic from a group of scholars of religious ethics that reflected on how the field might help them make sense of the complex religious, cultural, ethical, and political implications of the pandemic, and on how the pandemic might shape the future of religious ethics.

Organ donation after circulatory determination of death: lessons and unresolved controversies.

This article responds to the four pieces in this special symposium of the Journal of Law, Medicine & Ethics on uncontrolled organ donation following circulatory death (uDCD). The response will focus on lessons and debates about the kinds of consent necessary and sufficient for temporary organ preservation in the context of DCD and for organ donation itself; on conflicts of obligation, loyalty, and interest in DCD and ways to address those conflicts; and on benefit, cost, risk assessments of uDCD programs, including measures to achieve a more favorable balance of benefits, costs, and risks.

Reflections on the National Bioethics Advisory Commission and Models of Public Bioethics.

The National Bioethics Advisory Commission, of which I was a member, was established by a 1995 executive order that identified its "first priority" as "the protection of the rights and welfare of human research subjects." Not surprisingly, then, most of NBAC's work focused on research involving human subjects or participants. A second priority concerned "issues in the management and use of genetics information, including but not limited to, human gene patenting." NBAC's charter (in contrast to the executive order) listed this charge as "part B" of the "first priority." Nonetheless, NBAC never fully developed it. In addition to responding to requests and recommendations from the National Science and Technology Council, NBAC could accept suggestions from Congress and the public for bioethical issues it should consider, and it could also identify other issues to consider and set priorities among them. From its first meeting on October 4, 1996, until its charter expired on October 3, 2001, NBAC produced six reports, with 120 recommendations. In this essay, I make a few observations about principles and moral reasoning in NBAC's deliberations and about NBAC's attention to religious beliefs in the context of two bioethical controversies, provide a rough evaluation of NBAC's impact, and consider three possible models for future public bioethics directed at federal public policy.

Ethics, public policy, and human fetal tissue transplantation research.

This article focuses on the deliberations of the National Institutes of Health Human Fetal Tissue Transplantation Research Panel in 1988. It explores various arguments for and against the use of fetal tissue for transplantation research, following elective abortion, and for and against the use of federal funds for such research. After examining the relevance of various positions on the moral status of the fetus and the morality of abortion, the article critically examines charges that such research, especially with federal funds, would involve complicity in the moral evil of abortion, would legitimate abortion practices, and would provide incentives for abortions. Finally, it considers whether the donation model is appropriate for the transfer of human fetal tissue and whether the woman who chooses to have an abortion is the apppropriate donor of the tissue.

Conscience and conscientious actions in the context of MCOs.

Managed care organizations can produce conflicts of obligation and conflicts of interest that may lead to problems of conscience for health care professionals. This paper provides a basis for understanding the notions of conscience and conscientious objection and offers a framework for clinicians to stake out positions grounded in personal conscience as a way for them to respond to unacceptable pressures from managers to limit services.

Two by McCormick.

KIE: Childress reviews How Brave a New World? Dilemmas in Bioethics and Notes on Moral Theology, 1965 through 1980, two compilations of major writings by the influential theologian Richard A. McCormick, S.J. The reviewer, a professor of religious studies and medical education, discusses McCormick's methodology, his defense of a morality based on a broad understanding of natural law, his concern with the relation between norm and context, and his perspective on morality and public policy. The extent to which McCormick diverges from the Catholic Church's official stance on the issues of contraception, abortion, and sterilization is also explored.^ieng