Prescribing for co-workers: practices and attitudes of faculty and residents.

BACKGROUND: Physicians sometimes are asked by co-workers for prescriptions to deal with their medical problems. These "hallway" requests typically occur outside a formal doctor-patient relationship.There are professional guidelines on serving as physician for family members and friends, but no guidelines address writing prescriptions for co-workers. The frequency of these requests and the factors physicians consider in responding to them have not been examined. OBJECTIVES: To obtain data on the frequency of these requests and physicians' attitudes and practices in responding to them, and to explore the ethical considerations in writing prescriptions for co-workers. DESIGN: A survey was administered to all physician faculty and residents in an academic department of internal medicine. The questions included whether the respondent had ever been asked for a prescription by a co-worker and how often the respondent had received such requests and written such prescriptions in the previous three months. Respondents also were asked to rate how likely they would be to write such a prescription in 15 hypothetical scenarios. RESULTS: Of the 113 respondents who completed surveys, 68 percent reported having been asked for a prescription by a co-worker. Among those who had ever been asked, 59 percent had been asked one or more times during the previous three months and 88 percent had ever written such a prescription. Also, 88 percent of all respondents stated they were "very likely" or "likely" to write the prescription in one or more of the hypothetical scenarios. CONCLUSIONS: Most physicians in our sample had been asked for prescriptions by co-workers, and most had written such prescriptions. Many respondents indicated a willingness to write such prescriptions in a variety of scenarios, despite the absence of a formal doctor-patient relationship. Further discussion of the ethical considerations in writing prescriptions for co-workers is needed.

Reply to Marquis: how things stand with the 'future like ours' argument.

In an earlier essay in this journal I critiqued Don Marquis's well-known argument against abortion. I distinguished two versions of Marquis's argument, which I refer to as 'the essence argument' and 'the sufficient condition argument'. I presented two counterexamples showing that the essence argument was mistaken, and I argued that the sufficient condition argument should be rejected because Marquis had not adequately responded to an important objection to it. In response to my critique, Marquis put forward in this journal a revised version of his argument. In his modified approach he no longer advocates the essence argument and he offers a new version of the sufficient condition argument. In the current essay, I discuss how Marquis's revised argument deals with my original objections, and I argue that his new sufficient condition argument is unsuccessful.

Abortion decisions as inclusion and exclusion criteria in research involving pregnant women and fetuses.

From the perspective of investigators conducting research involving pregnant women and fetuses, a woman's decision about whether to have an abortion can sometimes be relevant to the suitability of the woman and fetus as research subjects. However, prominent ethicists disagree over whether it is permissible for a woman's decision about abortion to be an inclusion or exclusion criterion for participation in research. A widely held view is that fetuses to be aborted and fetuses to be carried to term should be treated equally as research subjects. Some hold that this principle implies that a woman's decision about whether to have an abortion should not be an inclusion or exclusion criterion. This paper identifies types of research in which investigators might want to have inclusion or exclusion criteria based on decisions about abortion. It examines the arguments for and against having the woman's decision about abortion included in such criteria. It is argued that there are types of research in which such criteria are ethically permissible.

Regulatory and ethical issues for phase I in utero gene transfer studies.

Clinical gene transfer research has involved adult and child subjects, and it is expected that gene transfer in fetal subjects will occur in the future. Some genetic diseases have serious adverse effects on the fetus before birth, and there is hope that prenatal gene therapy could prevent such disease progression. Research in animal models of prenatal gene transfer is actively being pursued. The prospect of human phase I in utero gene transfer studies raises important regulatory and ethical issues. One issue not previously addressed arises in applying U.S. research regulations to such studies. Specifically, current regulations state that research involving greater than minimal risk to the fetus and no prospect of direct benefit to the fetus or pregnant woman is not permitted. Phase I studies will involve interventions such as needle insertions through the uterus, which carry risks to the fetus including spontaneous abortion and preterm birth. It is possible that these risks will be regarded as exceeding minimal. Also, some regard the probability of therapeutic benefit in phase I studies to be so low that these studies do not satisfy the regulatory requirement that they "hold out the prospect of direct benefit" to subjects. On the basis of these considerations, investigators and institutional review boards might reasonably conclude that some phase I in utero studies are not to be permitted. This paper identifies considerations that are relevant to such judgments and explores ethically acceptable ways in which phase I studies can be designed so that they are permitted by the regulations.

Minimal risk in research involving pregnant women and fetuses.

The concept of minimal risk plays a key role in federal regulations on the protection of human research subjects. Although there has been considerable discussion of the meaning of minimal risk, the question of how this concept should be interpreted in research involving pregnant women and fetuses has not been addressed. This essay reviews the literature on minimal risk and argues for an interpretation of that concept in the context of research involving pregnant women and fetuses.

Theoretical and practical problems with wide reflective equilibrium in bioethics.

Various theories have been put forward in an attempt to explain what makes moral judgments justifiable. One of the main theories currently advocated in bioethics is a form of coherentism known as wide reflective equilibrium. In this paper, I argue that wide reflective equilibrium is not a satisfactory approach for justifying moral beliefs and propositions. A long-standing theoretical problem for reflective equilibrium has not been adequately resolved, and, as a result, the main arguments for wide reflective equilibrium are unsuccessful. Moreover, practical problems that arise in using the method of wide reflective equilibrium undermine the idea that it is a viable approach for justifying moral judgments about cases and policies. Given that wide reflective equilibrium is the most prominent version of coherentism, these considerations call into question the coherentist approach to justification in bioethics.

Justifying group-specific common morality.

Some defenders of the view that there is a common morality have conceived such morality as being universal, in the sense of extending across all cultures and times. Those who deny the existence of such a common morality often argue that the universality claim is implausible. Defense of common morality must take account of the distinction between descriptive and normative claims that there is a common morality. This essay considers these claims separately and identifies the nature of the arguments for each claim. It argues that the claim that there is a universal common morality in the descriptive sense has not been successfully defended to date. It maintains that the claim that there is a common morality in the normative sense need not be understood as universalist. This paper advocates the concept of group specific common morality, including country-specific versions. It suggests that both the descriptive and the normative claims that there are country-specific common moralities are plausible, and that a country-specific normative common morality could provide the basis for a country's bioethics.

Cloning and adoption: a reply to Levy and Lotz.

In previous articles I discussed the ethics of human reproductive cloning, focusing on a possible future scenario in which reproductive cloning can be accomplished without an elevated risk of anomalies to the children who are created. I argued that in such a scenario it would be ethically permissible for infertile couples to use cloning as a way to have genetically related children and that such use should not be prohibited. In 'Reproductive Cloning and a (Kind of) Genetic Fallacy', Neil Levy and Mianna Lotz raise objections to my conclusions. They disagree with the view, for which I argued, that some couples can have defensible reasons for desiring genetically related children. They also offer several new arguments against reproductive cloning, including an argument that it would diminish the number of adoptions, thereby adversely affecting the welfare of children who need to be adopted. In this paper I point out that Levy and Lotz's criticisms misconstrue my arguments and that there are serious problems with their arguments for prohibiting infertile couples from using cloning, including their argument from adoption.

Continuing the dialogue: a reply to Bernard Gert.

Continuing the dialogue begun in the March 2006 issue of the Kennedy Institute of Ethics Journal, I suggest that Bernard Gert's response to my paper does not adequately address the criticisms I make of his theory's application to bioethics cases.

Preembryo Personhood: an assessment of the President's Council arguments.

The President's Council on Bioethics has addressed the moral status of human preembryos in its reports on stem cell research and human therapeutic cloning. Although the Council has been criticized for being hand-picked to favor the right-to-life viewpoint concerning human preembryos, it has embraced the idea that the right-to-life position should be defended in secular terms. This is an important feature of the Council's work, and it demonstrates a recognition of the need for genuine engagement between opposing sides in the debate over stem cell research. To promote this engagement, the Council has stated in secular terms several arguments for the personhood of human preembryos. This essay presents and critiques those arguments, and it concludes that they are unsuccessful. If the best arguments in support of the personhood of human preembryos have been presented by the Council, then there are no reasonable secular arguments in support of that view.