Virtue ethics and the unsettled ethical questions in controlled human infection studies.

Controlled human infection studies (CHIs) involve the intentional infection of human subjects for a scientific aim. Though some past challenge trials have involved serious ethical abuses, in the last few decades, CHIs have had a strong track record of safety. Despite increased attention to the ethics of CHIs during the COVID-19 pandemic, CHIs remain controversial, and there has been no in-depth treatment of CHIs through the lens of virtue ethics. In this article, we argue that virtue theory can be helpful for addressing CHIs that present a constellation of controversial, unresolved, and/or under-regulated ethical issues. We begin with some brief background on virtue ethics. We then substantiate our claim that some CHIs raise a constellation of ethical issues that are unresolved in the ethics literature and/or lack adequate regulatory guidance by demonstrating that CHIs can present indeterminate social value, risks to third parties, limitations on the right to withdraw from research, and questions about the upper limit of allowable risk. We argue that the presence of a virtuous investigator, with virtues such as prudence, compassion, and integrity, is especially important when these unresolved research ethics issues arise, which is the case for certain types of controlled human infection studies. We use the historical example of Walter Reed and the Yellow Fever Commission to illustrate this claim, and we also highlight some contemporary examples. We end by sketching some practical implications of our view, such as ensuring that investigators with experience running CHIs are involved in novel CHI models.

Perceptions of COVID-19 patients in the use of bioethical principles and the physician-patient relationship: a qualitative approach.

BACKGROUND: The COVID-19 pandemic has influenced the approach to the health-disease system, raising the question about the principles of bioethics present in physician-patient relations. The principles while widely accepted may not be sufficient for a comprehensive ethical analysis. Therefore, the aim of this study was to explore the perception of these principles and the physician-patient relationship during a hospital stay through a qualitative approach. METHOD: Sixteen semi-structured interviews took place to know the patients' perception during their 2020 hospitalization for COVID-19. The data was analyzed through the constant comparison method, creating categories and comparing them. In the end, seven categories were established and were grouped in three: bioethical principles (dignity, charity, vulnerability, autonomy), doctor-patient relationship (participant commitment, informed consent, health staff-patient relationship) and the experience of the disease (illness, the role of the family). RESULTS: The research found that most patients described a positive experience, with the feeling of having been well cared for with no sense of discrimination or injustice done. The majority also reported that their autonomy was respected in the treatment decisions. The evaluation of these attitudes is an area of opportunity, especially when the patients' vulnerability is at risk. CONCLUSIONS: The ethics of virtue offers a better reflection of how human beings manifest themselves by emphasizing the development of virtuous character and behaviors that allow them to realize their values in life. Authorized by the Research Ethics Committee with registration: DI/18/105-B/3/308.

Disaster solidarity and survivor ethics: a case study of Hurricane María in Puerto Rico.

Liminal periods of disaster solidarity in the aftermath of disaster are a common experience of many survivors. These periods have a specifically ethical component in that people spontaneously engage in collective, altruistic action and magnanimously expand their ethical focus beyond normative social distinctions and hierarchies. Inevitably, however, such solidarity seems to wane, and people return to pre-disaster patterns of interaction. Nevertheless, some individuals move beyond opportune acts of assistance to more extensive reorganisations of their lives during the recovery period and reshape their ethical commitments in new and durable directions. These individuals help make visible marginalised 'others' and draw collaborators to share new ethical visions. Based on observational and interview data collected after Hurricane María (2017) in a mountainous Puerto Rican municipality and employing the framework of virtue ethics, this paper examines the differential effects of disaster solidarity on survivors' ethical responses and the different contributions these make to society.

The Role of Hospice and Palliative Medicine in the Ars Moriendi.

There is disagreement among physicians and medical ethicists on the precise goals of Hospice and Palliative Medicine (HPM). Some think that HPM's goals should differ from those of other branches of medicine and aim primarily at lessening pain, discomfort, and confusion, while others think that HPM's practices should aim, like all other branches of medicine, at promoting health. I take the latter position: using the ars moriendi to set a standard for what it means to die well, I argue that if HPM's practices were to aim at mitigating suffering with little regard to promoting health, some patients would die worse deaths than if HPM's practices were to aim at health. According to the ars moriendi, flourishing at the end of one's life requires that persons exercise their agency and pursue the goods most important to them. On this view, HPM's practices should promote patients' health to enable them to pursue these goods.

Pandemic ethics and beyond: Creating space for virtues in the social professions.

BACKGROUND: During the pandemic, social and health care professionals operated in 'crisis conditions'. Some existing rules/protocols were not operational, many services were closed/curtailed, and new 'blanket' rules often seemed inappropriate or unfair. These experiences provide fertile ground for exploring the role of virtues in professional life and considering lessons for professional ethics in the future. RESEARCH DESIGN AND AIM: This article draws on an international qualitative survey conducted online in May 2020, which aimed to explore the ethical challenges experienced by social workers during Covid-19. PARTICIPANTS AND RESEARCH CONTEXT: 607 social workers responded from 54 countries, giving written online responses. This article first summarises previously published findings from the survey regarding the range of ethical challenges experienced, then develops a new analysis of social workers' accounts of ethically challenging situations from a virtue ethics perspective. This analysis took a narrative ethics approach, treating respondents' accounts as stories featuring the tellers as moral agents, with implicit or explicit implications for their professional ethical identity and character. The article is illustrated with accounts from the 41 UK respondents, drawing particularly on two case examples. ETHICAL CONSIDERATIONS: Ethical approval was gained from Durham University and anonymity was ensured for participants. FINDINGS/RESULTS: This article explores the nature of the ethical space created during the pandemic showing how practitioners were able to draw more on 'inner resources' and professional discretion than usual, displaying virtues such as professional wisdom, care, respectfulness and courage as they took account of the specific contexts of their work, rather than simply adhering to blanket rules. CONCLUSION: Exploring practice through a virtue ethical lens provides valuable lessons for 'building back better' in social and health care professions.

Enhancing the moral courage of nurses: A modified Delphi study.

BACKGROUND: The urgency of ensuring adequate moral courage in clinical nursing practice is evident. However, currently, there are few formal intervention plans targeted at enhancing the moral courage of nurses. AIM: To develop a training program for improving the moral courage of nurses using the modified Delphi method. RESEARCH DESIGN: A modified Delphi study. PARTICIPANTS AND RESEARCH CONTEXT: From November to December 2022, a literature review and expert group discussion were conducted to develop a preliminary training plan framework. From January to March 2023, a two-round Delphi survey was performed, and a consensus was reached regarding the plan through online questionnaires. Descriptive statistics were used to analyze the data. ETHICAL CONSIDERATIONS: This study was approved by the institutional ethics committee (No. 138, 30 August 2021). All participants provided written informed consent. RESULTS: Consensus was reached on eight themes and 33 items to strengthen the moral courage training program for nurses. CONCLUSIONS: Guided by a unified goal of moral education, a multi-level and acceptable intervention plan was designed to enhance the moral courage of nurses.

Moral failure, moral prudence, and character challenges in residential care during the Covid-19 pandemic.

In many high-income countries, an initial response to the severe impact of Covid-19 on residential care was to shield residents from outside contacts. As the pandemic progressed, these measures have been increasingly questioned, given their detrimental impact on residents' health and well-being and their dubious effectiveness. Many authorities have been hesitant in adapting visiting policies, often leaving nursing homes to act on their own safety and liability considerations. Against this backdrop, this article discusses the appropriateness of viewing the continuation of the practice of shielding as a moral failure. This is affirmed and specified in four dimensions: preventability of foreseeable harm, moral agency, moral character, and moral practice (in MacIntyre's sense). Moral character is discussed in the context of prudent versus proportionate choices. As to moral practice, it will be shown that the continued practice of shielding no longer met the requirements of an (inherently moral) practice, as external goods such as security thinking and structural deficiencies prevented the pursuit of internal goods focusing on residents' interests and welfare, which in many places has led to a loss of trust in these facilities. This specification of moral failure also allows a novel perspective on moral distress, which can be understood as the expression of the psychological impact of moral failure on moral agents. Conclusions are formulated about how pandemic events can be understood as character challenges for healthcare professionals within residential care, aimed at preserving the internal goods of residential care even under difficult circumstances, which is understood as a manifestation of moral resilience. Finally, the importance of moral and civic education of healthcare students is emphasized to facilitate students' early identification as trusted members of a profession and a caring society, in order to reduce experiences of moral failure or improve the way to deal with it effectively.

Humans: An integrative review exploring dehumanisation in advanced dementia.

Background: People living with advanced dementia risk being seen as someone without personhood in contemporary societies, an understanding that has been described and challenged for decades in dementia scholarly literature. Such perception can be characterised as forms of existential dehumanisation, which still asserts itself in dementia care practices, adversely affecting the ethical and caring aspects of such care.Aim: To challenge dehumanisation in dementia care, we must first learn to recognise what foster it in caring relations. Thus, the aim of our study is to identify existing perceptions of care recipients living with advanced dementia, which elicit dehumanising attitudes among formal caregivers.Research design: We conducted an integrative review based on Whittemore and Knafl's updated methodology. This allowed us to identify and analyse 26 articles incorporating both qualitative- and quantitative studies as well as theoretical- and grey literature all describing perceptions of care recipients living with dementia that lead to dehumanisation.Ethical considerations: Studying the darker sides in caring relations was to be beneficial in improving dementia care practices.Findings: Through an analytical process five themes that can sprout dehumanising attitudes in caring relations were identified, which include perceiving people living with advanced dementia as (1) absurd, (2) shadow, (3) perilous, (4) void, or (5) repugnant. We argue that these perceptions can be seen as unintentional and stem from a misled embodied perception, which caregivers should learn to recognise and consequently be able to resist through virtue ethics.Conclusion: Our study indicates that challenging dehumanisation is a practical matter of identifying and reacting in a timely way to ones misled embodied perceptions. We suggest the five themes offer a potential means to warn formal caregivers of impending dehumanising attitudes and help them to review how they ethically are thinking and perceiving the person living with advanced dementia.

The role of conscience and virtue: contrasting two models of medicine.

Today's medical ethics involve two different viewpoints based on how we understand the role of conscience in medicine and the purpose of healthcare. The first view, called the health-directed model, sees medicine as a way to improve health and promote healing, while also respecting the values of both patients and doctors. In this model, doctors need some discretionary space to decide how to achieve the best health outcomes in their practice. On the other hand, the service-provider model sees the main goal of medicine as providing a service, especially healthcare, with a strong focus on protecting patient autonomy. In this view, doctors are required to provide care even when it goes against their personal beliefs.The goal of this article is to explore the foundations and arguments of these two medical models. Understanding the key ideas behind these models is important for deciding whether to support or oppose conscientious objection in medical ethics. Additionally, the article aims to figure out which model makes a stronger case and to offer advice on how to engage with the opposing view from a virtue ethics perspective.

Mandevillian vices.

Bernard Mandeville argued that traits that have traditionally been seen as detrimental or reprehensible, such as greed, ambition, vanity, and the willingness to deceive, can produce significant social goods. He went so far as to suggest that a society composed of individuals who embody these vices would, under certain constraints, be better off than one composed only of those who embody the virtues of self-restraint. In the twentieth century, Mandeville's insights were taken up in economics by John Maynard Keynes, among others. More recently, philosophers have drawn analogies to Mandeville's ideas in the domains of epistemology and morality, arguing that traits that are typically understood as epistemic or moral vices (e.g. closed-mindedness, vindictiveness) can lead to beneficial outcomes for the groups in which individuals cooperate, deliberate, and decide, for instance by propitiously dividing the cognitive labor involved in critical inquiry and introducing transient diversity. We argue that mandevillian virtues have a negative counterpart, mandevillian vices, which are traits that are beneficial to or admirable in their individual possessor, but are or can be systematically detrimental to the group to which that individual belongs. Whilst virtue ethics and epistemology prescribe character traits that are good for every moral and epistemic agent, and ideally across all situations, mandevillian virtues show that group dynamics can complicate this picture. In this paper, we provide a unifying explanation of the main mechanism responsible for mandevillian traits in general and motivate the case for the opposite of mandevillian virtues, namely mandevillian vices.

Interrogating multisystem intended pathways to youth thriving and resilience: Benefits of inclusive human development theoretical framing.

Moving more deeply into the 21st century and acknowledging the ongoing patterned needs of children, there continues to be broadly voiced sentiments about the importance of all children's thriving, adaptive coping, and resiliency. This paper notes that social science more broadly and developmental science specifically is a major resource determinative of the nature of remedies conceptualized, designed, and implemented. Evident is that the harms experienced by children and the solutions implemented by delivery systems are frequently unaligned. Efficacy and impact do not appear to be improved by multisystem integration delivery. This paper explores the benefits of incorporating inclusive and shared human development theory. As well, it examines the need to question the character virtue of the multisystem integration efforts intended to afford supportive solutions required for youths' thriving and resiliency. Specifically, it addresses whether democratic and equity relevant character values are integrated into public and privately funded intended supportive systems. The position taken is that whether considered under conditions of trauma illustrated by the global COVID pandemic or the efficacy of systems intended to aid the most vulnerable youngsters, the character of the content of support and its delivery matter and can benefit from inclusive human development interrogation and theorizing.

Professional Identity Formation in Medical Education: Some Virtue-Based Insights.

Issue: In 2010, the Carnegie Foundation published a call to reorient medical education in terms of the formation of identities rather than mere competencies, and the medical education literature on professional identity formation (PIF) has since grown rapidly. As medical learners navigate a hectic clinical learning environment fraught with challenges to professionalism and ethics, they must simultaneously orient their skills, behaviors, and evolving sense of professional identity. The medical education literature on PIF describes the psychosocial dimensions of that identity formation well. However, in its conceptual formulations, the literature risks underappreciating the pedagogical significance of the moral basis of identity formation-that is, the developing moral agencies and aspirations of learners to be good physicians. Evidence: Our conceptual analysis and argument build on a critical review of the medical education literature on PIF and draw on relevant insights from virtue ethics to deepen the conceptualization of PIF in moral, and not just psychosocial, terms. We show that a narrowly psychosocial view risks perpetuating institutional perceptions that can conceive professionalism norms primarily as standards of discipline or social control. By drawing on the conceptual resources of virtue ethics, we highlight not just the psychosocial development of medical learners but also their self-reflective, critical development as particular moral agents aspiring to embody the excellences of a good physician and, ultimately, to exhibit those traits and behaviors in the practice of medicine. Implications: We consider the pedagogical relevance of this insight. We show that drawing on virtue theory can more adequately orient medical pedagogy to socialize learners into the medical community in ways that nurture their personal growth as moral agents-in terms of their particular, restless aspirations to be a good physician and to flourish as such.

Moral courage of master's students of nursing during COVID-19.

BACKGROUND: Moral courage is a recognized virtue. In the context of the COVID-19 pandemic, the master's students of nursing (MSNs) in China have shown tenacious moral courage. OBJECTIVE: This study elaborates on the moral courage of Chinese MSNs through their experiences of volunteering during the pandemic. RESEARCH DESIGN: Descriptive qualitative, interview-based. PARTICIPANTS AND RESEARCH CONTEXT: Participants were nursing postgraduate students who participated in the prevention and control of the COVID-19 pandemic selected by purposeful sampling. The sample size was determined by data saturation, which was reached with 10 participants. Data were analyzed using a deductive method of content analysis. Because of the isolation policy, telephone interviews were adopted. ETHICAL CONSIDERATIONS: After obtaining the approval of the ethical institution of the author's school (No. 138, 30 August 2021), verbal consent was obtained before the interview with the participants. All data were processed anonymously and confidentially. In addition, we recruited participants through MSNs' counselors, and obtained their phone numbers with their permission. RESULTS: Data analysis resulted in 15 subcategories that were subsequently grouped into 3 major categories including proceed without hesitation, the outcome of practicing moral courage, and develop and maintain moral courage. CONCLUSION: This qualitative study is based on the special background of the COVID-19 pandemic, and the MSNs in China have shown tenacious moral courage in the work of epidemic prevention and control. Five factors led them to take action without hesitation, and six possible outcomes followed. Lastly, this study provides some suggestions for nurses and nursing students to enhance their moral courage. To better develop and support moral courage in the future, it is necessary to use different methods and multidisciplinary approaches to study moral courage.

Not Only Coping: Resilience and Its Sources from a Thomistic Perspective.

In describing the Christian moral ethos, Thomas Aquinas draws attention to the way in which adversities, trials or afflictions are overcome. This paper analyzes two types of resilience present in Aquinas's thought as well as their sources and manifestations. The first type, moral resilience, is based on the virtue of fortitude, which governs human behavior in the face of great fear. With regard to the second type of resilience, the focus is on showing how grace contributes to increasing power through weakness. In the concluding section, there are also certain suggestions as to how resilience education could be developed.

Credentialing Character: A Virtue Ethics Approach to Professionalizing Healthcare Ethics Consultation Services.

In the process of professionalization, the American Society for Bioethics and Humanities (ASBH) has emphasized process and knowledge as core competencies for clinical ethics consultants; however, the credentialing program launched in 2018 fails to address both pillars. The inadequacy of this program recalls earlier critiques of the professionalization effort made by Giles R. Scofield and H. Tristram Engelhardt, Jr.. Both argue that ethics consultation is not a profession and the effort to professionalize is motivated by self-interest. One argument they offer against professionalization is that ethics consultants lack normative expertise. Although the question of expertise cannot be resolved completely, the accusation of self-interest can be addressed. Underlying these critiques is a concern for hubris, which can be addressed in certification and the vetting of candidates.Drawing on the virtue ethics literature of Alasdair MacIntyre and Edmund D. Pellegrino, I argue that medicine is a moral community in which ethics consultants are moral agents with a duty to foster the virtue of humility (or what Pellegrino and Thomasma call self-effacement). The implications of this argument include a requirement for self-reflection in one's role as a moral agent and reflection on one's progress toward developing or deepening virtuous engagement with the moral community of medicine. I recommend that professionalization of clinical ethics consultants include a self-reflective narrative component in the initial certification and ongoing renewal of certification where clinical ethics consultants address the emotional dimensions of their work as well as their own moral development. Adopting a teleological view of ethics consultation and incorporating narratives that work toward that purpose will mitigate the self-interest and hubris of the professionalization project.

The epistemic vices of corporations.

Vice epistemology studies the qualities of individuals and collectives that undermine the creation, sharing, and storing of knowledge. There is no settled understanding of which epistemic vices exist at the collective level. Yet understanding which collective epistemic vices exist is important, both to facilitate research on the antecedents and effects of collective epistemic vice, and to advance philosophical discussions such as whether some collective epistemic vices are genuinely collective. I propose an empirical approach to identifying epistemic vices in corporations, analyzing a large dataset of online employee reviews. The approach has parallels to the methodology for identifying the big-five personality traits. It surfaces epistemic vices that are attributed to corporations by its own members and reduces the number of vices to the minimum required to describe differences between corporations. This approach yields a new taxonomy of epistemic vices for corporations. While two vices identified have close correlates in the existing literature, four others have not been identified at all or only in aspects. Two of these vices are 'genuinely' collective in the sense that they can only be attributed to collectives. Supplementary Information: The online version contains supplementary material available at 10.1007/s11229-023-04133-2.

What we know when we act.

Two traditions in action theory offer different accounts of what distinguishes intentional action from mere behavior. According to the causalist tradition, intentional action has certain distinguished causal antecedents, and according to the Anscombian tradition, intentional action has certain distinguished epistemological features. I offer a way to reconcile these ostensibly conflicting accounts of intentional action by way of appealing to "ability-constituting knowledge". After explaining what such knowledge is, and in particular its relationship to inadvertent virtue and knowledge-how, I suggest that, among other things, appealing to ability-constituting knowledge can help us flesh out what it is for an agent's reasons to non-deviantly cause and sustain her purposive behavior.

Too humble for words.

It's widely held that a lack of intellectual humility is part of the reason why flagrantly unjustified beliefs proliferate. In this paper, I argue that an excess of humility also plays a role in allowing for the spread of misinformation. Citing experimental evidence, I show that inducing intellectual humility causes people inappropriately to lower their confidence in beliefs that are actually justified for them. In these cases, they manifest epistemic humility in ways that make them epistemically worse off. I argue that epistemic humility may fail to promote better beliefs because it functions for us against the background of our individualistic theory of responsible epistemic agency: until we reject such theories, intellectual humility is as much a problem as a solution to epistemic ills. Virtue epistemology is inadequate as a response to unjustified beliefs if it does not look beyond the virtues to our background beliefs.

Pharmacosophrosyne Revisited: Drug Use and Virtue Ethics.

In a 1959 article, John C. Ford, SJ (1902-1989), proposed the existence of a new virtue to regulate recreational drug use which he names "pharmacosophrosyne." This article analyzes the soundness of Ford's proposal and extends it by providing a mereological analysis of how pharmacosophrosyne relates to the virtues of temperance and sobriety. It then shows how understanding both pharmacosophrosyne and sobriety can inform a moral evaluation of recreational drug use.

Subsidiarity and Participation in an Age of Catholic Mega-Systems.

While the number of Catholic healthcare facilities has held stable over the last several decades, Catholic healthcare has followed the trend of merging facilities and systems into "mega-systems." These consolidations can be beneficial for creating continuums of care, lowering operating costs, ensuring long-term viability, and sharing physical, digital, and human resources. However, with larger systems comes a practical need to be integrated to some degree, and the pressure to standardize policies and practices across regions is present. To address this need and pressure, the Catholic Social Teaching principles of subsidiarity and participation should guide system and local administrators. Subsidiarity and participation encourage all decision making to happen at the most local levels and to include as many of the people those decisions affect as possible. I will review both the pragmatic benefits of keeping decisions as local and rooted as possible as well as the moral benefits of allowing as many administrators and health care professionals to exercise and form their virtues as moral agents. In a time when changes to medical care have created many procedural responsibilities and cut into time spent in moral witness, institutions, even mega-systems, should remain attentive to the ways in which the moral agents of their system are formed and exercised.