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Principles of Biomedical Ethics, 8th Edition

ISBN-13: 978-0190640873
ISBN-10: 0190640871

Author: Tom L. Beauchamp (Author), James F. Childress (Author)

Principles of Biomedical Ethics provides a highly original, practical, and insightful guide to morality in the health professions. Acclaimed authors Tom L. Beauchamp and James F. Childress thoroughly develop and advocate for four principles that lie at the core of moral reasoning in health care: respect for autonomy, nonmaleficence, beneficence, and justice. Drawing from contemporary research–and integrating detailed case studies and vivid real-life examples and scenarios–they demonstrate how these prima facie principles can be expanded to apply to various conflicts and dilemmas, from how to deliver bad news to whether or not to withhold or withdraw life-sustaining treatments.

Ideal for courses in biomedical ethics, bioethics, and health care ethics, the text is enhanced by hundreds of annotated citations and a substantial introduction that clarifies key terms and concepts.

PREFACE

Biomedical ethics, or bioethics, was a youthful field when the first edition of this book went to press in late 1977, now over forty years ago. The word bioethics was a recently coined term when, in the mid-1970s, we began as a team writing in this field and lecturing to health professionals on the subject of moral theory and principles. The field had virtually no literature that engaged moral theory and methodology. Massive changes have since occurred both in the field and in this book. We have tried to stay as close to the frontiers of this field as we could, even though the literature is now sufficiently extensive and rapidly expanding that it is difficult to keep abreast of new topics under discussion.
For those who have stayed with us through the previous editions of Principles of Biomedical Ethics, we express our gratitude for your critical and constructive suggestions—for us a constant source of information and insight, as well as inspiration. Substantial changes have appeared in all editions after the first, and this eighth and perhaps final edition is no exception. No new changes have been made in the book’s basic structure, but the revisions are thoroughgoing in every chapter. We have attempted to sharpen our investigations, strengthen our arguments, address issues raised by critics, and both reference and assess new published material. As in previous editions, we have made changes in virtually every section and subsection of the book’s ten chapters.
Our clarifications, additions, expansions, and responses to critics can be crisply summarized as follows:
Part I, Moral Foundations: In Chapter 1, “Moral Norms,” we have clarified, augmented, and tightened our accounts of the common morality, universal morality, and how they differ from particular moralities. We have also clarified in this chapter and Chapter 10 the ways in which the four-principles framework is to be understood as a substantive framework of practical normative principles and a method of bioethics. We have had a major commitment to the virtues and moral character since our first edition. In Chapters 2 and 9 we have clarified and modestly expanded our discussion of the nature and importance of moral
virtues, moral ideals, and moral excellence; and we have also revised our account of the lines that separate what is obligatory, what is beyond obligation, and what is virtuous. In Chapter 3, “Moral Status,” we have revised our account of theories of moral status in several ways and revised our presentation in the section on “Guidelines Governing Moral Status: Putting Specification to Work.” We also engage some moral problems that have emerged about the use of human-nonhuman chimeras in biomedical research. We there concentrate on whether functional integration of human neural cells in a nonhuman primate
brain (and the brains of other species) would cause a morally significant change in the mind of the animal, and, if it did so, what the consequences should be for the moral status of the animal if it were born.
Part II, Moral Principles: The principles of basic importance for biomedical ethics are treated individually in Part II. In Chapter 4, “Respect for Autonomy,” we have expanded our presentations in several sections including addition of an analysis of the distinction between the justification of informed consent requirements and the several functions served by the doctrine, institutions, and practices of informed consent. Also added is a significant clarification of our theory of intentional nondisclosure in clinical practice and research and the conditions under which intentional nondisclosure is justified. In Chapter 5, “Nonmaleficence,” we have updated and deepened our constructive proposals about “Distinctions and Rules Governing Nontreatment,” proper and improper uses of the best-interest standard, and the place of anticipated quality of life in decisions regarding seriously ill newborns and children. The sections on decisions about physician-assisted dying are updated and arguments adjusted in light of global developments, especially in North America (Canada and several US states). In Chapter 6, “Beneficence,” we deepened our analysis of policies of expanded and continued access to investigational products in research as well as
our discussions of the ethical value of, concerns about, and constraints on riskbenefit, cost-benefit, and cost-effectiveness analyses. In Chapter 7, “Justice,” we updated and expanded the discussions of theories of justice, with restructured presentations of communitarian theories, capability theories, and well-being theories. Also updated are sections on problems of health insurance coverage, social implementation of the right to health care, and the right to a decent minimum of health care—as well as revised analyses of whether individuals forfeit this right through risky actions and what the fair opportunity rule requires by way of rectifying disparities in health care. Chapter 8, “Professional-Patient Relationships,” has expanded sections on “Veracity” and “Confidentiality,” each of which incorporates new cases. The section on arguments for intentionally limiting communication of bad news has been updated. In particular, we have deepened our account of when physicians’ decisions to use staged disclosures are ethically justified. Part III, Theory and Method: Chapter 9, “Moral Theories,” has an expanded section on “Virtue Theory” that fills out our account of the virtues introduced in Chapter 2 and furthers the application of our theory to biomedical ethics. We have also augmented and clarified the section on rights theory. Significant additions appear in the section on “The Rights of Incompetent, Disadvantaged, and Unidentified Members of Populations.” In Chapter 10, “Method and Moral Justification,” we have strengthened our critiques of theories of justification in what we call top-down models and casuistry. We have also expanded our accounts of common-morality theory, moral change, reflective equilibrium, considered judgments, and the ways in which our theory is committed to a global bioethics. Each of these parts has been recast to clarify and deepen our positions.
Finally, we want to correct some long-standing misinterpretations of our theory that have persisted over the forty years of editions of this book. Several critics have maintained that our book is committed to an American individualism in which the principle of respect for autonomy dominates all other moral principles and considerations. This interpretation of our book is profoundly mistaken. In a properly structured account of biomedical ethics, respect for autonomy has no distinctly American grounding and is not excessively individualistic or overriding. We do not emphasize individual rights to the neglect or exclusion of  social responsibilities and communal goals. We do not now, and have never, treated the principle of respect for autonomy in the ways several of our critics allege. To the contrary, we have always argued that many competing moral considerations validly override this principle under certain conditions. Examples include the following: If our choices endanger public health, potentially harm innocent others,
or require a scarce and unfunded resource, exercises of autonomy can justifiably be restricted by moral and legal considerations. The principle of respect for autonomy does not by itself determine what, on balance, a person ought to be free to do or what counts as a valid justification for constraining autonomy.
Our position is that it is a mistake in biomedical ethics to assign priority a priori to any basic principle over other basic principles—as if morality is hierarchically structured or as if we must value one moral norm over another without consideration of particular circumstances. The best strategy is to appreciate the contributions and the limits of various principles, virtues, and rights, which is the strategy we have embraced since the first edition and continue throughout this edition. A number of our critics have mistakenly maintained—without textual warrant—that our so-called principlism overlooks or even discounts the virtues.
We have given a prominent place in our theory—since the first edition—to the virtues and their significant role in biomedical ethics. We maintain and further develop this commitment in the present edition.
Fortunately, we have always had a number of valuable—and often constructive—critics of our theories, especially John Arras, Edmund Pellegrino, Raanan Gillon, Al Jonsen, Stephen Toulmin, Michael Yesley, Franklin Miller, David DeGrazia, Ronald Lindsay, Carson Strong, John-Stewart Gordon, Oliver Rauprich, Jochen Vollmann, Rebecca Kukla, Henry Richardson, Peter Herissone-Kelly, Robert Baker, Robert Veatch, Tris Engelhardt, Robert “Skip” Nelson, and Neal W. Dickert. Our book owes a great deal to these critics and friends. We again wish to remember with great fondness and appreciation the late Dan Clouser, a wise man who seems to have been our first—and certainly one of our sternest—critics. We also acknowledge the penetrating criticisms of Clouser’s friend, and ours, the late Bernard Gert, whose trenchant criticisms showed us the need for clarifications or modifications in our views. We also thank John Rawls for a lengthy conversation, shortly before his untimely death in 2002, about communitarian and egalitarian theories of justice that led to significant improvements in our chapter on justice.
We have continued to receive many helpful suggestions for improvements in our work from students, colleagues, health professionals, and teachers who use the book. Jim is particularly grateful to his University of Virginia colleagues: the late John Arras, already mentioned; Ruth Gaare Bernheim; Richard Bonnie; and the late John Fletcher for many illuminating discussions in team-taught courses and in other contexts. Discussions with many practicing physicians and nurses in the University of Virginia’s Medical Center, on its Ethics Committee, and with faculty in the Center for Biomedical Ethics and Humanities have been very helpful. In addition, Jim thanks the faculty and graduate students of the Centre for the Advanced Study of Bioethics at the University of Münster for gracious hospitality and vigorous and valuable conversation and debate, particularly about paternalism and autonomy, especially during extended visits in 2011 and 2016; Bettina Schöne-Seifert, Thomas Gutmann, and Michael Quante deserve special
thanks. Jim also expresses his deep gratitude to Marcia Day Childress, his wife for the last twenty-two years, for many valuable suggestions along with loving and unstinting support throughout the preparation of the eighth edition as well as the preceding three editions.
Tom likewise wishes to thank his many colleagues in Georgetown University’s Philosophy Department and Kennedy Institute of Ethics, as well as his colleagues in research at the Berman Institute of Bioethics of The Johns Hopkins University. Henry Richardson and Rebecca Kukla have been penetrating, as well as constructive, critics from whom several editions of this book have greatly benefited. Between the sixth and seventh editions, Tom benefited hugely from his work with colleagues at Johns Hopkins on an NIH grant to study the need to revise our understanding of the research–practice distinction: Ruth Faden, Nancy Kass, Peter Pronovost, Steven Goodman, and Sean Tunis. When one has colleagues this talented and well informed, multidisciplinary work is as invigorating as it is instructive.
Tom also wishes to express appreciation to five undergraduate research assistants: Patrick Connolly, Stacylyn Dewey, Traviss Cassidy, Kekenus Sidik, Patrick Gordon. Their research in the literature, their editing of copy, and their help with previous indexes have made this book more comprehensive and readable. Likewise, Jim wishes to thank three superb research and teaching assistants, Matt Puffer, Travis Pickell, and Laura Alexander, for their helpful contributions. Other teaching assistants in a lecture course at the University of Virginia that used this book also made valuable suggestions.
We also acknowledge with due appreciation the support provided by the Kennedy Institute’s library and information retrieval systems, which kept us in touch with new literature and reduced the burdens of library research. We owe a special debt of gratitude to Martina Darragh, who retired as the last chapter of this eighth edition was being completed. Martina gave us help when we thought no help could be found.
Retrospectively, we express our gratitude to Jeffrey House, our editor at Oxford University Press for the first thirty years of this book. Jeff encouraged us to write it before a single page was written, believed in it deeply, and saw it through all of its formative editions. He was an emulable editor. We also thank Robert Miller for efficiently facilitating the production of the recent editions of this book.
We dedicate this edition, just as we have dedicated each of the previous seven editions, to Georgia, Ruth, and Don. Georgia, Jim’s beloved wife of thirty-five years, died in 1994, just after the fourth edition appeared. Our dedication honors her wonderful memory and her steadfast support for this project from its inception. Tom also acknowledges the love, devotion, and intellectual contribution to this book of his wife, Ruth Faden, who has been the deepest influence on his career in bioethics, and salutes Donald Seldin, a brilliant physician and an inspiration to Tom and to biomedical ethics since the early years of the field. Don passed away at age ninety-seven in 2018, when we were in the midst of preparing this eighth edition. He will be sorely missed, and never forgotten.
Washington, DC, and Chilmark, MA T.L.B.
Charlottesville, VA J.F.C.