The American Journal of Bioethics
Fostering the Ethics of Ethics Consultants in Health Care: An Ongoing Participatory Approach Bert Molewijk, VU Medical Center Laura Hartman, VU Medical Center Froukje Weidema, VU Medical Center Yolande Voskes, VU Medical Center Guy Widdershoven, VU Medical Center We appreciate the process and content of the code of ethics for ethics consultants described by Tarzian and colleagues (Tarzian et al. 2015). Both method and results are in line with our view that quality assignment within HCEC should primarily be based on the views and experiences of professionals in practice (Molewijk et al. 2008; Widdershoven and Molewijk 2010). Yet we argue that the ASBH code has some limitations. In order to show one way of dealing with these limitations, we present a Dutch project that aims to develop quality criteria for ethics support, including ethical considerations, through an ongoing participatory research process. Finally, we reflect upon cultural and philosophical differences between both approaches and argue that exactly due to these differences the approaches may be seen and used as complimentary.
SOME CRITICAL REFLECTIONS ON THE ASBH ETHICS CODE The ASBH code provides guidelines that are appealing to HCEC professionals. This can be concluded from the fact that an overwhelming majority of the CECA members (90%) endorsed each code element in the second online survey. Yet this generous support may be due to the fact that the elements of the code are so general that it is almost impossible to disagree. However, core concepts such as “preserve integrity” require both practical interpretation and conceptual development in concrete practices. The actual meaning and normative implications of core concepts in clinical practice are not one-way derivatives from beforehand-settled core concepts from an ethics code. Both meaning and normative implications ultimately come down to how these core concepts are interpreted and used in practice. The authors acknowledge this when they remark: “The point at which preserving personal integrity interferes with one’s ability to preserve professional integrity can be subtle, and requires ongoing reflection” (Tarzian
et al 2015, 44, emphasis added). Yet they refrain from specifying how this process of reflection should be organized. The formulation of the concepts presented in the ASBH ethics code does certainly provide a preliminary framework, but the code lacks heuristic instructions for a contextual approach that may help to make this framework concrete in practice. Within this ethics code, within any ethics code, we suggest a shift in focus from “trust in concepts” toward more didactical instructions for an ongoing experiential learning process in practice. The concepts mentioned in the ASBH code remain quite abstract. An example is the concept of “just health care.” Although the authors aim to develop a substantial understanding of this moral concept, the emphasis is on the responsibilities of the HCE consultant and not on the actual meaning of just health care. We wonder why such a formal approach prevails. We think a more substantial approach to what may count as (un)just health care practices (i.e., how to determine that in practice and subsequently which possible actions could follow in order to deal with it) might be more helpful. In the “Implications and Future Directions” section the authors conclude that the code can “only” be seen as aspirational. This conclusion seems to follow from the alternatives mentioned by the authors: The code is seen as either being aspirational or being enforceable. It seems as if, implicitly, the authors say that a more formalistic approach of an ethics code is preferable. We think the code might also function in various other ways (e.g., in the context of teaching programs for clinical ethics support services [CESS], quality assurance and quality support audits, or narrative reports from HCE consultants on how the ethics code has inspired them and what needs to be improved or adjusted). In addition, within the ASBH ethics code, no concrete evaluative or follow-up plans are mentioned in that respect. Despite the nice process approach toward the development of the ASBH ethics code, suggestions for
Address correspondnece to Bert Molewijk, VU Medical Center, Department of Medical Humanities, Van der Boechortstraat 7, Amsterdam, NL 1081BT, The Netherlands. E-mail: [email protected]
60 ajob
May, Volume 15, Number 5, 2015
Code of Ethics for Health Care Ethics Consultants
ongoing learning processes and feedback loops, such as through interactive empirical ethics research, are lacking (Abma, Molewijk, and Widdershoven 2009; Widdershoven, Abma, and Molewijk 2009; Widdershoven, Molewijk, and Abma 2009). DEVELOPING QUALITY CRITERIA FOR CESS THROUGH A LEARNING NETWORK IN THE NETHERLANDS In the Netherlands, quality criteria for CESS are being developed in a learning network (Wenger, McDermott, and Snyder 2002). This network consists of participants involved in CESS. Through interviews, expert meetings and national conferences, joint learning processes are fostered, aimed at making explicit quality criteria for CESS. The network consists of a large variety of people involved in CESS (i.e., members of ethics committees, trained facilitators of moral case deliberation, ethics consultants, directors of institutions and umbrella organizations; managers in health care institutions; representatives of the Ministry of Health; academic ethicists, researchers, etc.). The network aims at realizing shared ownership among all of those who participate, in order to find common ground, but also to make explicit differences, in order to foster future processes of mutual understanding and learning. The project, funded by the Ministry of Health, resembles the approach described by Tarzian and colleagues as it focuses on a process of development of guidelines in interaction with professionals who are active in CESS. Yet it addresses a larger group of stakeholders and they are given a more active role in the process of developing quality standards. And even more important, from its starting point this learning network will continue to work on the development and use of the quality criteria in the future. This means that the development of the quality criteria is not seen as a project that ends when the first draft of the quality criteria is developed. As a matter of fact, then the work just starts: using it in practice and using participatory research for an ongoing developmental process. A philosophical presupposition of the project is that quality cannot be defined beforehand (i.e., before the actual experience): It should get developed in an ongoing dialogical deliberation involving various stakeholders, focusing on actual experiences. The learning network approach is based on the presuppositions that (1) there is no shared understanding of what quality of CESS means; (2) development of quality criteria should start from experiences in practice; (3) formulating quality criteria requires sharing of knowledge and joint learning processes; (4) participatory research methods may function as a change instrument; and (5) involving stakeholders fosters support for the quality criteria. To provide input to the learning network and the process of sharing experiences between professionals in the field of ethics support, we invited professionals to describe an example in their own practice that they consider instructive and helpful for their colleagues. We explicitly asked for best practices and less successful practices, since
May, Volume 15, Number 5, 2015
the latter may also be informative. We asked the professionals to describe the practices in a format consisting of specific questions, such as “What lessons do you believe can be drawn from your example?” This format has several advantages, as it (1) supports the professionals in describing the practice, (2) makes the descriptions accessible and enables comparison, (3) ensures that explicit attention is paid to the quality of the practice, and finally (4) stimulates reflection of the professional on the quality of his or her work. The participants are invited to structure, analyze, and validate the formats of practice-experiences during expert meetings. Next, they are published on the project’s website. Making these experiences accessible to others facilitates joint learning processes and contributes to the strengthening of the network. DIFFERENCES AND COMPLEMENTARITY The differences between the two approaches may reflect deeper cultural and philosophical differences. The ASBH approach appears to depart from values, norms, rules, and principles that are defined beforehand. It seems to presuppose a shared consensus on their meaning, normative appeal, and directive power. The Dutch approach is based on an ongoing dialogical and hermeneutical process with all stakeholders involved. Another difference is that in the United States, one of CESS’s core tasks seems to be to maintain certain professional, political, and institutional norms such as laws, policies, guidelines, and so on (ASBH 2011). In the Netherlands, CESS focuses more on reflection, dialogue, and meaning-making in a deliberative framework (Molewijk et al. 2008; Widdershoven et al. 2010). This does not imply that Dutch CESS merely aims at “educational” goals. Deliberative models of CESS may very well help professionals in health care to find morally sound solutions to concrete problems and support decisions on treatment and care, taking into account legal frameworks and professional guidelines. Yet the support is not provided in the form of advice or consultation, but through facilitation of health care professionals’ moral deliberation. Although the two approaches are different, they can be complementary. They have a common ground in that they aim to do justice to the views and experiences of people involved in the practice of CESS. They both aim to set standards that professionals in CESS should adhere to. The ASBH approach is, after an inductive developmental process, more deductive, by presenting a final set of principles. The Dutch approach is more inductive from the beginning, and continues to develop a preliminary set of standards by using an ongoing participatory research process within a learning network. In the end, the two approaches may supplement and inspire each other. & REFERENCES Abma, T., B. Molewijk, and G. Widdershoven. 2009. Good care in ongoing dialogue. Improving the quality of care through moral
ajob 61
The American Journal of Bioethics
deliberation and responsive evaluation. Health Care Analysis 17(3): 217–235. http://dx.doi.org/10.1007/s10728-008-0102-z American Society for Bioethics and Humanities Core Competencies Update Task Force. 2011. Core competencies for health care ethics consultation: The report of the American Society for Bioethics and Humanities, 2nd ed. Glenview, IL: American Society for Bioethics and Humanities. Molewijk, B., T. Abma, M. Stolper, and G. Widdershoven. 2008. Teaching ethics in the clinic: The theory and practice of moral case deliberation. Journal of Medical Ethics 34: 120–124.http://dx.doi. org/10.1136/jme.2006.018580 Tarzian, A. J., L. D. Wocial, and The ASBH Clinical Ethics Consultation Affairs Committee. 2015. A code of ethics for health care ethics consultants: Journey to the present and implications for the field. American Journal of Bioethics 15(5): 38–51.
Wenger, E., R. McDermott, and W. M. Snyder. 2002. Cultivating communities of practice: A guide to managing knowledge. Boston, MA: Harvard Business School Press. Widdershoven, G., T. Abma, and B. Molewijk. 2009. Empirical ethics as dialogical practice. Bioethics 23(4): 236–248. http://dx. doi.org/10.1111/j.1467-8519.2009.01712.x Widdershoven, G. A. M., and B. Molewijk. 2010. Philosophical foundations of clinical ethics: A hermeneutic perspective. In Clinical ethics consultation theories and methods, implementation, evaluation, ed. J. Schildmann, J.-S. Gordon, and J. Vollmann, 37–52. Williston, VT: Ashgate. Widdershoven, G., B. Molewijk, T. Abma. 2009. Improving care and ethics: A plea for interactive empirical ethics. American Journal of Bioethics 9(6-7): 99–101.
A Critique of the (Aspirational) Code of Ethics ~ a, Baylor College of Medicine and Houston Methodist Hospital System Adam Pen After decades of professional debate, establishing a Code of Ethics and Professional Responsibilities for Health Care Ethics Consultants is a milestone achievement in the professionalization of health care ethics consultation (HCEC). The purpose, in part, of the Code is to provide healthcare ethics (HCE) consultants with “practical” guidelines about their professional responsibilities toward those they serve. While the approval of the Code at the 2012 American Society for Bioethics and Humanities (ASBH) Conference is indicative of widespread professional acceptance, the Clinical Ethics Consultation Affairs (CECA) committee suggests that the Code is not currently enforceable, and is, therefore, merely aspirational (Tarzian et al. 2015). My focus for this discussion is the description of the Code as aspirational, rather than anything substantive within the Code itself. If a central purpose of a code of ethics is to be an authoritative guidance to practitioners, then an aspirational code (vs. an authoritative one) is problematic because it, as Baker (2005) describes, is another formalization of already accepted professional obligations, rather than an official codification of professional obligations that significantly moves the field toward professionalization. The ASBH Core Competencies for Health Care Ethics Consultation suggest that certain attributes and behaviors are associated with the acquisition of skills necessary to practice HCE effectively. In order to maintain professional
integrity, ethics consultants are expected to act consistently with the (shared and accepted) professional standards that constitute the obligations to those the consultants serve (American Society for Bioethics and Humanities’ Core Competencies Update Task Force 2011). These professional standards should, ideally, inform an ethics consultant’s actions. The current Code, as a practical tool, serves as a point of reference for a consultant’s behavior and encourages the reflection (and development) of professional attributes discussed in the Core Competencies (American Society for Bioethics and Humanities’ Core Competencies Update Task Force 2011, 33). Though the approved Code legitimizes and preserves health care ethics consultants’ professional integrity as an independent profession, my point of contention with the current Code is whether the professional field can, or should, recognize it as an authoritative guidance for consultants. Beyond preserving integrity, the Code is intended to serve as a means for further professionalization of the field. In his article “A Draft Model Aggregated Code of Ethics for Bioethicists,” Robert Baker describes the three stages of professional code development: (1) traditionalism, (2) formalization, and (3) professionalization (Baker 2005). For purposes of my commentary, I focus on formalization and professionalization. At the second stage of development, a code of ethics is an accumulation of previous documents and agreed-upon responsibilities and
Address correspondence to Adam Pe~ na, Center for Medical Ethics & Health Policy, Baylor College of Medicine, One Baylor Plaza, MS: BCM 420, Houston, TX 77030, USA. E-mail: [email protected]
62 ajob
May, Volume 15, Number 5, 2015
Copyright of American Journal of Bioethics is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Fostering the Ethics of Ethics Consultants in Health Care: An Ongoing Participatory Approach Bert Molewijk, VU Medical Center Laura Hartman, VU Medical Center Froukje Weidema, VU Medical Center Yolande Voskes, VU Medical Center Guy Widdershoven, VU Medical Center We appreciate the process and content of the code of ethics for ethics consultants described by Tarzian and colleagues (Tarzian et al. 2015). Both method and results are in line with our view that quality assignment within HCEC should primarily be based on the views and experiences of professionals in practice (Molewijk et al. 2008; Widdershoven and Molewijk 2010). Yet we argue that the ASBH code has some limitations. In order to show one way of dealing with these limitations, we present a Dutch project that aims to develop quality criteria for ethics support, including ethical considerations, through an ongoing participatory research process. Finally, we reflect upon cultural and philosophical differences between both approaches and argue that exactly due to these differences the approaches may be seen and used as complimentary.
SOME CRITICAL REFLECTIONS ON THE ASBH ETHICS CODE The ASBH code provides guidelines that are appealing to HCEC professionals. This can be concluded from the fact that an overwhelming majority of the CECA members (90%) endorsed each code element in the second online survey. Yet this generous support may be due to the fact that the elements of the code are so general that it is almost impossible to disagree. However, core concepts such as “preserve integrity” require both practical interpretation and conceptual development in concrete practices. The actual meaning and normative implications of core concepts in clinical practice are not one-way derivatives from beforehand-settled core concepts from an ethics code. Both meaning and normative implications ultimately come down to how these core concepts are interpreted and used in practice. The authors acknowledge this when they remark: “The point at which preserving personal integrity interferes with one’s ability to preserve professional integrity can be subtle, and requires ongoing reflection” (Tarzian
et al 2015, 44, emphasis added). Yet they refrain from specifying how this process of reflection should be organized. The formulation of the concepts presented in the ASBH ethics code does certainly provide a preliminary framework, but the code lacks heuristic instructions for a contextual approach that may help to make this framework concrete in practice. Within this ethics code, within any ethics code, we suggest a shift in focus from “trust in concepts” toward more didactical instructions for an ongoing experiential learning process in practice. The concepts mentioned in the ASBH code remain quite abstract. An example is the concept of “just health care.” Although the authors aim to develop a substantial understanding of this moral concept, the emphasis is on the responsibilities of the HCE consultant and not on the actual meaning of just health care. We wonder why such a formal approach prevails. We think a more substantial approach to what may count as (un)just health care practices (i.e., how to determine that in practice and subsequently which possible actions could follow in order to deal with it) might be more helpful. In the “Implications and Future Directions” section the authors conclude that the code can “only” be seen as aspirational. This conclusion seems to follow from the alternatives mentioned by the authors: The code is seen as either being aspirational or being enforceable. It seems as if, implicitly, the authors say that a more formalistic approach of an ethics code is preferable. We think the code might also function in various other ways (e.g., in the context of teaching programs for clinical ethics support services [CESS], quality assurance and quality support audits, or narrative reports from HCE consultants on how the ethics code has inspired them and what needs to be improved or adjusted). In addition, within the ASBH ethics code, no concrete evaluative or follow-up plans are mentioned in that respect. Despite the nice process approach toward the development of the ASBH ethics code, suggestions for
Address correspondnece to Bert Molewijk, VU Medical Center, Department of Medical Humanities, Van der Boechortstraat 7, Amsterdam, NL 1081BT, The Netherlands. E-mail: [email protected]
60 ajob
May, Volume 15, Number 5, 2015
Code of Ethics for Health Care Ethics Consultants
ongoing learning processes and feedback loops, such as through interactive empirical ethics research, are lacking (Abma, Molewijk, and Widdershoven 2009; Widdershoven, Abma, and Molewijk 2009; Widdershoven, Molewijk, and Abma 2009). DEVELOPING QUALITY CRITERIA FOR CESS THROUGH A LEARNING NETWORK IN THE NETHERLANDS In the Netherlands, quality criteria for CESS are being developed in a learning network (Wenger, McDermott, and Snyder 2002). This network consists of participants involved in CESS. Through interviews, expert meetings and national conferences, joint learning processes are fostered, aimed at making explicit quality criteria for CESS. The network consists of a large variety of people involved in CESS (i.e., members of ethics committees, trained facilitators of moral case deliberation, ethics consultants, directors of institutions and umbrella organizations; managers in health care institutions; representatives of the Ministry of Health; academic ethicists, researchers, etc.). The network aims at realizing shared ownership among all of those who participate, in order to find common ground, but also to make explicit differences, in order to foster future processes of mutual understanding and learning. The project, funded by the Ministry of Health, resembles the approach described by Tarzian and colleagues as it focuses on a process of development of guidelines in interaction with professionals who are active in CESS. Yet it addresses a larger group of stakeholders and they are given a more active role in the process of developing quality standards. And even more important, from its starting point this learning network will continue to work on the development and use of the quality criteria in the future. This means that the development of the quality criteria is not seen as a project that ends when the first draft of the quality criteria is developed. As a matter of fact, then the work just starts: using it in practice and using participatory research for an ongoing developmental process. A philosophical presupposition of the project is that quality cannot be defined beforehand (i.e., before the actual experience): It should get developed in an ongoing dialogical deliberation involving various stakeholders, focusing on actual experiences. The learning network approach is based on the presuppositions that (1) there is no shared understanding of what quality of CESS means; (2) development of quality criteria should start from experiences in practice; (3) formulating quality criteria requires sharing of knowledge and joint learning processes; (4) participatory research methods may function as a change instrument; and (5) involving stakeholders fosters support for the quality criteria. To provide input to the learning network and the process of sharing experiences between professionals in the field of ethics support, we invited professionals to describe an example in their own practice that they consider instructive and helpful for their colleagues. We explicitly asked for best practices and less successful practices, since
May, Volume 15, Number 5, 2015
the latter may also be informative. We asked the professionals to describe the practices in a format consisting of specific questions, such as “What lessons do you believe can be drawn from your example?” This format has several advantages, as it (1) supports the professionals in describing the practice, (2) makes the descriptions accessible and enables comparison, (3) ensures that explicit attention is paid to the quality of the practice, and finally (4) stimulates reflection of the professional on the quality of his or her work. The participants are invited to structure, analyze, and validate the formats of practice-experiences during expert meetings. Next, they are published on the project’s website. Making these experiences accessible to others facilitates joint learning processes and contributes to the strengthening of the network. DIFFERENCES AND COMPLEMENTARITY The differences between the two approaches may reflect deeper cultural and philosophical differences. The ASBH approach appears to depart from values, norms, rules, and principles that are defined beforehand. It seems to presuppose a shared consensus on their meaning, normative appeal, and directive power. The Dutch approach is based on an ongoing dialogical and hermeneutical process with all stakeholders involved. Another difference is that in the United States, one of CESS’s core tasks seems to be to maintain certain professional, political, and institutional norms such as laws, policies, guidelines, and so on (ASBH 2011). In the Netherlands, CESS focuses more on reflection, dialogue, and meaning-making in a deliberative framework (Molewijk et al. 2008; Widdershoven et al. 2010). This does not imply that Dutch CESS merely aims at “educational” goals. Deliberative models of CESS may very well help professionals in health care to find morally sound solutions to concrete problems and support decisions on treatment and care, taking into account legal frameworks and professional guidelines. Yet the support is not provided in the form of advice or consultation, but through facilitation of health care professionals’ moral deliberation. Although the two approaches are different, they can be complementary. They have a common ground in that they aim to do justice to the views and experiences of people involved in the practice of CESS. They both aim to set standards that professionals in CESS should adhere to. The ASBH approach is, after an inductive developmental process, more deductive, by presenting a final set of principles. The Dutch approach is more inductive from the beginning, and continues to develop a preliminary set of standards by using an ongoing participatory research process within a learning network. In the end, the two approaches may supplement and inspire each other. & REFERENCES Abma, T., B. Molewijk, and G. Widdershoven. 2009. Good care in ongoing dialogue. Improving the quality of care through moral
ajob 61
The American Journal of Bioethics
deliberation and responsive evaluation. Health Care Analysis 17(3): 217–235. http://dx.doi.org/10.1007/s10728-008-0102-z American Society for Bioethics and Humanities Core Competencies Update Task Force. 2011. Core competencies for health care ethics consultation: The report of the American Society for Bioethics and Humanities, 2nd ed. Glenview, IL: American Society for Bioethics and Humanities. Molewijk, B., T. Abma, M. Stolper, and G. Widdershoven. 2008. Teaching ethics in the clinic: The theory and practice of moral case deliberation. Journal of Medical Ethics 34: 120–124.http://dx.doi. org/10.1136/jme.2006.018580 Tarzian, A. J., L. D. Wocial, and The ASBH Clinical Ethics Consultation Affairs Committee. 2015. A code of ethics for health care ethics consultants: Journey to the present and implications for the field. American Journal of Bioethics 15(5): 38–51.
Wenger, E., R. McDermott, and W. M. Snyder. 2002. Cultivating communities of practice: A guide to managing knowledge. Boston, MA: Harvard Business School Press. Widdershoven, G., T. Abma, and B. Molewijk. 2009. Empirical ethics as dialogical practice. Bioethics 23(4): 236–248. http://dx. doi.org/10.1111/j.1467-8519.2009.01712.x Widdershoven, G. A. M., and B. Molewijk. 2010. Philosophical foundations of clinical ethics: A hermeneutic perspective. In Clinical ethics consultation theories and methods, implementation, evaluation, ed. J. Schildmann, J.-S. Gordon, and J. Vollmann, 37–52. Williston, VT: Ashgate. Widdershoven, G., B. Molewijk, T. Abma. 2009. Improving care and ethics: A plea for interactive empirical ethics. American Journal of Bioethics 9(6-7): 99–101.
A Critique of the (Aspirational) Code of Ethics ~ a, Baylor College of Medicine and Houston Methodist Hospital System Adam Pen After decades of professional debate, establishing a Code of Ethics and Professional Responsibilities for Health Care Ethics Consultants is a milestone achievement in the professionalization of health care ethics consultation (HCEC). The purpose, in part, of the Code is to provide healthcare ethics (HCE) consultants with “practical” guidelines about their professional responsibilities toward those they serve. While the approval of the Code at the 2012 American Society for Bioethics and Humanities (ASBH) Conference is indicative of widespread professional acceptance, the Clinical Ethics Consultation Affairs (CECA) committee suggests that the Code is not currently enforceable, and is, therefore, merely aspirational (Tarzian et al. 2015). My focus for this discussion is the description of the Code as aspirational, rather than anything substantive within the Code itself. If a central purpose of a code of ethics is to be an authoritative guidance to practitioners, then an aspirational code (vs. an authoritative one) is problematic because it, as Baker (2005) describes, is another formalization of already accepted professional obligations, rather than an official codification of professional obligations that significantly moves the field toward professionalization. The ASBH Core Competencies for Health Care Ethics Consultation suggest that certain attributes and behaviors are associated with the acquisition of skills necessary to practice HCE effectively. In order to maintain professional
integrity, ethics consultants are expected to act consistently with the (shared and accepted) professional standards that constitute the obligations to those the consultants serve (American Society for Bioethics and Humanities’ Core Competencies Update Task Force 2011). These professional standards should, ideally, inform an ethics consultant’s actions. The current Code, as a practical tool, serves as a point of reference for a consultant’s behavior and encourages the reflection (and development) of professional attributes discussed in the Core Competencies (American Society for Bioethics and Humanities’ Core Competencies Update Task Force 2011, 33). Though the approved Code legitimizes and preserves health care ethics consultants’ professional integrity as an independent profession, my point of contention with the current Code is whether the professional field can, or should, recognize it as an authoritative guidance for consultants. Beyond preserving integrity, the Code is intended to serve as a means for further professionalization of the field. In his article “A Draft Model Aggregated Code of Ethics for Bioethicists,” Robert Baker describes the three stages of professional code development: (1) traditionalism, (2) formalization, and (3) professionalization (Baker 2005). For purposes of my commentary, I focus on formalization and professionalization. At the second stage of development, a code of ethics is an accumulation of previous documents and agreed-upon responsibilities and
Address correspondence to Adam Pe~ na, Center for Medical Ethics & Health Policy, Baylor College of Medicine, One Baylor Plaza, MS: BCM 420, Houston, TX 77030, USA. E-mail: [email protected]
62 ajob
May, Volume 15, Number 5, 2015
Copyright of American Journal of Bioethics is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
