Editorial Note

The editorial team here at the Kennedy Institute of Ethics Journal is honored to be publishing a trio of papers in this issue that pay tribute to Edmund Pellegrino (June 22, 1920–June 13, 2013), to mark the one-year anniversary of his passing. Dr. Pellegrino spent a large portion of his career here at Georgetown University, where he was affiliated with the Kennedy Institute of Ethics. He was a towering figure in bioethics for many decades, and one of its founding parents. He helped pioneer the practice of teaching bioethics to medical students. He was also one of the first people to make serious use of the tools of virtue ethics in thinking through ethical issues in clinical practice. This enabled him to give subtle moral and human texture to his discussions of the physician-patient relationship, moving the discourse beyond the attempts to list professional rules of engagement that had previously dominated clinical bioethics.

Dr. Pellegrino was the president of the Catholic University of America from 1978 to 1982, and the chair of the President’s Council on Bioethics during George W. Bush’s second term. He is the founding director of the Center for Clinical Bioethics—recently renamed the Edmund D. Pellegrino Center for Clinical Bioethics—at Georgetown University. An extremely prolific author and the recipient of over fifty honorary doctorates, he was a member of the Institute of Medicine and the National Academy of Sciences, among other austere institutions.

In this issue, three extremely prominent and respected bioethics—Joseph Fins, Rebecca Dresser, and Daniel Sulmasy—reflect on the philosophical importance of Dr. Pellegrino’s work and the influence he had upon their own work and lives and the field of bioethics as a whole.

This issue also contains two articles on research ethics. In “The Risk-Escalation Model: A Principled Design Strategy for Early-Phase Trials,” Spencer Hey and Jonathan Kimmelman address the special ethical challenges researchers face during the early stages of a research program, in the face of radical uncertainty. In such early-phase trials, our normal techniques for balancing risks with potential benefits are not especially helpful, given our lack of knowledge of the impact of our interventions. Hey and Kimmelman defend a “risk-escalation” strategy, which calls for researchers to build up to the point where they are offering maximal benefit slowly, as uncertainty diminishes. They argue that this approach is more likely to sustain long-term drug development, avoid harm, and further the social goals of medicine. In “Clinical Research before Informed Consent,” Franklin Miller delves into the history of clinical research, examining the era right around when informed consent to participate in research became a live ethical concern. Miller argues that the mid-1960s were a period of serious reflection upon and tensions around the ethical role of informed consent in medical research, while prior to that transition, researchers felt quite comfortable proceeding without informed consent. Miller carefully examines the transition. He also asks, more generally, about the ethical underpinnings of our commitment to informed consent, and its appropriate limits. Informed consent, he concludes, is important just to the extent to which it furthers patient-centered care.

In “The Paradox of Conscientious Objection and the Anemic Concept of ‘Conscience’,” Alberto Giubilini argues, against the prevailing view, that the concepts of physician conscience and physician moral integrity do very little substantive work in health care ethics. The concept of conscience is ‘anemic’ in the sense that it does not enable progress in moral reasoning; it does not help us to draw helpful distinctions, constrain practices, or balance competing values and rights. In brief, his argument is that one must already have settled the important moral questions before it becomes possible to allot appropriate room for physicians’ conscientious objections in health care delivery. Appealing to the value of respect for moral integrity will not, in fact, add anything contentful to such discussions, unless we embrace a moral relativism or subjectivism that most theorists find unappealing. This is a philosophically subtle and bold paper that surely would have deeply engaged Dr. Pellegrino, even while he would have vigorously disagreed with it!