Bioethical decision‐making in pediatrics diverges from similar decisions in other medical domains because the young child is not an autonomous decision‐maker, while the teen is developing—and should be encouraged to develop—autonomy and decisional capacity. Thus the balance between autonomy and beneficence is fundamentally different in pediatrics than in adult medicine. While ethical dilemmas that reflect these fundamental issues are common, many pediatric physician and nursing training programs do not delve into the issues or offer specific training about how to deal (...) with borderline cases.To meet this need, the Children's Mercy Bioethics Center in Kansas City, Missouri, created a program specifically dedicated to serving practicing, experienced pediatric health professionals. Our students come from various professional disciplines: they are doctors, nurses, social workers, chaplains, lawyers, psychologists, counselors, and hospital administrators practicing in pediatrics. (shrink)

Advancements in fetal assessment and therapeutic intervention in medical practice and clinical research call for corresponding progress in regulatory and ethical guidance. In “A new ethical framewo...

Written with poignancy and compassion, ____Do We Still Need__ ____Doctors?__ is a personal account from the front lines of the moral and political battles that are reshaping America's health care system.

Spceial Care explores the moral and legal issues in neonatal intensive care. It is an urgently needed entry in the current discussions of treatment for badly damaged babies.

I am currently caring for a child named Priscilla who is ventilator-dependent and whose care confronted me with questions of justice. Priscilla was born at the County Hospital after a normal pregnancy to a 17-year-old single mother. At birth, she was noted to have some dysmorphic features: widely spaced eyes, low-set ears, and a cleft palate. Her chest X-ray showed hypoplastic ribs and scapulae. Her chromosome studies were normal. Eventually, a diagnosis of a rare dwarfing syndrome campomelic dysplasia – was (...) made. (shrink)

In current American medical practice, autonomy is assumed to be more valuable than human life: if a patient autonomously refuses lifesaving treatment, the doctors are supposed to let him die. In this paper we discuss two values that might be at stake in such clinical contexts. Usually, we hear only of autonomy and best interests. However, here, autonomy is ambiguous between two concepts—concepts that are tied to different values and to different philosophical traditions. In some cases, the two values (that (...) of agency and that of authenticity) entail different outcomes. We argue that the comparative value of these values needs to be assessed. (shrink)

It used to be futile to try to save babies born at 23 weeks. It isn’t anymore. It used to be futile to try to keep patients with end-stage congestive heart failure alive. It isn’t anymore. Futility is a moving target. Thus, it is not surprising that doctors, patients, and families often disagree about which treatments are efficacious or futile, appropriate or inappropriate, obligatory or obligatorily withheld. The goalposts keep moving. Yesterday’s impossibility is today’s routine. Why should a patient believe (...) a doctor who says that treatment is futile, inappropriate, or likely to cause more harm than good? Could it just mean that the doctors are unwilling to try everything that is available? When... (shrink)

Equipoise is an essential condition to justify a clinical trial. The term, describes a state of uncertainty: the data suggest but do not prove a drug's safety and efficacy The only way to resolve this uncertainty is further study In many cases, a clinical trial seems to be the most efficient way to prove safety and efficacy Equipoise is therefore not an esoteric philosophic construct applied to research ethics. Rather, since it is vital for the justification of clinical trials, it (...) is part of how society regulates medical progress. Where there is equipoise, drug design and development proceeds according to Food and Drug Administration and Health and Human Services regulations. When that equipoise ends, a drug is either not approved or becomes standard care. (shrink)

When should doctors seek protective custody to override a parent’s refusal of potentially lifesaving treatment for their child? The answer to this question seemingly has different answers for different subspecialties of pediatrics. This paper specifically looks at different thresholds for physicians overriding parental refusals of life-sustaining treatment between neonatology, cardiology, and oncology. The threshold for mandating treatment of premature babies seems to be a survival rate of 25–50%. This is not the case when the treatment in question is open heart (...) surgery for a child with congenital heart disease. Most cardiologists would not pursue legal action when parents refuse treatment, unless the anticipated survival rate after surgery is above 90%. In pediatric oncology, there are case reports of physicians requesting and obtaining protective custody for cancer treatment when the reported mortality rates are 40–50%. Such differences might be attributed to differences in care, a reasonable prioritization of quality of life over survival, or the role uncertainty plays on prognoses, especially for the extremely young. Nonetheless, other, non-medical factors may have a significant effect on inconsistencies in care across these pediatric subspecialties and require further examinations. (shrink)

Loneliness in medicine is a serious problem not just for patients, for whom illness is intrinsically isolating, but also for physicians in the contemporary condition of medicine. We explore this problem by investigating the ideal physician-patient relationship, whose analogy with friendship has held enduring normative appeal. Drawing from Talbot Brewer and Nir Ben-Moshe, we argue that this appeal lies in a dynamic form of companionship incompatible with static models of friendship-like physician-patient relationships: a mutual refinement of embodied virtue that draws (...) both persons together. The ideal physician-patient relationship has a dialectical character that fosters each member's improvement of phenomenologically recognizing and embodying moral virtues. A key component of this dynamic is a commitment to the common goal of the patient's health, realized through joint interactivities and conversations over time. The physician's presence to the patient's suffering—understood best as an alienating phenomenological condition for the patient—orients and discloses possibilities for virtuous caregiving by structuring the meanings of the goals, conversations, and joint narrative constitutive of their relationship. Presence to suffering, paradoxically, is perhaps an important prerequisite for this dynamic partnership. These activities dialectically build an interpretive horizon of understanding through which moral goods and character refinement—in and for the other—may become revealed for both persons in their shared being-in-the-world. This analysis of suffering, mood, and revealing of (possible) moral goods has implications for addressing the modern problem of loneliness for patients and physicians, who are increasingly inhibited from building flourishing relationships with each other. (shrink)

Star Trek scripts have often grappled with dilemmas of medical ethics. The most explicitly medical-ethics-oriented Star Trek episode is named, aptly enough, “Ethics.” The script was written by Sara Charno and Stuart Charno, authors of two other Star Trek episodes. “Ethics” first aired on 2 March 1992. In the fall of 1992, we began to use this “Ethics” episode to motivate discussions in our first-year medical students’ course on medical ethics and the doctor-patient relationship. We asked students to write essays (...) addressing one of the many ethical dilemmas posed by the episode. Over the years, the episode has become a tradition. Both students and instructors find the formulation of dilemmas in the context of a science-fiction story to be both liberating and stimulating. In this essay, we will discuss this particular episode in some detail and then provide a brief synopsis of other episodes that might be used in ethics courses in a similar way. (shrink)

Henry K. Beecher’s famous 1966 article on ethically problematic medical research was a pivot point. It came at the end of two decades of soul-searching among researchers and philosophers. It ushered in an era of legislation and regulation to address the complex issues that had been extensively discussed by Beecher and others. That soul-searching began with the Nuremberg trials and the disturbing recognition of how far the Nazi doctors had strayed from professional ethical norms. It led, eventually, to the creation (...) of the system of oversight that we have today.During these years, there were heated arguments about what sort of research ought or ought not to be permitted and with what sort of oversight. Often... (shrink)

It has become increasingly difficult to place a value on the work that doctors do. Yet fiscal pressures have lead to economic incentives for performing certain kinds work instead of others. So the question arises: what are the ethics and consequences of trying to objectively compare the many services physicians offer?

Many states prohibit patients from appointing their physicians as health care proxies, fearing paternalism and conflict of interest. But the potential for conflict is not unique to physicians, and patients may have compelling reasons to prefer that their doctor make decisions on their behalf. Managing potential conflicts serves patients better than denying them the right to choose who will make health care decisions for them when they are no longer competent.

Equipoise is an essential condition to justify a clinical trial. The term, describes a state of uncertainty: the data suggest but do not prove a drug's safety and efficacy The only way to resolve this uncertainty is further study In many cases, a clinical trial seems to be the most efficient way to prove safety and efficacy Equipoise is therefore not an esoteric philosophic construct applied to research ethics. Rather, since it is vital for the justification of clinical trials, it (...) is part of how society regulates medical progress. Where there is equipoise, drug design and development proceeds according to Food and Drug Administration and Health and Human Services regulations. When that equipoise ends, a drug is either not approved or becomes standard care. (shrink)

This book examines the many ethical issues that are encountered in the Pediatric Intensive Care Unit. It supports pediatricians, nurses, residents, and other providers in their daily management of critically ill children with the dilemmas that arise. It begins by examining the evolution of pediatric critical care, and who is now impacted by this advancing medical technology. Subsequent chapters explore specific ethical concerns and controversies that are commonly encountered. These topics include how to conduct end-of-life discussions with families facing a (...) myriad of challenging choices. It goes on to explore the concept of futility, and what that does and does not mean in the pediatric ICU setting. Controversial subjects such as children as organ donors, particularly using donation after cardiac death, in addition to issues surrounding the declaration of brain death are covered. Additional chapters address resource allocation, and also analyze the use of long-term technology in chronically critically ill children. Chapters include case examples with guidance on how to work through similar difficulties and decision-making. While this book is specifically targeted for care providers at the ICU bedside, it is also of benefit to medical students, students in bioethics, practicing ethical consultants and families who are dealing with critically ill children. (shrink)

The essays in this volume are concerned with our everyday and developed scientific systems of explanation of human behavior in terms of beliefs, attitudes,...

Ever since Copernicus, scientists have continually adjusted their view of human nature, moving it further and further from its ancient position at the center of Creation. But in recent years, a startling new concept has evolved that places it more firmly than ever in a special position. Known as the Anthropic Cosmological Principle, this collection of ideas holds that the existence of intelligent observers determines the fundamental structure of the Universe. In its most radical version, the Anthropic Principle asserts that (...) "intelligent information-processing must come into existence in the Universe, and once it comes into existence, it will never die out." This wide-ranging and detailed book explores the many ramifications of the Anthropic Cosmological Principle, covering the whole spectrum of human inquiry from Aristotle to Z bosons. Bringing a unique combination of skills and knowledge to the subject, John D. Barrow and Frank J. Tipler--two of the world's leading cosmologists--cover the definition and nature of life, the search for extraterrestrial intelligence, and the interpretation of the quantum theory in relation to the existence of observers. The book will be of vital interest to philosophers, theologians, mathematicians, scientists, and historians, as well as to anyone concerned with the connection between the vastness of the universe of stars and galaxies and the existence of life within it on a small planet out in the suburbs of the Milky Way. (shrink)

On June 16, 1966, the New England Journal of Medicine published “Ethics and Clinical Research” by Henry K. Beecher. Beecher’s account of 22 examples of unethical contemporary clinical research shook up the medical profession and helped pave the way for U.S. federal regulation of research involving human subjects. Five decades later, in this issue of Perspectives in Biology and Medicine, we pay tribute to the lasting significance of this whistle-blowing article and to the remarkable contributions of Henry Beecher. Beecher was (...) a pioneer in anesthesiology as an academic discipline and in research on pain and the placebo effect. He was an early and influential champion of randomized placebo-controlled... (shrink)

In books such as The World Within the World and The Anthropic Cosmological Principle, astronomer John Barrow has emerged as a leading writer on our efforts to understand the universe. Timothy Ferris, writing in The Times Literary Supplement of London, described him as "a temperate and accomplished humanist, scientist, and philosopher of science--a man out to make a contribution, not a show." Now Barrow offers the general reader another fascinating look at modern physics, as he explores the quest for (...) a single, unifying theory that will unlock nature's secrets. Theories of Everything is more than a history of science, more than a popular report on recent research and discoveries. Barrow provides a reflective, intelligent commentary on what a true Theory of Everything would be--its ingredients, its limitations, and what it could tell us about the universe. Never before, he writes, have physicists been so confident and so eager in the hunt for this "cosmic Rosetta Stone," as he calls it: "a single all-embracing picture of all the laws of nature from which the inevitability of all things seen must follow with unimpeachable logic." He lays out eight essential ingredients for a Theory of Everything and then explores each in turn, tracing how our knowledge has developed and how scientific discovery relates to our changing philosophy and religious thought in each area. Some of these ingredients are obvious--the laws of nature must be explained, for example, as well as its organizing principles--but others may be surprising, such as broken symmetries and selection biases. A Theory of Everything must account for the fact that the universe is "messy and complicated," he tells us, and for the limitations imposed by the questions we ask and the information we can obtain. The key lies in the remarkable capacity of mathematics to express the fundamental workings of the physical world--a language that the human mind is uniquely equipped to understand and manipulate. Barrow examines what mathematics actually is and describes how it makes the universe intelligible and provides a path to the underlying coherence in nature--which has led, in fact, to arguments that the universe itself is a vast computer. Yet even the most complete theory, even the most comprehensive mathematical explanation, cannot account for the uncomputable varieties of human experience and thought. "No non-poetic account of reality," he writes, "can be complete." In a field where the authorities converse in equations and mathematical notations, John Barrow speaks with the voice of thoughtful and knowledgeable humanist. Written with eloquence and expertise, Theories of Everything establishes a new perspective on humanity's efforts to explain the universe. (shrink)

The inaugural title in the new, Open Access series BSPS Open, The Material Theory of Induction will initiate a new tradition in the analysis of inductive inference. The fundamental burden of a theory of inductive inference is to determine which are the good inductive inferences or relations of inductive support and why it is that they are so. The traditional approach is modeled on that taken in accounts of deductive inference. It seeks universally applicable schemas or rules or a single (...) formal device, such as the probability calculus. After millennia of halting efforts, none of these approaches has been unequivocally successful and debates between approaches persist. The Material Theory of Induction identifies the source of these enduring problems in the assumption taken at the outset: that inductive inference can be accommodated by a single formal account with universal applicability. Instead, it argues that that there is no single, universally applicable formal account. Rather, each domain has an inductive logic native to it. Which that is, and its extent, is determined by the facts prevailing in that domain. Paying close attention to how inductive inference is conducted in science and copiously illustrated with real-world examples, The Material Theory of Induction will initiate a new tradition in the analysis of inductive inference. (shrink)

Will we ever discover a single scientific theory that explains everything that has ever happened and everything that will happen - a key that unlocks the ...

An infinite lottery machine is used as a foil for testing the reach of inductive inference, since inferences concerning it require novel extensions of probability. Its use is defensible if there is some sense in which the lottery is physically possible, even if exotic physics is needed. I argue that exotic physics is needed and describe several proposals that fail and at least one that succeeds well enough.

Contrary to formal theories of induction, I argue that there are no universal inductive inference schemas. The inductive inferences of science are grounded in matters of fact that hold only in particular domains, so that all inductive inference is local. Some are so localized as to defy familiar characterization. Since inductive inference schemas are underwritten by facts, we can assess and control the inductive risk taken in an induction by investigating the warrant for its underwriting facts. In learning more facts, (...) we extend our inductive reach by supplying more localized inductive inference schemes. Since a material theory no longer separates the factual and schematic parts of an induction, it proves not to be vulnerable to Hume's problem of the justification of induction. (shrink)

There can be no mistaking the importance of Caputo's work." —Edith Wyschogrod "No one interested in Derrida, in Caputo, or in the larger question of postmodernism and religion can afford to ignore this pathbreaking study.

John Barrow is increasingly recognized as one of our most elegant and accomplished science writers, a brilliant commentator on cosmology, mathematics, and modern physics. Barrow now tackles the heady topic of impossibility, in perhaps his strongest book yet. Writing with grace and insight, Barrow argues convincingly that there are limits to human discovery, that there are things that are ultimately unknowable, undoable, or unreachable. He first examines the limits on scientific inquiry imposed by the deficiencies of the human mind: (...) our brain evolved to meet the demands of our immediate environment, Barrow notes, and much that lies outside this small circle may also lie outside our understanding. Barrow investigates practical impossibilities, such as those imposed by complexity, uncomputability, or the finiteness of time, space, and resources. Is the universe finite or infinite? Can information be transmitted faster than the speed of light? The book also examines the deeper theoretical restrictions on our ability to know, including Godel's theorem--which proved that there were things that could not be proved--and Arrow's Impossibility theorem about democratic voting systems. Finally, having explored the limits imposed on us from without, Barrow considers whether there are limits we should impose upon ourselves. For instance, if the secrets of the atom are to be found only by recreating extreme environments at great financial cost, just how much should we devote to that quest? Weaving together this intriguing tapestry, he illuminates some of the most profound questions of science, from the possibility of time travel to the very structure of the universe. (shrink)

Canadian Journal of Philosophy, 26, pp. 333-66. 1996.

Mathias Frisch has argued that the requirement that electromagnetic dispersion processes are causal adds empirical content not found in electrodynamic theory. I urge that this attempt to reconstitute a local principle of causality in physics fails. An independent principle is not needed to recover the results of dispersion theory. The use of ‘causality conditions’ proves to be the mere adding of causal labels to an already presumed fact. If instead one seeks a broader, independently formulated grounding for the conditions, that (...) grounding either fails or dissolves into vagueness and ambiguity, as has traditionally been the fate of candidate principles of causality. 1. Introduction2. Scattering in Classical Electrodynamics3. Sufficiency of the Physics4. Failure of the Principle of Causality Proposed 4.1. A sometimes principle4.2. The conditions of applicability are obscure4.3. Effects can come before their causes4.4. Vagueness of the relata and of the notion of causal process5. Conclusion. (shrink)

"Against Ethics is beautifully written, clever, learned, thought-provoking, and even inspiring." —Theological Studies "Writing in the form of his ideas, Caputo offers the reader a truly exquisite reading experience.... his iconic style mirrors a truly refreshing honesty that draws the reader in to play." —Quarterly Journal of Speech "Against Ethics is, in my judgment, one of the most important works on philosophical ethics that has been written in recent years.... Caputo speaks with a passion and a concern that are rare (...) in academic philosophy. His profound sense of humor deepens the passion of the viewpoints he develops." —Mark C. Taylor "Obligation happens!" declares Caputo in this brilliant and witty postmodern critique of ethics, framed as a contemporary restaging of Kierkegaard’s Fear and Trembling. (shrink)

While there is general agreement on the need to teach ethics in the MBA classroom, there are great difficulties in completely integrating such material within the confines of an actual MBA program. This paper attempts to address these difficulties by focusing on the teaching of such issues in one particular class — MBA macroeconomics.Ethical dilemmas often arise due to failures of the market place or due to inappropriate assumptions regarding the market model. Thus, specific suggestions are offered in regard to (...) the integration of ethical issues into the traditional macroeconomic curriculum. Suggestions are even offered as how to scale back the basic macro material so that the additional material may be accommodated. (shrink)