As we go to press, the threat of biological or chemical warfare in the Persian Gulf is no longer imminent. Yet the questions raised by the proposed use of “investigational drugs,” without informed consent, to protect U.S. troops remain. The article by Edmund G. Howe and Edward D. Martin presents the arguments that informed the Pentagon's thinking on the subject. It and the commentaries, by George J. Annas and Michael A. Grodin, and Robert J. Levine, explore, among others, (...) issues of informed consent, of distinguishing ‘research’ and ‘treatment,’ and of the nature and extent of the autonomy of military personnel.—B‐JC, HLN. (shrink)

Alzheimer’s disease is singularly tragic in that it may rob patients of much or all of their personal identity. Some persons fear this outcome so much that they talk of wanting to find the “sweet spot,” a time midway in the course of everincreasing dementia, during which they are able to foresee a possible loss of identity in sufficient time to end their life before they lose the capacity to choose to do so, and before further devastation occurs. This article (...) presents the belief of some experts that patients always retain a basic, core underlying awareness. Practical approaches that careproviders and caregivers can take to maximize patients’ quality of life are discussed. The possibility that patients and loved ones can find meaning in last months and years of life is emphasized. (shrink)

In this issue of The Journal of Clinical Ethics, Emily Bell and Eric Racine are guest editors of a special section focusing on the use of deep brain stimulation (DBS) to treat Parkinson’s disease. In “Deep Brain Stimulation, Ethics, and Society,” Bell and Racine report that DBS already has been used to treat more than 50,000 patients. The ethical issues raised in this special section are important not only in regard to Parkinson’s disease and DBS, but in many areas of (...) medicine.The articles discuss sound, state-of-the-art ethical approaches. This introduction to the issue presents approaches that are adjunctive and intended to increase careproviders’ options, that should increase careproviders’ ability to individualize the care that they provide to their patients. (shrink)

Lainie Friedman Ross suggests that clinicians increase our efforts to meet children’s most basic needs in several ways. These include prioritizing, to a greater extent, children’s present and future feelings; placing greater decisional weight on other family members’ needs; spotting earlier threats from surrogate decision makers so that we can better prevent these threatened harms; and finding ways to intervene earlier so that we can allow parental surrogate decision makers to remain in this role. I offer some practical ways in (...) which Ross’s ideas might be applied. (shrink)

Shared decision making (SDM) is the state of the art for clinicians’ communication with patients and surrogate decision makers. SDM involves give and take, in which all parties interact to maximize the autonomy of patients. In this article I summarize the core steps of SDM and explore ways to use it to benefit patients to the greatest extent. I review three articles included in this issue of The Journal of Clinical Ethics that highlight additional approaches we can use to help (...) patients and parents to see what may be in their own or their child’s best interest. I describe how these approaches can be used in most other medical fields. I explore ways to share information with patients that are outside the usual scope of SDM. Finally, I discuss how we might look, together with patients, at what all parties are feeling before we begin the process of SDM. (shrink)

In this introduction to this issue of The Journal of Clinical Ethics (JCE), I will discuss the legacy of our recently departed friend and colleague, Edmund D. Pellegrino, MD. In this light, I will discuss three articles in this issue of the journal that provide insight into the cultures of China, Mexico, and the U.S., and propose alternative approaches for careproviders in the U.S. to include in their practice as they work with patients and family members at the end (...) of life. (shrink)

One of the most important and difficult tasks in medicine is to determine when patients have the capacity to make decisions for themselves. This determination may determine a patient’s life or death. This article presents criteria and approaches now used to make this assessment and discusses how these approaches are presently applied in five common disorders that can serve as paradigms for approaches in other disorders. I propose that since there are new diagnoses and treatments, reconsidering our current practices is (...) warranted. The possibilities that clinicians can nudge patients to make better choices for themselves and, above all, that clinicians can maintain and maximize positive patient/careprovider relationships during and after these assessments, are emphasized. (shrink)

One of the most difficult decisions a clinician may face is when, if ever, to decline what a patient wants, based on the clinician’s own moral conscience. Regardless of what the clinician decides, the outcome may be deeply emotionally painful for both parties, and the pain may last. I will discuss this pain, how it occurs, and what we can do to try to reduce it before, during, and after a conflict arises. Approaches include explaining how we are like the (...) patient or doctor, that no one is perfect, and that what we do is not who we are. (shrink)

Patients’ and families’ greatest need is often to do what for them is most meaningful. This may be, for example, their religion, their family, or their doing good for others. This piece will explore ways in which care providers may help maximize these ends. Paradigms offered will include Jehovah’s Witness patients needing kidney transplants, a transgender adolescent wanting his sperm preserved, care providers’ deciding whether to disclose that a deceased organ donor had HIV, and care providers seeking to do good (...) for children profoundly impaired and adults who feel shame for just existing. (shrink)

The approaches used in mediation may help ethics consultants, especially in difficult cases. In this piece, I primarily discuss these techniques. I also discuss how clinicians may be of the most help to parents of infants with severe genetic conditions, to research participants, and to patients who may be at risk for Alzheimer’s disease and their surrogate decision makers.

Psychedelic treatments, particularly 3,4-methylenedioxymethamphetamine (MDMA)-assisted and psilocybin-assisted therapies, have recently seen renewed interest in their clinical potential to treat various mental health conditions. Clinical trials for both MDMA-assisted and psilocybin-assisted therapies have shown to be highly efficacious for post-traumatic stress disorder and major depression. Recent research trials for psychedelic-assisted therapies (PAT) have demonstrated that although they are resource-intensive, their effects are rapid-acting, durable and cost-effective. These results have generated enthusiasm among researchers seeking to investigate psychedelic therapies in active-duty service members (...) of the US military, particularly those with treatment refractory mental health conditions. At the same time, psychedelics remain in early stages of clinical investigation, have not yet achieved regulatory approval for general clinical use and may confer unique psychological and neurobiological effects that could raise novel ethical considerations when treating active-duty service members. Should psychedelics achieve regulatory approval, military relevant considerations may include issues of access to these treatments, appropriate procedures for informed consent, confidentiality standards, and possible unanticipated mental health risks and other psychological sequelae. A service member’s deployability, as well as their ability to return to full military duty following PAT, may also be of unique concern. The authors argue that MDMA-assisted therapy currently represents a promising treatment that should be more rapidly investigated as a clinical therapy for service members while still taking a measured approach that accounts for the many military-specific uncertainties that remain. (shrink)

In the early twentieth century, China was on the brink of change. Different ideologies - those of radicalism, conservatism, liberalism, and social democracy - were much debated in political and intellectual circles. Whereas previous works have analyzed these trends in isolation, Edmund S. K. Fung shows how they related to one another and how intellectuals in China engaged according to their cultural and political persuasions. The author argues that it is this interrelatedness and interplay between different schools of thought (...) that are central to the understanding of Chinese modernity, for many of the debates that began in the Republican era still resonate in China today. The book charts the development of these ideologies and explores the work and influence of the intellectuals who were associated with them. In its challenge to previous scholarship and the breadth of its approach, the book makes a major contribution to the study of Chinese political philosophy and intellectual history. (shrink)

Presents a collection of papers by economists theorizing on the roles of altruism and morality versus self-interest in the shaping of human behavior and institutions. Specifically, the authors examine why some persons behave in an altruistic way without any apparent reward, thus defying the economist's model of utility maximization. The chapters are accompanied by commentaries from representatives of other disciplines, including law and philosophy.

ABSTRACT There are, at present, at least two basic forms of market economy: one that tends to be open to innovative ideas; the other that tends to be more oriented to social services. The normative significance of these two “models” of market society—roughly speaking, the American and the Continental models—can best be appreciated by noticing that in the first model, entrepreneurship, and participation in the economy more generally, can be a major source of satisfaction for the entrepreneurs and employees, independently (...) of their financial compensation. In the second model, the economy is primarily a means to the end of the goods it produces. Although the second type may be as suited to producing goods as the first type, it has fallen short—for reasons that economists now understand—in generating employee engagement and the satisfactions of exploration and self‐realization. (shrink)

This book offers an excellent survey of various macroeconomic topics that feature prominently in the research agenda and have inspired both theoretical and policy debate. The book presents an authoritative and comprehensive summary and original critique of macroeconomic approaches by a scholar whose own contribution to the field is considerable.

Growing out of a conference on Expectations Formation and Economic Disequilibrium held in New York City in 1981, the papers in this volume provide a complex view of market processes in which individual rationality is no guarantee of convergence to the 'correct' model and the equilibrium coordination of agents' plans. They reject the 'optimality' argument for the rational expectations hypothesis, opening the door to other hypotheses of optimal expectations of agents in the decentralized market economy.

In this article I will discuss how clinicians might best treat adolescents who may die. I initially discuss these patients’ cognition, emotional tendencies, and sensitivity to interpersonal cues. I next discuss their parents’ feelings of loss and guilt and their clinicians’ risk of imposing their own moral views without knowing this. I then address the practical concerns of helping these patients gain or regain resilience and to identify strengths they have had in the past. I finally explore who, among staff, (...) might be best able to do this. I highlight as the main goal that patients, their parents, and ideally also their clinicians are able to come to agree on the best course the patients should take. (shrink)

Physicians who are impaired, engage in unprofessional behavior, or violate laws may be barred from further practice. Likewise, medical students may be dismissed from medical school for many infractions, large and small. The welfare of patients and the general public must be our first priority, but when we assess physicians and students who have erred, we should seek to respond as caringly and fairly as possible. This piece will explore how we may do this at all stages of the proceedings (...) physicians and students may encounter. This may include helping them to resume their medical careers if and when this would be sufficiently safe and beneficial for patients. (shrink)

In this special issue of The Journal of Clinical Ethics, different views on both the ethical desirability of women delivering in hospitals or at home with midwives are discussed. What careproviders, including midwives, should recommend to mothers in regard to the place of giving birth is considered. Emotional concerns likely to be of importance to mothers, fathers, midwives, and doctors are also presented. Finally, possible optimal approaches at the levels of both policy and the bedside are suggested.

Vogelstein cautions medical organizations against jumping into the fray of controversial issues, yet proffers the 2012 American Academy of Pediatrics' Task Force policy position on infant male circumcision as ‘an appropriate use of position-statements.’ Only a scratch below the surface of this policy statement uncovers the Task Force's failure to consider Vogelstein's many caveats. The Task Force supported the cultural practice by putting undeserved emphasis on questionable scientific data, while ignoring or underplaying the importance of valid contrary scientific data. Without (...) any effort to quantitatively assess the risk/benefit balance, the Task Force concluded the benefits of circumcision outweighed the risks, while acknowledging that the incidence of risks was unknown. This Task Force differed from other Academy policy-forming panels by ignoring the Academy's standard quality measures and by not appointing members with extensive research experience, extensive publications, or recognized expertise directly related to this topic. Despite nearly 100 publications available at the time addressing the substantial ethical issues associated with infant male circumcision, the Task Force chose to ignore the ethical controversy. They merely stated, with minimal justification, the opinion of one of the Task Force members that the practice of infant male circumcision is morally permissible. The release of the report has fostered an explosion of academic discussion on the ethics of infant male circumcision with a number of national medical organizations now decrying the practice as a human rights violation. (shrink)