While many have suggested that to withdraw medical interventions is ethically equivalent to withholding them, the moral complexity of actually withdrawing life supportive interventions from a patient cannot be ignored. Utilizing interplay between expository and narrative styles, and drawing upon our experiences with patients, families, nurses, and physicians when life supports have been withdrawn, we explore the changeable character of boundaries in end-of-life situations. We consider ways in which boundaries imply differences – for example, between cognition and performance – and (...) how the encounter with boundaries can generate altered meanings important for understanding decisions and actions in these contexts. We conclude that the reliance on mere roles to support the moral weight of withdrawing medical interventions is inadequate. Roles that lead us to such moments are exceeded by the responsibility encountered in such moments. And here, we suggest, is the momentous character of withdrawal: it presents the grave astonishment, the trembling awe, in the not-being-there of the other in death. (shrink)

This book represents a unique contribution to the field of clinical ethics consultation. What might seem at first glance to be an anthology, that is, a collection of independent essays, is actually more akin to a conversation, a shared engagement, a mutual undertaking. At the center of this conversation is a steadfastness, abiding and serious in its orientation – exemplified in these voices and contributions collected from colleagues – to explore, identify, and examine the actual conduct of individuals who engage (...) in ethics consultation practice. Although there is some helpful resemblance to an anthology, for example in the variety of ways these essays describe and depict a complex array of different standpoints regarding the practical and conceptual commitments in this growing field, more important to the Zadeh Project is the deliberate focus on explicating and probing the ways these commitments influence how a particular individual acting as an “ethics consultant” might understand and interpret the roles and prevalent expectations represented by those differing standpoints. In that light, and perhaps more urgently, this book is motivated by a mutual recognition that part and parcel with the responsibility of doing clinical ethics is an ongoing and clear need to describe and consider what clinical ethics consultants actually encounter when actively working with physicians, nurses, social workers, and other healthcare providers as well as with patients, families, and others who care about patients. As a contribution to that necessity of being accountable, this Project and the resulting book represent much more than merely collecting together the thoughts and perspectives of a group of colleagues from within a common field: this book is an attempt to display, to model through written text, a set of practices and what is at stake in these practices. (shrink)

Despite the periodic table having been discovered by chemists half a century before the discovery of electronic structure, modern designs are invariably based on physicists’ definition of periods. This table is a chemists’ table, reverting to the phenomenal periods that led to the table’s discovery. In doing so, the position of hydrogen is clarified.

Several inquires about healthcare over the past several decades have shown that the evolution of healthcare practices exhibit their own microcosm of local and political influences. Likewise, other studies have shown clearly the ways in which both external and internal institutional factors establish the sectors within which healthcare is delivered. Although restrictions have always been present in some form, it seems obvious that whatever the precise form of healthcare delivery that results from current changes in its organization, there are going (...) to be broader restrictions not only on the choices that providers will be able to make about individual patients' care and needs, but also regarding the character of their clinical judgments. Indeed, there are already reports of instances where physicians' contracts with managed care organizations forbid them to disclose the existence of services not covered by a plan. (shrink)

Bruno and Arora (2018) present a range of important ethical issues emerging from the development of procedures for uterine transplant (UT). They approach those issues by drawing on parallels to oth...

Despite increased attention to the question of how best to evaluate clinical ethics consultations and emphasis on external evaluation, there has been little sustained focus on how we, as clinicians, make sense of and learn from our own experiences in the midst of any one consultation. Questions of how we evaluate the request for, unfolding of, and conclusion of any specific ethics consultation are often overlooked, along with the underlying question of whether it is possible to give an accurate account (...) of clinical ethics consultants’ experience as experienced by ethics consultants. Before the challenge of submitting one’s accounts or case reports for review and evaluation from others, there is an underlying challenge of understanding and evaluating our own accounts. To highlight this crucial and deeply challenging dimension of actual clinical ethics practice, we present an account of a complex consultation, explicitly constructed to engage the reader in the unfolding experience of the consultant by emphasizing the multiple perspectives unfolding within the consultant’s experience. Written in script format, the three perspectives presented—prototypical clinically descriptive account; didactically reflective and self-evidentiary account often seen in journal presentations; highly self-critical reflective account emphasizing uncertainties inherent to clinical ethics practice—reflect different manners for responding to the ways actual clinical involvement in ethics consultation practice accentuates and refocuses the question of how to understand and evaluate our own work, as well as that of our colleagues. (shrink)

Baylis, Tomlinson, and Hoffmaster each raise a number of critiques in response to Bliton's manuscript. In response, we focus on three themes we believe run through each of their critiques. The first is the ambiguity between the role of ethics consultation within an institution and the role of the actual ethics consultant in a particular situation, as well as the resulting confusion when these roles are conflated. We explore this theme by revisiting the question of What's going on? in clinical (...) ethics consultations. Moving from those issues associated with the role of the ethics consultant to those associated with the role of inquiry within the practice of ethics consultation, we then take up the serious challenge that Bliton seems shackled by the assumptions and institutional dispositions embedded in the medical culture in which he is working. This reveals the second theme, namely that there is a risk of co-optation when acting in a role that derives its legitimacy from institutional sources. Finally, we focus on an even more problematic implication stemming from the first two, namely that the focus on institutional power as the crucial factor for determining ethical significance has the effect of distorting, and perhaps obscuring, other forms of relational, interpersonal, and moral meaning. (shrink)

Furthermore, adults with decision-making capacity, including pregnant women, can currently accept interventions with moderate net risks for themselves in other settings (e.g., open f...

Clinical ethics literature typically presents ethics consultations as having clear beginnings and clear ends. Experience in actual clinical ethics practice, however, reflects a different characterization, particularly when the moral experiences of ethics consultants are included in the discussion. In response, this article emphasizes listening and learning about moral experience as core activities associated with clinical ethics consultation. This focus reveals that responsibility in actual clinical ethics practice is generated within the moral scope of an ethics consultant's activities as she or (...) he encounters the unique and specific features that emerge from interactions with a specific patient, or family, or practitioner within a given situation and over time. A long-form narrative about an ethics consultant's interactions is interwoven with a more didactic discussion to highlight the theme of responsibility and to probe questions that arise regarding follow-up within the practice of clinical ethics consultation. (shrink)

This Open Access book about the Zadeh Project demonstrates and explores a core question in clinical ethics: how can ethics consultants be accountable in the face of a robust plurality of ethical standpoints, especially those that underwrite practices and methods for doing ethics consultation as well as those viewpoints and values encountered in daily clinical ethics practice? Underscoring this question is the recognition that the field of clinical ethics consultation has arrived at a crucial point in its maturation. Many efforts (...) are underway to more formally “professionalize” the field, with most aimed toward stabilizing a specific set of institutional considerations. Stretched between these institutional and practical initiatives resides a crucial set of of ethical considerations, chief among them the meaning and scope of responsibility for clinical ethics consultants. Developed around a long-form case scenario, the Zadeh Project provides a multi-layered series of “peer-reviews”: critique of the actions of the case scenario’s ethics consultant; reflection on clinical ethics method; examination of the many ways that commitments to method and practice can, and do, intersect, overlap, and alter one another. The design and format of this book thus models a key element for clinical ethics practice: the need and ability to provide careful and thoughtful explanation of core moral considerations that emerge among diverse standpoints. Specifically designed for those studying to become and those who are ethics consultants, this book, with its innovative and multi-layered approach, allows readers to share a peer-review-like experience that shows accountability to be what it is, an ethical, not merely procedural or administrative, undertaking. (shrink)

(2001). Activities, Not Rules: The Need for Responsive Practice (On the Way Toward Responsibility) The American Journal of Bioethics: Vol. 1, No. 4, pp. 52-54.

This is a periodic table explicitly for chemists rather than physicists. It is derived from Newlands’ columns. It solves many problems such as the positions of hydrogen, helium, beryllium, zinc and the lanthanoids but all within a succinct format.

BackgroundCentral to ethically justified clinical trial design is the need for an informed consent process responsive to how potential subjects actually comprehend study participation, especially study goals, risks, and potential benefits. This will be particularly challenging when studying deep brain stimulation and whether it impedes symptom progression in Parkinson’s disease, since potential subjects will be Parkinson’s patients for whom deep brain stimulation will likely have therapeutic value in the future as their disease progresses.MethodAs part of an expanded informed consent process (...) for a pilot Phase I study of deep brain stimulation in early stage Parkinson’s disease, an ethics questionnaire composed of 13 open-ended questions was distributed to potential subjects. The questionnaire was designed to guide potential subjects in thinking about their potential participation.ResultsWhile the purpose of the study (safety and tolerability) was extensively presented during the informed consent process, in returned responses 70 percent focused on effectiveness and 91 percent included personal benefit as potential benefit from enrolling. However, 91 percent also indicated helping other Parkinson’s patients as motivation when considering whether or not to enroll.ConclusionsThis combination of responses highlights two issues to which investigators need to pay close attention in future trial designs: (1) how, and in what ways, informed consent processes reinforce potential subjects’ preconceived understandings of benefit, and (2) that potential subjects see themselves as part of a community of Parkinson’s sufferers with responsibilities extending beyond self-interest. More importantly, it invites speculation that a different paradigm for informed consent may be needed. (shrink)

The past few years have seen greater attention directed toward important procedural elements associated with ethics consultation. Examples include considerations about how best to document consulta...

The history of economic thought has always attracted some of the brightest minds in the discipline. These chroniclers of development have helped form our current views, and it is no surprise that many among them have been at the forefront of new movements in the history of ideas. This notable collection summarizes the work of these key historians of economics and attempts to quantify their impact. Some of the writers covered, such as Friedrich Hayek and Joan Robinson, are already assured (...) of their place among the greatest economists of the twentieth century, but the collection also stresses the influence of those still active in shaping our perceptions - including Mark Blaug, Samuel Hollander and Donald Winch. Written by an impressive roster of contributors, many of whom are themselves well-known in the history of economic thought, this key book features writings from John Creedy, Roger Blackhouse and Neil De Marchi, as well as the editors of the collection as a whole, Warren J. Samuels and Steven Medema. (shrink)

We revisit questions about the scientific status of the pilot Phase I study of deep brain stimulation (DBS) in early stage Parkinson’s disease (PD), as well as questions about enrolling and retaining subjects. In doing so, we highlight a compelling ethical dimension reported to us by patients thinking about becoming research subjects in that study.

This chapter critically reflects on the critiques, reviews, and many proposals presented in Parts Two, Three, and Four, and provides a summary conclusion for the entire Zadeh Project. Obvious differences between experience and reporting on experience are highlighted, with particular attention to the ways such differences are detailed by the Zadeh Scenario and in our colleagues’ responses to it. In addition, we discuss a key challenge associated with clinical ethics practice and the peer review of such practice: identifying what actually (...) matters for those engaged in these kinds of activities. In each case, we argue, the work of discovering what matters to the individuals actually involved cannot be overlooked. Furthermore, that work may even be the primary ingredient to responsible conduct for both consultation and peer review. Building on this idea that responding responsibly to that which is actually encountered in clinical practice serves as a primary activity of, and thus grounds responsibility in, clinical ethics practice, we then argue that ethical analysis of Finder’s activities in the Zadeh Scenario, and for clinical ethics peer review more generally, has at least three layers: that which addresses the immediate interactions between an ethics consultant and those whom the consultant engages; that which addresses the ethics consultant’s own sense of self-responsibility; that which addresses peer reviewers’ own frames for evaluating another’s clinical ethics practice. We conclude that the Zadeh Project exemplifies what is at stake in ethics consultation and peer review. Taken as a whole, then, the Zadeh Project reveals how peer review, in acknowledgement of the responsibility to create a context for peer education, rests upon a commitment to model – and demand critical engagement with – what is held to be most worthwhile for clinical ethics practice and the field of clinical ethics consultation as a whole. (shrink)

In “Bayesianism, Infinite Decisions, and Binding”, Arntzenius et al. (Mind 113:251–283, 2004 ) present cases in which agents who cannot bind themselves are driven by standard decision theory to choose sequences of actions with disastrous consequences. They defend standard decision theory by arguing that if a decision rule leads agents to disaster only when they cannot bind themselves, this should not be taken to be a mark against the decision rule. I show that this claim has surprising implications for (...) a number of other debates in decision theory. I then assess the plausibility of this claim, and suggest that it should be rejected. (shrink)

About one third of patients with epilepsy have seizures refractory to the medical treatment. Electrical stimulation mapping is the gold standard for the identification of “eloquent” areas prior to resection of epileptogenic tissue. However, it is time-consuming and may cause undesired side effects. Broadband gamma activity recorded with extraoperative electrocorticography during cognitive tasks may be an alternative to ESM but until now has not proven of definitive clinical value. Considering their role in cognition, the alpha and beta bands could further (...) improve the identification of eloquent cortex. We compared gamma, alpha and beta activity, and their combinations for the identification of eloquent cortical areas defined by ESM. Ten patients with intractable focal epilepsy participated in a delayed-match-to-sample task, where syllable sounds were compared to visually presented letters. We used a generalized linear model approach to find the optimal weighting of each band for predicting ESM-defined categories and estimated the diagnostic ability by calculating the area under the receiver operating characteristic curve. Gamma activity increased more in eloquent than in non-eloquent areas, whereas alpha and beta power decreased more in eloquent areas. Diagnostic ability of each band was close to 0.7 for all bands but depended on multiple factors including the time period of the cognitive task, the location of the electrodes and the patient’s degree of attention to the stimulus. We show that diagnostic ability can be increased by 3–5% by combining gamma and alpha and by 7.5–11% when gamma and beta were combined. We then show how ECoG power modulation from cognitive testing can be used to map the probability of eloquence in individual patients and how this probability map can be used in clinical settings to optimize ESM planning. We conclude that the combination of gamma and beta power modulation during cognitive testing can contribute to the identification of eloquent areas prior to ESM in patients with refractory focal epilepsy. (shrink)

The title of this work evokes suspicion: how can Soll aim at one "part"--metaphysics--of a philosophy such as Hegel's? How would one go about introducing only Hegel's metaphysics? One might, with some validity, go about discussing Hegel's metaphysics ; but how would one, assuming his reader's general unfamiliarity with Hegel, introduce his "metaphysics," and that alone? Alas, one's worst fears are soon realized: the opening sentence reads, "Hegel's method is best approached by asking what he was trying to accomplish with (...) it." Bifurcation. The operant supposition which guides the work is that Hegel "has" a method with which he attempts to "do" various things. This view is utterly un-Hegelian, as even a cursory reading of the introduction to the Logic, to cite only one source, illustrates. No guide to Hegel is going to be useful that clouds this fundamental point. The whole texture of Hegel's integrated and integrative system is never rescued. Soll's presentation approaches, and treats of, Hegel from the standpoint of pedestrian philosophizing, leaning heavily on the collected tradition to make distinctions in a glib and altogether external way. From his starting point, Soll proceeds, drawing on a handful of secondary sources, to deliver an extended series of facile, shotgun commentaries: but if one already has the ability to adjudge which of them find their mark, he does not need the book in the first place. The primary problem a book of this kind faces is the perhaps insuperable difficulty of creating a suitable "introduction" to Hegel's thought. And to be fair, one might say that most of the shortcomings of Soll's book are attributable to this problem. Where does one start, if not where Hegel did; and whither does one proceed, except in the direction Hegel did? One should either attempt to go that path, or elect not to go at all. It is too easy to lose one's way in so dense a forest.--R. J. G. (shrink)

We give anecdotal accounts from our own experience of scientific theories which have been generally accepted as the ruling opinion long after sufficient evidence has been collected for their disproof. This has led us to the opinion that the normal scientific process, of working hypothesis followed by experimental test aimed at disproof, is being replaced by the ruling opinion followed by experiment aimed at confirmation. The apparently widespread adoption of this procedure may be postulated to arise in part from the (...) need for workers entering a new field of study to obtain grants and to get their results published. (shrink)

A study was undertaken of the views of users of two genitourinary medicine (GUM) clinics in England on unlinked anonymous testing (UAT) for HIV. The UAT programme measures the prevalence of HIV in the population, including undiagnosed prevalence, by testing residual blood (from samples taken for clinical purposes) which is anonymised and irreversibly unlinked from the source. 424 clinic users completed an anonymous questionnaire about their knowledge of, and attitudes towards, UAT. Only 1/7 (14%) were aware that blood left over (...) from clinical testing may be tested anonymously for HIV. A large majority (89%) said they would agree to their blood being tested, although 74% wanted the opportunity to consent. These findings indicate broad support for UAT of blood in a group of patients whose samples are included in the HIV surveillance programme. The findings suggest the need for greater attention to be given to the provision of information and, if replicated in a larger survey, may justify a reappraisal of UK policy on UAT. (shrink)

This paper proposes a theory of institutional pluralism to deal with the question whether and to what extent limits should be placed on the market. It reconceives the pluralist position as it was presented by Michael Walzer and others in several respects. First, it argues that the options on the institutional menu should not be principles of distribution but rather economic mechanisms or ‘modes of provision’. This marks a shift from a distributive to a provisional logic. Second, it argues that (...) we should drop the assumption that any good should only be placed in one sphere, i.e. distributed according to one distributive principle. This marks a shift to ‘complex pluralism’: for at least some goods it is appropriate that they are provided through the market and through one or more non-market alternatives simultaneously. Finally, it argues that the often used conventionalist justification should be traded for a capability approach to the moral evaluation of markets and non-market alternatives. Any institutional option on our menu has value to the extent that it enhances the morally relevant capabilities of the producers and/or consumers of the good that is to be provided. This approach will be illustrated with two examples of goods for which it yields complex pluralist conclusions: the provision of care and the provision of media content. (shrink)

One might legitimately wonder why, if Christopher Middleton, in his Selected Letters of Friedrich Nietzsche, published translations of approximately ten per cent of the total available Nietzschean correspondence, the current translators have elected to repeat roughly sixty per cent of these in the present work. One might extend this misgiving to a further questioning as to why the co-translators have chosen to include "representative" passages of these letters when Middleton translates them in their entirety. Stripping sentences from paragraphs and paragraphs (...) from pages is surely no way to present a meaningful portrait of their author. If this were done with the intention of presenting a simple, non-contradictory view of Nietzsche's development or personality, it would be understandable, if unjustifiable. But it is not. If the present translations were markedly fresh and lucid in contrast to previously bungled efforts, it would be understandable. But they are not. If Middleton's content footnotes were occasionally lifted from Schlechta, they made up in substance what they lacked in originality. The few footnotes scattered here might be copiously expanded to explain what is going on--going on in the letter, going on in Nietzsche's development, going on in the book. As it is, all one can do is ask: Why bother?--R. J. G. (shrink)

(2011). Mindfulness: diverse perspectives on its meaning, origins, and multiple applications at the intersection of science and dharma. Contemporary Buddhism: Vol. 12, Mindfulness: diverse perspectives on its meaning, origins, and multiple applications at the intersection of science and dharma, pp. 1-18. doi: 10.1080/14639947.2011.564811.

This study examines the family environments and hormone profiles of 316 individuals aged 2 months-58 years residing in a rural village on the east coast of Dominica, a former British colony in the West Indies. Fieldwork was conducted over an eight-year period (1988–1995). Research methods and techniques include radioimmunoassay of cortisol and testosterone from saliva samples (N=22,340), residence histories, behavioral observations of family interactions, extensive ethnographic interview and participant observation, psychological questionnaires, and medical examinations.Analyses of data indicate complex, sex-specific effects (...) of family environment on endocrine function. Male endocrine profiles exhibit greater sensitivity to presence of father than do female endocrine profiles. Father-absent males tend to have (a) low cortisol levels during infancy, (b) high or abnormal cortisol profiles during childhood and adolescence, and (c) high cortisol and low testosterone levels during adulthood compared with those of males raised with a resident father. These results indicate that early family environment has significant effects on endocrine response throughout male life histories. (shrink)

Clinical ethics consultation is largely outside the scope of regulation and oversight, despite its importance. For decades, the bioethics community has been unable to reach a consensus on whether there should be accountability in this work, as there is for other clinical activities that influence the care of patients. The American Society for Bioethics and Humanities, the primary society of bioethicists and scholars in the medical humanities and the organizational home for individuals who perform CEC in the United States, has (...) initiated a two‐step quality attestation process as a means to assess clinical ethics consultants and help identify individuals who are qualified to perform this role. This article describes the process. (shrink)