Purpose Although surrogate decision-making is prevalent in intensive care units and concerns with decision quality are well documented, little is known about how clinicians help family members understand the surrogate role. We investigated whether and how clinicians provide normative guidance to families regarding how to function as a surrogate. Subjects and methods We audiorecorded and transcribed 73 ICU family conferences in which clinicians anticipated discussing goals of care for incapacitated patients at high risk of death. We developed and applied a (...) coding framework to identify normative statements by clinicians regarding what considerations should guide surrogates’ decisions, including whether clinicians explained one or more of Buchanan and Brock’s three standard principles of SDM to family members. Results Clinicians made at least one statement about how to perform the surrogate role in 24 conferences ). We observed three general types of normative guidance provided to surrogates, with some conferences containing more than one type of guidance: counselling about one or more standard principles of SDM ; counselling surrogates to make decisions centred on the patient as a person, without specifying how to accomplish that ; and counselling surrogates to make decisions based on the family’s values. Conclusions Clinicians did not provide normative guidance about the surrogate role in two-thirds of family conferences for incapacitated patients at high risk for death. When they did, clinicians’ guidance was often incomplete and sometimes conflicted with standard principles of SDM. Future work is needed to understand whether providing explicit guidance on how to perform the surrogate role improves decision-making or mitigates surrogates’ psychological distress. (shrink)

Purpose Although surrogate decision-making is prevalent in intensive care units and concerns with decision quality are well documented, little is known about how clinicians help family members understand the surrogate role. We investigated whether and how clinicians provide normative guidance to families regarding how to function as a surrogate. Subjects and methods We audiorecorded and transcribed 73 ICU family conferences in which clinicians anticipated discussing goals of care for incapacitated patients at high risk of death. We developed and applied a (...) coding framework to identify normative statements by clinicians regarding what considerations should guide surrogates’ decisions, including whether clinicians explained one or more of Buchanan and Brock’s three standard principles of SDM to family members. Results Clinicians made at least one statement about how to perform the surrogate role in 24 conferences ). We observed three general types of normative guidance provided to surrogates, with some conferences containing more than one type of guidance: counselling about one or more standard principles of SDM ; counselling surrogates to make decisions centred on the patient as a person, without specifying how to accomplish that ; and counselling surrogates to make decisions based on the family’s values. Conclusions Clinicians did not provide normative guidance about the surrogate role in two-thirds of family conferences for incapacitated patients at high risk for death. When they did, clinicians’ guidance was often incomplete and sometimes conflicted with standard principles of SDM. Future work is needed to understand whether providing explicit guidance on how to perform the surrogate role improves decision-making or mitigates surrogates’ psychological distress. (shrink)

This paper considers the view that medicine is both “science” and “art.” It is argued that on this view certain clinical knowledge – of patients’ histories, values, and preferences, and how to integrate them in decision-making – cannot be scientific knowledge. However, by drawing on recent work in philosophy of science it is argued that progress in gaining such knowledge has been achieved by the accumulation of what should be understood as “scientific” knowledge. I claim there are varying degrees of (...) objectivity pertaining to various aspects of clinical medicine. Hence, what is often understood as constituting the “art” of medicine is amenable to objective methods of inquiry, and so, may be understood as “science”. As a result, I conclude that rather than endorse the popular philosophical distinction between the art and science of medicine, in the future a unified, multifaceted epistemology of medicine should be developed to replace it. (shrink)

Three common ethical principles for establishing the limits of parental authority in pediatric treatment decision making are the harm principle, the principle of best interest, and the threshold view. This paper consider how these principles apply to a case of a premature neonate with multiple significant comorbidities whose mother wanted all possible treatments, and whose health care providers wondered whether it would be ethically permissible to allow him to die comfortably despite her wishes. Whether and how these principles help to (...) understand what was morally right for the child is questioned. The paper concludes that the principles were of some value in understanding the moral geography of the case, but that the case reveals common bioethical principles for medical decision making are problematically value-laden because they are inconsistent with the widespread moral value of medical vitalism. (shrink)

No abstract available. First paragraph: In this issue’s target article, Stier and Schoene-Siefert purport to ‘depotentialize’ the argument from potentiality based on their claim that any human cell may be “converted” into a morally significant entity, and consequently, the argument from potentiality finally succumbs to a reductio ad absurdum. I aim to convey two reasons for skepticism about the innocuousness of the notion of cell convertibility, and hence, the cogency of their argument.

This paper explores how current United States policies for funding nonreproductive cloning are justified and argues against that justification. I show that a common conceptual framework underlies the national prohibition on the use of public funds for cloning research, which I call the simple argument. This argument rests on two premises: that research harming human embryos is unethical and that embryos produced via fertilization are identical to those produced via cloning. In response to the simple argument, I challenge the latter (...) premise. I demonstrate there are important ontological differences between human embryos (produced via fertilization) and clone embryos (produced via cloning). After considering the implications my argument has for the morality of publicly funding cloning for potential therapeutic purposes and potential responses to my position, I conclude that such funding is not only ethically permissible, but also humane national policy. (shrink)

Philosophers of science deploy mathematical models to describe epistemic communities, or groups of people creating and sharing knowledge for individual and collective purposes. These models capture...

This paper explores how current United States policies for funding nonreproductive cloning are justified and argues against that justification. I show that a common conceptual framework underlies the national prohibition on the use of public funds for cloning research, which I call the simple argument. This argument rests on two premises: that research harming human embryos is unethical and that embryos produced via fertilization are identical to those produced via cloning. In response to the simple argument, I challenge the latter (...) premise. I demonstrate there are important ontological differences between human embryos (produced via fertilization) and clone embryos (produced via cloning). After considering the implications my argument has for the morality of publicly funding cloning for potential therapeutic purposes and potential responses to my position, I conclude that such funding is not only ethically permissible, but also humane national policy. (shrink)

This paper proposes a Rawlsian conception of moral justification as a social activity. Through a close reading, Rawls’ view of ethical justification is shown to be significantly more dialogical and deliberative than is commonly appreciated. The result is a view that emphasizes the social nature of ethical justification and identifies information sharing between persons as the crux of justification in metaethics, in contrast to normative ethics. I call it Rawlsian reflective equilibrium to distinguish it from other varieties.

Ellen Fox and collaborators have produced the most detailed description of healthcare ethics practices in the United States available. Some findings are shocking for anyone committed to promoting q...

Although ethics is an essential component of undergraduate medical education, research suggests current medical ethics curricula face considerable challenges in improving students’ ethical reasoning. This paper discusses these challenges and introduces a promising new mode of graduate and professional ethics instruction for overcoming them. We begin by describing common ethics curricula, focusing in particular on established problems with current approaches. Next, we describe a novel method of ethics education and assessment for medical students that we have devised, the Medical Ethics (...) Bowl. Finally, we suggest pedagogical advantages to MEBs when compared to other ethics curricula. (shrink)

For over three decades, clinical ethicists in the United States have recorded their consulting activities to supplement documentation in the medical record, often using locally developed instrument...

BackgroundNo standard method exists to assess how many consults a healthcare ethics consultation (HCEC) service should perform. To address this, we developed a method to estimate the volume of HCEC services based on a mixed-methods approach that included a systematic review and survey data on the volume of consult services requested.MethodsOur investigation included a systematic review of studies that reported the volume of HCEC services that were requested from 2000 to 2017, institutional surveys, and statistical analyses that estimated the volume (...) of HCEC services that were adjusted to the size of the hospitals in the survey and to population acuity.ResultsWe contacted the authors of 19 studies that met our inclusion criteria; 17 authors responded to the institutional survey and five provided annualized data points. We found that standard methods of reporting the volume of HCEC services led to inaccuracies in estimating the growth of HCEC services over time. To rectify this, we proposed two means to estimate volume based on either the service goals of HCEC services or hospital size and acuity.DiscussionThe statistical limitations of our study highlight the need to standardize the sharing and reporting of data in clinical ethics. Future work should further standardize methods of HCEC quality assessment using measures similar to those we describe. (shrink)

Scholars and professional organizations in bioethics describe various approaches to “quality assessment” in clinical ethics. Although much of this work represents significant contributions to the literature, it is not clear that there is a robust and shared understanding of what constitutes “quality” in clinical ethics, what activities should be measured when tracking clinical ethics work, and what metrics should be used when measuring those activities. Further, even the most robust quality assessment efforts to date are idiosyncratic, in that they represent (...) evaluation of single activities or domains of clinical ethics activities, or a range of activities at a single hospital or healthcare system. Countering this trend, in this article we propose a framework for moving beyond our current ways of understanding clinical ethics quality, toward comprehensive quality assessment. We first describe a way to conceptualize quality assessment as a process of measuring disparate, isolated work activities; then, we describe quality assessment in terms of tracking interconnected work activities holistically, across different levels of assessment. We conclude by inviting future efforts in quality improvement to adopt a comprehensive approach to quality assessment into their improvement practices, and offer recommendations for how the field might move in this direction. (shrink)

With the increasing professionalization of clinical ethics, some hospitals and health systems utilize both ethics committees and professional clinical ethicists to address their ethics needs. Drawing upon historical critiques of ethics committees and their own experiences, the authors argue that, in ethics programs with one or more professional clinical ethicists, ethics committees should be dissolved when they fail to meet minimum standards of effectiveness. The authors outline several criteria for assessing effectiveness, describe the benefits of a model that places primary (...) responsibility for ethics work with professional clinical ethicists—the PCE-primary model, and offer suggestions for alternative ethics program structures that empower healthcare professionals to contribute to ethics work in ways more tailored to their strengths and skills while minimizing the shortcomings of ethics committees. (shrink)

At the 2022 Clinical Ethics Unconference, the authors perceived a significant lack of racial and ethnic diversity, which was consistent with their experiences in other clinical ethics settings. As a result, they convened a working group to address the pervasive lack of diversity present in the field of clinical ethics and to propose strategies to increase the representation of people from racial and ethnic minority populations. This article identifies the harms associated with the lack of diversity in the healthcare setting (...) and translates these to the field of clinical ethics. The article then proposes a framework that may be used to help diversify the field of clinical ethics. Specifically, the authors identify existing barriers to appropriate diversity, actionable steps to increase diversity, and tools the field can utilize to systematically assess its progress with respect to achieving diversity. (shrink)

Harrowing stories reported in the media describe Covid‐19 ravaging through families. This essay reports professional experiences of this phenomenon, family clustering, as encountered during the pandemic's spread across Southern California. We identify three ethical challenges following from it: Family clustering impedes shared decision‐making by reducing available surrogate decision‐makers for incapacitated patients, increases the emotional burdens of surrogate decision‐makers, and exacerbates health disparities for and the suffering of people of color at increased likelihood of experiencing family clustering. We propose that, in (...) response to these challenges, efforts in advance care planning be expanded, emotional support offered to surrogates and family members be increased, more robust state guidance be issued on ethical decision‐making for unrepresented patients, ethics consultation be increased in the setting of conflict following from family clustering dynamics, and health care professionals pay more attention to systemic and personal racial biases and inequities that affect patient care and the surrogate experience. (shrink)

The concepts, health and disease, have received considerable attention in philosophy of medicine. The first goal of this paper is to demonstrate that three prominent analyses of health and disease can be synthesized if one assumes that medicine is both theoretical and practical, and, therefore, value-laden. The second goal of this paper is to give an account of one route by which evaluative and factual claims come together in medical knowledge, during medical conversations between clinicians and patients. Accomplishing these two (...) goals together yields an epistemology of medicine that moves past debates about health and disease. On this view the conceptual foundations of medicine rest on subjective and objective claims about health states and their evaluations. By making subjective and objective claims, patients and clinicians negotiate whether patients’ health states are sufficiently dysfunctional to warrant medical intervention, leading to the formation of complementary illness narratives, which are anchored to different degrees in personal experience and medical theory. On this view, health and disease are supplanted as the conceptual foundations of medicine. Rather, medicine is better understood in terms of two basic aims: The first aim of medicine is to fully understand patients in scientific and personal terms; the second aim is to intervene upon patients’ states of illness in ways that are consistent with full understanding. (shrink)

Recent work on the semantic view of scientific theories is highly critical of the position. This paper identifies two common criticisms of the view, describes two popular alternatives for responding to them, and argues those responses do not suffice. Subsequently, it argues that retuning to Patrick Suppes’ interpretation of the position provides the conceptual resources for rehabilitating the semantic view.

Responding to research indicating unsettling results with regard to the ability of University students to recognize and reflect on questions of morality, this paper aims to discuss these issues and to introduce a promising mode of ethics instruction for overcoming such challenges. The Curricular Ethics Bowl (CEB) is a method of ethics education and assessment for a wide range of students and is a descendent of the Medical Ethics Bowl (MEB) (Merrick et al., “Introducing the Medical Ethics Bowl”). We seek (...) in this article to show the similarities of CEB to MEB and to distinguish this model from the Intercollegiate Ethics Bowl (ICEB) sponsored by the Association for Professional and Practical Ethics (Landenson 2001). The CEB institutionalizes this mode of ethics education at the program, rather than at the individual course level, and shows advantages over other ethics curricula. (shrink)

Responding to research indicating unsettling results with regard to the ability of University students to recognize and reflect on questions of morality, this paper aims to discuss these issues and to introduce a promising mode of ethics instruction for overcoming such challenges. The Curricular Ethics Bowl (CEB) is a method of ethics education and assessment for a wide range of students and is a descendent of the Medical Ethics Bowl (MEB) (Merrick et al., “Introducing the Medical Ethics Bowl”). We seek (...) in this article to show the similarities of CEB to MEB and to distinguish this model from the Intercollegiate Ethics Bowl (ICEB) sponsored by the Association for Professional and Practical Ethics (Landenson 2001). The CEB institutionalizes this mode of ethics education at the program, rather than at the individual course level, and shows advantages over other ethics curricula. (shrink)

God and the Philosophers offers a series of highly personal, thoughtful essays by traditionally religious philosophers, such as William P. Alston, William J. Wainsright, and Marilyn McCord Adams, revealing the power of belief in their intellectually rigorous lives and work.

The Cognitive Reflection Test (CRT) is a measure of analytical reasoning that cues an intuitive but incorrect response that must be rejected for successful performance to be attained. The CRT yields two types of errors: Intuitive errors, which are attributed to Type 1 processes; and non-intuitive errors, which result from poor numeracy skills or deficient reasoning. Past research shows that participants who commit the highest numbers of errors on the CRT overestimate their performance the most, whereas those with the lowest (...) error-rates tend to slightly underestimate. This is an example of the Dunning-Kruger Effect (DKE). The present study examined how intuitive vs. non-intuitive errors contribute to overestimation in the CRT at different levels of performance. Female undergraduate students completed a seven-item CRT test and subsequently estimated their raw score. They also filled out the Faith in Intuition (FI) questionnaire, which is a dispositional measure of intuitive thinking. Data was separated into quartiles based on level of performance on the CRT. The results demonstrated the DKE. Additionally, intuitive and non-intuitive errors predicted miscalibration among low, but not high performers. However, intuitive errors were a stronger predictor of miscalibration. Finally, FI was positively correlated with CRT self-estimates and miscalibration, indicating that participants who perceived themselves to be more intuitive were worse at estimating their score. These results taken together suggest that participants who perform poorly in the CRT and also those who score higher in intuitive thinking disposition are more susceptible to the influences of heuristic-based cues, such as answer fluency, when judging their performance. (shrink)

Here we evaluate our current understanding of the function of the nervous system in Hydra, a non‐bilaterian animal which is among the first metazoans that contain neurons. We highlight growing evidence that the nervous system, with its rich repertoire of neuropeptides, is involved in controlling resident beneficial microbes. We also review observations that indicate that microbes affect the animal's behavior by directly interfering with neuronal receptors. These findings provide new insight into the original role of the nervous system, and suggest (...) that it emerged to orchestrate multiple functions including host‐microbiome interactions. The excitement of future research in the Hydra model now relies on uncovering the common rules and principles that govern the interaction between neurons and microbes and the extent to which such laws might apply to other and more complex organisms. (shrink)

In recent years, there has been a striking resurgence of interest in the traditional Judeo-Christian concept of God. This anthology contains a representative sample of some of the best contemporary philosophical work on this central religious idea, covering such topics as the existence of God, the physical nature of God, and the "divine attributes"--goodness, omnipotence, omniscience, eternity, immutability, and simplicity.

Thomas V. Morris introduces philosophical theology, examining God's goodness, power and knowledge; God's relationship to creation and time; and God's Incarnation and Trinity. A Contours of Christian Philosophy book. 180 pages, paper.

There are at least a few plausible grounds for our use of the term Beta in our title, notwithstanding that there is a key departure, in our framework, from classical Beta Existential Graphs. The situation, in brief, is as follows.The reader accustomed to Peirce’s graphical development of quantificational logic may, if desired, continue to think of formulas being written on a “sheet of assertion.” We retain the “cut” notation for negation and continue to represent conjunction simply by juxtaposition of diagrams. (...) However, on the side of departure, we dispense with the sometimes problematic “lines of identity” of classical Beta and instead represent a quantification by a.. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Virtue and Grace in the Theology of Thomas Aquinas by Justin M. AndersonThomas V. BergVirtue and Grace in the Theology of Thomas Aquinas by Justin M. Anderson (Cambridge: Cambridge University Press, 2020), xiii + 327 pp.To ignore Aquinas's theological backstory to his account of the virtues—namely, his account of grace in its relation to human action—is to distort his account of the virtues. This is the (...) very valid thesis explored by Justin Anderson in Virtue and Grace in the Theology of Thomas Aquinas. Anderson critiques the tendency among contemporary Anglophone virtue ethicists to quietly bracket his account of grace even as they admire his account the virtues. More pointedly, Anderson holds that Aquinas's account of virtue is inseparable from his account of sin, grace, "and God's presence in human life and action." He endeavors to evidence Aquinas's authentic account of virtue and its "inner reliance on the theological categories of grace, sin, and divine providence" (1).Anderson thus proposes a reading of Aquinas that is diachronic, analytical and systematic, and text-based, and which follows the logic inherent in Aquinas's own reasoning.And he delivers.After a brief overview of Aquinas's understanding of virtue in chapter 1, in chapter 2, Anderson explores the Thomistic distinction that will largely serve as a heuristic for most of the study: the distinction between virtue secundum quid (pagan virtue) and virtue simpliciter, virtue infused in us by God—virtue in the truest sense of the term.In chapter 3, Anderson traces the historical evolution in Aquinas's understanding of grace as this impacts his understanding of the conditions under which a person can possess or embody virtue. He bases this exploration in part on the work of both Henri Bouillard and Bernard Lonergan. First Anderson explores how that evolution came about in the context of the emergence of two powerful categories of thought: the Aristotelian concept of nature in the twelfth century and the category of the supernatural in the thirteenth. According to Bouillard, Aquinas's understanding of grace would [End Page 1421] have been further shaped by two sets of discoveries during his sojourn in Italy in the early 1260s, the first being two anti-Pelagian tracts of St. Augustine, and the second being the Liber de bona fortuna, a Latin compilation, possibly translated by William of Moerbeke, consisting of two chapters on good fortune, one taken from Aristotle's Magna Moralia, and the other from the Eudemian Ethics.Aquinas discovers in Augustine's anti-Pelagian works the contention that the beginning of faith is from God and not from the individual. As with the grace of final perseverance, both initiation and perdurance in faith are gratuitous gifts of God. In his encounter with the Liber (and particularly his consideration therein of the "problem of the first deliberation"), like other medievals, Aquinas "[was] presented Aristotelian investigations regarding the possibility of a divine movement, even unacknowledged by the agent, at the very roots of human action" (98). And, in Thomas's evolved understanding, this divine influence would constitute an inner movement within the human agent apart from those external circumstances ordained by providence.Anderson embraces the thesis that, in this context, and under these influences, Aquinas's understanding of grace underwent a "revolution," that a mature Aquinas—and this is the thesis of Lonergan—moves beyond a consideration of grace merely as habitus (gratia gratum faciens) to a notion of operative grace, of grace as a movement, utilizing "the unique idea of a 'moving grace', a movement of God in, and in some cases with, the human soul" (105).And—Anderson is emphatic—this revolution in thought quickly steers Aquinas clear of what centuries later will be termed semi-Pelagianism, and toward a firmly anti-Pelagian conception of the human capacity for virtue.Chapters 4–9 comprise the second and third parts of the book. It is here that Anderson masterfully and exhaustively engages in the heavy lifting of evincing just how, in fact, Aquinas's account of virtue is inseparable from his theology of grace. On the supposition that Aquinas's mature theology of grace understands the latter to... (shrink)