It has been demonstrated that death certificates do not accurately record the actual cause of death in up to one-fourth of cases, as determined from subsequent autopsy findings. The purpose of this study was to explore the use of natural language autopsy data bases as an automated quality assurance mechanism. We translated the account of the major process leading to death, or the primary diagnosis, from all 45,564 narrative autopsy reports obtained at The Johns Hopkins Hospital between May 28, 1889, (...) and June 30, 1987, into the hierarchical system of Medical Subject Heading (MeSH) titles. We obtained a total of 125,772 MeSH title translations, 1,563 of them distinct (average 2.8 per case), ranging in frequency from 6,029 occurrences of LUNG to 1 occurrence apiece of 357 MeSH titles. The natural-language-to-MeSH translations showed expected trends over the past century: fewer infectious diseases; more cardiovascular and neoplastic disease among adults; and more respiratory diseases and congenital malformations in the pediatric age group. The greater availability of autopsy documents in electronic form should increase the value of this resource for quality assurance. (shrink)

In the past, hypothesis testing in medicine has employed the paradigm of the repeatable experiment. In statistical hypothesis testing, an unbiased sample is drawn from a larger source population, and a calculated statistic is compared to a preassigned critical region, on the assumption that the comparison could be repeated an indefinite number of times. However, repeated experiments often cannot be performed on human beings, due to ethical or economic constraints. We describe a new paradigm for hypothesis testing which uses only (...) rearrangements of data present within the observed data set. The token swap test, based on this new paradigm, is applied to three data sets from cardiovascular pathology, and computational experiments suggest that the token swap test satisfies the Neyman Pearson condition. (shrink)

One of our great behavioral scientists, the bestselling author of Behave, plumbs the depths of the science and philosophy of decision-making to mount a devastating case against free will, an argument with profound consequences Robert Sapolsky's Behave, his now classic account of why humans do good and why they do bad, pointed toward an unsettling conclusion: We may not grasp the precise marriage of nature and nurture that creates the physics and chemistry at the base of human behavior, but (...) that doesn't mean it doesn't exist. Now, in Determined, Sapolsky takes his argument all the way, mounting a brilliant (and in his inimitable way, delightful) full-frontal assault on the pleasant fantasy that there is some separate self telling our biology what to do. Determined offers a marvelous synthesis of what we know about how consciousness works-the tight weave between reason and emotion and between stimulus and response in the moment and over a life. One by one, Sapolsky tackles all the major arguments for free will and takes them out, cutting a path through the thickets of chaos and complexity science and quantum physics, as well as touching ground on some of the wilder shores of philosophy. He shows us that the history of medicine is in no small part the history of learning that fewer and fewer things are somebody's "fault"; for example, for centuries we thought seizures were a sign of demonic possession. Yet, as he acknowledges, it's very hard, and at times impossible, to uncouple from our zeal to judge others and to judge ourselves. Sapolsky applies the new understanding of life beyond free will to some of our most essential questions around punishment, morality, and living well together. By the end, Sapolsky argues that while living our daily lives recognizing that we have no free will is going to be monumentally difficult, doing so is not going to result in anarchy, pointlessness, and existential malaise. Instead, it will make for a much more humane world. (shrink)

A model for ethical problem solving -- Values in health and illness -- What is the source of moral judgments? -- Benefiting the patient and others : duty to do good and avoid harm -- Justice : allocation of health resources -- Autonomy -- Veracity : honesty with patients -- Fidelity : promise-keeping, loyalty to patients, and impaired professionals -- Avoidance of killing -- Abortion, sterilization, and contraception -- Genetics, birth, and the biological revolution -- Mental health and behavior control (...) -- Confidentiality : ethical disclosure of medical information -- Organ transplants -- Health insurance, health system planning, and rationing -- Experimentation on human subjects -- Consent and the right to refuse treatment -- Death and dying. (shrink)

Every pharmacist, aware or not, is constantly making ethical choices. Sometimes these choices are dramatic, life-and-death decisions, but often they will be more subtle, less conspicuous choices that are nonetheless important. Assisted suicide, conscientious refusal, pain management, equitable and efficacious distribution of drug resources within institutions and managed care plans, confidentiality, and alternative and non-traditional therapies are among the issues that are of unique concern to pharmacists. One way of seeing the implications of such issues and the moral choices they (...) pose is to look at the experiences of practitioners and the kinds of choices they have had to make in situations typically faced by pharmacists. This book is a collection of those situations based on the real experiences of practicing pharmacists. The use of case studies in health care ethics is not new, but in pharmacy it is. This text is an important teaching tool that will help pharmacy students and pharmacists address the increasing number of ethical problems arising in their profession. It is not merely a compilation of cases, but rather is organized for the systematic study of applied ethics. Part I shows how to distinguish ethical problems from other kinds of evaluative judgments and examines the sources of values in pharmacy, posing basic questions about the meaning and justification of ethical claims. Part II explores the basic principles of ethics as they have an impact on pharmacy. Specific cases from clinical settings present in a systematic way the various questions raised by each of the major ethical principles -- benefiting the patient, distributing resources justly, respecting autonomy, dealing honestly with patients, keeping promises of confidentiality, and avoiding harm. Part II examines some of the special problems of contemporary pharmacy such as the linkages between pharmaceutical care and professional practice, human experimentation, reproductive issues, genetic technology, death and dying, and mental health. (shrink)

"M. F. Simone Roberts's A Poetics of Being-Two is animated by a lively and engaging voice, drawing readers in with a sense of serious purpose working (delightfully) in tandem with a sense of humor. Roberts's aesthetics and her close readings of Yves Bonnefoy, St-John Perse, and Jorie Graham clearly demonstrate the literary effectiveness of Irigarayan sexual difference as an analytic trope, even as they emphasize the philosophical and political possibilities sexual difference opens up for feminism, environmentalism, and all levels of (...) contemporary cultural critique and activism."—Gail M. Schwab, Hofstra University -/- In An Ethics of Sexual Difference, Irigaray calls for a new poetics in the sense of both art and life. Rather than a critique from within philosophy, A Poetics of Being-Two tests Irigaray's ethics by extending it to other sites of cultural production. Where Irigaray's method finds stirrings and repressions of sexual difference in philosophy, this project explores that tension in poetics. Building from Irigaray's ethics, the book describes a poetics of being-two as concerns gendered subjectivity in literary poetics and then traces the on-going emergence of a poetics of being-two in the post-symbolist poetic tradition. Irigaray scholars will be interested in the sustained interpolation of Irigaray's ethical concepts as principles for a critical aesthetics and in their hermeneutic application in reading a literary tradition. Readers in comparative literature will find the first sustained feminist engagements with the major French poets Bonnefoy and Perse and an elucidation of their influence on the Pulitzer Prize winning poet Jorie Graham. (shrink)

It was of course impossible for Mr. Miller within the limits of his paper to follow out all the implications of his position, and I merely want to raise some questions with regard to a few of the more important of these implications. If Plato assumed the role of historian, intent on giving an "accurate representation" of his characters in conversations that actually took place, it would clearly be incumbent on him to keep any independent philosophical interest of his own, (...) if he had any, completely out of the picture-his interest in philosophy was limited to reporting what Socrates, Protagoras, Gorgias, and the others had said on various subjects. Now, the only dialogues in which Socrates does not do the constructive thinking are a small group, consisting of the Sophist, Statesman, Timaeus, Critias, Laws, and Epinomis, written towards the end of Plato's life; but I am not certain whether Mr. Miller holds that these represent a continuance of the reporting function, or a sudden outburst of originality by Plato. The question that I would ask therefore is whether Mr. Miller's thesis would imply that Plato was merely an accurate reporter of other men's opinions either all his life or at least down to the last ten or fifteen years. (shrink)

THE fifteenth edition of the Encyclopaedia Britannica is another of the projects undertaken by philosophers Robert M. Hutchins and Mortimer Adler. Hutchins chaired the Board of Editors, while Adler served as director of planning. This latest edition has the distinction of being the largest single private publishing venture in history, involving a thirty-two million dollar investment, over fifteen years of effort, and many thousands of consultants and contributors. This essay will attempt to assess philosophy’s share in so (...) massive an undertaking. (shrink)

Assesses the ethical problems that doctors face every day and advocates a more universal code of medical ethics, one that draws on the traditions of religion and philosophy.

It is not too great an exaggeration to claim that On the Origin of Species was, along with Das Kapital, one of the two most significant works in the intellectual history of the nineteenth century. As George Henry Lewes wrote in 1868, ‘No work of our time has been so general in its influence’. However, the very generality of the influence of Darwin’s work provides the chief problem for the intellectual historian. Most books and articles on the subject assert the (...) influence but remain very imprecise about its nature. It is very difficult indeed to assess what it was about the Darwinian theory which was so influential and how its influence was felt. This problem in Victorian intellectual history intersects with a related one in the history of science. There has been a tendency on the part of historians of science to isolate Darwin in two related ways. The first is to single him out from the mainstream of nineteenth-century naturalism in Britain and allow ‘Darwinism’ to stand duty for the wider movement of which it was in fact but a part. The second is the tendency to single out his evolutionary theory and to demarcate it sharply from those of his predecessors and contemporaries. According to this interpretation Darwin stood alone as a real, empirical scientist and provided the first genuinely scientific hypothesis for the process by which evolution might have occurred. The theories of the other main evolutionists—Erasmus Darwin, Lamarck, Chambers, Spencer, and Wallace—were more or less besmirched by ideological, anthropomorphic, or other ‘non-scientific’ factors or by the uses to which they were put by their authors. Charles Darwin is thus made to stand out as a figure of comparatively unalloyed scientific status and is treated in relative isolation from the social and intellectual context in which he worked and into which his theory was received. (shrink)

In celebration of the fortieth anniversary of the publication of Beauchamp and Childress’s Principles of Biomedical Ethics, a review is undertaken to compare the lists of principles in various bioethical theories to determine the extent to which the various lists can be reconciled. Included are the single principle theories of utilitarianism, libertarianism, Hippocratism, and the theories of Pellegrino, Engelhardt, The Belmont Report, Beauchamp and Childress, Ross, Veatch, and Gert. We find theories all offering lists of principles numbering from one to (...) ten. Many of the differences can be reconciled, but some critical differences remain. (shrink)

Modern historical criticism of the gospels and Christian origins began in the seventeenth century largely as an attempt to debunk the Christian religion as a pious fraud. The gospels were seen as bits of priestcraft and humbug of a piece with the apocryphal Donation of Constantine. In the few centuries since Reimarus and his critical kin, historical criticism has been embraced and assimilated by many Christian scholars who have seen in it the logical extension of the grammatico-historical method of the (...) Reformers. The new views of New Testament exegesis and of early Christian history are important and well known. Many New Testament scholars would now hold with Schweitzer and Bultmann that Jesus was a preacher of the imminent end of the world. He may have secretly considered himself to be the Messiah, or he may have simply sought to pave the way for another, the apocalyptic Son of Man. After his execution, his disciples' experiences of his resurrection forced on them a conclusion already implicit in his teachings and personal piety: that Jesus was indeed, or had become, the Messiah, and was in fact God's Son. They expected he would soon return as the Son of Man he had predicted. (shrink)

No one really believes that literally all functions of the entire brain must be lost for an individual to be dead. A better definition of death involves a higher brain orientation.

Clinicians cannot obtain valid consent to treatment because they cannot guess which treatment option will serve a particular patient's best interests. These guesses could be made more accurately if patients were paired with providers who share their deep values.

It is not too great an exaggeration to claim that On the Origin of Species was, along with Das Kapital, one of the two most significant works in the intellectual history of the nineteenth century. As George Henry Lewes wrote in 1868, ‘No work of our time has been so general in its influence’. However, the very generality of the influence of Darwin’s work provides the chief problem for the intellectual historian. Most books and articles on the subject assert the (...) influence but remain very imprecise about its nature. It is very difficult indeed to assess what it was about the Darwinian theory which was so influential and how its influence was felt. This problem in Victorian intellectual history intersects with a related one in the history of science. There has been a tendency on the part of historians of science to isolate Darwin in two related ways. The first is to single him out from the mainstream of nineteenth-century naturalism in Britain and allow ‘Darwinism’ to stand duty for the wider movement of which it was in fact but a part. The second is the tendency to single out his evolutionary theory and to demarcate it sharply from those of his predecessors and contemporaries. According to this interpretation Darwin stood alone as a real, empirical scientist and provided the first genuinely scientific hypothesis for the process by which evolution might have occurred. The theories of the other main evolutionists—Erasmus Darwin, Lamarck, Chambers, Spencer, and Wallace—were more or less besmirched by ideological, anthropomorphic, or other ‘non-scientific’ factors or by the uses to which they were put by their authors. Charles Darwin is thus made to stand out as a figure of comparatively unalloyed scientific status and is treated in relative isolation from the social and intellectual context in which he worked and into which his theory was received. (shrink)

When a new, brain-based definition of death was proposed fifty years ago, no one realized that the issue would remain unresolved for so long. Recently, six new controversies have added to the debate: whether there is a right to refuse apnea testing, which set of criteria should be chosen to measure the death of the brain, how the problem of erroneous testing should be handled, whether any of the current criteria sets accurately measures the death of the brain, whether standard (...) criteria include measurements of all brain functions, and how minorities who reject whole-brain-based definitions should be accommodated. These controversies leave little hope of consensus on how to define death for social and public policy purposes. Rather, there is persistent disagreement among proponents of three major groups of definitions of death: whole-brain, cardiocirculatory or somatic, and higher-brain. Given the persistence and reasonableness of each of these groups of definitions, public policy should permit individuals and their valid surrogates to choose among them. (shrink)

After distinguishing two different meanings of the notion of a morality internal to medicine and considering a hypothetical case of a society that relied on its surgeons to eunuchize priest/cantors to permit them to play an important religious/cultural role, this paper examines three reasons why morality cannot be derived from reflection on the ends of the practice of medicine: (1) there exist many medical roles and these have different ends or purposes, (2) even within any given medical role, there exists (...) multiple, sometimes conflicting ends, and, most critically, (3) the ends of any practice such as medicine must come from outside the practice, that is, from the basic ends or purposes of human living. The paper concludes by considering whether these ends external to medicine are universally part of the moral reality or whether they are socially constructed. The paper argues that, even if various cultural accounts of the common, universal morality are socially constructed, they may, nevertheless, be reflections, however, imperfect, of a more universal common morality that should be thought of as real. Therefore, the morality of medicine must come from a more fundamental morality external to medicine. That external morality will be socially constructed, but may nevertheless reflect an underlying common morality. (shrink)

In its October 2001 issue, this journal published a series of articles questioning the Whole-Brain-based definition of death. Much of the concern focused on whether somatic integration - a commonly understood basis for the whole-brain death view - can survive the brain's death. The present article accepts that there are insurmountable problems with whole-brain death views, but challenges the assumption that loss of somatic integration is the proper basis for pronouncing death. It examines three major themes. First, it accepts the (...) claim of the "disaggregators" that some behaviors traditionally associated with death can be unbundled, but argues that other behaviors (including organ procurement) must continue to be associated. Second, it rejects the claims of the "somaticists," that the integration of the body is critical, arguing instead for equating death with the irreversible loss of "embodied consciousness," that is, the loss of integration of bodily and mental function. Third, it defends higher-brain views against the charge that they are necessarily "mentalist," that is, that they equate death with losing some mental function such as consciousness or personhood. It argues, instead, for the integration of bodily and mental function as the critical feature of human life and that its irreversible loss constitutes death. (shrink)

The dead donor rule (DDR) governs procuring life-prolonging organs. They should be taken only from deceased donors. Miller and Truog have proposed abandoning the rule when patients have decided to forgo life-sustaining treatment and have consented to procurement. Organs could then be procured from living patients, thus killing them by organ procurement. This proposal warrants careful examination. They convincingly argue that current brain or circulatory death pronouncement misidentifies the biologically dead. After arguing convincingly that physicians already cause death by withdrawing (...) treatment, they claim no bright-line differences preclude organ removal from the living. The argument fails for those who accept the double effect doctrine or other grounds for distinguishing forgoing life support from active, intentional killing. If the goal is determining irreversible loss of somatic function, they correctly label current death pronouncement a “legal fiction.” Recognizing a second, public policy meaning of the term death provides grounds for maintaining the DDR without jeopardizing procurement. (shrink)