A recent commentary defends 1) the concept of 'brain arrest' to explain what brain death is, and 2) the concept that death occurs at 2–5 minutes after absent circulation. I suggest that both these claims are flawed. Brain arrest is said to threaten life, and lead to death by causing a secondary respiratory then cardiac arrest. It is further claimed that ventilation only interrupts this way that brain arrest leads to death. These statements imply that brain arrest is not death (...) itself. Brain death is a devastating state that leads to death when intensive care, which replaces some of the brain's vital functions such as breathing, is withdrawn and circulation stops resulting in irreversible loss of integration of the organism. Circulatory death is said to occur at 2–5 minutes after absent circulation because, in the context of DCD, the intent is to not attempt reversal of the absent circulation. No defense of this weak construal of irreversible loss of circulation is given. This means that paents in identical physiologic states are dead (in the DCD context) or alive (in the resuscitation context); the current state of death (at 2–5 minutes) is contingent on a future event (whether there will be resuscitation) suggesting backward causation; and the commonly used meaning of irreversible as 'not capable of being reversed' is abandoned. The literature supporting the claim that autoresuscitation does not occur in the context of no cardiopulmonary resuscitation is shown to be very limited. Several cases of autoresuscitation are summarized, suggesting that the claim that these cases are not applicable to the current debate may be premature. I suggest that brain dead and DCD donors are not dead; whether organs can be harvested before death from these patients whose prognosis is death should be debated urgently. (shrink)

Many believe that the ethical problems of donation after cardiocirculatory death (DCD) have been "worked out" and that it is unclear why DCD should be resisted. In this paper we will argue that DCD donors may not yet be dead, and therefore that organ donation during DCD may violate the dead donor rule. We first present a description of the process of DCD and the standard ethical rationale for the practice. We then present our concerns with DCD, including the following: (...) irreversibility of absent circulation has not occurred and the many attempts to claim it has have all failed; conflicts of interest at all steps in the DCD process, including the decision to withdraw life support before DCD, are simply unavoidable; potentially harmful premortem interventions to preserve organ utility are not justifiable, even with the help of the principle of double effect; claims that DCD conforms with the intent of the law and current accepted medical standards are misleading and inaccurate; and consensus statements by respected medical groups do not change these arguments due to their low quality including being plagued by conflict of interest. Moreover, some arguments in favor of DCD, while likely true, are "straw-man arguments," such as the great benefit of organ donation. The truth is that honesty and trustworthiness require that we face these problems instead of avoiding them. We believe that DCD is not ethically allowable because it abandons the dead donor rule, has unavoidable conflicts of interests, and implements premortem interventions which can hasten death. These important points have not been, but need to be fully disclosed to the public and incorporated into fully informed consent. These are tall orders, and require open public debate. Until this debate occurs, we call for a moratorium on the practice of DCD. (shrink)

Brain death has been accepted worldwide medically and legally as the biological state of death of the organism. Nevertheless, the literature has described persistent problems with this acceptance ever since brain death was described. Many of these problems are not widely known or properly understood by much of the medical community. Here we aim to clarify these issues, based on the two intractable problems in the brain death debates. First, the metaphysical problem: there is no reason that withstands critical scrutiny (...) to believe that BD is the state of biological death of the human organism. Second, the epistemic problem: there is no way currently to diagnose the state of BD, the irreversible loss of all brain functions, using clinical tests and ancillary tests, given potential confounders to testing. We discuss these problems and their main objections and conclude that these problems are intractable in that there has been no acceptable solution offered other than bare assertions of an ‘operational definition’ of death. We present possible ways to move forward that accept both the metaphysical problem - that BD is not biological death of the human organism - and the epistemic problem - that as currently diagnosed, BD is a devastating neurological state where recovery of sentience is very unlikely, but not a confirmed state of irreversible loss of all [critical] brain functions. We argue that the best solution is to abandon the dead donor rule, thus allowing vital organ donation from patients currently diagnosed as BD, assuming appropriate changes are made to the consent process and to laws about killing. (shrink)

Volume 20, Issue 6, June 2020, Page 42-44.

Some patients who have been diagnosed as “dead by neurologic criteria” continue to exhibit certain brain functions, most commonly, neuroendocrine functions. This preservation of neurologic function after the diagnosis of “brain death” or “brainstem death” is an ongoing source of controversy and concern in the medical, bioethics, and legal literatures. Most obviously, if some brain function persists, then it is not the case that all functions of the entire brain have ceased and hence, declaring such a patient to be “dead” (...) would be a false positive, in any nation with so-called “whole brain death” laws. Furthermore, and perhaps more concerning, the preservation of any brain function necessarily entails the preservation of some amount of brain perfusion, thereby raising the concern as to whether additional areas of neural tissue may remain viable, including areas in the brainstem. These and other considerations cast significant doubt on the reliability of diagnosing either “brain death” or “brainstem death.”. (shrink)

We thank the authors of commentaries for their thoughtful discussion of our target article. Here we briefly summarize the points made in the target article (Nair-Collins and Joffe 2023). Then we em...

Pediatric health care workers often perform, promote, and advocate use of public funds for animal research . We aim to determine whether HCW consider common arguments in support of AR convincing.

Ariane Lewis reviewed medicolegal challenges to Death by Neurologic Criteria (DNC) in the United Kingdom in order to identify and discuss the ethical issues raised (Lewis 2024). Here I briefly clar...

BackgroundTo determine whether the public and scientists consider common arguments in support of animal research convincing.MethodsAfter validation, the survey was sent to samples of public, Amazon Mechanical Turk, a Canadian city festival and children’s hospital), medical students, and scientists. We presented questions about common arguments to justify the moral permissibility of AR. Responses were compared using Chi-square with Bonferonni correction.ResultsThere were 1220 public [SSI, n = 586; AMT, n = 439; Festival, n = 195; Hospital n = 107], 194/331 medical (...) student, and 19/319 scientist [too few to report] responses. Most public respondents were <45 years, had some College/University education, and had never done AR. Most public and medical student respondents considered ‘benefits arguments’ sufficient to justify AR; however, most acknowledged that counterarguments suggesting alternative research methods may be available, or that it is unclear why the same ‘benefits arguments’ do not apply to using humans in research, significantly weakened ‘benefits arguments’. Almost all were not convinced of the moral permissibility of AR by ‘characteristics of non-human-animals arguments’, including that non-human-animals are not sentient, or are property. Most were not convinced of the moral permissibility of AR by ‘human exceptionalism’ arguments, including that humans have more advanced mental abilities, are of a special ‘kind’, can enter social contracts, or face a ‘lifeboat situation’. Counterarguments explained much of this, including that not all humans have these more advanced abilities [‘argument from species overlap’], and that the notion of ‘kind’ is arbitrary [e.g., why are we not of the ‘kind’ ‘sentient-animal’ or ‘subject-of-a-life’?]. Medical students were more supportive of AR at the end of the survey.ConclusionsResponses suggest that support for AR may not be based on cogent philosophical rationales, and more open debate is warranted. (shrink)

Health care workers often perform, promote, and advocate use of public funds for animal research ; therefore, an awareness of the empirical costs and benefits of animal research is an important issue for HCW. We aim to determine what health-care-workers consider should be acceptable standards of AR methodology and translation rate to humans.

A commentary on “A Rationale in Support of Uncontrolled Donation after Circulatory Determination of Death,” from the January‐February 2013 issue.

The World Brain Death Project clarified many aspects of the diagnosis of brain death/death by neurologic criteria. Clearer descriptions than previously published were presented concerning the etiology, prerequisites, minimum clinical criteria, apnea testing targets, and indications for ancillary testing. Nevertheless, there remained many epistemic and metaphysical assertions that were either false, ad hoc, or confused. Epistemically, the project was not successful in explaining away remaining brain functions, complex reflexes as “spinal,” the risk and lack of utility of the apnea test, (...) the ignored and often present confounders of central endocrine dysfunction and high-cervical-spinal-cord injury, the limitations of ancillary tests, or the cases of reversibility of some findings of brain death/death by neurologic criteria. Metaphysically, the World Brain Death Project variously suggested different concepts of death that were not supported with argument. Concepts offered included simply restating the criterion of brain death/death by neurologic criteria; personhood, without recognizing it is a higher-brain concept; and emergent functions of the organism as a whole, without specifying what these might be, if not biologic anti-entropic integration that actually remains after brain death/death by neurologic criteria. The World Brain Death Project only offered confused metaphysical discussion, and gave no reason why the state they described as brain death/death by neurologic criteria should be considered death itself. The main epistemic and metaphysical problems with brain death/death by neurologic criteria remain untouched by the World Brain Death Project. (shrink)

Classic statements of research ethics advise against permitting physician-investigators to obtain consent for research participation from patients with whom they have preexisting treatment relationships. Reluctance about “dual-role” consent reflects the view that distinct normative commitments govern physician–patient and investigator–participant relationships, and that blurring the research–care boundary could lead to ethical transgressions. However, several features of contemporary research demand reconsideration of the ethics of dual-role consent. Here, we examine three arguments advanced against dual-role consent: that it creates role conflict for the (...) physician-investigator; that it can compromise the voluntariness of the patient-participant’s consent; and that it promotes therapeutic misconceptions. Although these concerns have merit in some circumstances, they are not dispositive in all cases. Rather, their force—and the ethical acceptability of dual-role consent—varies with features of the particular study. As research participation more closely approximates usual care, it becomes increasingly acceptable, or even preferable, for physicians to seek consent for research from their own patients. It is time for a more nuanced approach to dual-role consent. (shrink)

Volume 19, Issue 5, May 2019, Page W3-W4.

The conflicts of interest that may arise in relationships between academic researchers and industry continue to prompt controversy. The bulk of attention has focused on financial aspects of these relationships, but conflicts may also arise in the legal obligations that faculty acquire through consulting contracts. However, oversight of faculty members' consulting agreements is far less vigorous than for financial conflicts, creating the potential for faculty to knowingly or unwittingly contract away important rights and freedoms. Increased regulation could prevent this, but (...) it is unclear what forms of oversight universities view as feasible and effective. In this article, we report on a Delphi study to evaluate several approaches for oversight of consulting agreements by medical schools. The panel was comprised of 11 senior administrators with responsibility for oversight of faculty consulting relationships. We found broad agreement among panelists regarding the importance of institutional oversight to protect universities' interests. There was strong support for two specific approaches: providing educational resources to faculty and submitting consulting agreements for institutional review. Notwithstanding the complexities of asserting authority to regulate private consulting agreements between faculty members and companies, medical school administrators reached consensus that several approaches to improving institutional oversight are feasible and useful. (shrink)

According to international scientific medical consensus, death is a biological, unidirectional, ontological state of an organism, the event that separates the process of dying from the process of disintegration. Death is not merely a social contrivance or a normative concept; it is a scientific reality. Using this paradigm, the international consensus is that, regardless of context, death is operationally defined as “the permanent loss of the capacity for consciousness and all brainstem function. This may result from permanent cessation of circulation (...) or catastrophic brain injury. In the context of death determination, ‘permanent’ refers to loss of function that cannot resume spontaneously and will not be restored through intervention.” The word “permanent” replaces “irreversible” (used in the United States’ 1980 Uniform Declaration of Death Act) in this new definition, arguably invented to allow donation after circulatory determination of death (DCDD) while still complying with the dead donor rule. I will show that this invention fails, for at least four reasons. (shrink)

Brain death is accepted in most countries as death. The rationales to explain why brain death is death are surprisingly problematic. The standard rationale that in brain death there has been loss of integrative unity of the organism has been shown to be false, and a better rationale has not been clearly articulated. Recent expert defences of the brain death concept are examined in this paper, and are suggested to be inadequate. I argue that, ironically, these defences demonstrate the lack (...) of a defensible rationale for why brain death should be accepted as death itself. If brain death is death, a conceptual rationale for brain death being equivalent to death should be clarified, and this should be done urgently. (shrink)

BackgroundLarge-scale, centralized data repositories are playing a critical and unprecedented role in fostering innovative health research, leading to new opportunities as well as dilemmas for the medical sciences. Uncovering the reasons as to why citizens do or do not contribute to such repositories, for example, to population-based biobanks, is therefore crucial. We investigated and compared the views of existing participants and non-participants on contributing to large-scale, centralized health research data repositories with those of ex-participants regarding the decision to end their (...) participation. This comparison could yield new insights into motives of participation and non-participation, in particular the behavioural change of withdrawal.MethodsWe conducted 36 in-depth interviews with ex-participants, participants, and non-participants of a three-generation, population-based biobank in the Netherlands. The interviews focused on the respondents’ decision-making processes relating to their participation in a large-scale, centralized repository for health research data.ResultsThe decision of participants and non-participants to contribute to the biobank was motivated by a desire to help others. Whereas participants perceived only benefits relating to their participation and were unconcerned about potential risks, non-participants and ex-participants raised concerns about the threat of large-scale, centralized public data repositories and public institutes, such as social exclusion or commercialization. Our analysis of ex-participants’ perceptions suggests that intrapersonal characteristics, such as levels of trust in society, participation conceived as a social norm, and basic societal values account for differences between participants and non-participants.ConclusionsOur findings indicate the fluidity of motives centring on helping others in decisions to participate in large-scale, centralized health research data repositories. Efforts to improve participation should focus on enhancing the trustworthiness of such data repositories and developing layered strategies for communication with participants and with the public. Accordingly, personalized approaches for recruiting participants and transmitting information along with appropriate regulatory frameworks are required, which have important implications for current data management and informed consent procedures. (shrink)

COVID-19 vaccination of children has begun in various high-income countries with regulatory approval and general public support, but largely without careful ethical consideration. This trend is expected to extend to other COVID-19 vaccines and lower ages as clinical trials progress. This paper provides an ethical analysis of COVID-19 vaccination of healthy children. Specifically, we argue that it is currently unclear whether routine COVID-19 vaccination of healthy children is ethically justified in most contexts, given the minimal direct benefit that COVID-19 vaccination (...) provides to children, the potential for rare risks to outweigh these benefits and undermine vaccine confidence, and substantial evidence that COVID-19 vaccination confers adequate protection to risk groups, such as older adults, without the need to vaccinate healthy children. We conclude that child COVID-19 vaccination in wealthy communities before adults in poor communities worldwide is ethically unacceptable and consider how policy deliberations might evolve in light of future developments. (shrink)

The contributions in this volume treat aspects and manifestations of this cultural symbiosis, and they throw new light on authors and texts both more and less ...

Bioethics, Volume 36, Issue 6, Page 687-698, July 2022.

Public disclosure of industry payments to physicians is one way to address financial conflicts of interest in medicine. As part of the Patient Protection and Affordable Care Act, the Physician Payment Sunshine Act requires pharmaceutical, medical device, and biologics manufacturers who have at least one product reimbursed by Medicare or Medicaid to disclose payments to physicians and teaching hospitals on a public website starting in 2014. The physician payment data will contain individual physician names, monetary values, and specific products connected (...) to payments.According to the Final Regulations issued by the Centers for Medicare and Medicaid Services in February 2013, the law will make transparent the extent and nature of relationships between physicians, teaching hospitals, and manufacturers. (shrink)

In the South Korean film, The Parasite, the underling family, in an act of desperation, uses deceptive means to infiltrate the rich family. The term parasite refers nominally to the underling family, and their efforts to befriend and inhabit the class territory and social hierarchy of the rich family. How can this be of use for education? To answer this, we ask: what can we learn from Parasite to inform contemporary philosophy of education? Primarily, this experimental piece written from different (...) philosophical viewpoints, suggests that the images, narrative, and social context of the film cannot be read stereotypically. Using a blend of Deleuze and Stiegler ‘cinema-theory’, we present a heuristic perspective on the Parasite from three viewpoints: (1) South Korean society, and how a pedagogy of the parasite helps to understand the dynamics of contemporary philosophy of education in a global context. South Korea is uniquely placed at the cusp and threshold of deterritorializing Western capitalism, given its position next to the only in-tact communist state system; (2) The film shows how theorizing an exceptional notion of time contributes to the overall pedagogy of the parasite. Here, being a parasite is about waiting to attach oneself to a host, yet this waiting is an anxious, perceptive, adherent time, a reciprocal time, and one internally interconnected to that of the host; (3) The ethics of the parasite. The parasite chooses a host from a certain viewpoint before attaching itself and trying to be absorbed into the host. The pedagogy of the parasite suggests a unique ethical treatment of these assimilative processes and allows us to consider cinema as a parasitic means to shake the passive audience out of its stupor when bearing witness to the violence in the film and its own collusion in the trauma and reality of contemporary capitalism. (shrink)

Should people get vaccinated for the sake of others? What could ground—and limit—the normative claim that people ought to do so? In this paper, we propose a reasons-based consequentialist account of vaccination for the benefit of others. We outline eight harm-based and probabilistic factors that, we argue, give people moral reasons to get vaccinated. Instead of understanding other-directed vaccination in terms of binary moral duties (i.e., where people either have or do not have a moral duty to get vaccinated), we (...) develop a scalar approach according to which people can have stronger or weaker moral reasons to get vaccinated in view of the moral good of vaccination. One advantage of our approach is that it can capture why a person might have strong moral reasons to get vaccinated with Vaccine A, but only weak moral reasons to get vaccinated with Vaccine B. We discuss theoretical strengths of our approach and provide a case study of vaccination against COVID-19 to demonstrate its practical significance. (shrink)

As sharing and secondary research use of biospecimens increases, IRBs and researchers face the challenge of protecting and respecting donors without comprehensive regulations addressing the human subject protection issues posed by biobanking. Variation in IRB biobanking policies about these issues has not been well documented.

Large-scale sequencing tests, including whole-exome and whole-genome sequencing, are rapidly moving into clinical use. Sequencing is already being used clinically to identify therapeutic opportunities for cancer patients who have run out of conventional treatment options, to help diagnose children with puzzling neurodevelopmental conditions, and to clarify appropriate drug choices and dosing in individuals. To evaluate and support clinical applications of these technologies, the National Human Genome Research Institute and National Cancer Institute have funded studies on clinical and research sequencing under (...) the Clinical Sequencing Exploratory Research program as well as studies on return of results. Most of these studies use sequencing in real-world clinical settings and collect data on both the application of sequencing and the impact of receiving genomic findings on study participants. They are occurring in the context of controversy over how to obtain consent for exome and genome sequencing. (shrink)

The Technology Assessment (TA) Program established in 2003 as part of the Dutch R&D consortium NanoNed is interesting for what it did, but also as an indication that there are changes in how new science and technology are pursued: the nanotechnologists felt it necessary to spend part of their funding on social aspects of nanotechnology. We retrace the history of the TA program, and present the innovative work that was done on Constructive TA of emerging nanotechnology developments and on aspects (...) of embedding of nanotechnology in society. One achievement is the provision of tools and approaches to help make the co-evolution of technology and society more reflexive. We briefly look forward by outlining its successor program, TA NanoNextNL, in place since 2011. (shrink)

I show how a de se belief ascription such as "Privatus believes that he himself is rich" may be dealt with by means of a scope distinction over and above that one separating de dicto and de re ascriptions. The idea is, roughly, that 'Privatus...himself' forms in this statement a unity, a single "spread" sign that is at the same time in a de re and de dicto position. If so, H-N. Castañeda's contention that the "quasi-indicator" 'he himself' ('she herself', (...) 'it itself') belongs to a "unique, irreducible logical category" of singular terms is, at best, misleading. Further, my account is superior to the well-known theories of R. Chisholm and D. Lewis, according to which de se ascriptions state that the believer "directly attributes properties to himself or herself". 1. Introduction 2. Chisholm and Lewis on de se belief ascriptions 3. Fregean and Sellarsian theories of belief ascriptions 4. Geach on the reflexive pronoun 5. Admiring and self-admiring 6. A solution to the problem de se belief ascriptions 7. Belief de se 8. Conclusion. (shrink)

I have three main objectives in this essay. First, in chapter 2, I shall put forward and justify what I call worldlessness, by which I mean the following: All truths (as well as falsehoods) are wholly independent of any circumstances, not only time and place but also possible worlds. It follows from this view that whatever is actually true must be taken as true with respect to every possible world, which means that all truths are (in a sense) necessary. However, (...) the account I shall propound is different from what is known in the trade as necessitarianism, i.e. the view that there is only one possible world, viz. the actual one, for the doctrine of the worldlessness of truth values, despite its commitment to the necessity of truths and falsehoods, is quite compatible with the idea of there being other possible worlds. Another important issue in chapter 2, explored in particular in section 2.12, is the claim that there is no real change in the world. Secondly, in chapter 3 I consider the eminent traditional argument for determinism, deriving from Aristotle, namely, logical determinism, i.e. determinism justified by an appeal to the logical principle of bivalence (that all proper statements, including those concerning the future, are either true or false). In this connection I try to show that, (i), the formulation of the conclusion of this argument as "Whatever will happen will happen of necessity" is implausible, at least from the modern point of view, (ii), the formulation as "Whatever will happen will happen inevitably" is more to the point, and (iii), on the basis of the worldless and timeless aspect advocated in chapter 2, this latter formulation is quite harmless, essentially amounting to the trivial statement, "Whatever will happen will happen". Thirdly, in chapter 4 I study theological determinism, or determinism that arises from God's supposed providential control over everything that happens. In this connection, I shall survey some historical accounts of the relation between human free will and determinism (not only theological but also causal determinism); the philosophers the views of whom I shall attend to include Chrysippus, St. Augustine, Boethius and Aquinas. I shall in particular consider G.W. Leibniz' theodicean aspirations, viz. his solution to the problem of evil and, especially, his compatibilist attempts to reconcile human free will with the strictly deterministic flow of actual events. I think it is important to try to explicate Leibniz' ingenious account of these matters, since it seems that it has not been fully appreciated in the literature, not even by contemporary Leibniz scholars (such as B. Mates, R.C. Sleigh, C. Wilson, R.M. Adams and D. Rutherford). In providing the Leibnizian compatibilist solution of the problem of determinism and freedom in chapter 4, I shall utilize the approach of chapter 2. (shrink)