Book reviewed in this article: In That Case: Medical Ethics in Everyday Practice. By Alastair Campbell and Roger Higgs. Medical Genetics Casebook: A Clinical Introduction to Medical Ethics Systems Theory. By Colleen D. Clements. Cases in Bioethics from the Hastings Center Report. Edited by Carol Levine and Robert M. Veatch. Hastings‐on‐Hudson.

Discussions of research involving vulnerable populations have left the homeless comparatively ignored. Participation by these subjects in drug studies has the potential to be upsetting, inconvenient, or unpleasant. Participation occasionally produces injury, health emergencies, and chronic health problems. Nonetheless, no ethical justification exists for the categorical exclusion of homeless persons from research. The appropriate framework for informed consent for these subjects of pharmaceutical research is not a single event of oral or written consent, but a multi-staged arrangement of disclosure, dialogue, (...) and permission-giving. Payments and other rewards in biomedical research raise issues of whether it is ethical to offer inducements to the homeless in exchange for participation in drug studies. Such inducements can influence desperate persons who are seriously lacking in resources. The key is to strike a balance between a rate of payment high enough that it does not exploit subjects by underpayment and low enough that it does not create an irresistible inducement. This proposal does not underestimate the risks of research, which are often overestimated and need to be appraised in light of the relevant empirical literature. (shrink)

The spread of new information and communications technologies during the past two decades has helped reshape civic associations, political communities, and global relations. In the midst of the information revolution, we find that the speed of this technology-driven change has outpaced our understanding of its social and ethical effects. The moral dimensions of this new technology and its effects on social bonds need to be questioned and scrutinized: Should the Internet be understood as a new form of public space and (...) a source of public good? What are we to make of hackers? Does the Internet strengthen or weaken community? In The Internet in Public Life, essayists confront these and other important questions. This timely and necessary volume makes clear the need for a broader conversation about the effects of the Internet, and the questions raised by these seven essays highlight some of the most pressing issues at hand. (shrink)

The recent literature on mental causation has not been kind to nonreductive, materialist functionalism (‘functionalism’, hereafter, except where that term is otherwise qualified). The exclusion problem2 has done much of the damage, but the epiphenomenalist threat has taken other forms. Functionalism also faces what I will call the ‘problem of metaphysically necessary effects’ (Block, 1990, pp. 157-60, Antony and Levine, 1997, pp. 91-92, Pereboom, 2002, p. 515, Millikan, 1999, p. 47, Jackson, 1998, pp. 660-61). Functionalist mental properties are individuated (...) partly by their relation to the very effects those properties’ instantiations are thought to cause. Consequently, functionalist causal generalizations would seem to have the following problematical structure: The state of being, among other things, a cause of e (under such-andsuch conditions) causes e (under those conditions).3 The connection asserted lacks the contingency one would expect of a causal generalization. Mental states of the kind in question are, by metaphysical necessity, causes of e; any state that does not cause e is thereby a different kind of state. Yet, a mental state’s being the sort of state it is must play some causal role if functionalism is to account for mental causation.4 In what follows, I first articulate more fully the problem of metaphysically necessary effects. I then criticize three functionalist attempts to solve the problem directly. Given the failure of functionalist efforts to meet the problem head-on, I consider less direct strategies: these involve formulating functionalism or its causal claims in such a way that they appear not to generate the problem of metaphysically necessary effects. I argue against these indirect solutions, in each case concluding either that the problem still arises or that avoiding it requires the adoption of an unorthodox form of functionalism (itself a surprising result). In the final.. (shrink)

We believe that the professional responsibility of bioscience and biotechnology professionals includes a social responsibility to contribute to the resolution of ethically fraught policy problems generated by their work. It follows that educators have a professional responsibility to prepare future professionals to discharge this responsibility. This essay discusses two pilot projects in ethics pedagogy focused on particularly challenging policy problems, which we call “fractious problems”. The projects aimed to advance future professionals’ acquisition of “fractious problem navigational” skills, a set of (...) skills designed to enable broad and deep understanding of fractious problems and the design of good policy resolutions for them. A secondary objective was to enhance future professionals’ motivation to apply these skills to help their communities resolve these problems. The projects employed “problem based learning” courses to advance these learning objectives. A new assessment instrument, “Skills for Science/Engineering Ethics Test”, was designed and administered to measure the success of the courses in doing so. This essay first discusses the rationale for the pilot projects, and then describes the design of the pilot courses and presents the results of our assessment using SkillSET in the first pilot project and the revised SkillSET 2.0 in the second pilot project. The essay concludes with discussion of observations and results. (shrink)

The Structural Allegory is an important contribution to the evaluation of both structuralist and post-structuralist French social theory. What is particularly exciting about this volume is that the ten contributors represent a disciplinary breadth that is as far reaching as the impact of the new French thought itself. In addition, several authors (D'Amico, O'Neill, Levin, and Fekete) challenge directly the structuralist and post-structuralist failure to address the historicity of social formations, the constitutive dimension of human agency, and domination. However, all (...) the contributors argue convincingly that post-structuralism has something to offer through its antiempiricist and anti-rationalist framework that brings into question the presuppositions of western epistemology. (shrink)

The explanatory gap . Consciousness is a mystery. No one has ever given an account, even a highly speculative, hypothetical, and incomplete account of how a physical thing could have phenomenal states. Suppose that consciousness is identical to a property of the brain, say activity in the pyramidal cells of layer 5 of the cortex involving reverberatory circuits from cortical layer 6 to the thalamus and back to layers 4 and 6,as Crick and Koch have suggested for visual consciousness. .) (...) Still, that identity itself calls out for explanation! Proponents of an explanatory gap disagree about whether the gap is permanent. Some say that we are like the scientifically naive person who is told that matter = energy, but does not have the concepts required to make sense of the idea. If we can acquire these concepts, the gap is closable. Others say the gap is uncloseable because of our cognitive limitations. Still others say that the gap is a consequence of the fundamental nature of consciousness. (shrink)

The Covid-19 pandemic has led to severe shortages of many essential goods and services, from hand sanitizers and N-95 masks to ICU beds and ventilators. Although rationing is not unprecedented, never before has the American public been faced with the prospect of having to ration medical goods and services on this scale.

_A moving meditation on recent geopolitical crises, viewed through the lens of ancient and modern tragedy__ “Spare, elegant and poignant.... If there is a single contemporary book that should be pressed into the hands of those who decide issues of war and peace, this is it.”—John Gray, _New Statesman_ “It is tragic that Robert D. Kaplan’s luminous _The Tragic Mind_ is so urgently needed.”—George F. Will_ Some books emerge from a lifetime of hard-won knowledge. Robert D. Kaplan has (...) learned, from a career spent reporting on wars, revolutions, and international politics in Europe, the Middle East, and East Asia, that the essence of geopolitics is tragedy. In _The Tragic Mind_, he employs the works of ancient Greek dramatists, Shakespeare, German philosophers, and the modern classics to explore the central subjects of international politics: order, disorder, rebellion, ambition, loyalty to family and state, violence, and the mistakes of power. The great dilemmas of international politics, he argues, are not posed by good versus evil—a clear and easy choice—but by contests of good versus good, where the choices are often searing, incompatible, and fraught with consequences. A deeply learned and deeply felt meditation on the importance of lived experience in conducting international relations, this is a book for everyone who wants a profound understanding of the tragic politics of our time. (shrink)

The purpose of Plato’s investigation of justice in the ideal polis of the Republic is neither to formulate an abstract conception of justice in itself nor to work out a blueprint for the perfectly just state. Rather, through the contemplation of an ideal social/political order where justice might be found “writ large,” Plato intends to bring about the actualization of justice in the “polity” of the individual soul. It must be kept in mind, of course, that, while possessing a notion (...) of the individual, the Greeks lacked our modern, Cartesian conception of subjectivity, burdened as it is with the existential task of creating and sustaining a meaningful cosmos. But precisely for this reason the ancients had a clearer perspective of the synergistic and mutually determinative dialectic that conjoins the individual and the state, a conjunction grounded in the ethical. This can be seen, Hegel suggests, in terms of the “unwritten and infallible law” that Antigone takes to be the “law of the gods” which “is right because it is what is right,” placing the individual “within the ethical substance; and this substance is thus the essence of self-consciousness.”. (shrink)

Despite its familiarity and widespread acceptance, the concept of “brain death” remains incoherent in theory and confused in practice. Moreover, the only purpose served by the concept is to facilitate the procurement of transplantable organs. By abandoning the concept of brain death and adopting different criteria for organ procurement, we may be able to increase both the supply of transplantable organs and clarity in our understanding of death.

Stolorow and his collaborators' post-Cartesian psychoanalytic perspective – intersubjective-systems theory – is a phenomenological contextualism that illuminates worlds of emotional experience as they take form within relational contexts. After outlining the evolution and basic ideas of this framework, Stolorow shows both how post-Cartesian psychoanalysis finds enrichment and philosophical support in Heidegger's analysis of human existence, and how Heidegger's existential philosophy, in turn, can be enriched and expanded by an encounter with post-Cartesian psychoanalysis. In doing so, he creates an important psychological (...) bridge between post-Cartesian psychoanalysis and existential philosophy in the phenomenology of emotional trauma. (shrink)

Robert Rupert argues against the view that human cognitive processes comprise elements beyond the boundary of the organism, developing a systems-based conception in place of this extended view. He also argues for a conciliatory understanding of the relation between the computational approach to cognition and the embedded and embodied views.

We seek to change the conversation about brain death by highlighting the distinction between brain death as a biological concept versus brain death as a legal status. The fact that brain death does not cohere with any biologically plausible definition of death has been known for decades. Nevertheless, this fact has not threatened the acceptance of brain death as a legal status that permits individuals to be treated as if they are dead. The similarities between “legally dead” and “legally blind” (...) demonstrate how we may legitimately choose bright-line legal definitions that do not cohere with biological reality. Not only does this distinction bring conceptual coherence to the conversation about brain death, but it has practical implications as well. Once brain death is recognized as a social construction not grounded in biological reality, we create the possibility of changing the social construction in ways that may better serve both organ donors and recipients alike. (shrink)

The concept of brain death has become deeply ingrained in our health care system. It serves as the justification for the removal of vital organs like the heart and liver from patients who still have circulation and respiration while these organs maintain viability. On close examination, however, the concept is seen as incoherent and counterintuitive to our understandings of death. In order to abandon the concept of brain death and yet retain our practices in organ transplantation, we need to either (...) change the definition of death or no longer maintain a commitment to the dead donor rule, which is an implicit prohibition against removing vital organs from individuals before they are declared dead. After exploring these two options, the author argues that while new definitions of death are problematic, alternatives to the dead donor rule are both ethically justifiable and potentially palatable to the public. Even so, the author concludes that neither of these approaches is likely to be adopted and that resolution will most probably come when technological advances in immunology simply make the concept of brain death obsolete. (shrink)

Trauma and Human Existence effectively interweaves two themes central to emotional trauma--the first pertains to the contextuality of emotional life in general, and of the experience of emotional trauma in particular, and the second pertains to the recognition that the possibility of emotional trauma is built into the basic constitution of human existence. This volume traces how both themes interconnect, largely as they crystallize in the author’s personal experience of traumatic loss. As discussed in the book's final chapter, whether or (...) not this constitutive possibility will be brought lastingly into the foreground of our experiential world depends on the relational contexts in which we live. (shrink)

Savulescu and colleagues have provided interesting insights into how the UK public view the ‘best interests’ of children like Charlie Gard. But is best interests the right standard for evaluating these types of cases? In the USA, both clinical decisions and legal judgments tend to follow the ‘harm principle’, which holds that parental choices for their children should prevail unless their decisions subject the child to avoidable harm. The case of Charlie Gard, and others like it, show how the USA (...) and the UK have strikingly different approaches for making decisions about the treatment of severely disabled children. (shrink)

The concept of brain death was recently described as being “at once well settled and persistently unresolved.” Every day, in the United States and around the world, physicians diagnose patients as brain dead, and then proceed to transplant organs from these patients into others in need. Yet as well settled as this practice has become, brain death continues to be the focus of controversy, with two journals in bioethics dedicating major sections to the topic within the last two years.By way (...) of background, the Uniform Determination of Death Act states that “[a]n individual who has sustained either: irreversible cessation of circulatory and respiratory functions, or irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.” In other words, death can be defined by either cardiorespiratory or neurological criteria, with “brain death” representing the loss of all brain function. This standard, or closely related variants, has become the accepted approach throughout the United States and in many parts of the world. (shrink)

Over the past several decades, medical ethics has gained a solid foothold in medical education and is now a required course in most medical schools. Although the field of medical ethics is by nature eclectic, moral philosophy has played a dominant role in defining both the content of what is taught and the methodology for reasoning about ethical dilemmas. Most educators largely rely on the case‐based method for teaching ethics, grounding the ethical reasoning in an amalgam of theories drawn from (...) moral philosophy, including consequentialism, deontology, and principlism.In this article we hope to make a case for augmenting the focus of education in medical ethics. We propose complementing the traditional approach to medical ethics with a more embedded approach, one that has been described by others as “microethics,” the ethics of everyday clinical practice. (shrink)

This essay joins Wilhelm Dilthey’s conception of the metaphysical impulse as a flight from the tragedy of human finitude with Ludwig Wittgenstein’s understanding of how language bewitches intelligence. We contend that there are features of the phenomenology of language that play a constitutive and pervasive role in the formation of metaphysical illusion.

This special report is published in commemoration of the fiftieth anniversary of the “Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death,” a landmark document that proposed a new way to define death, with implications that advanced the field of organ transplantation. This remarkable success notwithstanding, the concept has raised lasting questions about what it means to be dead. Is death defined in terms of the biological failure of the organism to (...) maintain integrated functioning? Can death be declared on the basis of severe neurological injury even when biological functions remain intact? Is death essentially a social construct that can be defined in different ways, based on human judgment? These issues, and more, are discussed and debated in this report by leading experts in the field, many of whom have been engaged with this topic for decades. (shrink)

Jahi McMath's case has raised challenging uncertainties about one of the most profound existential questions that we can ask: how do we know whether someone is alive or dead? The case is striking in at least two ways. First, how can it be that a person diagnosed as dead by qualified physicians continued to live, at least in a biological sense, more than four years after a death certificate was issued? Second, the diagnosis of brain death has been considered irreversible; (...) in fact, there has never been a case of a person correctly diagnosed as brain‐dead who improved to the point that the person no longer fulfilled the diagnostic criteria. If the neurologist Alan Shewmon is correct that, prior to her cardiac arrest in June 2018, McMath no longer met the criteria for brain death and was actually in a minimally conscious state, this case could have momentous implications for how we think about this diagnosis going forward. In this essay, I will offer a hypothesis that could, perhaps, explain both these aspects of the case. The hypothesis is based on differences in how we distinguish between biological and legal categories. The law tends to prefer to draw bright‐line distinctions between categories, whereas biological categories tend to fall along a spectrum, without sharp distinctions. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:IRBs Under the MicroscopeJonathan D. Moreno (bio)The spring and summer of 1998 were seasons in the sun for institutional review board (IRB) aficionados. Rarely have the arcana of the local human subjects review panels been treated to so much attention in both the executive and the legislative branches of government, not only at the federal but also at the state level. And it looks as if the attention will (...) continue for some time. The spate of interest is due to a series of coincidences: a powerful House of Representatives subcommittee held hearings after its chairman learned about the IRB system during a previous session on research in underdeveloped communities; the Department of Health and Human Services’s Inspector General (DHHS-IG) released a report on IRBs; the National Institutes of Health (NIH) Office of Extramural Research completed a report on clinical trial monitoring; the National Bioethics Advisory Commission (NBAC) readied a report on research involving persons with mental disorders; the states of Maryland and New York completed studies of research with subjects who lack decision-making capacity; and advocacy groups protested a psychiatric research project involving inner city children.Underlying these proximate causes for the IRB blitz is a growing realization that the already considerable clinical trial enterprise will expand significantly over the next few years. Congress is talking about giving the politically popular NIH half again the budget it currently receives, which in turn will stimulate more commercially supported research. The director of the National Cancer Institute is considering a five-fold increase in the number of subjects enrolled in oncology studies over the next several years. Phase I cancer studies are among the most ethically sensitive, so IRBs will have more work cut out for them if this goal is reached. Adding to the rush of interest in IRBs are the government’s recent apology to the survivors of the syphilis study in Tuskegee, continuing congressional dissatisfaction with the way the Pentagon handled its vaccine distribution during the Gulf War, and the controversy about AZT trials in developing countries.On the HillCongressman Christopher Shays, the moderate Connecticut Republican who has developed an interest in human research issues, convened hearings on human [End Page 329] subjects research and the IRB system on 11 June 1998. Shays chairs the House Government Reform/Human Resources Subcommittee. The committee’s ranking minority member is Edolphus Towns of Brooklyn, NY, who shares Shays’s interest in this area.The immediate rationale for the hearings was the release that day of the DHHS-IG report, Institutional Review Boards: A Time for Reform. The subtitle was changed from A System in Jeopardy apparently after some people in DHHS expressed reservations about its seemingly alarmist tone, but the IG staffers who testified before Shays’s subcommittee insisted that they stood behind the message that the IRB system is in trouble if considerable reforms are not undertaken. Among the factors in the research environment cited as support for the bleak forecast: managed care, commercialization, multi-site trials, high IRB workloads, minimal IRB oversight of approved studies, conflicts of interest, insufficient training of IRB members and investigators, and lack of IRB self-studies (DHHS-IG 1998).As is normally the case for congressional oversight hearings, the first panel of witnesses consisted of executive branch officials, including Eric Meslin, Executive Director of the National Bioethics Advisory Commission, and Gary Ellis, Director of the Office for Protection from Research Risks (OPRR). Shays pressed Ellis on the extent to which OPRR conducts on-site investigations of complaints about abuse of human subjects. Admitting that on-site investigations are rare, Ellis suggested that the agency is inadequately staffed to follow up on complaints as quickly as it might wish. The members of Congress who were present at the hearings generally expressed concern about the DHHS-IG’s findings.The second panel that day, which Shays was unable to attend, set a different tone. Four of the panelists—Paul Appelbaum of the University of Massachusetts at Worcester, Robert Levine of Yale University, Angela Bowen of the Western IRB (a private clinical trials review firm), and I—were invited as authorities on the current condition of the IRB system. Bert Spilker... (shrink)

Recent debates over adults' theory of mind use have been fueled by surprising failures of perspective-taking in communication, suggesting that perspective-taking may be relatively effortful. Yet adults routinely engage in effortful processes when needed. How, then, should speakers and listeners allocate their resources to achieve successful communication? We begin with the observation that the shared goal of communication induces a natural division of labor: The resources one agent chooses to allocate toward perspective-taking should depend on their expectations about the other's (...) allocation. We formalize this idea in a resource-rational model augmenting recent probabilistic weighting accounts with a mechanism for (costly) control over the degree of perspective-taking. In a series of simulations, we first derive an intermediate degree of perspective weighting as an optimal trade-off between expected costs and benefits of perspective-taking. We then present two behavioral experiments testing novel predictions of our model. In Experiment 1, we manipulated the presence or absence of occlusions in a director–matcher task. We found that speakers spontaneously modulated the informativeness of their descriptions to account for “known unknowns” in their partner's private view, reflecting a higher degree of speaker perspective-taking than previously acknowledged. In Experiment 2, we then compared the scripted utterances used by confederates in prior work with those produced in interactions with unscripted directors. We found that confederates were systematically less informative than listeners would initially expect given the presence of occlusions, but listeners used violations to adaptively make fewer errors over time. Taken together, our work suggests that people are not simply “mindblind”; they use contextually appropriate expectations to navigate the division of labor with their partner. We discuss how a resource-rational framework may provide a more deeply explanatory foundation for understanding flexible perspective-taking under processing constraints. (shrink)

This paper engages critically with anti-representationalist arguments pressed by prominent enactivists and their allies. The arguments in question are meant to show that the “as-such” and “job-description” problems constitute insurmountable challenges to causal-informational theories of mental content. In response to these challenges, a positive account of what makes a physical or computational structure a mental representation is proposed; the positive account is inspired partly by Dretske’s views about content and partly by the role of mental representations in contemporary cognitive scientific (...) modeling. (shrink)

Summary of claims: (1) One of the most important relationships between the ontical and the ontological in Heidegger’s thought is the central, ontologically revelatory role that he gives to moods. (2) Heidegger uses the word “mood” as a term of art to refer to the whole range of disclosive affectivity. (3) Because of the role that Heidegger grants to mood as a primordial way of disclosing Being-in-the-world, and because it is impossible to think mood without also thinking the lived body, (...) Heidegger has placed the latter at the center of Dasein’s disclosedness. (4) Heidegger’s account of mood thus entails and highlights, rather than neglects, the ontological significance of the body. (shrink)

Clinical ethics is a relatively new discipline within medicine, generated not so much by the Can we . . . ? questions of fact and prognosis that physicians ...

Historically, the practice of medicine has been a physically intimate endeavor. Physicians have used their hands to palpate and reveal the secrets hidden within the body. Smelling the breath for the ketosis of diabetes or tasting the skin for the saltiness of cystic fibrosis were among the physician's essential practices. Today, perhaps the most defining characteristic of a brilliant clinician is the ability to synthesize many images—from electrocardiograms, ultrasounds, CT scans, and so forth—into a coherent picture that can guide our (...) diagnosis and treatment. Yet this is rapidly becoming a Sisyphean task. Just as we are about to drown in a deluge of data, AI is throwing us a life preserver, to save not only our patients but ourselves. But where will AI take us? (shrink)