Patients who experience difficulty making medical decisions are often referred to as “ambivalent.” However, the current lack of attention to the nuances between a cluster of phenomena that resemble...

Extracorporeal membrane oxygenation (ECMO) is typically viewed as a time-limited intervention—a bridge to recovery or transplant—not a destination therapy. However, some patients with decision-making capacity request continued ECMO support despite a poor prognosis for recovery and lack of viability as a transplant candidate. In response, critical care teams have asked for guidance regarding the ethical permissibility of unilateral withdrawal over the objections of a capacitated patient. In this article, we evaluate several ethical arguments that have been made in favor of (...) withdrawal, including distributive justice, quality of life, patients’ rights, professional integrity, and the Equivalence Thesis. We find that existing justifications for unilateral withdrawal of ECMO support in capacitated patients are problematic, which leads us to conclude that either: (1) additional ethical arguments are necessary to defend this approach or (2) the claim that it is not appropriate to use ECMO as a destination therapy should be questioned. (shrink)

Bioethics, Volume 36, Issue 6, Page 613-620, July 2022.

Volume 20, Issue 2, February 2020, Page 66-68.

In this paper, we examine healthcare organizations’ responses to high profile cases of doctor–parent disagreement. We argue that, once a conflict crosses a certain threshold of public interest, the stakes of the disagreement change in important ways. They are no longer only the stakes of the child’s interests or who has decision‐making authority, but also the stakes of public trust in healthcare practitioners and organizations and the wide scale spread of medical misinformation. These higher stakes call for robust organization‐level responses. (...) There are responsible and thoughtful ways for healthcare organizations to directly engage with these cases. Hospitals should seek an alliance with the parents around the goal of public discussion and utilize web‐based platforms to provide the public with information about medical conditions, experimental treatments, and how clinical ethics deliberation in hospitals works. We outline five important lessons for healthcare organizations to keep in mind when responding to such cases. Approached with care, these cases could become “teachable moments” for both healthcare organizations and society. (shrink)

Hastings Center Report, Volume 52, Issue 1, Page 42-50, January/February 2022.

Given the enduring debate over what constitutes quality, and therefore appropriate training, in clinical ethics consultation, it is unsurprising that there is variation in the structure and content of clinical ethics fellowship programs. However, this variation raises questions about the value of fellowship training when the ethicists that emerge from these programs might be quite different. The specifics of fellowship programs are largely internal. As such, the extent of variation and whether such variation is problematic remains unclear. In this article, (...) we summarize lessons learned from discussions between fellows, their mentors and program directors at the 2020 Clinical Ethics UnConference, and outline some possible ways to advance the conversation about variation in fellowship programs and training. We argue for the more open sharing of training specifics in order to help break down the siloed nature of fellowship programs. Greater transparency could, firstly, allow for more robust reflection on and refinement of training practices and, secondly, allow us to better balance professionally appropriate consistency with unavoidable or desirable variation based on local norms, culture and leadership. (shrink)

In this article, I sort through some of the confusion surrounding what constitutes the controversial notion of a “good death” for children. I distinguish, first, between metaphysical and practical disagreements about the notion of a good death, and, second, between accounts of a good death that minimally and maximally promote the dying child’s interests. I propose a narrowed account of the dying child’s interests, because they differ from the interests of non-dying children. Importantly, this account illustrates how disagreements at the (...) end of a child’s life are sometimes the result of a shift from a future to a present-oriented understanding of the child’s interests on the part of some stakeholders but not others, and sometimes the result of a values-based disagreement about how different interests should be weighted. This brings into sharper focus the questions of for whom, and in what way, a child’s death might be considered good. (shrink)

‘Why Not Common Morality?’ revisits an important and enduring question: is medical ethics distinct from ‘everyday’ ethics? In her paper, Rosamond Rhodes undertakes the ambitious project of answering this question, in addition to clarifying what constitutes a profession, how professions differ from ‘roles’ and how medical ethics relates to medical professionalism. Rhodes aims to challenge the status quo within medical ethics by departing from the views of certain giants within the field. The paper’s central contention is that the ethics of (...) everyday life and medical ethics are indeed distinct—the latter cannot be derived from the former and we consequently need a new theory of medical ethics. While I am sympathetic to the aims of the project and took no small delight in Rhodes’s gumption, the paper suffers from a number of issues. Putting aside the issue of whether Rhodes accurately represents the theories she critiques—and that is no small thing to set aside—first, many scholars have interrogated in great depth, and from many angles, the relationship between common morality and medical ethics.1–4 Scholarship from the philosophy of medicine, virtue ethics, role-differentiated ethics, narrative and care ethics has made a significant contribution to the projects of clarifying what is distinct about medical professionalism and understanding how we might subsequently treat ethical issues that arise in healthcare with due sensitivity to these myriad differences.5–10 Yet, Rhodes largely ignores this literature …. (shrink)

Patients and families are increasingly turning to crowdfunding to help them cover the cost of medical care. The ethics of crowdfunding has garnered some attention in the bioethical literature. In this paper I examine an ethical aspect of medical crowdfunding (MCF) that has received limited attention: the role of donors. I defend a virtue ethical approach to analyzing the role of donors in MCF. Vicious donation, where donors do not exercise the relevant virtues, can compound some of the ethical risks (...) associated with MCF, as seen in the several recent, high‐profile cases. My primary contention in this paper is that encouraging donors to think about how donating to a particular campaign would measure against the virtues I outline could help to discourage acts of ethically problematic donation to MCF campaigns. (shrink)

While experience often affords important knowledge and insight that is difficult to garner through observation or testimony alone, it also has the potential to generate conflicts of interest and unrepresentative perspectives. We call this tension the paradox of experience. In this paper, we first outline appeals to experience made in debates about access to unproven medical products and disability bioethics, as examples of how experience claims arise in bioethics and some of the challenges raised by these claims. We then motivate (...) the idea that experience can be an asset by appealing to themes in feminist and moral epistemology, distinguishing between epistemic and justice-based appeals. Next, we explain the concern that experience may be a liability by appealing to empirical work on cognitive biases and theoretical work about the problem of partial representation. We conclude with preliminary recommendations for addressing the paradox and offer several questions for future discussion. (shrink)

Dominic Wilkinson suggests that one of Schubert’s songs has relevance for neonatologists today. In the song, Schubert suggests that death sometimes comes as a friend. Wilkinson ponders whether the song has a message for doctors and parents, who sometimes struggle to figure out whether death is an enemy or a friend to a dying baby. Wilkinson reflects on the case of baby ‘Hal’, who was born with serious cardiomyopathy. Hal’s parents and doctors disagree about whether to withdraw life-support. Through his (...) recreations of their discussions, Wilkinson shows how hard it is to confront—and maybe even welcome—death for a child. While adults often frame their own decision to forego life-sustaining treatment with thoughts that they have lived a good life, death in childhood can seem unfair because it robs the child of their opportunity to live a good or completed life. Much as we try, we cannot really imagine what a critically ill neonate experiences or desires. We have very little insight into Hal’s interests or subjective experience. Without direct access to the child’s experience, it is impossible to know whether, like an adult, a child would choose to allow death to occur. We cannot verify the claim that the child’s death was good in the sense that it was good for them. Wilkinson proposes that a prolonged dying process …. (shrink)

In their article, ‘The Two Front War on Reproductive Rights,’ Minkoff, Vullikanti, and Marshall (2024) highlight the challenges faced by pregnant persons following the overturn of Roe v. Wade (Dobb...

Clinical ethics services are increasingly receiving case referrals regarding requests for access to experimental therapies. Sometimes, patients or families seek access to an experimental therapy that has not been subsidised by any government scheme, and for which no local clinical trial is underway. All else being equal, a patient may benefit from receiving an experimental therapy without making any other patient worse off. However, within public healthcare systems, treating only one patient with an experimental therapy, when others might also benefit (...) from it, evokes a troubling sense of inequity. In this paper, I examine the relevance of Pareto principles and the ‘levelling down’ objection to ethical deliberation about patient or family-initiated requests for experimental therapies. While facilitating access to an experimental therapy may benefit a patient without making any other patients worse off, this does not dispel ethically relevant considerations concerning equity. When deliberating about cases i... (shrink)

While it is not explicitly included in capacity assessment tools, “consistency” has come to feature as a central concern when assessing patients’ capacity. In order to determine whether inconsistency indicates incapacity, clinicians must determine the source of the inconsistency with respect to the process or content of a patient’s decision-making. In this paper, we outline common types of inconsistency and analyze them against widely accepted elements of capacity. We explore the question of whether inconsistency necessarily entails a deficiency in a (...) patient’s capacity. While inconsistency may count as _prima_ _facie_ evidence of incapacity—enough evidence to justify a closer look—when making such determinations, it is important for clinicians to slow down, inquire about the reasons underlying the inconsistency and clearly show which of the elements of capacity the patient fails to satisfy. (shrink)

Tim Wardle’s 2018 documentary film Three Identical Strangers is an exploration of identity, family, and loss. It’s also about nature versus nurture and the boundaries of ethically permissible research, particularly research involving children. The film tells the story of identical triplets who were separated soon after birth in 1961. A different family adopted each boy, without being told that their son had two identical brothers. The adoption agency responsible for finding the families was collaborating with a group of researchers working (...) on a study about … something. Three Identical Strangers details the boys’ fight to obtain information about the study and for closure. But while the film may have received rave reviews, it left us feeling uneasy. We came away with two sets of questions, one having to do with the story that the film documents and the second with the ethics of filmmaking itself. (shrink)

In pediatric health care, parents and clinicians sometimes have competing ideas of what should be done for a child. In this article, we explore the idea that notions of what should be done for a child partly depend on one's perception of one's role in the child's life and care. Although role‐based appeals are common in health care, role‐differentiated approaches to understanding parent‐clinician conflicts are underexplored in the pediatric bioethics literature. We argue that, while the parental role is recognized as (...) having social content or value, and sometimes legal force, it is not always recognized as having ethical content or value, as the clinician's role is. We draw together key insights from the normative and empirical literature on parental roles to show how a role‐based lens might inform clinicians’ and clinical ethicists’ approach to cases in which parents and clinicians disagree. (shrink)

While it is not explicitly included in capacity assessment tools, “consistency” has come to feature as a central concern when assessing patients’ capacity. In order to determine whether inconsistency indicates incapacity, clinicians must determine the source of the inconsistency with respect to the process or content of a patient’s decision-making. In this paper, we outline common types of inconsistency and analyze them against widely accepted elements of capacity. We explore the question of whether inconsistency necessarily entails a deficiency in a (...) patient’s capacity. While inconsistency may count as prima facie evidence of incapacity—enough evidence to justify a closer look—when making such determinations, it is important for clinicians to slow down, inquire about the reasons underlying the inconsistency and clearly show which of the elements of capacity the patient fails to satisfy. (shrink)

I had been on the phone with Madeleine's mother for fifteen minutes, and she had sobbed throughout. She pleaded with me, “You won't even let our family visit her together. If you really want to help my daughter, you will let us stay with her.” Madeleine, who was twenty‐four years old, was dying of end‐stage acute myeloid leukemia and was intubated in one of our intensive care units. Her intensivist had requested a clinical ethics consultation for potentially inappropriate medical treatment—in (...) my world of clinical ethics consultation, routine stuff. Except that, in March 2020, nothing was routine anymore. The Covid‐19 pandemic calls for creative thinking about ad hoc and post hoc bereavement efforts, and it may result in efforts to revise existing accounts of what constitutes a good death in order to accommodate patients’ and families’ experiences at the end of life during a pandemic. (shrink)

The moral status of the emotion of grief has garnered little recognition in philosophical literature. Existing inquiry has consisted for the most part of deontological and virtue ethical approaches to evaluating grief. In my paper I build upon established understandings of the morality grief and move beyond them, towards an understanding of what I call “eros-transformative grief” as a gateway or intermediary emotion that enables a powerful reassessment and revaluation of the self’s relation to the world. This fundamental moral revaluation (...) is a result of the phenomenological absence of the relational self. The nature of grief reveals something vital about the way in which we relate to those around us—it is a fundamental reaffirmation of the inescapable separateness of the self, which can never truly be accepted without experiencing deep loss, but it is also a fundamental reaffirmation of the relationship that existed, and ultimately, of love. In eros-transformative grief, part of the grieving process involves accepting the permanency of our loss and moving past it through assimilating an intangible part of the lost loved one into the self. Thus, in addition to strengthening deontological and virtue ethical normative understandings of grief, I provide an account of eros-transformative grief that links it to the concept of love, allowing for a positive reading of an oft-neglected emotion. (shrink)

In “Acquiescence Is Not Agreement: The Problem of Marginalization in Pediatric Decision Making,” Caruso Brown argues that clinicians and ethicists should attend to voices marginalized by hie...

Questions about when to limit unhelpful treatments are often raised in general medicine but are less commonly considered in psychiatry. Here we describe a survey of U.S. psychiatrists intended to characterize their attitudes about the management of suicidal ideation in patients with severely treatment-refractory illness. Respondents (n = 212) received one of two cases describing a patient with suicidal ideation due to either borderline personality disorder or major depressive disorder. Both patients were described as receiving all guideline-based and plausible emerging (...) treatments. Respondents rated the expected helpfulness and likelihood of recommending each of four types of intervention: hospitalization, additional medication changes, additional neurostimulation, and additional psychotherapy. Across both cases, most respondents said they were likely to provide each intervention, except for additional neurostimulation in borderline personality disorder, while fewer thought each intervention would be helpful. Substantial minorities of respondents indicated that they would provide an intervention they did not think was likely to be helpful. Our results suggest that while most psychiatrists recognize the possibility that some patients are unlikely to be helped by available treatments, many would continue to offer such treatments. (shrink)

How should clinical ethicists be trained? Scholars have stated that clinical ethics fellowships create well-trained, competent ethicists. While this appears intuitive, few features of fellowship programs have been publicly discussed, let alone debated. In this paper, we examine how fellowships can foster effective mentoring relationships. These relationships provide the foundation for the fellow’s transition from novice to competent professional. In this essay, we begin by discussing our pedagogical commitments. Next, we describe the structures our program has created to assist our (...) fellows in becoming competent ethicists. We then outline the kinds of knowledge, skills, and professional attributes mentors should possess. Following this, we focus on the knowledge, skills, and professional attributes that fellows develop as they co-create effective mentoring relationships. We will not prescribe a single approach to fellowship training; instead, our perspective will, we hope, become a catalyst for further conversation on training and mentoring clinical ethics fellows. (shrink)

Current work in language models (LMs) helps us speed up or even skip thinking by accelerating and automating cognitive work. But can LMs help us with critical thinking -- thinking in deeper, more reflective ways which challenge assumptions, clarify ideas, and engineer new concepts? We treat philosophy as a case study in critical thinking, and interview 21 professional philosophers about how they engage in critical thinking and on their experiences with LMs. We find that philosophers do not find LMs to (...) be useful because they lack a sense of selfhood (memory, beliefs, consistency) and initiative (curiosity, proactivity). We propose the selfhood-initiative model for critical thinking tools to characterize this gap. Using the model, we formulate three roles LMs could play as critical thinking tools: the Interlocutor, the Monitor, and the Respondent. We hope that our work inspires LM researchers to further develop LMs as critical thinking tools and philosophers and other 'critical thinkers' to imagine intellectually substantive uses of LMs. (shrink)

The Constitution of the Athenians ascribed to Xenophon the orator.--The Politeia of the Spartans by Xenophon.--The Boeotian Constitution from the Oxyrhynchus historian.--The Constitution of Athens by Aristotle.

This essay is concerned with six linguistic moves that we commonly make, each of which is considered in turn. These are: stating rules of representation; representing things categorically; mentioning expressions; saying truly or falsely how things are; saying vaguely how things are; and stating rules of rules of representation. A common-sense view is defended of what is involved in our doing each of these six things against a much more sceptical view emanating from the idea that linguistic behavior is fundamentally (...) messy. Both the fifth move and the sixth move involve vague concepts, and much of the essay is concerned with developing an approach to various problems and puzzles that attach to such concepts, most notably the sorites paradoxes. (shrink)

This study investigated the link between meditation, self-reported mindfulness and cognitive flexibility as well as other attentional functions. It compared a group of meditators experienced in mindfulness meditation with a meditation-naïve control group on measures of Stroop interference and the “d2-concentration and endurance test”. Overall the results suggest that attentional performance and cognitive flexibility are positively related to meditation practice and levels of mindfulness. Meditators performed significantly better than non-meditators on all measures of attention. Furthermore, self-reported mindfulness was higher in (...) meditators than non-meditators and correlations with all attention measures were of moderate to high strength. This pattern of results suggests that mindfulness is intimately linked to improvements of attentional functions and cognitive flexibility. The relevance of these findings for mental balance and well-being are discussed. (shrink)

This essay argues for a two-part thesis concerning the deflationist theories of truth and reference. First, I identify two points of contrast between the deflationist theories and their traditional inflationary opponents: (1) they each employ different orders of explanation for the variety of semantic phenomena, and (2) the inflationist is typically taken to be beholden to a reductive explanation of reference, whereas the deflationist is doubtful of this project. Secondly, I argue that these two points of contrast need not come (...) together to exhaust the space of possible views. There is room for a plausible middle ground: a moderate version of inflationism. My moderate inflationism will reject the deflationist's order of explanation, so it counts as genuinely inflationary. However, it also rejects the reductionist ambitions of the earlier inflationists, so it isn’t an apt target for deflationary scepticism. (shrink)

Considerations of accuracy – the epistemic good of having credences close to truth-values – have led to the justification of a host of epistemic norms. These arguments rely on specific ways of measuring accuracy. In particular, the accuracy measure should be strictly proper. However, the main argument for strict propriety supports only weak propriety. But strict propriety follows from weak propriety given strict truth directedness and additivity. So no further argument is necessary.

We investigate the processes underlying the feeling of control over one’s actions . Sense of agency may depend on internal motoric signals, and general inferences about external events. We used priming to modulate the sense of agency for voluntary and involuntary movements, by modifying the content of conscious thought prior to moving. Trials began with the presentation of one of two supraliminal primes, which corresponded to the effect of a voluntary action participants subsequently made. The perceived interval between movement and (...) effect was used as an implicit measure of sense of agency. Primes modulated perceived intervals for both voluntary and involuntary movements, but the modulation was greatest for involuntary movements. A second experiment showed that this modulation depended on prime–movement contiguity. We propose that sense of agency is based on a combination of internal motoric signals and external sensory evidence about the source of actions and effects. (shrink)

A prevailing view is that while human communication has an ‘ostensive-inferential’ or ‘Gricean’ intentional structure, animal communication does not. This would make the psychological states that support human and animal forms of communication fundamentally different. Against this view, I argue that there are grounds to expect ostensive communication in non-human clades. This is because it is sufficient for ostensive communication that one intentionally address one’s utterance to one’s intended interlocutor – something that is both a functional pre-requisite of successful communication (...) and cognitively undemanding. Furthermore, while ostension is an important feature of intentional communication, the inferences required in Gricean communication may be minimal: ostension and inference may come apart. The grounds for holding that animal communication could not be Gricean are therefore weak. I finish by defending the idea that a ‘minimally Gricean’ model of communication is a valuable tool for characterising the communicative interactions of many animal species. (shrink)

It is natural to think that there is something epistemically objectionable about avoiding evidence, at least in ideal cases. We argue that this thought is inconsistent with a kind of risk-avoidance...

In print for the first time in over ten years, Act and Crime provides a unified account of the theory of action presupposed by both Anglo-American criminal law and the morality that underlies it. The book defends the view that human actions are always volitionally caused bodily movements and nothing else. The theory is used to illuminate three major problems in the drafting and the interpretation of criminal codes: 1) what the voluntary act requirement both does and should require; 2) (...) what complex descriptions of actions prohibited by criminal codes both do and should require ; and 3) when two actions are 'the same' for purposes of assessing whether multiple prosecutions and multiple punishments are warranted. The book both contributes to the development of a coherent theory of action in philosophy, and it provides both legislators and judges a grounding in three of the most basic elements of criminal liability. (shrink)

This comprehensive introductory text with readings offers a historical overview of all major subdivisions of Western Philosophy perspectives--including both the analytic and Continental traditions--as well as Eastern philosophy, postcolonial philosophy, and feminist philosophy. Written in an engaging and captivating style, it makes philosophy accessible without oversimplifying the material, and shows that philosophy's powerful ideas affect the lives of real people.

This essay argues that the concept of ‘reasonableness’plays an important role in Scanlon's, Rawls's, and Barry's theories of justice (or morality). The relationship between moral motivation and reasonableness is critically analysed. Specifically, the paper questions whether it is plausible to impute to the agents of construction the desire ‘to justify our actions to others on impartial terms’. It also argues that most of the work is done by the assumption that people are reasonable rather than by the contractarian formulation. Indeed, (...) the paper argues, the argument could proceed entirely by making explicit and arguing for the moral assumptions embedded in the concept of reasonableness [1]. (shrink)

G. E. Moore was a central figure in twentieth-century philosophy. Along with Russell and Wittgenstein, he pioneered analytic philosophy, and his Principia Ethica shaped the contours of twentieth-century ethics. Indeed, until the publication of Rawls's A Theory of Justice, no single book in moral philosophy was to equal Principia's influence. Unfortunately, however, Principia Ethica has so dominated critical discussions of Moore's work that even experts on his moral philosophy have tended to ignore his Ethics, which he published eight (...) years later. But Ethics is Moore's only other book on moral philosophy, and one of only a handful of post-Principia publications dealing with ethics. Its detailed discussions of utilitarianism, free will, and the objectivity of moral judgements find no real counterpart in Principia while its account of right and wrong and of the nature of intrinsic value deepen our understanding of his moral philosophy. The republication of Ethics thus rounds out our understanding of Moore's ethical thought. But the book's value goes beyond its historical or scholarly interest. A short but philosophically rich text, Ethics stands independent of Principia and repays careful study in its own right. By raising a number of fundamental questions in ethics, questions that remain live today, by proffering clear, credible, and often innovative answers to them, and by doing so with a philosophical skill that is still impressive, Moore's short book is a minor classic. Almost a century after its original publication, it still amply rewards those who read it.This new edition of Moore's Ethics includes his essay 'The Nature of Moral Philosophy' as well as editorial notes, an introduction, and a guide to further reading. (shrink)