What is the future of genetic testing during pregnancy likely to look like? Given that the patterns of use of genetic testing in neonatology tend to precede, and thus predict, patterns of prenatal...

Medical students newly arrived on the wards encounter frustrating ethical predicaments that are complicated by students' place in the hospital hierarchy. A careful scrutiny of medical social structure and culture may enable medical schools to offer their students a more effective ethics education.

... and the baby has a large VSD. Otherwise appears well, gaining weight, smiling. No apnea, never been on ventilator. Local cardiac surgeon refused to operate, saying that surgery would be inappropriate. Have reached out to other centers, and some state that they never perform what they said was “futile” heart surgery on children with Trisomy 18, while other sites say they have and will continue to perform these operations. Can someone explain to me what is going on? In the (...) realm of medical care—given enough patients, clinicians, and time—conflict is inevitable. Someone will want to do something, such as give a drug or start a new form of technologic support, and someone else will think that this is a... (shrink)

Hope is like water, existing in different states, exhibiting different properties.In the solid form, hope is manifest as specific hopes: I hope for this, I hope for that. In these concrete forms, solidified hope can become firm and fixed, for better and for worse. Dogged determination aimed at achieving a fixed hope is a very good characteristic—that is, until the continued pursuit of this specific solid hope becomes foolish, harmful, unwise. At the other end of the spectrum, in the gaseous (...) form, hope is amorphous, a glowing feeling that one has to tune into to detect, akin to optimism. In between these two states, hope is liquid. Flowing. Assuming the shape of whatever holds it. Carving, eroding, even dissolving.. (shrink)

The Surfactant, Positive Pressure, and Oxygenation Randomized Trial (SUPPORT) has been the focal point of many different criticisms regarding the ethics of the study ever since publication of the trial's findings in 2010 and 2012. In this article, we focus on a concern that the technical design and implementation details of the study were ethically flawed. While the federal Office Human Research Protections focused on the consent form, rather than on the study design and implementation, OHRP's critiques of the consent (...) form reveal views about the study design and implementation that we believe are fundamentally flawed. These criticisms about the design and implementation of SUPPORT, if generalized, become relevant concerns about these aspects of many comparative effectiveness research studies.Our analytical approach will be to use SUPPORT as a prime example of comparative effectiveness research and show why it challenges some prevailing assumptions about the riskiness of research. We will address five aspects of the study design and implementation: 1) randomization, 2) treatment by protocol, 3) choice of endpoints, 4) lack of a “standard care” control group, and 5) the use of altered oximeters. Examining these aspects will allow us to answer two specific central questions. The first is a methodological question with ethical implications: was the study designed in such a way as to answer the primary study question? The second question is whether the study design added or decreased risk to the babies enrolled in the study compared to babies who were not in the study. (shrink)

In November 2018, the practice of health care ethics consultation crossed a major threshold when 138 candidates took the inaugural Healthcare Ethics Consultant Certification Examination. This accomplishment, long in the making, has had and continues to have both advocates and critics. The Healthcare Ethics Consultant Certification Commission, a functionally autonomous body created and funded by the American Society for Bioethics and Humanities, was charged with overseeing creation of the certification process, developing the exam, and formulating certification standards and policies to (...) assess candidates’ qualifications. In this essay, as members of the commission, we describe the process of developing, administering, and scoring the certification examination as well as the historical context and the outlook for certification. By detailing the decisions and actions of the commission, we aim to provide a transparent account of the commission's efforts to develop a psychometrically sound, reliable, and secure examination through a deliberative, fair, and data‐driven process. (shrink)

My colleagues and I had been asked by a member of a clinical team to help sort through the ethics of stopping a life-sustaining intervention for a very ill child. We had already talked with the parents, the physicians, and the folks from nursing, social work, and chaplaincy. Terms like “suffering,” “cruel,” “compassion,” and “moral distress” had been uttered, as had terms like “inappropriate,” “unethical,” “neglectful,” and “risk-management.” The group had now stuffed all of these polarizing thoughts and feelings into (...) this cramped room with only one door. And everyone was looking at me. What skill, competency, or inner capacity must one possess to hold and manage such tension? (shrink)

In her classic 1969 book, On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy, and Their Own Families (Kübler-Ross 2014), Kübler-Ross identified many short-comings in the care...

Some of the most difficult clinical ethics consultations involve patients who have both medical and mental health needs, as these cases can result in considerable moral distress on the part of the bedside staff. In this article we examine the issues that such consults raise through the illustrative example of a particular case: several years ago our ethics consultation service received a request from a critical care attending physician who was considering a rarely performed psychosurgical intervention to address intractable and (...) life-threatening agitation and aggression in an adolescent patient for whom standard treatments had proven unsuccessful. We consider strategies that may be useful in addressing not only the ethical dilemmas or the clinical problems, but also the emotional, social, and moral distress that arise in delivering care in such complex cases, in which standard routine practices of care have been exhausted. In addition, we explore the processes that led to this situation and suggest ways to promote early recognition and intervention for similar cases in the future. (shrink)

A commentary on “Were There ‘Additional Foreseeable Risks’ in the SUPPORT Study?,” by Henry J. Silverman and Didier Dreyfuss; “SUPPORT: Risks, Harms, and Equipoise,” by Robert M. Nelson; “The Controversy over SUPPORT Continues and the Hyperbole Increases,” by Alan R. Fleischman; and “SUPPORT and Comparative Effectiveness Trials: What's at Stake?,” by Lois Shepherd, all in the January‐February 2015 issue.

The American Journal of Bioethics, Volume 11, Issue 11, Page 15-16, November 2011.

Machine learning is fundamental to multiple visions of health care’s future, from precision medicine 2020) to a model of health delivery and research...

Since the early 1980’s, with the clinical advent of in vitro fertilization resulting in so-called “test tube babies,” a wide array of ethical considerations and concerns regarding artificial womb technology (AWT) have been described. Recent breakthroughs in the development of extracorporeal neonatal life support by means of AWT have reinitiated ethical interest about this topic with a sense of urgency. Most of the recent ethical literature on the topic, however, pertains not to the more imminent scenario of a physiologically improved (...) method of neonatal care through AWT, but instead to the remote scenario of “complete ectogenesis” that imagines human gestation occurring entirely outside of the womb. This scoping review of the ethical literature on AWT spans from more abstract concerns about complete ectogenesis to more immediate concerns about the soon-to-be-expected clinical life support of what we term the fetal neonate or fetonate. Within an organizing framework of different stages of human gestational development, from conception to the viable premature infant, we discuss both already identified and newly emerging ethical considerations and concerns regarding AWT and the care of the fetonate. (shrink)

Along with potential benefits to healthcare delivery, machine learning healthcare applications raise a number of ethical concerns. Ethical evaluations of ML-HCAs will need to structure th...

Some children living with life-shortening medical conditions may wish to attend school without the threat of having resuscitation attempted in the event of cardiopulmonary arrest on the school premises. Despite recent attention to in-school do-not-attempt-resuscitation (DNAR) orders, no assessment of state laws or school policies has yet been made. We therefore sought to survey a national sample of prominent school districts and situate their policies in the context of relevant state laws. Most (80%) school districts sampled did not have policies, (...) regulations, or protocols for dealing with student DNARs. A similar majority (76%) either would not honor student DNARs or were uncertain about whether they could. Frequent contradictions between school policies and state laws also exist. Consequently, children living with life-shortening conditions who have DNARs may not have these orders honored if cardiopulmonary arrest were to occur on school premises. Coordinated efforts are needed to harmonize school district, state, and federal approaches in order to support children and families' right to have important medical decisions honored. (shrink)

Background While prenatal surgery historically was performed exclusively for lethal conditions, today intrauterine surgery is also performed to decrease postnatal disabilities for non-lethal conditions. We sought to describe physicians' attitudes about prenatal surgery for lethal and non-lethal conditions and to elucidate characteristics associated with these attitudes. Methods Survey of 1200 paediatric surgeons, neonatologists and maternal–fetal medicine specialists. Results Of 1176 eligible physicians, 670 responded. In the setting of a lethal condition for which prenatal surgery would likely result in the child (...) surviving with a severe disability, most respondents either disagreed or strongly disagreed that they would recommend the surgery. Male physicians were twice as likely to recommend surgery for the lethal condition, as were physicians who believe that abortion is morally wrong. Older physicians were less likely to recommend surgery. For non-lethal conditions, most respondents agreed that they would recommend prenatal surgery, even if the surgery increases the risk of prematurity or fetal death. Compared with MFMs, surgeons were less likely to recommend such surgery, as were physicians not affiliated with a fetal centre, and physicians who were religious. Conclusion Physician’s attitudes about prenatal surgery relate to physicians’ beliefs about disability as well as demographic, cultural and religious characteristics. Given the variety of views, parents are likely to receive different recommendations from their doctors about the preferable treatment choice. (shrink)

Volume 20, Issue 3, March 2020, Page 1-5.

Caring for children with life-shortening illnesses is a humbling task. While some decisions are simple and safe, the emotionally-charged choices regarding how to best care for these children often...

Background: Families and clinicians must often weigh competing priorities when making medical decisions for a pediatric patient at the end of life. Few empirical data exist regarding the importance that clinicians place on varying priorities and whether clinical practice conforms to decision-making standards discussed in the literature. Methods: We administered a discrete choice experiment to understand the relative importance of nine pediatric end-of-life decision-making priorities using responses from 364 nurses and physicians from three intensive care units (ICUs) (pediatric ICU, pediatric (...) cardiothoracic ICU, neonatal ICU) in a large children's hospital, with a 54% response rate. We used latent class analysis to characterize subgroups of health professionals based on their patterns of importance for the nine attributes and examined differences in class membership using multinomial logistic regression. Results: Eighty-two percent of respondents were nurses, consistent with the proportion of nurse and physician staff in the units. Latent class analysis separated our sample of health professionals into five distinct classes. All five groups rated the child's comfort and the best interests as most important but differed regarding how they valued other considerations: Group 1 rated highly consideration of the entire family and medical judgment; Group 2, the entire family's interests, parents’ preferences, and religious beliefs; Group 3, maintaining harmony between parents and medical team; Group 4, responsible use of medical resources; and Group 5, medical evidence and prolonging the child's life. Those with more years of experience were less likely to fall in Group 5 (medical evidence/life-prolonging). Profession was not associated with group membership. Conclusions: Nurses and physicians who care for dying children prioritize foremost the child's best interests and comfort but then possess varying secondary priorities about what is most important when making medical decisions. Pediatric palliative care and ethics consultative services should be aware of and prepared to address these differing concerns. (shrink)

Just as theory of representation is deficient if it can’t explain how misrepresentation is possible, a theory of computation is deficient if it can’t explain how miscomputation is possible. Nonetheless, philosophers have generally ignored miscomputation. My primary goal in this paper is to clarify both what miscomputation is and how to adequately explain it. Miscomputation is a special kind of malfunction: a system miscomputes when it computes in a way that it shouldn’t. To explain miscomputation, you must provide accounts of (...) computational behavior, computational norms, and how computational behavior can deviate from computational norms. A secondary goal of this paper is to defend an (quasi-)individualist, mechanistic theory of miscomputation. Computational behavior is narrowly individuated. Computational norms are widely individuated. A system miscomputes when its behavior manifests a narrow computational structure that the widely individuated norms say that it should not have. (shrink)

A timely, well-grounded analysis that reveals an inconvenient truth: we can't save capitalism and save the planet.

Public arguments can be good or bad not only as a matter of logic, but also in the sense that speakers can do good or bad things with arguments. For example, hate speakers use public arguments to contribute to the subordination of their targets. But how can ordinary speakers acquire the authority to perform subordinating speech acts? This is the ‘Authority Problem’. This paper defends a solution inspired by McGowan’s (Australas J Philos 87:389–407, 2009) analysis of oppressive speech, including against (...) concerns raised by McGowan (Just words: On speech and hidden harm, Oxford University Press, Oxford, 2019) herself. A deflated kind of authority can be gained from the hate speaker’s standing in a norm-governed ‘activity of oppression’. We should be wary about engaging with such speakers in public argument. Even if we counter their arguments, we may still elevate their standing within that activity and so enable them to perform more pernicious speech acts than was previously possible. (shrink)

International Political Theory focuses on the point where two fields of study meet - International Relations and Political Theory. It takes from the former a central concern with the 'international' broadly defined; from the latter it takes a broadly normative identity. IPT studies the 'ought' questions that have been ignored or side-lined by the modern study of International Relations and the 'international' dimension that Political Theory has in the past neglected. A central proposition of IPT is that the 'domestic' and (...) the 'international' cannot be treated as self-contained spheres, although this does not preclude states and the states-system from being regarded by some practitioners of IPT as central points of reference. This Handbook provides an authoritative account of the issues, debates, and perspectives in the field, guided by two basic questions concerning its purposes and methods of inquiry. First, how does IPT connect with real world politics? In particular, how does it engage with real world problems, and position itself in relation to the practices of real world politics? And second, following on from this, what is the relationship between IPT and empirical research in international relations? This Handbook showcases the distinctive and valuable contribution of normative inquiry not just for its own sake but also in addressing real world problems. The Oxford Handbooks of International Relations is a twelve-volume set of reference books offering authoritative and innovative engagements with the principal sub-fields of International Relations. The series as a whole is under the General Editorship of Christian Reus-Smith of the University of Queensland and Duncan Snidal of the University of Oxford, with each volume edited by a distinguished pair of specialists in their respective fields. The series both surveys the broad terrain of International Relations scholarship and reshapes it, pushing each sub-field in challenging new directions. Following the example of the original Reus-Smit and Snidal The Oxford Handbook of International Relations, each volume is organized around a strong central thematic by a pair of scholars drawn from alternative perspectives, reading its sub-field in an entirely new way, and pushing scholarship in challenging new directions. (shrink)

The authors survey some debates about the nature and structure of physical theories and about the connections between our physical theories and naturalized metaphysics. The discussion is organized around an “ideal view” of physical theories and criticisms that can be raised against it. This view includes controversial commitments regarding the best analysis of physical modalities and intertheory relations. The authors consider the case in favor of taking laws as the primary modal notion, discussing objections related to alleged violations of the (...) laws, the apparent need to appeal to causality, and the status of probability. The “ideal view” includes a commitment that fundamental physical theories are explanatorily sufficient. The authors discuss several challenges to recovering the manifest image from fundamental physics, along with a distinct challenge to reductionism based on acknowledging the contributions of less fundamental theories in physical explanations. (shrink)

"Feminism, Theory and the Politics of Difference" looks at the question of difference across the full spectrum of feminist theory from liberal, radical, lesbian ...

Recent clinical trials show that psychedelics such as LSD and psilocybin can be given safely in controlled conditions, and can cause lasting psychological benefits with one or two administrations. Supervised psychedelic sessions can reduce symptoms of anxiety, depression, and addiction, and improve well-being in healthy volunteers, for months or even years. But these benefits seem to be mediated by "mystical" experiences of cosmic consciousness, which prompts a philosophical concern: do psychedelics cause psychological benefits by inducing false or implausible beliefs about (...) the metaphysical nature of reality? This book is the first scholarly monograph in English devoted to the philosophical analysis of psychedelic drugs. Its central focus is the apparent conflict between the growing use of psychedelics in psychiatry and the philosophical worldview of naturalism. Within the book, Letheby integrates empirical evidence and philosophical considerations in the service of a simple conclusion: this "Comforting Delusion Objection" to psychedelic therapy fails. While exotic metaphysical ideas do sometimes come up, they are not, on closer inspection, the central driver of change in psychedelic therapy. Psychedelics lead to lasting benefits by altering the sense of self, and changing how people relate to their own minds and lives-not by changing their beliefs about the ultimate nature of reality. The upshot is that a traditional conception of psychedelics as agents of insight and spirituality can be reconciled with naturalism (the philosophical position that the natural world is all there is). Controlled psychedelic use can lead to genuine forms of knowledge gain and spiritual growth-even if no Cosmic Consciousness or transcendent divine Reality exists. Philosophy of Psychedelics is an indispensable guide to the literature for researchers already engaged in the field of psychedelic psychiatry, and for researchers-especially philosophers-who want to become acquainted with this increasingly topical field. (shrink)

Using a vague predicate can make commitments about the appropriate use of that predicate in the remaining part of the discourse. For instance, if I assert that some particular pig is fat, I am committed to judging any fatter pig to be fat as well. We can model this update effect by recognizing that truth depends both on the state of the world and on the state of the discourse: the truth conditions of ‘This pig is fat’ rule out evaluation (...) points for which the pig in question in world w is thinner than the cutoff for fatness in the discourse d. Then disagreements about taste are disagreements about the discourse. Unlike disagreements about the world, disagreements about the discourse can be faultless, given that none of the discourse participants has privileged authority to make pronouncements about conventions for appropriate use of a predicate. Thus on the dynamic view developed here, whether or not a dispute about taste turns out to be faultless depends in part on predictable features of the previous discourse. On this account, faultless disagreement involving predicates of personal taste does not force relativizing truth to a judge or assessor. (shrink)

What is the nature of deep disagreement? In this paper, I consider two similar albeit seemingly rival answers to this question: the Wittgensteinian theory, according to which deep disagreements are disagreements over hinge propositions, and the fundamental epistemic principle theory, according to which deep disagreements are disagreements over fundamental epistemic principles. I assess these theories against a set of desiderata for a satisfactory theory of deep disagreement, and argue that while the fundamental epistemic principle theory does better than the Wittgensteinian (...) theory on this score, the fundamental epistemic principle theory nevertheless struggles to explain the variety of deep disagreement. (shrink)

Users of psychedelic drugs often report that their sense of being a self or ‘I’ distinct from the rest of the world has diminished or altogether dissolved. Neuroscientific study of such ‘ego dissolution’ experiences offers a window onto the nature of self-awareness. We argue that ego dissolution is best explained by an account that explains self-awareness as resulting from the integrated functioning of hierarchical predictive models which posit the existence of a stable and unchanging entity to which representations are bound. (...) Combining recent work on the ‘integrative self' and the phenomenon of self-binding with predictive processing principles yields an explanation of ego dissolution according to which self-representation is a useful Cartesian fiction: an ultimately false representation of a simple and enduring substance to which attributes are bound which serves to integrate and unify cognitive processing across levels and domains. The self-model is not a mere narrative posit, as some have suggested; it has a more robust and ubiquitous cognitive function than that. But this does not mean, as others have claimed, that the self-model has the right attributes to qualify as a self. It performs some of the right kinds of functions, but it is not the right kind of entity. Ego dissolution experiences reveal that the self-model plays an important binding function in cognitive processing, but the self does not exist. (shrink)

This book takes concepts developed by researchers in theoretical computer science and adapts and applies them to the study of natural language meaning. Summarizing over a decade of research, Chris Barker and Chung-chieh Shan put forward the Continuation Hypothesis: that the meaning of a natural language expression can depend on its own continuation.

Philosophers often treat racist and sexist slurs as a special sort of puzzle. What is the difference between a slur and its correlates? In attempting to answer this question, a second distinction has been overlooked: that between slurs and insults. What makes a term count as a slur? This is not an unnecessary taxonomical question as long as ableist terms such as ‘moron’ are dismissed as mere insults. Attempts to resolve the insult/slur distinction by considering the communicative content of slurs (...) are not promising. A better solution is offered by speech act theory, and this paper develops a novel way to describe ordinary slurring utterances as oppressive speech acts. This can both explain the difference between slurs and insults, and challenge the dismissal of ableist terms. (shrink)