Editors provide a substantive introduction to the history and theories of perfectionism and neutrality, expertly contextualizing the essays and making the collection accessible.

Shared views regarding the moral respect which is owed to children in family life are used as a guide in determining the moral permissibility of nontherapeutic clinical research procedures involving children. The comparison suggests that it is not appropriate to seek assent from the preadolescent child. The analogy with interventions used in family life is similarly employed to specify the permissible limit of risk to which children may be exposed in nontherapeutic research procedures. The analysis indicates that recent writers misconceive (...) how certain moral principles, such as respect for personal autonomy, require us to act toward children. The results are also used to assess proposed federal regulations on research with children. (shrink)

Should a brain-dead woman be artificially maintained for the sake of her fetus? Does a physician have the right to administer a life-saving transfusion despite the patient's religious beliefs? Can a family request a hysterectomy for their retarded daughter? Physicians are facing moral dilemmas with increasing frequency. But how should these delicate questions be resolved and by whom? A Casebook of Medical Ethics offers a real-life view of the central issue involved in clinical medical ethics. Since the analysis of cases (...) plays a critical role in this study, the authors have assembled a broad collection of histories encountered in their work as medical ethics educators and consultants. The cases are developed in substantial detail to reflect the rich medical and psychosocial complexity involved, and each is brought to a decision point at which a course of action must be chosen. Among the issues examined are conflicts between patients' wishes and respect for their well-being, tensions concerning duties to patients unable to care for themselves and obligations to family members, and clashes between patient care obligations and the interests of other persons, including physicians, third parties, and the general public. The book also includes commentaries that combine general discussion of ethical principles with specific analysis of the cases examined in the text, as well as various options for resolving conflicts. Readers are invited to assess the comparative merits and liabilities of these approaches. An ideal text for undergraduate and medical school courses, A Casebook of Medical Ethics brings readers to the forefront of medicine, where they share in the determination of crucial ethical decisions. (shrink)

Two dogmas of liberalism in the therapeutic setting are challenged: (1) that patients have a ready-made ability to act autonomously; and (2) that non-intervention by physicians is the best strategy for protecting the autonomy of patients. Recognition of the impact of illness upon autonomous behavior forms the basis of this challenge. It is suggested that autonomy is better conceived as a process of personal growth by which patients become better able to overcome the disruptive effects of illness. The physician is (...) assigned an active role in the achievement of this therapeutic goal. The implications of this new liberal theory are illustrated by reference to the informed consent issue. (shrink)

Basson's commentary on my proposals regarding the structure and function of research in bioethics provides a welcome opportunity for extended comparison of standard approaches with the suggestions made in ‘What Bioethics Should Be.’ I begin by noting a common assumption underlying our respective views. I then address points of fundamental difference, indicating why the experimental method proposed in my original essay presents a potentially more productive strategy for examining moral issues in biomedicine. In the latter respect, I certainly disagree with (...) Basson's contention that "we are unable to test" metaethical hypotheses "against reality" (Basson, p. 185) – a proposition which seems no more defensible than the equally untenable claim that we cannot refine methods of natural science research through examination of their usefulness in advancing our understanding of the correlation of events in nature. (shrink)

The view of names that plantinga advances in "the nature of necessity" seems to have unacceptable consequences for names in propositional attitude contexts. In this paper, I argue that he is unsuccessful in his attempt to avoid these consequences.

Although we are still in the dark when it comes to giving necessary and jointly sufficient criteria for what it takes to be thinking a singular thought, the paradigm cases are just ones where an agent is thinking about some particular object. When we erroneously think that Vulcan is a planet, our thought appears to be singular since it is, after all, about Vulcan. A promising way to explain this is to claim that there is something, a merely hypothetical entity, (...) that is Vulcan. There have been notable supporters for positing hypothetical entities for some time now, but the account of how we create hypothetical entities is still underdeveloped. In fact, we face a puzzle if we assume: hypothetical entities are created by us; we create a given hypothetical entity only when we falsely hypothesize something to be the unique F; we create the hypothetical entity long before we learn that there is no unique F. How can we possibly manage to conditionally and unknowingly create some entity when there is no unique F? In showing how this is possible, it will become clear that we have good reason for preferring a view that posits hypothetical entities over the alternative ways of accounting for our apparently singular thoughts about Vulcan, Pegasus, the Fountain of Youth, and so on. (shrink)

Fiction can help make students better thinkers about some philosophical issues, but this does not mean it will make them morally better people.

This paper describes a practice innovation: the addition of formal weekly discussions of patients with prolonged PICU stay to reduce healthcare providers’ moral distress and decrease length of stay for patients with life-threatening illnesses. We evaluated the innovation using a pre/post intervention design measuring provider moral distress and comparing patient outcomes using retrospective historical controls. Physicians and nurses on staff in our pediatric intensive care unit in a quaternary care children's hospital participated in the evaluation. There were 60 patients in (...) the interventional group and 66 patients in the historical control group. We evaluated the impact of weekly meetings to establish goals of care for patients with longer than 10 days length of stay in the ICU for a year. Moral distress was measured intermittently and reported moral distress thermometer scores fluctuated. "Clinical situations" represented the most frequent contributing factor to moral distress. Post intervention, overall moral distress scores, measured on the moral distress scale revised, were lower for respondents in all categories, and on three specific items. Patient outcomes before and after PEACE intervention showed a statistically significant decrease in PRISM indexed LOS, a statistically significant increase in both code status changes DNR, and in-hospital death, with no change in patient 30 or 365 day mortality. The addition of a clinical ethicist and senior intensivist to weekly inter-professional team meetings facilitated difficult conversations regarding realistic goals of care. The study demonstrated that the PEACE intervention had a positive impact on some factors that contribute to moral distress and can shorten PICU length of stay for some patients. (shrink)

Introduction Tourette Syndrome is a childhood onset disorder characterized by vocal and motor tics and often remits spontaneously during adolescence. For treatment refractory patients, Deep Brain Stimulation may be considered. Methods and Results We discuss ethical problems encountered in two adolescent TS patients treated with DBS and systematically review the literature on the topic. Following surgery one patient experienced side effects without sufficient therapeutic effects and the stimulator was turned off. After a second series of behavioural treatment, he experienced a (...) tic reduction of more than 50%. The second patient went through a period of behavioural disturbances that interfered with optimal programming, but eventually experienced a 70% tic reduction. Sixteen DBS surgeries in adolescent TS patients have been reported, none of which pays attention to ethical aspects. Discussion Specific ethical issues arise in adolescent TS patients undergoing DBS relating both to clinical practice as well as to research. Attention should be paid to selecting patients fairly, thorough examination and weighing of risks and benefits, protecting the health of children and adolescents receiving DBS, special issues concerning patient’s autonomy, and the normative impact of quality of life. In research, registration of all TS cases in a central database covering a range of standardized information will facilitate further development of DBS for this indication. Conclusion Clinical practice should be accompanied by ongoing ethical reflection, preferably covering not only theoretical thought but providing also insights in the views and perspectives of those concerned, that is patients, family members and professionals. (shrink)