Purpose Although surrogate decision-making is prevalent in intensive care units and concerns with decision quality are well documented, little is known about how clinicians help family members understand the surrogate role. We investigated whether and how clinicians provide normative guidance to families regarding how to function as a surrogate. Subjects and methods We audiorecorded and transcribed 73 ICU family conferences in which clinicians anticipated discussing goals of care for incapacitated patients at high risk of death. We developed and applied a (...) coding framework to identify normative statements by clinicians regarding what considerations should guide surrogates’ decisions, including whether clinicians explained one or more of Buchanan and Brock’s three standard principles of SDM to family members. Results Clinicians made at least one statement about how to perform the surrogate role in 24 conferences ). We observed three general types of normative guidance provided to surrogates, with some conferences containing more than one type of guidance: counselling about one or more standard principles of SDM ; counselling surrogates to make decisions centred on the patient as a person, without specifying how to accomplish that ; and counselling surrogates to make decisions based on the family’s values. Conclusions Clinicians did not provide normative guidance about the surrogate role in two-thirds of family conferences for incapacitated patients at high risk for death. When they did, clinicians’ guidance was often incomplete and sometimes conflicted with standard principles of SDM. Future work is needed to understand whether providing explicit guidance on how to perform the surrogate role improves decision-making or mitigates surrogates’ psychological distress. (shrink)

Purpose Although surrogate decision-making is prevalent in intensive care units and concerns with decision quality are well documented, little is known about how clinicians help family members understand the surrogate role. We investigated whether and how clinicians provide normative guidance to families regarding how to function as a surrogate. Subjects and methods We audiorecorded and transcribed 73 ICU family conferences in which clinicians anticipated discussing goals of care for incapacitated patients at high risk of death. We developed and applied a (...) coding framework to identify normative statements by clinicians regarding what considerations should guide surrogates’ decisions, including whether clinicians explained one or more of Buchanan and Brock’s three standard principles of SDM to family members. Results Clinicians made at least one statement about how to perform the surrogate role in 24 conferences ). We observed three general types of normative guidance provided to surrogates, with some conferences containing more than one type of guidance: counselling about one or more standard principles of SDM ; counselling surrogates to make decisions centred on the patient as a person, without specifying how to accomplish that ; and counselling surrogates to make decisions based on the family’s values. Conclusions Clinicians did not provide normative guidance about the surrogate role in two-thirds of family conferences for incapacitated patients at high risk for death. When they did, clinicians’ guidance was often incomplete and sometimes conflicted with standard principles of SDM. Future work is needed to understand whether providing explicit guidance on how to perform the surrogate role improves decision-making or mitigates surrogates’ psychological distress. (shrink)

This paper considers the view that medicine is both “science” and “art.” It is argued that on this view certain clinical knowledge – of patients’ histories, values, and preferences, and how to integrate them in decision-making – cannot be scientific knowledge. However, by drawing on recent work in philosophy of science it is argued that progress in gaining such knowledge has been achieved by the accumulation of what should be understood as “scientific” knowledge. I claim there are varying degrees of (...) objectivity pertaining to various aspects of clinical medicine. Hence, what is often understood as constituting the “art” of medicine is amenable to objective methods of inquiry, and so, may be understood as “science”. As a result, I conclude that rather than endorse the popular philosophical distinction between the art and science of medicine, in the future a unified, multifaceted epistemology of medicine should be developed to replace it. (shrink)

Three common ethical principles for establishing the limits of parental authority in pediatric treatment decision making are the harm principle, the principle of best interest, and the threshold view. This paper consider how these principles apply to a case of a premature neonate with multiple significant comorbidities whose mother wanted all possible treatments, and whose health care providers wondered whether it would be ethically permissible to allow him to die comfortably despite her wishes. Whether and how these principles help to (...) understand what was morally right for the child is questioned. The paper concludes that the principles were of some value in understanding the moral geography of the case, but that the case reveals common bioethical principles for medical decision making are problematically value-laden because they are inconsistent with the widespread moral value of medical vitalism. (shrink)

This paper explores how current United States policies for funding nonreproductive cloning are justified and argues against that justification. I show that a common conceptual framework underlies the national prohibition on the use of public funds for cloning research, which I call the simple argument. This argument rests on two premises: that research harming human embryos is unethical and that embryos produced via fertilization are identical to those produced via cloning. In response to the simple argument, I challenge the latter (...) premise. I demonstrate there are important ontological differences between human embryos (produced via fertilization) and clone embryos (produced via cloning). After considering the implications my argument has for the morality of publicly funding cloning for potential therapeutic purposes and potential responses to my position, I conclude that such funding is not only ethically permissible, but also humane national policy. (shrink)

No abstract available. First paragraph: In this issue’s target article, Stier and Schoene-Siefert purport to ‘depotentialize’ the argument from potentiality based on their claim that any human cell may be “converted” into a morally significant entity, and consequently, the argument from potentiality finally succumbs to a reductio ad absurdum. I aim to convey two reasons for skepticism about the innocuousness of the notion of cell convertibility, and hence, the cogency of their argument.

This paper proposes a Rawlsian conception of moral justification as a social activity. Through a close reading, Rawls’ view of ethical justification is shown to be significantly more dialogical and deliberative than is commonly appreciated. The result is a view that emphasizes the social nature of ethical justification and identifies information sharing between persons as the crux of justification in metaethics, in contrast to normative ethics. I call it Rawlsian reflective equilibrium to distinguish it from other varieties.

For over three decades, clinical ethicists in the United States have recorded their consulting activities to supplement documentation in the medical record, often using locally developed instrument...

This paper explores how current United States policies for funding nonreproductive cloning are justified and argues against that justification. I show that a common conceptual framework underlies the national prohibition on the use of public funds for cloning research, which I call the simple argument. This argument rests on two premises: that research harming human embryos is unethical and that embryos produced via fertilization are identical to those produced via cloning. In response to the simple argument, I challenge the latter (...) premise. I demonstrate there are important ontological differences between human embryos (produced via fertilization) and clone embryos (produced via cloning). After considering the implications my argument has for the morality of publicly funding cloning for potential therapeutic purposes and potential responses to my position, I conclude that such funding is not only ethically permissible, but also humane national policy. (shrink)

Philosophers of science deploy mathematical models to describe epistemic communities, or groups of people creating and sharing knowledge for individual and collective purposes. These models capture...

Ellen Fox and collaborators have produced the most detailed description of healthcare ethics practices in the United States available. Some findings are shocking for anyone committed to promoting q...

BackgroundNo standard method exists to assess how many consults a healthcare ethics consultation (HCEC) service should perform. To address this, we developed a method to estimate the volume of HCEC services based on a mixed-methods approach that included a systematic review and survey data on the volume of consult services requested.MethodsOur investigation included a systematic review of studies that reported the volume of HCEC services that were requested from 2000 to 2017, institutional surveys, and statistical analyses that estimated the volume (...) of HCEC services that were adjusted to the size of the hospitals in the survey and to population acuity.ResultsWe contacted the authors of 19 studies that met our inclusion criteria; 17 authors responded to the institutional survey and five provided annualized data points. We found that standard methods of reporting the volume of HCEC services led to inaccuracies in estimating the growth of HCEC services over time. To rectify this, we proposed two means to estimate volume based on either the service goals of HCEC services or hospital size and acuity.DiscussionThe statistical limitations of our study highlight the need to standardize the sharing and reporting of data in clinical ethics. Future work should further standardize methods of HCEC quality assessment using measures similar to those we describe. (shrink)

Although ethics is an essential component of undergraduate medical education, research suggests current medical ethics curricula face considerable challenges in improving students’ ethical reasoning. This paper discusses these challenges and introduces a promising new mode of graduate and professional ethics instruction for overcoming them. We begin by describing common ethics curricula, focusing in particular on established problems with current approaches. Next, we describe a novel method of ethics education and assessment for medical students that we have devised, the Medical Ethics (...) Bowl. Finally, we suggest pedagogical advantages to MEBs when compared to other ethics curricula. (shrink)

With the increasing professionalization of clinical ethics, some hospitals and health systems utilize both ethics committees and professional clinical ethicists to address their ethics needs. Drawing upon historical critiques of ethics committees and their own experiences, the authors argue that, in ethics programs with one or more professional clinical ethicists, ethics committees should be dissolved when they fail to meet minimum standards of effectiveness. The authors outline several criteria for assessing effectiveness, describe the benefits of a model that places primary (...) responsibility for ethics work with professional clinical ethicists—the PCE-primary model, and offer suggestions for alternative ethics program structures that empower healthcare professionals to contribute to ethics work in ways more tailored to their strengths and skills while minimizing the shortcomings of ethics committees. (shrink)

At the 2022 Clinical Ethics Unconference, the authors perceived a significant lack of racial and ethnic diversity, which was consistent with their experiences in other clinical ethics settings. As a result, they convened a working group to address the pervasive lack of diversity present in the field of clinical ethics and to propose strategies to increase the representation of people from racial and ethnic minority populations. This article identifies the harms associated with the lack of diversity in the healthcare setting (...) and translates these to the field of clinical ethics. The article then proposes a framework that may be used to help diversify the field of clinical ethics. Specifically, the authors identify existing barriers to appropriate diversity, actionable steps to increase diversity, and tools the field can utilize to systematically assess its progress with respect to achieving diversity. (shrink)

Harrowing stories reported in the media describe Covid‐19 ravaging through families. This essay reports professional experiences of this phenomenon, family clustering, as encountered during the pandemic's spread across Southern California. We identify three ethical challenges following from it: Family clustering impedes shared decision‐making by reducing available surrogate decision‐makers for incapacitated patients, increases the emotional burdens of surrogate decision‐makers, and exacerbates health disparities for and the suffering of people of color at increased likelihood of experiencing family clustering. We propose that, in (...) response to these challenges, efforts in advance care planning be expanded, emotional support offered to surrogates and family members be increased, more robust state guidance be issued on ethical decision‐making for unrepresented patients, ethics consultation be increased in the setting of conflict following from family clustering dynamics, and health care professionals pay more attention to systemic and personal racial biases and inequities that affect patient care and the surrogate experience. (shrink)

Scholars and professional organizations in bioethics describe various approaches to “quality assessment” in clinical ethics. Although much of this work represents significant contributions to the literature, it is not clear that there is a robust and shared understanding of what constitutes “quality” in clinical ethics, what activities should be measured when tracking clinical ethics work, and what metrics should be used when measuring those activities. Further, even the most robust quality assessment efforts to date are idiosyncratic, in that they represent (...) evaluation of single activities or domains of clinical ethics activities, or a range of activities at a single hospital or healthcare system. Countering this trend, in this article we propose a framework for moving beyond our current ways of understanding clinical ethics quality, toward comprehensive quality assessment. We first describe a way to conceptualize quality assessment as a process of measuring disparate, isolated work activities; then, we describe quality assessment in terms of tracking interconnected work activities holistically, across different levels of assessment. We conclude by inviting future efforts in quality improvement to adopt a comprehensive approach to quality assessment into their improvement practices, and offer recommendations for how the field might move in this direction. (shrink)

This book is a philosophical examination of the logical problems associated with the claim that Jesus of Nazareth was one and the same person as God the Son, the Second Person of the divine Trinity.

Thomas V. Morris introduces philosophical theology, examining God's goodness, power and knowledge; God's relationship to creation and time; and God's Incarnation and Trinity. A Contours of Christian Philosophy book. 180 pages, paper.

In an article which appeared a few years ago, entitled ‘God's Death’ , A.D. Smith launched one of the most interesting of recent attacks on the traditional doctrine of the Incarnation. Focusing on the death of Christ, he claimed to demonstrate the logical impossibility of Jesus having been both human and divine. Each of the premises of his argument was said to be a commitment of orthodox theology. He thus presented his reasoning as displaying an internal incoherence in that way (...) of thinking about divinity, humanity, and the person of Christ. The argument was basically quite simple: According to Christian theology and in concurrence with general thought on the matter, we must hold that human death involves the possibility of annihilation. As a man, Jesus of Nazareth faced and underwent a human death. He thus faced the possibility of annihilation. But orthodox theologians hold God to be of such an ontological status that no divine being could even possibly be annihilated. So no divine person could die a human death. From this follows the impossibility of the traditional claim that the Second Person of the divine Trinity became a man, lived a human life, and died a human death for us and our salvation. The qualitative difference between God and man is such as to render incarnational christology an incoherent theological stance. (shrink)

One of the most difficult and perplexing tenets of classical theism is the doctrine of divine simplicity. Broadly put, this is generally understood to be the thesis that God is altogether without any proper parts, composition, or metaphysical complexity whatsoever. For a good deal more than a millennium, veritable armies of philosophical theologians – Jewish, Christian and Islamic – proclaimed the truth and importance of divine simplicity. Yet in our own time, the doctrine has enjoyed no such support. Among many (...) otherwise orthodox theists, those who do not just disregard it completely explicitly deny it. However, in a couple of recent articles, William E. Mann has attempted to expound the idea of divine simplicity anew and to defend it against a number of criticisms. He even has gone so far as to hint at reaffirming its importance, suggesting that the doctrine may have a significant amount of explanatory power and other theoretical virtue as part of an overall account of the nature of God, by either entailing or in other ways providing for much else that traditional theists have wanted to say about God. In this paper, I want to take a close look at Mann's formulation of the doctrine and at a general supporting theory he adumbrates in his attempt to render more plausible, or at least more defensible, various of its elements and implications. As Mann has made what is arguably the best attempt to defend the doctrine in recent years, I think that such an examination is important and will repay our efforts. (shrink)

Thomas V. Morris discusses life, death, religion, the nature of faith and more. This captivating book is ideal both for thoughtful unbelievers who consider Christianity unreasonable, and Christians wanting to know how to share their faith with sceptics. Writing in an engaging, conversational style, Morris takes an intriguing new look at the big questions that keep coming up -- questions about life, death, God, religion, the nature of faith, the formation of an adequate worldview, and the meaning of life. (...) Morris explores these kinds of questions in an earnest yet thoroughly entertaining and easily readable way, relating numerous personal anecdotes, incorporating intriguing material from the films of Woody Allen and the journals of Tolstoy, and using the writings of the seventeenth-century genius Blaise Pascal as a central guide. (shrink)

One of the most difficult and perplexing tenets of classical theism is the doctrine of divine simplicity. Broadly put, this is generally understood to be the thesis that God is altogether without any proper parts, composition, or metaphysical complexity whatsoever. For a good deal more than a millennium, veritable armies of philosophical theologians – Jewish, Christian and Islamic – proclaimed the truth and importance of divine simplicity. Yet in our own time, the doctrine has enjoyed no such support. Among many (...) otherwise orthodox theists, those who do not just disregard it completely explicitly deny it. However, in a couple of recent articles, William E. Mann has attempted to expound the idea of divine simplicity anew and to defend it against a number of criticisms. He even has gone so far as to hint at reaffirming its importance, suggesting that the doctrine may have a significant amount of explanatory power and other theoretical virtue as part of an overall account of the nature of God, by either entailing or in other ways providing for much else that traditional theists have wanted to say about God. In this paper, I want to take a close look at Mann's formulation of the doctrine and at a general supporting theory he adumbrates in his attempt to render more plausible, or at least more defensible, various of its elements and implications. As Mann has made what is arguably the best attempt to defend the doctrine in recent years, I think that such an examination is important and will repay our efforts. (shrink)

In recent years, there has been a striking resurgence of interest in the traditional Judeo-Christian concept of God. This anthology contains a representative sample of some of the best contemporary philosophical work on this central religious idea, covering such topics as the existence of God, the physical nature of God, and the "divine attributes"--goodness, omnipotence, omniscience, eternity, immutability, and simplicity.