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)

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)

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...

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...

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

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)

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

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)

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

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)

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)

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)

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)

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)

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)

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)

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...

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)

In the late Middle Ages the philosopher and mystic Meister Eckhart preached that to know the truth you must be the truth. But how to be the truth? Eckhart's answer comes in the form of an imperative: release yourself, let be. Only then will you be able to understand that the deepest meaning of being is releasement. Only then will you become who you truly are. This book interprets Eckhart's Latin and Middle High German writings under the banner of an (...) imperative of releasement, and then shows how the twentieth-century thinker Martin Heidegger creatively appropriates this idea at several stages of his career. Heidegger had a lifelong fascination with Eckhart, referring to him as "the old master of letters and life." Drawing on archival material and Heidegger's marginalia in his personal copies of Eckhart's writings, Moore argues that Eckhart was one of the most important figures in Heidegger's philosophy. This book also contains previously unpublished documents by Heidegger on Eckhart, as well as the first English translation of Nishitani Keiji's essay "Nietzsche's Zarathustra and Meister Eckhart," which he initially gave as a presentation in one of Heidegger's classes in 1938. (shrink)

Abstract:This paper is a further development of two previous pieces of work (Moore 2002, 2005) in which modern virtue ethics, and in particular MacIntyre’s (1985) related notions of “practice” and “institution,” have been explored in the context of business. It first introduces and defines the concept of corporate character and seeks to establish why it is important. It then reviews MacIntyre’s virtues-practice-institution schema and the implications of this at the level of the institution in question—the corporation—and argues that the (...) concept of corporate character follows from, but is a novel development of, MacIntyre’s schema. The paper contrasts corporate character and virtues with the more familiar concepts of corporate culture and values. The constitutive and substantive elements of corporate character, including the essential corporate virtues, are then drawn out and illustrated with reference to the cases explored in Koehn (1998). Finally, the paper acknowledges and counters a specific criticism of this approach. (shrink)

Nonreductive physicalism states that actions have sufficient physical causes and distinct mental causes. Nonreductive physicalism has recently faced the exclusion problem, according to which the single sufficient physical cause excludes the mental causes from causal efficacy. Autonomists respond by stating that while mental-to-physical causation fails, mental-to-mental causation persists. Several recent philosophers establish this autonomy result via similar models of causation :1031–1049, 2016; Zhong, J Philos 111:341–360, 2014). In this paper I argue that both of these autonomist models fail on account (...) of the problem of Edwards’s Dictum. However, I appeal to foundational principles of action theory to resuscitate mental-to-mental causation in a manner that is consistent with the models of causation endorsed by these autonomists. (shrink)

This cutting edge volume provides an overview of the dynamic new field of cyberphilosophy – the intersection of philosophy and computing.

Abstract:This paper is a further development of two previous pieces of work (Moore 2002, 2005) in which modern virtue ethics, and in particular MacIntyre’s (1985) related notions of “practice” and “institution,” have been explored in the context of business. It first introduces and defines the concept of corporate character and seeks to establish why it is important. It then reviews MacIntyre’s virtues-practice-institution schema and the implications of this at the level of the institution in question—the corporation—and argues that the (...) concept of corporate character follows from, but is a novel development of, MacIntyre’s schema. The paper contrasts corporate character and virtues with the more familiar concepts of corporate culture and values. The constitutive and substantive elements of corporate character, including the essential corporate virtues, are then drawn out and illustrated with reference to the cases explored in Koehn (1998). Finally, the paper acknowledges and counters a specific criticism of this approach. (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)

It is a long time since I have admired a book as much as I admire this one. It is a long time since I have disagreed with a book as profoundly as I disagree with this one. I hope this combination of reactions on my part has more than whatever limited biographical interest it has. I hope it helps to signal the combination of excellence and provocation that mark Timothy Williamson's book, which is at once beautifully clear, forcefully argued, (...) continually insightful, and, in my view, deeply wrong.One thing that I admire about the book is Williamson's preparedness to reflect philosophically on the nature of philosophy, something that is surprisingly rare in a discipline that is marked by such a high degree of self-consciousness and in which there are so few scruples about reflecting on the nature of other disciplines. One thing that gives me pause is Williamson's lack of serious engagement with the history of philosophy. 1 I am convinced that the philosophy of philosophy will always be seriously handicapped if it is as dissociated from the history of philosophy as this. But I shall not dwell on that concern here, because Williamson is clear enough about where his interests lie and I would be in danger, if I did, of succumbing to that familiar absurdity of berating an author for not having written a numerically different book.What I will say is that Williamson's failure to engage seriously with the history of philosophy seems to me indicative of a scientism about philosophy which, despite how much he does to motivate his conception of the discipline, is manifest in how much …. (shrink)

Many appraisal theories claim that appraisal causes emotion. Critics have rejected this claim because they believe (a) it is incompatible with the claim that appraisal is a part of emotion, (b) it is not empirically supported, (c) it is circular and hence nonempirical, and (d) there are alternative causes. I reply that (a) the causal claim is incompatible with the part claim on some but not all interpretations of the causal claim and the part claim, (b) the lack of empirical (...) support can be remedied, (c) there may even be ways to cope with the circularity problem, and (d) it is unclear to what extent the alternative causes differ from appraisal. (shrink)

Libertarian free will is, roughly, the view that agents cause actions to occur or not occur: Maddy’s decision to get a beer causes her to get up off her comfortable couch to get a beer, though she almost chose not to get up. Libertarian free will notoriously faces the luck objection, according to which agential states do not determine whether an action occurs or not, so it is beyond the control of the agent, hence lucky, whether an action occurs or (...) not: Maddy’s reasons for getting beer in equipoise with her reasons to remain in her comfortable seat do not determine that she will get up or stay seated, so it seems beyond her control, hence lucky, that she gets up. In this paper I consider a sub-set of the luck objection called the Physical Indeterminism Luck Objection, according to which indeterministic physical processes cause actions to occur or not, and agent’s lack control over these indeterministic physical processes, so agent’s lack control over, hence it is lucky, whether action occurs or not. After motivating the physical indeterminism luck objection, I consider responses from three recent event-causal libertarian models, and conclude that they fail to overcome the problem, though one promising avenue is opened up. (shrink)

It is sometimes argued that while human gestures are produced ostensively and intentionally, great ape gestures are produced only intentionally. If true, this would make the psychological mechanisms underlying the different species’ communication fundamentally different, and ascriptions of meaning to chimpanzee gestures would be inappropriate. While the existence of different underlying mechanisms cannot be ruled out, in fact claims about difference are driven less by empirical data than by contested assumptions about the nature of ostensive communication. On some accounts, there (...) are no reasons to doubt that great ape gestural communication is ostensive. If these accounts are correct, attributions of meaning to chimpanzee gestures would be justified. (shrink)

This thesis focuses on expressively rich languages that can formalise talk about probability. These languages have sentences that say something about probabilities of probabilities, but also sentences that say something about the probability of themselves. For example: (π): “The probability of the sentence labelled π is not greater than 1/2.” Such sentences lead to philosophical and technical challenges; but can be useful. For example they bear a close connection to situations where ones confidence in something can affect whether it is (...) the case or not. The motivating interpretation of probability as an agent's degrees of belief will be focused on throughout the thesis. -/- This thesis aims to answer two questions relevant to such frameworks, which correspond to the two parts of the thesis: “How can one develop a formal semantics for this framework?” and “What rational constraints are there on an agent once such expressive frameworks are considered?”. (shrink)