Members of the Clinical Ethics Consultation Affairs Standing Committee of the American Society for Bioethics and Humanities present a collection of insights and recommendations developed from their collective experience, intended for those engaged in the work of healthcare ethics consultation.

From computerized medical records to databases of pharmacological interactions and automated provisional EKG readings, the emergence of information technology has significantly altered the practice of medicine. Information technology has been widely used to enhance diagnosis and treatment and to improve communication between providers. The advent of the Internet also brings far-reaching implications for patient–physician communication, challenging physicians, patients, and policymakers to consider its impact on the delivery of medical care and the therapeutic relationship. A new set of practices by patients (...) and physicians is unfolding in cyberspace, ranging from the use of e-mail to communicate between physicians and patients in an existing relationship to one-to-one consultations with an anonymous physician and ongoing online treatment, such as psychotherapy. These practices are emerging in both the for-profit and not-for-profit spheres. (shrink)

Physicians generally recommend that patients resuscitated with naloxone after opioid overdose stay in the emergency department for a period of observation in order to prevent harm from delayed sequelae of opioid toxicity. Patients frequently refuse this period of observation despiteenefit to risk. Healthcare providers are thus confronted with the challenge of how best to protect the patient’s interests while also respecting autonomy, including assessing whether the patient is making an autonomous choice to refuse care. Previous studies have shown that physicians (...) have widely divergent approaches to navigating these conflicts. This paper reviews what is known about the effects of opioid use disorder on decision-making, and argues that some subset of these refusals are non-autonomous choices, even when patients appear to have decision making capacity. This conclusion has several implications for how physicians assess and respond to patients refusing medical recommendations after naloxone resuscitation. (shrink)

What term is most appropriate in describing the limits of medicine? That depends on who determines the limits and the bases on which those limits are delineated and communicated. Schneiderman, Jecker, and Jonsen critique two recent policy statements by critical care providers—Bosslet et al. and Nates et al. —for their rejection of the use of the term futile for treatment. Both statements recommend using the adjective inappropriate for the problematic treatment, rather than futile, based on the lack of consensus of (...) just what constitutes futility. Schneiderman, Jecker, and Jonsen also assert that, despite a lack of consensus about the determination of futility, the definitions they have... (shrink)

The problem of decision-making capacity in patients with dementia, such as those with early stage Alzheimer's, can be vexing, especially when these patients refuse life-sustaining medical treatments. However, these patients should not be presumed to lack decision-making capacity. Instead, an analysis of the patient's decision-making capacity should be made. Patients who have some degree of decision-making capacity may be able to make a choice about life-sustaining medical treatment and may, in many cases, choose to forgo treatment.

Although clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems, progress in developing standards for quality is challenging. In this article, we describe the results of a pilot project utilizing portfolios as an evaluation tool. We found that this approach is feasible and resulted in a reasonably wide distribution of scores among the 23 submitted portfolios that we evaluated. We discuss limitations and implications of these results, and suggest that this is a significant step (...) on the pathway to an eventual certification process for clinical ethics consultants. (shrink)

Clinical ethics consultation is largely outside the scope of regulation and oversight, despite its importance. For decades, the bioethics community has been unable to reach a consensus on whether there should be accountability in this work, as there is for other clinical activities that influence the care of patients. The American Society for Bioethics and Humanities, the primary society of bioethicists and scholars in the medical humanities and the organizational home for individuals who perform CEC in the United States, has (...) initiated a two‐step quality attestation process as a means to assess clinical ethics consultants and help identify individuals who are qualified to perform this role. This article describes the process. (shrink)

In this issue, Raphael Cohen-Almagor reviews some of the terms used in the discussion of bioethical issues at the end of a patient's life; he argues that they are “valueladen” and serve “primarily the physicians, at times at the expense of the patients’ best interest.” Each of the following terms comes under scrutiny: “death with dignity,” “persistent vegetative state,” “futility,” “double effect,” and “brain death.” He argues that these concepts, developed in recent decades, “have generated an unhealthy atmosphere for patients, (...) which might lead to undesirable actions at the end of patients’ lives.” He issues a plea to discontinue the use of the term “persistent vegetative state” because it is dehumanizing, to explain “double effect” and “futility” in detail and with sincerity, and to clarify the motivation for using these terms and others. He warns physicians not to use terminology that is offensive to patients and loved ones or that weakens their patients’ will to live. (shrink)

In this issue, Raphael Cohen-Almagor reviews some of the terms used in the discussion of bioethical issues at the end of a patient's life; he argues that they are “valueladen” and serve “primarily the physicians, at times at the expense of the patients’ best interest.” Each of the following terms comes under scrutiny: “death with dignity,” “persistent vegetative state,” “futility,” “double effect,” and “brain death.” He argues that these concepts, developed in recent decades, “have generated an unhealthy atmosphere for patients, (...) which might lead to undesirable actions at the end of patients’ lives.” He issues a plea to discontinue the use of the term “persistent vegetative state” because it is dehumanizing, to explain “double effect” and “futility” in detail and with sincerity, and to clarify the motivation for using these terms and others. He warns physicians not to use terminology that is offensive to patients and loved ones or that weakens their patients’ will to live. (shrink)

Childress and coauthors present a case considering ECMO withdrawal over the objection of the conscious patient who is no longer a candidate for transplantation or other definitive therapeutic inter...

It is now a default obligation to provide cardiopulmonary resuscitation (CPR), in the absence of knowledge of a patient’s or surrogate’s wishes to the contrary. We submit that it is time to reevaluate this position. Attempting CPR should be subject to the same scrutiny demanded of other medical interventions that involve balancing a great benefit against grievous harms.

To examine the ethical duty to patients and families in the setting of the resuscitation bay, we address a case with a focus on providing optimal care and communication to family members. We present a case of nonsurvivable traumatic injury in a minor, focusing on how allowing family more time at the bedside impacts the quality of death and what duty exists to maintain an emotionally optimal environment for family grieving and acceptance. Our analysis proposes tenets for patient and family-centric (...) care that, in alignment with trauma-informed care principles, optimize the long-term well-being of the family, namely valuing family desires and sensitivity to location. (shrink)

Many adoptees face a number of challenges relating to separation from biological parents during the adoption process, including issues concerning identity, intimacy, attachment, and trust, as well as language and other cultural challenges. One common health challenge faced by adoptees involves lack of access to genetic-relative family health history. Lack of GRFHx represents a disadvantage due to a reduced capacity to identify diseases and recommend appropriate screening for conditions for which the adopted person may be at increased risk. In this (...) article, we draw out common features of traditionally understood “health disparities” in order to identify analogous features in the context of adoptees’ lack of GRFHx. (shrink)

Civility is an essential feature of health care, as it is in so many other areas of human interaction. The article examines the meaning of civility, reviews its origins, and provides reasons for its moral significance in health care. It describes common types of uncivil behavior by health care professionals, patients, and visitors in hospitals and other health care settings, and it suggests strategies to prevent and respond to uncivil behavior, including institutional codes of conduct and disciplinary procedures. The article (...) concludes that uncivil behavior toward health care professionals, patients, and others subverts the moral goals of health care and is therefore unacceptable. Civility is a basic professional duty that health care professionals should embrace, model, and teach. (shrink)

For over a decade, managed care has profoundly altered how healthcare is delivered in the United States. There have been concerns that the patient-physician relationship may be undermined by various aspects of managed care, such as restrictions on physician choice, productivity requirements that limit the time physicians may spend with patients, and the use of compensation formulas that reward physicians for healthcare dollars not spent. We have previously published data on the effects of managed care on the physician-patient relationship from (...) the physician's perspective. In 1999, we collected data on the impact of managed care arrangements on the physician-patient relationship from the patient's perspective. This article discusses our collective findings. (shrink)

Over the past several years, healthcare has been profoundly altered by the growth of managed care. Because managed care integrates the financing and delivery of healthcare services, it dramatically alters the roles and relationships among providers, payers, and patients. While analysis of this change has focused on whether and how managed care can control costs, an increasingly important concern among healthcare providers and recipients is the impact of managed care on the physicianpatient relationship, but little data have been collected and (...) analyzed. We designed a survey for distribution to Wisconsin physicians to analyze the prevalence and types of managed care arrangements in the state, and the impact of these arrangements on physicians and their relationships with patients. (shrink)

The field of clinical ethics consultation has matured into a multidisciplinary profession, with clinical ethics consultants (CECs) being trained in bioethics, philosophy, theology, law, medicine, n...

In this article, we develop a non-rights-based argument based on beneficence (i.e., the welfare of individuals and communities) and justice as the disposition to act justly to promote equity in health care resource allocation. To this end, we structured our analysis according to the following main sections. The first section examines the work of Amartya Sen and his equality of capabilities approach and outlines a framework of health care as a fundamental human need. In the subsequent section, we provide a (...) definition of health equity based on the moral imperative to guarantee that every individual ought to have the freedom to pursue health goals and well-being. In the later part of the article, we outline a non-right approach to health care based on three pillars: (1) human flourishing, (2) justice as a disposition not a process, and (3) solidarity. (shrink)

What is "critical thinking"? -- What is "law"? : thinking critically about legal perspectives -- Putting critical thinking into legal practice -- Thinking critically about assessments -- Thinking critically in the workplace and beyond.

This article devotes the relevant problem, which wasn’t examined in B. Pasternak’s works- the problem of historicism. The aim of the author – ideological and artistic quests of the poet which are connected with his Christian view of history as a part of universal history and artist’s place within. The article shows the opposition between two conceptions of B. Pasternak history: politico-social and all the Christian. The evolution of poet’s works is fully connected with this opposition. In first post-revolutionary decade (...) Pasternak-pantheist perceived modern history as natural and necessary he saw historic and moral probity there. Tragic events in the country in 1930s, the arrest of his friends-artists and deepening into his Christian feelings led B. Pasternak to a rupture with modern life/reality and a change of his social-pantheistic historicism with religious-ethic one. Christian philosophy of history in mature works of the poet is inseparably connected with a theme of artist’s soul as it is a benefaction of his moral not social choice in history. The most part of religious-ethic historicism was embodied in cyclus of ‘Yuri Zhivago’s poems‘ especially in ‘Hamlet‘ that was created on an analogy Hamlet-Christ-Artist. The persona of the poetry and the novel ‘Doctor Zhivago‘ by B. Pasternak chooses fatal way predetermined to him by his father – the Lord in universal history, and he refuses to take part in "drama" of modern history. Christian historicism of the poet ends up at social-anti-historicism when the persona doesn’t participate in politico-social history and oblational shares fatal destiny given by Christ with a nation. Late works of B. Pasternak arise the theme about destinies unity – the artist and the nation, about equality of sufferings in a tragic century. It proofs, that theologically-ethic historicism peculiar to the poet relieves him of all the accusations because of his isolation of the destiny of his country and the folk, because of his anti-patriotism and anti-nationalism. Ontological optimism of the poet, his philosophy of art appeared in Christian point of time and human’s part within. (shrink)

There appears to be a wide measure of agreement, both amongst biologists and others, that Darwin's theory of evolution marks a major breakthrough in the science of biology; Darwin has even been called ‘Biology's Newton’, the highest term of praise that could be bestowed on a scientist. A. G. N. Flew, considering the matter from a philosophical point of view, says: ‘Yet one of the most important of all scientific theories is that developed by Darwin in his Origin of Species (...) . Covering the entire range of biological phenomena its scope is enormous. While if any scientific theory is interesting philosophically this one is.’ In spite of the testimony of both biologists and philosophers of science to the importance of the theory, it does not appear to play anything like the same role in biology as does Newton's theory in physics. For modern physics would be. (shrink)

In this paper we conduct an analysis of the critical narratives of Stardew Valley and compare them to other relevant videogames in order to develop new possibilities for an ecological critique of capitalist extractive econo­mies. Critical narratives of this game are aimed primarily at the alienating conditions of labour and deeply devastating modes of production under capitalism that impact and severely damage the environment. Analysing these narratives, we superimpose the immediate messages of the game with the procedural rhetoric and material (...) conditions of their existence. Over the course of our analysis, we highlight a material-narrative disso­nance which, in the case of Stardew Valley, fails to function as a commu­nicative strategy of the game and remains its mere external contradiction. Although the game’s critical narrative may seem overly utopian and its political imaginary a bit underdeveloped, the game elaborates on concrete ways to tackle the alienation of labour and resolve the ecological crisis. In addition to this, the paper covers the history of the interplay between the video game industry and the field of global ecological crisis research. We compare the attempts to raise awareness of the videogames’ own material­ity that preceded Stardew Valley. We conclude that Stardew Valley utilises the language of sustainable co-existence and wasteless local production, expanding this logic both to the sphere of labour and the spectrum of en­vironmental problems. In the case of ecological critique, some gameplay decisions in Stardew Valley enable us to come up with new strategies aimed at creating critical narratives about the environment in videogames. Thus supplementing Stardew Valley’s findings with critical tropes derived from other games (mainly, Rain World), we were able to gather a set of theoretical instruments that could facilitate the creation of games about ecosystems. Following Donna Haraway’s emphasis on the crucial role of narrative fram­ing (“it matters which stories tell stories”), we highlight new opportunities for the entire medium of videogames. (shrink)

When this work was first published in 1960, it immediately filled a void in Kantian scholarship. It was the first study entirely devoted to Kant's _Critique of Practical Reason_ and by far the most substantial commentary on it ever written. This landmark in Western philosophical literature remains an indispensable aid to a complete understanding of Kant's philosophy for students and scholars alike. This _Critique_ is the only writing in which Kant weaves his thoughts on practical reason into a unified argument. (...) Lewis White Beck offers a classic examination of this argument and expertly places it in the context of Kant's philosophy and of the moral philosophy of the eighteenth century. (shrink)

New arguments against Bayesian regularity and an otherwise plausible domination principle are offered on the basis of rotational symmetry. The arguments against Bayesian regularity work in very general settings.

This paper examines the perceived ethical values of Malaysian managers. It is based on the opinions of 15 hypothetical ethical/unethical business situations from the 81 managers who agreed to participate in the survey. The findings of this study showed that these Malaysian managers have high ethical values. However 53% of the respondents believed that the ethical standards of today are lower than that of 15 years ago. Apparently, this is related to the existence of many unethical business practices prevalent in (...) the modern business world. The behavior of one's immediate superior is the most important factor in influencing managers to commit unethical practices. The results also indicate only a slight variation among the managers in terms of perceived ethical values by virtue of job position, job specialization, type of business activity or the size of the business organization. (shrink)

A law, say, prohibits homosexual conduct or punishes the prostitute for plying her trade. According to some it is a bad law, according to others a necessary one. Those who argue that it is a bad law do so on a variety of grounds—that it is sheer folly to try to change human nature by law, that such legislation can only be effective at the price of the right to privacy, that the punishment of acts arising from compelling desires is (...) cruel and excessive, that the law has no business meddling in what people do to others with their consent. Those who argue that it is a necessary law do so on one ground, that the act in question is immoral, and that what is wrong must be punished, lest the law itself fall into disrepute by failing to carry out a consistent campaign against wrong-doing. (shrink)

Trope theory is a leading metaphysical theory in analytic ontology. One of its classic statements is found in the work of Donald C. Williams who argued that tropes qua abstract particulars are the very alphabet of being. The concept of an abstract particular has been repeatedly attacked in the literature. Opponents and proponents of trope theory alike have levelled their criticisms at the abstractness of tropes and the associated act of abstraction. In this paper I defend the concept of a (...) trope qua abstract particular by rejecting arguments that purport to show that tropes should not be understood as abstract and by arguing that the abstractness of tropes plays an indispensable role in one of our more promising trope-theoretic analyses of universals and of concrete objects. (shrink)

Appearing in the “Cairo Declaration on Human Rights in Islam” as an undefined referent for the limits on freedom of expression in Islam, Shariah is still to be chased as an indefinable referent which restricts freedom of the expression in the Islamic Republic of Iran. Iran’s Press Law as well as Constitution unveil Shariah’s referent to be a person: the Jurist-Ruler around whom a cult of personality is legalized in terms of “Imamate” and around whom all the limits on freedom (...) of expression revolve. Interpretation of Shariah is not a solution but part of the problem in Iran. Such problem can be dealt in terms of three modes of self-expression which were invented by the Iranian Reformists to avoid self-censorship. The notion of master-signifier can be the key to unraveling the problem of self-referentiality in freedom of expression and its Reformist solution in Iran’s legal system. (shrink)

In this paper I want to examine the notion of desert, which seems to have been neglected by contemporary philosophers. Apartfrom its interest in its own right, it is important to be clear about the meaning of the word if there is to be any understanding of the idea of punishment. And that we are confused over the whole issue of punishment is obvious both from the remarks of professional philosophers and from the comments of the ‘man in the street’. (...) Because of this confusion, the discussion of any actual punishment seems to take place between two parties who never get to grips with the arguments of the other, as in the whole debate over the death penalty. To one set of people, it is obvious that the retention of hanging depends to a large extent on the question of its effectiveness in deterring murderers; to another it is equally obvious that the murderer ‘deserves’ to hang, and that there is no more to be said about the matter. Capital punishment is not a good starting-point for a discussion of punishment in general, for death is clearly unique among penalties; in addition, the topic gives rise inevitably to much sentimentality and resulting muddle-headedness. (shrink)

Consent transforms an otherwise illegitimate act into a legitimate one. To be valid, however, it must be adequately informed. The legal requirement is vague and provides little assistance in predicting when it will be satisfied. This is particularly so when a patient consents to a procedure and the physician subsequently varies one of the components of that procedure. Using three legal judgments and one General Medical Council decision as a springboard, I have explored the concept of a medical procedure within (...) the context of consent and developed a theoretical model to elucidate a more predictable and consistent informational requirement. (shrink)

The concept of instantiation is realized differently across a variety of metaphysical theories. A certain realization of the concept in a given theory depends on what roles are specified and associated with the concept and its corresponding term as well as what entities are suited to fill those roles. In this paper, the classic realization of the concept of instantiation in a one-category ontology of abstract particulars or tropes is articulated in a novel way and defended against unaddressed objections.