Copyright © 2015 by the Society of Criti. Objective: Global lung stress varies considerably with low tidal volume ventilation for acute respiratory distress syndrome. High stress despite low tidal volumes may worsen lung injury and increase risk of death. No widely available parameter exists to assess global lung stress. We aimed to determine whether the volume delivered during a recruitment maneuver is inversely associated with lung stress and mortality in acute respiratory distress syndrome. Design: Substudy of an acute respiratory distress (...) syndrome clinical trial on esophageal pressure-guided positive end-expiratory pressure titration. Setting: U.S. academic medical center. Patients: Forty-two patients with acute respiratory distress syndrome in whom airflow, airway pressure, and esophageal pressure were recorded during the recruitment maneuver. Interventions: A single recruitment maneuver was performed before initiating protocol-directed ventilator management. Recruitment maneuvers consisted of a 30-second breath hold at 40 cm H2O airway pressure under heavy sedation or paralysis. VRM was calculated by integrating the flow-time waveform during the maneuver. End-inspiratory stress was defined as the transpulmonary pressure during end-inspiratory pause of a tidal breath and tidal stress as the transpulmonary pressure difference between end-inspiratory and end-expiratory pauses. Measurements and Main Results: VRM ranged between 7.4 and 34.7 mL/kg predicted body weight. Lower VRM predicted high end-inspiratory and tidal lung stress. After adjusting for Pao2/Fio2 and either driving pressure, tidal volume, or plateau pressure and positive end-expiratory pressure, VRM remained independently associated with both end-inspiratory and tidal stress. In unadjusted analysis, low VRM predicted increased risk of death. VRM remained significantly associated with mortality after adjusting for study arm. Conclusions: Low VRM independently predicts high lung stress and may predict risk of death in patients with acute respiratory distress syndrome. (shrink)

THE CENTRALITY OF "SYMPATHY" to Adam Smith's Theory of Moral Sentiments points to the centrality of love in the book. While Smith delineates a somewhat unusual, technical sense of "sympathy", his actual use of the term frequently slips into its more ordinary sense of "compassion" or affectionate fellow feeling. This no doubt intentional equivocation on Smith's part helps suffuse the book with these themes, to the point that, without much exaggeration, one could say that the Theory of Moral Sentiments is (...) generally about love: our need for love and sympathy, love as friendship, self-love, the love of praise and praiseworthiness, the love of beauty. Even in the Wealth of Nations, our loves are thought to be very important in explaining our behavior. Smith is unusual among modern moral philosophers in according so central a place to love in this broad sense, although of course Christianity made love a central theme in reflection on ethical life, and philosophers such as Hutcheson made benevolence a key virtue in their ethical systems. However, it is not our purpose to examine Smith's critique of Hutcheson or indeed of any of his predecessors. Rather we aim in this paper to reflect on his treatment of this topic. We shall do so in part by means of comparisons with Aristotle and Plato, first with respect to friendship and then with respect to love generally. Smith's writing is replete with classical references, raising the issue of the degree to which his thought is "ancient" or "modern." Friendship is arguably the pinnacle of social relations for the ancients, and thus it provides us with a useful device for determining the degree to which Smith's thought embodies classical moral and philosophical principles. The subtlety of Smith's interweaving of traditions will become visible as we reflect not just on the ways Smith's thought exhibits classical conceptions of friendship and love, but also on the ways he departs from them. For in at least one important respect, love is a closed book from Smith's standpoint, and thus, as it turns out, also at odds with classical friendship. (shrink)

Patient outcome after serious brain injury is highly variable. Following a period of coma, some patients recover while others progress into a vegetative state (unresponsive wakefulness syndrome) or minimally conscious state. In both cases, assessment is difficult and misdiagnosis may be as high as 43%. Recent advances in neuroimaging suggest a solution. Both functional magnetic resonance imaging and electroencephalography have been used to detect residual cognitive function in vegetative and minimally conscious patients. Neuroimaging may improve diagnosis and prognostication. These techniques (...) are beginning to be applied to comatose patients soon after injury. Evidence of preserved cognitive function may predict recovery, and this information would help families and health providers. Complex ethical issues arise due to the vulnerability of patients and families, difficulties interpreting negative results, restriction of communication to “yes” or “no” answers, and cost. We seek to investigate ethical issues in the use of neuroimaging in behaviorally nonresponsive patients who have suffered serious brain injury. The objectives of this research are to: (1) create an approach to capacity assessment using neuroimaging; (2) develop an ethics of welfare framework to guide considerations of quality of life; (3) explore the impact of neuroimaging on families; and, (4) analyze the ethics of the use of neuroimaging in comatose patients. (shrink)

BackgroundSevere brain injury is a leading cause of death and disability. Diagnosis and prognostication are difficult, and errors occur often. Novel neuroimaging methods can improve diagnostic and prognostic accuracy, especially in patients with prolonged disorders of consciousness (PDoC). Yet it is currently unknown how family caregivers understand this information, raising ethical concerns that disclosure of neuroimaging results could result in therapeutic misconception or false hope.MethodsTo examine these ethical concerns, we conducted semi-structured interviews with caregivers of patients with PDoC who were (...) enrolled in a concurrent neuroimaging research program designed to detect covert consciousness following severe brain injury. Caregivers held surrogate decision-making status for a patient. Interviews were conducted at two time points for each caregiver. The first interview occurred before the disclosure of neuroimaging results. The second occurred after disclosure. Descriptive analysis was applied to the data of four interview topics: (1) expectations for neuroimaging; (2) reactions to evidence of preserved cognition; (3) reactions to null results; and (4) understanding of the results and study.ResultsTwelve caregivers participated in the study; two caregivers shared surrogate decision-making status for one patient with PDoC. Twenty-one interviews were completed; one caregiver declined to participate in the post-disclosure interview. Three patients with PDoC associated with the study displayed evidence of covert consciousness. Overall, caregivers understood the neuroimaging research and results. Caregivers who received results of covert consciousness were generally pleased. However, there was some variation in expectations and reactions to these data and null results.ConclusionThis study, for the first time, reveals caregiver expectations for and reactions to neuroimaging evidence of covert consciousness in patients with PDoC. Caregivers understood the neuroimaging research and results, casting doubt on speculative ethical concerns regarding therapeutic misconception and false hope. However, disclosure of neuroimaging result could be improved. Pre-disclosure consultations might assist professionals in shaping caregiver expectations. Standardization of disclosure might also improve comprehension of the results. (shrink)

PLATO’S Protagoras is composed of three distinct frames. The outer frame consists in Socrates’ brief discussion with an unnamed companion. The remainder of the Protagoras is willingly narrated by Socrates to the companion, from memory of course, and apparently right after the main action. The inner frame consists in Socrates’ dialogue with Hippocrates. Roused before dawn by the impetuous young man, Socrates leads Hippocrates to reflect on the wisdom of his enthusiastic desire to study with Protagoras. This is a classic (...) and successful little example of Socratic dialogue. He then takes Hippocrates to meet Protagoras; the bulk of the dialogue—call it the innermost frame—consists in Socrates’ exchanges with Protagoras. Hippocrates does not utter a word in this part of the dialogue, though it is initiated at his request and seems undertaken by Socrates for his benefit. (shrink)

After severe brain injury, one of the key challenges for medical doctors is to determine the patient’s prognosis. Who will do well? Who will not do well? Physicians need to know this, and families need to do this too, to address choices regarding the continuation of life supporting therapies. However, current prognostication methods are insufficient to provide a reliable prognosis. -/- Functional Magnetic Resonance Imaging (MRI) holds considerable promise for improving the accuracy of prognosis in acute brain injury patients. Nonetheless, (...) research on functional MRI in the intensive care unit context is ethically challenging. These studies raise several ethical issues that have not been addressed so far. In this article, Prof. Charles Weijer and his co-workers provide a framework for researchers and ethics committees to design and review these studies in an ethically sound way. (shrink)

Views of the self may be plotted on a set of coordinates. On the axis that runs from fragmentation to unity, Rorty and Rorty's Freud champion the decentered self while Wallwork, Taylor, and Ricoeur argue for a sovereign, unified self. On the other axis, which runs from the disengaged, inward-turning self to the engaged and "sedimented" self, Wallwork, would be positioned near Rorty, defending self-creation against the narrative identity affirmed by Taylor and Ricoeur. Despite his skepticism concerning the communitarian agenda (...) of the narrativists, Flanagan grants that the self is social and relational--a position further explored by Oliver, Stendahl, Deutsch, and Mack in "Selves, People, and Persons". (shrink)

This article considers the various emergence of an explicitly recognized right to life in papal teaching and the canon law of the last century and a quarter. The Church's opposition to abortion is deeply embedded within the tradition and law of the Church. It was, however, only in recent times, since the middle twentieth century, really, that the Church began to speak explicitly of a right to life. This paper explores the consequences for papal thought of this explicit recognition of (...) rights. By speaking of a right to life, the Church has moved beyond the abortion debate to embrace a variety of other concerns. This is not to say that abortion does not remain important. Direct participation in abortion is a crime at canon law that results in automatic excommunication. But the language of rights has allowed the Church to address such matters as the protection of refugees; the moral requirement of adequate health care; the odious use of child-soldiers; and the use of economic embargoes that have the effect of destroying the civilian infrastructure (and public health systems) of entire societies. (shrink)

“Every step and every movement of the multitude, even in what are termed enlightened ages, are made with equal blindness to the future; and nations stumble upon establishments, which are indeed the result of human action, but not the execution of any human design.”—_Adam Ferguson_ During the Scottish Enlightenment, David Hume, Adam Smith, Adam Ferguson, and other lesser thinkers described a theory of spontaneously generated social order. Ronald Hamowy discusses their contributions to this significant area of social theory, noting that (...) the revolutionary aspect of these philosophers’ thoughts was “the proposition that social phenomena of a high degree of intricacy are not the product of intentional design.” Hamowy shows that Hume is best known for his application of the theory to justice, developing it most thoroughly in the _Treatise of Human Nature. _Adam Smith’s first treatment of it is in the _Theory of Moral Sentiment, _published before the significant _Wealth of Nations. _There Smith uses it to explain the development of general rules that compose the moral fabric of societies. All of these thinkers used their notion of spontaneously generated social order to explain systems of moral rules and social systems. In addition Adam Ferguson and David Hume applied the theory to language, as well as to economic development. (shrink)

Listening represents a welcome contribution to the now substantial body of recent literature on Phaedrus. In the book's seven chapters, Ferrari discusses various parts of the dialogue and offers many helpful points along the way. For example, Ferrari's remarks are good on the controverted question as to whether the lover in the palinode "uses" the beloved, as are his observations about the struggle between the three parts of the soul. Ferrari persuasively points out that each part of the soul really (...) represents a way of life, a possible human type. Ferrari offers the novel and probably correct view that the question as to the authenticity of the speech attributed to Lysias is intended ironically by Plato to parallel the question as to whether the "demythologizers" are right to pursue the historical origins of myths. In his last chapter Ferrari surveys various approaches to the famous critique of writing, opting for a modified version of the view that the critique is meant to express a serious distrust of writing, that Plato thought he had discovered a way of writing that avoided the thrust of critique, and that the spoken word ultimately remains superior. Ferrari thus positions himself against Burger's and Derrida's interpretations. Ferrari rightly sees that the critique of writing engages the major issues of the dialogue and ought not be severed from them. (shrink)

In book Ten of the Laws, Plato's Athenian Stranger sets out the out lines of an argument of the sort that effectively dominated thinking for several millennia about the political role of religion. A polis that is to be free from faction and free for the right development of character requires a shared understanding of the human good and of the virtues of soul that are its components; religion provides that understanding in a way that connects up the human good (...) with the nature of the whole; as the function of government is to support civic peace and a flourishing citizenry, it must support the means thereto, namely, a civic religion; and effective support, in turn, requires state-enforced prohibitions against publicly expressed disavowals or corruptions of that dogma. Not just any dogma will do, of course, and the Stranger devotes a good deal of energy to setting out the principles of the new religion. (shrink)

Based on a survey of deans and marketing department chairs, this study explores the business and marketing curriculum in the areas of ethics, corporate social responsibility (CSR), and sustainability. The findings indicate that there was limited support for providing students with an understanding of these topics, in believing the concepts provide a competitive advantage in the job market, or would be utilized by students at a later point in their education. Finally, the value placed on research in these areas was (...) considerably less than on theory development or applied and pedagogical research. (shrink)

The purpose of this dissertation is to provide a defence of Aristotle's principle of contradiction against the critique made on it by Jan Lukasiewicz in an article he wrote in 1910 which was translated and published in the March 1971 number of The Review of Metaphysics. Lukasiewicz maintains in general that the law of contradiction has no logical worth. Specifically, he charges Aristotle with having several laws of contradiction instead of one as Aristotle claims; with attempting to prove the law (...) despite his claim that this is impossible and finally with failing in the very attempt to prove the law, or at least one of its formulations. In 20 chapters, each dealing with a respective section of Lukasiewicz's article, I attempt to show that all of Lukasiewicz's allegations are unfounded. My methodology is simply to follow Lukasiewicz through his 20 sections and compare what he says with what Aristotle actually wrote. If successful, this dissertation will show, in basic agreement with Professor Joseph Owens, that the best way to read Aristotle is on his own terms and not, as in the case of Lukasiewicz, via the latest developments in symbolic logic. I reiterate, with Aristotle, that the law of contradiction is the basic principle of being qua being and has logical worth precisely because of that fact. (shrink)

Over the past decade, we have witnessed some early signs of progress in the battle against international bribery and corruption, a problem that throughout the history of commerce had previously been ignored. We present a model that we then use to assess progress in reducing bribery. The model components include both hard law and soft law legislation components and enforcement and compliance components. We begin by summarizing the literature that convincingly argues that bribery is an immoral and unethical practice and (...) that the economic harm it causes falls most heavily on those least able to absorb it. The next section summarizes the main provisions of anti-bribery legislation including the Foreign Corrupt Practices Act (FCPA), the Organization for Eco nomic Development's Convention on Combating Bribery of Foreign Officials in International Business Transactions, the United Nations Convention Against Corruption and the laws of selected countries. We conclude this section with a discussion of the "moral imperialism" argument for not imposing Western laws and values on other cultures. The next section focuses on the roles played by NGOs including Transparency International (TI), the World Economic Forum (WEF), and the International Chamber of Commerce. We review trends in enforcement and prosecution, including a review of the United States' enforcement processes, mechanisms for cross-border legal assistance, a discussion of the distinctive nature of FCPA cases, and an assessment of what the future holds for enforcement. The final section focuses on compliance processes for corporations aimed at reducing the risk of FCPA and related violations. This section also addresses the ethics of gift giving and "grease" payments. The article concludes with a summary and suggestions for further research. Throughout the article, we reference important bribery cases and include comments from several authorities who are on the front lines of the battle against international bribery. (shrink)

Functional MRI shows promise as a candidate prognostication method in acutely comatose patients following severe brain injury. However, further research is needed before this technique becomes appropriate for clinical practice. Drawing on a clinical case, we investigate the process of obtaining informed consent for this kind of research and identify four ethical issues. After describing each issue, we propose potential solutions which would make a patient’s participation in research compatible with her rights and interests. First, we defend the need for (...) traditional proxy consent against two alternative approaches. Second, we examine the impact of the intensive care unit environment on the informed consent process. Third, we discuss the therapeutic misconception and its potential influence on informed consent. Finally, we deal with issues of timing in recruiting participants and related factors which may affect the risks of participation. (shrink)

Ontology is one strategy for promoting interoperability of heterogeneous data through consistent tagging. An ontology is a controlled structured vocabulary consisting of general terms (such as “cell” or “image” or “tissue” or “microscope”) that form the basis for such tagging. These terms are designed to represent the types of entities in the domain of reality that the ontology has been devised to capture; the terms are provided with logical defi nitions thereby also supporting reasoning over the tagged data. Aim: This (...) paper provides a survey of the biomedical imaging ontologies that have been developed thus far. It outlines the challenges, particularly faced by ontologies in the fields of histopathological imaging and image analysis, and suggests a strategy for addressing these challenges in the example domain of quantitative histopathology imaging. The ultimate goal is to support the multiscale understanding of disease that comes from using interoperable ontologies to integrate imaging data with clinical and genomics data. (shrink)