There has been an ongoing appeal in the bioethics literature for a broader understanding and conceptual clarity of the phenomenon of moral distress. Several authors argue that greater conceptual cl...

We say that a ring admits elimination of quantifiers, if in the language of rings, {0, 1, +, ·}, the complete theory of R admits elimination of quantifiers. Theorem 1. Let D be a division ring. Then D admits elimination of quantifiers if and only if D is an algebraically closed or finite field. A ring is prime if it satisfies the sentence: ∀ x ∀ y ∃ z (x = 0 ∨ y = 0 ∨ xzy ≠ 0). Theorem (...) 2. If R is a prime ring with an infinite center and R admits elimination of quantifiers, then R is an algebraically closed field. Let A be the class of finite fields. Let B be the class of 2 × 2 matrix rings over a field with a prime number of elements. Let C be the class of rings of the form $GF(p^n) \bigoplus GF(p^k)$ such that either n = k or g.c.d. (n, k) = 1. Let D be the set of ordered pairs (f, Q) where Q is a finite set of primes and f: Q → A ∪ B ∪ C such that the characteristic of the ring f(q) is q. Finally, let E be the class of rings of the form $\bigoplus_{q \in Q}f(q)$ for some (f, Q) in D. Theorem 3. Let R be a finite ring without nonzero trivial ideals. Then R admits elimination of quantifiers if and only if R belongs to E. Theorem 4. Let R be a ring with the descending chain condition of left ideals and without nonzero trivial ideals. Then R admits elimination of quantifiers if and only if R is an algebraically closed field or R belongs to E. In contrast to Theorems 2 and 4, we have Theorem 5. If R is an atomless p-ring, then R is finite, commutative, has no nonzero trivial ideals and admits elimination of quantifiers, but is not prime and does not have the descending chain condition. We also generalize Theorems 1, 2 and 4 to alternative rings. (shrink)

Let n ≥ 3. The following theorems are proved. Theorem. The theory of the class of strictly upper triangular n × n matrix rings over fields is finitely axiomatizable. Theorem. If R is a strictly upper triangular n × n matrix ring over a field K, then there is a recursive map σ from sentences in the language of rings with constants for K into sentences in the language of rings with constants for R such that $K \vDash \varphi$ if (...) and only if $R \vDash \sigma$. Theorem. The theory of a strictly upper triangular n × n matrix ring over an algebraically closed field is ℵ 1 -categorical. (shrink)

We describe the ethics consultation service (ECS) at the Cleveland Clinic and report on its activities over a 24-month period in which 478 consultations were performed. To our knowledge, this is the largest case series of ethics consultations reported to date. Established more than 25 years ago, the ECS at the Cleveland Clinic is staffed by multiple consultants with advanced training in bioethics. Several of these ethicists work closely with specialized clinical units and research departments, where they participate in multidisciplinary (...) meetings and provide specialized assistance. This combination of historical experience, large numbers of consultation requests, and specialized clinical ethicists suggests that the experience at the Cleveland Clinic may be helpful to ethicists and others who may be considering how to structure and sustain a vibrant ECS. Our results highlight the diversity of activities performed by a high-volume ECS at a tertiary care facility. Our hope in sharing the inner workings of the ECS at the Cleveland Clinic is to promote dialogue on common practices and approaches across medical institutions that support ethics consultation. (shrink)

It is generally accepted that appropriate documentation of activities and recommendations of ethics consultants in patients’ medical records is critical. Despite this acceptance, the bioethics literature is largely devoid of guidance on key elements of an ethics chart note, the degree of specificity that it should contain, and its stylistic tenor. We aim to provide guidance for a variety of persons engaged in clinical ethics consultation: new and seasoned ethics committee members who are new to ethics consultation, students and trainees (...) in clinical ethics, and those who have significant experience with ethics consultation so that they can reflect on their practice. Toward the goal of promoting quality charting practices in ethics consultations, we propose recommendations on a broad array of questions concerning clinical ethics consultation chart notes, including whether and when to write a chart note, and practical considerations for the tenor, purpose, and content of a chart note. Our broader aim is to promote discussion about good charting practices in clinical ethics, with the hope of contributing to clear standards of excellence in clinical ethics consultation. (shrink)

The authors work in a variety of clinical ethics consultation services (CECSs) that employ a range of methods and approaches. This article discusses the approach to ethics consultation at the Center for Medical Ethics and Health Policy at Baylor College of Medicine and describes the development and transformation of the authors’ CECSs. It discusses how one CECS shifted from a nascent program with only fifty consultations a year to a vibrant, heavily staffed service with five hundred ethics consultations a year.

While valuable work has been done addressing clinical ethics within established healthcare systems, we anticipate that the projected growth in acquisitions of community hospitals and facilities by large tertiary hospitals will impact the field of clinical ethics and the day-to-day responsibilities of clinical ethicists in ways that have yet to be explored. Toward the goal of providing clinical ethicists guidance on a range of issues that they may encounter in the systematization process, we discuss key considerations and potential challenges in (...) implementing system-wide ethics consultation services. Specifically, we identify four models for organizing, developing, and enhancing ethics consultation activities within a system created through acquisitions: train-the-trainer, local capacity-building, circuit-riding, and consolidated accountability. We note each model’s benefits and challenges. To our knowledge, this is the first paper to consider the broader landscape of issues affected by consolidation. We anticipate that clinical ethicists, volunteer consultants, and hospital administrators will benefit from our recommendations. (shrink)

In November 2018, the practice of health care ethics consultation crossed a major threshold when 138 candidates took the inaugural Healthcare Ethics Consultant Certification Examination. This accomplishment, long in the making, has had and continues to have both advocates and critics. The Healthcare Ethics Consultant Certification Commission, a functionally autonomous body created and funded by the American Society for Bioethics and Humanities, was charged with overseeing creation of the certification process, developing the exam, and formulating certification standards and policies to (...) assess candidates’ qualifications. In this essay, as members of the commission, we describe the process of developing, administering, and scoring the certification examination as well as the historical context and the outlook for certification. By detailing the decisions and actions of the commission, we aim to provide a transparent account of the commission's efforts to develop a psychometrically sound, reliable, and secure examination through a deliberative, fair, and data‐driven process. (shrink)

Despite the interpersonal nature of family meetings and the frequency in which they occur, the clinical ethics literature is devoid of any rich descriptions of what clinical ethicists should actually be doing during family meetings. Here, we propose a framework for describing and understanding “transitioning” facilitation skills based on a retrospective review of our internal documentation of 100 consecutive cases wherein a clinical ethicist facilitated at least one family meeting. The internal documents were analyzed using qualitative methodologies, i.e., “codes”, to (...) identify emergent themes. We identified four different transitioning strategies clinical ethicists use to reach a meaningful resolution. These transitioning strategies serve as a jumping-off point for additional analyses, future research, evaluating clinical ethics consultation, and overall performance improvement of a consultation service. (shrink)

Developing a care plan in a critical care context can be challenging when the therapeutic alliance between clinicians and families is compromised by anger. When these cases occur, clinicians often turn to clinical ethics consultants to assist them with repairing this alliance before further damage can occur. This paper describes five different reasons family members may feel and express anger and offers concrete strategies for clinical ethics consultants to use when working with angry families acting as surrogate decision makers for (...) critical care patients. We reviewed records of consults using thematic analysis between January 2015 and June 2016. Each case was coded to identify whether the case involved a negative encounter with an angry family. In our review, we selected 11 cases with at least one of the following concerns or reasons for anger: perceived or actual medical error, concerns about the medical team’s competence, miscommunication, perceived conflict of interest or commitment, or loss of control. To successfully implement these strategies, clinical ethics consultants, members of the medical team, and family members should share responsibility for creating a mutually respectful relationship. (shrink)

Lei, a twenty‐seven‐year‐old Mandarin speaker, visits the United States seeking curative treatments for his acute myeloid leukemia. His mother, Hua, has traveled with him. Neither she nor Lei speak English, and the hospital does not have an onsite professional Mandarin‐speaking interpreter. Using a professional interpreter over the phone, Lei's oncologist, Dr. Branson, attempts to initiate a face‐to‐face goals‐of‐care conversation with Hua as the surrogate decision‐maker. Dr. Branson explains that Lei has “only weeks to months to live” and recommends initiating comfort‐care‐only (...) measures, but Hua says that she wants (and that Lei would want) continued aggressive measures. Hua says that her son might be a candidate for a phase I trial. Eventually, Dr. Branson brings in Dr. Chou, a Mandarin‐speaking resident to provide face‐to‐face interpretation. Hua insists that “there must be more standard therapies available” and says that she will wait until the trial begins. She begins crying, and the meeting disintegrates. Following this, Dr. Branson calls for an ethics consultation for “help in end‐of‐life communicating and reconciling discordance about prognostic information.”How should the ethicist use the institution's interpreter services? (shrink)

Patients who enter the health care system for acute care may become “permanent” patients of the hospital when a lack of resources precludes discharge to the next level of post-acute care. Legal, professional, and ethical norms prohibit physician and acute care hospital “dumping” of these patients. However, limitless use of hospital resources for indefinite stays is untenable. In the absence of hospital policy addressing this specific issue, the availability of financial support will be determined by health care professionals' willingness to (...) advocate for the patient and negotiate with hospital administrators and the ability and willingness of administrators to authorize the use of hospital resources. We propose five mid-level ethical principles to guide advocacy and administrative decision-making about provision of financial support for post-acute care for those patients who cannot afford it. We use two actual, de-identified cases to illustrate how these principles can be used to make reasoned, consistent decisions about the provision of post-acute financial support. (shrink)

Patients who enter the health care system for acute care may become “permanent” patients of the hospital when a lack of resources precludes discharge to the next level of post-acute care. The care of these patients contributes to the rising costs of health care and will remain largely unaffected by the Affordable Care Act. For example, some resources may be available for treatment of undocumented persons, but Medicaid enrollment is unavailable for this population. Even where patients have access to Medicaid, (...) it takes up to three months between applying for and actually receiving Medicaid benefits. During that time, patients may be ready for hospital discharge. However, post-acute care facilities have no financial incentive or legal obligation to accept patients with no insurance or only pending Medicaid coverage. (shrink)

In their article “Structuring a Written Examination to Assess ASBH Health Care Ethics Consultation Core Competencies” (2014), White, Jankowski, and Shelton argue that a written examination to evalu...

The clinical ethicist met with Ms. H to clarify what information she wants and does not want to know. First, she wants to receive any treatment that could prolong her life, regardless of how the treatment affects her ability to engage in activities of daily living. Second, she wants to be included in the decision‐making process as much as possible, as long as clinicians use only “positive” language. Ms. H considers the words “dying,” “chemotherapy,” “radiation,” and “cancer” to be “bad (...) words.” For conversations in which these words cannot be avoided, she wants her clinicians to talk to her son. Her desired engagement includes hearing about risks, benefits, and alternatives to treatments if clinicians use only “positive” language. Finally, she says that she rarely sees doctors and that she is “very scared” of hospitals, despite exhibiting a comfortable demeanor.Should clinicians honor Ms. H's waiver of specified information and, if so, to what degree? (shrink)

The authors of this article are previous or current members of the Clinical Ethics Consultation Affairs (CECA) Committee, a standing committee of the American Society for Bioethics and Humanities (ASBH). The committee is composed of seasoned healthcare ethics consultants (HCECs), and it is charged with developing and disseminating education materials for HCECs and ethics committees. The purpose of this article is to describe the educational research and development processes behind our teaching materials, which culminated in a case studies book called (...) A Case-Based Study Guide for Addressing Patient-Centered Ethical Issues in Health Care (hereafter, the Study Guide). In this article, we also enumerate how the Study Guide could be used in teaching and learning, and we identify areas that are ripe for future work. (shrink)

Hospital administrators may lack familiarity with what clinical ethicists do (and do not do), and many clinical ethicists report receiving inadequate financial support for their clinical ethics consultation services (CECSs). Ethics consultation is distinct in that it is not reimbursable by third parties, and its financial benefit to the hospital may not be quantifiable. These peculiarities make it difficult for clinical ethicists to resort to tried-and-true outcome-centered evaluative strategies, like cost reduction or shortened length of stay for patients, to show (...) a “need” for ethics consultation. Likewise, it can be difficult for clinical ethicists to “speak the same language” as healthcare administrators and managers, which, in turn, means that CECSs run the risk of being unable to demonstrate value to those who pay for the service. The purpose of this descriptive article is to provide practical guidance to clinical ethicists and program directors on how to cultivate administrative support for a CECS. Specifically, we discuss two elements that clinical ethics leaders must critically appraise and successfully argue to meet the expectations of administrators— the value of a CECS and its fit in clinical workflow. (shrink)

Steven Rose regards oversimplification of biology as the supreme sin, inevitably leading to evil consequences, and requiring an unique distortion of scientific practice to avoid it. To avoid this, he proposes a short-cut to scientific knowledge by defining certain areas of biology that are intrinsically flawed. But this achieves only a subordination of science to politics. There are no general-purpose shortcuts for evaluating the validity of theories, and no substitutes for testing specific theories using relevant evidence.

Apparently, the wall was something of an engineering miracle even prior to the events that exposed it to the light of day. People used to go down to the basement where part of it was visible, and marvel at its ability to resist 3500 pounds per square inch of pressure over 3300 feet. When it was called upon to bear even more it rose to the challenge, anthropomorphically speaking. Now it is being compared to the Liberty Bell,1 a physical (...) object that symbolizes a signature and defining event. This wall, built to hold back the Hudson River from flooding the basement of the World Trade Center, was once the foundation and physical site of a place, but has now itself become a place. It has transformed from site to situation. It is being written retrospectively as a humble and unglamorous object that rose to be a noble, even heroic place, one which because of the “ miracle ” of superior engineering stood when everything else fell. This object which newly defines a place has become the classic American story of triumph over insurmountable odds. It has become personified, narrativized, and valorized - it “held” against the onslaught like a defender protecting a city, saving the lives of people who were rushing out of the building. It is a place of memory, although precisely what is being remembered depends on who faces the wall. It is the Wailing Wall. It is being incorporated into the new design for the site by the architects and the memorial planners, an unlikely remembrance to and representation of horrific events. It is the hypostatization of a narrative of siege, another quintessentially American story about the triumph of the inside over the outside. It is the Alamo, it is Independence Day, it is homeland security. Less literally but no less viscerally than Maya Ying Lin’s Vietnam. (shrink)

The first longevity revolution began in the middle of the 19th century, accelerated through the first half of the 20th century, and led to the first and only quantum leap in human life expectancy.In the 20th century alone, life expectancy at birth in most developed nations rose by about 30 years. The first three quarters of the century were notable for gains made at younger and middle ages, and in the last quarter century, old age mortality declined. Nothing in (...) history has ever come close to the magnitude of this benefit to humanity. The rise in life expectancy occurred swiftly because the primary beneficiaries of advances in public health and... (shrink)

Biological individuality is a notoriously thorny topic for biologists and philosophers of biology. In this paper we argue that biological individuality presents multiple, interconnected questions for biologists and philosophers that together form a problem agenda. Using a case study of an interdisciplinary research group in ecology, behavioral and evolutionary biology, we claim that a debate on biological individuality that seeks to account for diverse practices in the biological sciences should be broadened to include and give prominence to questions about uniqueness (...) and temporality. We show that broadening the problem agenda of biological individuality draws attention to underrecognized philosophical issues and discussions and thereby organizes and enriches the existing debate. (shrink)

Does the Ship of Theseus present a genuine puzzle about persistence due to conflicting intuitions based on “continuity of form” and “continuity of matter” pulling in opposite directions? Philosophers are divided. Some claim that it presents a genuine puzzle but disagree over whether there is a solution. Others claim that there is no puzzle at all since the case has an obvious solution. To assess these proposals, we conducted a cross-cultural study involving nearly 3,000 people across twenty-two countries, speaking eighteen (...) different languages. Our results speak against the proposal that there is no puzzle at all and against the proposal that there is a puzzle but one that has no solution. Our results suggest that there are two criteria—“continuity of form” and “continuity of matter”— that constitute our concept of persistence and these two criteria receive different weightings in settling matters concerning persistence. (shrink)

Since the introduction of mathematical population genetics, its machinery has shaped our fundamental understanding of natural selection. Selection is taken to occur when differential fitnesses produce differential rates of reproductive success, where fitnesses are understood as parameters in a population genetics model. To understand selection is to understand what these parameter values measure and how differences in them lead to frequency changes. I argue that this traditional view is mistaken. The descriptions of natural selection rendered by population genetics models are (...) in general neither predictive nor explanatory and introduce avoidable conceptual confusions. I conclude that a correct understanding of natural selection requires explicitly causal models of reproductive success. *Received May 2006; revised December 2006. †To contact the author, please write to: Department of Philosophy, Kansas State University, 201 Dickens Hall, Manhattan, KS 66506; e‐mail: [email protected] . (shrink)

The most successful theory in all of science--and the basis of one third of our economy--says the strangest things about the world and about us. Can you believe that physical reality is created by our observation of it? Physicists were forced to this conclusion, the quantum enigma, by what they observed in their laboratories. Trying to understand the atom, physicists built quantum mechanics and found, to their embarrassment, that their theory intimately connects consciousness with the physical world. Quantum Enigma explores (...) what that implies and why some founders of the theory became the foremost objectors to it. Schrodinger showed that it "absurdly" allowed a cat to be in a "superposition" simultaneously dead and alive. Einstein derided the theory's "spooky interactions." With Bell's Theorem, we now know Schrodinger's superpositions and Einstein's spooky interactions indeed exist. Authors Bruce Rosenblum and Fred Kuttner explain all of this in non-technical terms with help from some fanciful stories and bits about the theory's developers. They present the quantum mystery honestly, with an emphasis on what is and what is not speculation. Physics' encounter with consciousness is its skeleton in the closet. Because the authors open the closet and examine the skeleton, theirs is a controversial book. Quantum Enigma's description of the experimental quantum facts, and the quantum theory explaining them, is undisputed. Interpreting what it all means, however, is controversial. Every interpretation of quantum physics encounters consciousness. Rosenblum and Kuttner therefore turn to exploring consciousness itself--and encounter quantum physics. Free will and anthropic principles become crucial issues, and the connection of consciousness with the cosmos suggested by some leading quantum cosmologists is mind-blowing. Readers are brought to a boundary where the particular expertise of physicists is no longer a sure guide. They will find, instead, the facts and hints provided by quantum mechanics and the ability to speculate for themselves. (shrink)

It is widely agreed that possession of consciousness contributes to an entity’s moral status, even if it is not necessary for moral status (Levy and Savulescu 2009). An entity is considered to have...

We live, according to some, in the century of biology, where we now understand ourselves in radically new ways as the insights of genomics and neuroscience have opened up the workings of our bodies and our minds to new kinds of knowledge and intervention. Is a new figure of the human, and of the social, taking shape in the 21st century? With what consequences for the politics of life today? And with what implications, if any, for the social, cultural and (...) human sciences? These are the issues that are discussed in this article, which argues that a new relation is requred with the life sciences, beyond commentary and critique, if the social and human sciences are to revitalize themselves for the 21st century. (shrink)

Systems of units still fail to attract the philosophical attention they deserve, but this could change with the current reform of the International System of Units. Most of the SI base units will henceforth be based on certain laws of nature and a choice of fundamental constants whose values will be frozen. The theoretical, experimental and institutional work required to implement the reform highlights the entanglement of scientific, technological and social features in scientific enterprise, while it also invites a philosophical (...) inquiry that promises to overcome the tensions that have long obstructed science studies. (shrink)

The way metrologists conceive of measurement has undergone a major shift in the last two decades. This shift can in great part be traced to a change in the statistical methods used to deal with the expression of measurement results, and, more particularly, with the calculation of measurement uncertainties. Indeed, as we show, the incapacity of the frequentist approach to the calculus of uncertainty to deal with systematic errors has prompted the replacement of the customary frequentist methods by fully Bayesian (...) procedures. The epistemological ramifications of the Bayesian approach merge with a deep empiricist mood tantamount to an “epistemic turn”: measurement results are analysed in terms of degrees of belief, and central concepts such as error and accuracy are called into question. We challenge the perspective entailed by this epistemic turn: we insist on the centrality of the concepts of error and accuracy by underlining the intentional character of measurement that is intimately linked to the process of correction of experimental data. We further circumvent the difficulties posed by the classical analysis of measurement by stressing the social rather than the epistemic dimension of measurement activities. (shrink)

Judaism and Modernity: Philosophical Essays challenges the philosophical presentation of Judaism as the sublime 'other' of modernity. Here, Gillian Rose develops a philosophical alternative to deconstruction and post-modernism by critically re-engaging the social and political issues at stake in every reconstruction.

Offers a compelling vision of how to achieve and conduct a liberal but democratic society through the ideal of Neutrality--between people and ideas of the good--and using the tool of Neutral dialogue.

Prabhpal Singh has recently defended a relational account of the difference in moral status between fetuses and newborns as a way of explaining why abortion is permissible and infanticide is not. He claims that only a newborn can stand in a parent–child relation, not a fetus, and this relation has a moral dimension that bestows moral value. We challenge Singh’s reasoning, arguing that the case he presents is unconvincing. We suggest that the parent–child relation is better understood as an extension (...) of an existing relationship formed during the gestational period. The change in this relation at birth is not sufficient to justify the radical change in moral status required to rule out infanticide while accepting the permissibility of abortion. Given that the moral status of orphans is also problematic under Singh’s account, we conclude that Singh has not shown that a newborn has greater moral worth than a fetus. (shrink)

HIV stigma, a social-medical problem, continues to confound researchers and health professionals, while undermining outcomes. Empathy may reduce stigma; its absence may predict stigma. This research investigates: How does Kafka’s _Metamorphosis_ advance understandings of HIV stigma in medical health education? _Metamorphosis_ amplifies the sociological-relational mechanisms fostering HIV stigma. It offers a multi-disciplinary, responsive space for ethical, humanistic and clinical inquiry to meet: enabling students to consider how social structures shape health inequities, moral, social experience, and their professional identity within. _Metamorphosis_ (...) may ultimately promote medical health humanities’ social mission—allowing literature to unfold such revelations towards greater equity in health. (shrink)

A standard view in contemporary philosophy is that belief is involuntary, either as a matter of conceptual necessity or as a contingent fact of human psychology. We present seven experiments on patterns in ordinary folk-psychological judgments about belief. The results provide strong evidence that voluntary belief is conceptually possible and, granted minimal charitable assumptions about folk-psychological competence, provide some evidence that voluntary belief is psychologically possible. We also consider two hypotheses in an attempt to understand why many philosophers have been (...) tempted to view belief as involuntary: that belief is a prototype concept and that belief is a dual character concept. Altogether, our findings contribute to longstanding philosophical debates about the relationship between the will and the intellect, while also advancing scientific understanding of important social judgments. (shrink)

The second edition of The Great Psychotherapy Debate has been updated and revised to include a history of healing practices, medicine, and psychotherapy, an expanded theoretical presentation of the contextual model, an examination of therapist effects, and a thorough review of the research on common factors such as the alliance, expectations, and empathy.