During public health crises including the COVID-19 pandemic, resource scarcity and contagion risks may require health systems to shift—to some degree—from a usual clinical ethic, focused on the well-being of individual patients, to a public health ethic, focused on population health. Many triage policies exist that fall under the legal protections afforded by “crisis standards of care,” but they have key differences. We critically appraise one of the most fundamental differences among policies, namely the use of criteria to categorically exclude (...) certain patients from eligibility for otherwise standard medical services. We examine these categorical exclusion criteria from ethical, legal, disability, and implementation perspectives. Focusing our analysis on the most common type of exclusion criteria, which are disease-specific, we conclude that optimal policies for critical care resource allocation and the use of cardiopulmonary resuscitation (CPR) should not use categorical exclusions. We argue that the avoidance of categorical exclusions is often practically feasible, consistent with public health norms, and mitigates discrimination against persons with disabilities. (shrink)

We propose six guideposts that states and hospitals should follow to respect disability rights when designing policies for the allocation of scarce, lifesaving medical treatments. Four relate to criteria for decisions. First, do not use categorical exclusions, especially ones based on disability or diagnosis. Second, do not use perceived quality of life. Third, use hospital survival and near-term prognosis (e.g., death expected within a few years despite treatment) but not long-term life expectancy. Fourth, when patients who use ventilators in their (...) daily lives (e.g., home ventilation) present to acute care hospitals, their personal ventilators should not be reallocated to other patients. Fifth, designate triage officers to assess patients individually on the basis of objective medical evidence, not stereotypes or assumptions. Sixth, include disability rights advocates in policy development and dissemination. (shrink)

We wholeheartedly agree with Schmidt and colleagues’ efforts to promote equity in intensive care unit triage. We also take issue with their characterisation of the New Jersey allocation framework for ICU beds and ventilators, which is modelled after the multi-principle allocation framework we developed early in the pandemic. They characterise it as a two-criterion allocation framework and claim—without evidence—that it will ‘compound disadvantage for black patients’. However, the NJ triage framework—like the model allocation policy we developed—actually contains four allocation criteria: (...) the two criteria that the authors mentioned and two criteria that they failed to mention which we included to promote equity: giving priority to frontline essential workers and giving priority to younger patients. These omissions are problematic both for reasons of factual accuracy and because the two criteria they failed to acknowledge would likely mitigate rather than exacerbate racial disparities during triage. (shrink)

In recent years, philosophers have identified a number of moral and psychological harms associated with the attention economy (Alysworth & Castro, 2021; Castro & Pham, 2020; Williams, 2018). Missing from many of these accounts of the attention economy, however, is what exactly attention is. As a result of this neglect of the cognitive science of attention, many of these accounts are not empirically credible. They rely on oversimplified and unsophisticated accounts of not only attention, but self- control, and addiction as (...) well. Of note are accounts of the attention economy that rely on the ‘brain disease’ rhetoric of addiction and subsequent control failures (Aylsworth & Castro, 2021; Bhargava & Velasquez, 2021), accounts that rely on a strict dichotomy of top-down vs. bottom-up attention (Williams, 2018; Aylsworth & Castro, 2021), and accounts that construe attention as a limited resource (Williams, 2018). -/- Drawing on recent work from the neuroscience and psychology of attention, I demonstrate the shortcomings of these accounts and sketch a way forward for an empirically grounded account of the attention economy. These accounts tend to uphold strict dichotomies of voluntary control (e.g., compulsion versus choice, dual-process models of self-control, and top-down versus bottom-up) that cannot account for the complexities of attentional control, mental agency, and decision-making. As such, these empirically and conceptually impoverished accounts cannot adequately address the current so-called crisis of attention. To better understand the harms associated with the attention economy, we need an empirically responsible account of the nature and function of attention and mental agency. (shrink)

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

Over the last decade, the increased use of work teams within organizations has been one of the most influential and far-reaching trends to shape the business world. At the same time, corporations have continued to struggle with increased unethical employee behavior. Very little research has been conducted that specifically examines the developmental aspects of employee ethical decision-making in a team environment. This study examines the impact of a team leader’s perceived integrity on his or her subordinates’ behavior. The results, which (...) came from a survey of 245 MBA students functioning for 2 years in a work team environment, indicate an interaction between leader integrity and team member ethical intentions. (shrink)

Hastings Center Report, Volume 51, Issue 5, Page 42-47, September‐October 2021.

The coronavirus disease 2019 (COVID-19) pandemic has motivated medical ethicists and several task forces to revisit or issue new guidelines on allocating scarce medical resources. Such guidelines are relevant for the allocation of scarce therapeutics and vaccines and for allocation of ICU beds, ventilators, and other life-sustaining treatments or potentially scarce interventions. Principles underlying these guidelines, like saving the most lives, mitigating disparities, reciprocity to those who assume additional risk (eg, essential workers and clinical trial participants), and equal access may (...) compete with one another. We propose the use of a “categorized priority system” (also known as a “reserve system”) as an improvement over existing allocation methods, particularly because it may be able to achieve disparity mitigation better than other methods. (shrink)

Coronavirus disease 2019 can lead to respiratory failure. Some patients require extracorporeal membrane oxygenation support. During the current pandemic, health care resources in some cities have been overwhelmed, and doctors have faced complex decisions about resource allocation. We present a case in which a pediatric hospital caring for both children and adults seeks to establish guidelines for the use of extracorporeal membrane oxygenation if there are not enough resources to treat every patient. Experts in critical care, end-of-life care, bioethics, and (...) health policy discuss if age should guide rationing decisions. (shrink)

Over the past fifty years, a number of approaches to the recovery of the multiple pasts of Hinduism have held the field. These include that of the discipline of History of Religions as it is constituted in North America as well as those of the Hindu nationalists, the col and post-colonial historians, and the Subaltern Studies School. None of these approaches have proven satisfactory because, for methodological or ideological reasons, none have adequately addressed human agency or historical change in their (...) accounts of the pasts out of which modern-day Hinduism has emerged. The Hindu nationalist historians hark back to an extended Vedic golden age in which religious practice remained unchanged until the corruptions spawned by the Turkish invasions of the eleventh century. Many Western indologists and historians of religion specializing in Hinduism never leave the unalterable ideal worlds of the scriptures they interpret to investigate the changing real-world contexts out of which those texts emerged. The colonial and postcolonial historians focus on the past two hundred years as the period in which all of the categories through which India continues to interpret itself—including Hinduism—were imposed upon it from without. Adducing examples of Hindu practitioners and thinkers from the colonial period, subaltern theorists and others argue that historical thought is itself alien to the authentic Indian mind. This article suggests a number of interpretive strategies for retrieving the multiple Hinduisms of the past and of the medieval period in particular as that time out of which most modern-day practices of Hinduism emerged. These include an increased emphasis on non-scriptural sources and a focus on regional traditions. (shrink)

This study investigates the processes involved in the shaping of a society's economic ethos. The discussion of ethics and economics has a very long history across multiple disciplines. The founder of modern economics, Adam Smith, likewise had a keen interest in this topic. However, with the development of economic science, scholarly assessment has shifted toward positive analysis while normative analysis has been left mainly to philosophers. By utilizing the newly developed morality of profit-making scale, the authors sought to understand how (...) respondents' economic ethical worldview shifts over time. Specifically, we theorized that the news media's copious negative coverage of the gasoline price crisis of 2006 would significandy impact individuals' MPM worldview. The results show that respondents' explicit attitudes toward MPM were significantly impacted. However, respondents' more deeply held, implicit economic ethical worldview was only slightly impacted. The authors argue that only patient, long-term explanation and argumentation can permanently affect a society's economic ethos. Implications and future research directions for business researchers are oudined. (shrink)

This article takes stock of the project of ecological democracy, a project that has been central to debates in Environmental Values since the late 1990s. Whilst we can identify quite distinct articulations of eco-democratic thinking emerging out of the fields of green political theory, postcolonial/feminist political ecology and science studies/radical geography, it is argued that these discussions have reached something of an impasse of late following the rise of climate scepticism, authoritarian populisms and technocratic eco-modernisms. Resurgent eco-authoritarian impulses and the (...) hankering for a 'green leviathan', a climate Lenin or a 'dictatorship of the sustainment' to resolve our climate crisis make it more important than ever to affirm the need for just, rapid and democratic post-carbon transitions. The article goes on to outline how emerging discussions in radical design studies focused on redirective practice in conjunction with a revived eco-socialist focus on labour-focused political ecologies might open up different possibilities for a materialist re-grounding of ecodemocratic discussions. It is suggested that a political ecology of design embedded in public institutions, the workplace and civil society could possibleyreground a more substantive vision of ecological democracy but also allow us to think about the forms of creative labour that could drive the just transition. (shrink)

Jacques Derrida's extensive early writings devoted considerable attention to "being as presence," the reality underlying the history of metaphysics. In Derrida on Being as Presence: Questions and Quests, David A. White develops the intricate conceptual structure of this notion by close exegetical readings drawn from these writings. White discusses cardinal concepts in Derrida's revamping of theoretical considerations pertaining to language--signification, context, negation, iterability--as these considerations depend on the structure of being as presence and also as they ground "deconstructive" reading. White's (...) appraisal raises questions invoking a range of problems. He deploys these questions in conjunction with thematically related quests that arise given Derrida's conviction that the history of metaphysics, as variations on being as presence, has concealed and skewed vital elements of reality. White inflects this critical apparatus concerning being as presence with texts drawn from that history--e.g., by Plato, Aristotle, Bacon, Hume, Kant, Whitehead. The essay concludes with a speculative ensemble of provisional categories, or zones of specificity. Implementing these categories will ground the possibility that philosophy in general and metaphysics in particular can be pursued in ways which acknowledge the relevance of Derrida's thought when integrated with the philosophical enterprise as traditionally understood. (shrink)

This paper reframes the futility debate, moving away from the question “Who decides when to end what is considered to be a medically inappropriate or futile treatment?” and toward the question “How can society make policy that will best account for the multitude of values and conflicts involved in such decision-making?” It offers a pragmatist moral epistemology that provides us with a clear justification of why it is important to take best standards, norms, and physician judgment seriously and a clear (...) justification of why ample opportunity must be made for patients, families, and society to challenge those standards and norms. (shrink)

By introducing the concept of “mental data,” Palermos (2023) highlights an underappreciated aspect of data ethics that policymakers would do well to heed. Sweeping artificial intelligence (AI) legi...

This book shows how the details of the myth and the accounts of interaction between lovers are based on a carefully articulated metaphysical structure.

This study utilizes an exploratory research design to investigate the influence of historical socialism and communism on the shaping of a society’s economic ethos. The discussion of ethics and economics has a very long history across multiple disciplines including the founder of modern economics, Adam Smith. However, with the growth of economic science, academic consideration has shifted toward positive analysis while normative analysis has been left mainly to philosophers. By utilizing the newly developed Morality of Profit-Making scale, the authors sought (...) to understand how historical socialism and communism influences respondents’ economic ethical worldview utilizing an exploratory research design. Data were collected from respondents in the Czech Republic, Slovenia, Slovakia, Serbia, Poland, and Hungary. (shrink)

Physicians are expected to engage patients as partners in identifying the possible benefits and harms associated with treatment options and selecting from among medically appropriate treatment options, rather than simply dictating what treatments patients will and will not receive. This collaborative model reflects the recognition that citizens in multicultural societies have diverse values and are likely to have different views about whether the possible benefits of a medical intervention outweigh the possible harms. However, there are circumstances in which the collaborative (...) process breaks down due to irresolvable disagreement. Especially challenging are cases in which patients are expected to die if they do not receive a treatment and either the patients or their surrogates insist on the treatment despite the physician's belief that providing it is ill advised. The source of disagreement is often differing appraisals of the risks and potential benefits. In such cases, physicians generally judge that there is insufficient likelihood or magnitude of benefit to justify the burdens or expense of treatment, while patients or surrogates believe that the small chance of preventing the patient's death is sufficient to justify the costs and potential burdens to the patient.There is a perception that surgeons enjoy considerable discretion in deciding when the risks of a procedure outweigh the expected benefits. An important contrast can be drawn between surgeons and intensivists—physicians who specialize in the medical management of critically ill patients. We will argue that there are good reasons for subjecting the decisions of both surgeons and intensivists to some oversight. We begin by showing that, for many cases, major professional society guidelines for intensivists recommend oversight via a procedural mechanism rather than unilateral decision‐making by individual clinicians. Next, we present reasons for adopting a procedural approach to dispute resolution, and we argue that these reasons apply to situations in which intensivists believe that patients or surrogates are requesting inappropriate life support as well as to many disagreements between surgeons and surrogates. Finally, we present and respond to several objections. (shrink)

This study intends principally to isolate and describe the function of myth in the Phaedo in order to show its effect on the complex metaphysics developed throughout the dialogue. It further illustrates how these metaphysical concepts structure the dialogue's concluding eschatological myth.

We appreciate the opportunity to respond to Schneiderman and colleagues’ opinions on the recent Multiorganization Policy Statement, “An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units”. We will first point out three areas in which Schneiderman and colleagues seem to perceive a disagreement where there is none, then we will respond to their main criticisms of the Multiorganization Policy Statement. In doing so, we will point out areas in which we believe Schneiderman and (...) colleagues have either misunderstood or misrepresented the statement. First, we agree with Schneiderman and... (shrink)

Shortages of new therapeutics to treat coronavirus disease (COVID-19) have forced clinicians, public health officials, and health systems to grapple with difficult questions about how to fairly allocate potentially life-saving treatments when there are not enough for all patients in need (1). Shortages have occurred with remdesivir, tocilizumab, monoclonal antibodies, and the oral antiviral Paxlovid (2) -/- Ensuring equitable allocation is especially important in light of the disproportionate burden experienced during the COVID-19 pandemic by disadvantaged groups, including Black, Hispanic/Latino and (...) Indigenous communities, individuals with certain disabilities, and low-income persons. However, many health systems have resorted to first-come, first-served approaches to allocation, which tend to disadvantage individuals with barriers in access to care (3). There is mounting evidence of racial, ethnic, and socioeconomic disparities in access to medications for COVID-19 (4, 5). -/- One potential method to promote equitable allocation is to use a weighted lottery, which is an allocation strategy that gives all eligible patients a chance to receive the scarce treatment while also allowing the assignment of higher or lower chances according to other ethical considerations (6). We sought to assess the feasibility of implementing a weighted lottery to allocate scarce COVID-19 medications in a large U.S. health system and to determine whether the weighted lottery promotes equitable allocation. (shrink)

From climate change to fossil fuel dependency, from the uneven effects of natural disasters to the loss of biodiversity: complex socio-environmental problems indicate the urgency for cross-disciplinary research into the ways in which the social, the natural and the technological are ever more entangled. This ground breaking text moves between environmental sociology and environmental geography, political and social ecology and critical design studies to provide a definitive mapping of the state of environmental social theory in the age of the anthropocene. (...) Environments, Natures and Social Theory provokes dialogue and confrontation between critical political economists, actor network theorists, neo-Malthusians and environmental justice advocates. It maps out the new environmental politics of hybridity moving from hybrid neo-liberals to end times ecologists, from post environmentalists to cyborg eco-socialists. White, Rudy and Gareau insist on the necessity of a critical but optimistic hybrid politics, arguing that a more just, egalitarian, democratic and sustainable anthropocene is within our grasp. This will only be brought into being, however, by reclaiming, celebrating and channeling the reconstructive potential of entangled hybrid humans as inventive hominids, creative gardeners, critical publics and political agents. Written in an accessible style, Environments, Natures and Social Theory is an essential resource for undergraduate and postgraduate students across the social sciences. (shrink)

Background: Relatively little is known about neonatologists' roles in helping families navigate the difficult decision to attempt or withhold resuscitation for a neonate delivering at the threshold...

In lieu of an abstract, here is the chapter's first paragraph: MOST OF BERTRAND RUSSELL'S BIOGRAPHERS do not even mention Horace Liveright, yet Liveright was a key player in the development of Russell as a popular philosopher and public intellectual. In particular, it was on a commission from Liveright that Russell wrote three of his best-selling books, books that are still in print and that many people have found helpful.

RationaleSurrogates of critically ill patients often have inaccurate expectations about prognosis. Yet there is little research on how intensive care unit clinicians should discuss prognosis, and existing expert opinion-based recommendations give only general guidance that has not been validated with surrogate decision makers.ObjectiveTo determine the perspectives of key stakeholders regarding how prognostic information should be conveyed in critical illness.MethodsThis was a multicenter study at three academic medical centers in California, Pennsylvania, and Washington. One hundred eighteen key stakeholders completed in-depth semistructured (...) interviews. Participants included 47 surrogates of adult patients with acute respiratory distress syndrome; 45 clinicians working in study ICUs, including physicians, nurses, social workers, and spiritual care providers; and 26 experts in health communication, decision science, ethics, family-centered care, geriatrics, healthcare disparities, palliative care, psychology, psychiatry, and critical care.Measurements and main resultsThere was broad support among surrogates for existing expert recommendations, including truthful prognostic disclosure, emotional support, tailoring the disclosure strategy to each family's needs, and checking for understanding. In addition, stakeholders offered suggestions that add specificity to existing recommendations, including: In addition to conveying prognostic estimates, clinicians should help families "see the prognosis for themselves" by showing families radiographic images and explaining the clinical significance of physical manifestations of severe disease at the bedside. Many physicians did not support using numeric estimates to convey prognosis to families, whereas many surrogates, clinicians from other disciplines, and experts believed numbers could be helpful. Clinicians should conceptualize prognostic communication as an iterative process that begins with a preliminary mention of the possibility of death early in the ICU stay and becomes more detailed as the clinical situation develops. Although prognostic information should be initially disclosed by physicians, other members of the multidisciplinary team-nurses, social workers, and spiritual care providers-should be given explicit role responsibilities to reinforce physicians' prognostications and help families process a poor prognosis emotionally.ConclusionsFamily members, clinicians, and experts identified specific communication behaviors that clinicians should use to discuss prognosis in the critical care setting. These findings extend existing opinion-based recommendations and should guide interventions to improve communication about prognosis in ICUs. (shrink)

Objective: Even when critically ill patients are almost certain to die from their illnesses, there is generally an element of prognostic uncertainty. Little is known about how physicians handle this uncertainty in conversations with surrogate decision makers. We sought to evaluate whether and how physicians discuss prognostic uncertainty with surrogate decision makers of patients who are highly likely, but not certain, to die. Design: We audiotaped and transcribed discussions between clinicians and surrogate decision makers at two major California teaching hospitals (...) from 2006 through 2008. Physicians completed a questionnaire addressing their prognostic estimates for patients' survival to hospital discharge. Participants: We included physicians and surrogates of 12 incapacitated, critically ill patients. Measurements: We analyzed transcripts of discussions in which physicians' estimates of patients' chances of hospital survival were 1% to 5%; we coded whether physicians disclosed the prognostic uncertainty and, if so, how they conveyed that death was highly likely but not certain. Results: Physicians' estimates of short-term survival were 1% to 5% for 12 of the 70 patients enrolled in the original study. In 8 of 12 cases, physicians conveyed prognostic uncertainty by using probabilistic language or by an explicit mention of uncertainty. In four cases, physicians made at least one statement that either implied or was ambiguous about whether death was certain. Conclusion: We observed variability in how physicians handle prognostic uncertainty in their discussions with surrogates of patients who are highly likely, but not certain, to die, including some circumstances in which physicians stated or implied that death was certain. (shrink)