A comprehensive analysis of ethical topics in palliative care, combining clinical experience and philosophical rigor. A broad array of topics are explored from historical, legal, clinical, and ethical perspectives, offering both the seasoned clinician and interested lay reader a thorough examination of the complex ethical issues facing patients suffering from life-threatening illness.

The semantic paradoxes are often associated with self-reference or referential circularity. Yablo (Analysis 53(4):251–252, 1993), however, has shown that there are infinitary versions of the paradoxes that do not involve this form of circularity. It remains an open question what relations of reference between collections of sentences afford the structure necessary for paradoxicality. In this essay, we lay the groundwork for a general investigation into the nature of reference structures that support the semantic paradoxes and the semantic hypodoxes. We develop (...) a functionally complete infinitary propositional language endowed with a denotation assignment and extract the reference structural information in terms of graph-theoretic properties. We introduce the new concepts of dangerous and precarious reference graphs, which allows us to rigorously define the task: classify the dangerous and precarious directed graphs purely in terms of their graph-theoretic properties. Ungroundedness will be shown to fully characterize the precarious reference graphs and fully characterize the dangerous finite graphs. We prove that an undirected graph has a dangerous orientation if and only if it contains a cycle, providing some support for the traditional idea that cyclic structure is required for paradoxicality. This leaves the task of classifying danger for infinite acyclic reference graphs. We provide some compactness results, which give further necessary conditions on danger in infinite graphs, which in conjunction with a notion of self-containment allows us to prove that dangerous acyclic graphs must have infinitely many vertices with infinite out-degree. But a full characterization of danger remains an open question. In the appendices we relate our results to the results given in Cook (J Symb Log 69(3):767–774, 2004) and Yablo (2006) with respect to more restricted sentences systems, which we call $\mathcal{F}$ -systems. (shrink)

As the population in the United States gets older, more people suffer from dementia, which often causes neuropsychiatric symptoms such as agitation and paranoia. This can lead patients to refuse medications, prompting consideration of covert administration (that is, concealing medication in food or drink). While many condemn this practice as paternalistic, deceptive, and potentially harmful, the end result of assuming the “moral high ground” can be increased suffering for patients and families. This article addresses common criticisms of covert medication and (...) presents a detailed algorithm by which to determine whether the practice is ethically permissible in specific cases. It also explores why so little attention has been paid in the U.S. to this presumably common practice, and reviews professional statements from Europe that endorse the practice. Finally, it presents a compelling argument for the role of Ulysses clauses in advance care planning, not only for patients with psychiatric illness but also for those who may suffer from dementia, which is far more common. (shrink)

For all of the emphasis on quality improvement—as well as the acknowledged overlap between assessment of the quality of healthcare services and clinical ethics—the quality of clinical ethics consultation has received scant attention, especially in terms of empirical measurement. Recognizing this need, the second edition of Core Competencies for Health Care Ethics Consultation identified four domains of ethics quality: (1) ethicality, (2) stakeholders’ satisfaction, (3) resolution of the presenting conflict/dilemma, and (4) education that translates into knowledge. This study is the (...) first, to our knowledge, to directly measure all of these domains. Here we describe the quality improvement process undertaken at a tertiary care academic medical center, as well as the tools developed to measure the quality of ethics consultation, which include post-consultation satisfaction surveys and weekly case conferences. The information gained through these tools helps to improve not only the process of ethics consultation, but also the measurement and assurance of quality. (shrink)

_Explores the ancient and perennial notion of the four elements as environmental ideas._.

Clinical simulation using standardized patients has become standard in medical education—and is now being incorporated into some graduate programs in bioethics—for both formative and summative evaluation. In most hospitals, though, clinical ethics consultation is done by the ethics committee (or a subset of it). This study is the first, to our knowledge, to examine the effectiveness of standardized patient simulation in training hospital ethics committees to deal with ethically complex and emotionally fraught clinical situations. Following a substantial revision of the (...) institution’s nonbeneficial treatment policy, ethics committee members underwent a simulation to determine whether a specific requested treatment should be withheld on the basis of futility. Pre- and postintervention surveys showed improvement in all domains, although the small sample size limited the power of the study, with only one measure showing a statistically significant difference. An interesting incidental finding was that one-quarter of committee members voted against a determination of futility, even though the case clearly met the definition set forth in the policy. This highlights the emotional challenges in implementing an ethically rigorous, unanimously accepted policy that ultimately determines the timing and manner of a patient’s death. (shrink)

Philosophers, Henri Bergson once observed, "seem to philosophize as if they were sealed in the privacy of their study and did not live on a planet surrounded by the vast organic world of animals, plants, insects, and protozoa." Providing a solid overview of ecological philosophy and original insights into this developing field, Minding Nature focuses on some of the most influential thinkers who, in fact, have emphasized our natural relations to the earth, our social creations, and each other. Combining philosophy, (...) ecology, and political theory, chapters thoroughly examine, critique, and build upon the ideas of such luminaries as Thomas Hobbes, Martin Heidegger, Ernst Bloch, Hannah Arendt, Herbert Marcuse, Barry Commoner, Rachel Carson, and Jurgen Habermas, among others. Each thinker considered has contributed significantly to both contemporary discussion and historical understanding of political, epistemological, or social aspects related to nature and, with several exceptions, stimulated constructive dialogue within progressive, democratic, and radical left circles. By challenging the notion that conservation is inherently politically conservative or that our oikos (home) must be rendered uniformly economic where ecology is concerned, they enable us to rethink the possibility of creating a more democratic and ecological society. (shrink)

Many patients believe that cardiopulmonary resuscitation is more likely to be successful than it really is in clinical practice. Even when working with accurate information, some nevertheless remain resolute in demanding maximal treatment. They maintain that even if survival after cardiac arrest with CPR is extremely low, the fact remains that it is still greater than the probability of survival after cardiac arrest without CPR. Without realising it, this line of reasoning is strikingly similar to Pascal’s Wager, a Renaissance-era argument (...) for accepting the proposition for God’s existence. But while the original argument is quite logical—if not universally compelling—the modern variant makes several erroneous assumptions. The authors here present a case of a patient who unwittingly appeals to Pascal’s Wager to explain his request for maximal treatment, in order to highlight the crucial divergences from the original Wager. In understanding the faulty assumptions inherent in the application of Pascal’s Wager to code status decisions—and identifying the underlying motivations which the Wager serves to confirm—providers can better ensure that the true values and preferences of patients are upheld. (shrink)

This paper examines some of the key ways in which water is mediated by technology and human artifacts. I show how the modes in which we conceive and experience this vital fluid are affected deeply by the techniques and instruments we use to interact with it. I argue that a notion of the domestication of water enables us to better grasp our relations with the environment given that vast volumes of water are now neither completely natural nor artificial in the (...) conventional senses of the terms. Instead, water is often filtered through an expansive technological network that not merely changes its flows and phenomenal forms but greatly alters or multiplies its meanings. As examples of this process, I investigate the practical engagement with water by the first Western philosopher; the construction of several large hydrological projects; efforts at river management in the aesthetic landscape; and the emergence of bottled water. (shrink)

The sky proclaimed Emerson is “the daily bread of the eyes.” Despite the apparent truth of this observation, we often fail to appreciate the complex canopy of air above and around us in considerations of environmental aesthetics and ecological awareness. I examine the sky and aerial phenomena that are bound to, closely allied with, or materially emergent from, this ocean of blue. In the process, I develop a perspective for thinking about some of the aesthetic characteristics and dimensions of this (...) realm. I show that understanding and appreciating the sky must attend to features related to ephemerality, protean colors, the lack of aclear and definite frame, and other non-anthropogenic qualities. I pay particular attention to explorations of horizontally-mobile clouds and, for the sake of contrast, vertically-originating snow by painters, poets, and philosophers who are able to express imaginative components of these phenomena and to reveal or vivify aspects that complement or complete the more realistic descriptions provided by natural scientists. The always-accessible and ever-fluctuating beauty of the sky offers the potential for deepening our daily experiences of and encounters with the elemental world in which we are sensually immersed and physicallyembedded. It also helps to offer an indirect rationale for respecting and protecting this vital other-than-human sphere. (shrink)

The sky proclaimed Emerson is “the daily bread of the eyes.” Despite the apparent truth of this observation, we often fail to appreciate the complex canopy of air above and around us in considerations of environmental aesthetics and ecological awareness. I examine the sky and aerial phenomena that are bound to, closely allied with, or materially emergent from, this ocean of blue. In the process, I develop a perspective for thinking about some of the aesthetic characteristics and dimensions of this (...) realm. I show that understanding and appreciating the sky must attend to features related to ephemerality, protean colors, the lack of aclear and definite frame, and other non-anthropogenic qualities. I pay particular attention to explorations of horizontally-mobile clouds and, for the sake of contrast, vertically-originating snow by painters, poets, and philosophers who are able to express imaginative components of these phenomena and to reveal or vivify aspects that complement or complete the more realistic descriptions provided by natural scientists. The always-accessible and ever-fluctuating beauty of the sky offers the potential for deepening our daily experiences of and encounters with the elemental world in which we are sensually immersed and physicallyembedded. It also helps to offer an indirect rationale for respecting and protecting this vital other-than-human sphere. (shrink)

I examine the kindred phenomena of shadows and night in order to reveal their significance for better understanding our lifeworld and the elemental environment. I first describe how light is primary to ecological perception and how it conditions our conceptions of space, truth, and beauty. Light and darkness are involved in a dialectical relationship rather than conceived as polar opposites. Borne of the interplay of both realms, shadows have been disparaged historically and deserve to be reconsidered for their aesthetic appearance (...) and their relevance to an ecology and anthropology of perception. Night, in turn, is often marked by a negative ontology that points toward the possibility of a kind of elemental a priori, but it is important to characterize darkness in terms of its subtle shades and filtering by way of the creative matrix of the human imagination. Seeing the night in novel and unexpected ways, especially via the insights and descriptions of phenomenologists, poets, and artists, enables us to grasp the depth and atmosphere of the surrounding world and to light up our geographical perspectives, our philosophical visions, and our environmental awareness. (shrink)

Given narrow operating margins, health care organizations are increasingly relying on philanthropy to fund operations. Since individuals provide the majority of philanthropic support, many organizations have expanded their “grateful patient fundraising” programs to include current inpatients, both established donors as well as persons of wealth. While this is legally permissible under HIPAA, it raises substantial ethical concerns for potential coercion of vulnerable patients, as well as unequal care stemming from preferential treatment and provided “amenities.” While some have drawn the analogy (...) to the additional comforts provided to first-class airline passengers, this analogy is flawed because of the potential clinical impact of the opportunities and services provided, especially to merely potential donors. From an ethical perspective, such programs should only provide non-clinical amenities to established donors, and at the same time strive for maximal transparency whereby all patients are assured of equal care and are fully informed of the specific benefits associated with any potential donation. (shrink)

: Health care reform is bottled up. Socially responsible physicians, forced to curtail care to uninsured patients, should respond with organized, open defiance, by billing the costs of the care to the accounts of patients covered under Medicaid or Medicare. Reverse cost-shifting: maybe it could work, certainly it would be justified.

Health care reform is bottled up. Socially responsible physicians, forced to curtail care to uninsured patients, should respond with organized, open defiance, by billing the costs of the care to the accounts of patients covered under Medicaid or Medicare. Reverse cost‐shifting: maybe it could work, certainly it would be justified.

Typically, the determination of death by neurological criteria follows a very specific protocol. An apnea test is performed with further confirmation as necessary, and then mechanical ventilation is withdrawn with the consent of the family after they have had an opportunity to “say goodbye,” and at such a time to permit organ retrieval (with authorization of the patient or consent of the next of kin). Such a process maximizes transparency and ensures generalizability. In exceptional circumstances, however, it may be necessary (...) to deviate from this protocol in order to spare family members unnecessary suffering and to reduce moral distress felt by clinical staff. It may also be appropriate, we argue, to refrain from even inquiring about organ donation when the next-of-kin is not only certain to refuse, but lacks the decision-making capacity to potentially consent. The case described in this article calls into question generally reliable assumptions about determination of death by neurological criteria, where the best the clinical team could do for the patient and his family was “the least bad option.”. (shrink)

I examine the ancient and perennial notion of the elements (stoicheia) and its relation to an idea of place proper (topos) and natural place (topos oikeios) in Aristotle's work. Through an exploration of his accounts, I argue that Aristotle develops a robust theory of place that is relevant to current environmental and geographical thought. In the process, he provides a domestic household and home for earth, air, fire and water that offers a supplement or an alternative to more abstract and (...) controversial uses of a conception of 'nature' (physis). I identify and elaborate upon environmental aspects of place-based and elemental philosophy. (shrink)

Background Because opioids can suppress respiratory drive, the principle of double effect (PDE) has been used to justify their use for terminally ill patients. Recent studies, however, suggest that the risk of respiratory depression in typical end-of-life (EOL) situations may be overstated and that heightened concern for this rare occurrence can lead to inadequate treatment of pain. The purpose of this study is to examine the role of the PDE in medical school ethics education, with specific reference to its potential (...) impact on pain management at EOL. Method After obtaining institutional review board approval, an electronic survey was sent to ethics educators at every allopathic medical school in the USA. Results One-third of ethics educators felt that opioids were ‘likely’ to cause significant respiratory depression that could hasten death. Educators' opinions of opioid effects did not influence their view of the relevance of the PDE, with approximately 70% deeming it relevant to EOL care. Only 15% of ethics educators believed that associating the PDE with opioid use might discourage clinicians from optimally treating pain, out of concern for respiratory depression. Conclusion This study demonstrates that a significant minority of ethics educators believe, contrary to current evidence, that opioids are ‘likely’ to cause significant respiratory depression that could hasten death in terminally ill patients. Yet, many of those who do not feel this is likely still rely on the PDE to justify this possibility, potentially (and unknowingly) contributing to clinical misperceptions and underutilisation of opioids at EOL. (shrink)

The COVID-19 pandemic has raised a host of ethical challenges, but key among these has been the possibility that health care systems might need to ration scarce critical care resources. Rationing p...

The study of landscape and place has become an increasingly fertile realm of inquiry in the humanities and social sciences. In this new book of essays, selected from presentations at the first annual meeting of the Society for Philosophy and Geography, scholars investigate the experiences and meanings that inscribe urban and suburban landscapes. Gary Backhaus and John Murungi bring philosophy and geography into a dialogue with a host of other disciplines to explore a fundamental dialectic: while our collective and personal (...) activity modifies the landscape, in turn, the landscape modifies human identities, and social and environmental relations. Whether proposing a peripatetic politics, conducting a sociological analysis of building security systems, or critically examining the formation of New York City's municipal parks, each essay sheds distinctive light on this fascinating and engaging aspect of contemporary environmental studies. (shrink)

We introduce a framework for a graph-theoretic analysis of the semantic paradoxes. Similar frameworks have been recently developed for infinitary propositional languages by Cook and Rabern, Rabern, and Macauley. Our focus, however, will be on the language of first-order arithmetic augmented with a primitive truth predicate. Using Leitgeb’s notion of semantic dependence, we assign reference graphs (rfgs) to the sentences of this language and define a notion of paradoxicality in terms of acceptable decorations of rfgs with truth values. It (...) is shown that this notion of paradoxicality coincides with that of Kripke. In order to track down the structural components of an rfg that are responsible for paradoxicality, we show that any decoration can be obtained in a three-stage process: first, the rfg is unfolded into a tree, second, the tree is decorated with truth values (yielding a dependence tree in the sense of Yablo), and third, the decorated tree is re-collapsed onto the rfg. We show that paradoxicality enters the picture only at stage three. Due to this we can isolate two basic patterns necessary for paradoxicality. Moreover, we conjecture a solution to the characterization problem for dangerous rfgs that amounts to the claim that basically the Liar- and the Yablo graph are the only paradoxical rfgs. Furthermore, we develop signed rfgs that allow us to distinguish between ‘positive’ and ‘negative’ reference and obtain more fine-grained versions of our results for unsigned rfgs. (shrink)

James Mill (1773-1836) is today best known as Jeremy Bentham's chief disciple and John Stuart Mill's father. Yet Mill himself was a formidable and important Utilitarian thinker in his own right, who earned the respect of even those who disagreed with him. His range was enormous (historian, political philosopher, psychologist, educational theorist, and economist), repeatedly crossing the disciplinary boundaries we take for granted today. This volume presents a wide sampling of Mill's political writings and polemical essays. It begins with his (...) classic work, the Essay on Government, it also includes pieces on the protection of rights, the importance of education, the free press, the secret ballot, and government's use of punishment against those who violate the rights of fellow citizens. The collection concludes with Macauley's famous critique of the Essay, and Mill's heretofore unnoticed reply in his Fragment on Mackintosh (1835). This is the first time that such a selection of Mill's political works has appeared as one volume. (shrink)