One of the most important questions in the ethics of human clinical research asks what obligations investigators owe the people who enroll in their studies. Research differs in many ways from standard care - the added uncertainties, for instance, and the nontherapeutic interventions such as diagnostic tests whose only purpose is to measure the effects of the research intervention. Hence arises the question whether a physician engaged in clinical research has the same obligations toward research subjects that he owes his (...) medical patients, or whether they differ in any fundamental way.Perhaps the most common answer is that the relationship is the same. Investigators, like physicians, are said to be fiduciaries of the volunteers who enroll in research trials. Each owes the best available medical care, which means that a physician can only justify enrolling his patient in research if the study meets the requirements of clinical equipoise, namely, that there is legitimate disagreement within the medical community as to whether the standard treatment or the investigational intervention is superior. (shrink)

In 1887 Georg Cantor gave an influential but cryptic proof of theimpossibility of infinitesimals. I first give a reconstruction ofCantor's argument which relies mainly on traditional assumptions fromEuclidean geometry, together with elementary results of Cantor's ownset theory. I then apply the reconstructed argument to theinfinitesimals of Abraham Robinson's nonstandard analysis. Thisbrings out the importance for the argument of an assumption I call theChain Thesis. Doubts about the Chain Thesis are seen to render thereconstructed argument inconclusive as an attack on the (...) infinitelysmall. (shrink)

In 1887 Georg Cantor gave an influential but cryptic proof of theimpossibility of infinitesimals. I first give a reconstruction ofCantor's argument which relies mainly on traditional assumptions fromEuclidean geometry, together with elementary results of Cantor's ownset theory. I then apply the reconstructed argument to theinfinitesimals of Abraham Robinson's nonstandard analysis. Thisbrings out the importance for the argument of an assumption I call theChain Thesis. Doubts about the Chain Thesis are seen to render thereconstructed argument inconclusive as an attack on the (...) infinitelysmall. (shrink)

Cognitive Development and Acquisition of Language.

The discussion about complementary and alternative medicine is sometimes rather heated. “Quackery!” the cry goes. A large proportion “of unconventional practices entail theories that are patently unscientific.” “It is time for the scientific community to stop giving alternative medicine a free ride. There cannot be two kinds of medicine — conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work.” “I submit that (...) if these treatments cannot withstand the test of empirical research, … then we have wasted a lot of time and effort. The time has been wasted on all the people who have spent years learning falsehoods about acupuncture points and the principles of homeopathy. And the patients have wasted their time, money, and efforts receiving treatments that were not what they were represented to be or were harmful.”. (shrink)

The “futility debate” turns on intractable conflicts of deeply held beliefs about the value of life. It raises practical moral dilemmas of how best to permit parties to honor their own values without coercing unwilling others.

The Archimedean Axiom is often held to be an intuitively obvious truth about the geometry of physical space. After a general discussion of the varieties of geometrical intuition that have been proposed, I single out one variety which we can plausibly be held to have and then argue that it does not underwrite the intuitive obviousness of the Archimedean Axiom. Generalizing that result, I conclude that the Axiom is not intuitively obvious.

In response to rapidly rising health care costs in the United States, federal and state governments and private industry are instituting numerous and diverse cost-containment plans. As devices for coping with a scarcity of resources, such plans present serious challenges to physicians' traditional single-minded devotion to patient welfare. Those which contain costs by directly limiting medical options or by controlling physicians' daily clinical decisions can threaten the quality of medical care by allowing economic authorities to make essentially medical judgments. In (...) contrast, other plans coax compliance by arranging incentives, e.g., offering financial rewards for successful cost containment. While they allow for clinical freedom, these plans create conflicts between physicians' fiduciary obligations to their patients and the competing interests of the payers. Such conflicts arise as physicians try to work within governmental or corporate cost containment policies, and also as they attempt to streamline clinical efficiency. Throughout, issues of justice emerge as physicians seek to reconcile their own patients' claims upon limited common resources with others' equally legitimate claims. (shrink)

Universal access to health care is still a dream rather than a reality in the United States. This is partly because a rule of rescue, by impelling us to help people in need, urges us to ignore the limits of our health care policies wherever those limits would adversely affect a given individual. As the rule of rescue undermines whatever limits we set on health care entitlements, it can thwart the cost containment so essential to expanding access. Rather than accept (...) unlimited expense, we have thus far declined to universalize health care. The situation is exacerbated by an economic insulation shielding patients and physicians from the costs of care, prompting both to regard health care as free, an unlimited right. To reverse this costly entitlement mentality and place reasonable limits on rescue, patients must exercise greater personal responsibility for the costs of their care by directly experiencing some of the economic consequences of their health care decisions. Several mechanisms are available to accomplish this goal without posing economic barriers to needed care or penalizing people for becoming ill. Keywords: Clinton health plan, rationing, rule of rescue CiteULike Connotea Del.icio.us What's this? (shrink)

Public discussion of new medical trials is desirable, but not moment‐by‐moment disclosure of patients' ups and down. Nor is such disclosure necessary: the public is not entitled to all information about a trial as soon as it is available. What should be given the press, and what withheld, cannot be decided without appreciating the surprising number and intricate interrelations of the parties' needs and interests.

The federal government's introduction in 1983 of DRG‐based reimbursement for Medicare patients shook the entire health care industry into the vigorous and dramatic cost containment efforts which today are reshaping health care in America.

In recent years a number of commentators have discussed the importance of measuring quality of life in health care. We want to know whether an intervention will help people to live better, not just longer, and whether some treatments cause more trouble than they are worth. New technologies promise wondrous benefits. But when millions of people have no insured access to health care, and when many others face increasingly stringent limits on care, technologies’ high costs require us to choose what (...) we should do from the broader universe of what we can do.The challenges to measuring QL are formidable. Researchers debate whether to measure general QL or disease-specific QL; whether to focus on functional status such as the patient's ability to walk and dress himself, or on the value people ascribe to that functional status; whether to seek the values of the general public, or to concentrate on people actually affected by a given disease or disability. (shrink)

Cost‐containment pressures impose fiscal responsibilities upon physicians that can conflict with their fiduciary commitment to patients. Should the law permit health care providers to adjust standards of care according to patients' financial resources? The legal concept of “rebuttable presumption” should be used to reconceive the traditional requirement of a uniform standard of care.

Human clinical research has become a huge economic enterprise (Morin et al. 2002; Noah 2002). Because the human subject at the center can be so easily marginalized, many commentators recommend spec...

As managed care organizations provide an increasing proportion of citizens' health care, the move toward asking individuals to help control costs by taking more responsibility for their health is likely to intensify. Economic, medical, and legal responses to lifestyle‐induced health care costs raise concerns as well as possibilities for using resources responsibly.

Traditional medical approaches to moral issues found in the clinical setting can, if properly understood, enlighten our philosophical understanding of moral issues. Moral problem-solving, as distinct from ethical and metaethical theorizing, requires that one reckon with practical complexities and uncertainties. In this setting the quality of one's answer depends not so much upon its content as upon the quality of reasoning which supports it. As the discipline which especially focuses upon the attributes of good-quality reasoning, philosophy therefore has much to (...) contribute to the clinical enterprise of moral (and medical) problem-solving. (shrink)

David Hyman and Charles Silver are quite right. Opinion 6.01 in the American Medical Association's Code of Medical Ethics is difficult to defend. Ties between compensation and outcomes need not mislead patients into thinking that results are guaranteed; they are widely used in other fields with considerable success, even if they have some disadvantages; they can potentially bring patients more actively into decision-making about whether and from whom to purchase which medical care; and, if carefully tuned, they can promote quality (...) by aligning providers’ welfare more closely with patients’.The purpose of this commentary is thus not to disagree with the fundamental thesis that result-based compensation arrangements can be appropriate and useful in the health-care setting. Rather, the objective is to “cut the next swath,” so to speak. While Hyman and Silver are right that RBCAs have potential to do good, they may be overly optimistic about benefits, while underestimating the potential limitations and hazards. (shrink)

Responding to the failings of peers can be difficult, but as professionals physicians should not leave the moral management of errant colleagues to chance. Distinguishing levels of adverse outcomes helps physicians more clearly assess each others' conduct and respond appropriately to those who threaten the integrity of the profession.

Expounds on the ethical hazards of advertising cosmetic surgery. Impact of physician entrepreneurialism on the fiduciary concept of physician-patient relationship; Expectation on physician's non-abuse of superior position; Physician's responsibility to inform patient to enhance the latter's control over personal life and health care; Exacerbation of patient's vulnerability through misleading advertising.

Responding to the failings of peers can be difficult, but as professionals physicians should not leave the moral management of errant colleagues to chance. Distinguishing levels of adverse outcomes helps physicians more clearly assess each others' conduct and respond appropriately to those who threaten the integrity of the profession.

In recent years, science and the courts have created new options whereby prospective parents can avoid the birth of a diseased or defective child. We can ascertain the likelihood that certain genetic diseases will be transmitted; We can detect a number of fetal abnormalities in utero ; we have legal permission to abort for any reason, including fetal abnormality. With these new options come new questions concerning our moral obligations toward our prospective offspring. An important conceptual question concerns whether such (...) congenital diseases and defects constitute harms to the children who bear them. In this essay I shall examine the prevailing analysis of harm, the "Otherwise-Condition" approach, which denies that we can predicate harm of such abnormalities. I will show first that this analysis is inadequate even to account for certain very ordinary, clear cases of harm. It thus is suspect regardless of its stance on congenital anomalies. Second, it sets up an ill-considered connection between harm and causation – a connection which renders its harm ascriptions slippery, arbitrary. Finally, this analysis cannot be squared with certain of our deeply entrenched moral intuitions. By thus rebutting this most influential definition of harm, I will have opened the door to the possibility of ascribing harm for congenital disease and defect. Keywords: Harm, Otherwise-condition, Congenital anomaly * I would like to thank A. D. Woozley, Derek Parfit, Daniel Devereux, and the editors and reviewers of the JMP for their helpful comments on earlier drafts of this paper. CiteULike Connotea Del.icio.us What's this? (shrink)

Jewish by birth, though from a secular family, Alan Morinis took a deep journey into Hinduism and Buddhism as a young man. He received a doctorate for his study of Hindu pilgrimage, learned yoga in India with B. K. S. Iyengar, and attended his first Buddhist meditation course in the Himalayas in 1974. But in 1997, when his film career went off track and he reached for some spiritual oxygen, he felt inspired to explore his Jewish heritage. In his reading (...) he happened upon a Jewish tradition of spiritual practice called Mussar. Gradually he realized he had stumbled on an insightful discipline for self-development, complete with meditative, contemplative, and other well-developed transformative practices designed to penetrate the deepest roots of the inner life. Eventually reaching the limits of what he could learn on his own, he decided to seek out a Mussar teacher. That was not easily achieved, since almost the entire world of the Mussar tradition had been wiped out in the Holocaust. In time, he did find an accomplished master who stood in an unbroken line of transmission of the Mussar tradition, and who lived at the center of a community of Orthodox Jews on Long Island. This book tells the story of Morinis’s journey to meet his teacher and what he learned from him, and reveals the central teachings and practices that are the spiritual treasury and legacy of Mussar. Alan Morinis has written this book because the wisdom and practices that helped him so much have not penetrated the world beyond the confines of Orthodox Judaism, and may not be fully appreciated even there at this time. His hope is that Jews and non-Jews alike will find in Mussar a time-tested path of spiritual practice that will help them discover the hidden radiance within. (shrink)