Although decision‐making algorithms are not new to medicine, the availability of vast stores of medical data, gains in computing power, and breakthroughs in machine learning are accelerating the pace of their development, expanding the range of questions they can address, and increasing their predictive power. In many cases, however, the most powerful machine learning techniques purchase diagnostic or predictive accuracy at the expense of our ability to access “the knowledge within the machine.” Without an explanation in terms of reasons or (...) a rationale for particular decisions in individual cases, some commentators regard ceding medical decision‐making to black box systems as contravening the profound moral responsibilities of clinicians. I argue, however, that opaque decisions are more common in medicine than critics realize. Moreover, as Aristotle noted over two millennia ago, when our knowledge of causal systems is incomplete and precarious—as it often is in medicine—the ability to explain how results are produced can be less important than the ability to produce such results and empirically verify their accuracy. (shrink)

Abstract:This paper considers novel ethical issues pertaining to near-future artificial intelligence (AI) systems that seek to support, maintain, or enhance the capabilities of older adults as they age and experience cognitive decline. In particular, we focus on smart assistants (SAs) that would seek to provide proactive assistance and mediate social interactions between users and other members of their social or support networks. Such systems would potentially have significant utility for users and their caregivers if they could reduce the cognitive load (...) for tasks that help older adults maintain their autonomy and independence. However, proactively supporting even simple tasks, such as providing the user with a summary of a meeting or a conversation, would require a future SA to engage with ethical aspects of human interactions which computational systems currently have difficulty identifying, tracking, and navigating. If SAs fail to perceive ethically relevant aspects of social interactions, the resulting deficit in moral discernment would threaten important aspects of user autonomy and well-being. After describing the dynamic that generates these ethical challenges, we note how simple strategies for prompting user oversight of such systems might also undermine their utility. We conclude by considering how near-future SAs could exacerbate current worries about privacy, commodification of users, trust calibration and injustice. (shrink)

The history of Australian art has been punctuated with survey exhibitions in London from the late 19th century to the present, just as our artists were drawn to Europe both to study and for the possibilities of wider recognition. This review article focuses on the post-war years from 1950 to 1965, a high point of Australian cultural expatriatism focused on London – now viewed as a significant episode in the history of Australian art. The two most influential figures (...) supporting key Australian artists were Kenneth Clark and Bryan Robertson, director of the avant-gardist Whitechapel Gallery. Robertson was responsible for organizing the most significant of these exhibitions of Australian art: Australian Painting Today in 1961, focusing on the work of a younger generation of artists that included Charles Blackman, John Olsen, Fred Williams and Brett Whiteley. Australian’s most significant art historian, Bernard Smith, who had also sought to bring about comparable exhibitions, but without success, challenged the orientation and the cultural framing by Robertson and the young Australian art critic Robert Hughes in the catalogue of this key exhibition. (shrink)

in Angelique M. Rietsma and Jonathan D. Moreno eds., Ethical Guidelines for Innovative Surgery. (Hagerstown, MD: University Publishing Group) 19-52. [PDF].

These range from merely good reads to really outstanding books. A raw ranking of them would be of little use to others, unless I explained why I gave them the ranks I did, and anyway I'd probably give different rankings by the time your read this. (When I know of an on-line review about a book which I agree with --- e.g., because I wrote it --- I've included a link; also some exceedingly short remarks about interesting cases.).

La mayoría de interpretaciones sobre la noción de comunidad en Hannah Arendt, han pasado por alto el esfuerzo por parte de la autora de deslindarse de lo que ella considera -la tradición de la filosofía política-. Arendt encuentra que dicha tradición ha sido incapaz de reconocer la pluralidad y contingencia propias de los asuntos humanos. Este libro se propone buscar en el pensamiento de la autora una posible noción de Comunidad que conciba la pluralidad como -ley de la tierra-, y (...) vea en la acción esa puesta en escena de dicha pluralidad. (shrink)

Statements of the core ethical and professional responsibilities of medical professionals are incomplete in ways that threaten fundamental goals of medicine. First, in the absence of explicit guida...

The foundations of research ethics are riven with fault lines emanating from a fear that if research is too closely connected to weighty social purposes an imperative to advance the common good through research will justify abrogating the rights and welfare of study participants. The result is an impoverished conception of the nature of research, an incomplete focus on actors who bear important moral responsibilities, and a system of ethics and oversight highly attuned to the dangers of research but largely (...) silent about threats of ineffective, inefficient, and inequitable medical practices and health systems. -/- In For the Common Good: Philosophical Foundations of Research Ethics, Alex John London defends a conception of the common good that grounds a moral imperative with two requirements. The first is to promote research that generates the information necessary to enable key social institutions to effectively, efficiently, and equitably safeguard the basic interests of individuals. The second is to ensure that research is organized as a voluntary scheme of social cooperation that respects its various contributors' moral claims to be treated as free and equal. Connecting research to the goals of a just social order grounds a framework for assessing and managing research risk that reconciles these requirements and justifies key oversight practices in non-paternalistic terms. Reconceiving research ethics as resolving coordination problems and providing credible assurance that these requirements are being met expands the issues and actors that fall within the purview of the field and provides the foundation for a more unified and coherent approach to domestic and international research. -/- This is an open access title available under the terms of a CC BY-NC-ND 4.0 license. It is free to read at Oxford Scholarship Online and offered as a free PDF download from OUP and selected open access locations. (shrink)

: The debate over when medical research may be performed in developing countries has steered clear of the broad issues of social justice in favor of what seem more tractable, practical issues. A better approach will reframe the question of justice in international research in a way that makes explicit the links between medical research, the social determinants of health, and global justice.

The debate over when medical research may be performed in developing countries has steered clear of the broad issues of social justice in favor of what seem more tractable, practical issues. A better approach will reframe the question of justice in international research in a way that makes explicit the links between medical research, the social determinants of health, and global justice.

The “fair benefits” approach to international research is designed to produce results that all can agree are fair without taking a stand on divisive questions of justice. But its appealing veneer of collaboration masks ambiguities at both a conceptual and an operational level. An attempt to put it into practice would look a lot like an auction, leaving little reason to think the outcomes will satisfy even minimal conditions of fairness.

The 2016 CIOMS International ethical guidelines for health‐related research involving humans states that ‘health‐related research should form an integral part of disaster response’ and that, ‘widespread emergency use [of unproven interventions] with inadequate data collection about patient outcomes must therefore be avoided’ (Guideline 20). This position is defended against two lines of criticism that emerged during the 2014 Ebola outbreak. One holds that desperately ill patients have a moral right to try unvalidated medical interventions (UMIs) and that it is therefore (...) unethical to restrict access to UMIs to the clinical trial context. The second holds that clinical trials in contexts of high‐mortality diseases are morally suspect because equipoise does not exist between a standard of care that offers little prospect of clinical benefit and a UMI that might offer some clinical advantage. (shrink)

To judge from the rash of recent law review articles, it is a miracle that research with human subjects in the U.S. continues to draw breath under the asphyxiating heel of the rent-seeking, creativity-stifling, jack-booted bureaucrethics that is the current system of research ethics oversight and review. Institutional Review Boards, sometimes called Research Ethics Committees, have been accused of perpetrating “probably the most widespread violation of the First Amendment in our nation's history,” resulting in a “disaster, not only for academics, (...) but for the whole nation.” One member of the President's Council on Bioethics went so far as to assert, “There has been no greater damage to academic freedom in the United States in my lifetime. And my lifetime encompasses McCarthy and it encompasses political correctness, both.” Locked in the bureaucratic “iron cage” of IRB oversight, critics charge that researchers have been transformed into a vulnerable, exposed population, subject to domination, that has been likened in one case to a kind of “Tuskegee in reverse.”. (shrink)

Regulators rely on clinical trials for drug approval and labeling decisions. Health systems and clinicians rely on the evidence from trials to determine treatment, and patients rely on it to decide which courses of care to undertake. Many of these stakeholders presume that the careful review of individual studies is enough to address the ethical and scientific questions that arise in clinical trials. In what follows, however, we demonstrate that explicit consideration of trial portfolios—series of trials that are interrelated by (...) a common set of objectives—is crucial. the ethical acceptability and evidentiary probity of individual trials can change depending on the characteristics of the portfolios in which they are embedded. Second, how trial portfolios are composed, how well they are coordinated, and how efficiently they use information determines the balance of risks and benefits they present as well as their different prospects for generating socially valuable information; these three factors also raise distinct questions of justice. (shrink)

To give substance to the rhetoric of ‘learning health systems’, a variety of novel trial designs are being explored to more seamlessly integrate research with medical practice, reduce study duration and reduce the number of participants allocated to ineffective interventions. Many of these designs rely on response adaptive randomisation. However, critics charge that RAR is unethical on the grounds that it violates the principle of equipoise. In this paper, I reconstruct critiques of RAR as holding that it is inconsistent with (...) five important ethical principles. I then argue that these criticisms rest on a faulty view of equipoise encouraged by the idea that a RAR study models the beliefs of a single rational agent about the relative merits of the interventions being studied. I outline a view in which RAR models an idealised health system in which diverse communities of fully informed experts shrink or grow as their constituent members update their expert opinions in light of reliable medical evidence. I show how a proper understanding of clinical equipoise can reconcile this conception of RAR with these five ethical principles. This analysis removes an in-principle objection to RAR and sheds important light on the relationship between clinical equipoise and transient diversity in the scientific community. (shrink)

This paper examines the concept of a 'standard of care' as it has been used in recent arguments over the ethics of international human-subjects research. It argues that this concept is ambiguous along two different axes, with the result that there are at least four possible standard of care arguments that have not always been clearly distinguished. As a result, it has been difficult to assess the implications of opposing standard of care arguments, to recognize important differences in their supporting (...) rationales, and even to locate the crux of the disagreement in some instances. The goal of the present discussion, therefore, is to disambiguate the concept of a 'standard of care' and to highlight the areas of genuine disagreement among different standards. In the end it is argued that one standard of care argument in particular is more complex than either its proponents or its critics may have recognized and that understanding this possibility opens up a potentially promising avenue of inquiry that remains to be carefully explored. (shrink)

This paper examines the role of equipoise in evaluating international research. It distinguishes two possible formulations of the equipoise requirement that license very different evaluations of international research proposals. The interpretation that adopts a narrow criterion of similarity between clinical contexts has played an important role in one recent controversy, but it suffers from a number of problems. An alternative interpretation that adopts a broader criterion of similarity does a better job of avoiding both exploitation of the brute fact of (...) social deprivation and the exploitation of needy populations for the benefit of more well-off populations. It also holds out the promise of reconciling the need to find interventions that can be employed in developing world contexts with the cluster of moral values that must constrain the way such research is carried out. (shrink)

This article argues that lingering uncertainty about the normative foundations of research ethics is perpetuated by two unfounded dogmas of research ethics. The first dogma is that clinical research, as a social activity, is an inherently utilitarian endeavor. The second dogma is that an acceptable framework for research ethics must impose constraints on this endeavor whose moral force is grounded in role-related obligations of either physicians or researchers. This article argues that these dogmas are common to traditional articulations of the (...) equipoise requirement and to recently articulated alternatives, such as the non-exploitation approach. Moreover, important shortcomings of these approaches can be traced to their acceptance of these dogmas. After highlighting these shortcomings, this article illustrates the benefits of rejecting these dogmas by sketching the broad outlines of an alternative called the "integrative approach" to clinical research. (shrink)

Following a boom in investment and overinflated expectations in the 1980s, artificial intelligence entered a period of retrenchment known as the “AI winter.” With advances in the field of machine learning and the availability of large datasets for training various types of artificial neural networks, AI is in another cycle of halcyon days. Although medicine is particularly recalcitrant to change, applications of AI in health care have professionals in fields like radiology worried about the future of their careers and have (...) the public tittering about the prospect of soulless machines making life‐and‐death decisions. Medicine thus appears to be at an inflection point—a kind of Groundhog Day on which either AI will bring a springtime of improved diagnostic and predictive practices or the shadow of public and professional fear will lead to six more metaphorical weeks of winter in medical AI. (shrink)

Recent debates over the use of sham surgery as a control for studies of fetal tissue transplantation for Parkinson’s disease have focused primarily on rival interpretations of the US federal regulations governing human-subjects research. Using the core ethical and methodological considerations that underwrite the equipoise requirement, we nd strong prima facie reasons against using sham surgery as a control in studies of cellular-based therapies for Parkinson’s disease and more broadly in clinical research. Additionally, we believe that these reasons can be (...) generalized to apply to the use of other placebo controls that carry signi cant risks of positive harms in and of themselves. As a result, our arguments are centrally relevant to the emerging drive to subject therapies with a surgical component to the same rigorous standards of evaluation as those governing the approval of new pharmaceuticals. (shrink)

There is near universal agreement within the scientific and ethics communities that a necessary condition for the moral permissibility of cross-national, collaborative research is that it be responsive to the health needs of the host community. It has proven difficult, however, to leverage or capitalize on this consensus in order to resolve lingering disputes about the ethics of international medical research. This is largely because different sides in these debates have sometimes provided different interpretations of what this requirement amounts to (...) in actual practice. The goal of the discussion that follows is to clarify the nature of this important moral requirement. The first section explains the requirement for responsiveness to host community health needs in the context of international medical research. The second section examines various formulations of this requirement as they are enunciated in some of the core consensus documents in research ethics. The third section then defends a particular interpretation of this requirement, and the final sections examine more liberal alternatives with the aim of highlighting points of agreement and assessing the significance of areas of disagreement. (shrink)

Before participants can be enrolled in a clinical trial, an institutional review board must determine that the risks that the research poses to participants are ‘reasonable.’ This paper examines the two dominant frameworks for assessing research risks and argues that each approach suffers from significant shortcomings. It then considers what issues must be addressed in order to construct a framework for risk assessment that is grounded in a compelling normative foundation and might provide more operationally precise guidance to the deliberations (...) of various stakeholders. The paper concludes by sketching the outlines of what is referred to as the ‘Integrative Approach’ to risk assessment and by highlighting some of the ways in which this approach may be more promising than current alternatives. (shrink)

There is considerable enthusiasm about the prospect that artificial intelligence (AI) will help to improve the safety and efficacy of health services and the efficiency of health systems. To realize this potential, however, AI systems will have to overcome structural problems in the culture and practice of medicine and the organization of health systems that impact the data from which AI models are built, the environments into which they will be deployed, and the practices and incentives that structure their development. (...) This perspective elaborates on some of these structural challenges and provides recommendations to address potential shortcomings. (shrink)

Any view of equipoise faces perhaps the most radical and far-reaching objections from moral foundations. These objections hold that the equipoise requirement conflates the ethics of medical research and the ethics of clinical medicine. Once this conflation is recognized, this position holds, research can be given a new foundation on the imperative to avoid exploiting research participants. This article argues that what is novel in this critique is not as successful as its proponents claim and that the ultimate success of (...) this approach actually hinges on a version of the objection from utility. Nevertheless, this criticism highlights the limited scope of applicability of the equipoise requirement. The article concludes, therefore, by describing the outlines of what the article calls an ‘integrative approach’ to clinical trials. This approach represents one way in which the normative requirements of equipoise and the non-exploitation approach might be unified under a single, broad framework. (shrink)

This paper challenges the first Gettier counterexample to the tripartite account of knowledge. Noting that 'the man who will get the job' is a description and invoking Donnellan's distinction between their 'referential' and 'attributive' uses, I argue that Smith does not actually believe that the man who will get the job has ten coins in his pocket. Smith's ignorance about who will get the job shows that the belief cannot be understood referentially, his ignorance of the coins in his pocket (...) shows that it cannot be understood attributively. An explanation for why Smith appeared to have justified true belief is given by distinguishing between 'belief' and 'belief in truth'. Smith believes the sentence 'the man who will get the job has ten coins in his pocket' to be true (he mistakenly believes that Jones will get the job, of whom he knows that he has ten coins in his pocket) (hence his 'belief'), the sentence is true (hence 'truth'), and he has sufficient reason to assent to it (hence his 'justification'). But he does not believe the proposition expressed. Hence he does not know it either. (shrink)

Wars must be won if our country … is to be protected from unthinkable outcomes, as the events on September 11th most recently illustrated…. This best protection unequivocally requires armed forces having military physicians committed to doing what is required to secure victory…. As opposed to needing neutral physicians, we need military physicians who can and do identify as closely as possible with the military so that they, too, can carry out the vital part they play in meeting the needs (...) of the mission.Counterpoint:We believe the role of the “physician–soldier” to be an inherent moral impossibility because the military physician, in an environment of military control, is faced with the difficult problems of mixed agency that include obligations to the “fighting strength” and … “national security.”. (shrink)

One of the fundamental challenges in any field of practical ethics is to articulate a framework for deliberation and decision making that is capable of providing warranted guidance about contentious ethical questions.1 Such a framework has to function effectively in the face of empirical uncertainty and what Rawls refers to as the fact of reasonable pluralism—the fact that individuals often differ in their ideals, ambitions, preferences and conceptions of the good life. One of the perennial questions in normative and metaethics (...) concerns the source of the warrant for such judgments, and a major preoccupation of practical ethics has been to find a way to generate such warrant without having to first settle all contentious philosophical questions about the nature and source of normativity. To the extent that scholars use the term ‘common morality’ to refer to a set of moral norms or concerns that are sufficiently common and widespread that they can be used as starting points for moral deliberation and inquiry, I am sympathetic to the term.2 To the extent that appeals to common morality are supposed to do more significant epistemic or justificatory work, they have always struck me as dangerously ad hoc and insufficiently responsive to the legitimate need to explain the ground for common normative claims. Although I am relatively sceptical of appeals to common morality, I am concerned that the version of this view that is critiqued in ‘Why not common morality’ is simply a straw person. Throughout the paper, Rhodes treats common morality as synonymous with everyday ethics and the ethics of everyday life. She says, ‘If common morality and medical ethics were the same, then the ethically justified behaviour for medical professionals and everyone else would be the same’.3 In effect, the view that Rhodes attacks is …. (shrink)

The idea that there is a fundamental difference in value between persons and things, and that respecting this difference is an important moral requirement, has strong intuitive appeal. Kantian ethics is unique in placing this requirement at the center of a moral system and in explicating the conditions for complying with it. Unlike challenges to Kantian ethics that focus on tragic cases that pit respect for one person against respect for another, this paper focuses on the question of how we (...) can respect the value distinction between persons and things under conditions of uncertainty. After exploring why decision making under uncertainty is a neglected topic among Kantians and demonstrating how uncertainty challenges our ability to comply with this norm, we propose a notion of morally insignificant risk within a framework that allows agents to navigate real-world decisions involving material benefit and some risk to dignity without violating the Kantian’s core commitments. We conclude by exploring some of the challenges facing this approach. (shrink)