Empirical research pertaining to cardiopulmonary resuscitation (CPR), clinician behaviors related to do-not-resuscitate (DNR) orders and substituted judgment suggests potential contributions to medical ethics. Research quantifying the likelihood of surviving CPR points to the need for further philosophical analysis of the limitations of the patient autonomy in decision making, the nature and definition of medical futility, and the relationship between futility and professional standards. Research on DNR orders has identified barriers to the goal of patient involvement in these life and death (...) discussions. The initial data on surrogate decision making also points to the need for a reexamination of the moral basis for substituted judgment, the moral authority of proxy decision making and the second-order status of the best interests standard. These examples of empirical research suggest that an interplay between empirical research, ethical analysis and policy development may represent a new form of interdisciplinary scholarship to improve clinical medicine. (shrink)

For more than sixty years, surgeons have used bioethical strategies to promote patient self‐determination, many of these now collectively described as “informed consent.” Yet the core framework—understanding, risks, benefits, and alternatives—fails to support patients in deliberation about treatment. We find that surgeons translate this framework into an overly complicated technical explanation of disease and treatment and an overly simplified narrative that surgery will “fix” the problem. They omit critical information about the goals and downsides of surgery and present untenable options (...) as a matter of patient choice. We propose a novel framework called “better conversations.” Herein, surgeons provide context about clinical norms, establish the goals of surgery, and comprehensively delineate the downsides of surgery to generate a deliberative space for patients to consider whether surgery is right for them. This paradigm shift meets the standards for informed consent, supports deliberation, and allows patients to anticipate and prepare for the experience of treatment. (shrink)

When do descriptive regularities become prescriptive norms? We examined children's and adults' use of group regularities to make prescriptive judgments, employing novel groups that engaged in morally neutral behaviors. Participants were introduced to conforming or non-conforming individuals. Children negatively evaluated non-conformity, with negative evaluations declining with age. These effects were replicable across competitive and cooperative intergroup contexts and stemmed from reasoning about group regularities rather than reasoning about individual regularities. These data provide new insights into children's group concepts and have (...) important implications for understanding the development of stereotyping and norm enforcement. (shrink)

We review recent developments in ethical pluralism, ethical particularism, Kantian intuitionism, rights theory, and climate change ethics, and show the relevance of these developments in ethical theory to contemporary business ethics. This paper explains why pluralists think that ethical decisions should be guided by multiple standards and why particularists emphasize the crucial role of context in determining sound moral judgments. We explain why Kantian intuitionism emphasizes the discerning power of intuitive reason and seek to integrate that with the comprehensiveness of (...) Kant’s moral framework. And we show how human rights can be grounded in human agency, and explain the connections between human rights and climate change. (shrink)

The dead donor rule—that persons must be dead before their organs are taken—is a central part of the moral framework underlying organ procurement. Efforts to increase the pool of transplantable organs have been forced either to redefine death (e.g., anencephaly) or take advantage of ambiguities in the current definition of death (e.g., the Pittsburgh protocol). Society's growing acceptance of circumstances in which health care professionals can hasten a patient's death also may weaken the symbolic importance of the dead donor rule. (...) We consider the implications of these efforts to continually revise the line between life and death and ask whether it would be preferable to abandon the dead donor rule and rely entirely on informed consent as a safeguard against abuse. (shrink)

Since the Harvard Committees bold and highly successful attempt to redefine death in 1968 (Harvard Ad Hoc committee, 1968), multiple controversies have arisen. Stimulated by several factors, including the inherent conceptual weakness of the Harvard Committees proposal, accumulated clinical experience, and the incessant push to expand the pool of potential organ donors, the lively debate about the definition of death has, for the most part, been confined to a relatively small group of academics who have created a large body of (...) literature of which this issue of the Journal of Medicine and Philosophy is an example. Law and public policy, however, have remained essentially unaffected. This paper will briefly review the multiple controversies about defining death in an attempt to explain why they have and will remain unresolved in the academic community and have even less chance of being understood and resolved by politicians, legislators, and the general public. Considering this, we will end by suggesting the probable course of public policy and clinical practice in the decades ahead. (shrink)

ABSTRACT:We review recent developments in ethical pluralism, ethical particularism, Kantian intuitionism, rights theory, and climate change ethics, and show the relevance of these developments in ethical theory to contemporary business ethics. This paper explains why pluralists think that ethical decisions should be guided by multiple standards and why particularists emphasize the crucial role of context in determining sound moral judgments. We explain why Kantian intuitionism emphasizes the discerning power of intuitive reason and seek to integrate that with the comprehensiveness of (...) Kant’s moral framework. And we show how human rights can be grounded in human agency, and explain the connections between human rights and climate change. (shrink)

In the clinical setting, questions of medical ethics raise a host of perplexing problems, often complicated by conflicting perspectives and the need to make immediate decisions. In this volume, bioethicists and physicians provide a nuanced, in-depth approach to the difficult issues involved in bioethics consultation. Addressing the needs of researchers, clinicians, and other health professionals on the front lines of bioethics practice, the contributors focus primarily on practical concerns -- whether ethics consultation is best done by individuals, teams, or committees (...) how an ethics consult service should be structured the need for institutional support and techniques and programs for educating and training staff -- without neglecting more theoretical considerations, such as the importance of character or the viability of organizational ethics. (shrink)

Originally published in 1937, this book provides a detailed discussion of the nature of Christian faith and belief in its relationship with the concept of redemption.

One way of increasing the supply of vital organs without violating the dead donor rule is to declare death on cardiopulmonary criteria after withdrawing life support. The question then is how quickly death may be declared.

Advertising by health care institutions has increased steadily in recent years. While direct-to-consumer prescription drug advertising is subject to unique oversight by the Federal Drug Administration, advertisements for health care services are regulated by the Federal Trade Commission and treated no differently from advertisements for consumer goods. In this article, we argue that decisions about pursuing health care services are distinguished by informational asymmetries, high stakes, and patient vulnerabilities, grounding fiduciary responsibilities on the part of health care providers and health (...) care institutions. Using examples, we illustrate how common advertising techniques may mislead patients and compromise fiduciary relationships, thereby posing ethical risks to patients, providers, health care institutions, and society. We conclude by proposing that these risks justify new standards for advertising when considered as part of the moral obligation of health care institutions and suggest that mechanisms currently in place to regulate advertising for prescription pharmaceuticals should be applied to advertising for health care services more broadly. (shrink)

Obese people consume significantly greater amounts of health resources. This study set out to determine if health resource utilization by obese people decreases after losing weight in a comprehensive medically supervized weight management programme. Four hundred and fifty-six patients enrolled in a single-centred, multifaceted weight loss programme in a universal health care system were studied. Patient information was anonymously linked with administrative databases to measure health resource utilization for 1 year before and after the programme. Mean body mass index (BMI) (...) decreased by more than 15%. The mean annual physician visits (pre = 9.6, post = 9.4) did not change significantly after the programme. However, patients saw a significantly fewer number of different physicians per year following the programme (pre = 4.5, post = 3.9; P < 0.001). Mean annual number of emergency visits (pre = 0.2; post = 0.2) and hospital admissions (pre = 0.05; post = 0.08) did not change. Neither baseline BMI, nor its change during the programme, influenced changes in health resource utilization. Our study suggests that weight loss in a supervized weight management programme does not necessarily decrease short-term health resource utilization. Further study is required to determine if patients who maintain their weight loss experience a decrease in health utilization. (shrink)

Many studies have shown that marijuana can negatively affect the cognitive development of adolescents. For some individuals, marijuana use may also initiate opioid use, dose escalation, and opioid use disorder. States that legalize marijuana should help adolescents through regulation of advertising and availability of marijuana-infused edibles. Such policies may assist in protecting neurodevelopment of the adolescent and young adult brain. The federal government should also remove its prohibition of marijuana sales and use, leaving their regulation to state law-makers.

In lieu of an abstract, here is a brief excerpt of the content:Back to the Future:Obtaining Organs from Non-Heart-Beating CadaversRobert M. Arnold (bio) and Stuart J. Youngner (bio)Organ Transplantation requires viable donor organs. This simple fact has become the Achilles' heel of transplantation programs. Progress in immunology and transplant surgery has outstripped the supply of available organs. Between 1988 and 1991, for example, the number of transplant candidates on waiting lists increased by about 55 percent, while the number of (...) donors increased only about 16 percent.1 By the end of March 1993, more than 30,000 potential recipients awaited transplantation (United Network for Organ Sharing Database (UNOS) 1993). Every day six of these patients die prior to receiving a heart or liver transplant, while patients needing kidney transplants must tolerate a lower quality of life on dialysis (Grenvik 1992; Evans, Orians, and Ascher 1992).This scarcity is likely to get worse. As transplantation becomes more successful, it is being offered to sicker and older patients. Attempts to transplant other solid organs, such as small bowel and pancreas, will only fuel the demand for donors. However, the current source of organs is unlikely to grow. Most organs come from patients who have been declared dead by neurologic criteria (commonly referred to as "brain dead" or heart-beating cadaver donors (HBCDs) because their hearts are beating at the time of procurement). Estimates of the potential pool of HBCDs have been revised downward from 20,000-27,000 to roughly 10,000-12,000 (Nathan et al. 1991). Improvements in automobile safety and handgun legislation will likely lead to further reductions. Moreover, the rate of procurement from HBCDs has remained relatively flat despite extensive public awareness campaigns and legislation requiring hospitals to routinely request donation from families of dead patients (Caplan et al. 1992).If organ transplantation is going to continue to flourish, alternative [End Page 103] sources of organs must be found. Recently the University of Pittsburgh Medical Center (UPMC) proposed procuring organs from patients who have been declared dead by traditional cardiopulmonary rather than brain-oriented criteria after they or their families have decided to forgo life-sustaining treatment—hereafter referred to as the Pittsburgh protocol (UPMC Policy 1993). These patients are typically referred to as non-heart-beating cadaver donors (NHBCDs) because their hearts are no longer beating at the time of organ procurement.Although NHBCDs were a major source of transplantable kidneys prior to the institution of death by neurologic criteria, their usefulness was limited by "warm ischemia time." This term refers to the injury to tissues that occurs when the blood supply is interrupted and before the organs are cooled and reperfused. Under the Pittsburgh protocol, therapy is withdrawn in the operating room where a waiting surgical team removes organs immediately after death is declared. By controlling the place and time of death, it has been possible to minimize warm ischemia time and thus solve the technical problems previously associated with procurement from NHBCDs.The potential contribution of NHBCD organs is significant. Nathan (1992), using data from Delaware Valley Transplant Program, concludes that the use of severely brain injured, but not "brain dead" patients, would increase the donor pool by 20-25 percent. Moreover, unpublished data from the Pittsburgh organ procurement organization, the Center for Organ Recovery and Education (CORE), suggests that these organs, particularly kidneys, function as well as those procured from HBCDs (Broznick 1993).This volume is devoted to the ethical, psychosocial, and public policy implications of procuring organs from non-heart-beating cadaver donors after a discussion to forgo life-sustaining treatment. The genesis of this volume was a project in which we invited leading experts in transplantation, ethics, and public policy to use the Pittsburgh protocol as a starting point for exploring a broad range of issues associated with attempts to procure organs from NHBCDs. The issues raised by NHBCDs turned out to have important implications about the fundamental conceptual and moral assumptions underlying organ procurement.Although each of the papers in this volume can be read separately, we intend the volume to be read as a whole. Many of the latter pieces on the ethical implications of the policy are best understood in light of the earlier background papers... (shrink)

This book explores the relationship between scientific fact and metaphysical reality, offering a fresh perspective on the intersection of these two seemingly disparate fields. This work has been selected by scholars as being culturally important, and is part of the knowledge base of civilization as we know it. This work is in the "public domain in the United States of America, and possibly other nations. Within the United States, you may freely copy and distribute this work, as no entity (individual (...) or corporate) has a copyright on the body of the work. Scholars believe, and we concur, that this work is important enough to be preserved, reproduced, and made generally available to the public. We appreciate your support of the preservation process, and thank you for being an important part of keeping this knowledge alive and relevant. (shrink)

One way of increasing the supply of vital organs without violating the dead donor rule is to declare death on cardiopulmonary criteria after withdrawing life support. The question then is how quickly death may be declared.

: In this brief commentary, we reflect on the recent study by Siminoff, Burant, and Youngner of public attitudes toward "brain death" and organ donation, focusing on the implications of their findings for the rules governing from whom organs can be obtained. Although the data suggest that many seem to view "brain death" as "as good as dead" rather than "dead" (calling the dead donor rule into question), we find that the study most clearly demonstrates that understanding an individual's definition (...) of death is neither a straightforward task nor a good predictor of views about donation. Reflecting on the implications for ongoing debates over the dead donor rule, we suggest that perhaps it is not a change in policy that is warranted, but rather a change in the priorities that have garnered such intense focus on this issue within the field of bioethics. (shrink)

In “Bioethics and the Whole: Pluralism, Consensus, and the Transmutation of Bioethical Methods into Gold,” Patricia Martin identifies themes common to three emerging approaches to clinical bioethics--clinical pragmatism, ethics facilitation, and mediation-in order to develop an “ethical consensus method” that can serve as a “practical, step-by-step guide” for decision making She is to be applauded both for her identification of themes common to these three approaches and for her contribution to what we hope will be a growing literature on practical (...) methods for problem solving in clinical bioethics that take seriously the ideal of consensus. After a few preliminary remarks concerning Martin's working model, we focus the majority of our commentary on the notion of “consensus,” which is at the heart of her “ethical consensus method,” and the three approaches from which it is drawn. (shrink)

Objective: To determine the usefulness of Q methodology to locate and describe shared subjective influences on clinical decision making among participant physicians using hypothetical cases containing common ethical issues. Design: Qualitative study using by-person factor analysis of subjective Q sort data matrix. Setting: University medical center. Participants: Convenience sample of internal medicine attending physicians and house staff (n = 35) at one midwestern academic health sciences center. Interventions: Presented with four hypothetical cases involving urgent decision making near the end of (...) life, participants selected one of three specific clinical actions offered for each case. Immediately afterward and while considering their decision, each respondent sorted twenty-five subjective self-referent items in terms of the influence of each statement on their decision-making process. By-person factor analysis, where participants are defined as variates, yielded information about the attitudinal background the physicians brought to their consideration of each hypothetical case. We performed a second-order factor analysis on all of the subjective viewpoints to determine if a smaller core of shared attitudes existed across some or all of the four case vignettes. Factor scores for each item and post-sort comments from interviews conducted individually with each respondent guided the interpretation of ethical perspective used by these respondents in making clinical decisions about the cases. Measurements and Main Results: Second-order factor analysis on seventeen viewpoints used by physicians in the four hypothetical urgent decision cases revealed three moderately correlated (r 2 < 40%) subjective core attitudinal guides used broadly among all the cases and among sixteen of the seventeen original factors. Across all the cases, our participants were guided in general by: (1) patient-focused beneficence, (2) a patient- and surrogate-focused perspective that includes risk avoidance, and (3) best interest of the patient guided by ethical values. Economic impact on the physician, expediency in resolution of the situation, and the expense of medical treatment were not found to be influential determinants in this study. Conclusions: Q sorting and by-person factor analysis are useful qualitative methodological tools to study the complex structure of subjective attitudes that influence physicians in making medical decisions. This study revealed the subjective viewpoints used by our physician participants as they made ethically challenging treatment decisions. The three second-order factors identified here are grounded in current bioethical values as well as the personal traits of physicians. The participants' decision methods appear to resemble casuistry more than principle-based decision making. Generalizability of results will require further studies. (shrink)

The current policy of the National Institute of Health designed to increase the participation of women and minorities is radically different from previous policies designed to protect minorities from abuses in research studies. The principal arguments to support this policy are twofold: 1) Increased representation of minorities and women in research would increase the generalizability of research data and allow for valid analyses of differences in subpopulations; and 2) being in a clinical research study is advantageous to participants regardless of (...) the final research study results. It remains unclear whether minorities find these arguments compelling. Instead of telling minorities that participation in research is good for them, the research community should focus on understanding what minority communities want from clinical research and then tailoring the message to meet this need. Persuasive arguments to promote long-term increased representation of minorities in clinical research must come from within minority communities. (shrink)

One of the traditional pragmatic approaches to vagueness suggests that there needs to be a significant gap between individuals or objects that can be described using a vague adjective like tall and those that cannot. In contrast, intuitively, an explicit comparative like taller does not require fulfillment of the gap requirement. Our starting point for this paper is the consideration that people cannot make precise measures under time pressure and their ability to discriminate approximate heights obeys Weber’s law. We formulate (...) and experimentally test three hypotheses relating to the difference between positive and comparative forms of the vague adjectives, gap requirement, and Weber’s law. In two experiments, participants judged appropriateness of usage of positive and comparative forms of vague adjectives in a sentence-picture verification task. Consequently, we review formal analysis of vagueness using weak orders and semi-orders and suggest adjustments based on the experimental results and properties of Weber’s law. (shrink)