Developing a reasonable approach to the medical care of older people with dementia will be essential in the coming decades. Physicians are the locus of decision making for persons with dementia. It is the responsibility of the physician to assure that the surrogate understands the nature and trajectory of the disease and then to elicit the desired goal of care. Physicians need to ascertain whether any advance directives are available, and if so, whether they apply to the situation of advanced (...) dementia. Finally, physicians should help surrogates understand how the goals of care are best translated into practice. When the goal is comfort, this is achieved by assuring dignity, minimizing suffering, and promoting caring. In general, comfort should be the default goal of care, best implemented through palliative care or hospice. (shrink)

America is aging. But even more striking than the rise in the proportion of the population over age 65 is the unprecedented number of individuals who are living into their eighties and nineties. While many people remain robust well into advanced age, the dramatic increase in the number of the oldest old has brought with it an epidemic of Alzheimer’s disease and other dementias. Dementia is a highly prevalent condition — currently 5.4 million Americans have Alzheimer’s disease, a number which (...) may rise to 16 million by 2050 if there is no breakthrough in the prevention or treatment of the disease — but it disproportionately affects those over age 85, striking between one-third and one-half of this cohort. Developing a reasonable approach to the medical care of older people with dementia will be essential in the coming decades. (shrink)

With the passage by virtually every state legislature of healthcare proxy laws, the medical profession increasingly can expect to rely on the participation of surrogates in making decisions on behalf of incompetent patients. Several concerns about the legitimacy of proxy decision making have been discussed in the ethical and general medical literature: the lack of concordance between the views of patients and their surrogates have been documented on multiple occasions, and cases of abuse by proxies or potential conflict of interest (...) have been reported. Another dilemma that deserves discussion arises when proxies demand withdrawal of treatment that physicians and nurses regard as essential to the wellbeing of the patient. The following case highlights this dilemma. (shrink)

Several religious traditions are widely believed to advocate the use of life-sustaining treatment in all circumstances. Hence, many believe that these faiths would require the use of a feeding tube in patients with advanced dementia who have lost interest in or the capacity to swallow food. This article explores whether one such tradition—halachic Judaism—in fact demands the use of artificial nutrition and hydration in this setting. Traditional arguments have been advanced holding that treatment can be withheld in persons who are (...) dying, in individuals whose condition causes great suffering, or in the event that the treatment would produce suffering. Individuals with advanced dementia can be considered to be dying, often suffer as a result of their dementia, and are likely to suffer from the use of a feeding tube. Given these observations and the absence of a compelling case for distinguishing between tube feeding and other forms of medical treatment, traditional Judaism appears compatible with withholding artificial nutrition for individuals with advanced dementia. (shrink)

In light of the central role that medications play in medical progress, the declining rate of new drug development over the past decade is cause for concern . Without important breakthroughs in drug discovery, the future will not be auspicious for the many people suffering from chronic and incurable illnesses. The sluggish pace of pharmaceutical innovation has been particularly characteristic of the largest drug manufacturers, which have generally focused their energies on potential blockbuster medications, those that can generate over $1 (...) billion in annual revenue . Given Pharma’s struggles, the success of the country’s largest drug manufacturer in bringing the .. (shrink)

With great fanfare, the first baby boomer turned 65 on January 1, 2011, ushering in the new, gray society. We—I'm one of the 76 million baby boomers—were expected to transform aging: better educated, healthier, reared in an era of unprecedented prosperity, committed to individual autonomy, we would singlehandedly turn retirement from a time of decline, disability, and despair into a period of travel, adventure, and personal growth. If we did become ill, despite regular exercise, a wholesome diet, and a goodly (...) dose of vitamins, we would demand, and receive, the fruits of American technological ingenuity, vanquishing disease and perhaps even death. Concurrent with the designation of age 70 as "the new 40," we have... (shrink)

Modern gerontology has debunked the myth of old age as a period of inevitable decline. But what science has not been able to change is the reality that old age often is a time of illness and disability, particularly for the oldest old—those over age 85. The vaunted compression of morbidity hasn't happened; while the period of decline before death may have shrunk, it hasn't vanished. The trajectory in the last phase of life is rarely a precipice, with older people (...) living healthy lives until, abruptly, they fall off a cliff. Rather, it typically takes the form of a series of dips that return to an ever-lowering baseline or a slow fade.The... (shrink)

With the passage by virtually every state legislature of healthcare proxy laws, the medical profession increasingly can expect to rely on the participation of surrogates in making decisions on behalf of incompetent patients. Several concerns about the legitimacy of proxy decision making have been discussed in the ethical and general medical literature: the lack of concordance between the views of patients and their surrogates have been documented on multiple occasions, and cases of abuse by proxies or potential conflict of interest (...) have been reported. Another dilemma that deserves discussion arises when proxies demand withdrawal of treatment that physicians and nurses regard as essential to the wellbeing of the patient. The following case highlights this dilemma. (shrink)

Recent findings have provided evidence for the existence of non‐vertebrate acquired immunity. We survey these findings and propose that all living organisms must express both innate and acquired immunity. This is opposed to the paradigm that only vertebrates manifest the two forms of immune mechanism; other species are thought to use innate immunity alone. We suggest new definitions of innate and acquired immunity, based on whether immune recognition molecules are encoded in the inherited genome or are generated through somatic processes. (...) We reason that both forms of immunity are similarly ancient, and have co‐evolved in response to lifestyle, cost‐benefit tradeoffs and symbiosis versus parasitism. However, different species have evolved different immune solutions that are not necessarily genetically related, but serve a similar general function – allowing individuals to learn from their own immune experience; survival of species is contingent on the acquired immune experience of its individuals. (shrink)

The Democratic Republic of the Congo is facing two crises: a potentially explosive Ebola epidemic and a major insurgency. But they are not wholly distinct from each other: the first is intertwined with the second, and public mistrust and political violence add a dangerous dimension to the Ebola epidemic. The World Health Organization and other health emergency responders will increasingly find themselves fighting outbreaks in insecure, misgoverned or ungoverned zones, possibly experiencing active conflict. Yet the WHO has neither the mission (...) nor the capabilities to navigate these security threats. We cannot expect that the usual public health strategy will succeed when health workers’ lives are directly imperiled and community resistance runs deep. Tackling health emergencies amidst complex humanitarian crises requires fresh thinking. Here, we offer a blueprint for fighting diseases in complex humanitarian emergencies. The building blocks of security and trust include high‐level political support, street‐level diplomacy, community engagement, enhanced funding, and protection of health professionals working in conflict or disaster zones. (shrink)

Based on 10 months of mixed ethnographic and archival research, this study is concerned with ways in which contemporary agro-environmental subjectivities and practices in a southwestern Oklahoma farming community are rooted in the massive state-level interventions of the New Deal era and their successors. We are likewise concerned with how those interventions have become interdigitated with moral discourses and community ethics, as simultaneous expressions of both farmers’ identities and the systems of power in which they practice farming. Through historic and (...) ethnographic evidence, we demonstrate the ways in which the localization of American agricultural conservation and the attendant, edificatory role of resource bureaucracies have shaped contemporary practices and ideologies of natural resource stewardship among conventional farmers and ranchers. (shrink)

Kierkegaard's leap of faith is one of the most thoroughly explored topics in modern philosophy. What can yet another inquiry into this notion hope to achieve? A number of significant things, I think, of both historical and systematic value. The main contention of this paper is that the leap of faith, often associated with the emergence of existentialism, is Kierkegaard's response to a problem which is essentially Kantian in origin and structure. Kierkegaard wants to accomodate both the Kantian interpretation of (...) morality as rational command and Kant's insistence on morality as the sole point of access to religion, while rejecting the Kantian moralization of religion and rationalization of faith. The leap of faith is not, as existentialism would have it, an absolute beginning in philosophy or in individual reflection but a transition from morality to religion within an essentially Kantian context. (shrink)

The consensus recommendations by Salter and colleagues (2023) regarding pediatric decision-making intentionally omitted adolescents due to the additional complexity their evolving autonomy presented. Using two case studies, one focused on truth-telling and disclosure and one focused on treatment refusal, this article examines medical decision-making with and for adolescents in the context of the six consensus recommendations. It concludes that the consensus recommendations could reasonably apply to older children.

A basic problem of daily life is determining who owns what. One way that people may solve this problem is by relying on a ‘first possession’ heuristic, according to which the first person who possesses an object is its owner, even if others subsequently possess the object. We investigated preschoolers’ use of this heuristic in five experiments. In Experiments 1 and 2, 3- and 4-year-olds inferred that an object was owned by the character who possessed it first, even though another (...) character subsequently possessed it. Two-year-olds also showed this bias, but only when the object was placed between the characters when children were asked about ownership. Experiment 3 ruled out the possibility that children’s bias to select the first possessor results from a tendency to select the character first associated with the object. Experiment 4 showed that 3- and 4-year-olds have difficulty disregarding the first possession heuristic, even when provided with evidence that the character who first possessed an object is not its owner. But Experiment 5 found that children can disregard the heuristic in at least some situations. These five experiments suggest that the first possession heuristic guides children’s ownership inferences. The findings provide the first evidence that preschoolers can infer who owns what, when not explicitly told, and when not reasoning about objects with which they are personally acquainted. (shrink)

This study examined preschool children’s reasoning about and behavioral interactions with one of the most advanced robotic pets currently on the retail market, Sony’s robotic dog AIBO. Eighty children, equally divided between two age groups, 34–50 months and 58–74 months, participated in individual sessions with two artifacts: AIBO and a stuffed dog. Evaluation and justification results showed similarities in children’s reasoning across artifacts. In contrast, children engaged more often in apprehensive behavior and attempts at reciprocity with AIBO, and more often (...) mistreated the stuffed dog and endowed it with animation. Discussion focuses on how robotic pets, as representative of an emerging technological genre, may be blurring foundational ontological categories, and impacting children’s social and moral development. (shrink)

The advanced donation program was proposed in 2014 to allow an individual to donate a kidney in order to provide a voucher for a kidney in the future for a particular loved one. In this article, we explore the logistical and ethical issues that such a program raises. We argue that such a program is ethical in principle but there are many logistical issues that need to be addressed to ensure that the actual program is fair to both those who (...) do and do not participate in this program. (shrink)

Based on 10 months of mixed ethnographic and archival research, this study is concerned with ways in which contemporary agro-environmental subjectivities and practices in a southwestern Oklahoma farming community are rooted in the massive state-level interventions of the New Deal era and their successors. We are likewise concerned with how those interventions have become interdigitated with moral discourses and community ethics, as simultaneous expressions of both farmers’ identities and the systems of power in which they practice farming. Through historic and (...) ethnographic evidence, we demonstrate the ways in which the localization of American agricultural conservation and the attendant, edificatory role of resource bureaucracies have shaped contemporary practices and ideologies of natural resource stewardship among conventional farmers and ranchers. (shrink)

KANT IS, TO BORROW ONE OF HIS OWN METAPHORS, the keystone of the modern defense of religion. This defense turns on the contention that religion is not to be understood in terms of its own metaphysical claims--the most notable being that God exists--for this claim, as well as the obvious counterclaim, cannot be demonstrated. The existence of God is an antinomy--a claim that theoretical reason can neither prove nor disprove. Religion, however, can be, indeed must be defended, because of the (...) claims that a completely dispassionate, even irreligious, reason must make consequent to an analysis of morality. If we understand the nature of duty, conscience, and the moral law, and the end or good to which the moral law obligates us, we will conclude, Kant argues, that we must accept the existence of God as a postulate of practical reason. Kant's defense of religion rests on a strategy that aims to prove the limits of theoretical reason and the necessity of assuming the primacy of practical reason. (shrink)