The capacity to designate a surrogate is not simply another kind of medical decision-making capacity. A patient with DMC can express a preference, understand information relevant to that choice, appreciate the significance of that information for their clinical condition, and reason about their choice in light of their goals and values. In contrast, a patient can possess the CDS even if they cannot appreciate their condition or reason about the relative risks and benefits of their options. Patients who lack DMC (...) for many or most kinds of medical choices may nonetheless possess the CDS, particularly since the complex means-ends reasoning required by DMC is one of the first capacities to be lost in progressive cognitive diseases. That is, patients with significant cognitive decline or mental illness may still understand what a surrogate does, express a preference about a potential surrogate, and be able to provide some kind of justification for that selection. Moreover, there are many legitimate and relevant rationales for surrogate selection that are inconsistent with the reasoning criterion of DMC. Unfortunately, many patients are prevented from designating a surrogate if they are judged to lack DMC. When such patients possess the CDS, this practice is ethically wrong, legally dubious and imposes avoidable burdens on healthcare institutions. (shrink)

This book systematically reviews a variety of methods for addressing ethical problems in medicine, accounting for both their weaknesses and strengths. Illustrated throughout with specific cases or controversies, the book aims to develop an informed eclecticism that knows how to pick the right tool for the right job.

Professor Cole is correct in his conclusion that the University of Pittsburgh Medical Center (UPMC) protocol does not violate requirements of "irreversibility" in criteria of death, but wrong about the reasons. "Irreversible" in this context is best understood not as an ontological or epistemic term, but as an ethical one. Understood that way, the patient declared dead under the protocol is "irreversibly" so, even though resuscitation by medical means is still possible. Nonetheless, the protocol revives difficult questions about our concept (...) of death. (shrink)

The research importance of biobanked biological materials and their derived data is growing, especially as these are increasingly linked with individual and population‐level medical and health information. The number, diversity, and size of biobanks are growing in tandem. So, too, is the number of individuals whose donations are being used in biobank‐supported research, with or without their knowledge. Pretty soon, we all will be “participants” in a variety of research projects we know nothing about. Until recently, our leftover tissue or (...) deidentified medical information could be used for research without our consent or even our knowledge. Even if we've been asked–as the current regulations require when research uses are anticipated‐we were most likely asked to give a blanket consent to any future use, with no prospect of learning about or controlling how our material is later used. This is an ethically problematic state of affairs, but there are options for improving it. (shrink)

Donors to biobanks are typically asked to give blanket consent, allowing their donation to be used in any research authorized by the biobank. This type of consent ignores the evidence that some donors have moral, religious, or cultural concerns about the future uses of their donations – concerns we call “non-welfare interests”. The nature of non-welfare interests and their effect on willingness to donate to a biobank is not well understood. In order to better undersand the influence of non-welfare interests, (...) we surveyed a national sample of the US population using a probability-based internet panel. Logistic regression models assessed the demographic and attitudinal characteristics associated with participants’ willingness to give consent for unspecified future uses of their donation when presented with 7 research scenarios that raised possible non-welfare interest concerns. Most people had non-welfare interests that significantly affect their willingness to donate to a biobank using blanket consent. Some non-welfare interests are associated with subgroups but others are not. A positive attitude toward biomedical research in general was associated with increased willingness to donate, while concerns about privacy and being African American were associated with decreased willingness. Non-welfare interests matter and can diminish willingness to donate to a biobank. Our data suggest that trust in research promotes willingness to donate. Ignoring non-welfare interests could erode this trust. Donors’ non-welfare interests could be accommodated through greater transparency and easier access to information about the uses of donations. (shrink)

Book reviewed in this article: Life and Death: Philosophical Essays in Biomedical Ethics. By Dan W. Brock.

: New genetic technologies continue to emerge that allow us to control the genetic endowment of future children. Increasingly the claim is made that it is morally "irresponsible" for parents to fail to use such technologies when they know their possible children are at risk for a serious genetic disorder. We believe such charges are often unwarranted. Our goal in this article is to offer a careful conceptual analysis of the language of irresponsibility in an effort to encourage more care (...) in its use. Two of our more important sub-claims are: A fair judgment of genetic irresponsibility necessarily requires a thick background description of the specific reproductive choice; and there is no necessary connection between an act's being morally wrong and its being irresponsible. These are distinct judgments requiring distinct justifications. (shrink)

For a number of reasons, casuistry has come into vogue in medical ethics. Despite the frequency with which it is avowed, the application of casuistry to issues in medical ethics has been given virtually no systematic defense in the ethics literature. That may be for good reason, since a close examination reveals that casuistry delivers much less than its advocates suppose, and that it shares some of the same weaknesses as the principle-based methods it would hope to supplant.

Hospital futility policies are ethically defensible, but they require the proper understanding of futility and should be embedded in a larger process for making decisions about limiting treatment.

Volume 20, Issue 9, September 2020, Page 29-31.

The whole brain-death criterion of death now enjoys a wide acceptance both within the medical profession and among the general public. That acceptance is in large part the product of the contention that brain death is the proper criterion for even a conservative definition of death – the irreversible loss of the integrated functioning of the organism as a whole. This claim – most recently made in the report of the Presidential Commission and in a comprehensive article by James Bernat (...) and others – is based upon a series of fallacious arguments. Chief among these is the argument that whole brain-death is the proper criterion for the conservative definition because the brain is the organ that integrates the rest of the organism. A central part of the paper shows that this argument rests upon a confusion between a function and the mechanism that performs it, and replies to the defenses that the Presidential Commission makes on this point. The concluding portion of the paper argues that this issue is not merely of academic interest, but has the potential for undermining the present consensus that supports the use of whole brain-death criteria. * Keywords: brain-death, definition of death, determination of death * I would like to thank Howard Brody and Bruce Miller for helpful suggestions and criticisms. CiteULike Connotea Del.icio.us What's this? (shrink)

Bioethicists appearing in the media have been accused of "shooting from the hip" (Rachels, 1991). The criticism is sometimes justified. We identify some reasons our interactions with the press can have bad results and suggest remedies. In particular we describe a target (fostering better public dialogue), obstacles to hitting the target (such as intrinsic and accidental defects in our knowledge) and suggest some practical ways to surmont those obstacles (including seeking out ways to write or speak at length, rather than (...) in sound bites). We make use of our own research into the way journalists quote bioethicists. We end by suggesting that the profession as a whole look into this question more fully. (shrink)

The emergence several years ago of SARS, with its high rate of infection and death among healthcare workers, resurrected a recurring ethical question: do health professionals have a duty to provide care to patients with deadly infectious diseases, even at some substantial risk to themselves and their families? The conventional answer, repeated on the heels of the SARS epidemic, is that they do. In this paper, I argue that the arguments in support of such a duty are wanting in significant (...) respects, and that the language of duty is simply not adequate to an understanding of all the moral dimensions of professional responses to the care of risky patients. Instead, we should speak the language of virtues and ideals if we want to do justice to the complexity of such harrowing circumstances. (shrink)

Although the traditional physician ethic sees nothing objectionable about the doctor's influence over patients, superficial conceptions of the patient's right to self-determination imply that this influence may be manipulative. On the contrary, there are several different lines of argument which can reconcile self-determination with the physician's influence. Nevertheless, drawing the boundaries between legitimate methods of persuasion, and manipulation or coercion sometimes proves difficult.

In the latest edition of Principles of Biomedical Ethics, Tom Beauchamp and James Childress provide an expanded discussion of the ethical theory underlying their treatment of issues in medical ethics. Balancing judgements remain central to their method, as does the contention that such judgements are more than intuitive. This theory is developed precisely in response to the common skepticism directed at "principlism" in medical ethics. Such skepticism includes the claim that moral reasoning comes to a dead halt when confronted by (...) competing conflicts between moral norms in a given pluralistic situation. In this paper, I use examples from the text to show that despite the authors’s arguments to the contrary, balancing judgements are the product of unreasoned intuitions. Given the necessity of some such judgements in any principle-based system, my argument highlights the degree to which principled ethical reasoning rests upon an arational core. (shrink)

Like many other bioethicists, I often give talks on clinical topics that may touch on the patient's right of autonomy with regard to medical treatment and, from there, may move to questions about whether said patient has the capacity to exercise said right. When I get to that subject, I might ask, “Is this person competent to refuse treatment?” A stunned silence falls over the room, until finally a hand shoots up. “‘Competent’ is a legal term,” I am instructed. “Don't (...) you mean to ask whether he has the capacity to make decisions for himself?” The tone suggests that I'm being helped to make a very important distinction. But it's not a very important distinction; and it's misleading to boot. (shrink)

Contrary to the revised Common Rule, and contrary to the views of many bioethicists and researchers, we argue that broad consent should be sought for anticipated later research uses of deidentified biospecimens and health information collected during medical care. Individuals differ in the kinds of risk they find concerning and in their willingness to permit use of their biospecimens for future research. For this reason, asking their permission for unspecified research uses is a fundamental expression of respect for them as (...) persons and should be done absent some compelling moral consideration to the contrary. We examine three moral considerations and argue that each of them fails: that there is a duty of easy rescue binding on all, that seeking consent creates a selection bias that undermines the validity of biospecimen research, and that seeking and documenting consent will be prohibitively expensive. (shrink)

A response to commentaries by David Wendler and by Bartha M. Knoppers, Edward S. Dove, and Ma'n H. Zawati on “Respecting Donors to Biobank Research,” from the January‐February 2013 issue.

For methodological or other legitimate reasons it may sometimes be advantageous to withhold an incentive from research participants who don’t meet certain conditions. This commentary describes a case in which the researchers propose such a plan. The IRB reviewers object to the plan, claiming that it exacts a penalty against participants’ right to withdraw, and that it exerts an undue influence on their continued participation. Each of these arguments is critically evaluated and found unpersuasive.

The primary goal of ethics consultation should be to provide effective assistance to patients and families in obtaining care that is duly responsive to their rights and their needs. The consultation reported by Mark Bliton fails in this regard because it never ascertains why the consultation was called; makes little attempt to ascertain the motives of those involved; avoids exploration of the ethical concerns of family, attending or staff; makes no connection with institutional policies or practices; uncritically adopts and serves (...) the medical treatment ethos; and substitutes fellowfeeling for compassionate action. (shrink)

The modern debate on whether—and why—physicians and hospitals can refuse patient or family demands for treatment on grounds of “futility” will be reaching its 20th anniversary this year (Blackhall, 1987). The early debate focused on the use of CPR, for good historical and clinical reasons, and CPR probably remains the primary target of hospital policy. But the reach of the arguments over futility extends well beyond this context, most vividly illustrated by the case of Helga Wanglie and the many commentaries (...) it spawned (Brody, 1998; Schneiderman, 1998; Trotter, 1999). There seems no obvious reason in principle that questions about futility cannot be raised about virtually any form of treatment that patients or families might demand, including such things as chemotherapy for cancer (Tomlinson, 2001). Still, we might fairly ask what new dimensions and complexities the futility question acquires when it moves onto decisions about treatments other than CPR. This is what I would like to do in this essay. I will use dialysis as the case in point, although I hope to extract lessons from the dialysis example that will be pertinent to other forms of life-sustaining treatment, like ventilators. (shrink)

Book reviewed in this article: Life and Death: Philosophical Essays in Biomedical Ethics. By Dan W. Brock.

The New Medicine and the Old Ethics. By Albert R. Jonsen.