The laser chaos decision maker has been demonstrated to enable ultra-high-speed solutions of multiarmed bandit problems or decision-making in the GHz order. However, the underlying mechanisms are not well understood. In this paper, we analyze the chaotic dynamics inherent in experimentally observed laser chaos time series via surrogate data and further accelerate the decision-making performance via parameter optimization. We first evaluate the negative autocorrelation in a chaotic time series and its impact on decision-making detail. Then, we analyze the (...) decision-making ability using three different surrogate chaos time series to examine the underlying mechanism. We clarify that the negative autocorrelation of laser chaos improves decision-making and that the amplitude distribution of the original laser chaos time series is not optimal. Hence, we introduce a new parameter for adjusting the amplitude distribution of the laser chaos to enhance the decision-making performance. This study provides a new insight into exploiting the supremacy of chaotic dynamics in artificially constructed intelligent systems. (shrink)

Cochrane has developed a linked data infrastructure to make the evidence and data from its rich repositories more discoverable to facilitate evidence-based health decision-making. These annotated resources can enhance the study and understanding of biomarkers and surrogate endpoints.

The increasing accuracy of algorithms to predict values and preferences raises the possibility that artificial intelligence technology will be able to serve as a surrogate decision-maker for incapacitated patients. Following Camillo Lamanna and Lauren Byrne, we call this technology the autonomy algorithm. Such an algorithm would mine medical research, health records, and social media data to predict patient treatment preferences. The possibility of developing the AA raises the ethical question of whether the AA or a relative ought to (...) serve as surrogate decision-maker in cases where the patient has not issued a medical power of attorney. We argue that in such cases, and against the standard practice of vesting familial surrogates with decision making authority, the AA should have sole decision-making authority. This is because the AA will likely be better at predicting what treatment option the patient would have chosen. It would also be better at avoiding bias and, therefore, choosing in a more patient-centered manner. Furthermore, we argue that these considerations override any moral weight of the patient’s special relationship with their relatives. (shrink)

To what extent are people able to make predictions about other people’s preferences and values? We report two experiments that present a novel method assessing some of the basic processes in surrogate decision-making, namely surrogate-utility estimation. In each experiment participants formed dyads who were asked to assign utilities to health related items and commodity items, and to predict their partner’s utility judgments for the same items. In experiment one we showed that older adults in long-term relationships were able (...) to accurately predict their partner’s wishes. In experiment two we showed that younger adults who were relatively unfamiliar with one another were also able to predict other people’s wishes. Crucially we demonstrated that these judgments were accurate even after partialling out each participant’s own preferences indicating that in order to make surrogate utility estimations people engage in perspective-taking rather than simple anchoring and adjustment, suggesting that utility estimation is not the cause of inaccuracy in surrogate decision-making. The data and implications are discussed with respect to theories of surrogate decision-making. (shrink)

The establishment of a Research Ethics Committee (REC) is a significant step to ensure the standard procedures in ethics review process that protect human participants. However, in instances when RECs are not yet established, surrogate activities are practiced by some institutions. The objective of this study was to identify prevailing research ethical practices of research directors and faculty researchers in the absence of a research ethics committee in their respective academic institutions. Specifically, it aimed to explore the participants’ 1) (...) experiences in research subject protection and 2) challenges when there is no existing REC in the institution. Participants were selected from universities in Manila City whose institutions did not have RECs at the time of the conduct of this study. Key informant interviews and focus group discussions were used as approaches for data collection. The authors used NVivo to organize data from the transcribed audio-recorded interviews and were analyzed utilizing a basic interpretive qualitative approach. Based on the results, surrogate practices of participants involved (1) providing “informed consent forms” to target participants and the (2) roles of different personalities in the evaluation/conduct of the research paper. Implications of this study and recommendations were likewise discussed in this paper. (shrink)

A general view in philosophy of science says that the appropriateness of an object to act as a surrogate depends on the user’s decision to utilize it as such. This paper challenges this claim by examining the role of surrogative reasoning in high-throughput sequencing technologies as they are used in contemporary microbiome science. Drawing on this, we argue that, in technology-driven surrogates, knowledge about the type of inference practically permitted and epistemically justified by the surrogate constrains their use (...) and thus puts a limit to the user’s intentions to use any object as a surrogate for what they please. Ignoring this leads to a serious epistemic misalignment, which ultimately prevents surrogative reasoning. Thus, we conclude that knowledge about the type of surrogate reasoning that the technologies being used allow is fundamental to avoid misinterpreting the consequences of the data obtained with them, the hypothesis this data supports, and what these technologies are surrogates of. (shrink)

Because an increasing number of patients have medical conditions that render them incompetent at making their own medical choices, more and more medical choices are now made by surrogates, often patient family members. However, many studies indicate that surrogates often do not discharge their responsibilities adequately, and in particular, do not choose in accordance with what those patients would have chosen for themselves, especially when it comes to end-of-life medical choices. This chapter argues that a significant part of the explanation (...) of such surrogate failure is that family surrogates are likely to undergo anticipatory grief when making end-of-life decisions. After clarifying both the emotional structure and object of grief, I propose that the pending death of a loved one induces an emotional conflict in surrogates between the care demanded by their responsibility as surrogates and the attachment surrogates feel toward their dying loved one, an attachment surrogates "resolve" in the direction of attachment rather than care. This hypothesis helps to explain both surrogates' general inability to exercise "substituted judgment" on behalf of their loved ones and a wide swath of the particular data regarding this inability (e.g., that surrogates more often err by choosing overtreatment). I conclude by considering possible clinical and philosophical responses to this hypothesis. (shrink)

German legislation demands that decisions about the treatment of mentally incompetent patients require an ‘informed consent’. If this was not given by the patient him-/herself before he/she became incompetent, it has to be sought by the physician from a guardian, who has to be formally legitimized before. Additionally this surrogate has to seek the permission of a Court of Guardianship (Vormundschaftsgericht), if he/she intends to consent to interventions, which pose significant risks to the health or the life of the (...) person under his/her care. This includes ‘end-of-life decisions’. Deviations from this procedure are only allowed in acute emergencies or cases of ‘medical futility’. On the basis of epidemiological and demographical data it can be shown that the vast majority of surrogate decisions on incompetent patients in Germany is not covered by legally valid consent. Moreover, the data suggests that if consent were to be requested according to the legal regulations, both the legal and medical system could realistically never cope with the practical consequences of this. Additionally, empiric research has revealed serious deficits concerning medical ‘end of life-decisions’ and practical performance in palliative care. As a consequence a multidisciplinary discussion has developed in Germany about the reform of present legislation with respect to key-issues like• the assessment of mental competence• the options for exercising patient self-determination via advance directives and durable powers of attorney• the improvement of palliative care facilities,• the clarification of formal procedures for surrogate decision-making in health care and towards the end of life• and the possibilities and their limitations of controlling these decision-making processes ‘externally’ (e.g., by Guardianship Courts or committees).The authors discuss those proposals, which clearly dominate the present debate: They all aim to comply with the scientific basis of German law, jurisdiction and the European traditions of philosophy of health care and bioethics. (shrink)

ebec and Queensland, we applied four methods to assess the extent to which environmental surrogates can represent biodiversity components: (1) surrogacy graphs; (2) marginal representation plots; (3) Hamming distance function; and (4) Syrjala statistical test for spatial congruence. For Qu´ebec we used 719 faunal and floral species as biodiversity components, and for Queensland we used 2348 plant species. We used four climatic parameter types (annual mean temperature, minimum temperature during the coldest quarter, maximum temperature during the hottest quarter, and annual (...) precipitation), along with slope, elevation, aspect, and soil types, as environmental surrogates. To study the effect of scale, we analyzed the data at seven spatial scales ranging from 0.01◦ to 0.10◦ longitude and latitude. At targeted representations of 10% for environmental surrogates and biodiversity components, all four methods indicated that using a full set of environmental surrogates systematically provided better results than selecting areas at random, usually ensuring that ≥90% of the biodiversity components achieved the 10%. (shrink)

Background Empirical studies of surrogate decision-making tend to assume that surrogates should make only a 'substituted judgement'—that is, judge what the patient would want if they were mentally competent. Objectives To explore what people want in a surrogate decision-maker whom they themselves select and to test the assumption that people want their chosen surrogate to make only a substituted judgement. Methods 30 undergraduate students were recruited. They were presented with a hypothetical scenario about their expected loss of (...) mental capacity in the future and asked to answer some questions about their choice of surrogate. These data were analysed qualitatively using thematic content analysis. Results Most respondents talked about choosing someone who was caring and competent in certain ways, giving interesting evidence for their judgements. Surprisingly few highlighted how well they thought their chosen surrogate knew their preferences and would be able to make a substituted judgement. Moreover, few specified that their chosen surrogate had similar attitudes and values to their own and so would make a similar decision to theirs in the circumstances presented. Some respondents also referred to the social role of their chosen surrogate or the social dynamics of their situation which influenced their choices, as well as to ideas of reciprocity and characteristics of honesty and loyalty. Conclusion In the event that they lose mental capacity, many people will not select a surrogate to decide about medical treatments on their behalf solely on the basis that they expect their surrogate to make a substituted judgement. (shrink)

Two articles in this issue of the Hastings Center Report explore two sides of the same problematic coin. In “The Limits of Surrogates’ Moral Authority and Physician Professionalism,” Jeffrey Berger discusses the moral problem of a surrogate refusing a treatment, palliative sedation, on behalf of a patient whose suffering is refractory to intensive palliative efforts provided by a multidisciplinary team. In “After the DNR: Surrogates Who Persist in Requesting Cardiopulmonary Resuscitation,” Ellen Robinson and her colleagues analyze data from (...) a study of cases in which physicians wished not to perform cardiopulmonary resuscitation on patients whom they thought it would harm. Both articles begin from the idea of a professional determination about a physician's duty to a patient that conflicted with a surrogate's determination about what should or should not be done for that patient. Berger's argument stops just short of a solution, however, because a physician's professional obligation to help patients, even within guidelines set by other professionals, is insufficient protection for patients. But if Berger's theory is right—that sometimes surrogates lack moral authority to make decisions on behalf of patients—then the Robinson team has developed a careful and public process for attending to that conflict. (shrink)

In today’s science, the output of measurement processes are often visual representations of the data detected. Moreover, we find such visual data as parts of scientific reasoning in different contexts. In this article, we will take a look at two of them. On the one hand, visual representations are used as a kind of surrogate for the real object to ask questions about it – we will call this the exploratory use of visual data. On the (...) other hand, visualisations are often used to communicate research results to scientific peers or to laymen. Instances of the latter case we will subsequently call the explanatory use of visual data. However, in both contexts the question arises what might justify these epistemic practices. Believing without reasons is epistemically irresponsible, it leads to gullibility. Thus, we will try to answer the question whether there are any reasons to support our epistemic practices concerning scientific visualisations in the above-mentioned senses and whether these are good reasons to rely on. (shrink)

We expect Big Data methods to contribute to research with results that are not inferior to those attained in other ways but possibly better, or hard or impossible to generate in other ways. Those who apply these methods may also aspire to augment the arsenal of research methods, offer surrogates for existing research designs, and re-orient research. Moreover, we can critically examine the institutional, societal and political effects of the Big Data methods and the conditions for the solid (...) institutionalization of these methods in social and political research. To reach its primary objective, this article elaborates conclusions on how Big Data methods, not only by means of their ‘social life’ but also by their ‘political life’, may influence the institutionalization of social and political research. To reach its secondary objective, the article re-examines a study of budgetary legislation in 13 countries carried out by means of Big Data methods to draw conclusions concerning the augmentation of the arsenal of research methods, the surrogation of existing research designs, and the re-orientation of research. (shrink)

Classic conceptions of model simplicity for machine learning are mainly based on the analysis of the structure of the model. Bayesian, Frequentist, information theoretic and expressive power concepts are the best known of them, which are reviewed in this work, along with their underlying assumptions and weaknesses. These approaches were developed before the advent of the Big Data deluge, which has overturned the importance of structural simplicity. The computational simplicity concept is presented, and it is argued that it is (...) more encompassing and closer to actual machine learning practices than the classic ones. In order to process the huge datasets which are commonplace nowadays, the computational complexity of the learning algorithm is the decisive factor to assess the viability of a machine learning strategy, while the classic accounts of simplicity play a surrogate role. Some of the desirable features of computational simplicity derive from its reliance on the learning system concept, which integrates key aspects of machine learning that are ignored by the classic concepts. Moreover, computational simplicity is directly associated with energy efficiency. In particular, the question of whether the maximum possibly achievable predictive accuracy should be attained, no matter the economic cost of the associated energy consumption pattern, is considered. (shrink)

My argument in this paper is given in two parts. In Part I, I review the ancient understanding of aporia, focusing on works by Plato and Aristotle. I illustrate two ways of understanding aporia: “cathartic” and “zetetic.” Cathartic aporia refers to the experience of being purged of hubris and ignorance through the dialectic. Zetetic aporia, on the other hand, requires us to engage in, recognize, and work through certain philosophical puzzles or problems. In Part II, I discuss the idea of (...) Big Data and then argue that in the “age of answers” neither conception of aporia appears to be necessarily cultivated by the average Internet user. Our experience of wonder suffers when we rely so heavily on the Internet as a “surrogate expert,” and when our social media use betrays the fact that we always seem to gravitate towards the like-minded. (shrink)

My argument in this paper is given in two parts. In Part I, I review the ancient understanding of aporia, focusing on works by Plato and Aristotle. I illustrate two ways of understanding aporia: “cathartic” and “zetetic.” Cathartic aporia refers to the experience of being purged of hubris and ignorance through the dialectic. Zetetic aporia, on the other hand, requires us to engage in, recognize, and work through certain philosophical puzzles or problems. In Part II, I discuss the idea of (...) Big Data and then argue that in the “age of answers” neither conception of aporia appears to be necessarily cultivated by the average Internet user. Our experience of wonder suffers when we rely so heavily on the Internet as a “surrogate expert,” and when our social media use betrays the fact that we always seem to gravitate towards the like-minded. (shrink)

Clinicians sometimes disagree about how much to honor surrogates’ deeply held cultural values or traditions when they differ from those of the host country. Such a controversy arose when parents requested a cultural accommodation to let their infant die by withdrawing life saving care. While both the parents and clinicians claimed to be using the Best Interests Standard to decide what to do, they were at an impasse. This standard is analyzed into three necessary and jointly sufficient conditions and used (...) to resolve the question of how much to accommodate cultural preferences and how to treat this infant. The extreme versions of absolutism and relativism are rejected. Properly understood, the Best Interests Standard can serve as a powerful tool in settling disputes about how to make good decisions for those who cannot decide for themselves. (shrink)

Biomarkers are widely used not only as prognostic or diagnostic indicators, or as surrogate markers of disease in clinical trials, but also to formulate theories of pathogenesis. We identify two problems in the use of biomarkers in mechanistic studies. The first problem arises in the case of multifactorial diseases, where different combinations of multiple causes result in patient heterogeneity. The second problem arises when a pathogenic mediator is difficult to measure. This is the case of the oxidative stress (OS) (...) theory of disease, where the causal components are reactive oxygen species (ROS) that have very short half-lives. In this case, it is usual to measure the traces left by the reaction of ROS with biological molecules, rather than the ROS themselves. Borrowing from the philosophical theories of signs, we look at the different facets of biomarkers and discuss their different value and meaning in multifactorial diseases and system medicine to inform their use in patient stratification in personalized medicine. (shrink)

Philosophy of dialectical materialism and logic.

The quantification of phase synchrony between neuronal signals is of crucial importance for the study of large-scale interactions in the brain. Two methods have been used to date in neuroscience, based on two distinct approaches which permit a direct estimation of the instantaneous phase of a signal [Phys. Rev. Lett. 81 (1998) 3291; Human Brain Mapping 8 (1999) 194]. The phase is either estimated by using the analytic concept of Hilbert transform or, alternatively, by convolution with a complex wavelet. In (...) both methods the stability of the instantaneous phase over a window of time requires quantification by means of various statistical dependence parameters (standard deviation, Shannon entropy or mutual information). The purpose of this paper is to conduct a direct comparison between these two methods on three signal sets: (1) neural models; (2) intracranial signals from epileptic patients; and (3) scalp EEG recordings. Levels of synchrony that can be considered as reliable are estimated by using the technique of surrogate data. Our results demonstrate that the differences between the methods are minor, and we conclude that they are fundamentally equivalent for the study of neuroelectrical signals. This offers a common language and framework that can be used for future research in the area of synchronization. © 2001 Published by Elsevier Science B.V. (shrink)

estimated surrogates for biodiversity. Using data setsfrom Quebec and Queensland, zve applied four methods to assess the extent to zvhich environmental surrogates can represent biodiversity components: (1) surrogacy graphs; (2) marginal representation plots; (3) Hamming distance function; and (4) Syj rala statistical test for..

There are substantial data establishing that surrogates are often mistaken in predicting what treatments incompetent patients would have wanted and that supplements such as advance directives have not resulted in significant improvements. Rid and Wendler’s Patient Preference Predictor (PPP) proposal will attempt to gather data about what similar patients would prefer in a variety of treatment choices. It accepts the usual goal of patient autonomy and the Substituted Judgment principle for surrogate decisions. I provide reasons for questioning (...) sole reliance on autonomy when surrogates, not patients, are deciding and for giving some independent weight to patient well-being. Moreover, that family members, typical surrogates, will know best what the patient if incompetent would have wanted is not the only reason why they are chosen. The more pressing problem is that the PPP would fail to remove the more serious mistakes that empirical psychology over the last few decades has shown to infect such decision making. (shrink)

Both clinical research and basic science rely on the epistemic practice of extrapolation from surrogate models, to the point that explanatory accounts presented in review papers and biology textbooks are in fact composite pictures reconstituted from data gathered in a variety of distinct experimental setups. This raises two new challenges to previously proposed mechanistic-similarity solutions to the problem of extrapolation: one pertaining to the absence of mechanistic knowledge in the early stages of research and the second to the (...) large number of extrapolations underpinning explanatory accounts. An analysis of the strategies deployed in experimental research supports the conclusion that while results from validated surrogate models are treated as a legitimate line of evidence supporting claims about target systems, the overall structure of research projects also demonstrates that extrapolative inferences are not considered definitive or sufficient evidence, but only partially justified hypotheses subjected to further testing. 1 Introduction2 Surrogate Models2.1 What exactly is a surrogate model?2.2 Why use surrogate models?3 Prior Validation of Surrogate Models3.1 The validation and ranking of surrogate models in the early stages of basic research3.2 The validation of surrogate models in later stages of basic research and in clinical research4 ‘Big Picture’ Accounts and the Extrapolations Underpinning Them4.1 The mosaic nature of mechanistic descriptions in basic science4.2 Challenges for mechanistic-similarity-based validation protocols5 Retrospective Testing of Extrapolated Knowledge5.1 Holistic confirmation5.2 Fallback strategies6 Conclusions. (shrink)

This article explores the intersections of power within transnational surrogacy in India, using the lens of geography to examine surrogate women’s and commissioning parents’ experiences and perceptions of space and mobility. The author analyzes ethnographic data within a geographical framework to examine how actors embody and experience power relations through space and movement, revealing how power is not simply about who moves and who doesn’t. Rather, in recognizing the specificity of the Indian context, and how different actors inhabit (...) and move through distinct spaces, a geographical lens reveals the shifting complexity of structures of agency and power. Drawing on extensive ethnographic fieldwork in India, the author traces how both surrogate mothers and commissioning parents experience moments of mobility and movement punctuated by intervals of immobility and stillness, in distinct ways that illuminate the power relations inherent in transnational reproduction. (shrink)

Background: The introduction of healthcare AI to society as well as the clinical setting will improve individual health statuses and increase the possible medical choices. AI can be, however, regarded as a double-edged sword that might cause medically and socially undesirable situations. In this paper, we attempt to predict several negative situations that may be faced by healthcare professionals, patients and citizens in the healthcare setting, and our society as a whole. Discussion: We would argue that physicians abuse healthcare AI (...) through their excessive and dependent use of it, and they will focus only on the AI services in their office and patient medical data and information, and forget to observe the patient in their clinical encounters. In the era of AI introduction, data from the wearable terminal or AI advice will become the primary target of the physician’s interest, and could be regarded as a patient surrogate. Paternalism would be paradoxically resurrected by the introduction of state-of-the-art AI. A physician’s conflict of interest related to AI as a commercial product could strongly influence his or her actions in clinical settings. We also worry that the general public will become uneasy and hypersensitive slaves to information, compulsively and uninterruptedly requesting healthcare information concerning their own health and advice from AI. An AI system capable of expressing proper and timely empathy to suffering patients could deprive healthcare professionals of their roles in terms of hospitality and emotional exchange. Finally, entire societies would soon share and consolidate healthcare sensitive information from all in the general public as part of a totalitarian healthcontrolled society where individual privacy and personal secrets could be neglected. The advent of the healthcontrolled society could lead to the metamorphosis of the concept of privacy itself into something completely different. Conclusion: Although AI which surpasses human healthcare professionals may never appear, hoping for the best and preparing for the worst is the best approach to take. To this end, we present some potential countermeasures including conducting clinical research and social investigations concerning problems surrounding the introduction of AI and developing guidelines for its appropriate use. (shrink)

When making substituted judgments for incapacitated patients, surrogates often struggle to guess what the patient would want if they had capacity. Surrogates may also agonize over having the (sole) responsibility of making such a determination. To address such concerns, a Patient Preference Predictor (PPP) has been proposed that would use an algorithm to infer the treatment preferences of individual patients from population-level data about the known preferences of people with similar demographic characteristics. However, critics have suggested that even if (...) such a PPP were more accurate, on average, than human surrogates in identifying patient preferences, the proposed algorithm would nevertheless fail to respect the patient’s (former) autonomy since it draws on the ‘wrong’ kind of data: namely, data that are not specific to the individual patient and which therefore may not reflect their actual values, or their reasons for having the preferences they do. Taking such criticisms on board, we here propose a new approach: the Personalized Patient Preference Predictor (P4). The P4 is based on recent advances in machine learning, which allow technologies including large language models to be more cheaply and efficiently ‘fine-tuned’ on person-specific data. The P4, unlike the PPP, would be able to infer an individual patient’s preferences from material (e.g., prior treatment decisions) that is in fact specific to them. Thus, we argue, in addition to being potentially more accurate at the individual level than the previously proposed PPP, the predictions of a P4 would also more directly reflect each patient’s own reasons and values. In this article, we review recent discoveries in artificial intelligence research that suggest a P4 is technically feasible, and argue that, if it is developed and appropriately deployed, it should assuage some of the main autonomy-based concerns of critics of the original PPP. We then consider various objections to our proposal and offer some tentative replies. (shrink)

Parsimony arguments are advanced in both science and philosophy. How are they related? This question is a test case for Naturalismp, which is the thesis that philosophical theories and scientific theories should be evaluated by the same criteria. In this paper, I describe the justifications that attach to two types of parsimony argument in science. In the first, parsimony is a surrogate for likelihood. In the second, parsimony is relevant to estimating how accurately a model will predict new (...) class='Hi'>data when fitted to old. I then consider how these two justifications apply to parsimony arguments in philosophy concerning theism and atheism, the mind/body problem, ethical realism, the question of whether mental properties are causally efficacious, and nominalism versus Platonism about numbers. (shrink)

The patient preference predictor is a proposed computer-based algorithm that would predict the treatment preferences of decisionally incapacitated patients. Incorporation of a PPP into the decision-making process has the potential to improve implementation of the substituted judgement standard by providing more accurate predictions of patients’ treatment preferences than reliance on surrogates alone. Yet, critics argue that methods for making treatment decisions for incapacitated patients should be judged on a number of factors beyond simply providing them with the treatments they would (...) have chosen for themselves. These factors include the extent to which the decision-making process recognises patients’ freedom to choose and relies on evidence the patient themselves would take into account when making treatment decisions. These critics conclude that use of a PPP should be rejected on the grounds that it is inconsistent with these factors, especially as they relate to proper respect for patient autonomy. In this paper, we review and evaluate these criticisms. We argue that they do not provide reason to reject use of a PPP, thus supporting efforts to develop a full-scale PPP and to evaluate it in practice. There are no data in this work. (shrink)

Objectives—While clinical practice is complicated by many ethical dilemmas, clinicians do not often request ethics consultations. We therefore investigated what triggers clinicians' requests for ethics consultation. Design—Cross-sectional telephone survey.Setting—Internal medicine practices throughout the United States.Participants—Randomly selected physicians practising in internal medicine, oncology and critical care.Main measurements—Socio-demographic characteristics, training in medicine and ethics, and practice characteristics; types of ethical problems that prompt requests for consultation, and factors triggering consultation requests. Results—One hundred and ninety of 344 responding physicians (55%) reported requesting ethics (...) consultations. Physicians most commonly reported requesting ethics consultations for ethical dilemmas related to end-of-life decision making, patient autonomy issues, and conflict. The most common triggers that led to consultation requests were: 1) wanting help resolving a conflict; 2) wanting assistance interacting with a difficult family, patient, or surrogate; 3) wanting help making a decision or planning care, and 4) emotional triggers. Physicians who were ethnically in the minority, practised in communities under 500,000 population, or who were trained in the US were more likely to request consultations prompted by conflict. Conclusions—Conflicts and other emotionally charged concerns trigger consultation requests more commonly than other cognitively based concerns. Ethicists need to be prepared to mediate conflicts and handle sometimes difficult emotional situations when consulting. The data suggest that ethics consultants might serve clinicians well by consulting on a more proactive basis to avoid conflicts and by educating clinicians to develop mediation skills. (shrink)

What makes a multimillion-dollar, transnational intimate industry possible when most people see it as exploitative? Using the newly emergent case of commercial surrogacy in India, this article extends the literature on stratified reproduction and intimate industries by examining how surrogacy persists and thrives despite its common portrayal as the “rent-a-womb industry” and “baby factory.” Using interview data with eight infertility specialists, 20 intended parents, and 70 Indian surrogate mothers, as well as blogs and media stories, we demonstrate how (...) market actors justify their pursuits through narrating moral frames of compassion and altruism that are not incidental but systematic to and constitutive of transnational surrogacy. We observed two predominant moral frames: surrogacy liberates and empowers Indian women from patriarchal control; and surrogacy furthers reproductive rights. Within these frames, the market exchange of money for babies is cast as compassion, which allows commissioning clients to sidestep accusations of racism, classism, and sexism. Yet, we reveal that the ability to navigate around these threats relies on racist, classist, and sexist tropes about Third World working-class women. Further, we find that surrogate mothers did not experience significant changes in economic status after surrogacy. (shrink)

As the field of clinical ethics consultation sets standards and moves forward with the Quality Attestation process, questions should be raised about what ethical issues really do arise in practice. There is limited data on the type and number of ethics consultations conducted across different settings. At Loyola University Medical Center, we conducted a retrospective review of our ethics consultations from 2008 through 2013. One hundred fifty-six cases met the eligibility criteria. We analyzed demographic data on these patients (...) and conducted a content analysis of the ethics consultation write-ups coding both the frequency of ethical issues and most significant, or key, ethical issue per case. Patients for whom ethics consultation was requested were typically male, white, between 50 and 69 years old, of non-Hispanic origin, and of Roman Catholic faith. Nearly half were in the intensive care unit and 44.2 % died in the hospital. The most frequent broad ethical categories were decision-making, goals of care/treatment, and end-of-life. More specifically, capacity, patient’s wishes/autonomy, and surrogate decision maker were the most frequent particular ethical issues. The most common key ethical issues were withdrawing/withholding treatment, patient wishes/autonomy, and capacity. Our findings provide additional data to inform the training of clinical ethics consultants regarding the ethical issues that arise in practice. A wider research agenda should be formed to collect and compare data across institutions to improve education and training in our field. (shrink)

Significant criticisms have been raised regarding the ethical and psychological basis of living wills. Various solutions to address these criticisms have been advanced, such as the use of surrogate decision makers alone or data science‐driven algorithms. These proposals share a fundamental weakness: they focus on resolving the problems of living wills, and, in the process, lose sight of the underlying ethical principle of advance care planning, autonomy. By suggesting that the same sweeping solutions, without opportunities for choice, be (...) applied to all, individual patients are treated as population‐level groups—as a theoretical patient who represents a population, not the specific patient crafting his or her individualized future care plans. Instead, advance care planning can be improved through a multimodal approach that both mitigates cognitive biases and allows for customization of the decision‐making process by allowing for the incorporation of a variety of methods of advance care planning. (shrink)

AimsThis study evaluates a protocol for early, routine ethics consultation for patients on extracorporeal membrane oxygenation to support decision-making in the context of clinical uncertainty with the aim of mitigating ethical conflict and moral distress.MethodsWe conducted a single-site qualitative analysis of EC documentation for all patients receiving ECMO support from 15 August 2018 to 15 May 2019. Detailed analysis of 20 ethically complex cases with protracted ethics involvement identifies four key ethical domains: limits of prognostication, bridge to nowhere, burden of (...) treatment and system-level concerns. There are three subthemes: relevant contextual factors, the role of EC and observed outcomes. Content analysis of transcripts from interviews with 20 members of the multidisciplinary ECMO team yields supplemental data on providers’ perceptions of the impact of the early intervention protocol.ResultsLimited outcome data for ECMO, unclear indications for withdrawal, adverse effects of treatment and an obligation to attend to programme metrics present significant ethical challenges in the care of this patient population. Upstream EC mitigates ethical conflict by setting clear expectations about ECMO as a time limited trial, promoting consistent messaging among multiple services and supporting surrogate decision-makers. When ECMO becomes a ‘bridge to nowhere’, EC facilitates decision-making that respects patient values yet successfully sets limits on non-beneficial use of this novel therapy.ConclusionData from this study support the conclusion that ECMO poses unique ethical challenges that necessitate a standardised protocol for early, routine EC—at least while this medical technology is in its nascent stages. (shrink)

Despite increased calls for hospital ethics committees to serve as default decision-makers about life-sustaining treatment for unrepresented patients who lack decision-making capacity or a surrogate decision-maker and whose wishes regarding medical care are not known, little is known about how committees currently function in these cases. This was a retrospective cohort study of all ethics committee consultations involving decision-making about LST for unrepresented patients at a large academic hospital from 2007 to 2013. There were 310 ethics committee consultations, twenty-five (...) of which involved unrepresented patients. In thirteen cases, the ethics consultants evaluated a possible substitute decision-maker identified by social workers and/or case managers. In the remaining cases, the ethics consultants worked with the medical team to contact previous healthcare professionals to provide substituted judgement, found prior advance care planning documents, or identified the patient’s best interest as the decision-making standard. In the majority of cases, the final decision was to limit or withdraw LST or to change code status to Do Not Resuscitate/Do Not Intubate. Substitute decision-makers who had been evaluated through the ethics consultation process and who made the final decision alone were more likely to continue LST than cases in which physicians made the final decision. In our centre, the primary role of ethics consultants in decision-making for unrepresented patients is to identify appropriate decision-making standards. In the absence of other data suggesting that ethics committees, as currently constituted, are ready to serve as substitute decision-makers for unrepresented patients, caution is necessary before designating these committees as default decision-makers. (shrink)

In gestational surrogacy arrangements, the womb is often figured as a holding environment that brings the child of commissioning parents to fruition but does not shape fetal identity. This article probes the racial imaginary of such a figuration—what I term the “nonracializing womb”—where gestation is seen as peripheral to racial transmission. Drawing on feminist science studies frameworks and data from interviews with parents who commissioned surrogates, this article traces the cultural politics of the nonracializing womb, positioning it as an (...) index for broader understandings of race, reproductive labor, and kinship that hinge on nuclear and biogenetic forms. It then problematizes this figure of gestation by engaging emerging research on environmental epigenetics, which offers a lively model of pregnancy as shaping fetal biology, blurring the lines between surrogate and fetus. I argue that epigenetics offers a resource to reimagine gestation as a racializing process, by theorizing race not as solely genetic, but as relational, socio-environmental, and forged through distributed kinship lineages. (shrink)

Experiences of substitute decision-makers with requests for consent to non-therapeutic research participation during the dying process, including to what degree such requests are perceived as burdensome, have not been well described. In this study, we explored the lived experiences of family members who consented to non-therapeutic research participation on behalf of an imminently dying patient. We interviewed 33 family members involved in surrogate research consent decisions for dying patients in intensive care. Non-therapeutic research involved continuous physiological monitoring of dying (...) patients prior to and for 30 min following cessation of circulation. At some study centres participation involved installation of bedside computers. At one centre electroencephalogram monitoring was used with a subset of participants. Aside from additional monitoring, the research protocol did not involve deviations from usual end-of-life care. Thematic analysis of interviews suggests most family members did not perceive this minimal-risk, non-therapeutic study to affect their time with patients during the dying process, nor did they perceive research consent as an additional burden. In our analysis, consenting for participation in perimortem research offered families of the dying an opportunity to affirm the intrinsic value of patients’ lives and contributions. This opportunity may be particularly important for families of patients who consented to organ donation but did not proceed to organ retrieval. Our work supports concerns that traditional models of informed consent fail to account for possible benefits and harms of perimortem research to surviving families. Further research into consent models which integrate patient and family perspectives is needed. All data relevant to the study are included in the article. (shrink)

Objective Although patients exercise greater autonomy than in the past, and shared decision making is promoted as the preferred model for doctor-patient engagement, tensions still exist in clinical practice about the primary locus of decision-making authority for complex, scarce, and resource-intensive medical therapies: patients and their surrogates, or physicians. We assessed physicians’ attitudes toward decisional authority for adult venoarterial extracorporeal membrane oxygenation (VA-ECMO), hypothesizing they would favor a medical locus. Design, Setting, Participants A survey of resident/fellow physicians and internal medicine (...) attendings at an academic medical center, May to August 2013. Measurements We used a 24-item, internet-based survey assessing physician-respondents’ demographic characteristics, knowledge, and attitudes regarding decisional authority for adult VA-ECMO. Qualitative narratives were also collected. Main Results A total of 179 physicians completed the survey (15 percent response rate); 48 percent attendings and 52 percent residents/ fellows. Only 32 percent of the respondents indicated that a surrogate’s consent should be required to discontinue VA-ECMO; 56 percent felt that physicians should have the right to discontinue VA-ECMO over a surrogate’s objection. Those who self-reported as “knowledgeable” about VA-ECMO, compared to those who did not, more frequently replied that there should not be presumed consent for VA-ECMO (47.6 percent versus 33.3 percent, p = 0.007), that physicians should have the right to discontinue VAECMO over a surrogate’s objection (76.2 percent versus 50 percent, p = 0.02) and that, given its cost, the use of VA-ECMO should be restricted (81.0 percent versus 54.4 percent, p = 0.005). Conclusions Surveyed physicians, especially those who self-reported as knowledgeable about VA-ECMO and/or were specialists in pulmonary/ critical care, favored a medical locus of decisional authority for VA-ECMO. VA-ECMO is complex, and the data may (1) reflect physicians’ hesitance to cede authority to presumably less knowledgeable patients and surrogates, (2) stem from a stewardship of resources perspective, and/or (3) point to practical efforts to avoid futility and utility disputes. Whether these results indicate a more widespread reversion to paternalism or a more circumscribed usurping of decisional authority occasioned by VA-ECMO necessitates further study. (shrink)

This chapter discusses the following: (i) The Kantian concept of the Transcendental Object, and of its relation to that of the Noumenon and the Thing-in-itself; (ii) Kant's theory of knowledge cannot be positivistically interpreted, but requires underlying unities that hold appearances together, and which, by their identity, give the latter constancy of character; (iii) Kant's theory of knowledge cannot be idealistically interpreted, since it accepts the reality of a Transcendental Subject and of transcendental acts that exist beyond experience and knowledge, (...) and are constitutive of it. It also accepts the reality of many Transcendental Objects that affect our subjectivity and which have characters and relations not given to the latter, at best corresponding to phenomenal characters and relations; (iv) Kant's phenomenalism is more radical than other phenomenalisms in that it accepts space and time only as ordering forms for phenomena. But it advances important arguments, based mainly on ontological criteria, for restricting them to what is thus phenomenal; (v) The regular connection among the appearances of objects is the necessary empirical surrogate for the unity of the objects from which they spring. Kant therefore makes use of his metempirical presuppositions to illuminate phenomenal data. (shrink)

The mother–adult daughter relationship has been highlighted in both the social sciences and the public health literature as an important facet of social support networks, particularly as they pertain to maternal and child health. Evolutionary anthropologists also have shown positive associations between support from maternal grandmothers and various outcomes related to reproductive success; however, many of these studies rely on proximity as a surrogate measure of support. Here I present data from the Puerto Rican Maternal and Infant Health (...) Survey (PRMIHS) comparing geographic proximity of mother and daughter with a self-reported measure of mother-to-daughter support. These two measures were used to predict infant health outcomes as well as various measures of instrumental and emotional aid provided during pregnancy and after birth. Primary support was shown to have a positive effect across the analyses, whereas geographic proximity was associated with an increased risk of infant mortality and low birth weight as well as reduced odds of receiving support. This paradox was then examined using a combination variable that teased out the interactions of maternal support and proximity. Women who were geographically close to their mothers but who did not consider them a primary source of support had increased odds of infant death and low birth weight, and were less likely to receive either tangible or intangible forms of aid, while women whose mothers were both close and primary showed uniformly positive outcomes. These results place the role of propinquity within the larger context of social support and highlight the need for more detailed studies of social support within evolutionary anthropology. (shrink)

Background: In the USA, the Food and Drug Administration waiver of informed consent permits certain emergency research only if community consultation occurs. However, uncertainty exists regarding how to define the community or their representatives.Objective: To collect data on the actual preferences and values of a group—those at risk for stroke—most directly affected by the waiver of informed consent for emergency research.Design: Face to face focused interviews were conducted with 12 patients who were hospitalised with a stroke diagnosis in the (...) previous year. The interviews were audiotaped and a transcript based method was used for their analysis.Results: All 12 participants felt “that it was important that new treatments for stroke be developed”, but they were initially confused about the distinction between “research for stroke” and “emergency research for stroke”. However, after explanation, most expressed willingness to participate in the latter. In the absence of a surrogate to give informed consent in a stroke emergency situation, the majority said they would want the physician to “go ahead and enrol them in the trial”.Conclusions: This study is the first to identify the values and concerns of individuals most directly affected by stroke emergency research. Further interviews and focus groups are needed to develop and test a validated questionnaire on the preferences and values surrounding emergency research for stroke. (shrink)