The chronic worldwide lack of organs for transplantation and the continuing improvement of strategies for in situ organ preservation have led to renewed interest in elective non-therapeutic ventilation of potential organ donors. Two types of situation may be eligible for elective intensive care: patients definitely evolving towards brain death and patients suitable as controlled non-heart beating organ donors after life-supporting therapies have been assessed as futile and withdrawn. Assessment of the ethical acceptability and the risks of these strategies is essential. (...) We here offer such an ethical assessment using the four principles of medical ethics of Beauchamp and Childress applying them in their broadest sense so as to include patients and their families, their caregivers, other potential recipients of intensive care, and indeed society as a whole. The main ethical problems emerging are the definition of beneficence for the potential organ donor, the dilemma between the duty to respect a dying patient's autonomy and the duty not to harm him/her, and the possible psychological and social harm for families, caregivers other potential recipients of therapeutic intensive care, and society more generally. Caution is expressed about the ethical acceptability of elective non-therapeutic ventilation, along with some proposals for precautionary measures to be taken if it is to be implemented. (shrink)

This issue of the Journal of Medical Ethics features a special symposium on ‘elective ventilation’ . EV ) was originally described in the 1990s by doctors working in Exeter in the UK.1 At that time there was concern about the large shortfall in organs for transplantation. Patients could become organ donors if they were diagnosed as being brain dead, but this only ever occurred in patients on breathing machines in intensive care who developed signs of brainstem failure. Doctors wondered if (...) there were patients dying outside intensive care who, if they were ventilated, could become brain dead and hence eligible to donate their organs. They embarked on a process of identifying patients who were dying who would not normally be taken to intensive care because their prognosis was judged to be too poor, and then ‘electing’ to insert breathing tubes when they stopped breathing.1 With the consent of family members the patients were supported in intensive care until they were diagnosed as having signs of brain death, or until the family and doctors together judged that this was unlikely to occur.1 The Exeter team saw a 50% increase in their numbers of organs for transplantation.Box 1 Definition of elective ventilation Elective ventilation is the provision to a patient of intensive medical treatment with the sole purpose of facilitating organ donation, in the absence of an expected medical benefit.EV was a controversial practice at the time. There were a number of papers written from points of view defending2 ,3 and criticising it.4 A Department of Health guideline in 1994 concluded that EV was not in the best interests of patients and was therefore unlawful5; subsequently, the practice effectively ceased.2 However, debate about EV has not …. (shrink)

This paper examines questions concerning elective ventilation, contextualised within English law and policy. It presents the general debate with reference both to the Exeter Protocol on elective ventilation, and the considerable developments in legal principle since the time that that protocol was declared to be unlawful. I distinguish different aspects of what might be labelled elective ventilation policies under the following four headings: ‘basic elective ventilation’; ‘epistemically complex elective ventilation’; ‘practically complex elective ventilation’; and ‘epistemically and practically complex elective ventilation’. (...) I give a legal analysis of each. In concluding remarks on their potential practical viability, I emphasise the importance not just of ascertaining the legal and ethical acceptability of these and other forms of elective ventilation, but also of assessing their professional and political acceptability. This importance relates both to the successful implementation of the individual practices, and to guarding against possible harmful effects in the wider efforts to increase the rates of posthumous organ donation. (shrink)

This paper examines questions concerning elective ventilation, contextualised within English law and policy. It presents the general debate with reference both to the Exeter Protocol on elective ventilation, and the considerable developments in legal principle since the time that that protocol was declared to be unlawful. I distinguish different aspects of what might be labelled elective ventilation policies under the following four headings: ‘basic elective ventilation’; ‘epistemically complex elective ventilation’; ‘practically complex elective ventilation’; and ‘epistemically and practically complex elective ventilation’. (...) I give a legal analysis of each. In concluding remarks on their potential practical viability, I emphasise the importance not just of ascertaining the legal and ethical acceptability of these and other forms of elective ventilation, but also of assessing their professional and political acceptability. This importance relates both to the successful implementation of the individual practices, and to guarding against possible harmful effects in the wider efforts to increase the rates of posthumous organ donation. (shrink)

With the aging of the general population and the ability of intensivists to support patients using ventilator support, tracheostomy has become a vital tool in the medical management of critically ill patients. While much of the medical literature on tracheostomy has focused on the optimal timing of and indications for performing this procedure, little is written on the ethical tensions that can revolve around decisions by patients, surrogates, and physicians on its use. This article will elucidate the ethical dilemmas that (...) can arise surrounding the use of tracheostomy in critically ill patients and how ethics consultants and committees can approach these cases to allow resolution. (shrink)

Critics of organ donation after circulatory death (DCD) argue that, even if donors are past the point of autoresuscitation, they have not satisfied the “irreversibility” requirement in the circulatory and respiratory criteria for determining death, since their circulation and respiration could be artificially restored. Thus, removing their vital organs violates the “dead-donor” rule. I defend DCD donation against this criticism. I argue that practical medical-ethical considerations, including respect for do-not-resuscitate orders, support interpreting “irreversibility” to mean permanent cessation of circulation and (...) respiration. Assuming a consciousness-related formulation of human death, I then argue that the loss of circulation and respiration is significant, because it leads to the permanent loss of consciousness and thus to the death of the human person. The DNR request by an organ donor should thus be interpreted to mean “do not restore to consciousness.” Finally, I respond to an objection that if “irreversibility” has a medical-ethical meaning, it would entail the absurd possibility that one of two individuals in the same physical state could be alive and the other dead—an implication that some think is inconsistent with understanding death as an objective biological state of the organism. I argue that advances in medical technology have created phenomena that challenge the assumption that human death can be understood in strictly biological terms. I argue that ethical and ontological considerations about our nature bear on the definition and determination of death and thus on the permissibility of DCD. (shrink)

Advances in medicine have brought us the stethoscope, artificial kidneys, and computerized health records. They have also changed the doctor-patient relationship. This book explores how the technologies of medicine are created and how we respond to the problems and successes of their use. Stanley Joel Reiser, MD, walks us through the ways medical innovations exert their influence by discussing a number of selected technologies, including the X-ray, ultrasound, and respirator. Reiser creates a new understanding of thinking about how health (...) care is practiced in the United States and thereby suggests new methods to effectively meet the challenges of living with technological medicine. As healthcare reform continues to be an intensely debated topic in America, Technological Medicine shows us the pros and cons of applying technological solutions health and illness. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Incoherence of Determining Death by Neurological Criteria: A Commentary on Controversies in the Determination of Death, A White Paper by the President’s Council on Bioethics*Franklin G. Miller** (bio) and Robert D. Truog (bio)Traditionally the cessation of breathing and heart beat has marked the passage from life to death. Shortly after death was determined, the body became a cold corpse, suitable for burial or cremation. Two technological changes in (...) the second half of the twentieth century prompted calls for a new, or at least expanded, definition of death: the development of intensive care medicine, especially the use of mechanical ventilators, and the advent of successful transplantation of vital organs. Patients with profound neurological damage, leaving them incapable of breathing on their own and in an irreversible coma, could be maintained for some period of time with the aid of mechanical ventilation. The situation of these patients posed two ethical questions. Is it appropriate to stop life-sustaining treatment? If so, is it acceptable to retrieve vital organs for transplantation to save the lives of others before stopping treatment?In 1968, the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death proposed that death could be determined on the basis of neurological criteria, thus providing a positive answer to these two questions (Ad Hoc Committee 1968). According to the position of this committee, patients diagnosed with the cessation of brain function are dead, despite the fact that they breathe and circulate blood with the aid of mechanical ventilation. [End Page 185] Because they are dead, it is appropriate, indeed imperative, to stop mechanical ventilation. And because they are dead, it becomes ethical to procure vital organs for transplantation before stopping what otherwise would be life-sustaining treatment. Remarkably, this innovative neurological determination of death became, with little debate or controversy, the established position in medical ethics and the law throughout the United States.The Harvard Committee articulated the diagnosis of “irreversible coma,” but merely asserted that this condition constituted death. No explanatory rationale was provided. It fell to the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research to provide an authoritative rationale in its 1981 report, Defining Death. The second paragraph of the report set the stage as follows: “The question addressed here is not inherently difficult or complicated. Simply, it is whether the law ought to recognize new means for establishing that the death of a human being has occurred” (President’s Commission 1981, p. 3). The Commission claimed that “death is a unitary phenomenon” (p. 7) and that the determination of death by neurological criteria, in terms of the absence of all brain function, is consistent with the traditional conception of death as the cessation of vital functioning of the organism as a whole. The key issue is the integrative functioning of the human organism, which ceases to exist, according to the Commission, when the whole brain, including higher cortical areas and the brain stem, fails to function. Although “brain-dead” patients do not appear to be dead—i.e., the reality of their death is “masked” by the activity of mechanical ventilation—the patient’s body has irreversibly lost all capacity for integrative functioning. In the words of the Commission: “When artificial means of support mask this loss of integration as measured by the old methods [cessation of respiration and heart beat], brain-oriented criteria and tests provide a new window on the same phenomenon” (p. 33). The President’s Commission was instrumental in developing and establishing “The Uniform Definition of Death Act”: “An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead” (p. 2).Although the question posed by the President’s Commission was easy to articulate, the answer, over time, has proved complicated and controversial. The coherence and cogency of determining death by neurological criteria has been challenged. Various experts have demonstrated that “brain-dead” patients maintained on mechanical ventilation display a range of vital, integrative, functioning, which conflicts with the judgment that they are dead (Truog and... (shrink)

The ‘decapitation gambit’ holds that, if physical decapitation normally entails the death of the human being, then physiological decapitation, evident in cases of total brain failure, entails the death of the human being. This argument has been challenged by Franklin Miller and Robert Truog, who argue that physical decapitation does not necessarily entail the death of human beings and that therefore, by analogy, artificially sustained human bodies with total brain failure are living human beings. They thus challenge the current neurological (...) criterion for determining death and argue for a return to the traditional criterion of the irreversible loss of circulation and respiration. In this paper, I defend the decapitation gambit and total brain failure as a criterion for determining death against Miller and Truog's criticism. (shrink)

As human–machine teams are being considered for a variety of mixed-initiative tasks, detecting and being responsive to human cognitive states, in particular systematic cognitive states, is among the most critical capabilities for artificial systems to ensure smooth interactions with humans and high overall team performance. Various human physiological parameters, such as heart rate, respiration rate, blood pressure, and skin conductance, as well as brain activity inferred from functional near-infrared spectroscopy or electroencephalogram, have been linked to different systemic cognitive states, (...) such as workload, distraction, or mind–wandering among others. Whether these multimodal signals are indeed sufficient to isolate such cognitive states across individuals performing tasks or whether additional contextual information (e.g., about the task state or the task environment) is required for making appropriate inferences remains an important open problem.In this paper, we introduce an experimental and machine learning framework for investigating these questions and focus specifically on using physiological and neurophysiological measurements to learn classifiers associated with systemic cognitive states like cognitive load, distraction, sense of urgency, mind wandering, and interference. Specifically, we describe a multitasking interactive experimental setting used to obtain a comprehensive multimodal data set which provided the foundation for a first evaluation of various standard state-of-the-art machine learning techniques with respect to their effectiveness in inferring systemic cognitive states. While the classification success of these standard methods based on just the physiological and neurophysiological signals across subjects was modest, which is to be expected given the complexity of the classification problem and the possibility that higher accuracy rates might not in general be achievable, the results nevertheless can serve as a baseline for evaluating future efforts to improve classification, especially methods that take contextual aspects such as task and environmental states into account. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Comment on Hospice of Washington's PolicyJohn A. Robertson (bio)The recent history of medical ethics may accurately be described as a history of coming to terms with personal autonomy and informed consent across the range of medical practice. Nowhere has this recognition been more important than in decisions to withhold or withdraw life-sustaining medical procedures from terminal and chronically ill patients.Despite the widespread acceptance of autonomy in these decisions, many (...) people—physicians, families, and policymakers—have balked at extending it to the withdrawal of artificially supplied fluids and nutrition. The symbolic connotations of food and water have led some persons to perceive cessation of medically-supplied fluids and nutrition to be a cruel, barbarous act, rather than the merciful respect for the dying patient that such withdrawal usually represents.Two recent events might help resolve the controversy, and ensure that decisions about artificial fluid and nutrition are handled like any other medical intervention—according to patient and family choice and patient welfare. One event is the Supreme Court decision in Cruzan (Cruzan v. Director of Missouri Department of Health, 110 S.Ct. 2841, 1990). Although the Supreme Court upheld Missouri's constitutional power to require artificial nutrition for a patient in a persistent vegetative state, its decision was not based on the symbolic importance of artificial fluids and nutrition. No Supreme Court justice saw a significant difference between medically-supplied nutrition and hydration and other medical interventions, thus allowing them to be discontinued either directly or by advance directive on the same basis as other medical interventions.The second event is the publication of the statement of "Philosophy Regarding Medical Intervention to Supply Fluids and Nutrition" by Hospice of Washington (or similar statements by other organizations). This statement is useful and important because it removes the issue of food and water from its symbolic overlay [End Page 139] and places it in the real context of dying hospice patients. It makes clear that the overriding consideration should be benefit to the patient "in accord with the patient's wishes or those of the appropriate surrogate(s) for the patient." Depending on those wishes and their impact on the patient, this position may or may not involve medically-supplied fluids and nutrition.This statement is also helpful in showing the medical complexity of such decisions in terms of their actual effect on dying patients. Rather than an either/or position, it recognizes that fluids may harm a dying patient by increasing discomfort, and that "persons near death do not ordinarily tolerate substantial volumes of enteral feedings." Thus rather than adhere to a symbolically-based position about the meaning of food and water to a dying patient, the important thing is to look to that patient's needs and give fluids or not, as the patient's wishes and situation demand.Fortunately, the law in most jurisdictions will recognize such a position. In those few jurisdictions that have made a fetish of artificial fluids and nutrition, the law should be changed, for the HOW statement makes clear that such a position may actually end up harming dying patients. Patient welfare should be privileged above all else, and patient welfare may often entail that fluids and nutrition not be medically supplied. Even then, however, caregivers will look to patient comfort and remedy dry mouths and lips with lubricants and ice chips.The HOW statement is, in my view, a very useful guideline not only for hospices but for hospitals, too—for any situation in which a patient is terminally ill and soon to die. A somewhat different set of issues arises, however, when the patient is chronically ill and incompetent, and will survive for long periods with medically-supplied fluids and nutrition. Recognition of patient rights in those situation should also permit cessation of fluids and nutrition on the same basis that respirators, antibiotics, and other life-sustaining measures may be withheld. But the withholding of medically-supplied fluids and nutrition from a patient who no longer has interests in surviving in an extremely debilitated condition raises different issues from withholding fluids that could cause such discomfort and nutrition when the patient is imminently dying. In either case, patient... (shrink)

The esophageal obturator airway is a device used throughout the United States to facilitate artificial respiration of critically ill patients who are not hospitalized. Its use is restricted to persons who are over 15 years old because obturators for children are not available. A protocol submitted to an institutional review board intended to develop EOAs suitable for use in children. The investigators proposed to perform preliminary testing of these devices on children who had sustained irreversible loss of brain function. (...) In its review of this protocol, the IRB had to confront several vexing questions. (shrink)

Right to die legal cases in the United States have evolved over the last 25 years, beginning with the Karen Quinlan case in 1975. Different substantive and procedural issues have been raised in these cases, and society's thinking has changed as a result of the far more complex legal issues that appear today as opposed to the simplistic views raised in early landmark cases. Many of the early cases involved patients in a vegetative state, but more recently patients who were (...) in a minimally conscious state have been the center of attention. Early cases involved the withdrawal of respirators and other sophisticated technology, but later cases centered on the withdrawal of artificial nutrition and hydration, and even whether it was permissible for competent patients to stop eating and drinking in a normal manner. Initial cases pitted families who argued for withdrawal of treatment, usually against the attending physicians and hospitals and/or the state or federal government, who argued for continuation of treatment. (shrink)

The various proponents of the DDA differ over how it should be understood. It might be thought that the distinction between doing and allowing reduces to the distinction between action and inaction. As against this, Philippa Foot has argued that some actions, such as pulling the plug on an artificial respirator, should be treated as “allowings.” On her view, the relevant distinction is primarily one between initiating or sustaining a harmful causal sequence, and allowing or enabling a harmful causal (...) sequence to run its course. The view that this is the proper interpretation of the DDA has been challenged by Warren Quinn, who argues that Foot’s distinction either fails to account for our considered intuitions in some cases or collapses back into the action/inaction distinction. Quinn offers an interpretation of the DDA that is closer to the action/inaction distinction, but in which intentions are made to play a significant role. (shrink)

Background Bioethics and law distinguish between the practices of "physician-assisted death" and "allowing the patient to die." Discussion Advances in biotechnology have allowed medical devices to be used as destination therapy that are designed for the permanent support of cardiac function and/or respiration after irreversible loss of these spontaneous vital functions. For permanent support of cardiac function, single ventricle or biventricular mechanical assist devices and total artificial hearts are implanted in the body. Mechanical ventilators extrinsic to the body are (...) used for permanent support of respiration. Clinical studies have shown that destination therapy with ventricular assist devices improves patient survival compared to medical management, but at the cost of a substantial alteration in end-of-life trajectories. The moral and legal assessment of the appropriateness and permissibility of complying with a patient's request to electively discontinue destination therapy in a life-terminating act in non-futile situations has generated controversy. Some argue that complying with this request is ethically justified because patients have the right to request withdrawal of unwanted treatment and be allowed to die of preexisting disease. Other commentators reject the argument that acceding to an elective request for death by discontinuing destination therapy is 'allowing a patient to die' because of serious flaws in interpreting the intention, causation, and moral responsibility of the ensuing death. Summary Destination therapy with cardiac and/or ventilatory medical devices replaces native physiological functions and successfully treats a preexisting disease. We posit that discontinuing cardiac and/or ventilatory support at the request of a patient or surrogate can be viewed as allowing the patient to die if--and only if--concurrent lethal pathophysiological conditions are present that are unrelated to those functions already supported by medical devices in destination therapy. In all other cases, compliance with a patient's request constitutes physician-assisted death because of the pathophysiology induced by the turning off of these medical devices, as well as the intention, causation, and moral responsibility of the ensuing death. The distinction between allowing the patient to die and physician-assisted death is pivotal to the moral and legal status of elective requests for death by discontinuing destination cardiac and/or ventilatory medical devices in patients who are not imminently dying. This distinction also represents essential information that must be disclosed to patients and surrogates in advance of consent to this type of therapy. (shrink)

Ever since the 1960s, when medical science became capable of prolonging the dying process beyond bounds that many patients would find acceptable, people have sought “death with dignity,” or “a natural death,” or “a good death.” Once debilitation from a fatal affliction has reached a personally intolerable point, dying patients have sought to control the manner and timing of death via diverse techniques. Some sought the disconnection of life-sustaining medical interventions, such as respirators and dialysis machines. Beyond freedom from unwelcome (...) interventions, some patients intent on avoiding suffering sought access to pain relief medication—even in dosages posing some risk of hastening death. Other dying patients sought access to deep sedation, even knowing that they would never emerge from the resultant unconsciousness. Still other patients voluntarily refused to eat or drink or to accept artificial nutrition and hydration. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:FEEDING THE COMATOSE AND THE COMMON GOOD IN THE CATHOLIC TRADITION ROBERT BARRY, O.P. University of Illinois Ohampaign-Urbana, IlUnoi8 AA RECENT convention :sponsored by the Catholic Health Associaition in Boston, Laurence J. O'Connell, vice-president for ethics and theology, ma.de the following comments: I am concerned that some of those who are legitimately alarmed by the potential abuses associated with the public policy that authorizes the withholding and withdrawing of (...) mechanical means of nutrition and hydration are sometimes publicly misrepresenting the Catholic moral tradition. In other words, in their well-intentioned and perfectly legitimate efforts to avoid the slippery-slope-that is, the wrongful withholding or withdrawing of nutrition or hydration from vulnerable dasses of patients-those advocates are placing the Roman Catholic moral tradition itself on the slippery slope. It is mistaken to say it is the church's teaching that we may never withhold or withdraw artificial nutrition and hydration. It is mistaken to uncritically refer to the removal of medically engineered nutrition in all cases as starvation-that is, the willful withholding of nutrition as morally obligatory. It is mistaken to say that the ethical standards of a single Catholic hospital are necessarily coextensive with the ethical standards of the Catholic Church. Just because an individual Catholic facility, for whatever reason, uniformly refuses to allow the withholding or withdrawing of technological feeding, does not mean that the Church itself disallows such withholdings or withdrawals.1 It is not clear how the Catholic moral tradition can be put on the " slippery slope " by opposing certain forms of with1 "Church and State Overlap in Ethical Debate", American Medicai News. February 27, 1987. p. I. 1 ROBERT BARRY, O.P. drawal of feeding from specific classes of patients. Dr. O'Connell has misrepresented the thought of most of those who oppose the recent American Medical Association's new opinion which holds that artificially administered nutrition and fluids can be removed from terminally ill patients, even when they are not imminently dying.2 There are no Catholic moralists who claim that it is always and everywhere morally wrong to withhold or withdraw feeding from patients. However, there are a number of moralists as well as bishops who now hold it to be wrong to withhold or withdraw feeding in those cases where the withholding or withdrawal becomes the fundamental and underlying cause of death. O'Connell is p11obably correct in saying that the policies of one hospital do not necessarily deteJ1IDine the moral doctrines of the universal Church, but neither does one national organization such as the Catholic Health Association with only a loose affiliation with the magisterial hierarchy of the Church necessarily do this either. The debate over the provision of,aissisted feeding is a debate over whether iit is morally legitimate ito withdraw feeding so 1tihat.t:he primary and fundamental reason why the person dies is that withdrawal. It is a debate over whether those with a certain " quality of life " can be permitted to be killed by omission. It is a debate over whether feeding provided by routine nursing measures that can significantly sustain the life is a medical treatment that should he governed by the criteria governing other treatments, or whether it is an 2 "Withholding or Withdrawing Life Prolonging :Medical Treatment" adopted by the Council on Ethical and Judicial.Affairs of the.Amercian Medical.Association on March 15, 1987, In its pertinent parts, it stated: The social commitment of the physician is to sustain life and relieve suffering. Where the performance of one duty conflicts with the other, the choice of the patient, or his family or legal representative if the·patient to act in his own behalf, should prevail. Life prolonging medical treatment includes medication and artificially or technologically supplied respiration, nutrition or hydration. In treating a terminally ill or irreversibly comatose patient, the physician should determine whether the benefits of treatment outweigh its burdens..At all times, the dignity of the patient should be maintained.•. FEEDING THE COMATOSE 8 aspect of normal care, like protection from exposure or hygienic care, that is to be accorded to all patients. In this piece, I wish to review the thoughts of some... (shrink)

BackgroundBioethics and law distinguish between the practices of "physician-assisted death" and "allowing the patient to die."DiscussionAdvances in biotechnology have allowed medical devices to be used as destination therapy that are designed for the permanent support of cardiac function and/or respiration after irreversible loss of these spontaneous vital functions. For permanent support of cardiac function, single ventricle or biventricular mechanical assist devices and total artificial hearts are implanted in the body. Mechanical ventilators extrinsic to the body are used for permanent (...) support of respiration. Clinical studies have shown that destination therapy with ventricular assist devices improves patient survival compared to medical management, but at the cost of a substantial alteration in end-of-life trajectories. The moral and legal assessment of the appropriateness and permissibility of complying with a patient's request to electively discontinue destination therapy in a life-terminating act in non-futile situations has generated controversy. Some argue that complying with this request is ethically justified because patients have the right to request withdrawal of unwanted treatment and be allowed to die of preexisting disease. Other commentators reject the argument that acceding to an elective request for death by discontinuing destination therapy is 'allowing a patient to die' because of serious flaws in interpreting the intention, causation, and moral responsibility of the ensuing death.SummaryDestination therapy with cardiac and/or ventilatory medical devices replaces native physiological functions and successfully treats a preexisting disease. We posit that discontinuing cardiac and/or ventilatory support at the request of a patient or surrogate can be viewed as allowing the patient to die if--and only if--concurrent lethal pathophysiological conditions are present that are unrelated to those functions already supported by medical devices in destination therapy. In all other cases, compliance with a patient's request constitutes physician-assisted death because of the pathophysiology induced by the turning off of these medical devices, as well as the intention, causation, and moral responsibility of the ensuing death. The distinction between allowing the patient to die and physician-assisted death is pivotal to the moral and legal status of elective requests for death by discontinuing destination cardiac and/or ventilatory medical devices in patients who are not imminently dying. This distinction also represents essential information that must be disclosed to patients and surrogates in advance of consent to this type of therapy. (shrink)

Since the early 1980’s, with the clinical advent of in vitro fertilization resulting in so-called “test tube babies,” a wide array of ethical considerations and concerns regarding artificial womb technology (AWT) have been described. Recent breakthroughs in the development of extracorporeal neonatal life support by means of AWT have reinitiated ethical interest about this topic with a sense of urgency. Most of the recent ethical literature on the topic, however, pertains not to the more imminent scenario of a physiologically (...) improved method of neonatal care through AWT, but instead to the remote scenario of “complete ectogenesis” that imagines human gestation occurring entirely outside of the womb. This scoping review of the ethical literature on AWT spans from more abstract concerns about complete ectogenesis to more immediate concerns about the soon-to-be-expected clinical life support of what we term the fetal neonate or fetonate. Within an organizing framework of different stages of human gestational development, from conception to the viable premature infant, we discuss both already identified and newly emerging ethical considerations and concerns regarding AWT and the care of the fetonate. (shrink)

There is general consensus that explainable artificial intelligence is valuable, but there is significant divergence when we try to articulate why, exactly, it is desirable. This question must be distinguished from two other kinds of questions asked in the XAI literature that are sometimes asked and addressed simultaneously. The first and most obvious is the ‘how’ question—some version of: ‘how do we develop technical strategies to achieve XAI?’ Another question is specifying what kind of explanation is worth having in (...) the first place. As difficult and important as the challenges are in answering these questions, they are distinct from a third question: why do we want XAI at all? There is vast literature on this question as well, but I wish to explore a different kind of answer. The most obvious way to answer this question is by describing a desirable outcome that would likely be achieved with the right kind of explanation, which would make the explanation valuable instrumentally. That is, XAI is desirable to attain some other value, such as fairness, trust, accountability, or governance. This family of arguments is obviously important, but I argue that explanations are also intrinsically valuable, because unexplainable systems can be dehumanizing. I argue that there are at least three independently valid versions of this kind of argument: an argument from participation, from knowledge, and from actualization. Each of these arguments that XAI is intrinsically valuable is independently compelling, in addition to the more obvious instrumental benefits of XAI. (shrink)

In the development of governmental policy for artificial intelligence that is informed by ethics, one avenue currently pursued is that of drawing on “AI Ethics Principles”. However, these AI Ethics Principles often fail to be actioned in governmental policy. This paper proposes a novel framework for the development of ‘Actionable Principles for AI’. The approach acknowledges the relevance of AI Ethics Principles and homes in on methodological elements to increase their practical implementability in policy processes. As a case study, (...) elements are extracted from the development process of the Ethics Guidelines for Trustworthy AI of the European Commission’s “High Level Expert Group on AI”. Subsequently, these elements are expanded on and evaluated in light of their ability to contribute to a prototype framework for the development of 'Actionable Principles for AI'. The paper proposes the following three propositions for the formation of such a prototype framework: preliminary landscape assessments; multi-stakeholder participation and cross-sectoral feedback; and, mechanisms to support implementation and operationalizability. (shrink)

In this book, the author examines the ethical implications of Artificial Intelligence systems as they integrate and replace traditional social structures in new sociocognitive-technological environments. She discusses issues related to the integrity of researchers, technologists, and manufacturers as they design, construct, use, and manage artificially intelligent systems; formalisms for reasoning about moral decisions as part of the behavior of artificial autonomous systems such as agents and robots; and design methodologies for social agents based on societal, moral, and legal (...) values. Throughout the book the author discusses related work, conscious of both classical, philosophical treatments of ethical issues and the implications in modern, algorithmic systems, and she combines regular references and footnotes with suggestions for further reading. This short overview is suitable for undergraduate students, in both technical and non-technical courses, and for interested and concerned researchers, practitioners, and citizens. (shrink)

This paper discusses the problem of responsibility attribution raised by the use of artificial intelligence technologies. It is assumed that only humans can be responsible agents; yet this alone already raises many issues, which are discussed starting from two Aristotelian conditions for responsibility. Next to the well-known problem of many hands, the issue of “many things” is identified and the temporal dimension is emphasized when it comes to the control condition. Special attention is given to the epistemic condition, which (...) draws attention to the issues of transparency and explainability. In contrast to standard discussions, however, it is then argued that this knowledge problem regarding agents of responsibility is linked to the other side of the responsibility relation: the addressees or “patients” of responsibility, who may demand reasons for actions and decisions made by using AI. Inspired by a relational approach, responsibility as answerability thus offers an important additional, if not primary, justification for explainability based, not on agency, but on patiency. (shrink)

Some artificial intelligence systems can display algorithmic bias, i.e. they may produce outputs that unfairly discriminate against people based on their social identity. Much research on this topic focuses on algorithmic bias that disadvantages people based on their gender or racial identity. The related ethical problems are significant and well known. Algorithmic bias against other aspects of people’s social identity, for instance, their political orientation, remains largely unexplored. This paper argues that algorithmic bias against people’s political orientation can arise (...) in some of the same ways in which algorithmic gender and racial biases emerge. However, it differs importantly from them because there are strong social norms against gender and racial biases. This does not hold to the same extent for political biases. Political biases can thus more powerfully influence people, which increases the chances that these biases become embedded in algorithms and makes algorithmic political biases harder to detect and eradicate than gender and racial biases even though they all can produce similar harm. Since some algorithms can now also easily identify people’s political orientations against their will, these problems are exacerbated. Algorithmic political bias thus raises substantial and distinctive risks that the AI community should be aware of and examine. (shrink)

Presupposing no familiarity with the technical concepts of either philosophy or computing, this clear introduction reviews the progress made in AI since the inception of the field in 1956. Copeland goes on to analyze what those working in AI must achieve before they can claim to have built a thinking machine and appraises their prospects of succeeding.There are clear introductions to connectionism and to the language of thought hypothesis which weave together material from philosophy, artificial intelligence and neuroscience. John (...) Searle's attacks on AI and cognitive science are countered and close attention is given to foundational issues, including the nature of computation, Turing Machines, the Church-Turing Thesis and the difference between classical symbol processing and parallel distributed processing. The book also explores the possibility of machines having free will and consciousness and concludes with a discussion of in what sense the human brain may be a computer. (shrink)

By the time Hobbes wrote Leviathan, he was a theist, but not in the sense presumed by either side of the present-day debate concerning the sincerity of his professed theism. On the one hand, Hobbes’s expressed theology was neither merely deistic, nor confined to natural theology: the Hobbesian God is not merely a first mover, but a person who counsels, commands, and threatens. On the other hand, the Hobbesian God’s existence depends on being constructed artificially by human convention. The Hobbesian (...) God is not a natural person; he exists as a person only insofar as he is by fiction represented. Like the state and pagan gods, he is an artificial person by fiction. The upshot is that Hobbes was a sincere theist and that his seventeenth-century critics were right to think that, in their sense, he was an atheist: he did not steadfastly believe in an independently existing deity who precedes human convention. Hobbes was agnostic on this question. He nevertheless believed that God is brought into being as an artificial person. This ‘personal theology’ not only involved a heretical interpretation of the Trinity, it also came to play a significant role in his moral and political philosophy. (shrink)

In a recent publication, I argued that there is a conceptual difference between artificial womb (AW) technology, capable of facilitating gestation ex utero, and neonatal intensive care, providing incubation to neonates born prematurely. One of the reasons I provided for this distinction was that the subjects of each process are different entities. The subject of the process of gestation ex utero is a unique human entity: a ‘gestateling’, rather than a fetus or a newborn preterm neonate. Nick Colgrove wrote (...) a response to my paper, claiming that my distinction between the subject of an AW and a newborn (in intensive care) was false. He claims that I have not accounted for the proper definition of ‘birth’ and that gestatelings are not a distinct product of human reproduction. Further, Colgrove posits that even if I can successfully distinguish gestatelings from preterms, such a distinction is morally irrelevant because the entities would have the same moral status. In this paper, I address the three challenges raised and defend the claim that gestatelings are unique entities. Moreover, I argue that moral status should not be considered ipso facto determinative in the debate about AWs. (shrink)

This chapter examines the possibility of using AI technologies to improve human moral reasoning and decision-making, especially in the context of purchasing and consumer decisions. We characterize such AI technologies as artificial ethics assistants (AEAs). We focus on just one part of the AI-aided moral improvement question: the case of the individual who wants to improve their morality, where what constitutes an improvement is evaluated by the individual’s own values. We distinguish three broad areas in which an individual might (...) think their own moral reasoning and decision-making could be improved: one’s actions, character, or other evaluable attributes fall short of one’s values and moral beliefs; one sometimes misjudges or is uncertain about what the right thing to do is in particular situations, given one’s values; one is uncertain about some fundamental moral questions or recognizes a possibility that some of one’s core moral beliefs and values are mistaken. We sketch why one might think that AI tools could be used to support moral improvement in those areas, and describe two types of assistance: preparatory assistance, including advice and training supplied in advance of moral deliberation; and on-the-spot assistance, including on-the-spot advice and facilitation of moral functioning over the course of moral deliberation. Then, we turn to some of the ethical issues that AEAs might raise, looking in particular at three under-appreciated problems posed by the use of AI for moral self-improvement: namely, reliance on sensitive moral data; the inescapability of outside influences on AEAs; and AEA usage prompting the user to adopt beliefs and make decisions without adequate reasons. (shrink)

The idea of using artificial intelligence as a support system in the sentencing process has attracted increasing attention. For instance, it has been suggested that machine learning algorithms may help in curbing problems concerning inter-judge sentencing disparity. The purpose of the present article is to examine the merits of this possibility. It is argued that, insofar as the unfairness of sentencing disparity is held to reflect a retributivist view of proportionality, it is not necessarily the case that increasing inter-judge (...) uniformity in sentencing is desirable. More generally, it is shown that the idea of introducing machine learning algorithms, that produce sentencing predictions on the ground of a dataset that is built of previous sentencing decisions, faces serious problems if there exists a discrepancy between actual sentencing practice and the sentences that are ideally desirable. (shrink)

Artificial General Intelligence (AGI) is said to pose many risks, be they catastrophic, existential and otherwise. This paper discusses whether the notion of risk can apply to AGI, both descriptively and in the current regulatory framework. The paper argues that current definitions of risk are ill-suited to capture supposed AGI existential risks, and that the risk-based framework of the EU AI Act is inadequate to deal with truly general, agential systems.

As artificial intelligence becomes ubiquitous, it will be increasingly involved in novel, morally significant situations. Thus, understanding what it means for a machine to be morally responsible is important for machine ethics. Any method for ascribing moral responsibility to AI must be intelligible and intuitive to the humans who interact with it. We argue that the appropriate approach is to determine how AIs might fare on a standard account of human moral responsibility: a Strawsonian account. We make no claim (...) that our Strawsonian approach is either the only one worthy of consideration or the obviously correct approach, but we think it is preferable to trying to marry fundamentally different ideas of moral responsibility into a single cohesive account. Under a Strawsonian framework, people are morally responsible when they are appropriately subject to a particular set of attitudes—reactive attitudes—and determine under what conditions it might be appropriate to subject machines to this same set of attitudes. Although the Strawsonian account traditionally applies to individual humans, it is plausible that entities that are not individual humans but possess these attitudes are candidates for moral responsibility under a Strawsonian framework. We conclude that weak AI is never morally responsible, while a strong AI with the right emotional capacities may be morally responsible. (shrink)

Background Artificial intelligence (AI) has revolutionized various healthcare domains, where AI algorithms sometimes even outperform human specialists. However, the field of clinical ethics has remained largely untouched by AI advances. This study explores the attitudes of anesthesiologists and internists towards the use of AI-driven preference prediction tools to support ethical decision-making for incapacitated patients. Methods A questionnaire was developed and pretested among medical students. The questionnaire was distributed to 200 German anesthesiologists and 200 German internists, thereby focusing on physicians (...) who often encounter patients lacking decision-making capacity. The questionnaire covered attitudes toward AI-driven preference prediction, availability and utilization of Clinical Ethics Support Services (CESS), and experiences with ethically challenging situations. Descriptive statistics and bivariate analysis was performed. Qualitative responses were analyzed using content analysis in a mixed inductive-deductive approach. Results Participants were predominantly male (69.3%), with ages ranging from 27 to 77. Most worked in nonacademic hospitals (82%). Physicians generally showed hesitance toward AI-driven preference prediction, citing concerns about the loss of individuality and humanity, lack of explicability in AI results, and doubts about AI’s ability to encompass the ethical deliberation process. In contrast, physicians had a more positive opinion of CESS. Availability of CESS varied, with 81.8% of participants reporting access. Among those without access, 91.8% expressed a desire for CESS. Physicians' reluctance toward AI-driven preference prediction aligns with concerns about transparency, individuality, and human-machine interaction. While AI could enhance the accuracy of predictions and reduce surrogate burden, concerns about potential biases, de-humanisation, and lack of explicability persist. Conclusions German physicians frequently encountering incapacitated patients exhibit hesitance toward AI-driven preference prediction but hold a higher esteem for CESS. Addressing concerns about individuality, explicability, and human-machine roles may facilitate the acceptance of AI in clinical ethics. Further research into patient and surrogate perspectives is needed to ensure AI aligns with patient preferences and values in complex medical decisions. (shrink)

Temporal Logic: From Ancient Ideas to Artificial Intelligence deals with the history of temporal logic as well as the crucial systematic questions within the field. The book studies the rich contributions from ancient and medieval philosophy up to the downfall of temporal logic in the Renaissance. The modern rediscovery of the subject, which is especially due to the work of A. N. Prior, is described, leading into a thorough discussion of the use of temporal logic in computer science and (...) the understanding of natural language. Temporal Logic: From Ancient Ideas to Artificial Intelligence thus interweaves linguistic, philosophical and computational aspects into an informative and inspiring whole. (shrink)

Human excellences such as intelligence, morality, and consciousness are investigated by philosophers as well as artificial intelligence researchers. One excellence that has not been widely discussed by AI researchers is practical wisdom, the highest human excellence, or the highest, seventh, stage in Dreyfus’s model of skill acquisition. In this paper, I explain why artificial wisdom matters and how artificial wisdom is possible (in principle and in practice) by responding to two philosophical challenges to building artificial wisdom (...) systems. The result is a conceptual framework that guides future research on creating artificial wisdom. (shrink)

As the COVID-19 outbreak remains an ongoing issue, there are concerns about its disruption, the level of its disruption, how long this pandemic is going to last, and how innovative technological solutions like Artificial Intelligence (AI) and expert systems can assist to deal with this pandemic. AI has the potential to provide extremely accurate insights for an organization to make better decisions based on collected data. Despite the numerous advantages that may be achieved by AI, the use of AI (...) can be perceived differently by society, where moral and ethical issues may be raised, especially in regards to accessing and exploiting public data gathered from social media platforms. To better comprehend the concerns and ethical challenges, utilitarianism and deontology were used as business ethics frameworks to explore the aforementioned challenges of AI in society. The framework assists in determining whether the AI’s deployment is ethically acceptable or not. The paper lays forth policy recommendations for public and private organizations to embrace AI-based decision-making processes to avoid data privacy violations and maintain public trust. (shrink)

This article isolates ten prepositions, which constitute the undercurrent paradigm of contemporary discourse of health disease and medicine. Discussion of the interrelationship between those prepositions leads to a systematic refutation of this paradigm. An alternative set is being forwarded. The key notions of the existing paradigm are that health is the natural condition of humankind and that disease is a deviance from that nature. Natural things are harmonious and healthy while human made artifacts are coercive interference with natural balance. It (...) is suggested that the current paradigm is influenced by the world of finances and by instrumental reason. The alternative model suggests that human nature cannot be delineated. Humans fashion their own selves and nature by artificial means, medicine among them. The article discusses the implications of the paradigm adapted in various scholarly and popular debates such as the use of sex hormones for contraception, the care of the elderly, holistic medicine and distributive justice in health care. Medicine is not an isolated or a privileged realm. There is no unique entitlement to health care. It is always part of a broader agenda of social values and institutions. A open view of human societies, values and practices as they are situated within concrete material conditions is the platform required for an integrative and creative discourse of health care. (shrink)

Traditional medical Artificial Intelligence models, approved for clinical use, restrict themselves to single-modal data e.g. images only, limiting their applicability in the complex, multimodal environment of medical diagnosis and treatment. Multimodal Transformer Models in healthcare can effectively process and interpret diverse data forms such as text, images, and structured data. They have demonstrated impressive performance on standard benchmarks like USLME question banks and continue to improve with scale. However, the adoption of these advanced AI models is not without challenges. (...) While multimodal deep learning models like Transformers offer promising advancements in healthcare, their integration requires careful consideration of the accompanying ethical and environmental challenges. (shrink)

Since the early nineteenth century a membrane or wall has been central to the cell’s identity as the elementary unit of life. Yet the literally and metaphorically marginal status of the cell membrane made it the site of clashes over the definition of life and the proper way to study it. In this article I show how the modern cell membrane was conceived of by analogy to the first “artificial cell,” invented in 1864 by the chemist Moritz Traube (1826–1894), (...) and reimagined by the plant physiologist Wilhelm Pfeffer (1845–1920) as a precision osmometer. Pfeffer’s artificial cell osmometer became the conceptual and empirical basis for the law of dilute solutions in physical chemistry, but his use of an artificial analogue to theorize the existence of the plasma membrane as distinct from the cell wall prompted debate over whether biology ought to be more closely unified with the physical sciences, or whether it must remain independent as the science of life. By examining how the histories of plant physiology and physical chemistry intertwined through the artificial cell, I argue that modern biology relocated vitality from protoplasmic living matter to nonliving chemical substances—or, in broader cultural terms, that the disenchantment of life was accompanied by the (re)enchantment of ordinary matter. (shrink)