In 2015, the major critical care societies issued guidelines outlining a procedural approach to resolving intractable conflict between healthcare professionals and surrogates over life-sustaining treatments (LST). We report our experience with a resolving conflict procedure. This was a retrospective, single-centre cohort study of ethics consultations involving intractable conflict over LST. The resolving conflict process was initiated eleven times for ten patients over 2,015 ethics consultations from 2000 to 2020. In all cases, the ethics committee recommended withdrawal of the contested LST. (...) In seven cases, the patient died or was transferred or a legal injunction was obtained before completion of the process. In the four cases in which LST was withdrawn, the time from ethics consultation to withdrawal of LST was 24.8 ± 12.2 days. Healthcare provider and surrogate were often distressed during the process, sometimes resulting in escalation of conflict and legal action. In some cases, however, surrogates appeared relieved that they did not have to make the final decision regarding LST. Challenges regarding implementation included the time needed for process completion and limited usefulness in emergent situations. Although it is feasible to implement a due process approach to conflict over LST, there are factors that limit the procedure’s usefulness. (shrink)

Describes 100 real-life ethical dilemmas faced by school administrators.

Whether surrogate decisionmakers have the authority to refuse pain and symptom management measures on behalf of incapacitated patients is a particularly timely question to ask in this era of growing commitment to ensuring appropriate pain and symptom management measures for all patients.

The debate about what constitutes the discipline of ethics and who qualifies as an ethics consultant is linked unavoidably to a debate that is potentiated by the reality of a rapidly changing and high-stakes health care consultation marketplace. Who we are and what we can offer to the moral gesture that is medicine is shaped by our fundamental understanding of the place of expert knowledge in the transformation of social reality. The struggle for self-definition is particularly freighted since clinical ethics (...) consultation aspires to be more than academic contemplation. Two recent books (Ethics Consultation by John La Puma and David Schiedermayer and The Health Care Ethics Consultant: A Practical Guide, edited by Francoise Baylis) exemplify the two most popular but most widely divergent positions on these issues. We argue that while useful, neither book addresses fully the particular and distinct role of the professional ethicist. (shrink)

This book brings together essays on themes of human rights and legal history, reflecting the long and distinguished career as academic writer and human rights activist of Brian Simpson. Written by colleagues and friends in the United States and Britain, the essays are intended to reflect Simpson's own legal interests. The collection opens with biography of Simpson's academic life which notes his major contribution to legal thought, and closes with an account of his career in the United States and a (...) bibliography of his writings. As a tribute to Simpson's varied interests in the law, the collection is grouped around themes in human rights, legal philosophy, and legal history. The human rights papers are concerned with the history of the right of individual petition to the European Court of Human Rights, and recent successes in which Brian Simpson played a part; the evolution of a transnational common law of human rights; the United Nations Convention on the Rights of the Child and the interpretation of the provisions on identity in France and England; the suspension of human rights which would have occurred, had the emergency War Zone Courts scheme been brought into effect during wartime; historical resistance to colonial laws in Papua New Guinea; and the ratio decidendi of the story of the Prodigal Son. Historical themes are found in essays concerned with three nineteenth-century Lord Chancellors; in two essays relating to the fate of the civil jury on either side of the Atlantic which provide a fascinating comparison; in the 'battle of the books' which led to changes in eighteenth-century copyright law; and judicial rivalry between King's Bench and Common Pleas in the early modern period. (shrink)

Clinical ethics, like the broader field of bioethics from which it emerged, is at a critical crossroads in its development, with conflicting paths ahead. It can either claim its distinctive place in the clinical arena, insisting unapologetically on certain minimal standards of professional training, practice and competence, addressing head on debates about various models of and methodological approaches to consultation, and establishing a shared vision of the purpose and meaning of the enterprise of clinical ethics itself. Or, it can devolve (...) into a hobby that untrained, albeit interested, and generally well intentioned individuals can dabble in for fun or even profit, as they see fit, and without regard to the deep history and rich disciplinary roots of the field, the serious debates in the academic literature of bioethics, the foundational case histories and legal theories, or even any sense of professional accountability. (shrink)

With “The Zadeh Scenario,” Finder offers us a gift…a rich and thoughtful first-person account of the gradual unfolding of a specific ethics consultation conducted by a specific ethics consultant in a specific context. This is not your average case report, stripped to the bare facts and devoid of the ambiguity of real-time human interactions. It’s also not simply an example of thick description, offering the reader a detailed account of the context out of which an abstract ethical dilemma has emerged, (...) with the ethics consultant describing all from a distance, above the fray. What Finder offers and models for us instead is something entirely new and different. He offers us a case narrative into which he has chosen to place himself squarely and explicitly. And in the spirit of “peer review” he has generously revealed his own inner dialogue in response to twists and turns in the case, sharing his personal reflections as events unfolded, and his musings about various actions he took and choices he made in his role. By inviting us to ponder his story about the story of the case, he generously extends a gift to us: the opportunity to reflect on his—and therefore our own—consultation practice, and the opportunity to try a new kind of peer review. (shrink)

This article argues that we could improve the design of research protocols by developing an awareness of and a responsiveness to the social contexts of all the actors in the research enterprise, including subjects, investigators, sponsors, and members of the community in which the research will be conducted. ?Social context? refers to the settings in which the actors are situated, including, but not limited to, their social, economic, political, cultural, and technological features. The utility of thinking about social contexts is (...) introduced and exemplified by the presentation of a hypothetical case in which one central issue is limitation of the probability of injury to subjects by selection of individuals who are not expected to live long enough for the known risks of the study to become manifest as harms. Benefits of such considerations may include enhanced subject satisfaction and cooperation, community acceptance, and improved data quality, among other desirable consequences. (shrink)

This article argues that we could improve the design of research protocols by developing an awareness of and a responsiveness to the social contexts of all the actors in the research enterprise, including subjects, investigators, sponsors, and members of the community in which the research will be conducted. “Social context” refers to the settings in which the actors are situated, including, but not limited to, their social, economic, political, cultural, and technological features. The utility of thinking about social contexts is (...) introduced and exemplified by the presentation of a hypothetical case in which one central issue is limitation of the probability of injury to subjects by selection of individuals who are not expected to live long enough for the known risks of the study to become manifest as harms. Benefits of such considerations may include enhanced subject satisfaction and cooperation, community acceptance, and improved data quality, among other desirable consequences. (shrink)

Several researchers have recently argued that p values lose their meaning in exploratory analyses due to an unknown inflation of the alpha level (e.g., Nosek & Lakens, 2014; Wagenmakers, 2016). For this argument to be tenable, the familywise error rate must be defined in relation to the number of hypotheses that are tested in the same study or article. Under this conceptualization, the familywise error rate is usually unknowable in exploratory analyses because it is usually unclear how many hypotheses have (...) been tested on a spontaneous basis and then omitted from the final research report. In the present article, I argue that it is inappropriate to conceptualize the familywise error rate in relation to the number of hypotheses that are tested. Instead, it is more appropriate to conceptualize familywise error in relation to the number of different tests that are conducted on the same null hypothesis in the same study. Under this conceptualization, alpha level adjustments in exploratory analyses are (a) less necessary and (b) objectively verifiable. As a result, p values do not lose their meaning in exploratory analyses. (shrink)

We prove that the logics of Magidor-Malitz and their generalization by Rubin are distinct even for PC classes. Let $M \models Q^nx_1 \cdots x_n \varphi(x_1 \cdots x_n)$ mean that there is an uncountable subset A of |M| such that for every $a_1, \ldots, a_n \in A, M \models \varphi\lbrack a_1, \ldots, a_n\rbrack$ . Theorem 1.1 (Shelah) $(\diamond_{\aleph_1})$ . For every n ∈ ω the class $K_{n + 1} = \{\langle A, R\rangle \mid \langle A, R\rangle \models \neg Q^{n + (...) 1} x_1 \cdots x_{n + 1} R(x_1, \ldots, x_{n + 1})\}$ is not an ℵ 0 -PC-class in the logic L n , obtained by closing first order logic under Q 1 , ..., Q n . I.e. for no countable L n -theory T, is K n + 1 the class of reducts of the models of T. Theorem 1.2 (Rubin) $(\diamond_{\aleph_1}).^3$ . Let $M \models Q^E x y\varphi(x, y)$ mean that there is $A \subseteq |M|$ such that $E_{A, \varphi} = \{\langle a, b \rangle \mid a, b \in A$ and $M \models \varphi\lbrack a, b\rbrack\}$ is an equivalence relation on A with uncountably many equivalence classes, and such that each equivalence class is uncountable. Let $K^E = \{\langle A, R\rangle\mid \langle A, R\rangle\models \neg Q^Exy R(x, y)\}$ . Then K E is not an ℵ 0 -PC-class in the logic gotten by closing first order logic under the set of quantifiers {Q n ∣ n ∈ ω} which were defined in Theorem 1.1. (shrink)

Gelman and Loken (2013, 2014) proposed that when researchers base their statistical analyses on the idiosyncratic characteristics of a specific sample (e.g., a nonlinear transformation of a variable because it is skewed), they open up alternative analysis paths in potential replications of their study that are based on different samples (i.e., no transformation of the variable because it is not skewed). These alternative analysis paths count as additional (multiple) tests and, consequently, they increase the probability of making a Type I (...) error during hypothesis testing. The present article considers this forking paths problem and evaluates four potential solutions that might be used in psychology and other fields: (a) adjusting the prespecified alpha level, (b) preregistration, (c) sensitivity analyses, and (d) abandoning the Neyman-Pearson approach. It is concluded that although preregistration and sensitivity analyses are effective solutions to p-hacking, they are ineffective against result-neutral forking paths, such as those caused by transforming data. Conversely, although adjusting the alpha level cannot address p-hacking, it can be effective for result-neutral forking paths. Finally, abandoning the Neyman-Pearson approach represents a further solution to the forking paths problem. (shrink)

Assuming GCH, we prove that for every successor cardinal μ > ω1, there is a superatomic Boolean algebra B such that |B| = 2μ and |Aut B| = μ. Under ◊ω1, the same holds for μ = ω1. This answers Monk's Question 80 in [Mo].

Let B be a superatomic Boolean algebra (BA). The rank of B (rk(B)), is defined to be the Cantor Bendixon rank of the Stone space of B. If a ∈ B - {0}, then the rank of a in B (rk(a)), is defined to be the rank of the Boolean algebra $B b \upharpoonright a \overset{\mathrm{def}}{=} \{b \in B: b \leq a\}$ . The rank of 0 B is defined to be -1. An element a ∈ B - {0} is (...) a generalized atom $(a \in \widehat{At}(B))$ , if the last nonzero cardinal in the cardinal sequence of B $\upharpoonright$ a is 1. Let a,b $\in\widehat{At}$ (B). We denote a ∼ b, if rk(a) = rk(b) = rk(a · b). A subset H $\subseteq \widehat{At}$ (B) is a complete set of representatives (CSR) for B, if for every a $\in \widehat{At}$ (B) there is a unique h ∈ H such that h ∼ a. Any CSR for B generates B. We say that B is canonically well-generated (CWG), if it has a CSR H such that the sublattice of B generated by H is well-founded. We say that B is well-generated, if it has a well-founded sublattice L such that L generates B. THEOREM 1. Let B be a Boolean algebra with cardinal sequence $\langle\aleph_0: i . If B is CWG, then every subalgebra of B is CWG. A superatomic Boolean algebra B is essentially low (ESL), if it has a countable ideal I such that rk(B/I) ≤ 1. Theorem 1 follows from Theorem 2.9, which is the main result of this work. For an ESL BA B we define a set F B of partial functions from a certain countably infinite set to ω (Definition 2.8). Theorem 2.9 says that if B is an ESL Boolean algebra, then the following are equivalent. (1) Every subalgebra of B is CWG; and (2) F B is bounded. THEOREM 2. If an ESL Boolean algebra is not CWG, then it has a subalgebra which is not well-generated. (shrink)

For a complete theory of Boolean algebras T, let MT denote the class of countable models of T. For B1, B2 ∈ MT, let B1 ≤ B2 mean that B1 is elementarily embeddable in B2. Theorem 1. For every complete theory of Boolean algebras T, if T ≠ Tω, then $\langle M_T, \leq\rangle$ is well-quasi-ordered. ■ We define Tω. For a Boolean algebra B, let I(B) be the ideal of all elements of the form a + s such that $B\upharpoonright (...) a$ is an atomic Boolean algebra and $B\upharpoonright s$ is an atomless Boolean algebra. The Tarski derivative of B is defined as follows: B(0) = B and B(n + 1) = B(n)/I(B(n)). Define Tω to be the theory of all Boolean algebras such that for every n ∈ ω, B(n) ≠ {0}. By Tarski [1949], Tω is complete. Recall that $\langle A, \leq\rangle$ is a partial well-quasi-ordering, if it is a partial quasi-ordering and for every $\{a_i\mid i \in \omega\} \subseteq A$ , there are $i < j < \omega$ such that ai ≤ aj. Theorem 2. $\langle M_{T_\omega}, \leq\rangle$ contains a subset M such that the partial orderings $\langle M, \leq \upharpoonright M \rangle$ and $\langle\mathscr{P}(\omega), \subseteq\rangle$ are isomorphic. ■ Let M'0 denote the class of all countable Boolean algebras. For B1, B2 ∈ M'0, let B1 ≤' B2 mean that B1 is embeddable in B2. Remark. $\langle M'_0, \leq'\rangle$ is well-quasi-ordered. ■ This follows from Laver's theorem [1971] that the class of countable linear orderings with the embeddability relation is well-quasi-ordered and the fact that every countable Boolean algebra is isomorphic to a Boolean algebra of a linear ordering. (shrink)

This paper analyzes Kierkegaard's Religiousness A sphere of existence, presented in his edifying works, and Heidegger's concept of authenticity, proposed in Being and Time, as responses to modern nihilism. While Kierkegaard argues that Religiousness A is an unsuccessful response to modern nihilism, Heidegger claims that authenticity, a secularized version of Religiousness A, is a successful response. We argue that Heidegger's secularization of Religiousness A is incomplete and unsuccessful, that Heidegger's later work offers a reconsideration of the problem of modern nihilism, (...) and that later Heidegger suggests a way out of nihilism which is compatible with Kierkegaard's Religiousness B sphere of existence. (shrink)

THEOREM 1. (⋄ ℵ 1 ) If B is an infinite Boolean algebra (BA), then there is B 1 such that $|\operatorname{Aut} (B_1)| \leq B_1| = \aleph_1$ and $\langle B_1, \operatorname{Aut} (B_1)\rangle \equiv \langle B, \operatorname{Aut}(B)\rangle$ . THEOREM 2. (⋄ ℵ 1 ) There is a countably compact logic stronger than first-order logic even on finite models. This partially answers a question of H. Friedman. These theorems appear in §§ 1 and 2. THEOREM 3. (a) (⋄ ℵ 1 ) If (...) B is an atomic ℵ 1 -saturated infinite BA, ψ ε L ω 1ω and $\langle B, \operatorname{Aut} (B)\rangle \models\psi$ then there is B 1 such that $|\operatorname{Aut}(B_1)| \leq |B_1| = \aleph_1$ and $\langle B_1, \operatorname{Aut}(B_1)\rangle\models\psi$ . In particular if B is 1-homogeneous so is B 1 . (b) (a) holds for B = P(ω) even if we assume only CH. (shrink)

For a complete first order theory of Boolean algebras T which has nonisomorphic countable models, we determine the first limit ordinal α = α(T) such that We show that for some and for all other T‘s, A nonprincipal ideal I of B is almost principal, if a is a principal ideal of B} is a maximal ideal of B. We show that the theory of Boolean algebras with an almost principal ideal has complete extensions and characterize them by invariants similar (...) to the Tarski’s invariants. (shrink)

A Boolean algebra B that has a well-founded sublattice L which generates B is called a well-generated Boolean algebra. If in addition, L is generated by a complete set of representatives for B , then B is said to be canonically well-generated .Every WG Boolean algebra is superatomic. We construct two basic examples of superatomic non well-generated Boolean algebras. Their cardinal sequences are 1,0,1,1 and 0,0,20,1.Assuming MA , we show that every algebra with one of the cardinal sequences , α<1, (...) λ<20, or 0,20,1,1 is CWG.Assuming CH, or alternatively assuming MA , we determine which cardinal sequences admit only WG Boolean algebras.We find a necessary and sufficient condition for the canonical well-generatedness of algebras whose cardinal sequence has the form , α<1. We conclude that if such an algebra is CWG, then all of its quotients are CWG. We show that the above is not true for general Boolean algebras. We also conclude that if the cardinality of such an algebra is less than the cardinal defined below, then it is CWG. The cardinal is the least cardinality of an unbounded subset of {f f : ω → ω}.We investigate questions concerning embeddability, quotients and subalgebras of WG and CWG Boolean algebras, and construct various counter-examples. (shrink)

While the HVTN 505 trial showed no overall efficacy of the tested vaccine to prevent HIV infection over placebo, markers measuring immune response to vaccination were strongly correlated with infection. This finding generated the hypothesis that some marker-defined vaccinated subgroups were partially protected whereas others had their risk increased. This hypothesis can be assessed using the principal stratification framework (Frangakis and Rubin, 2002) for studying treatment effect modification by an intermediate response variable, using methods in the sub-field of principal (...) surrogate (PS) analysis that studies multiple principal strata. Unfortunately, available methods for PS analysis require an augmented study design not available in HVTN 505, and make untestable structural risk assumptions, motivating a need for more robust PS methods. Fortunately, another sub-field of principal stratification, survivor average causal effect (SACE) analysis (Rubin, 2006) – which studies effects in a single principal stratum – provides many methods not requiring an augmented design and making fewer assumptions. We show how, for a binary intermediate response variable, methods developed for SACE analysis can be adapted to PS analysis, providing new and more robust PS methods. Application to HVTN 505 supports that the vaccine partially protected individuals with vaccine-induced T-cells expressing certain combinations of functions. (shrink)

This paper distinguishes four major types of futility (physiological, imminent demise, lethal condition, and qualitative) that have been advocated in the literature either in a patient dependent or a patient independent fashion. It proposes five criteria (precision, prospective, social acceptability, significant number, and non-agreement) that any definition of futility must satisfy if it is to serve as the basis for unilaterally limiting futile care. It then argues that none of the definitions that have been advocated meet the criteria, primarily because (...) their proponents have not paid sufficient attention to the problematic nature of the data supporting the use of their definitions. (shrink)

Psychoactive drugs are being prescribed to millions of Americans at an increasing rate. In many cases these drugs are necessary in order to overcome debilitating emotional problems. Yet in other instances, these drugs are used to supplant, not supplement, interpersonal therapy. The process of overcoming emotional obstacles by introspection and the attainment of self knowledge is gradually being eroded via the gratuitous use of psychoactive medication in order to rapidly attain a release from the common problems that life inevitably presents (...) us with. In this paper, I argue that Kant’s formula of humanity, which maintains that persons ought never to treat others or themselves soley as a means to an end, proscribes this. Moreover, Kant argues that we have an imperfect duty of self development, and I argue that we fail to adhere to such a duty whenever we seek to evade the process of introspection and self knowledge in favour of the expedient results that drugs may provide us with as we attempt to overcome the emotional hurdles in our lives. (shrink)

This study is an analysis of surrogate-focused ethics consultations in the Intensive Care Unit (ICU) and the general wards (Ward) of a large community hospital in Northern California. We identified the major themes of surrogate-focused ethics consultations to better understand the root cause of surrogate conflicts, and identified the similarities and differences between surrogate-based conflicts in the two settings. Consults requested because the surrogate had desires that conflicted with the physicians medical opinion of ‘best interest’, or cases involving surrogates not (...) upholding a patient’s known values reflected the root cause of the majority of surrogate conflicts (72.7% ICU, 83.3% Ward). (shrink)

In this paper, I consider a variety of objections against the covering-law model of scientific explanation, show that Aristotle was already aware of them and had solutions for them, and argue that these solutions are correct. These solutions involve the notions of nonHumean causality and of essential properties. There are a great many familiar objections, both methodological and epistemological, to introducing these concepts into the methodology of science, but I show that these objections are based upon misunderstandings of these concepts.

Sections R1 to R3 attempt to take the sting out of hostile commentaries. Sections R4 to R5 engage Berlin and Kay and the World Color Survey to correct the record. Section R6 begins the formulation of a new theory of colour as an engineering project with a technological developmental trajectory. It is recommended that the colour space be abandoned.

Neuronal aggregates involved in conscious awareness are not evenly distributed throughout the CNS but comprise key components referred to as the neural network correlates of consciousness (NNCC). A critical node in this network is the posterior cingulate, precuneal, and retrosplenial cortices. The cytological and neurochemical composition of this region is reviewed in relation to the Brodmann map. This region has the highest level of cortical glucose metabolism and cytochrome c oxidase activity. Monkey studies suggest that the anterior thalamic projection likely (...) drives retrosplenial and posterior cingulate cortex metabolism and that the midbrain projection to the anteroventral thalamic nucleus is a key coupling site between the brainstem system for arousal and cortical systems for cognitive processing and awareness. The pivotal role of the posterior cingulate, precuneal, and retrosplenial cortices in consciousness is demonstrated with posterior cingulate epilepsy cases, midcingulate lesions that de-afferent this region and are associated with unilateral sensory neglect, observations from stroke and vegetative state patients, alterations in blood flow during sleep, and the actions of general anesthetics. Since this region is critically involved in self reflection, it is not surprising that it is similarly a site for the NNCC. Interestingly, information processing during complex cognitive tasks and during aversive sensations such as pain induces efforts to terminate self reflection and result in decreased processing in posterior cingulate and precuneal cortices. (shrink)