This paper reframes the futility debate, moving away from the question “Who decides when to end what is considered to be a medically inappropriate or futile treatment?” and toward the question “How can society make policy that will best account for the multitude of values and conflicts involved in such decision-making?” It offers a pragmatist moral epistemology that provides us with a clear justification of why it is important to take best standards, norms, and physician judgment seriously and a clear (...) justification of why ample opportunity must be made for patients, families, and society to challenge those standards and norms. (shrink)

Recent influential criticisms attack the reputation of Thomas Harriot by citing the contents of his ethnographic and economic survey, A briefe and true report of the new found land of Virginia, first published in 1588. This interpretation makes Harriot, together with Shakespeare and others, agents of a colonialist project. But profound differences are indicated in the comparison of the relatively unbiased depiction and analysis by Harriot and his artist collaborator John White with the interpretations of America and Americans by some (...) of their contemporaries. A briefe and true report conveys, and John White's drawings support, insight into particular non-European features of the cultural and economic lives of the Algonquian peoples. On the contrary, Captain Arthur Barlowe's Discourse and the illustrations by Theodore de Bry for the 1600 edition of Harriot's book instance romanticizing, stereotyping, and unanalytic condescension very unlike Harriot's and White's. These differences prove the faultiness of the recent assessment. (shrink)

Shortages of new therapeutics to treat coronavirus disease (COVID-19) have forced clinicians, public health officials, and health systems to grapple with difficult questions about how to fairly allocate potentially life-saving treatments when there are not enough for all patients in need (1). Shortages have occurred with remdesivir, tocilizumab, monoclonal antibodies, and the oral antiviral Paxlovid (2) -/- Ensuring equitable allocation is especially important in light of the disproportionate burden experienced during the COVID-19 pandemic by disadvantaged groups, including Black, Hispanic/Latino and (...) Indigenous communities, individuals with certain disabilities, and low-income persons. However, many health systems have resorted to first-come, first-served approaches to allocation, which tend to disadvantage individuals with barriers in access to care (3). There is mounting evidence of racial, ethnic, and socioeconomic disparities in access to medications for COVID-19 (4, 5). -/- One potential method to promote equitable allocation is to use a weighted lottery, which is an allocation strategy that gives all eligible patients a chance to receive the scarce treatment while also allowing the assignment of higher or lower chances according to other ethical considerations (6). We sought to assess the feasibility of implementing a weighted lottery to allocate scarce COVID-19 medications in a large U.S. health system and to determine whether the weighted lottery promotes equitable allocation. (shrink)

The sudden emergence of the COVID-19 pandemic brought global disruption to every aspect of society including healthcare, supply chain, the economy, and social interaction. Among the many emergent considerations were the safety and public health of the public, patients, essential workers, and healthcare professionals. In certain locations, clinical research was halted—or terminated—in deference to the immediate needs of patient care, and clinical trials focusing on the treatment and prevention of coronavirus infection were prioritized over studies focusing on other diseases. Difficult (...) decisions were made rapidly; flexibility and reconsideration were necessary not only because the intensity and severity of infection varied over time and by locale but also because knowledge of the disease and understanding of its treatment grew. Here we discuss the ethical challenges in decision-making and competing ethical tensions during the pandemic in an effort to advance future preparedness. (shrink)

The enormous destructive power of present stocks of nuclear weapons poses the greatest threat to public health in human history. Technical changes in weapons design are leading to an increased emphasis on the ability to fight a nuclear war, eroding the concept of deterrence based on mutually assured destruction and increasing the risk of nuclear war. Medical planning and civil defence preparations for nuclear war have recently been increased in several countries although there is little evidence that they will be (...) of significant value in the aftermath of a nuclear conflict. These developments have raised new ethical dilemmas for those in health professions. If there is any risk of use of weapons of mass destruction, then support for deterrence with these weapons as a policy for national or global security appears to be incompatible with basic principles of medical ethics and international law. The primary medical responsibility under such circumstances is to participate in attempts to prevent nuclear war. (shrink)

During public health crises including the COVID-19 pandemic, resource scarcity and contagion risks may require health systems to shift—to some degree—from a usual clinical ethic, focused on the well-being of individual patients, to a public health ethic, focused on population health. Many triage policies exist that fall under the legal protections afforded by “crisis standards of care,” but they have key differences. We critically appraise one of the most fundamental differences among policies, namely the use of criteria to categorically exclude (...) certain patients from eligibility for otherwise standard medical services. We examine these categorical exclusion criteria from ethical, legal, disability, and implementation perspectives. Focusing our analysis on the most common type of exclusion criteria, which are disease-specific, we conclude that optimal policies for critical care resource allocation and the use of cardiopulmonary resuscitation (CPR) should not use categorical exclusions. We argue that the avoidance of categorical exclusions is often practically feasible, consistent with public health norms, and mitigates discrimination against persons with disabilities. (shrink)

In an introduction to Louis J. Halle's Civilization and Foreign Policy, Dean Acheson notes with approval that Halle believed a group of men, formerly members of the Policy Planning Staff of the United States State Department, to be seeking a new theory of foreign policy which would lie outside the traditional theory. Halle's work, like that of the others whose names were mentioned (George F. Kennan, Paul Nitze, and C. B. Marshall), represented a serious and searching analysis of the conceptual (...) frame of American foreign policy, a search largely accompanied by a demand for a more realistic consideration of problems of power. The members of the Policy Planning Staff were by no means the only, or even the first, Americans to question American thinking on foreign policy from the standpoint of power politics. Without going back to Alexander Hamilton, we must consider, in particular, Hans J. Morgenthau and Reinhold Niebuhr. This kind of thinking is still being advanced; and, more recently, the warning that Americans misunderstood the problem of power was put with some forcefulness by Robert Endicott Osgood : “More than any other great nation, America's basic predispositions and her experience in world politics encourage the dissociation of power and policy.” There is no doubt that work of recent years has shown the increased seriousness of American interest in the problems of foreign policy and civilization. The contribution which these and other writers have made is a very great one. Despite many differences among themselves, their trend seems to embody a certain oneness, which lies in a perception of the problems of power. Acheson points to the practical experience of the State Department group and their intention to “see life steadily and see it whole,” in Matthew Arnold's famous phrase. Yet, a few years after these writers, whom Acheson so highly regarded, had tried to acquaint the American people with the realities of power in foreign policy, one of them, George F. Kennan, was publicly criticized by Acheson himself for “never having understood the realities of power politics.” Shortly thereafter, Acheson, in his latest book, reiterated the charge that “power politics” was, for Americans, still a derogatory term. Kennan, one of our most thoughtful and sensitive writers on foreign policy, and Acheson, one of our most articulate and eloquent secretaries of state, had failed to satisfy the American people, and Kennan had failed, apparently, to satisfy Acheson regarding the significance and the reality of power politics. Yet in the light of some of the literature which has appeared since the rise of these writers, whom we may call “realists” though they do not necessarily so characterize themselves, one may question whether the danger is still that which Acheson described. One who reads Henry A. Kissinger's Nuclear Weapons and Foreign Policy may wonder not whether Americans understand the realities of power but whether, indeed, some of them understand anything else. We face the danger that the wheel may come full circle, that a naïve idealism may be replaced by a purely methodical realism, and that the very words “politics” and “strategy” may become interchangeable terms. We face that danger, but let no one suspect that Americans, in general, have succumbed to it. (shrink)

Supernatural beliefs are ubiquitous around the world, and mounting evidence indicates that these beliefs partly rely on intuitive, cross‐culturally recurrent cognitive processes. Specifically, past research has focused on humans' intuitive tendency to perceive minds as part of the cognitive foundations of belief in a personified God—an agentic, morally concerned supernatural entity. However, much less is known about belief in karma—another culturally widespread but ostensibly non‐agentic supernatural entity reflecting ethical causation across reincarnations. In two studies and four high‐powered samples, including mostly (...) Christian Canadians and mostly Hindu Indians (Study 1, N = 2,006) and mostly Christian Americans and Singaporean Buddhists (Study 2, N = 1,752), we provide the first systematic empirical investigation of the cognitive intuitions underlying various forms of belief in karma. We used path analyses to (a) replicate tests of the previously documented cognitive predictors of belief in God, (b) test whether this same network of variables predicts belief in karma, and (c) examine the relative contributions of cognitive and cultural variables to both sets of beliefs. We found that cognitive tendencies toward intuitive thinking, mentalizing, dualism, and teleological thinking predicted a variety of beliefs about karma—including morally laden, non‐agentic, and agentic conceptualizations—above and beyond the variability explained by cultural learning about karma across cultures. These results provide further evidence for an independent role for both culture and cognition in supporting diverse types of supernatural beliefs in distinct cultural contexts. (shrink)

The spectacular development of medical knowledge over the last two centuries has brought intrusive advances in the capabilities of medical technology. These advances have been remarkable over the last century, but especially over the last few decades, culminating in such high technology interventions as heart transplants and renal dialysis. These increases in medical powers have attracted societal interest in acquiring more such knowledge. They have also spawned concerns regarding the use of human subjects in research and regarding the byproducts of (...) basic research as in the recent recombinant DNA debate. As a consequence of the development of new biomedical knowledge, physicians and biomedical scientists have been placed in positions of new power and responsibility. The emergence of this group of powerful and knowledgeable experts has occasioned debates regarding the accountability of physicians and biomedical scientists. But beyond that, the very investment of resources in the acquisition of new knowledge has been questioned. Societies must decide whether finite resources would not be better invested at this juncture, or in general, in the alleviation of the problems of hunger or in raising general health standards through interventions which are less dependent on the intensive use of high technology. To put issues in this fashion touches on philosophical notions concerning the claims of distributive justice and the ownership of biomedical knowledge. (shrink)

The Latin manuscript of Hobbes’s critique of White’s De mundo dialogi tres was discovered among the Mersenne papers in the Bibliothèque Nationale by Jean Jacquot and published by Jacquot and Jones. The present English translation makes generally available a text that, while following the disposition of White’s, goes beyond commentary to constitute a work of philosophy in its own right and a significant addition to the Hobbesian corpus.

RationaleSurrogates of critically ill patients often have inaccurate expectations about prognosis. Yet there is little research on how intensive care unit clinicians should discuss prognosis, and existing expert opinion-based recommendations give only general guidance that has not been validated with surrogate decision makers.ObjectiveTo determine the perspectives of key stakeholders regarding how prognostic information should be conveyed in critical illness.MethodsThis was a multicenter study at three academic medical centers in California, Pennsylvania, and Washington. One hundred eighteen key stakeholders completed in-depth semistructured (...) interviews. Participants included 47 surrogates of adult patients with acute respiratory distress syndrome; 45 clinicians working in study ICUs, including physicians, nurses, social workers, and spiritual care providers; and 26 experts in health communication, decision science, ethics, family-centered care, geriatrics, healthcare disparities, palliative care, psychology, psychiatry, and critical care.Measurements and main resultsThere was broad support among surrogates for existing expert recommendations, including truthful prognostic disclosure, emotional support, tailoring the disclosure strategy to each family's needs, and checking for understanding. In addition, stakeholders offered suggestions that add specificity to existing recommendations, including: In addition to conveying prognostic estimates, clinicians should help families "see the prognosis for themselves" by showing families radiographic images and explaining the clinical significance of physical manifestations of severe disease at the bedside. Many physicians did not support using numeric estimates to convey prognosis to families, whereas many surrogates, clinicians from other disciplines, and experts believed numbers could be helpful. Clinicians should conceptualize prognostic communication as an iterative process that begins with a preliminary mention of the possibility of death early in the ICU stay and becomes more detailed as the clinical situation develops. Although prognostic information should be initially disclosed by physicians, other members of the multidisciplinary team-nurses, social workers, and spiritual care providers-should be given explicit role responsibilities to reinforce physicians' prognostications and help families process a poor prognosis emotionally.ConclusionsFamily members, clinicians, and experts identified specific communication behaviors that clinicians should use to discuss prognosis in the critical care setting. These findings extend existing opinion-based recommendations and should guide interventions to improve communication about prognosis in ICUs. (shrink)

Coronavirus disease 2019 can lead to respiratory failure. Some patients require extracorporeal membrane oxygenation support. During the current pandemic, health care resources in some cities have been overwhelmed, and doctors have faced complex decisions about resource allocation. We present a case in which a pediatric hospital caring for both children and adults seeks to establish guidelines for the use of extracorporeal membrane oxygenation if there are not enough resources to treat every patient. Experts in critical care, end-of-life care, bioethics, and (...) health policy discuss if age should guide rationing decisions. (shrink)

AimWhite matter changes in individuals at ultra-high risk for psychosis (UHR) may be involved in the transition to psychosis. Sleep-wake disturbances commonly precede the first psychotic episode and predict development of psychosis. We examined associations between white matter microstructure and sleep-wake disturbances in UHR individuals compared to healthy controls (HC), as well as explored the confounding effect of medication, substance use, and level of psychopathology.MethodsSixty-four UHR individuals and 35 HC underwent clinical interviews and diffusion weighted imaging. Group differences on global (...) and callosal mean fractional anisotropy (FA) was tested using general linear modeling. Sleep-wake disturbances were evaluated using the subjective measures disturbed sleep index (DSI) and disturbed awakening index (AWI) from the Karolinska Sleep Questionnaire, supported by objective sleep measures from one-night actigraphy. The primary analyses comprised partial correlation analyses between global FA/callosal FA and sleep-wake measures. Secondary analyses investigated multivariate patterns of covariance between measures of sleep-wake disturbances and FA in 48 white matter regions of interest using partial least square correlations.ResultsUltra-high risk for psychosis individuals displayed lower global FA (F = 14.56, p < 0.001) and lower callosal FA (F = 11.34, p = 0.001) compared to HC. Subjective sleep-wake disturbances were significantly higher among the UHR individuals (DSI: F = 27.59, p < 0.001, AWI: F = 36.42, p < 0.001). Lower callosal FA was correlated with increased wake after sleep onset (r = −0.34, p = 0.011) and increased sleep fragmentation index (r = −0.31, p = 0.019) in UHR individuals. Multivariate analyses identified a pattern of covariance in regional FA which were associated with DSI and AWI in UHR individuals (p = 0.028), but not in HC. Substance use, sleep medication and antipsychotic medication did not significantly confound these associations. The association with objective sleep-wake measures was sustained when controlling for level of depressive and UHR symptoms, but symptom level confounded the covariation between FA and subjective sleep-wake measures in the multivariate analyses.ConclusionCompromised callosal microstructure in UHR individuals was related to objectively observed disruptions in sleep-wake functioning. Lower FA in ventrally located regions was associated with subjectively measured sleep-wake disturbances and was partly explained by psychopathology. These findings call for further investigation of sleep disturbances as a potential treatment target. (shrink)

The vestibular system encodes motion and orientation of the head in space and is essential for negotiating in and interacting with the world. Recently, random waveform electric vestibular stimulation has become an increasingly common means of probing the vestibular system. However, many of the methods used to analyze the behavioral response to this type of stimulation assume a linear relationship between frequencies in the stimulus and its associated response. Here we examine this stimulus-response frequency linearity to determine the validity of (...) this assumption. Forty-five university-aged subjects stood on a force-plate for 4 min while receiving vestibular stimulation. To determine the linearity of the stimulus-response relationship we calculated the cross-frequency power coupling between a 0 and 25 Hz bandwidth limited white noise stimulus and induced postural responses, as measured using the horizontal forces acting at the feet. Ultimately, we found that, on average, the postural response to a random stimulus is linear across stimulation frequencies. This result supports the use of analysis methods that depend on the assumption of stimulus-response frequency linearity, such as coherence and gain, which are commonly used to analyze the body’s response to random waveform electric stimuli. (shrink)

Examining the nature of Václav Havel's 'postmodernism,' we suggest that his use of this ambiguous label can be best understood if interpreted outside the conventional binary framework of modern/postmodern philosophy, which does not sufficiently answer to the lingering crisis of foundational certainty in political theory. In our view, the Czech playwright-turned-politician offers not merely a less confining sense of what it means to be 'postmodern,' but his commitment to moral political action also lends itself to overcoming some of the limitations (...) of contemporary postmodern theorizing by reentering the depreciated terrain of ontology. Specifically, we argue that an assessment of Havel's brand of postmodernism yields a rich interpretive harvest when read through ontological lenses. Indeed, Havel's theoretical posture serves as an instructive example of what political theorist Stephen K. White has called a 'felicitous weak ontology.'. (shrink)

Public health care interventions—regarding vaccination, obesity, and HIV, for example—standardly take the form of information dissemination across a community. But information networks can vary importantly between different ethnic communities, as can levels of trust in information from different sources. We use data from the Greater Pittsburgh Random Household Health Survey to construct models of information networks for White and Black communities--models which reflect the degree of information contact between individuals, with degrees of trust in information from various sources correlated with (...) positions in that social network. With simple assumptions regarding belief change and social reinforcement, we use those modeled networks to build dynamic agent-based models of how information can be expected to flow and how beliefs can be expected to change across each community. With contrasting information from governmental and religious sources, the results show importantly different dynamic patterns of belief polarization within the two communities. (shrink)

Analytic philosophers have been rather timid about moving beyond the relatively well defined epistemological issues and meta-ethical issues which have been the central concern of Anglo-Saxon philosophers. Yet there has always been the implicit claim that analytic tools could be extended to a much larger horizon. While there is little that is dramatic in this collection of essays, it does present some of the best contemporary Anglo-Saxon philosophers attempting to chart the logical geography of the concept of education and to (...) clear up a number of muddles that persistently cling to discussions of education. In addition to Peters, there are essays by Hamlyn, Hirst, Vesey, Dearsen, Black, Ryle, Scheffler, Oakeshott, J. P. White and Passmore.--R. J. B. (shrink)

Smart grids are rolling out internationally, with the United States nearing completion of a significant USD4-plus-billion federal program funded under the American Recovery and Reinvestment Act. The emergence of smart grids is widespread across developed countries. Multiple approaches to analyzing the benefits of smart grids have emerged. The goals of this white paper are to review these approaches and analyze examples of each to highlight their differences, advantages, and disadvantages. This work was conducted under the auspices of a joint U.S.-China (...) research effort, the Climate Change Working Group Implementation Plan, Smart Grid. We present comparative benefits assessments of smart grid demonstrations in the U.S. and China along with a BA of a pilot project in Europe. In the U.S., we assess projects at two sites: the University of California, Irvine campus, which consists of two distinct demonstrations: Southern California Edison’s Irvine Smart Grid Demonstration Project and the UCI campus itself; and the Navy Yard area in Philadelphia, which has been repurposed as a mixed commercial-industrial, and possibly residential, development. In China, we cover several smart-grid aspects of the Sino-Singapore Tianjin Eco-city and the Shenzhen Bay Technology and Ecology City. In Europe, we look at a BA of a pilot smart grid project in the Malagrotta area west of Rome, Italy, contributed by the Joint Research Centre of the European Commission. The Irvine sub-project BAs use the U.S. Department of Energy Smart Grid Computational Tool, which is built on methods developed by the Electric Power Research Institute. The TEC sub-project BAs apply Smart Grid Multi-Criteria Analysis developed by the State Grid Corporation of China based on the analytic hierarchy process with fuzzy logic. The B-TEC and TNY sub-project BAs are evaluated using new approaches developed by those project teams. JRC has adopted an approach similar to EPRI’s but tailored to the Malagrotta distribution grid. (shrink)

If stem cell-based therapies are developed, we will likely confront a difficult problem of justice: for biological reasons alone, the new therapies might benefit only a limited range of patients. In fact, they might benefit primarily white Americans, thereby exacerbating long-standing differences in health and health care.

The ethical principle of ‘respect for persons’ in clinical research has traditionally focused on protecting individuals’ autonomy rights, but respect for participants also includes broader, although less well understood, ethical obligations to regard individuals’ rights, needs, interests and feelings. However, there is little empirical evidence about how to effectively convey respect to potential and current participants. To fill this gap, we conducted exploratory, qualitative interviews with participants in a clinical genomics implementation study. We interviewed 40 participants in English or Spanish (...) about their experiences with respect in the study and perceptions of how researchers in a hypothetical observational study could convey respect or a lack thereof. Most interviewees were female, identified as Hispanic/Latino or non-Hispanic white, reported annual household income under US$60 000 and did not have a Bachelor’s degree ; 30% had limited health literacy. We identified four key domains for demonstrating respect: personal study team interactions, with an emphasis on empathy, appreciation and non-judgment; study communication processes, including following up and sharing results with participants; inclusion, particularly ensuring materials are understandable and procedures are accessible; and consent and authorisation, including providing a neutral informed consent and keeping promises regarding privacy protections. While the experience of respect is inherently subjective, these findings highlight four key domains that may meaningfully demonstrate respect to potential and current research participants. Further empirical and normative work is needed to substantiate these domains and evaluate how best to incorporate them into the practice of research. (shrink)

A high percent of oxidative energy metabolism is needed to support brain growth during infancy. Unhealthy diets and limited nutrition, as well as other environmental insults, can compromise these essential developmental processes. In particular, iron deficiency anemia has been found to undermine both normal brain growth and neurobehavioral development. Even moderate ID may affect neural maturation because when iron is limited, it is prioritized first to red blood cells over the brain. A primate model was used to investigate the neural (...) effects of a transient ID and if deficits would persist after iron treatment. The large size and postnatal growth of the monkey brain makes the findings relevant to the metabolic and iron needs of human infants, and initiating treatment upon diagnosis of anemia reflects clinical practice. Specifically, this analysis determined whether brain maturation would still be compromised at 1 year of age if an anemic infant was treated promptly once diagnosed. The hematology and iron status of 41 infant rhesus monkeys was screened at 2-month intervals. Fifteen became ID; 12 met clinical criteria for anemia and were administered iron dextran and B vitamins for 1–2 months. MRI scans were acquired at 1 year. The volumetric and diffusion tensor imaging measures from the ID infants were compared with monkeys who remained continuously iron sufficient. A prior history of ID was associated with smaller total brain volumes, driven primarily by significantly less total gray matter and smaller GM volumes in several cortical regions. At the macrostructual level, the effect on white matter volumes was not as overt. However, DTI analyses of WM microstructure indicated two later-maturating anterior tracts were negatively affected. The findings reaffirm the importance of iron for normal brain development. Given that brain differences were still evident even after iron treatment and following recovery of iron-dependent hematological indices, the results highlight the importance of early detection and preemptive supplementation to limit the neural consequences of ID. (shrink)