Objective: To examine i) how ethical frameworks can be used in concrete cases of parent–doctors’ disagreements for extremely preterm infants born in the grey zone to guide such difficult decision-making; and ii) what challenges stakeholders may encounter in using these frameworks. Design: We did a case analysis of a concrete case of parent–doctor disagreement in the grey zone using two ethical frameworks: the best interest standard and the zone of parental discretion. Results: Both ethical frameworks entailed similar advantages and challenges. (...) They have the potential 1) to facilitate decision-making because they follow a structured method; 2) to clarify the situation because all relevant ethical issues are explored; and 3) to facilitate reaching an agreement because all parties can explain their views. We identified three main challenges. First, how to objectively evaluate the risk of severe disability. Second, parents’ interests should be considered but it is not clear to what extent. Third, this is a value-laden situation and different people have different values, meaning that the frameworks are at least partially subjective. Conclusions: These challenges do not mean that the ethical frameworks are faulty; rather, they reflect the complexity and the sensitivity of cases in the grey zone. (shrink)

This study used a laboratory experiment with monetary incentives to test the impact of three personal factors (moral reasoning, value orientation and risk preference), and three situational factors (the presence/absence of audits, tax inequity, and peer reporting behavior), while controlling for the impact of other demographic characteristics, on tax compliance. Analysis of Covariance (ANCOVA) reveals that all the main effects analyzed are statistically significant and robustly influence tax compliance behavior. These results highlight the importance of obtaining a proper understanding of (...) these factors for developing effective policies for increasing the level of compliance, and indicate that standard enforcement polices based on punishment alone should be supplemented by an information system that would acquaint tax payers with the compliance level of other tax payers; reinforce the concept of fairness of the tax system among tax payers; and develop programs that enhance and appeal to a taxpayer's moral conscience and reinforce social cohesion. (shrink)

The upcoming U.S. Supreme Court decision in Dobbs v. Jackson Women’s Health Organization has the potential to eliminate or severely restrict access to legal abortion care in the United States. We a...

SummaryA sample of 104 British parents with criminal convictions had an average fertility of 3·91 children as compared with 2·21 for the general population. The result suggests that fertility for criminal behaviour is dysgenic involving an increase in the genes underlying criminal behaviour in the population.

Unrealistic optimism is a bias that leads people to believe, with respect to a specific event or hazard, that they are more likely to experience positive outcomes and/or less likely to experience negative outcomes than similar others. The phenomenon has been seen in a range of health-related contexts—including when prospective participants are presented with the risks and benefits of participating in a clinical trial. In order to test for the prevalence of unrealistic optimism among participants of early-phase oncology trials, we (...) conducted a survey with patients over 18 years of age who were enrolled in a phase I, phase I/II, or phase II clinical cancer trial in the New York City area between August 2008 and October 2009. Participants in our study were asked to compare their own chances of experiencing a range of risks and benefits related to the trial they were enrolled in with the chances of the other trial participants. We found a significant optimistic bias in their responses. Respondents tended to overestimate the benefits of the trial they were enrolled in and underestimate its risks. In addition, we found no significant relationship between respondents’ understanding of the trial’s purpose and how susceptible they were to unrealistic optimism. Our findings suggest that improving the consent process for oncology studies requires more than addressing deficits in understanding. (shrink)

We have conducted a retrospective study of deaths on a paediatric medical intensive care unit over a two-year period and reviewed similar series from outside the UK. There were 89 deaths out of 651 admission (13.7% mortality). In almost two-thirds of the cases death occurred with a decision to limit medical treatment or withdraw mechanical ventilation, implying that additional or further therapy was considered futile. We highlight this as a crucially important issue in the practice of intensive care. More comprehensive (...) studies are needed to help clinicians derive consensus on what constitutes a futile intervention, and therefore when such an intervention should be withheld. This will help families and society better understand the limitations of intensive care. (shrink)

The University of Pittsburgh Medical Center (UPMC) "Policy for the Management of Terminally Ill Patients Who May Become Organ Donors after Death" proposes to take organs from certain patients as soon as possible after expected cardiopulmonary death. This policy requires clear understanding of the descriptive state of the donor's critical cardiopulmonary and neurologic functional capacity at the time interventions to sustain or harvest organs are undertaken. It also requires strong consensus about the moral and legal status of the donor during (...) dying and confirmation of death. There has been no need for the clarity and precision that this policy relies upon, and thus the needed research and conceptual work has not previously been generated. The empiric base and societal consensus are both too frail to provide justification for this policy at this time. (shrink)

The first new translation of this work to appear in more than twenty-five years, the Columbia I Ching presents the classic book of changes for the world of today.

This paper argues that moral thinking is an essential management capability which strengthens organizations and contributes to theirperformance in the marketplace. The paper explains what moral thinking is, and addresses the most common reasons for considering it inappropriate or irrelevant to managerial practice. The argument provides a compelling rationale for the corporate ethics initiatives undertaken in recent years.

Drawing the line on physician assistance in physician-assisted death (PAD) continues to be a contentious issue in many legal jurisdictions across the USA, Canada and Europe. PAD is a medical practice that occurs when physicians either prescribe or administer lethal medication to their patients. As more legal jurisdictions establish PAD for at least some class of patients, the question of the proper scope of this practice has become pressing. This paper presents an argument for restricting PAD to the terminally ill (...) that can be accepted by defenders as well as critics of PAD for the terminally ill. The argument appeals to fairness-based paternalism and the social meaning of medical practice. These two considerations interact in various ways, as the paper explains. The right way to think about the social meaning of medical practice bears on fair paternalism as it relates to PAD and vice versa. The paper contends that these considerations have substantial force when directed against proposals to extend PAD to non-terminally ill patients, but considerably less force when directed against PAD for the terminally ill. The paper pays special attention to the case of non-terminally ill patients who suffer from treatment-resistant depression, as these patients present a potentially strong case for extending PAD beyond the terminally ill. (shrink)

The relationship between ethics and economics has never been easy. Opponents in a tug of war, friends in a warm embrace, ships passing in the night—the relationship has been highly variable. In recent years, the friendship model has been gaining credence, particularly among U.S. corporate executives. Increasingly, companies are launching ethics programs, values initiatives, and community involvement activities premised on management’s belief that “Ethics pays.”.

If people sometimes participate in research because of altruism—because they want to help in the search for treatments—should we revise our views about what kinds of experiments are ethical? If participants act out of altruism, we might let them accept greater risks than we would if they are motivated only by a desire for personal gain. But how can we know when participants are genuinely altruistic?

The requirement by the National Science Foundation (NSF) that research proposals include plans for “broader impact” activities to foster connections between Science, Technology, Engineering, and Math (STEM) research and service to society has been controversial since it was first introduced. A chief complaint is that the requirement diverts time and resources from the focus of research and toward activities for which researchers may not be well prepared. This paper describes the theoretical framework underlying a new strategy to pair NSF-funded nano (...) research centres with science museums in order to achieve greater success in the broader impact mission, and to transform the perceived burden of the requirement into an opportunity to provide enhanced value to the constituencies of the partnering organizations, as well as to the larger community. This partnership approach is presented as a model that also can be applied to NSF-funded research centres in other STEM fields, and to non-NSF-funded STEM research centres nevertheless looking to pursue broader impacts types of activities. The model also provides an opportunity to stretch the typical spectrum of broader impacts activities to include citizen engagement in science, technology and societal concerns. (shrink)

While pursuing agreement in a pluralistic society, American higher education has reduced the human identities necessary for the moral formation it inherently provides. Consequently, it fails to supply moral expertise for living the good life. Identity Excellence addresses this problem by proposing an interdisciplinary theory of identity excellence.

Recent years have witnessed a growing concern that terminally illpatients are needlessly suffering in the dying process. This has ledto demands that physicians become more attentive in the assessment ofsuffering and that they treat their patients as `whole persons.'' Forthe most part, these demands have not fallen on deaf ears. It is nowwidely accepted that the relief of suffering is one of the fundamentalgoals of medicine. Without question this is a positive development.However, while the importance of treating suffering has generally (...) beenacknowledged, insufficient attention has been paid to the question ofwhether different types of terminal suffering require differnt responsesfrom health care professionals. In this paper we introduce a distinctionbetween two types of suffering likely to be present at the end of life,and we argue that physicians must distinguish between these types if theyare to respond appropriately to the suffering of their terminally illpatients. After introducing this distinction and explaining its basis,we further argue that the distinction informs a (novel) principle ofproportionality, one that should guide physicians in balancing theircompeting obligations in responding to terminal suffering. As weexplain, this principle is justified by reference to the intereststerminally ill patients have in restoration, as well as in therelief of suffering, at the end of life. (shrink)

In this paper, we defend the ethics of clinical research against the charge of paternalism. We do so not by denying that the ethics of clinical research is paternalistic, but rather by defending the legitimacy of paternalism in this context. Our aim is not to defend any particular set of paternalistic restrictions, but rather to make a general case for the permissibility of paternalistic restrictions in this context. Specifically, we argue that there is no basic liberty-right to participate in clinical (...) research and that considerations of distributive fairness justify some paternalistic protections of research subjects. (shrink)

Some commentators have recently proposed that “clinical equipoise,” although widely accepted, is not necessary for morally acceptable research on human subjects. If this concept is rejected, however, we may find that trials not in the best medical interests of their subjects—”bad deal trials”—could be justified. To avoid exploiting participants, we must find a way to distribute the risks fairly, even if it means embracing radical changes in the way clinical research is conducted.

: "Clinical pragmatism" is an important new method of moral problem solving in clinical practice. This method draws on the pragmatic philosophy of John Dewey and recommends an experimental approach to solving moral problems in clinical practice. Although the method may shed some light on how clinicians and their patients ought to interact when moral problems are at hand, it nonetheless is deficient in a number of respects. Clinical pragmatism fails to explain adequately how moral problems can be solved experimentally, (...) it underestimates the relevance and importance of judgment in clinical ethics, and it presents a questionable account of the role that moral principles should play in moral problem solving. (shrink)

Moral distress is a phenomenon that has been receiving increasing attention in nursing and other health care disciplines. Moral distress is a concept that entered the nursing literature – and subsequently the health care ethics lexicon – in 1984 as a result of the work done by American philosopher and bioethicist Andrew Jameton. Over the past decade, research into moral distress has extended beyond the profession of nursing as other health care disciplines have come to question the impact of moral (...) constraint on individual practitioners, professional practice, and patient outcomes. Along with increased interest in the phenomenon of moral distress have come increasing critiques – critiques that in their essence point to a serious lack of conceptual clarity in the definition, study, and application of the concept. Foundational to gaining conceptual clarity in moral distress in order to develop strategies to prevent and ameliorate the experience is a careful revisiting of the epistemological assumptions underpinning our knowledge and use of the concept of moral distress. It is our contention that the conceptual challenges reveal flaws in the original understanding of moral distress that are based on an epistemological stance that holds a linear conception of cause and effect coupled with a simplistic perspective of ‘constraint’ and ‘agency’. We need a more nuanced approach to our study of moral distress such that our ontological and epistemological stances help us to better appreciate the complexity of moral agents acting in organizational contexts. We believe that critical realism offers such a nuanced approach. (shrink)

The term “exploitation” has gained wide currency in recent discussions of biomedical and research ethics. This is due in no small measure to the influence of Alan Wertheimer’s path-breaking work on the topic (Wertheimer 1999, 2011). Wertheimer presented a clear and compelling non-Marxist account of the concept of exploitation—one that stressed the connection between exploitation and unfair distributive outcomes. On this account, when one party exploits another, she takes advantage of the other to gain unfairly. A number of contemporary bioethicists (...) have accepted Wertheimer’s account of exploitation and have proceeded to apply it to a range of issues in research ethics (Hawkins and Emanuel 2008; Miller and Brody .. (shrink)

Scholars in the early seventeenth century who studied ancient Greek scientific theories often drew upon philology and history to reconstruct a more general picture of the Greek past. Gassendi's training as a humanist historiographer enabled him to formulate a conception of the history of philosophy in which the rationality of scientific and philosophical inquiry depended on the historical justifications which he developed for his beliefs. Professor Joy examines this conception and analyzes the nature of Gassendi's historical training, especially its relationship (...) to his career as a physicist and astronomer. She shows how he rehabilitated Epicurean atomism by bringing together the arguments of the Greek atomists and those of his contemporaries. In doing so, he produced an account of the natural world which made it an object of empirical study and mechanical explanation. (shrink)

The philosopher Donald Davidson has argued in an influential article, “On the Very Idea of a Conceptual Scheme,” that there is no intelligible basis on which to distinguish between conceptual schemes that Kuhn and Feyerabend have treated as incommensurable or incompatible. He concludes that, given the underlying methodology of interpretation of speech behavior, we cannot be in a position to judge that others have concepts or beliefs radically different from our own. Thus, he adds, we cannot talk meaningfully about the (...) existence of conceptual schemes. I offer a historical rejoinder to Davidson, focusing on the famous seventeenth-century debate between Descartes and Gassendi regarding the use of the first-person pronoun. I show that, in this particular debate, their failure to translate the pronoun “I” was so basic and fundamental a failure that, although it turned on just one word, it forced Gassendi to question the longstanding Renaissance humanist principle of the intertranslatability of all natural languages. Could the Gassendi-Descartes debate similarly challenge Davidson’s assertion of the intertranslatability of all natural languages and his consequent denial of the existence of conceptual schemes? (shrink)

Synaesthesia is an excellent model for understanding perceptual binding in the human brain. Current evidence suggests that if synaesthetic colour is bound, it is through the same attention-dependent integration of feature maps that occurs in other forms of binding. synaesthetic colour arises after the point that separate wavelengths blend in normal colour vision, which creates a perceptual paradox where synaesthetic and print colour can appear bound to a single location without blending. If a letter is printed in a colour that (...) is different from the synaesthetic colour it induces, the two hues will activate different hue-selective maps allowing for dual representation of colour, but if synaesthetic and print colours are the same/similar they will co-activate the same hue-selective map and create an amplified colour signal. Studies suggest that the parietal cortex plays a key role in this binding of synaesthetic and/or print colour to shape. (shrink)

Abstract:This essay reviews the 2013 Human Life International (HLI) propaganda video, Central America and Mexico: Fighting for Life, Faith, and Family, which, we argue, illustrates the well-orchestrated counteroffensive against reproductive and sexual rights movements occurring in the region. First we summarize the film's key themes, including the assertion that Catholicism is fundamental to Mexican and Central American identities and that the international “pro-abortion movement” is waging war against Catholics. Second, we note the development of a new strategic alliance between Catholics (...) and evangelicals that relies on lay religious activists working in the fields of medicine, bioethics, law, and government. Third, we show how the video appeals to HLI donors by asking them to support crisis pregnancy centres, homes for unwed mothers, adoption programs, and “natural” fertility assistance. We argue that the film conspicuously ignores the consequences of abortion bans already in place in Nicaragua, El Salvador, and Honduras, and does not consider that what it terms “international pressures” also includes treaty obligations with the United Nations and Organization of American States. This essay offers insights into the strategies used by opponents of reproductive and sexual rights movements in Mexico and Central America. (shrink)

When healthcare professionals feel constrained from acting in a patient’s best interests, moral distress ensues. The resulting negative sequelae of burnout, poor retention rates, and ultimately poor patient care are well recognized across healthcare providers. Yet an appreciation of how particular disciplines, including physicians, come to be “constrained” in their actions is still lacking. This paper will examine how the application of shared decision-making may contribute to the experience of moral distress for physicians and why such distress may go under-recognized. (...) Appreciation of these dynamics may assist in cross-discipline sensitivity, enabling more constructive dialogue and collaboration. (shrink)

This article critically analyzes the principle of beneficence and the principle of nonmaleficence in clinical medical ethics. It resists some recent skepticism about the principle of nonmaleficence, and then seeks to explain its role in medicine. The article proposes that the two principles are informed by different accounts of what is in the patient’s best interests. The principle of beneficence is tied to the patient’s best overall interests, whereas the principle of nonmaleficence is tied to the patient’s best medical interests (...) only. The article argues that the principle of nonmaleficence takes priority over the principle of beneficence in that it filters the treatment options that are appropriately subject to the principle of beneficence. Understanding how both principles can play an important role in medical practice, and how they relate when they come into conflict, can help clinicians to avoid certain mistakes in thinking about their duties to their patients. (shrink)

The persistence, and international expansion, of food banks as a non-governmental response to households experiencing food insecurity has been decried as an indicator of unacceptable levels of poverty in the countries in which they operate. In 1998, Poppendieck published a book, Sweet charity: emergency food and the end of entitlement, which has endured as an influential critique of food banks. Sweet charity‘s food bank critique is succinctly synthesized as encompassing seven deadly “ins” (1) inaccessibility, (2) inadequacy, (3) inappropriateness, (4) indignity, (...) (5) inefficiency, (6) insufficiency, and (7) instability. The purpose of this paper is to examine if and how the contemporary food bank critique differs from Sweet charity’s “ins” as a strategy for the formulation of synthesizing arguments for policy advocacy. We used critical interpretive synthesis methodology to identify relationships within and/or between existing critiques in the peer-reviewed literature as a means to create “‘synthetic constructs’ (new constructs generated through synthesis)” of circulating critiques. We analyzed 33 articles on food banks published since Sweet charity, with the “ins” as a starting point for coding. We found that the list of original “ins” related primarily to food bank operations has been consolidated over time. We found additional “ins” that extend the food bank critique beyond operations (ineffectiveness, inequality, institutionalization, invalidation of entitlements, invisibility). No synthetic construct emerged linking the critique of operational challenges facing food banks with one that suggests that food banks may be perpetuating inequity, posing a challenge for mutually supportive policy advocacy. (shrink)

ABSTRACT When applying moral principles to concrete cases, we assume a background shared understanding of the boundaries of the persons to whom the principles apply. In most contexts, this assumption is unproblematic. However, in end‐of‐life contexts, when patients are receiving ‘artificial’ life‐support, judgments about where a person's self begins and ends can become controversial. To illustrate this possibility, this paper presents a case in which a decision must be made whether to deactivate a patient's pacemaker as a means to hasten (...) his death. After discussing some common moral principles that are often applied to resolve ethical problems at the end of life and after explaining why they are of no help here, the paper argues that the correct analysis of this case, and of cases of this sort, turns on considerations that relate to the constitution of the self. These considerations, the paper further argues, sometimes resist resolution. The constitution of the self is fixed in large measure by our concepts and social conventions, and these do not always provide determinate grounds for delimiting the boundaries of the self. (shrink)

The movement in bioethics toward disclosure of financial conflicts of interest is well and good, most of the time. But in some cases, disclosure is not only unnecessary but destructive. When bioethicists advance arguments whose premises and logical moves are open to scrutiny, disclosure—far from clearing the air of bias—introduces bias.

This essay critiques feminist treatments of maternal-fetal "relationality" that unwittingly replicate features of Western individualism (for example, the Cartesian division between the asocial body and the social-cognitive person, or the conflation of social and biological birth). I argue for a more reflexive perspective on relationality that would acknowledge how we produce persons through our actions and rhetoric. Personhood and relationality can be better analyzed as dynamic, negotiated qualities realized through social practice.

The ethical standards that regulate clinical research have multiple rationales. Among them is the need to protect potential subjects from making imprudent decisions, which extends beyond the soft paternalistic concern to protect people from making uninformed decisions to participate in trials. This article argues that a plausible risk/benefit restriction on clinical trials is presumptively justified by hard paternalism, which in turn is supported by a deeper fairness-based rationale. This presumptive case for hard paternalism in research is not defeated by the (...) alleged right to participate in clinical trials, by concerns about insult or status, by the need to conduct early phase trials that promise little to no benefit to participants, or by the recognition that some potential subjects are altruistically motivated. (shrink)