Conflicts of interest. None to report. Despite widespread acceptance in the United States of neurological criteria to determine death, clinicians encounter families who object, often on religious grounds, to the categorization of their loved ones as “brain dead.” The concept of “reasonable accommodation” of objections to brain death, promulgated in both state statutes and the bioethics literature, suggests the possibility of compromise between the family’s deeply held beliefs and the legal, professional and moral values otherwise directing clinicians to withdraw medical (...) interventions. Relying on narrative to convey the experience of a family and clinical caregivers embroiled in this complex dilemma, the case analyzed here explores the practical challenges and moral ambiguities presented by the concept of reasonable accommodation. Clarifying the term’s meaning and boundaries, and identifying guidelines for its clinical implementation, could help to reduce uncertainty for both health care professionals and families and, thereby, the incremental moral distress such uncertainty creates. (shrink)

Van de Poel argues that nuclear power should be treated as an ongoing social experiment that needs to be continuously monitored and evaluated. In his reports (2009; Jacobs, Van de Poel, & Os...

Using a contingency theory framework, this study examines the relationship between a firm’s business-government relations (BGR) strategy, BGR structure, and BGR performance. Based on previous work, the study hypothesizes that BGR strategy determines, in part, the structure of the public affairs function, as well as the function’s effectiveness. Furthermore, the study contends that an appropriate fit between BGR strategy and BGR structure leads to improved BGR performance. Results indicate that there is a positive association between BGR strategies (buffering and bridging) (...) and BGR performance. There is also a positive association between BGR strategy and BGR formalization (structure). However, the study finds no direct association between BGR structure and performance. Further analysis reveals that it is a fit between a firm’s BGR strategy and BGR structure that leads to improved BGR performance. The associations between strategy, structure, fit, and performance offer empirical support for the relevance of the contingency theory framework to BGR research. (shrink)

This article examines the issue of illicit drug control across three broad levels of analysis. On one level, it examines the nature of the response to a ‘global phenomenon’ and its impact on national sovereignty. On a second level, it considers emergent state forms and practices and their relationship to global changes; and, thirdly, it grounds the analysis temporally and empirically in the contemporary European Union. The complex, evolving and essentially fragmented character of state power is placed in the context (...) of the classic state functions of authority and control. This is set against the growing transnational role of expert knowledge in policy‐making, and concludes with an assessment of the political implications that can be drawn from analysis of this complex set of factors. (shrink)

In this issue of Journal of Medical Ethics, Pugh1 offers a pluralist justice-based argument in support of the spirit, if not the precise letter, of the UK approach to the use of genetic test results to underwrite life insurance. We agree with Dr Pugh’s general contention that there is ethical and philosophical support for curtailment of insurers’ access to, and use of, applicants’ GTR in underwriting. However, we disagree with the contention that broad revisionary implications of certain theories of justice (...) render them unpersuasive. In fact, despite the competing theories, the United Nations Universal Declaration on the Human Genome and Human Rights has already made a clear statement on this issue. Article 6 of the Declaration,2 unanimously adopted in 1997 by 77 countries, along with a resolution for its implementation,3 states, ‘No one shall be subjected to discrimination based on genetic characteristics that is intended to infringe or has the effect of infringing human rights, fundamental freedoms and human dignity.’ Further, Article 25 of the UN Convention on the Rights of Persons with Disabilities prohibits discrimination against persons with disabilities in the provision of life insurance. These statements are not contingent on the acceptability of the degree of revisionary implications. They are clear, unambiguous statements about the obligations of signatory countries. Despite this, few countries have taken steps commensurate with this expectation, possibly due to the scale of changes required for proper ratification. However, genetic discrimination is recognised as one …. (shrink)

The International Committee of Medical Journal Editors is a working group of editors of selected medical journals that meets annually. Founded in Vancouver, Canada, in 1978, it currently consists of 11 member journals and a representative of the US National Library of Medicine. The major purpose of the Committee is to address and provide guidance for the conduct and publishing of biomedical research and the ethical tenets underpinning these activities. This advice is detailed in the Committee's Uniform Requirements for Manuscripts (...) Submitted to Biomedical Journals: Writing and Editing for Biomedical Publication . Recently, the ICMJE has adopted an interventionist role to ensure transparency of conflict of interest revelations in the conduct and publication of industry supported research. It also pursues a policy for the lodgement with trial registries of specified details of Phase III clinical trials. Failure to comply would jeopardise publication of trial outcomes in ICMJE member journals. This policy has resulted in the coming on stream of trial registries, international agreement on trial minimal datasets and compliance with trial registration requirements. (shrink)

We describe and analyze 13 cases handled by our ethics consultation service (ECS) in which families requested continuation of physiological support for loved ones after death by neurological criteria (DNC) had been declared. These ethics consultations took place between 2005 and 2013. Patients’ ages ranged from 14 to 85. Continued mechanical ventilation was the focal intervention sought by all families. The ECS’s advice and recommendations generally promoted “reasonable accommodation” of the requests, balancing compassion for grieving families with other ethical and (...) moral concerns such as stewardship of resources, professional integrity, and moral distress. In cases we characterized as finitegoal accommodation, a “reasonable accommodation” strategy proved effective in balancing stakeholders’ interests and goals, enabling steady progress toward resolution. When a family objected outright to a declaration of DNC and asked for an indefinite accommodation, the “reasonable accommodation” approach offered clinicians little practical direction, and resolution required definitive action by either the family or the clinical team. Based on our analysis and reflections on these 13 cases, we propose ethically justified and practical guidelines to assist healthcare professionals, administrators, and ECSs faced with similar cases. (shrink)

Editorial independence is crucial for the viability of a journal and editors have many masters - the public, the readers, the authors and the owners. Negotiating the resultant minefield requires a purposeful and independent stance. This is particularly so in instances of a relatively modern phenomenon: concerted attempts by clinical groups to influence, or even abort, publication of articles, which may threaten their practice. Moreover, modern social media facilitates this manipulation.

The theory that AIDS originated from contaminated polio vaccines raises a number of challenging issues with ethical dimensions. The Journal of Medical Ethics dealt with a submission about the theory a decade ago; subsequent developments have raised further issues. Four areas of contention are addressed: whether the theory should be investigated; whether anyone should be blamed; whether defamation actions are appropriate, and whether the scientific community has a responsibility to examine unorthodox theories.

Non-invasive prenatal testing is at the forefront of prenatal screening. Current uses for NIPT include fetal sex determination and screening for chromosomal disorders such as trisomy 21. However, NIPT may be expanded to many different future applications. There are a potential host of ethical concerns around the expanding use of NIPT, as examined by the recent Nuffield Council report on the topic. It is important to examine what NIPT might be used for before these possibilities become consumer reality. There is (...) limited research exploring views of women on possible future uses of NIPT, particularly those of women who have undergone NIPT. In this study, we examined the views of women who undertook NIPT previously on the acceptability of and interest levels in using NIPT for a number of current and possible future applications. These included several medical conditions encompassing psychiatric, neurodevelopmental and adult-onset conditions as well as non-medical traits such as intelligence. One thousand women were invited to participate and 235 eligible surveys were received. Women generally reported an interest in using NIPT for medical conditions that severely impacted quality of life and with an onset earlier in life and stressed the importance of the accuracy of the test. Concerns were raised about the use of NIPT for non-medical traits. Respondents indicated that termination of pregnancy was not their only reason for testing, particularly in the case of sex. These results can further inform the ethical debate around the increasing integration of NIPT into healthcare systems. (shrink)

The scope of noninvasive prenatal testing (NIPT) could expand in the future to include detailed analysis of the fetal genome. This will allow for the testing for virtually any trait with a genetic contribution, including “non-medical” traits. Here we discuss the potential use of NIPT for these traits. We outline a scenario which highlights possible inconsistencies with ethical decision-making. We then discuss the case against permitting these uses. The objections include practical problems; increasing inequities; increasing the burden of choice; negative (...) impacts on the child, family, and society; and issues with implementation. We then outline the case for permitting the use of NIPT for these traits. These include arguments for reproductive liberty and autonomy; questioning the labeling of traits as “non-medical”; and the principle of procreative beneficence. This summary of the case for and against can serve as a basis for the development of a consistent and coherent ethical framework. (shrink)

Although universal schooling has been adopted as a goal by international organizations, bilateral aid agencies, national governments, and non-profit organizations, little sustained international attention has been devoted to the purposes or goals of universal education. What is universal primary and secondary education intended to accomplish? This book, which grew out of a project of the American Academy of Arts & Sciences, offers views from Asia, Africa, Europe, North America and South America on the purposes of universal education while considering diverse (...) cultures, religions, and professions. It is the first book in which renowned authors from around the world have proposed, considered, and debated goals of basic and secondary education, engaging in a constructive dialogue on one of the most pressing issues facing education today. (shrink)

Checklists have been used to improve quality in many industries, including healthcare. The use of checklists, however, has not been extensively evaluated in clinical ethics consultation. This article seeks to fill this gap by exploring the efficacy of using a checklist in ethics consultation, as tested by an empirical investigation of the use of the checklist at a large academic medical system (Cleveland Clinic). The specific aims of this project are as follows: (1) to improve the quality of ethics consultations (...) by providing reminders to ethics consultants about process steps that are important for most patient-centered ethics consultations, (2) to create consistency in the ethics consultation process across the medical system, and (3) to establish an effective educational tool for trainers and trainees in clinical ethics consultation. The checklist was developed after a thorough literature review and an iterative process of revising and testing by a group of experienced ethics consultants. To pilot test the checklist, it was distributed to 46 ethics consultants. After a six-month pilot period in which ethics professionals used the checklist during their clinical activities, a survey was distributed to all of those who used the checklist. The 10-item survey examined consultants’ perceptions regarding the three aims listed above. Of the 25 survey respondents, 11 self-reported as experts in ethics consultation, nine perceived themselves to have mid-level expertise, and five self-reported as novices. The majority (68 percent) of all respondents, regardless of expertise, believed that the checklist could be a “helpful” or “very helpful” tool in the consultation process generally. Novices were more likely than experts to believe that the checklist would be useful in conducting consultations. The limitations of this study include: reduced generalizability given that this project was conducted at one medical system, utilized a small sample size, and used self-reported quality outcome measures. Despite these limitations, to the authors’ knowledge this is the first investigatation of the use of a checklist systematically to improve quality in ethics consultation. Importantly, our findings shed light on ways this checklist can be used to improve ethics consultation, including its use as an educational tool. The authors hope to test the checklist with consultants in other healthcare systems to explore its usefulness in different healthcare environments. (shrink)

Predictive genetic testing is now routinely offered to asymptomatic adults at risk for genetic disease. However, testing of minors at risk for adult-onset conditions, where no treatment or preventive intervention exists, has evoked greater controversy and inspired a debate spanning two decades. This review aims to provide a detailed longitudinal analysis and concludes by examining the debate's current status and prospects for the future. Fifty-three relevant theoretical papers published between 1990 and December 2010 were identified, and interpretative content analysis was (...) employed to catalogue discrete arguments within these papers. Novel conclusions were drawn from this review. While the debate's first voices were raised in opposition of testing and their arguments have retained currency over many years, arguments in favour of testing, which appeared sporadically at first, have gained momentum more recently. Most arguments on both sides are testable empirical claims, so far untested, rather than abstract ethical or philosophical positions. The dispute, therein, lies not so much in whether minors should be permitted to access predictive genetic testing but whether these empirical claims on the relative benefits or harms of testing should be assessed. (shrink)

The commercialization of ‘big science’ is in full swing, leading to situations in which the ethical principles of academia are beginning to be compromised. This is exemplified by the profitable business of genetic ancestry testing. The goals of this sort of ‘big science’ are not necessarily in any way novel, however. In particular, large genotyping projects have a certain start‐up time when their design is frozen in, so that the projects often lag behind the development of genetic knowledge. On the (...) other hand, extremely provisional knowledge about potential disease markers is being rapidly turned into questionable ‘tests’, purporting to determine risk factors for complex disorders, by private companies that are eager to get their share of a profitable market of the future. The flow of money generated by such concerns looks likely to erode traditional research operations and small‐scale projects, which risk becoming pebbles on the ‘big science’ landscape. BioEssays 30:1246–1251, 2008. © 2008 Wiley Periodicals, Inc. (shrink)

What are the most fundamental features of the world? Do minds stand outside the natural order? Is a unified picture of mental and physical reality possible? The Mind in Nature provides a staunchly realist account of the world as a unified system incorporating both the mental and the physical.

IT IS SHOWN IN DETAIL THAT RECENT ACCOUNTS FAIL TO DISTINGUISH BETWEEN INTENTIONALITY AND MERELY CAUSALLY DISPOSITIONAL STATES OF INORGANIC PHYSICAL OBJECTS—A QUICK ROAD TO PANPSYCHISM. THE CLEAR NEED TO MAKE SUCH A DISTINCTION GIVES DIRECTION FOR FUTURE WORK. A BEGINNING IS MADE TOWARD PROVIDING SUCH AN ACCOUNT.

Using traditional meta-analytic techniques, we compile relevant research to enhance conceptual appreciation of ethical climate theory (ECT) as it has been studied in the descriptive and applied ethics literature. We explore the various treatments of ethical climate to understand how the theoretical framework has developed. Furthermore, we provide a comprehensive picture of how the theory has been extended by describing the individual-level work climate outcomes commonly studied in this theoretical context. Meta-analysis allows us to resolve inconsistencies in previous findings as (...) well as confirm the central tenets of the overall ethical climate framework. In addition, we consider the ethical climate relationships in the larger context of the␣theoretical framework, using path analysis to test the structural relationships. Overall, our results provide evidence of the relationships between ethical climate perceptions and individual-level work outcomes. Based on our analyses, we offer future research directions important for further development of ECT. (shrink)

'Why did the window break when it was hit by the stone? Because the window is brittle and the stone is hard; hardness and brittleness are powers, dispositional properties or dispositions.' Dispositions are essential to our understanding of the world. This book is a record of the debate on the nature of dispositions between three distinguished philosophers - D. M. Armstrong, C. B. Martin and U. T. Place - who have been thinking about dispositions all their working lives. Their (...) distinctive accounts cover many of the issues surrounding dispositions such as the nature of mind, matter, universals, existence, laws of nature and causation. Dispositions illuminates this central topic in analytic philosophy and at the same time highlights deeper concerns of metaphysics. (shrink)

0-categorical o-minimal structures were completely described by Pillay and Steinhorn 565–592), and are essentially built up from copies of the rationals as an ordered set by ‘cutting and copying’. Here we investigate the possible structures which an 0-categorical weakly o-minimal set may carry, and find that there are some rather more interesting examples. We show that even here the possibilities are limited. We subdivide our study into the following principal cases: the structure is 1-indiscernible, in which case all possibilities are (...) classified up to binary structure; the structure is 2-indiscernible, classified up to ternary structure; the structure is 3-indiscernible, in which case we show that it is k-indiscernible for every finite k. We also make some remarks about the possible structures of higher arities which an 0-categorical weakly o-minimal structure may carry. (shrink)