The COVID-19 pandemic has raised a host of ethical challenges, but key among these has been the possibility that health care systems might need to ration scarce critical care resources. Rationing p...

For all of the emphasis on quality improvement—as well as the acknowledged overlap between assessment of the quality of healthcare services and clinical ethics—the quality of clinical ethics consultation has received scant attention, especially in terms of empirical measurement. Recognizing this need, the second edition of Core Competencies for Health Care Ethics Consultation identified four domains of ethics quality: (1) ethicality, (2) stakeholders’ satisfaction, (3) resolution of the presenting conflict/dilemma, and (4) education that translates into knowledge. This study is the (...) first, to our knowledge, to directly measure all of these domains. Here we describe the quality improvement process undertaken at a tertiary care academic medical center, as well as the tools developed to measure the quality of ethics consultation, which include post-consultation satisfaction surveys and weekly case conferences. The information gained through these tools helps to improve not only the process of ethics consultation, but also the measurement and assurance of quality. (shrink)

Given narrow operating margins, health care organizations are increasingly relying on philanthropy to fund operations. Since individuals provide the majority of philanthropic support, many organizations have expanded their “grateful patient fundraising” programs to include current inpatients, both established donors as well as persons of wealth. While this is legally permissible under HIPAA, it raises substantial ethical concerns for potential coercion of vulnerable patients, as well as unequal care stemming from preferential treatment and provided “amenities.” While some have drawn the analogy (...) to the additional comforts provided to first-class airline passengers, this analogy is flawed because of the potential clinical impact of the opportunities and services provided, especially to merely potential donors. From an ethical perspective, such programs should only provide non-clinical amenities to established donors, and at the same time strive for maximal transparency whereby all patients are assured of equal care and are fully informed of the specific benefits associated with any potential donation. (shrink)

As the population in the United States gets older, more people suffer from dementia, which often causes neuropsychiatric symptoms such as agitation and paranoia. This can lead patients to refuse medications, prompting consideration of covert administration (that is, concealing medication in food or drink). While many condemn this practice as paternalistic, deceptive, and potentially harmful, the end result of assuming the “moral high ground” can be increased suffering for patients and families. This article addresses common criticisms of covert medication and (...) presents a detailed algorithm by which to determine whether the practice is ethically permissible in specific cases. It also explores why so little attention has been paid in the U.S. to this presumably common practice, and reviews professional statements from Europe that endorse the practice. Finally, it presents a compelling argument for the role of Ulysses clauses in advance care planning, not only for patients with psychiatric illness but also for those who may suffer from dementia, which is far more common. (shrink)

Clinical simulation using standardized patients has become standard in medical education—and is now being incorporated into some graduate programs in bioethics—for both formative and summative evaluation. In most hospitals, though, clinical ethics consultation is done by the ethics committee (or a subset of it). This study is the first, to our knowledge, to examine the effectiveness of standardized patient simulation in training hospital ethics committees to deal with ethically complex and emotionally fraught clinical situations. Following a substantial revision of the (...) institution’s nonbeneficial treatment policy, ethics committee members underwent a simulation to determine whether a specific requested treatment should be withheld on the basis of futility. Pre- and postintervention surveys showed improvement in all domains, although the small sample size limited the power of the study, with only one measure showing a statistically significant difference. An interesting incidental finding was that one-quarter of committee members voted against a determination of futility, even though the case clearly met the definition set forth in the policy. This highlights the emotional challenges in implementing an ethically rigorous, unanimously accepted policy that ultimately determines the timing and manner of a patient’s death. (shrink)

Background Because opioids can suppress respiratory drive, the principle of double effect (PDE) has been used to justify their use for terminally ill patients. Recent studies, however, suggest that the risk of respiratory depression in typical end-of-life (EOL) situations may be overstated and that heightened concern for this rare occurrence can lead to inadequate treatment of pain. The purpose of this study is to examine the role of the PDE in medical school ethics education, with specific reference to its potential (...) impact on pain management at EOL. Method After obtaining institutional review board approval, an electronic survey was sent to ethics educators at every allopathic medical school in the USA. Results One-third of ethics educators felt that opioids were ‘likely’ to cause significant respiratory depression that could hasten death. Educators' opinions of opioid effects did not influence their view of the relevance of the PDE, with approximately 70% deeming it relevant to EOL care. Only 15% of ethics educators believed that associating the PDE with opioid use might discourage clinicians from optimally treating pain, out of concern for respiratory depression. Conclusion This study demonstrates that a significant minority of ethics educators believe, contrary to current evidence, that opioids are ‘likely’ to cause significant respiratory depression that could hasten death in terminally ill patients. Yet, many of those who do not feel this is likely still rely on the PDE to justify this possibility, potentially (and unknowingly) contributing to clinical misperceptions and underutilisation of opioids at EOL. (shrink)

Typically, the determination of death by neurological criteria follows a very specific protocol. An apnea test is performed with further confirmation as necessary, and then mechanical ventilation is withdrawn with the consent of the family after they have had an opportunity to “say goodbye,” and at such a time to permit organ retrieval (with authorization of the patient or consent of the next of kin). Such a process maximizes transparency and ensures generalizability. In exceptional circumstances, however, it may be necessary (...) to deviate from this protocol in order to spare family members unnecessary suffering and to reduce moral distress felt by clinical staff. It may also be appropriate, we argue, to refrain from even inquiring about organ donation when the next-of-kin is not only certain to refuse, but lacks the decision-making capacity to potentially consent. The case described in this article calls into question generally reliable assumptions about determination of death by neurological criteria, where the best the clinical team could do for the patient and his family was “the least bad option.”. (shrink)

A comprehensive analysis of ethical topics in palliative care, combining clinical experience and philosophical rigor. A broad array of topics are explored from historical, legal, clinical, and ethical perspectives, offering both the seasoned clinician and interested lay reader a thorough examination of the complex ethical issues facing patients suffering from life-threatening illness.

Health care reform is bottled up. Socially responsible physicians, forced to curtail care to uninsured patients, should respond with organized, open defiance, by billing the costs of the care to the accounts of patients covered under Medicaid or Medicare. Reverse cost‐shifting: maybe it could work, certainly it would be justified.

Many patients believe that cardiopulmonary resuscitation (CPR) is more likely to be successful than it really is in clinical practice. Even when working with accurate information, some nevertheless remain resolute in demanding maximal treatment. They maintain that even if survival after cardiac arrest with CPR is extremely low, the fact remains that it is still greater than the probability of survival after cardiac arrestwithoutCPR (ie, zero). Without realising it, this line of reasoning is strikingly similar to Pascal’s Wager, a Renaissance-era (...) argument for accepting the proposition for God’s existence. But while the original argument is quite logical—if not universally compelling—the modern variant makes several erroneous assumptions. The authors here present a case of a patient who unwittingly appeals to Pascal’s Wager to explain his request for maximal treatment, in order to highlight the crucial divergences from the original Wager. In understanding the faulty assumptions inherent in the application of Pascal’s Wager to code status decisions—and identifying the underlying motivations which the Wager serves to confirm—providers can better ensure that the true values and preferences of patients are upheld. (shrink)

Obese people consume significantly greater amounts of health resources. This study set out to determine if health resource utilization by obese people decreases after losing weight in a comprehensive medically supervized weight management programme. Four hundred and fifty-six patients enrolled in a single-centred, multifaceted weight loss programme in a universal health care system were studied. Patient information was anonymously linked with administrative databases to measure health resource utilization for 1 year before and after the programme. Mean body mass index (BMI) (...) decreased by more than 15%. The mean annual physician visits (pre = 9.6, post = 9.4) did not change significantly after the programme. However, patients saw a significantly fewer number of different physicians per year following the programme (pre = 4.5, post = 3.9; P < 0.001). Mean annual number of emergency visits (pre = 0.2; post = 0.2) and hospital admissions (pre = 0.05; post = 0.08) did not change. Neither baseline BMI, nor its change during the programme, influenced changes in health resource utilization. Our study suggests that weight loss in a supervized weight management programme does not necessarily decrease short-term health resource utilization. Further study is required to determine if patients who maintain their weight loss experience a decrease in health utilization. (shrink)

Trust is both ethically important and essential for business but difficult to measure. This paper contributes toward clarifying the nature of trust in a way that is both conceptually helpful for ethical inquiries concerning business and pertinent to the measurement of trust as an element in organizations. Several papers hypothesize that increasing the role of trust in a corporation reduces the need for external monitoring and contracts. Assessing this important hypothesis requires a way to gauge whether a firm has a (...) trusting corporate culture. We develop an objective measure of trust in a firm’s corporate culture by counting the number of times 21 trust-related words appear in an important kind of document: the Management Discussion and Analysis section of the annual report. We report two significant findings: that, contrary to what one might think, firms with a trusting culture frequently use audit and control-type words and that trust is positively linked with subsequent share price volatility. We propose explanations of these findings with the hope of facilitating the objective measurement of trust and enhancement of a trusting atmosphere in corporate culture. (shrink)

: One of the greatest poets of the Victorian period, Robert Browningis taught universally from school through university levels. Given suchmagnitude, the multifaceted poet deserves research attention from variousperspectives. A fascinating aspect of his poetry is that, in spite of his refusal tobe labelled as a Christian, he displays strong faith in God and the afterlife. Hispoetry is steeped in religious connotations that derive heavily from the Bible.There are striking similarities between many concepts preached by Islam andChristianity. It will (...) be interesting to view his poetry from the perspectiveof the former. Islam emphasises its own unique concepts and values to helpits adherents achieve their vision of success. Browning, though acceptingthe central ideas of Christianity, deviates from it conceptually. Given thisbackground, this article attempts to evaluate his notion of faith and its practicefrom Islamic perspectives and discover where the poet’s ideas converge withthose of Islam and where they differ. (shrink)

Kant famously argued in the Groundwork that our fundamental moral obligation is simply to respect the humanity in persons. However, his fuller view, found in the Metaphysic of Morals, is that the humanity in persons not only demands our respect, but also our love. Neither of these demands, of course, requires that we feel anything for others, and Kant is much more specific here about what constitutes respect between persons. But in elaborating this position he also claims that these demands (...) are somehow opposed, as though love were a sort of moral gravity and respect a sort of moral centrifugal force, which together create a cohesive moral/social bond, but alone would allow “nothingness (immorality)... [to] drink up the whole kingdom of (moral) beings” (MdS 6:449). Marcia Baron, in her illuminating paper, argues that this and related remarks are surely an exaggeration. After all, respect sometimes requires that we come closer and love sometimes imposes limits. And not only does Kant ground all duties in respect, but this is the same philosopher who, early on in the Groundwork, claimed that the Christian command to “love our neighbor” must be understood as commanding, not a feeling, but “beneficence from duty” (G 4:399). Since acting from duty is acting out of respect, “practical” love itself requires respect. So why does he think that they are opposing forces? (shrink)

This is a superb anthology that questions the value and even the existence of honor in the contemporary world. Although readers have had the benefit of excellent works on this concept from mainly a...

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:A Nietzschean Bestiary: Becoming Animal Beyond Docile and BrutalRobert N. MatuozziA Nietzschean Bestiary: Becoming Animal Beyond Docile and Brutal, edited by Christa Davis Acampora and Ralph R. Acampora ; xxxii & 371 pp. Lanham, MD: Rowman & Littlefield, 2004. $75.00 cloth, $29.95 paper.What if instead of re-reading Nietzsche's corpus, one imagines what it would be like to view his works on the "Nietzsche Network." Imagine a spectator situated (...) in the middle of a vast amphitheatre preparing to watch these simulacra. Gazing up and around a series of giant, flat-screen video monitors arrayed in layers around the interior wall of an amphitheatre, the spectator views and listens to Nietzsche's multi-media texts as, simultaneously, they seductively flash their provocative narratives in flickering streams of high-resolution sounds, words, and images.The Nietzsche Network is a roaring carnival. It consists of colorful, speculative historical dramatizations and equally enticing philosophical tableaux. Dark ambient musical motifs, laced with interludes of explosive, uncontrollable laughter, are a subliminal presence. Lurid detective stories and somber cultural narratives and slashing polemics implicate cultures and ideologies in festivals of cruelty and soul-murder. Poignant genealogical and aphoristic asides on joy [End Page 443] and work and suffering, weird psychological skits starring well-known ensemble casts are accompanied by hoarse oratory, soaring denunciations, and sober etymological digressions. Intermittently, the spectator is startled by abrupt, sometimes strident proclamations, like confessional bulletins shot from nowhere.Nietzsche's siren-like prose exhibits an extraordinary rhetorical range. This is particularly true of the polychromatic works originally published in the gloaming of his career in the period after 1886. Nietzsche's compelling, fluvial style is accounted for in this volume by the kinetic movements of lizards and the halcyon tones of birds, to his study of the ancient Greek and Roman classics (and to the lost musicality of Greek tragedy in particular), and to his emphatic embrace of a kind of plosive, Dionysian philosophical technics.The content of the Nietzsche Network spans thousands of years of human experience and thought. A prequel features a substantial bestiary of traditional animals and emergent biomorphic forms set in a variety of carefully animated zoological dioramas. Among the modernists, has there been another thinker as strangely original and subversive? Allowing for fundamental differences, only Valéry comes to mind. Like the silent, ruminating cow in his "untimely" essay on history, Nietzsche prevents the past from injecting noise into present and future philosophizing. He will be the exemplary philosopher of the other-than-human as he campaigns to re-inscribe human animality into the zoological text of nature. Through explicit pronouncements and in scattered philosophical sorties involving human animality and his (desperate) utopist vision of human perfectibility, Nietzsche attempted to attain—at least conceptually—what Richard Rorty aptly calls the "historical sublime, a future which has broken all relations with the past."This excellent collection of essays on Nietzsche's bestiary demonstrates the surprising persistence of the animal imaginary in his thought. The various pieces also illuminate the multiple thematic and linguistic transformations Nietzsche develops as he enlists animals in his feral, anti-essentialist dialectic on the obscure continuum between "humans," "animals," and "nature." It turns out that a degraded version of Nietzsche's strangest thought experiment on animalism, the übermensch, is perhaps only a few years away from being produced through emerging boutique bioengineering, a prospect that has some commentators on both the left and the right blinking with apprehension. These essays amply demonstrate that Nietzsche's bestial philosophy of human and animal alterity subverts, among other paradigms, the strange Cartesian notion that animals are mechanical automata while humans are transcendental rationalists. As one commentator in this book broadly puts it, Nietzsche shows that the various schemes concocted to put an illusory distance between humans and animals have ended up being an immensely corrupting "pretense" (p. 224).Precursor bestiaries are indicated in this volume, though the medieval tradition originating in the Physiologus is here mostly displaced by a different [End Page 444] menagerie of cultural affiliations. The fabulist Aesop is present, along with Aristotle and Montaigne, though La Fontaine is not, and Pico Mirandola's famous remarks in his Oration on... (shrink)

Little is known about how researchers view ethically salient aspects of human studies. As part of a National Institutes of Mental Health-funded study, the authors performed a confidential written survey to assess the attitudes, views, and experiences of researchers with institutional review board approved protocols at the University of New Mexico. A total of 363 researchers (57% response rate) participated. Investigators overall held favorable views of general ethical aspects of research and ethics-based safeguards, and they identified a positive role of (...) ethics training. Investigators with more experience encountering ethical problems (p < .001), more ethics training (p = .001), and a PhD or MD/PhD (p = .003) held more favorable general ethical perspectives. Women investigators (p < .03), nonphysician investigators (p < .001), those whose training had been helpful in resolving ethical dilemmas (p = .006), and those for whom spirituality is important (p = .008) more strongly endorsed ethical safeguards. Investigators perceive the scientific and ethical aspects of their work as valuable and linked, and they affirm the role of safeguards in human studies. Formal ethics preparation and training initiatives were also viewed positively by investigators. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Post-Genomic RevolutionA Paradigm Shift for Biopsychosocial SystemsClaude Robert Cloninger, MD, PhD (bio)The pstchologist Danielle Dick and psychiatrist Kenneth Kendler (DK) began an ongoing study in 2011 called Spit for Science (S4S) in which they obtained saliva as a peripheral source of DNA along with assessment of detailed self-report information on alcohol and other substance use, selected personality traits, and psychosocial history about the students entering a large (...) university (Dick et al., 2014). They hoped to identify the genes underlying the heritability of alcohol use and related behaviors to inform students about their individual risk, and thereby to promote increased self-awareness and health. The students were highly cooperative volunteers, and many peer-reviewed research papers have been published from these data.Eric Turkheimer, a psychologist who studies how genes and environments shape the development of human behavior (Harden et al., 2007; Loehlin et al., 2009; Turkheimer et al., 2003), reviewed all the resulting publications coming from S4S along with coauthor Sarah Greer (Turkheimer & Greer, 2024). Turkheimer and Greer (TG) were surprised to find the study has failed to identify any genes that have substantial (“nontrivial”) effects on reported levels of consumption or problems related to their use of alcohol or other substances, except for a variant of the gene for aldehyde dehydrogenase (ALDH2), which was already known to cause many people of Asian descent to flush when they drink alcohol. TG state that, “Again and again, the results of S4S investigations demonstrated tiny, and frequently null, contributions of genetics to differences in drinking and related behaviors among college students. GWAS [genome-wide association studies] revealed practically no genome-wide significant SNPs [single nucleotide polymorphisms], and the SNPs identified at less stringent levels of significance were never mentioned more than once” (Turkheimer & Greer, 2024).TG concluded that the design, execution, psychometric measures, and analysis of the data were excellent. However, they also discuss facts that raise doubts about the adequacy of the design and methods. Namely, it is an inconvenient fact, [End Page 429] but widely known, that approaches to GWAS that are frequently used in psychiatric genetics require huge samples (often hundreds of thousands) to detect statistically significant genes because the observed effects have consistently been weak whenever genes are assumed to act independently, as did DK. Consequently, polygenic risk scores are weak and inconsistent predictors of behavioral phenotypes (Zwir et al., 2020c). Nevertheless, TG fault DK and their coauthors for an overemphasis on statistical significance in large samples rather than prominently reporting that the observed effect sizes of genes were only weakly and inconsistently associated with any measured features of substance use.TG report that they were surprised by the weak and inconsistent findings from genetic variants from this GWAS because they knew that twin and family studies (i.e., what they call “genetics at altitude”) have previously found strong and consistent evidence of the heritability of phenotypes like those measured by DK. For example, in my own research with adoptees separated from their biological parents at an early age and reared by adoptive parents, the risk of alcohol abuse in adoptees was strongly predicted by alcohol abuse and related behaviors in their biological, but not adoptive, parents (Bohman et al., 1981; Cloninger et al., 1981; Sigvardsson et al., 1996) and by their childhood personality, particularly novelty seeking, when the children were followed into young adulthood (Cloninger, 1987; Cloninger et al., 1988). However, it is well-known that the methods used by DK for GWAS consistently fail to detect most of the heritable variance for behavioral phenotypes estimated in twin studies, which include much variability from complex patterns of gene–gene interaction (Table 1) (Cloninger & Zwir, 2022). This consistent observation in GWAS studies that assume genes act independently is called the missing or hidden heritability problem.Nevertheless, DK expressed optimism in 2011 that genome-wide measurement of genetic variants would identify genetic markers to predict risk of alcohol-related phenotypes in college students. They do so because they assume that all the information about heritable processes can be extracted from genome-wise scans of SNPS. The heritable phenotypes of interest in S4S included patterns of use of alcohol and other recreational... (shrink)

Jack Henry Abbott, In the Belly of the Beast: Letters from Prison, New York: Random House, 1981, xvi + 166 pp. John Monahan, The Clinical Prediction of Violent Behavior Rockville, Md.: National Institute of Mental Health, 1981, xi + 134 pp.

Calls for the “translation” of research from bench to bedside are increasingly demanding. What is translation, and why does it matter? We sketch the recent history of outcome-oriented translational research in the United States, with a particular focus on the Roadmap Initiative of the National Institutes of Health (Bethesda, MD). Our main example of contemporary translational research is stem cell research, which has superseded genomics as the translational object of choice. We explore the nature of and obstacles to translational research (...) and assess the ethical and biomedical challenges of embracing a translational ethos. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Ethics & the Enviornment 6.2 (2001) 114-118 [Access article in PDF] Book Review Child versus Childmaker: Future Persons and Present Duties in Ethics and the Law Child versus Childmaker: Future Persons and Present Duties in Ethics and the Law. Melinda A. Roberts. Lanham, Md.: Rowman & Littlefield, 1998. Pp. 235. ISBN 0-8476-8901-8 (Paperback) This book will provide the reader with a systematic examination of some of the most difficult (...) philosophical issues involved in procreation, and most notably those raised by wrongful life claims and the non-identity problem. Can an action without which a given child would not even exist be simultaneously said to harm this very child? This is the key question addressed in this book. It is relevant not only to bioethicists, but also to those concerned with the possibility of harming members of future generations in general. The author proceeds with remarkable clarity in three steps. First, she unveils the core intuition and unfolds the key implications of what is standardly referred to as the person-affecting view. Second, she focuses on the now famous non-identity problem that is supposed to raise a serious challenge to the plausibility of the person-affecting view. Third, wrongful life and human cloning are taken as illustrations of the problem.The starting point is thus the person-affecting or personalist view. The author argues that what is at stake in such a view is not only a concern for [End Page 114] persons (as opposed to plants or stones), but also for definite persons. The core intuition that "what is bad must be bad for someone" (Derek Parfit) implies a comparison between two states of the same person. As she puts it, "the pairwise comparisons of worlds appealed to within personalism are always in respect of particular people" (6). This does not necessarily imply consequentialism, contrary to what Roberts claims (e.g., 1), at least if we understand the latter, for example, as Philip Pettit does. 1 Moreover, one may very well argue that what is at the heart of the person-affecting intuition is a sense that an action needs to be assessed on the basis of its effect on persons, which would not necessarily imply that such effects require a comparison between two states of the same person. Nevertheless, the extent to which a person-affecting conception--as defined by Roberts--will be in trouble depends on the extent to which comparisons between the same person's states cannot operate. This is precisely where to introduce the idea of a non-identity context, that is, a situation in which not committing an allegedly harmful act would or could also have meant the nonexistence of the allegedly harmed person. For example, had a medical doctor not committed this preconceptional diagnostic mistake (or a father taken a slower or faster means of transportation to come back home), this child would or could not have existed. Can we thus say that the practitioner harmed the child who turned out to be heavily handicapped due, for example, to a genetically transmissible disease (or that the father harmed his child by leaving him with a very polluted environment due to his use of big cars as a means of transportation)?One key feature of Roberts's approach is that she restricts the scope of the non-identity problem to cases where not committing the allegedly harmful action would have made it impossible for this child to have existed ("two-alternative" cases) (26, 319, 325). This entails that whenever this very child could still have come to existence in the allegedly harmful action's absence, whatever the likelihood of such a coming to existence, we would fall outside a non-identity context ("three-alternative" cases) (27; 94-95). What matters to Roberts is whether or not the same child could have been born better than he is, not whether he would, as a matter of fact, have been born at all. The consequence is that in cases where the same child could have been born, say, unhandicapped, the author remains... (shrink)

Is goodness without god good enough? A debate on faith, secularism, and ethics Content Type Journal Article DOI 10.1007/s11153-010-9243-8 Authors Wes Morriston, University of Colorado, Boulder Department of Philosophy Boulder CO 80309-0232 USA Journal International Journal for Philosophy of Religion Online ISSN 1572-8684 Print ISSN 0020-7047.

Robert Corrington's ever-emerging theory of ecstatic naturalism is dense with possibilities for secondary studies. The task of attending to the rich theoretical territory of Corrington's philosophical world is in itself deserving of many monograph-length treatments. Nam T. Nguyen's Natures Primal Self not only takes on this task but also triples the workload by attempting to compare and contrast Corrington's ideas with the philosophies of Charles Peirce and Karl Jaspers, who are notably difficult to penetrate in their own right and (...) conspicuously disparate from one another. As would be expected, Nguyen's study brings a plethora of interesting philosophical questions to the foreground with respect to these three .. (shrink)

Robert Sullivan, Liberalism and Crime: The British Experience Lanham, Md: Lexington Books, 2000, vii + 227pp.

At the turn of the century Martin Buber arrived on the philosophic scene... The path to his maturity was one long struggle with the problem of unity- in particular with the problem of the unity of spirit and life; and he saw the problem itself to be rooted in the supposition of the primacy of the subject-object relation, with subjects "over here," objects "over there," and their relation a matter of subjects "taking in" objects or, alternatively, constituting them. But Buber (...) moved into a position which undercuts the subject-object dichotomy and initiates a second "Copernican revolution" in philosophical thought. (shrink)