The concept of brain death was recently described as being “at once well settled and persistently unresolved.” Every day, in the United States and around the world, physicians diagnose patients as brain dead, and then proceed to transplant organs from these patients into others in need. Yet as well settled as this practice has become, brain death continues to be the focus of controversy, with two journals in bioethics dedicating major sections to the topic within the last two years.By way (...) of background, the Uniform Determination of Death Act states that “[a]n individual who has sustained either: irreversible cessation of circulatory and respiratory functions, or irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.” In other words, death can be defined by either cardiorespiratory or neurological criteria, with “brain death” representing the loss of all brain function. This standard, or closely related variants, has become the accepted approach throughout the United States and in many parts of the world. (shrink)

Over the past several decades, medical ethics has gained a solid foothold in medical education and is now a required course in most medical schools. Although the field of medical ethics is by nature eclectic, moral philosophy has played a dominant role in defining both the content of what is taught and the methodology for reasoning about ethical dilemmas. Most educators largely rely on the case‐based method for teaching ethics, grounding the ethical reasoning in an amalgam of theories drawn from (...) moral philosophy, including consequentialism, deontology, and principlism.In this article we hope to make a case for augmenting the focus of education in medical ethics. We propose complementing the traditional approach to medical ethics with a more embedded approach, one that has been described by others as “microethics,” the ethics of everyday clinical practice. (shrink)

Normothermic regional perfusion (NRP) is a relatively new approach to procuring organs for transplantation. After circulatory death is declared, perfusion is restored to either the thoracoabdominal organs (in TA-NRP) or abdominal organs alone (in A-NRP) using extracorporeal membrane oxygenation. Simultaneously, surgeons clamp the cerebral arteries, causing a fatal brain injury. Critics claim that clamping the arteries is the proximate cause of death in violation of the dead donor rule and that the procedure is therefore unethical. We disagree. This account does (...) not consider the myriad other factors that contribute to the death of the donor, including the presence of a fatal medical condition, the decision to withdraw life support, and the physician's actions in withdrawing life support and administering medication that may hasten death. Instead, we claim that physicians play a causative role in many of the events that lead to a patient's death and that these actions are often ethically and legally justified. We advance an “all things considered” view according to which TA-NRP may be considered ethically acceptable insofar as it avoids suffering and respects the wishes of the patient to improve the lives of others through organ donation. We conclude with a series of critical questions related to the practice of NRP and call for the development of national consensus on this issue in the United States. (shrink)

_A moving meditation on recent geopolitical crises, viewed through the lens of ancient and modern tragedy__ “Spare, elegant and poignant.... If there is a single contemporary book that should be pressed into the hands of those who decide issues of war and peace, this is it.”—John Gray, _New Statesman_ “It is tragic that Robert D. Kaplan’s luminous _The Tragic Mind_ is so urgently needed.”—George F. Will_ Some books emerge from a lifetime of hard-won knowledge. Robert D. Kaplan has (...) learned, from a career spent reporting on wars, revolutions, and international politics in Europe, the Middle East, and East Asia, that the essence of geopolitics is tragedy. In _The Tragic Mind_, he employs the works of ancient Greek dramatists, Shakespeare, German philosophers, and the modern classics to explore the central subjects of international politics: order, disorder, rebellion, ambition, loyalty to family and state, violence, and the mistakes of power. The great dilemmas of international politics, he argues, are not posed by good versus evil—a clear and easy choice—but by contests of good versus good, where the choices are often searing, incompatible, and fraught with consequences. A deeply learned and deeply felt meditation on the importance of lived experience in conducting international relations, this is a book for everyone who wants a profound understanding of the tragic politics of our time. (shrink)

Despite its familiarity and widespread acceptance, the concept of “brain death” remains incoherent in theory and confused in practice. Moreover, the only purpose served by the concept is to facilitate the procurement of transplantable organs. By abandoning the concept of brain death and adopting different criteria for organ procurement, we may be able to increase both the supply of transplantable organs and clarity in our understanding of death.

We seek to change the conversation about brain death by highlighting the distinction between brain death as a biological concept versus brain death as a legal status. The fact that brain death does not cohere with any biologically plausible definition of death has been known for decades. Nevertheless, this fact has not threatened the acceptance of brain death as a legal status that permits individuals to be treated as if they are dead. The similarities between “legally dead” and “legally blind” (...) demonstrate how we may legitimately choose bright-line legal definitions that do not cohere with biological reality. Not only does this distinction bring conceptual coherence to the conversation about brain death, but it has practical implications as well. Once brain death is recognized as a social construction not grounded in biological reality, we create the possibility of changing the social construction in ways that may better serve both organ donors and recipients alike. (shrink)

Savulescu and colleagues have provided interesting insights into how the UK public view the ‘best interests’ of children like Charlie Gard. But is best interests the right standard for evaluating these types of cases? In the USA, both clinical decisions and legal judgments tend to follow the ‘harm principle’, which holds that parental choices for their children should prevail unless their decisions subject the child to avoidable harm. The case of Charlie Gard, and others like it, show how the USA (...) and the UK have strikingly different approaches for making decisions about the treatment of severely disabled children. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 8.1 (2001) 17-19 [Access article in PDF] A Kleinian Contribution to the External World Robert D. Hinshelwood Radical feminism overstates its case and ignores the importance of individual psychology; at the same time, an individual psychology like psychoanalysis lacks a broader perspective that feminism might supply. Sarah Richmond's paper advocates a mutual enhancement of both psychoanalysis and feminism by combining the two perspectives. It (...) is a version of the old controversy over social influences versus innate influences--nature versus nurture.Richmond's thesis places a stress on the kind of psychoanalysis that might be most amenable to a reconciliation between social and psychological causations of individual attitudes. Interestingly, she argues that Kleinian psychoanalysis, which, by reputation, gives the greatest emphasis to the internal world of individuals, is the most suited for any reconciliation with the social--an argument that I would in fact endorse. It is simply because Kleinian psychoanalysis dwells on the internal world as a little society of internal beings that it may be most suited to bringing into contact with social explanations.One important dimension of this kind of reconciliation is that the world of internal objects (a kind of internal society) and the world of social persons could be seen in some correspondence, and indeed in the Kleinian view, there is a real correspondence between the two. That correspondence is actively and continuously mediated by phantasies of internalizing or externalizing persons and internal objects. The interchange can profoundly alter an individuals' internal objects, an influence determined by the external world of other persons and vice versa.This kind of correspondence between internal and external worlds (the individual and the social) can accomplish a mutual influencing of perceptions of other people and of the self. It can be the mechanism for the development of sets of attitudes on a social/cultural basis--including attitudes to gender. Similarly, the internalization of actual relations that exist between persons becomes the individual's accepted expectations of relationships, including sexual and erotic ones.The whole exchange process of internalization and externalization involves a primary evaluation of persons/objects and of the relations between them. Kleinian psychoanalysis argues that a primary function of the earliest ego in the individual is to evaluate objects as good or bad. Gendered persons are then internalized as objects having high or low values.Richmond exemplifies the necessary convergence of social and individual/personal points of view by considering the personal experiences that occur in anorexia. Clearly, the incidence of eating disorders varies between the genders, and the implication is that this is in part socially aroused--especially through the use of slender female bodies [End Page 17] in advertising and fashion. But also it is clearly mediated through individual agency (albeit probably the unconscious motivations known to psychoanalysts). Two Kleinian authors are examined to explore the possibilities of this kind of analysis.Richmond's thesis is applicable to gender relations in important ways, enriching both the psychoanalytic and socio-economic approaches that she is concerned with. However, where more work needs to be done, it seems to me, is in terms of power relations. Power relations are not theorized in psychoanalysis. There is thus little from the individual point of view that can contribute to a feminist analysis of power. And indeed this might be one significant point that Richmond refers to, where psychoanalysis can learn something from the social point of view.Elsewhere I have tried to conceptualize what a Kleinian view of power relations might be. 1 The account of Kleinian psychoanalysis above and in Richmond concerns the interchange of persons and internal objects, but we must also take account of Klein's descriptions of the paranoid-schizoid position (Klein 1946). There, the exchange of parts of the self with other persons is central. As an example, the study of institutionalization as an interpersonal process indicates an exchange between certain sub-groups within an institution of active and powerful parts of the self, as well the interchange of weak and submissive parts of the self. In a mental hospital, for instance, this ends... (shrink)

The Covid-19 pandemic has led to severe shortages of many essential goods and services, from hand sanitizers and N-95 masks to ICU beds and ventilators. Although rationing is not unprecedented, never before has the American public been faced with the prospect of having to ration medical goods and services on this scale.

Johan Brännmark's article “Patients as Rights Holders,” in this issue of the Hastings Center Report, squarely identifies some important problems with the way we in clinical practice conceive of our obligations to our patients. As a solution, he helpfully suggests augmenting our focus on autonomy and informed consent with a broader menu of considerations drawn from the literature on human rights. Respect for autonomy is, of course, one of the hallowed principles of bioethics. In our traditional understanding, our patients deserve (...) our respect because they are capable of autonomous choice, and the way we demonstrate our respect is by seeking their informed consent for our care. This model is so deeply ingrained that many of us have difficulty imagining that there could be any other way of thinking about it. But this model has two very serious drawbacks, problems that speak to much of what is wrong with health care today. (shrink)

Recent debates over adults' theory of mind use have been fueled by surprising failures of perspective-taking in communication, suggesting that perspective-taking may be relatively effortful. Yet adults routinely engage in effortful processes when needed. How, then, should speakers and listeners allocate their resources to achieve successful communication? We begin with the observation that the shared goal of communication induces a natural division of labor: The resources one agent chooses to allocate toward perspective-taking should depend on their expectations about the other's (...) allocation. We formalize this idea in a resource-rational model augmenting recent probabilistic weighting accounts with a mechanism for (costly) control over the degree of perspective-taking. In a series of simulations, we first derive an intermediate degree of perspective weighting as an optimal trade-off between expected costs and benefits of perspective-taking. We then present two behavioral experiments testing novel predictions of our model. In Experiment 1, we manipulated the presence or absence of occlusions in a director–matcher task. We found that speakers spontaneously modulated the informativeness of their descriptions to account for “known unknowns” in their partner's private view, reflecting a higher degree of speaker perspective-taking than previously acknowledged. In Experiment 2, we then compared the scripted utterances used by confederates in prior work with those produced in interactions with unscripted directors. We found that confederates were systematically less informative than listeners would initially expect given the presence of occlusions, but listeners used violations to adaptively make fewer errors over time. Taken together, our work suggests that people are not simply “mindblind”; they use contextually appropriate expectations to navigate the division of labor with their partner. We discuss how a resource-rational framework may provide a more deeply explanatory foundation for understanding flexible perspective-taking under processing constraints. (shrink)

While it may be controversial to categorize Plato’s Theatetetus as “epistemological,” given what is implied by this term, the dialogue does offer a discourse on knowledge, at least in the minimal sense of questioning knowledge. But more than that, the dialogue “situates” its questioning, and its critical examination of attempted definitions of knowledge, in two ways that are particularly illuminating: first, its dramatization of Socrates coming-to-know Theaetetus through philosophical dialogue; second, its taking for granted a whole array of epistemic practices (...) and keeping them in view, peripherally, throughout the discussion. The most interesting example of the latter is found in the famous Digression of the Theaetetus, where the difference between philosophy and rhetoric is understood in terms of the knowledge/lack-of-knowledge belonging to each. (shrink)

As a member of the committee that authored the Multiorganization Policy Statement under discussion, I fully endorse the response of Bosslet and my colleagues to the provocative article by Schneiderman, Jecker, and Jonson. In addition, I would like to offer some thoughts about how the different positions reflected here may be at least partially reconciled by considering the different contexts in which the word and the concept of futility may be invoked. The main thrust of the classic paper by Schneiderman, (...) Jecker, and Jonsen, which is that medicine should not offer or perform treatments that are futile, still resonates with many clinicians, including myself. I... (shrink)

This special report is published in commemoration of the fiftieth anniversary of the “Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death,” a landmark document that proposed a new way to define death, with implications that advanced the field of organ transplantation. This remarkable success notwithstanding, the concept has raised lasting questions about what it means to be dead. Is death defined in terms of the biological failure of the organism to (...) maintain integrated functioning? Can death be declared on the basis of severe neurological injury even when biological functions remain intact? Is death essentially a social construct that can be defined in different ways, based on human judgment? These issues, and more, are discussed and debated in this report by leading experts in the field, many of whom have been engaged with this topic for decades. (shrink)

The purpose of Plato’s investigation of justice in the ideal polis of the Republic is neither to formulate an abstract conception of justice in itself nor to work out a blueprint for the perfectly just state. Rather, through the contemplation of an ideal social/political order where justice might be found “writ large,” Plato intends to bring about the actualization of justice in the “polity” of the individual soul. It must be kept in mind, of course, that, while possessing a notion (...) of the individual, the Greeks lacked our modern, Cartesian conception of subjectivity, burdened as it is with the existential task of creating and sustaining a meaningful cosmos. But precisely for this reason the ancients had a clearer perspective of the synergistic and mutually determinative dialectic that conjoins the individual and the state, a conjunction grounded in the ethical. This can be seen, Hegel suggests, in terms of the “unwritten and infallible law” that Antigone takes to be the “law of the gods” which “is right because it is what is right,” placing the individual “within the ethical substance; and this substance is thus the essence of self-consciousness.”. (shrink)

Robert Rupert argues against the view that human cognitive processes comprise elements beyond the boundary of the organism, developing a systems-based conception in place of this extended view. He also argues for a conciliatory understanding of the relation between the computational approach to cognition and the embedded and embodied views.

Hastings Center Report, Volume 51, Issue 5, Page 56-57, September‐October 2021.

Some patients in intensive care units are too sick to derive much benefit from being there, while others are too well to require the technology and skills offered. When ICU resources are scarce, they may ethically be withdrawn from either sort of patient in favor of one more likely to benefit from the care.

The United States Marine Corps (USMC) trains 40,000 recruits in ethical conduct each year. The Marines operate under highly stressful conditions and are perceived as moral exemplars. This study investigates their recruit training practices at Parris Island, SC and suggests applications consistent with ethical and psychological research that offer potential for building ethical corporate cultures and improving ethical behavior. The lessons were: 1) select values that fit the business, 2) use organizational-derived “hero stories”, 3) socialize members with conviction and repetition, (...) 4) utilize line leaders to conduct the training to provide specific guidelines for behavior, 5) closely monitor and reward ethical behavior, 6) add emotional control to the cognitive training, and 7) train with realistic business simulations. The seven lessons from the USMC can help business leaders earn a reputation for trustworthy leadership, a vital corporate asset. (shrink)

According to Jerry Fodor’s atomistic theory of content, subjects’ dispositions to token mentalese terms in counterfactual circumstances fix the contents of those terms. I argue that the pattern of counterfactual tokenings alone does not satisfactorily fix content; if Fodor’s appeal to patterns of counterfactual tokenings has any chance of assigning correct extensions, Fodor must take into account the contents of subjects’ various mental states at the times of those tokenings. However, to do so, Fodor must abandon his semantic atomism. And (...) while Fodor has recently qualified his atomism, the cognitively holistic nature of dispositions continues to undermine his view. (shrink)