Many health care systems include programs that allow patients in exceptional circumstances to access medical interventions of as yet unproven benefit. In this article we consider the ethical justifications for—and demands on—these special access programs (SAPs). SAPs have a compassionate basis: They give patients with limited options the opportunity to try interventions that are not yet approved by standard regulatory processes. But while they signal that health care systems can and will respond to individual suffering, SAPs have several disadvantages, including (...) the potential to undermine regulatory and knowledge-generation structures that constitute significant public goods. The “balance” between these considerations depends in part on how broadly SAPs are used, but also on whether SAPs can be made to contribute to the generation of knowledge about the effects of health interventions. We argue that patients should usually be required to contribute outcome data while using SAPs. (shrink)

Los discursos públicos que circulan sobre las matemáticas y su aprendizaje determinan el modo en que las familias y los alumnos dan sentido a sus experiencias escolares. En Estados Unidos, estos discursos pueden desempeñar un papel importante en el desarrollo de la política educativa pública debido al compromiso de los consejos escolares públicos de escuchar las voces de la comunidad, así como al reciente (aunque no nuevo) aumento de la organización de grupos de padres conservadores bien financiados que trabajan para (...) mantener -y exacerbar- la desigualdad de oportunidades educativas que persiste en este país. En este trabajo analizamos el discurso público en torno al aprendizaje de las matemáticas en una reunión del consejo escolar local de la ciudad de Nueva York. Utilizando herramientas de análisis de la interacción, examinamos el discurso en torno a una propuesta para restablecer la selección basada en exámenes para la admisión en la escuela secundaria. Delineamos dos características clave de los supuestos de "sentido común" en torno al aprendizaje de las matemáticas que circularon en esta reunión -los estudiantes de matemáticas permanecen en una trayectoria de aprendizaje unidimensional, y con diferentes tasas de avance- e investigamos cómo estos supuestos jugaron en la construcción de un mundo figurado de "matemáticas escolarizadas". Argumentamos que las consecuencias que se derivan necesariamente de estos supuestos de sentido común construyen las matemáticas como jerárquicas y fijas, situando a los alumnos en una trayectoria de aprendizaje unidimensional. Por último, situamos este conjunto de supuestos emergentes en el proyecto racial neoliberal y consideramos las formas en que configuran una imaginación particular de la escolarización y las matemáticas bajo el neoliberalismo. (shrink)

This article reports the findings of a qualitative study that explored the organizational influences on moral distress for health professionals working in pediatric intensive care units across Canada. Participants were recruited to the study from PICUs across Canada. The PICU is a high-tech, fast-paced, high-pressure environment where caregivers frequently face conflict and ethical tension in the care of critically ill children. A number of themes including relationships with management, organizational structure and processes, workload and resources, and team dynamics were identified. (...) This study provides a rare and important multi-disciplinary perspective on this topic and the findings have implications for administrators and leaders who seek to improve the moral climate of healthcare delivery. (shrink)

This paper raises questions about the epistemological foundations of evidence-based medicine . We argue that EBM is based upon reliabilist epistemological assumptions, and that this is appropriate - we should focus on identifying the most reliable processes for generating and collecting medical knowledge. However, we note that this should not be reduced to narrow questions about which research methodologies are the best for gathering evidence. Reliable processes for generating medical evidence might lie outside of formal research methods. We also question (...) the notion of the knower that is assumed by EBM. We argue that EBM assumes an enlightenment conception of knowers as autonomous, substitutable individuals. This conception is troubled by the way that clinicians learn the role of anecdote in health care and the role of patient choice, all of which bring into play features of clinicians and patients as situated individuals with particular backgrounds and experiences. EBM's enlightenment conception of the knower is also troubled by aspects of the way evidence is produced. Given these limitations, we argue that EBM should retain its reliabilist bent, but should look beyond formal research methodologies in identifying processes that yield reliable evidence for clinical practice. We suggest looking to feminist epistemology, with its focus on the standpoints of individual situated knowers, and the role of social context in determining what counts as knowledge. (shrink)

This article provides a critical comparative analysis of the substantive and procedural values and ethical concepts articulated in guidelines for allocating scarce resources in the COVID-19 pandemic. We identified 21 local and national guidelines written in English, Spanish, German and French; applicable to specific and identifiable jurisdictions; and providing guidance to clinicians for decision making when allocating critical care resources during the COVID-19 pandemic. US guidelines were not included, as these had recently been reviewed elsewhere. Information was extracted from each (...) guideline on: 1) the development process; 2) the presence and nature of ethical, medical and social criteria for allocating critical care resources; and 3) the membership of and decision-making procedure of any triage committees. Results of our analysis show the majority appealed primarily to consequentialist reasoning in making allocation decisions, tempered by a largely pluralistic approach to other substantive and procedural values and ethical concepts. Medical and social criteria included medical need, co-morbidities, prognosis, age, disability and other factors, with a focus on seemingly objective medical criteria. There was little or no guidance on how to reconcile competing criteria, and little attention to internal contradictions within individual guidelines. Our analysis reveals the challenges in developing sound ethical guidance for allocating scarce medical resources, highlighting problems in operationalising ethical concepts and principles, divergence between guidelines, unresolved contradictions within the same guideline, and use of naïve objectivism in employing widely used medical criteria for allocating ICU resources. (shrink)

Forms of Artificial Intelligence (AI) are already being deployed into clinical settings and research into its future healthcare uses is accelerating. Despite this trajectory, more research is needed regarding the impacts on patients of increasing AI decision making. In particular, the impersonal nature of AI means that its deployment in highly sensitive contexts-of-use, such as in healthcare, raises issues associated with patients’ perceptions of (un) dignified treatment. We explore this issue through an experimental vignette study comparing individuals’ perceptions of being (...) treated in a dignified and respectful way in various healthcare decision contexts. Participants were subject to a 2 (human or AI decision maker) x 2 (positive or negative decision outcome) x 2 (diagnostic or resource allocation healthcare scenario) factorial design. We found evidence of a “human bias” (i.e., a preference for human over AI decision makers) and an “outcome bias” (i.e., a preference for positive over negative outcomes). However, we found that for perceptions of respectful and dignified interpersonal treatment, it matters more who makes the decisions in diagnostic cases and it matters more what the outcomes are for resource allocation cases. We also found that humans were consistently viewed as appropriate decision makers and AI was viewed as dehumanizing, and that participants perceived they were treated better when subject to diagnostic as opposed to resource allocation decisions. Thematic coding of open-ended text responses supported these results. We also outline the theoretical and practical implications of these findings. (shrink)

In this study, we discuss the colonial project as an eliminatory structure of indigenous ways of knowing and doing that is built into Canadian social and health institutions. We elaborate on the role nursing plays in maintaining systemic racism, marginalization and discrimination of Indigenous Peoples. Based on historical practices and present‐day circumstances, we argue that changing language in research and school curriculums turns decolonization into what Tuck and Yang call a ‘metaphor’. Rather, we propose decolonization as a political project where (...) nurses acknowledge their involvement in colonial harms and disrupt the assumptions that continue to shape how nurses interact with Indigenous people, including knowledge systems that perpetuate colonial interests and privilege. Decolonization requires nurses to understand the colonial practices that led to dispossession of land, erasure of knowledge, culture and identity, while upholding indigenous ways of knowing and doing in health, healing and living. As a political manifesto that liberates indigenous life from oppressive structures of colonialism and capitalism, The Red Deal is presented as a visionary platform for decolonization. The aim of this study is to articulate three dimensions of caretaking within The Red Deal as a framework to decolonize nursing knowledge development and practice. Based on the philosophical dimension embedded in The Red Deal that revoke norms and knowledge assumptions of capitalism that destroy indigenous ways of knowing and doing, we underscore an approach toward decolonizing nursing. Our approach rejects the apolitical nature of nursing as well as the unilateral western scientific knowledge approach to knowledge development and recognition. A critical emancipatory approach that addresses the socio‐political and historical context of health care, recognizes dispossession of land and adopts a ‘multilogical’ vision of knowledge that gives space for representation and voice is needed for true decolonization of nursing. (shrink)

Offering a format that is significantly different than that offered by other books, Ethical Health Care beings by asking what is meant by health and how it is achieved. The book then proceeds to explore with care and context the nature of the relationship between patients and clinicians, health care providers and the societies in which they inhabit, and finally the relationship between the health care enterprise and the international community. By emphasizing the ethical issues that arise in the broad (...) quest to foster human health, and appreciating that health is not primarily a function of medical interventions, Ethical Health Care introduces students to problems such as the international distribution of pharmaceuticals and the dangers of reemerging infections. To a far greater extent than is done traditionally, Ethical Health Care provides an interdisciplinary perspective to bioethics, relying heavily upon the teachings of economics, law, and public health. (shrink)

Values such as justice, fairness, reason, and truth permeate the cultural fabric of societies. A key image of these values in many Western democracies is the legal icon of Justitia or Lady Justice as she embodies notions of justice. Examining such cultural constructions promotes discussion of assumed values and meanings pertaining to iconic representations. Semiotic analysis of Justitia and her compositional elements — the sword of justice, scales of justice, and blind-fold reveal tensions between the rhetoric and reality of our (...) interpretations of justice. This paper makes explicit the iconic representations of societal values imbued in Justitia and raises questions about the invisible power of cultural reproduction. (shrink)

The American Journal of Bioethics, Volume 11, Issue 11, Page 42-43, November 2011.

We have been asked to consider the feasibility of piloting a Citizens’ Basic Income : a basic, unconditional, universal, individual, regular payment that would replace aspects of social security and be introduced alongside changes to taxes. Piloting and evaluating a CBI as a Cluster Randomized Control Trial raises the question of whether intervention and comparison groups would be in equipoise, and thus whether randomization would be ethical. We believe that most researchers would accept that additional income, or reduced conditions on (...) receiving income would be likely to improve health, especially at lower income levels. However, there are genuine uncertainties about the impacts on other outcomes, and CBI as a mechanism of providing income. There is also less consensus amongst civil servants and politicians about the impacts on health, and substantial disagreement about whether these would outweigh other impacts. We believe that an RCT is ethical because of these uncertainties. We also argue that the principle of equipoise should apply to randomized and non-randomized trials; that randomization is a fairer means of allocating to intervention and comparison groups; and that there is an ethical case for experimentation to generate higher-quality evidence for policymaking that may otherwise do harm. (shrink)

This paper draws attention to gendered dimensions of surgical device failure, focusing on two case studies—hernia repair mesh for pelvic organ prolapse, and metal-on-metal hip implants. We explore possible reasons for higher rates of harms to women, including systematic biases in health research and device regulation. Given that these factors are readily identifiable, we look to feminist scholarship to understand what might maintain them, including the role of cultural factors within surgery, such as gendered communication patterns and sexism. We then (...) canvas potential measures to mitigate the increased risk of harms faced by women who use implanted devices. (shrink)

The neurobiological mechanisms associated with affiliation, that Depue & Collins argue are a central component of extraversion are not specified in their model. In addition, only the involvement of the prefrontal cortex in extraversion is discussed, although recent evidence suggests that activity associated with additional cortical regions may be related to this trait. Finally, the assumption that neurobiological mechanisms underlie or play a causal, and therefore, more fundamental role than psychological constructs in the trait is challenged.

Lloyd (2009) contends that climate models are confirmed by various instances of fit between their output and observational data. The present paper argues that what these instances of fit might confirm are not climate models themselves, but rather hypotheses about the adequacy of climate models for particular purposes. This required shift in thinking—from confirming climate models to confirming their adequacy-for-purpose—may sound trivial, but it is shown to complicate the evaluation of climate models considerably, both in principle and in practice.

Unable to answer the call of our patients: mental health nurses’ experience of moral distress When health practitioners’ moral choices and actions are thwarted by constraints, they may respond with feelings of moral distress. In a Canadian hermeneutic phenomenological study, physicians, nurses, psychologists and non‐professional aides were asked to identify care situations that they found morally distressing, and to elaborate on how moral concerns regarding the care of patients were raised and resolved. In this paper, we describe the experience of (...) moral distress related by nurses working in mental healthcare settings who believed that lack of resources (such as time and staff) leads to dispiritedness, lack of respect, and absence of recognition (for both patients and staff) which severely diminished their ability to provide quality care. The metaphors of flashlight and hammer are used to elaborate nurses’ possible responses to intolerable situations. (shrink)

Whether in characterizing Catharine MacKinnon's theory of gender as itself pornographic or in identifying liberalism as unable to make good on its promises, Wendy Brown pursues a central question: how does a sense of woundedness become the basis for a sense of identity? Brown argues that efforts to outlaw hate speech and pornography powerfully legitimize the state: such apparently well-intentioned attempts harm victims further by portraying them as so helpless as to be in continuing need of governmental protection. "Whether (...) one is dealing with the state, the Mafia, parents, pimps, police, or husbands," writes Brown, "the heavy price of institutionalized protection is always a measure of dependence and agreement to abide by the protector's rules." True democracy, she insists, requires sharing power, not regulation by it; freedom, not protection.Refusing any facile identification with one political position or another, Brown applies her argument to a panoply of topics, from the basis of litigiousness in political life to the appearance on the academic Left of themes of revenge and a thwarted will to power. These and other provocations in contemporary political thought and political life provide an occasion for rethinking the value of several of the last two centuries' most compelling theoretical critiques of modern political life, including the positions of Nietzsche, Marx, Weber, and Foucault. (shrink)

First published in 1982. Routledge is an imprint of Taylor & Francis, an informa company.

In order to summarize a story, it is necessary to access a high level analysis of the story that highlights its central concepts. A technique of memory representation based on plot units appears to provide a rich foundation for such an analysis. Plot units are conceptual structures that overlap with each other when a narrative is cohesive. When overlapping intersections between plot units are interpreted as arcs in a graph of plot units, the resulting graph encodes the plot of the (...) story. Structural features of the graph then reveal which concepts are central to the story, and which concepts are peripheral. Plot unit analysis is currently being investigated as a processing strategy for narrative summarization by both computer simulation and psychological experiments. (shrink)

Wendy Brown's work commands widespread attention and respect, and there has been considerable interest as to how it would develop after "States of Injury." This book will not disappoint.

This study begins with the question of whether the press is conveying messages that help readers in their moral development. Using a Kohlbergian model, this study explores the question by analyzing the moral language in columns and letters to the editor from three Oregon newspapers. The study's content analysis reveals that most arguments presented in the opinion section of the three papers are done so at either Kohlberg's preconventional or conventional levels.

Philosophers continue to debate both the actual and the ideal roles of values in science. Recently, Eric Winsberg has offered a novel, model-based challenge to those who argue that the internal workings of science can and should be kept free from the influence of social values. He contends that model-based assignments of probability to hypotheses about future climate change are unavoidably influenced by social values. I raise two objections to Winsberg’s argument, neither of which can wholly undermine its conclusion but (...) each of which suggests that his argument exaggerates the influence of social values on estimates of uncertainty in climate prediction. I then show how a more traditional challenge to the value-free ideal seems tailor-made for the climate context. (shrink)

It is increasingly recognised that evidence generated using “real-world data” is crucial for assessing the safety and effectiveness of health-related interventions. This, however, raises a number of issues, including those related to the quality of RWD, and of the scientific methods used to generate evidence from it, and the potential for those gathering and using RWD be driven by commercial, political, professional or personal self-interest. This article is an application of the framework presented in this issue of ABR. Please refer (...) to that article for more information on how this framework is to be used, including a full explanation of the key values involved and the balancing approach used in the case study at the end to demonstrate how those generating or using RWD can make use of values when deliberating about ethical issues. (shrink)

DIVA reader aimed at revitalizing left legal and political critique./div.

T. G. Masaryk’s thought is famous for his concept of the Czech nation as well as his ideals of humanity. As a philosopher, sociologist, and politician, he was confronted with Czech anti-Semitism, and after Czechoslovakia was founded, with issues of the Jewish national minority. He tried to solve all the questions with respect to his ethical conviction and the ideals of democracy and equality. The most difficult personal situation for Masaryk emerged with the ‘Hilsner affair’, when his brave stance against (...) anti-Semitism caused animosity and even hatred from the public. As a consequence of that Masaryk had to abandon his public activities including lecturing at university for some time. The philosopher Jan Patočka analysed Masaryk’s involvement in this case and the following events in his study Masaryk’s struggle against anti-Semitism. Patočka pointed out that there is an interconnection between Masaryk’s involvement in this affair and his engagement in the question of Czech nationality, as Masaryk intended to improve the ethical level of the nation by disposing of bias and namely the ritual murder myth. The second part of the present contribution is focused on Masaryk’s views on Zionism and the assimilation movement and his ambiguity in relation to the issue. It seems that Masaryk’s concept of the Czech nation, formed for the struggle against the Habsburg monarchy, became inadequate in the new republic, as it was not inclusive of the many minorities, the Jewish one included. On the other hand, Masaryk’s ideals of humanity provide a certain solution on the level of ethics. (shrink)

Biomedical innovation and translation are increasingly emphasizing research using “big data.” The hope is that big data methods will both speed up research and make its results more applicable to “real-world” patients and health services. While big data research has been embraced by scientists, politicians, industry, and the public, numerous ethical, organizational, and technical/methodological concerns have also been raised. With respect to technical and methodological concerns, there is a view that these will be resolved through sophisticated information technologies, predictive algorithms, (...) and data analysis techniques. While such advances will likely go some way towards resolving technical and methodological issues, we believe that the epistemological issues raised by big data research have important ethical implications and raise questions about the very possibility of big data research achieving its goals. (shrink)

Twenty-nine environmental activists (mean age, 49.8) responded in writing to questions on influences that gave rise to environmental ethics in their own lives. Answers represented all phases of the lifespan. Through a qualitative analysis, six principle themes emerged: (a) deep environmental concern and an affiliation with nature often began in early childhood; (b) a combination of intellectual or academic and direct experiences with nature contributed to the development of environmental ethics; (c) familial and extra familial models were influential; (d) for (...) some, environmental ethics was tied to spiritual, cultural, or religious feeling; (e) the development of environmental ethics was linked with identity and generativity issues; and (f) historical events interacted with individual development in the formation of an environmental ethics. These themes are discussed in terms of continuities and discontinuities in lifespan development, the role of the family and of history, and the relation between reason and emotion in the development of an environmental ethics. (shrink)

Tolerance is generally regarded as an unqualified achievement of the modern West. Emerging in early modern Europe to defuse violent religious conflict and reduce persecution, tolerance today is hailed as a key to decreasing conflict across a wide range of other dividing lines-- cultural, racial, ethnic, and sexual. But, as political theorist Wendy Brown argues in Regulating Aversion, tolerance also has dark and troubling undercurrents. Dislike, disapproval, and regulation lurk at the heart of tolerance. To tolerate is not to (...) affirm but to conditionally allow what is unwanted or deviant. And, although presented as an alternative to violence, tolerance can play a part in justifying violence--dramatically so in the war in Iraq and the War on Terror. Wielded, especially since 9/11, as a way of distinguishing a civilized West from a barbaric Islam, tolerance is paradoxically underwriting Western imperialism. Brown's analysis of the history and contemporary life of tolerance reveals it in a startlingly unfamiliar guise. Heavy with norms and consolidating the dominance of the powerful, tolerance sustains the abjection of the tolerated and equates the intolerant with the barbaric. Examining the operation of tolerance in contexts as different as the War on Terror, campaigns for gay rights, and the Los Angeles Museum of Tolerance, Brown traces the operation of tolerance in contemporary struggles over identity, citizenship, and civilization. (shrink)

In this paper we explore the nature of the emerging purpose ecosystem and its role in transforming and supporting business to help address the UN Sustainable Development Goals. We argue that interactions among its ‘private actors’, who share efforts and belief in changing and redefining the purpose and nature of business by advocating broader non-financial performance outcomes, have the potential to contribute to a wider sustainability-oriented transformation of the business sector. Through interview data collected in the UK and Australia, we (...) identify six main roles that characterise the activities and interactions among its actors and their stakeholders. Our research contributes to expanding knowledge on the emerging phenomenon of the purpose ecosystem and how its actors support the achievement of the UN SDGs by seeking to change the purpose of business and integrating the goals into their operations and engagements with stakeholders. (shrink)

Our aim is to explore and develop notions of objectivity that are useful and appropriate for critical realist empirical research. In Part I, we provided an initial definition that introduced the idea that objectivity is a value that must be chosen but that its significance is rooted in a series of other epistemological and ontological matters. We also addressed why it is worthwhile in realist terms to develop the notion of objectivity, and began to develop a revision of the concept (...) to recognise the role of subjectivities. This, we maintain, is an important clarification in developing social research. Part II explores the linkages between objectivity and situated action. In Part II we argue that the growth of knowledge requires engagement and critical analysis. We develop the idea that if subjects are engaged through multiple standpoints, then objectivity becomes significant as a lever of agency in the service of dialogue and debate and of transformations. Again, our aim is to be of use to practical researchers by providing underlying arguments. Specifically, we argue that objectivity is a bridge between the subjectivities of subjects and the rest of the real world. In so doing, the paper works through various desirable characteristics of an adequate theorisation of knowledge that could make objectivity part of the ontological underpinnings as well as the daily practices of a realist researcher. Objectivity thus links philosophical work to the everyday work of realist researchers. (shrink)

A political philosopher dissects the duties and dilemmas of the unelected spokesperson, from Martin Luther King, Jr., to Greta Thunberg. -/- Political representation is typically assumed to be the purview of formal institutions and elected officials. But many of the people who represent us are not senators or city councilors—think of Martin Luther King, Jr., or Malala Yousafzai or even a neighbor who speaks up at a school board meeting. Informal political representatives are in fact ubiquitous, often powerful, and some (...) bear enormous responsibility. In Speaking for Others, political philosopher Wendy Salkin develops the first systematic conceptual and moral analysis of informal political representation. -/- Salkin argues that informal representation can be a political lifeline, particularly for oppressed and marginalized groups that are denied representation in formal political institutions. Yet informal political representatives exert outsized influence over the ways these groups’ interests are understood by the public, without the represented having much recourse to hold them accountable. And many informal political representatives are selected not by the groups they represent but by outsiders, sticking these groups with representatives they would not choose but cannot shake. The role of informal political representatives is therefore fraught with moral questions. What exactly are their duties and to whom are they owed? Should they be members of the groups they represent? When is informal representation permissible and when is it best avoided? -/- Informal political representation is taking place all around us. In fact, you yourself may be an informal political representative without knowing it. Speaking for Others explores the tensions central to this pervasive yet underexamined practice, bringing light to both its perils and its promise. (shrink)

Bioethics, Volume 35, Issue 7, Page 623-633, September 2021.

According to an adequacy-for-purpose view, models should be assessed with respect to their adequacy or fitness for particular purposes. Such a view has been advocated by scientists and philosophers...