Children are the real victims of world hunger: at least 70% of the malnourished people of the world are children. By best estimates forty thousand children a day die of starvation (FAO 1989: 5). Children do not have the ability to forage for themselves, and their nutritional needs are exceptionally high. Hence, they are unable to survive for long on their own, especially in lean times. Moreover, they are especially susceptible to diseases and conditions which are the staple of undernourished (...) people: simple infections and simple diarrhea (UNICEF 1993: 22). Unless others provide adequate food, water, and care, children will suffer and die (WHO 1974: 677, 679). This fact must frame any moral discussions of the problem. And so it does — at least pre-philosophically. When most of us first see pictures of seriously undernourished children, we want to help them, we have a sense of responsibility to them, we feel sympathy toward them (Hume 1978: 368-71). Even those who think we needn't or shouldn't help the starving take this initial response seriously: they go to great pains to show that this sympathetic response should be constrained. They typically claim that assisting the hungry will demand too much of us, or that assistance would be useless and probably detrimental. The efforts of objectors to undermine this natural sympathetic reaction would be pointless unless they saw its psychological force. We want to explain and bolster this sympathetic reaction — this conviction that those of us in a position to help are responsible to the.. (shrink)

Scientists are divided on the status of hypothesis H that low doses of ionizing radiation (under 20 rads) cause hormetic (or non-harmful) effects. Military and industrial scientist s tend to accept H, while medical and environmental scientists tend to reject it. Proponents of the strong programme claim this debate shows that uncertain science can be clari ed only by greater attention to the social values in uencing it. While they are in part correct, this paper argues that methodological analyses (not (...) merely attention to social values) also can help clarify uncertain science. The paper analyzes ve measurement uncertainties , as well as seven methodological value judgments, relevant to H. Using criteria of internal and external consistency, as well as predictive power, it argues that metascience also helps resolve this debate. And if so, then value-laden, policy-relevan t science may need, not only more attention to social values in order to resolve and to clarify disputes, but also more conceptual and methodological analyses of science. (This paper suggests what such methodological analyses might be like and uses the case of low-dose risks from radiation to illustrate its points, while a companion paper (“Chemical Hormesis, Conceptual Clari cation, and the Warrant for Policy-Driven Science”) in this same issue of POS suggests what such conceptual analyses might be like and uses the case of low-dose risks from chemicals to illustrate its points.) If this paper’s thesis holds in the very politicize d “hard case” of radiation hormesis, then it suggests that the metascientist s may be right about what is also often necessary to clarify scienti c disputes. (shrink)

Philosophy and Happiness addresses the need to situate any meaningful discourse about happiness in a wider context of human interests, capacities and circumstances. How is happiness manifested and expressed? Can there be any happiness if no worthy life projects are pursued? How is happiness affected by relationships, illness, or cultural variants? Can it be reduced to preference satisfaction? Is it a temporary feeling or a persistent way of being? Is reflection conducive to happiness? Is mortality necessary for it? These are (...) the questions people ask themselves when they stop and think about how they feel, how their lives are going, and how they would be going if different choices had been made or different values had been prioritized. These are the questions that contributors to this volume begin to answer, adopting different methodologies, among which the analysis of widespread intuitions about imaginary and real-life scenarios, and reflection on the interpretation of the relevant empirical evidence emerging from psychology and economics. (shrink)

A number of theoretical ideas have emerged recently in the legal, bioethical and philosophical fields that could usefully be applied to these and other issues ...

Is it permissible for a doctor or nurse to knowingly administer a placebo in a clinical setting? There is certainly something suspicious about it: placebos are typically said to be ‘sham’ treatments, with no ‘active’ properties and so giving a placebo is usually thought to involve tricking or deceiving the patient who expects a genuine treatment. Nonetheless, some physicians have recently suggested that placebo treatments are sometimes the best way to help their patients and can be administered in an honest (...) way. These physicians conclude that placebo treatments are a perfectly acceptable, and ethically unproblematic, mode of treatment.While I grant the common idea that placebos are deceptive is correct, I argue that widespread misunderstandings concerning why this is so has led proponents of placebo treatments to respond to the charge of deception in a way that misses the mark entirely. My goal in this paper, then, is to develop a precise conception of what makes something a placebo, which in turn will clarify the central charge concerning the ethics of placebo treatment, viz. that it is deceptive. (shrink)

In this paper we claim that individual subjects do not have so much control over sleep that it is aptly characterized as a personal choice; and that normative implications related to public health and sleep hygiene do not necessarily follow from current findings. It should be true of any empirical study that normative implications do not necessarily follow, but we think that many public health sleep recommendations falsely infer these implications from a flawed explanatory account of the decision to sleep: (...) the consumer choice view. This view, which we criticize here, proposes that sleep duration and sleep quality be understood as one choice among many. (shrink)

The ethics of medically-authorized limb amputation in individuals with Body integrity identity disorder (BIID) remains extremely controversial. One factor to consider is the putative locus of a disease process, and whether the proposed treatment--in this case, limb amputation—reasonably addresses the issue of what organ is mediating the patient’s complaint.

Palliative care is a recent branch of health care. The doctors, nurses, and other professionals involved in it took their inspiration from the medieval idea of the hospice, but have now extended their expertise to every area of health care: surgeries, nursing homes, acute wards, and the community. This has happened during a period when patients wish to take more control over their own lives and deaths, resources have become scarce, and technology has created controversial life-prolonging treatments. Palliative care is (...) therefore faced with more ethical problems that other areas of health care. This book, by a clinician, teacher, and writer on health care ethics, has been written to provide all those who care for the terminally ill--doctors, nurses, social workers, clergymen, physiotherapists--with the concepts and principles which will assist them with difficult decisions. It challenges many received doctrines of palliative care, but its well-illustrated central theme is that technical expertise must be controlled by humane, non-technical judgments. (shrink)

This paper argues that the medical conception of health as absence of disease is a value-free theoretical notion. Its main elements are biological function and statistical normality, in contrast to various other ideas prominent in the literature on health. Apart from universal environmental injuries, diseases are internal states that depress a functional ability below species-typical levels. Health as freedom from disease is then statistical normality of function, i.e., the ability to perform all typical physiological functions with at least typical efficiency. (...) This conception of health is as value-free as statements of biological function. The view that health is essentially value-laden, held by most writers on the topic, seems to have one of two sources: an assumption that health judgments must be practical judgments about the treatment of patients, or a commitment to "positive" health beyond the absence of disease. I suggest that the assumption is mistaken, the commitment possibly misdescribed. (shrink)

Philosophy and Happiness addresses the need to situate any meaningful discourse about happiness in a wider context of human interests, capacities and circumstances. How is happiness manifested and expressed? Can there be any happiness if no worthy life projects are pursued? How is happiness affected by relationships, illness, or cultural variants? Can it be reduced to preference satisfaction? Is it a temporary feeling or a persistent way of being? Is reflection conducive to happiness? Is mortality necessary for it? These are (...) the questions people ask themselves when they stop and think about how they feel, how their lives are going, and how they would be going if different choices had been made or different values had been prioritized. These are the questions that contributors to this volume begin to answer, adopting different methodologies, among which the analysis of widespread intuitions about imaginary and real-life scenarios, and reflection on the interpretation of the relevant empirical evidence emerging from psychology and economics. (shrink)

The challenges posed by chronic illness have pointed out to epidemiologists the multifactorial complex nature of disease causality. This notion has been referred to as a web of causality. This web extends theoretically beyond risk markers. It includes determinants of emergence/non-emergence of disease. This web of determinants is a form of complex system. Due to its complexity, the determinants within such system are not linked to each others in a linear, predictable manner only. Predictability is possible only on a short-term (...) basis, and unpredictability sets in over the long run. Understanding such a system of determinants calls for articulation and testing of complex models which synthesize our knowledge of multiple determinants at many scales, both biological and otherwise. Given the complexity of this web and existing knowledge about the nonlinearity of such systems, the following question is posed: Can the challenge of studying causality be adequately addressed if emphasis continues to be placed on using tools and methods that are geared towards looking at such system from a linear paradigm? Or is it time to add to the epidemiologic research agenda the notion of nonlinearity and its relevant form of analytical approaches that are being tested in other disciplines? Furthermore, the question posed here applies as well to the study of determinants of health. Addressing determinants of heath adds further complexity to our task. (shrink)

Many existing biomedical vocabulary standards rest on incomplete, inconsistent or confused accounts of basic terms pertaining to diseases, diagnoses, and clinical phenotypes. Here we outline what we believe to be a logically and biologically coherent framework for the representation of such entities and of the relations between them. We defend a view of disease as involving in every case some physical basis within the organism that bears a disposition toward the execution of pathological processes. We present our view in the (...) form of a list of terms and definitions designed to provide a consistent starting point for the representation of both disease and diagnosis in information systems in the future. (shrink)

Currently, any dentist in the UK who is HIV-seropositive must stop treating patients. This is despite the fact that hepatitis B-infected dentists with a low viral load can continue to practise, and the fact that HIV is 100 times less infectious than hepatitis B. Dentists are obliged to treat HIV-positive patients, but are obliged not to treat any patients if they themselves are HIV-positive. Furthermore, prospective dental students are now screened for hepatitis B and C and HIV, and are not (...) allowed to enrol on Bachelor of Dental Surgery degrees if they are infectious carriers of these diseases. -/- This paper will argue that: (i) the current restriction on HIV-positive dentists is unethical, and unfair; (ii) dentists are more likely to contract HIV from patients than vice versa, and this is not reflected by the current system; (iii) the screening of dental students for HIV is also unethical; (iv) the fact that dentists can continue to practise despite hepatitis B infection, but infected prospective students are denied matriculation, is unethical; and (v) that the current Department of Health protocols, as well as being intrinsically unfair, have further unethical effects, such as the waste of valuable resources on ‘lookback’ exercises and the even more damaging loss of present and future dentists. Regulation in this area seems to have been driven by institutional fear of public fear of infection, rather than any scientific evidence or ethical reasoning. (shrink)

The integration of biomedical terminologies is indispensable to the process of information integration. When terminologies are linked merely through the alignment of their leaf terms, however, differences in context and ontological structure are ignored. Making use of the SNAP and SPAN ontologies, we show how three reference domain ontologies can be integrated at a higher level, through what we shall call the OBR framework (for: Ontology of Biomedical Reality). OBR is designed to facilitate inference across the boundaries of domain ontologies (...) in anatomy, physiology and pathology. (shrink)

Chapter 1 Introduction The man was coughing again. Shocked he was as he discovered that his saliva had a reddish taint. Would he have a lung disease after all? Cancer perhaps? Long ago, relatives of his had died from LC, lung cancer.

The challenges posed by chronic illness have pointed out to epidemiologists the multifactorial complex nature of disease causality. This notion has been referred to as a web of causality. This web extends theoretically beyond risk markers. It includes determinants of emergence/non-emergence of disease. This web of determinants is a form of complex system. Due to its complexity, the determinants within such system are not linked to each others in a linear, predictable manner only. Predictability is possible only on a short-term (...) basis, and unpredictability sets in over the long run. Understanding such a system of determinants calls for articulation and testing of complex models which synthesize our knowledge of multiple determinants at many scales, both biological and otherwise. Given the complexity of this web and existing knowledge about the nonlinearity of such systems, the following question is posed: Can the challenge of studying causality be adequately addressed if emphasis continues to be placed on using tools and methods that are geared towards looking at such system from a linear paradigm? Or is it time to add to the epidemiologic research agenda the notion of nonlinearity and its relevant form of analytical approaches that are being tested in other disciplines? Furthermore, the question posed here applies as well to the study of determinants of health. Addressing determinants of heath adds further complexity to our task. (shrink)

The idea that the immune system distinguishes between self and non-self was one of the central assumptions of immunology in the second half of 20th century. This idea influenced experimental design and data interpretation. However, in the face of new evidence there is a need for a new conceptual framework in immunology.

In this article, I argue that depression and suicide are natural kinds insofar as they are classes of abnormal behavior underwritten by sets of stable biological mechanisms. In particular, depression and suicide are neurobiological kinds characterized by disturbances in serotonin functioning that affect various brain areas (i.e., the amygdala, anterior cingulate, prefrontal cortex, and hippocampus). The significance of this argument is that the natural (biological) basis of depression and suicide allows for reliable projectable inferences (i.e., predictions) to be made about (...) individual members of a kind. In the context of assisted suicide, inferences about the decision-making capacity of depressed individuals seeking physician-assisted suicide are of special interest. I examine evidence that depression can hamper the decision-making capacity of individuals seeking assisted suicide and discuss some implications. (shrink)

As the quality movement in health care now enters its fourth decade, the language of quality is ubiquitous. Practitioners, organizations, and government agencies alike vociferously testify their commitments to quality and accept numerous forms of governance aimed at improving quality of care. Remarkably, the powerful phrase ‘‘quality of care’’ is rarely defined in the health care literature. Instead it operates as an accepted and assumed goal worth pursuing. The status of evidence-based medicine, for instance, hinges on its ability to improve (...) quality of care, and efforts are made by both proponents and detractors to unpack the contents and outcomes of evidence-based practice while the contents of ‘‘quality of care’’ are presumed to be understood. Because the goals of medicine are far from obvious, this paper investigates the neglected term, ‘‘quality of care,’’ in an effort to understand what it is that health care practices are so uncritically assumed to be striving for. Finding lack of consensus on the terminology in the quality literature, I propose that the term operates rhetorically by way of persuasive appeal (and lack of descriptive meaning). Unsatisfied that ‘‘quality of care’’ operates as a mere buzzword in morally contentious debates over resource allocation and duties of care, I implore health care communities to go beyond mere commitments to quality and, instead, to focus attention on the difficult task of specifying what counts as quality care within an economically constrained health care system. (shrink)

Background: The requirement that animals be used in research and testing in order to protect humans was formalized in the Nuremberg Code and subsequent national and international laws, codes, and declarations.DiscussionWe review the history of these requirements and contrast what was known via science about animal models then with what is known now. We further analyze the predictive value of animal models when used as test subjects for human response to drugs and disease. We explore the use of animals for (...) models in toxicity testing as an example of the problem with using animal models.SummaryWe conclude that the requirements for animal testing found in the Nuremberg Code were based on scientifically outdated principles, compromised by people with a vested interest in animal experimentation, serve no useful function, increase the cost of drug development, and prevent otherwise safe and efficacious drugs and therapies from being implemented. (shrink)

This paper explores the claim that someone can reasonably consider themselves to be under a duty to respect the autonomy of a person who does not have the capacities normally associated with substantial self-governance.

Eudaimonistic theorists of welfare have recently attacked conative accounts of welfare. Such accounts, it is claimed, are unable to classify states normally associated with physical and emotional health as non-instrumentally good and states associated with physical and psychological damage as non-instrumentally bad. However, leading eudaimonistic theories such as the self-fulfillment theory and developmentalism have problems of their own. Furthermore, conative theorists can respond to this challenge by dispositionalizing their theories, i.e., by saying that it is not merely the realization of (...) one’s values that is non-instrumentally good for one, but that the disposition to realize one’s values is also non-instrumentally good for one. This approach, properly elaborated, can accommodate the idea that, in many cases, states normally associated with physical and psychological health (or unhealth) are non-instrumentally good (or bad). It also preserves the many well known advantages of conative theories. (shrink)

The primacy in modern medical ethics of the principle of respect for autonomy has led to the widespread assumption that it is unethical to change someone’s beliefs, because doing so would constitute coercion or paternalism., In this Viewpoint we suggest that persuasion is not necessarily paternalistic and is an essential component of modern medical practice.