Extracorporeal membrane oxygenation (ECMO) is typically viewed as a time-limited intervention—a bridge to recovery or transplant—not a destination therapy. However, some patients with decision-making capacity request continued ECMO support despite a poor prognosis for recovery and lack of viability as a transplant candidate. In response, critical care teams have asked for guidance regarding the ethical permissibility of unilateral withdrawal over the objections of a capacitated patient. In this article, we evaluate several ethical arguments that have been made in favor of (...) withdrawal, including distributive justice, quality of life, patients’ rights, professional integrity, and the Equivalence Thesis. We find that existing justifications for unilateral withdrawal of ECMO support in capacitated patients are problematic, which leads us to conclude that either: (1) additional ethical arguments are necessary to defend this approach or (2) the claim that it is not appropriate to use ECMO as a destination therapy should be questioned. (shrink)

Significant challenges arise for clinical care teams when a patient or surrogate decision-maker hopes a miracle will occur. This article answers the question, “How should clinical bioethicists respond when a medical decision-maker uses the hope for a miracle to orient her medical decisions?” We argue the ethicist must first understand the complexity of the miracle-invocation. To this end, we provide a taxonomy of miracle-invocations that assist the ethicist in analyzing the invocator's conceptions of God, community, and self. After the ethicist (...) appreciates how these concepts influence the invocator's worldview, she can begin responding to this hope with specific practices. We discuss these practices in detail and offer concrete recommendations for a justified response to the hope for a miracle. (shrink)

Readers have much to consider when evaluating Greenblum and Hubbard’s conclusion that ‘physicians have no business doing theology’.1 The two central arguments the authors offer are fairly convincing within the confines they set for themselves, the provisos they stipulate and their notions of ‘privacy’ and ‘public reason’. However, I would ask readers to consider two questions, the answers to which I believe the authors leave opaque. First, what is theological negotiation? Second, what makes chaplains the singular group of healthcare professionals (...) responsible for theological negotiation? In this Commentary, I explore these questions not with the goal of rejecting the authors’ conclusion, but rather with the goal of highlighting relevant considerations when evaluating the authors’ central tenets. First, I would like readers to consider Greenblum and Hubbard’s descriptions of theological negotiation. They categorise theological negotiation into metaphysical, normative and alternative responses, and hold that this kind of negotiation is, for the most part, impermissible for healthcare professionals, save chaplains.1 The examples of Dr Chatterjee and Dr Thompson expand theological negotiation to include instances where physicians add a theological veneer to their clinical recommendations. In both the examples, the physician has made the case for accepting or rejecting a certain intervention—for Dr Chatterjee, accepting …. (shrink)

The Covid‐19 pandemic has brought about renewed conversation about equality and equity in the distribution of medical resources. Much of the recent conversation has focused on creating and implementing policies in times of crisis when resources are exhausted. Depending on how the pandemic develops, some communities may implement crisis measures, but many health care facilities are currently experiencing shortages of staff and materials even if the facilities have not implemented crisis standards. There is a need for shared conversation about equality (...) and equity in these times of contingency between conventional and crisis medicine. To respond well to these challenges, I recommend that institutions rely on policy, professional education, and ethics consultation. As is the case with crisis policies, creating contingency policies requires that health care professionals decide on how, specifically, to achieve equity. A policy is only as effective as its implementation; therefore, institutions should invest in context‐specific education on contingency policies. Finally, ethics consultation should be available for questions that contingency policies cannot address. (shrink)

How should clinical ethicists be trained? Scholars have stated that clinical ethics fellowships create well-trained, competent ethicists. While this appears intuitive, few features of fellowship programs have been publicly discussed, let alone debated. In this paper, we examine how fellowships can foster effective mentoring relationships. These relationships provide the foundation for the fellow’s transition from novice to competent professional. In this essay, we begin by discussing our pedagogical commitments. Next, we describe the structures our program has created to assist our (...) fellows in becoming competent ethicists. We then outline the kinds of knowledge, skills, and professional attributes mentors should possess. Following this, we focus on the knowledge, skills, and professional attributes that fellows develop as they co-create effective mentoring relationships. We will not prescribe a single approach to fellowship training; instead, our perspective will, we hope, become a catalyst for further conversation on training and mentoring clinical ethics fellows. (shrink)

Lei, a twenty‐seven‐year‐old Mandarin speaker, visits the United States seeking curative treatments for his acute myeloid leukemia. His mother, Hua, has traveled with him. Neither she nor Lei speak English, and the hospital does not have an onsite professional Mandarin‐speaking interpreter. Using a professional interpreter over the phone, Lei's oncologist, Dr. Branson, attempts to initiate a face‐to‐face goals‐of‐care conversation with Hua as the surrogate decision‐maker. Dr. Branson explains that Lei has “only weeks to months to live” and recommends initiating comfort‐care‐only (...) measures, but Hua says that she wants (and that Lei would want) continued aggressive measures. Hua says that her son might be a candidate for a phase I trial. Eventually, Dr. Branson brings in Dr. Chou, a Mandarin‐speaking resident to provide face‐to‐face interpretation. Hua insists that “there must be more standard therapies available” and says that she will wait until the trial begins. She begins crying, and the meeting disintegrates. Following this, Dr. Branson calls for an ethics consultation for “help in end‐of‐life communicating and reconciling discordance about prognostic information.”How should the ethicist use the institution's interpreter services? (shrink)

Mrs. Duong had coronary artery disease, ischemic cardiomyopathy, and mildly altered mental status when her case was presented before an advanced heart therapy medical review board. She was accepted for left ventricular assist device placement pending additional insight into her cognitive state. Before the LVAD could be implanted, however, Mrs. Duong went into cardiogenic shock, and her heart failure team placed an intra‐aortic balloon pump in her subclavian artery. Within two weeks, Mrs. Duong became IABP dependent and deconditioned. The attending (...) deemed her as lacking capacity to make complex medical decisions, and the medical review board officially declined her for LVAD placement. The heart failure and CICU teams feel that Mrs. Duong is not being helped by the care they are giving her. They recommend terminal weaning of the IABP and initiation of comfort care. Her family disagrees, pointing to activities like continued eating and interacting with family. At an impasse after yet another family meeting, the attending for the heart failure team asks the clinical ethics consultant, “Do we have to replace the balloon pump when it fails?”. (shrink)

Every clinical ethics consultant, no matter their own spirituality, will meet patients, families, and healthcare professionals whose spiritualities anchor their moral worldviews. How might ethicists respond to those who rely on spirituality when making medical decisions? And further, should ethicists incorporate their own spiritual commitments into their clinical analyses and recommendations? These questions prompt reflection on foundational issues in the philosophy of medicine, political and moral theory, and methods of proper clinical ethics consultation. Rather than attempting to offer definitive answers (...) to these questions, this essay prompts readers to consider their own answers to these questions. Specifically, it offers a taxonomic analysis of six (6) distinct responses: assessment, delegation, examination, translation, incorporation, and assertion. Furthermore, this essay describes the role of the ethicist’s own spiritual commitments during the responses. Each section also names several strengths and weaknesses that ethicists ought to consider when evaluating the purpose and scope of each response. This paper prompts readers to consider circumstances under which they might promote, critique, or incorporate spiritual worldviews—their own and those of their patients—when offering clinical analyses and recommendations. (shrink)

Volume 20, Issue 7, July 2020, Page 202-204.

Despite the interpersonal nature of family meetings and the frequency in which they occur, the clinical ethics literature is devoid of any rich descriptions of what clinical ethicists should actually be doing during family meetings. Here, we propose a framework for describing and understanding “transitioning” facilitation skills based on a retrospective review of our internal documentation of 100 consecutive cases wherein a clinical ethicist facilitated at least one family meeting. The internal documents were analyzed using qualitative methodologies, i.e., “codes”, to (...) identify emergent themes. We identified four different transitioning strategies clinical ethicists use to reach a meaningful resolution. These transitioning strategies serve as a jumping-off point for additional analyses, future research, evaluating clinical ethics consultation, and overall performance improvement of a consultation service. (shrink)

Mr. M is an eighty-five-year-old who presented to the hospital with congestive heart failure exacerbation, pneumonia, altered mental status, and sepsis. A physician determines that he lacks capacity, and the team in the intensive care unit looks to the patient's daughter, Celia, as his surrogate decision-maker because she is named as an agent in his medical power of attorney form. While in the ICU, Mr. M suffers acute respiratory distress secondary to pneumonia and thus requires intubation. Celia accepts several life-sustaining (...) interventions, but she sporadically refuses other medically indicated therapies. Although providers explain the importance of the ICU insulin regimen for glucose control, she either refuses the insulin or requests a lower dose. The health care team believes that it is providing substandard care and that Celia's medical decisions are not in the patient's best interests, so they request an ethics consultation. When the clinical ethicist attempts to talk with Celia, she refuses to speak with him, saying flatly, “I am not interested in talking with you.” The clinical ethicist meets with Celia on a couple of occasions, but she consistently refuses to have a conversation with him. He wonders if the patient's surrogate decision-maker can refuse a clinical ethics consultation and is unsure what his next steps should be. (shrink)

Although shared decision-making is a standard in medical care, unilateral decisions through process-based conflict resolution policies have been defended in certain cases. In patients who do not stand to receive proportional clinical benefits, the harms involved in interventions such as cardiopulmonary resuscitation seem to run contrary to the principle of non-maleficence, and provision of such interventions may cause clinicians significant moral distress. However, because the application of these policies involves taking choices out of the domain of shared decision-making, they face (...) important ethical and legal problems, including a recent challenge to their constitutionality. In light of these concerns, we suggest a re-conceptualization of informed non-dissent as an alternative approach in cases where the application of process-based policies is being considered. This clinician-directed communication model still preserves what is valuable in such policies and salvages professional integrity, while minimising ethical and legal challenges. (shrink)

This article discusses the triage response to the COVID-19 delta variant surge of 2021. One issue that distinguishes the delta wave from earlier surges is that by the time it became the predominant strain in the USA in July 2021, safe and effective vaccines against COVID-19 had been available for all US adults for several months. We consider whether healthcare professionals and triage committees would have been justified in prioritising patients with COVID-19 who are vaccinated above those who are unvaccinated (...) in first-order or second-order triage. Given that lack of evidence for a correlation between short-term survival and vaccination, we argue that using vaccination status during first-order triage would be inconsistent with accepted triage standards. We then turn to notions of procedural fairness, equity and desert to argue that that there is also a lack of justification for using vaccination status in second-order triage. In planning for future surges, we recommend that medical institutions base their triage decisions on principles meant to save the most lives, minimise inequity and protect the public’s trust, which for the time being would not be served by the inclusion of vaccination status. (shrink)

It is shown that the Kapitza-Dirac effect with atoms, which has been considered to be evidence for their wavelike character, can be interpreted as a scattering of pointlike objects by the periodic laser field.

In Metaphor and Film, Trevor Whittock demonstrates that feature films are permeated by metaphors that were consciously introduced by directors. An examination of cinematic metaphor forces us to reconsider the nature of metaphor itself, and the ways by which such visual imagery can be recognised and understood, as well as interpreted. Metaphor and Film identifies the principal forms of cinematic metaphor, and also provides an analysis of the mental operations that one must bring to it. Recent developments in cognitive (...) psychology, especially those relating to the nature and formation of categories, are called upon to explain these processes. Metaphor and Film ranges widely over film theory as it does over philosophical, literary, linguistic, and psychological accounts of metaphor. Particularly useful to those studying film, literature, and aesthetics, this study is also a provocative contribution to an important debate in which film theorists and philosophers are currently engaged. (shrink)

This paper first argues that we can bring out a tension between the following three popular doctrines: (i) the canonical reduction of metaphysical modality to essence, due to Fine, (ii) contingentism, which says that possibly something could have failed to be something, and (iii) the doctrine that metaphysical modality obeys the modal logic S5. After presenting two such arguments (one from the theorems of S4 and another from the theorems of B), I turn to exploring various conclusions we might draw (...) in light of these results, and argue that none comes cost free. In the course of laying out possible responses to my arguments, we'll have a chance to evaluate various doctrines about the interplay between contingency and essence, as well as develop some alternative reductions of metaphysical modality to essence. I don't decisively come down in favor of one response over the others, though I say some things that point towards the conclusion that essence has no role to play in reducing metaphysical modality. (shrink)

The consensus among spacetime substantivalists is to respond to Leibniz's classic shift arguments, and their contemporary incarnation in the form of the hole argument, by pruning the allegedly problematic metaphysical possibilities that generate these arguments. Some substantivalists do so by directly appealing to a modal doctrine akin to anti-haecceitism. Other substantivalists do so by appealing to an underlying hyperintensional doctrine that implies some such modal doctrine. My first aim in this paper is to pose a challenge for all extant forms (...) of this consensus position. My second aim is to show what form substantivalism must take in order to uphold the consensus while addressing this challenge. The result is a novel "plenitudinous" substantivalist view, which predicts that certain modal facts about spacetime are vague or indeterminate. I then argue against this view on independent grounds, concluding that substantivalists should reject the consensus position. The paper also discusses the way forward for substantivalists in light of this conclusion. (shrink)

The hole argument purports to show that all spacetime theories of a certain form are indeterministic, including the General Theory of Relativity. The argument has given rise to an industry of searching for a metaphysics of spacetime that delivers the right modal implications to rescue determinism. In this paper, I first argue that certain prominent extant replies to the hole argument—namely, those that appeal to an essentialist doctrine about spacetime—fail to deliver the requisite modal implications. As part of my argument, (...) I show that threats to determinism of the sort brought out by the hole argument are more general than has heretofore been recognized. I then use these results to propose a novel essentialist doctrine about spacetime that successfully rescues determinism, what I call sufficiency metric essentialism. However, I go on to argue that once we realize what an essentialist doctrine about spacetime must look like in order to address the hole argument, we should reject all such doctrines, because they can't fulfill their ambition of improving on standard modal replies to the argument. I close by suggesting some lessons for future work on spacetime and the metaphysics of physics more broadly, and also drawing some general morals for contemporary metaphysics, in particular about (i) whether essence can be used to articulate a precise structuralist doctrine, and (ii) the relationship between essence and modality. (shrink)

Formal criteria of theoretical equivalence are mathematical mappings between specific sorts of mathematical objects, notably including those objects used in mathematical physics. Proponents of formal criteria claim that results involving these criteria have implications that extend beyond pure mathematics. For instance, they claim that formal criteria bear on the project of using our best mathematical physics as a guide to what the world is like, and also have deflationary implications for various debates in the metaphysics of physics. In this paper, (...) I investigate whether there is a defensible view according to which formal criteria have significant non-mathematical implications, of these sorts or any other, reaching a chiefly negative verdict. Along the way, I discuss various foundational issues concerning how we use mathematical objects to describe the world when doing physics, and how this practice should inform metaphysics. I diagnose the prominence of formal criteria as stemming from contentious views on these foundational issues, and endeavor to motivate some alternative views in their stead. (shrink)

I demonstrate that a set of well-known objections defeat John Stuart Mill’s plural voting proposal, but do not defeat plural voting as such. I adopt the following as a working definition of political equality: a voting system is egalitarian if and only if departures from a baseline of equally weighted votes are normatively permissible. I develop an alternative proposal, called procedural plural voting, which allocates plural votes procedurally, via the free choices of the electorate, rather than according to a substantive (...) standard of competence. The alternative avoids standards objections to Mill’s proposal. Moreover, reflection on the alternative plural voting scheme disrupts our intuitions about what counts as an egalitarian voting system. Undue emphasis on Mill’s version of plural voting obscures three important reasons to reject plural voting in favor of strictly egalitarian voting systems: that certain choices that generate inequalities of political power are morally impermissible; that even... (shrink)

This paper will explore an epistemic aspect of hope, namely hope’s relationship to knowledge. It has been taken for granted that people do not hope for things to occur that they know will occur. I will be giving an argument that hope and knowledge are compatible, and I will defend that argument against one primary objection. More specifically, I will argue that there are instances when an agent knows that p and still hopes that p.

Background independence begins life as an informal property that a physical theory might have, often glossed as 'doesn't posit a fixed spacetime background'. Interest in trying to offer a precise account of background independence has been sparked by the pronouncements of several theorists working on quantum gravity that background independence embodies in some sense an essential discovery of the General Theory of Relativity, and a feature we should strive to carry forward to future physical theories. This paper has two goals. (...) The first is to investigate what a world must be like in order to be truly described by a background independent theory given extant accounts of background independence. The second is to argue that there are no non-empirical reasons to be more confident in theories that satisfy extant accounts of background independence than in theories that don't. The paper concludes by drawing a general moral about a way in which focussing primarily on mathematical formulations of our physical theories can adversely affect debates in the metaphysics of physics. (shrink)

In this paper I seek to show how cultural niche construction theory offers the potential to extend the human evolutionary story beyond the Pleistocene, through the Neolithic, towards the kind of very large-scale societies in which we live today. The study of the human past has been compartmentalised, each compartment using different analytical vocabularies, so that their accounts are written in mutually incompatible languages. In recent years social, cognitive and cultural evolutionary theories, building on a growing body of archaeological evidence, (...) have made substantial sense of the social and cultural evolution of the genus Homo. However, specialists in this field of studies have found it difficult to extend their kind of analysis into the Holocene human world. Within southwest Asia the three or four millennia of the Neolithic period at the beginning of the Holocene represents a pivotal point, which saw the transformation of human society in the emergence of the first large-scale, permanent communities, the domestication of plants and animals, and the establishment of effective farming economies. Following the Neolithic, the pace of human social, economic and cultural evolution continued to increase. By 5000 years ago, in parts of southwest Asia and northeast Africa there were very large-scale urban societies, and the first large-scale states. An extension of cultural niche construction theory enables us to extend the evolutionary narrative of the Pleistocene into the Holocene, opening the way to developing a single, long-term, evolutionary account of human history. (shrink)

Environmental ethicists have not reached a consensus about whether or not individuals who contribute to climate change have a moral obligation to reduce their personal greenhouse gas emissions. In this paper, I side with those who think that such individuals do have such an obligation by appealing to the concept of integrity. I argue that adopting a political commitment to work toward a collective solution to climate change—a commitment we all ought to share—requires also adopting a personal commitment to reduce (...) one’s emissions. On these grounds, individuals who contribute to climate change have a prima facie moral duty to lower their personal greenhouse gas emissions. After presenting this argument and supporting each of its premises, I defend it from two major lines of objection: skepticism about integrity’s status as a virtue and concerns that the resulting moral duty would be too demanding to be morally required. I then consider the role that an appeal to integrity could play in galvanizing the American public to take personal and political action regarding climate change. (shrink)

In Pragmatism’s Evolution, Trevor Pearce demonstrates that the philosophical tradition of pragmatism owes an enormous debt to specific biological debates in the late 1800s, especially those concerning the role of the environment in development and evolution. Many are familiar with John Dewey’s 1909 assertion that evolutionary ideas overturned two thousand years of philosophy—but what exactly happened in the fifty years prior to Dewey’s claim? What form did evolutionary ideas take? When and how were they received by American philosophers? Although (...) the various thinkers associated with pragmatism—from Charles Sanders Peirce to Jane Addams and beyond—were towering figures in American intellectual life, few realize the full extent of their engagement with the life sciences. In his analysis, Pearce focuses on a series of debates in biology from 1860 to 1910—from the instincts of honeybees to the inheritance of acquired characteristics—in which the pragmatists were active participants. If we want to understand the pragmatists and their influence, Pearce argues, we need to understand the relationship between pragmatism and biology. (shrink)

This book examines the link between population growth and environmental impact and explores the implications of this connection for the ethics of procreation. In light of climate change, species extinctions, and other looming environmental crises, Trevor Hedberg argues that we have a collective moral duty to halt population growth to prevent environmental harms from escalating. This book assesses a variety of policies that could help us meet this moral duty, confronts the conflict between protecting the welfare of future people (...) and upholding procreative freedom, evaluates the ethical dimensions of individual procreative decisions, and sketches the implications of population growth for issues like abortion and immigration. It is not a book of tidy solutions: Hedberg highlights some scenarios where nothing we can do will enable us to avoid treating some people unjustly. In such scenarios, the overall objective is to determine which of our available options will minimize the injustice that occurs. This book will be of great interest to those studying environmental ethics, environmental policy, climate change, sustainability, and population policy. (shrink)

It is argued that philosophical realism is well suited to serve as a perspective from which to understand nursing, and that it should be considered as an alternative to positivist, interpretivist, hermeneutical and phenomenological approaches. However, existing forms of realism, including theory and entity realism are shown to be faced with serious problems. In response, an alternative form ‘constraint realism’ is outlined, and shown to be apposite for illuminating the rule or convention governed behaviour characteristic of human beings. A brief (...) sketch is offered of its application to the social practice of nursing. (shrink)

It is argued that philosophical realism is well suited to serve as a perspective from which to understand nursing, and that it should be considered as an alternative to positivist, interpretivist, hermeneutical and phenomenological approaches. However, existing forms of realism, including theory and entity realism are shown to be faced with serious problems. In response, an alternative form ‘constraint realism’ is outlined, and shown to be apposite for illuminating the rule or convention governed behaviour characteristic of human beings. A brief (...) sketch is offered of its application to the social practice of nursing. (shrink)

f gravity is examined in the context of a five-dimensional Kaluza-Klein theory with degenerate metric. In this theory electromagnetism is described by two vector fields, and there is a reflection symmetry between them which unifies them with gravitation. For matter, it is shown how the Lagrangian may be any function and still generate the same equations of motion, provided that some simple conditions are satisfied. The field equations are derived, and it is found that f gravity is not consistent with (...) the reflection symmetry. (shrink)

Understanding People provides an overview and critique of current psychological assumptions about people and what differentiates them, and replaces them with a set of ideas taken from social constructionism. It begins with an examination of contemporary theories, then explores the critique of the social constructionists, before laying out the basis of an understanding of human action and behavior, drawing on phenomenology and personal construct theory. Using everyday experience to illustrate the issues in personality theory (Is behavior situation-specific? Why do we (...) have a sense of self? Is there an unconscious?), this book will breathe life into an area of psychology that is so often arid, and, in the eyes of students, divorced from their world. (shrink)

We live in anagewhere"progressive" intellectualspresuppose that true democracy demands the affirmation of "global values" and the drive toward a world government, a"universal and homogenous state." Intellectuals, journalists, and educators bemoan the effects of "globalization" even as they uncritically endorse cosmopolitanism and dismissnational attachments as parochial and outdated. They confuse thoughtful patriotism - and commitment to the self-governing nation - with the narrowest form of nationalism. In a wonderfullylucid and learned essay, Trevor Shelley recovers a humane liberal tradition, from Montesquieu (...) to Manent, that takes the political seriously and does full justice to the legitimate claims of both universality and particularity. Whether discussing Tocqueville's critique of the pantheistic reveries of democratic man or Pierre Manent's erudite defense of the nation, the political form that provides the indispensable framework for democratic self-government, Shelley thoughtfully illumines the place and limits of globalization in a democratic age. --Daniel J. Mahoney, Augustine Chair in Distinguished Scholarship, Assumption College. (shrink)

Trevor Pateman; Can Schools Educate?, Journal of Philosophy of Education, Volume 14, Issue 2, 30 May 2006, Pages 139–148, https://doi.org/10.1111/j.1467-9752.19.

Trevor Pateman; Can Schools Educate?, Journal of Philosophy of Education, Volume 14, Issue 2, 30 May 2006, Pages 139–148, https://doi.org/10.1111/j.1467-9752.19.

_Peter Greenaway's Postmodern/Poststructuralist Cinema_ Edited by Paula Willoquet-Maricondi and Mary Alemany-Galway Lanham, MD: The Scarecrow Press, 2001 ISBN 0-8108-3892-3 xxviii + 360 pp.