Volume 20, Issue 2, February 2020, Page 49-50.

: Dr. Smith is an internist in private practice who works at an inner city clinic affiliated with a university hospital. He is also a member of the university faculty. Many of Dr. Smith’s patients have type 2 diabetes mellitus and struggle with health care and other costs. Thinking about opportunities to better serve his patients and advance his career, Dr. Smith considers conducting clinical research in his office. ACME is a respected pharmaceutical company that for decades has engaged in (...) research, development, and production of widely used drugs. Several of ACME’s oral agents for type 2 diabetes will soon go off patent. In an effort to retain its market share in this class of drugs, ACME wants to complete clinical trials expeditiously and obtain approval for its new oral hypoglycemic medicine. The company approaches Dr. Smith to be a coinvestigator in its multicenter clinical trial. (shrink)

Background Following passage of the Patient Self Determination Act in 1990, health care institutions that receive Medicare and Medicaid funding are required to inform patients of their right to make their health care preferences known through execution of a living will and/or to appoint a surrogate-decision maker. We evaluated the impact of external factors and perceived patient preferences on physicians’ decisions to honor or forgo previously established advance directives (ADs). In addition, physician views regarding legal risk, patients’ ability to comprehend (...) complexities involved with their care, and impact of medical costs related to end-of-life care decisions were explored. Methods Attendees of two Mayo Clinic continuing medical education courses were surveyed. Three scenarios based in part on previously court-litigated matters assessed impact of external factors and perceived patient preferences on physician compliance with patient-articulated wishes regarding resuscitation. General questions measured respondents’ perception of legal risk, concerns over patient knowledge of idiosyncrasies involved with their care, and impact medical costs may have on compliance with patient preferences. Responses indicating strength of agreement or disagreement with statements were treated as ordinal data and analyzed using the Cochran Armitage trend test. Results Three hundred eighty-eight of 951 surveys were completed (41% response rate). Eighty percent reported they were likely to honor a patient’s AD despite its 5 year age. Fewer than half (41%) would honor the AD of a patient in ventricular fibrillation who had expressed a desire to “pass away in peace.” Few (17%) would forgo an AD following a family’s request for continued resuscitative treatment. A majority (52%) considered risk of liability to be lower when maintaining someone alive against their wishes than mistakenly failing to provide resuscitative efforts. A large percentage (74%) disagreed that patients could not appreciate complexities surrounding their care while 69% agreed that costs should never impact a physician’s decision as to whether to comply with a patient’s AD. Conclusions Our findings highlight the impact, albeit small, external factors have on physician AD compliance. Most respondents based their decision on the clinical situation at hand and interpretation of the patient’s initial wishes and preferences expressed by the AD. (shrink)

BackgroundAn analysis of the position statements of secular US medical and surgical professional societies on physician-assisted suicide (PAS) and euthanasia have not been published recently. Available statements were evaluated for position, content, and sentiment.MethodsIn order to create a comprehensive list of secular medical and surgical societies, the results of a systematic search using Google were cross-referenced with a list of societies that have a seat on the American Medical Association House of Delegates. Societies with position statements were identified. These statements (...) were divided into 5 categories: opposed to PAS and/or euthanasia, studied neutrality, supportive, acknowledgement without statement, and no statement. Linguistic analysis was performed using RapidMinder in order to determine word frequency and sentiment respective to individual statements. To ensure accuracy, only statements with word counts > 100 were analyzed. A 2-tailed independentttest was used to test for variance among sentiment scores of opposing and studied neutrality statements.ResultsOf 150 societies, only 12 (8%) have position statements on PAS and euthanasia: 11 for PAS (5 opposing and 4 studied neutrality) and 9 for euthanasia (6 opposing and 2 studied neutrality). Although the most popular words used in opposing and studied neutrality statements are similar, notable exceptions exist (suicide,medicine, andtreatmentappear frequently in opposing statements, but not in studied neutrality statements, whereaspsychologists,law, andindividualsappear frequently in studied neutrality statements, but not in opposing statements). Sentiment scores for opposing and studied neutrality statements do not differ (mean, 0.094 vs. 0.104;P = 0.90).ConclusionsFew US medical and surgical societies have position statements on PAS and euthanasia. Among them, opposing and studied neutrality statements share similar linguistic sentiment. Opposing and studied neutrality statements have clear differences, but share recommendations. Both opposing and studied neutrality statements cite potential risks of PAS legalization and suggest that good palliative care might diminish a patient’s desire for PAS. (shrink)

State governments provide preprinted advance directive forms to the general public. However, many adults in the United States (US) lack the skills necessary to read and comprehend health care-related materials. In this study, we sought to determine the readability of state government-sponsored advance directive forms.

In lieu of an abstract, here is a brief excerpt of the content:Bibliography of Resources by and about André E. Hellegers*Compiled by Doris Mueller Goldstein (bio)This bibliography is derived from the holdings of the National Reference Center for Bioethics Literature and the BIOETHICSLINE© database (both of which are at the Kennedy Institute of Ethics and supported by the National Library of Medicine); the archives of Lauinger Library, Georgetown University; the Medline databases of the National Library of Medicine; the WorldCat (...) database of OCLC, Dublin, Ohio, and selected Internet sites.Primarily comprised of writings by Dr. Hellegers, the list also includes interviews and media programs in which he participated, as well as writings about him that were written following his death. The arrangement within each section is by date. The 231 authored pieces reflect the transition from Dr. Hellegers’s early career as a researcher in fetal physiology at Johns Hopkins Medical School, where he published his first research report at the age of 29, to the early years of the Kennedy Institute, where he produced so many provocative columns on bioethical issues that influenced the growth of the field.Due to the diversity of sources and the 40-year time span covered, there are some variations in bibliographic style. Time and availability constraints precluded verifying all of the citations with the original documents. Any additions or corrections should be submitted to the compiler.Works Authored by André E. HellegersNo Date Ethical Issues in Sterilization of the Retarded. Unpublished paper.1956Vitamin B12 Serum Level and Pregnancy. American Journal of Clinical Nutrition 4: 440+, 1956. [With Bacon F. Chow and Kunio Okuda] [End Page 89]1957Vitamin B12 Absorption in Pregnancy and in the Newborn. American Journal of Clinical Nutrition 5: 327+, 1957. [With Bacon F. Chow, Robert E. L. Nesbitt, Kunio Okuda, and David W. Smith]1958The Effects of Acute Hypoxia on the Osmotic Pressure of the Plasma. Quarterly Journal of Experimental Physiology 43: 197+, 1958. [With Donald H. Barron, Frederick C. Battaglia, and Giacomo Meschia]Studies on the Absorption of Vitamin B12 in Human Pregnancy with Especial Reference to the Effect of D-Sorbitol. American Journal of Obstetrics and Gynecology 76: 91+, 1958. [With Bacon F. Chow, Harry Prystowsky, and Vernon Wong]1959The Alveolar PCO2 and PO2 in Pregnant and Nonpregnant Women at Altitude. Proceedings of the Society for Clinical Investigation 38: 1010+, 1959. [With Donald Barron, William Huckabee, Giacomo Meschia, James Metcalfe, and Harry Prystowsky]A Comparison of the Oxygen Dissociation Curves of the Bloods of Maternal and Fetal Goats at Various pHs. Quarterly Journal of Experimental Physiology 44: 215–21, July 1959. [With Donald Barron, Giacomo Meschia, Harry Prystowsky, and A. Stark Wolkoff]Fetal Blood Studies. XII. On the Relationship Between the Position of the Oxygen Dissociation Curve of Human Fetal Blood and Adult Fetal Hemoglobin. American Journal of Obstetrics and Gynecology 77: 585+, 1959. [With Paul D. Bruns, Julian Cotter, and Harry Prystowsky]Fetal Blood Studies. XIV. A Comparative Study of the Oxygen Dissociation Curve of Nonpregnant, Pregnant and Fetal Human Blood. American Journal of Obstetrics and Gynecology 78: 489–93, September 1959. [With Paul D. Bruns and Harry Prystowsky]Fetal Blood Studies. XVI. On the Changes in Total Osmotic Pressure and Sodium and Potassium Concentration of Amniotic Fluid During the Course of Human Gestation. Surgery, Gynecology and Obstetrics 109: 509–12, October 1959. [With Frederick Battaglia, Paul D. Bruns, Harry Prystowsky, and Clayton Smisson]Further Observations on the Metabolism of Vitamin B12 in Human Pregnancy. American Journal of Obstetrics and Gynecology 77: 1+, 1959. [With Bacon F. Chow, Harry Prystowsky, Bruno Ranke, and Elma Ranke]The Oxygen Dissociation Curves of the Bloods of Adult and Fetal Llamas. Federation Proceedings 18, 1959. [With Donald Barron, William Huckabee, Giacomo Meschia, James Metcalfe, and Harry Prystowsky] [End Page 90]Transfer of Oxygen Across the Sheep Placenta at High Altitude. Federation Proceedings 18, 1959. [With Donald Barron, William Huckabee, Giacomo Meschia, and Harry Prystowsky]Uterine Blood Flow and Metabolism in Pregnant Sheep at High Altitude. Federation Proceedings 18, 1959. [With Donald Barron, William Huckabee, Giacomo Meschia, James Metcalfe, and Harry Prystowsky]Uterine Blood Flow and Metabolism in Unanesthetized Pregnant Sheep. Federation Proceedings 18, 1959. [With Donald Barron, William Huckabee, Giacomo... (shrink)

For most observers of economics from both inside and outside the science, the term ‘economics’ is synonymous with neoclassical economics. It is the methodology of neoclassical economics that defines the discipline of economics. ‘Mainstream economics’ is neoclassical economics and anyone entering the discipline today who wishes to obtain an appointment at one of the leading universities of the world is well advised to master its techniques. The fact that virtually every winner of a Nobel prize from Paul Samuelson up (...) to his student Joseph Stiglitz has been a practitioner of neoclassical economics is ample proof of the methodology’s triumph. Despite the dominance of this methodology, however, neoclassical economics has been subject to a steady stream of criticisms and proposals for alternative methodological approaches throughout its life. This article focuses on two relatively recent challenges to the neoclassical orthodoxy that seem to have taken hold of a non-negligible minority of the profession, some of whom can be found at leading universities. These two challenges come from behavioural economics and evolutionary economics. The article describes the strengths and weaknesses of both of these methodological approaches and contrasts them with that of neoclassical economics. It concludes that all three methodologies have something positive to contribute to the study of human behaviour. Key Words: neoclassical economics • behavioural economics • evolutionary economics. (shrink)

Quine claims that holism (i.e., the Quine-Duhem thesis) prevents us from defining synonymy and analyticity (section 2). In Word and Object, he dismisses a notion of synonymy which works well even if holism is true. The notion goes back to a proposal from Grice and Strawson and runs thus: R and S are synonymous iff for all sentences T we have that the logical conjunction of R and T is stimulus-synonymous to that of S and T. Whereas Grice and Strawson (...) did not attempt to defend this definition, I try to show that it indeed gives us a satisfactory account of synonymy. Contrary to Quine, the notion is tighter than stimulus-synonymy – particularly when applied to sentences with less than critical semantic mass (section 3). Now according to Quine, analyticity could be defined in terms of synonymy, if synonymy were to make sense: A sentence is analytic iff synonymous to self-conditionals. This leads us to the following notion of analyticity: S is analytic iff, for all sentences T, the logical conjunction of S and T is stimulus-synonymous to T; an analytic sentence does not change the semantic mass of any theory to which it may be conjoined (section 4). This notion is tighter than Quine's stimulus-analyticity; unlike stimulus-analyticity, it does not apply to those sentences from the very center of our theories which can be assented to come what may, even though they are not synthetic in the intuitive sense (section 5). Conclusion: We can have well-defined notions of synonymy and analyticity even if we embrace Quine's holism, naturalism, behaviorism, and radical translation. Quine's meaning skepticism is to be repudiated on Quinean grounds. (shrink)

Recently, Kenneth Westphal has presented a highly interesting and innovative reading of Kant's critical philosophy.2 This reading continues a tradition of Kantscholarship of which, e.g., Paul Guyer's work is representative, and in which the antiidealistic potential of Kant's critical philosophy is pitted against its idealistic selfunderstanding. Much of the work in this tradition leaves matters at observing the tensions this introduces in Kant's work. But Westphal's proposed interpretation goes farther. Its attractiveness derives for the most part from the promise (...) that it permits an internal critique of Kant's transcendental idealism (TI), that is, a critique that is based on the very resources of Kantian transcendental philosophy.3 In contrast to these resources, which currently seem to go through a sort of revival in an enormous array of fields, TI is notorious for dismaying even sympathetic interpreters. How attractive and needed such an internal critique of TI would be becomes all the more patent when we place such a promise in the context of some of the contemporary discussions about TI after Allison's famous defense of it. Before directly engaging with Westphal's interpretation, I would therefore like to quickly sketch on what background it acquires its force (I). After characterizing the main features of Westphal's view (II), and supporting it in more detail by an account of Kant's theory of cognitive significance (III), I then want to review the extent of its success to present Kant as issuing an anti-skeptical argument (IV.1), or semantic views that are incompatible with TI (IV.2), or a 'proof of not merely empirical realism' (IV.3). I agree that purely idealist readings of Kant are mistaken. Westphal's... (shrink)

This chapter contains sections titled: Recurrence‐Awareness Recurrence‐Evidence Recurrence‐Significance Recurrence‐Time Recurrence‐Coherence Conclusion.

This book presents a heuristic and critical study of comparative theology in engagement with phenomenological methodology and sociological inquiry. It elucidates a postcolonial study of religion in the context of multiple modernities.

This book is the fourth in a series of essay collections on defences in private law. It addresses defences to liability arising in equity. The essays range from those adopting a mainly doctrinal perspective to others that explore the law from a more philosophical perspective. Some essays concentrate on specific defences, while others are concerned with the links between defences, or with how defences relate to the structure of the law of equity generally. One aim of the book is to (...) shed light on equitable doctrines by analysing them through the lens of defences. The essays offer original contributions to this complex, important but neglected field of scholarly investigation. The contributors – judges, practitioners and academics – are all distinguished jurists. The essays are addressed to all of the major common law jurisdictions. (shrink)

Voluntariness of consent to research has not been sufficiently explored through empirical research. The aims of this study were to develop a more comprehensive approach to assessing voluntariness and to generate preliminary data on the extent and correlates of limitations on voluntariness. We developed a questionnaire to evaluate subjects’ reported motivations and constraints on voluntariness. 88 subjects in five different areas of clinical research—substance abuse, cancer, HIV, interventional cardiology, and depression—were assessed. Subjects reported a variety of motivations for participation. Offers (...) of financial incentives were common but not influential, pressures from others were rare, and no threats were reported. However, certain financial incentives and—paradoxically—altruistic motivations led some subjects to feel more constrained. Consistent with previous studies, no one pattern of motivation was common to all research subjects. There was little evidence of constrained voluntariness, but some suggestion of areas of concern. Voluntariness appears to be susceptible to systematic empirical investigation. (shrink)

The eternal recurrence of the same. Simmel's critique ; Awareness ; Evidence ; Significance ; Coherence -- Demon or god? Deathbed revelation ; Daimonic prophecy ; Dionysian doctrine ; Diagnostic test -- The dwarf and the gateway. The gateway to Hades ; The dwarf's interpretation ; Zarathustra's cross-examination ; The inescapable cycle ; Crossing the gateway ; No time until rebirth ; The ancient memory ; Midnight swan song -- The great noon. Two conclusions ; Tragic end and analeptic satyr (...) play ; Zarathustra's hour ; Noon crucifixion ; Seventh-day convalescence ; Last temptation ; Third-day resurrection -- The laughing lions. Revaluation of values ; Dawn reunion ; Morning consecration ; Call to arms ; Final farewell and last will ; Zarathustra's great destiny -- The shepherd and the serpent. The eternally recurring human ; The future human ; Zarathustra the dragon-slayer ; The decapitation ; The heavy hammer ; No longer shepherd -- Circulus vitiosus deus. Impotence and revenge ; Backward-willing ; Self-redemption ; The third transformation ; The child spirit ; No longer human ; Zarathustra's dying gift -- Post-Zarathustra. Nietzsche and Zarathustra ; Reversing the bad conscience ; Atheism and the death of God ; Countering the ascetic ideal. (shrink)

In this study of Nietzsche's Thus Spoke Zarathustra, Paul S. Loeb proposes a fresh account of the relation between the book's literary and philosophical aspects and argues that the book's narrative is designed to embody and exhibit the truth of eternal recurrence. Loeb shows how Nietzsche constructed a unified and complete plot in which the protagonist dies, experiences a deathbed revelation of his endlessly repeating life, and then returns to his identical life so as to recollect this revelation and (...) gain a power over time that advances him beyond the human. Through close textual analysis and careful attention to Nietzsche's use of Platonic, biblical, and Wagnerian themes, Loeb explains how this novel design is the key to solving the many riddles of Thus Spoke Zarathustra - including its controversial fourth part, its obscure concept of the Übermensch, and its relation to Nietzsche's Genealogy of Morals. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Ought We to Require Emotional Capacity as Part of Decisional Competence?Paul S. Appelbaum* (bio)AbstractThe preceding commentary by Louis Charland suggests that traditional cognitive views of decision-making competence err in not taking into account patients’ emotional capacities. Examined closely, however, Charland’s argument fails to escape the cognitive bias that he condemns. However, there may be stronger arguments for broadening the focus of competence assessment to include emotional capacities, centering (...) on the ways in which emotions aid humans in processing information. Before emotional capacities are added to the list of functions essential for decisional competence, though, the feasibility and utility of such a reorientation must be demonstrated.To what extent ought persons’ capacities to experience emotion be taken into account when determining whether they should be deemed competent to make their own decisions? In the previous article, Louis Charland (1998) argues that traditional models of decision-making competence—of which the MacArthur Competence Treatment Study is a typical example—are mistaken in focusing narrowly on persons’ cognitive abilities to the neglect of emotional factors. In contrast, he suggests, constructs of competence ought explicitly to require a capacity to experience emotions, which he believes is central to meaningful decision making, before deeming persons competent.Charland, as he acknowledges, is not the first to suggest that the presence of some degree of emotional capacity is a necessary element of competence, but his argument is among the most elaborate to date and is certainly worth closer examination. Looked at carefully, however, Charland’s argument does not make quite the case for the determination of emotional capacity in competence assessment that he claims for it. Indeed, as I demonstrate below, Charland may share the same “pernicious [End Page 377] cognitive bias” that he ascribes to more traditional approaches. However, despite what I identify as the problems in Charland’s argument, others have raised more disturbing questions about the lack of attention to emotional issues in competence assessment. Thus, I am not ready to reject entirely the possibility that determinations of decisional competence ought to consider emotional factors. I conclude by outlining the questions that remain to be answered to identify more clearly the potential benefits of such an approach.The Construct of Decision-Making CompetenceSome preliminary comments about the nature of the dominant construct of decision-making competence may provide a useful frame for my response to Charland’s paper. Contemporary ideas of competence are tied inextricably to the ideal of self-determination in modern Western societies. Such societies are committed to respect for individual choice, both as a good in its own right and on the grounds that each person knows best what choices will maximize his or her own welfare. In general, therefore, states will not intervene to prevent persons from acting on their decisions, even when the choices they make—like the decision to smoke or to refuse potentially life-saving medical care—may objectively be thought to be detrimental to them.In some cases, however, the presumption that people will act in their own interests, as well as the notion that there is something intrinsically valuable in respecting their choices, fails (Buchanan and Brock 1989). When people’s minds are so disordered that they cannot be said to be making meaningful choices, other values come into play. Such people are called “incompetent.” When persons reach that point, the state’s interest in protecting its citizens becomes primary and someone else must make decisions on their behalf. Note that the size of this group must be sharply limited, lest a liberal society’s commitment to self-determination be undermined: There is no more profound infringement of the rights of citizens than the determination that they are incompetent. Thus, the criteria for incompetence must be selected in a deliberately narrow fashion—alternately, one might say that the standards for competence are made intentionally broad—so that all but a tiny percentage of citizens will be permitted to make decisions on their own.In the Anglo-American world, the process of formulating criteria of competence by and large has been left to the common law courts. Over the course of centuries they have identified the capacities that are, in... (shrink)

(2002). Clarifying the Ethics of Clinical Research: A Path toward Avoiding the Therapeutic Misconception. The American Journal of Bioethics: Vol. 2, No. 2, pp. 22-23.

The ‘universal cell reaction’ (UCR), a coordinated biphasic response to external (noxious and other) stimuli observed in all living cells, was described by Nasonov and his colleagues in the mid‐20th century. This work has received no attention from cell biologists in the West, but the UCR merits serious consideration. Although it is non‐specific, it is likely to be underpinned by precise mechanisms and, if these mechanisms were characterized and their relationship to the UCR elucidated, then our understanding of the integration (...) of cellular function could be improved. As a step towards identifying such mechanisms, I review some recent advances in understanding cell mechanics and the stress response and I suggest potentially testable hypotheses. There is a particular need for time‐course studies of cellular responses to different stimulus doses or intensities. I also suggest a correspondence with hormesis; re‐investigation of the UCR using modern biophysical and molecular‐biological techniques might throw light on this much‐discussed phenomenon. BioEssays 29:324–333, 2007. © 2007 Wiley Periodicals, Inc. (shrink)

Volume 19, Issue 5, May 2019, Page 22-24.

Genomic research—including whole genome sequencing and whole exome sequencing—has a growing presence in contemporary biomedical investigation. The capacity of sequencing techniques to generate results that go beyond the primary aims of the research—historically referred to as “incidental findings”—has generated considerable discussion as to how this information should be handled—that is, whether incidental results should be returned, and if so, which ones.Federal regulations governing most human subjects research in the United States require the disclosure of “the procedures to be followed” in (...) the research as part of the informed consent process. It seems reasonable to assume—and indeed, many commentators have concluded—that genomic investigators will be expected to inform participants about, among other procedures, the prospect that incidental findings will become available and the mechanisms for dealing with them. Investigators, most of whom will not have dealt with these issues before, will face considerable challenges in framing meaningful disclosures for research participants.To help in this task, we undertook to identify the elements that should be included in the informed consent process related to incidental findings. We did this by surveying a large number of genomic researchers (n = 241) and by conducting in‐depth interviews with a smaller number of researchers (n = 28) and genomic research participants (n = 20). Based on these findings, it seems clear to us that routine approaches to informed consent are not likely to be effective in genomic research in which the prospect of incidental findings exists. Ensuring that participants’ decisions are informed and meaningful will require innovative approaches to dealing with the consent issue. We have identified four prototypical models of a consent process for return of incidental findings. (shrink)

Cognitive science has converged in many ways with cognitive psychology, but while also maintaining a distinctive interdisciplinary nature. Here we further characterize this existing state of the field before proposing how it might be reconceptualized toward a broader and more distinct, and thus more stable, position in the realm of sciences.

: Responding to the paper by Miller and Joffe, we review the development of the concept of therapeutic misconception (TM). Our concerns about TM's impact on informed consent do not derive from the belief that research subjects have poorer outcomes than persons receiving ordinary clinical care. Rather, we believe that subjects with TM cannot give an adequate informed consent to research participation, which harms their dignitary interests and their abilities to make meaningful decisions. Ironically, Miller and Joffe's approach ends up (...) largely embracing the very position that they inaccurately attribute to us: the belief that, with some exceptions, it is only the prospect of poorer outcomes that should motivate efforts to dispel TM. In the absence of empirical studies on the steps required to dispel TM and the impact of such procedures on subject recruitment, it is premature to surrender to the belief that TM must be widely tolerated in clinical research. (shrink)

Exploring the 'roads less travelled', MacDonald continues his monumental essay in the history of ideas. The history of heterodox ideas about the concept of mind takes the reader from the earliest records about human nature in Ancient Egypt, the Ancient Near East, and the Zoroastrian religion, through the secret teachings in the Hermetic and Gnostic scriptures, and into the transformation of ideas about the mind, soul and spirit in the late antique and early medieval epochs. These transitions include discussion of (...) the influence of Central Asian shamanism, Manichean ideas about the soul in light and darkness, and Neoplatonic theurgy, 'working-on-god-within'. Sections on the medieval period are concerned with the rediscovery of magical practices and occult doctrines from Roger Bacon to Francis Bacon, the adaptation of Neoplatonic and esoteric ideas in the medieval Christian mystics, and the survival of these ideas mixed with natural science in the works of von Helmont, Leibniz and Goethe. The book concludes with an investigation of the many forms of dualism in accounts of the human mind and soul, and the concept of dual-life which underpins our aspiration to understand how humans could have an immortal nature like the gods. (shrink)