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)

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)

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)

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)

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)

In 1924 Banach and Tarski demonstrated the existence of a paradoxical decomposition of the 3-ball B, i.e., a piecewise isometry from B onto two copies of B. This article answers a question of de Groot from 1958 by showing that there is a paradoxical decomposition of B in which the pieces move continuously while remaining disjoint to yield two copies of B. More generally, we show that if n ≥ 2, any two bounded sets in.

We consider a weak version of Schindler’s remarkable cardinals that may fail to be ${{\rm{\Sigma }}_2}$-reflecting. We show that the ${{\rm{\Sigma }}_2}$-reflecting weakly remarkable cardinals are exactly the remarkable cardinals, and that the existence of a non-${{\rm{\Sigma }}_2}$-reflecting weakly remarkable cardinal has higher consistency strength: it is equiconsistent with the existence of an ω-Erdős cardinal. We give an application involving gVP, the generic Vopěnka principle defined by Bagaria, Gitman, and Schindler. Namely, we show that gVP + “Ord is not ${{\rm{\Delta (...) }}_2}$-Mahlo” and ${\text{gVP}}$ + “there is no proper class of remarkable cardinals” are both equiconsistent with the existence of a proper class of ω-Erdős cardinals, extending results of Bagaria, Gitman, Hamkins, and Schindler. (shrink)

We show that Weak Vopěnka’s Principle, which is the statement that the opposite category of ordinals cannot be fully embedded into the category of graphs, is equivalent to the large cardinal principle Ord is Woodin, which says that for every class [Formula: see text] there is a [Formula: see text]-strong cardinal. Weak Vopěnka’s Principle was already known to imply the existence of a proper class of measurable cardinals. We improve this lower bound to the optimal one by defining structures whose (...) nontrivial homomorphisms can be used as extenders, thereby producing elementary embeddings witnessing [Formula: see text]-strongness of some cardinal. (shrink)

We show that Weak Vopěnka’s Principle, which is the statement that the opposite category of ordinals cannot be fully embedded into the category of graphs, is equivalent to the large cardinal princi...

We define a generic Vopěnka cardinal to be an inaccessible cardinal \ such that for every first-order language \ of cardinality less than \ and every set \ of \-structures, if \ and every structure in \ has cardinality less than \, then an elementary embedding between two structures in \ exists in some generic extension of V. We investigate connections between generic Vopěnka cardinals in models of ZFC and the number and complexity of \-Suslin sets of reals in models (...) of ZF. In particular, we show that ZFC + is equiconsistent with ZF + \\) where \ is the pointclass of all \-Suslin sets of reals, and also with ZF + \\) + \\) where \ is the least ordinal that is not a surjective image of the reals. (shrink)

We define a generic Vopěnka cardinal to be an inaccessible cardinal \ such that for every first-order language \ of cardinality less than \ and every set \ of \-structures, if \ and every structure in \ has cardinality less than \, then an elementary embedding between two structures in \ exists in some generic extension of V. We investigate connections between generic Vopěnka cardinals in models of ZFC and the number and complexity of \-Suslin sets of reals in models (...) of ZF. In particular, we show that ZFC + is equiconsistent with ZF + \\) where \ is the pointclass of all \-Suslin sets of reals, and also with ZF + \\) + \\) where \ is the least ordinal that is not a surjective image of the reals. (shrink)

We give a new proof of a theorem of Shelah which states that for every family of labeled trees, if the cardinality κ of the family is much larger (in the sense of large cardinals) than the cardinality λ of the set of labels, more precisely if the partition relation holds, then there is a homomorphism from one labeled tree in the family to another. Our proof uses a characterization of such homomorphisms in terms of games.

Unethical behavior coordinated and concealed by teams continues to represent a troubling and all-too-frequent occurrence in organizations. Unfortunately, those who are most knowledgeable about this behavior and thereby best suited to report it to authorities—the complicit members themselves—are susceptible to unique pressures that often discourage them from blowing the whistle. Team members rely on their teammates for relational and other beneficial resources, making it more difficult to potentially break those ties by snitching. However, we argue that the pressure to stay (...) silent is alleviated for members who are ostracized by their team members. Drawing on social exchange theory, we theorize that ostracism decreases positive affect and increases negative affect, decreasing individuals’ communion striving motivation and, in turn, increasing the propensity to blow the whistle. In Study 1, we examined the link between ostracism and whistleblowing utilizing a field sample of diverse employees surveyed over time. In Study 2, we built upon Study 1 and conducted a lab study to examine affect and communion striving motivation as serial mediators. Results were generally supportive of our arguments, although we did not find support for the mediating effect of negative affect. (shrink)

We give a level-by-level analysis of the Weak Vopěnka Principle for definable classes of relational structures ( $\mathrm {WVP}$ ), in accordance with the complexity of their definition, and we determine the large-cardinal strength of each level. Thus, in particular, we show that $\mathrm {WVP}$ for $\Sigma _2$ -definable classes is equivalent to the existence of a strong cardinal. The main theorem (Theorem 5.11) shows, more generally, that $\mathrm {WVP}$ for $\Sigma _n$ -definable classes is equivalent to the existence of (...) a $\Sigma _n$ -strong cardinal (Definition 5.1). Hence, $\mathrm {WVP}$ is equivalent to the existence of a $\Sigma _n$ -strong cardinal for all $n<\omega $. (shrink)

Scale is a contested concept in human geography fostering debates and contestation that have escalated to the point where some have argued for the term to be expunged from the geographical lexicon. Yet, despite the importance of scale in the geography of religion, the scalar debates in human geography have only rarely penetrated the conceptual base of the sub-discipline. This article addresses the scale debate through a case study of adherents in three churches in West Virginia, USA. The study explores (...) these highly theoretical scalar issues through an empirical analysis of adherents, congregations and denominational leaders. A critical realist framework of emergence is used to demonstrate the value of a stratified, non-reductionist approach to the geography of religion. An emergent geography of religion is considered alongside other forms of religious social analysis such as poststructural ‘crossings and dwellings’ and actor network theory, and the role of critical realism in the broader scale debates in geography is evaluated. (shrink)

We show that the statement “every universally Baire set of reals has the perfect set property” is equiconsistent modulo ZFC with the existence of a cardinal that we call virtually Shelah for supercompactness. These cardinals resemble Shelah cardinals and Shelah-for-supercompactness cardinals but are much weaker: if $0^\sharp $ exists then every Silver indiscernible is VSS in L. We also show that the statement $\operatorname {\mathrm {uB}} = {\boldsymbol {\Delta }}^1_2$, where $\operatorname {\mathrm {uB}}$ is the pointclass of all universally Baire (...) sets of reals, is equiconsistent modulo ZFC with the existence of a $\Sigma _2$ -reflecting VSS cardinal. (shrink)

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)

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)

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)

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)

The volumes in the Clarendon Aristotle Series seek to meet the needs of philosophically inclined readers who do not know Greek by providing accurate translations of selected Aristotelian texts accompanied by philosophical commentaries. To these ends, Trevor Saunders’s welcome addition to the series, a treatment of the first two books of Aristotle’s Politics, provides a number of useful tools. First there is a new translation of books I and II. Saunders numbers the paragraphs of the translation and the corresponding (...) sections of the commentary to facilitate reference to the text and commentary within the discussion of each chapter, though not across chapters. Saunders provides Greek-English and English-Greek glossaries. These will be especially useful to Greek-less readers, because Saunders is often traditional in his translation of key terms and thus, for example, obscures connections that have to be made explicit. So, for example, Saunders follows the very common practice of rendering the cognates polis, politês, and politeia as ‘state’, ‘citizen’, and ‘constitution’, respectively. Each section of the commentary begins with an introduction and proceeds to discuss each paragraph in turn, often including several recommendations for where to go next in the secondary literature. The book also has a guide to the translation and commentary, a brief but helpful introduction, a short appendix on the alleged oligarchic bias in Plato’s Laws, a list of departures from Ross’s Oxford Classical Text, a bibliography of works cited, and a selective index. Sadly, but in company with most of its companions in the Clarendon Aristotle Series, it lacks an index locorum. (shrink)

For forty years, beginning with the publication of the first modern English translation of the Dialogue Concerning the Two Chief World Systems, Stillman Drake was the most original and productive scholar of Galileo's scientific work of our age. During that time, he published sixteen books on Galileo, including translations of almost all the major writings, and Galileo at Work, the most comprehensive study of Galileo's life and works ever written. His collection Discoveries and Opinions on Galileohas remained in print since (...) its appearance in 1957 and has become the most widely read of all books on Galileo. In addition to his books, Drake published about 130 papers, of which nearly 100 are on Galileo and the rest on related aspects of the history and philosophy of science. This three-volume collection includes eighty of those papers. Drake's papers are an essential supplement to his translations and other books because it was in his papers that he wrote his most detailed technical studies of Galileo's scientific work. There is hardly a subject in Galileo's science that is not considered. Perhaps the most important is the series on mechanics and motion, in which Drake analysed Galileo's manuscript notes recording the experiments by which he discovered and confirmed the law of the acceleration of falling bodies. There are also papers on the notes in which Galileo recorded his discovery of Jupiter's satellites and on other aspects of Galileo's astronomy, including his defence of the Copernican theory. Other papers consider Galileo's life and scientific work in general, exploring what Drake calls the 'scientific personality' of Galileo along with his scientific method and philosophy of science. In addition to the papers on Galileo, there are a number of papers on medieval and early modern science, principally on mechanics, and on the philosophers A.B. Johnson and J.B. Stallo, both of whom influenced Drake's own philosophy of science. (shrink)

The design and analysis of norms is a somewhat neglected topic in AI and Law, but this is not so in other areas of Computer Science. In recent years powerful techniques to model and analyse norms have been developed in the Multi-Agent Systems community, driven both by the practical need to regulate electronic institutions and open agent systems, and by a theoretical interest in mechanism design and normative systems. Agent based techniques often rely heavily on enforcing norms using the software (...) to prevent violation, but I will also discuss the use of sanctions and rewards, and the conditions under which compliance by autonomous agents (including humans) can be expected or encouraged without sanctions or rewards. In the course of the paper a suggested framework for the exploration of these issues is developed. (shrink)

This article shares reflections from members of the community of philosophers of education in the United States and Canada who were invited to express their insights in response to the theme ‘Snaps...

There is a growing interest in how people conceptualise the legal domain for the purpose of legal knowledge systems. In this paper we discuss four such conceptualisations (referred to as ontologies): McCarty's language for legal discourse, Stamper's norma formalism, Valente's functional ontology of law, and the ontology of Van Kralingen and Visser. We present criteria for a comparison of the ontologies and discuss the strengths and weaknesses of the ontologies in relation to these criteria. Moreover, we critically review the criteria.

In this paper I argue that to explain and resolve some kinds of disagreement we need to go beyond what logic alone can provide. In particular, following Perelman, I argue that we need to consider how arguments are ascribed different strengths by different audiences, according to how accepting these arguments promotes values favoured by the audience to which they are addressed. I show how we can extend the standard framework for modelling argumentation systems to allow different audiences to be represented. (...) I also show how this formalism can explain how some disputes can be resolved while in others the parties can only agree to differ. I illustrate this by consideration of a legal example. Finally, I make some suggestions as to where these values come from, and how they can be used to explain differences across jurisdictions, and changes in views over time. (shrink)

This paper describes one way in which a precise reason model of precedent could be developed, based on the general idea that courts are constrained to reach a decision that is consistent with the assessment of the balance of reasons made in relevant earlier decisions. The account provided here has the additional advantage of showing how this reason model can be reconciled with the traditional idea that precedential constraint involves rules, as long as these rules are taken to be defeasible. (...) The account presented is firmly based on a body of work that has emerged in AI and Law. This work is discussed, and there is a particular discussion of approaches based on theory construction, and how that work relates to the model described in this paper. (shrink)

Norms provide a valuable mechanism for establishing coherent cooperative behaviour in decentralised systems in which there is no central authority. One of the most influential formulations of norm emergence was proposed by Axelrod :1095–1111, 1986). This paper provides an empirical analysis of aspects of Axelrod’s approach, by exploring some of the key assumptions made in previous evaluations of the model. We explore the dynamics of norm emergence and the occurrence of norm collapse when applying the model over extended durations. It (...) is this phenomenon of norm collapse that can motivate the emergence of a central authority to enforce laws and so preserve the norms, rather than relying on individuals to punish defection. Our findings identify characteristics that significantly influence norm establishment using Axelrod’s formulation, but are likely to be of importance for norm establishment more generally. Moreover, Axelrod’s model suffers from significant limitations in assuming that private strategies of individuals are available to others, and that agents are omniscient in being aware of all norm violations and punishments. Because this is an unreasonable expectation, the approach does not lend itself to modelling real-world systems such as online networks or electronic markets. In response, the paper proposes alternatives to Axelrod’s model, by replacing the evolutionary approach, enabling agents to learn, and by restricting the metapunishment of agents to cases where the original defection is observed, in order to be able to apply the model to real-world domains. This work can also help explain the formation of a “social contract” to legitimate enforcement by a central authority. (shrink)