Hastings Center Report, Volume 51, Issue 5, Page 42-47, September‐October 2021.

This paper reframes the futility debate, moving away from the question “Who decides when to end what is considered to be a medically inappropriate or futile treatment?” and toward the question “How can society make policy that will best account for the multitude of values and conflicts involved in such decision-making?” It offers a pragmatist moral epistemology that provides us with a clear justification of why it is important to take best standards, norms, and physician judgment seriously and a clear (...) justification of why ample opportunity must be made for patients, families, and society to challenge those standards and norms. (shrink)

Physicians are expected to engage patients as partners in identifying the possible benefits and harms associated with treatment options and selecting from among medically appropriate treatment options, rather than simply dictating what treatments patients will and will not receive. This collaborative model reflects the recognition that citizens in multicultural societies have diverse values and are likely to have different views about whether the possible benefits of a medical intervention outweigh the possible harms. However, there are circumstances in which the collaborative (...) process breaks down due to irresolvable disagreement. Especially challenging are cases in which patients are expected to die if they do not receive a treatment and either the patients or their surrogates insist on the treatment despite the physician's belief that providing it is ill advised. The source of disagreement is often differing appraisals of the risks and potential benefits. In such cases, physicians generally judge that there is insufficient likelihood or magnitude of benefit to justify the burdens or expense of treatment, while patients or surrogates believe that the small chance of preventing the patient's death is sufficient to justify the costs and potential burdens to the patient.There is a perception that surgeons enjoy considerable discretion in deciding when the risks of a procedure outweigh the expected benefits. An important contrast can be drawn between surgeons and intensivists—physicians who specialize in the medical management of critically ill patients. We will argue that there are good reasons for subjecting the decisions of both surgeons and intensivists to some oversight. We begin by showing that, for many cases, major professional society guidelines for intensivists recommend oversight via a procedural mechanism rather than unilateral decision‐making by individual clinicians. Next, we present reasons for adopting a procedural approach to dispute resolution, and we argue that these reasons apply to situations in which intensivists believe that patients or surrogates are requesting inappropriate life support as well as to many disagreements between surgeons and surrogates. Finally, we present and respond to several objections. (shrink)

During public health crises including the COVID-19 pandemic, resource scarcity and contagion risks may require health systems to shift—to some degree—from a usual clinical ethic, focused on the well-being of individual patients, to a public health ethic, focused on population health. Many triage policies exist that fall under the legal protections afforded by “crisis standards of care,” but they have key differences. We critically appraise one of the most fundamental differences among policies, namely the use of criteria to categorically exclude (...) certain patients from eligibility for otherwise standard medical services. We examine these categorical exclusion criteria from ethical, legal, disability, and implementation perspectives. Focusing our analysis on the most common type of exclusion criteria, which are disease-specific, we conclude that optimal policies for critical care resource allocation and the use of cardiopulmonary resuscitation (CPR) should not use categorical exclusions. We argue that the avoidance of categorical exclusions is often practically feasible, consistent with public health norms, and mitigates discrimination against persons with disabilities. (shrink)

We propose six guideposts that states and hospitals should follow to respect disability rights when designing policies for the allocation of scarce, lifesaving medical treatments. Four relate to criteria for decisions. First, do not use categorical exclusions, especially ones based on disability or diagnosis. Second, do not use perceived quality of life. Third, use hospital survival and near-term prognosis (e.g., death expected within a few years despite treatment) but not long-term life expectancy. Fourth, when patients who use ventilators in their (...) daily lives (e.g., home ventilation) present to acute care hospitals, their personal ventilators should not be reallocated to other patients. Fifth, designate triage officers to assess patients individually on the basis of objective medical evidence, not stereotypes or assumptions. Sixth, include disability rights advocates in policy development and dissemination. (shrink)

The coronavirus disease 2019 (COVID-19) pandemic has motivated medical ethicists and several task forces to revisit or issue new guidelines on allocating scarce medical resources. Such guidelines are relevant for the allocation of scarce therapeutics and vaccines and for allocation of ICU beds, ventilators, and other life-sustaining treatments or potentially scarce interventions. Principles underlying these guidelines, like saving the most lives, mitigating disparities, reciprocity to those who assume additional risk (eg, essential workers and clinical trial participants), and equal access may (...) compete with one another. We propose the use of a “categorized priority system” (also known as a “reserve system”) as an improvement over existing allocation methods, particularly because it may be able to achieve disparity mitigation better than other methods. (shrink)

Coronavirus disease 2019 can lead to respiratory failure. Some patients require extracorporeal membrane oxygenation support. During the current pandemic, health care resources in some cities have been overwhelmed, and doctors have faced complex decisions about resource allocation. We present a case in which a pediatric hospital caring for both children and adults seeks to establish guidelines for the use of extracorporeal membrane oxygenation if there are not enough resources to treat every patient. Experts in critical care, end-of-life care, bioethics, and (...) health policy discuss if age should guide rationing decisions. (shrink)

Objective: Even when critically ill patients are almost certain to die from their illnesses, there is generally an element of prognostic uncertainty. Little is known about how physicians handle this uncertainty in conversations with surrogate decision makers. We sought to evaluate whether and how physicians discuss prognostic uncertainty with surrogate decision makers of patients who are highly likely, but not certain, to die. Design: We audiotaped and transcribed discussions between clinicians and surrogate decision makers at two major California teaching hospitals (...) from 2006 through 2008. Physicians completed a questionnaire addressing their prognostic estimates for patients' survival to hospital discharge. Participants: We included physicians and surrogates of 12 incapacitated, critically ill patients. Measurements: We analyzed transcripts of discussions in which physicians' estimates of patients' chances of hospital survival were 1% to 5%; we coded whether physicians disclosed the prognostic uncertainty and, if so, how they conveyed that death was highly likely but not certain. Results: Physicians' estimates of short-term survival were 1% to 5% for 12 of the 70 patients enrolled in the original study. In 8 of 12 cases, physicians conveyed prognostic uncertainty by using probabilistic language or by an explicit mention of uncertainty. In four cases, physicians made at least one statement that either implied or was ambiguous about whether death was certain. Conclusion: We observed variability in how physicians handle prognostic uncertainty in their discussions with surrogates of patients who are highly likely, but not certain, to die, including some circumstances in which physicians stated or implied that death was certain. (shrink)

RationaleSurrogates of critically ill patients often have inaccurate expectations about prognosis. Yet there is little research on how intensive care unit clinicians should discuss prognosis, and existing expert opinion-based recommendations give only general guidance that has not been validated with surrogate decision makers.ObjectiveTo determine the perspectives of key stakeholders regarding how prognostic information should be conveyed in critical illness.MethodsThis was a multicenter study at three academic medical centers in California, Pennsylvania, and Washington. One hundred eighteen key stakeholders completed in-depth semistructured (...) interviews. Participants included 47 surrogates of adult patients with acute respiratory distress syndrome; 45 clinicians working in study ICUs, including physicians, nurses, social workers, and spiritual care providers; and 26 experts in health communication, decision science, ethics, family-centered care, geriatrics, healthcare disparities, palliative care, psychology, psychiatry, and critical care.Measurements and main resultsThere was broad support among surrogates for existing expert recommendations, including truthful prognostic disclosure, emotional support, tailoring the disclosure strategy to each family's needs, and checking for understanding. In addition, stakeholders offered suggestions that add specificity to existing recommendations, including: In addition to conveying prognostic estimates, clinicians should help families "see the prognosis for themselves" by showing families radiographic images and explaining the clinical significance of physical manifestations of severe disease at the bedside. Many physicians did not support using numeric estimates to convey prognosis to families, whereas many surrogates, clinicians from other disciplines, and experts believed numbers could be helpful. Clinicians should conceptualize prognostic communication as an iterative process that begins with a preliminary mention of the possibility of death early in the ICU stay and becomes more detailed as the clinical situation develops. Although prognostic information should be initially disclosed by physicians, other members of the multidisciplinary team-nurses, social workers, and spiritual care providers-should be given explicit role responsibilities to reinforce physicians' prognostications and help families process a poor prognosis emotionally.ConclusionsFamily members, clinicians, and experts identified specific communication behaviors that clinicians should use to discuss prognosis in the critical care setting. These findings extend existing opinion-based recommendations and should guide interventions to improve communication about prognosis in ICUs. (shrink)

We appreciate the opportunity to respond to Schneiderman and colleagues’ opinions on the recent Multiorganization Policy Statement, “An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units”. We will first point out three areas in which Schneiderman and colleagues seem to perceive a disagreement where there is none, then we will respond to their main criticisms of the Multiorganization Policy Statement. In doing so, we will point out areas in which we believe Schneiderman and (...) colleagues have either misunderstood or misrepresented the statement. First, we agree with Schneiderman and... (shrink)

Background: Relatively little is known about neonatologists' roles in helping families navigate the difficult decision to attempt or withhold resuscitation for a neonate delivering at the threshold...

The ethical principle of ‘respect for persons’ in clinical research has traditionally focused on protecting individuals’ autonomy rights, but respect for participants also includes broader, although less well understood, ethical obligations to regard individuals’ rights, needs, interests and feelings. However, there is little empirical evidence about how to effectively convey respect to potential and current participants. To fill this gap, we conducted exploratory, qualitative interviews with participants in a clinical genomics implementation study. We interviewed 40 participants in English or Spanish (...) about their experiences with respect in the study and perceptions of how researchers in a hypothetical observational study could convey respect or a lack thereof. Most interviewees were female, identified as Hispanic/Latino or non-Hispanic white, reported annual household income under US$60 000 and did not have a Bachelor’s degree ; 30% had limited health literacy. We identified four key domains for demonstrating respect: personal study team interactions, with an emphasis on empathy, appreciation and non-judgment; study communication processes, including following up and sharing results with participants; inclusion, particularly ensuring materials are understandable and procedures are accessible; and consent and authorisation, including providing a neutral informed consent and keeping promises regarding privacy protections. While the experience of respect is inherently subjective, these findings highlight four key domains that may meaningfully demonstrate respect to potential and current research participants. Further empirical and normative work is needed to substantiate these domains and evaluate how best to incorporate them into the practice of research. (shrink)

The Theory of Multidimensional Reality is the latest development of this information theory of existence by the Author. The book applies the theory to explain what causes light, gravity, time, Planck's constant, and other phenomena found in physics. The Theory provides a foundation philosophy for all of science to explain some of the hardest phenomenon found.

If “perfectionism” in ethics refers to those normative theories that treat the fulfillment or realization of human nature as central to an account of both goodness and moral obligation, in what sense is “human flourishing” a perfectionist notion? How much of what we take “human flourishing” to signify is the result of our understanding of human nature? Is the content of this concept simply read off an examination of our nature? Is there no place for diversity and individuality? Is the (...) belief that the content of such a normative concept can be determined by an appeal to human nature merely the result of epistemological naiveté? What is the exact character of the connection between human flourishing and human nature? These questions are the ultimate concern of this essay, but to appreciate the answers that will be offered it is necessary to understand what is meant by “human flourishing.” “Human flourishing” is a relatively recent term in ethics. It seems to have developed in the last two decades because the traditional translation of the Greek term eudaimonia as “happiness” failed to communicate clearly that eudaimonia was an objective good, not merely a subjective good. (shrink)

How can we establish a political/legal order that in principle does not require the human flourishing of any person or group to be given structured preference over that of any other? Addressing this question as the central problem of political philosophy,_ Norms of Liberty_ offers a new conceptual foundation for political liberalism that takes protecting liberty, understood in terms of individual negative rights, as the primary aim of the political/legal order. Rasmussen and Den Uyl argue for construing individual rights as (...) metanormative principles, directly tied to politics, that are used to establish the political/ legal conditions under which full moral conduct can take place. These they distinguish from normative principles, used to provide guidance for moral conduct within the ambit of normative ethics. This crucial distinction allows them to develop liberalism as a metanormative theory, not a guide for moral conduct. The moral universe need not be minimized or morality grounded in sentiment or contracts to support liberalism, they show. Rather, liberalism can be supported, and many of its internal tensions avoided, with an ethical framework of Aristotelian inspiration—one that understands human flourishing to be an objective, inclusive, individualized, agent-relative, social, and self-directed activity. (shrink)

Aristotle's way of thinking has normally been understood as hostile to any liberal, pluralistic, or commercial society. In Liberal Nature, Rasmussen and Den Uyl set out to show that the Aristotelian approach to ethics supports the natural rights which form the most secure basis for liberal principles. The authors lay the foundations for their thesis by rebutting the most prominent arguments against the Aristotelian approach; they then offer a new interpretation for Aristotelian ethics as a natural-end ethics in which human (...) flourishing is the ultimate moral standard. (shrink)

Despite the prominence of person‐centred care (PCC) in nursing, there is no general agreement on the assumptions and the meaning of PCC. We sympathize with the work of others who rethink PCC towards relational, embedded, and temporal selfhood rather than individual personhood. Our perspective addresses criticism of humanist assumptions in PCC using critical posthumanism as a diffraction from dominant values We highlight the problematic realities that might be produced in healthcare, leading to some people being more likely to be disenfranchised (...) from healthcare than others. We point to the colonial, homo‐ and transphobic, racist, ableist, and ageist consequences of humanist traditions that have influenced the development of PCC. We describe the deep rooted conditions that structurally uphold inequality and undermine nursing practice that PCC reproduces. We advocate for the self‐determination of patients and emphasize that we support the fundamental mechanisms of PCC enabling patients' choice; however, without critical introspection, these are limited to a portion of humans. Last, we present limitations of our perspective based on our white*‐cisheteropatriarchy** positionality. We point to the fact that any reimagining of models such as PCC should be carefully done by listening, following, and ceding power to people with diversity dimensions*** and the lived experience or expertise that exists from diverse perspectives. We point towards Black, queer feminism, and critical disabilities studies to contextualize our point of critique with humanism and PCC to amplify equity for all people and communities. Theory and philosophy are useful to understand restrictive factors in healthcare delivery and to inform systematic strategies to improve the quality of care so as not to perpetuate the oppression of groups of people with diversity dimensions. *We purposely capitalize Black and use lower case for white to decentre whiteness and as an intentional act of antiracism (see White Homework a podcast series by Tori W. Douglas). **Cisheteropatriarchy describes people with intersecting identities of dominant social groups; cisgender is the gender identity that aligns with the gender you were assigned at birth, hetero means heterosexual, and patriarchy refers to structural systems of power based on maleness where women are often excluded and hold less power. ***With diversity dimensions, we refer to subjective lived experience and material realities of people that exist outside the ‘dominant minorities' of white‐cisheteropatriarchy, meaning groups of people in society who historically and currently hold more power and through this, structurally dominate the norms and possibilities of living for other people. (shrink)

Perceptual experience seems to involve distinct intentional and qualitative features. Inasmuch as one can visually perceive that there is a Coke can in front of one, perceptual experience must be intentional. But such experiences seem to differ from paradigmatic intentional states in having introspectible qualitative character. Peacocke argues that a perceptual experience’s qualitative character is determined by intrinsic, nonrepresentational properties. But and also argues that perceptual experiences have nonconceptual representational content in addition to conceptual content and nonrepresentational sensational properties. He (...) thus distinguishes between conceptual, nonrepresentational, and nonconceptual but representational aspects of perceptual experience. I will argue that Peacocke posits too much. Contrary to his arguments, the sensational properties Peacocke claims are nonrepresentational are best construed as representational; they are best explained in terms of their relation to the perceptible properties they enable us to perceive. Since sensational properties are arguably nonconceptual, they are best construed as nonconceptual representational properties. I offer the Homomorphism View of sensory qualities, pioneered by Sellars , as a unified account of qualitative character and nonconceptual sensory representation. According to this view, a sensory quality represents a perceptible stimulus property in virtue of resembling and differing from other sensory qualities in ways parallel to the ways the stimulus property resembles and differs from other perceptible properties. (shrink)

It is considered in some quarters that hypothesis‐driven methods are the only valuable, reliable or significant means of scientific advance. Data‐driven or ‘inductive’ advances in scientific knowledge are then seen as marginal, irrelevant, insecure or wrong‐headed, while the development of technology—which is not of itself ‘hypothesis‐led’ (beyond the recognition that such tools might be of value)—must be seen as equally irrelevant to the hypothetico‐deductive scientific agenda. We argue here that data‐ and technology‐driven programmes are not alternatives to hypothesis‐led studies in (...) scientific knowledge discovery but are complementary and iterative partners with them. Many fields are data‐rich but hypothesis‐poor. Here, computational methods of data analysis, which may be automated, provide the means of generating novel hypotheses, especially in the post‐genomic era. BioEssays 26:99–105, 2004. © 2003 Wiley Periodicals, Inc. (shrink)

This study examined the efficacy of corrected feedback for improving consent recall throughout the course of an ongoing longitudinal study. Participants were randomly assigned to either a corrected feedback or a no-feedback control condition. Participants completed a consent quiz 2 weeks after consenting to the host study and at months 1, 2, and 3. The corrected feedback group received corrections to erroneous responses and the no-feedback control group did not. The feedback group displayed significantly greater recall overall and in specific (...) content areas. Results support the use of corrected feedback for improving consent recall. (shrink)

Douglas B. Rasmussen examines, in this revised and extended version of his 1990 address to the Ayn Rand Society, whether Rand's ethics are best interpreted as dependent on a "pre-moral" choice. He argues that such an interpretation undercuts Rand's claim to provide a rational foundation for ethics. He suggests an alternative, neo-Aristotelian interpretation of Rand's ethics, which treats "man's survival qua man" as the telos of human choice and takes the obligation to achieve this ultimate end as the result (...) of its being the good for human beings. (shrink)

Despite many significant points of intersection between his work and that of Hannah Arendt, the legal scholar Robert Cover largely declined to engage her perspective, which posed major challenges to his own. While scholars seeking to rethink Cover's legacy in order to develop a jurisprudence of violence have criticized Cover's acquiescence to the Hobbesian model of the sovereign state, they have similarly ignored Arendt's critique of the Hobbesian model and her attempts to build an alternative to it. This article examines (...) central issues of convergence and divergence between Arendt's and Cover's approaches to law, politics, and violence with the aim to redress this neglect of Arendt's perspective. It begins by focusing on their interpretations of the role and significance of the courtroom trial. It then compares their analysis of the character, effects, and implications of domination as a type of organized power and as a means of conceptualizing punishment, before it concentrates on their instrumental conception of violence, the issue of justification, and its relationship to power. The article concludes by arguing that Arendt's approach, which situates an analysis of law and violence within a broader critique of modernity, provides a more trenchant critical framework for examining the rise of the carceral state than does Cover's. (shrink)

Collecting information that one expects to be useful is a powerful way to facilitate learning. However, relatively little is known about how people decide which information is worth sampling over the course of learning. We describe several alternative models of how people might decide to collect a piece of information inspired by “active learning” research in machine learning. We additionally provide a theoretical analysis demonstrating the situations under which these models are empirically distinguishable, and we report a novel empirical study (...) that exploits these insights. Our model-based analysis of participants' information gathering decisions reveals that people prefer to select items which resolve uncertainty between two possibilities at a time rather than items that have high uncertainty across all relevant possibilities simultaneously. Rather than adhering to strictly normative or confirmatory conceptions of information search, people appear to prefer a “local” sampling strategy, which may reflect cognitive constraints on the process of information gathering. (shrink)

There is nothing new or even faintly original in the neoconservative foreign policy vision. It simply recycles the old national security ideology for a post-Cold War era. Consistent with this ideological agenda, conservatives have also been advancing the case for the strong executive who operates above the law. In championing the principle of the strong executive, they are seeking to re-define the meaning of modern republicanism around this principle. During the 1960s Hannah Arendt and Hans Morgenthau developed a broad critique (...) of the national security state and its ideology in their opposition to the Vietnam War. This essay examines their critique, and the alternative conception of republicanism they developed as part of this critique. (shrink)

One's contemporaneous conscious mental states seem bound in a single, unified experience. Dainton argues, against what he calls the S-Thesis, that we cannot explain such co-consciousness in terms of states' being located in a single phenomenal space, a functional space posited to explain our ability to locate ourselves relative to perceived stimuli. But Dainton's argument rests on a conflation of egocentric and allocentric self-localizing, and thus fails to undermine the S-Thesis. Nevertheless, experiments on visual neglect suggest one can have unconscious (...) mental states that are located in the same phenomenal field, so the S-Thesis fails after all. I examine a modified version of the S-Thesis according to which mental states are co-conscious when one is aware of them via a higher-order sensation that represents them as located in the same phenomenal field. But among other problems, this view fails to explain the co-consciousness of intentional states, which aren't located in phenomenal fields. Finally, I argue that a higher-order-thought model of consciousness best explains the apparent unity of experience in terms of one's tacit assumption that all the first-person thoughts in virtue of which one is conscious of one's mental states refer to the same individual. (shrink)

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This essay examines the relationship between human choice and Rand's ethical standard for moral goodness and obligation. It shows that the neo-Aristotclian interpretation of Rand's ethics—an interpretation that does not accept the doctrine of "premoral choice" but instead claims that flourishing as a rational animal is the telos of human life and choice—is crucial to the viability of her ethical theory. The defenders of premoral choice confuse the conceptual order with the real and, despite their intentions, make Rand's ethics into (...) a voluntarist ethics, that is, an ethics in which reason is subordinate to will. (shrink)

In response to Robert Hartford's criticisms of his Spring 2006 Journal of Ayn Rand Studies essay, "Regarding Choice and the Foundations of Morality," Rasmussen argues against "the official" interpretation of Rand's ethics as resting on a basic "choice to live." Drawing from his work with Douglas Den Uyl, Rasmussen argues that Rand's metaethics is best understood in "biocentric," neo-Aristotelian terms: that human choice does not set the context in which it operates and that "man's life qua man" is the (...) natural end of human life. (shrink)

In response to Robert Hartford's criticisms of his Spring 2006 Journal of Ayn Rand Studies essay, "Regarding Choice and the Foundations of Morality," Rasmussen argues against "the official" interpretation of Rand's ethics as resting on a basic "choice to live." Drawing from his work with Douglas Den Uyl, Rasmussen argues that Rand's metaethics is best understood in "biocentric," neo-Aristotelian terms: that human choice does not set the context in which it operates and that "man's life qua man" is the (...) natural end of human life. (shrink)

Benjamin Lipscomb (The Women Are Up to Something) and Clare Mac Cumhaill and Rachel Wiseman (Metaphysical Animals) have written books discussing the same four women philosophers—Elizabeth Anscombe, Philippa Foot, Mary Midgley, and Iris Murdoch—and their rise to prominence in the almost exclusively male-dominated academies of Oxford and Cambridge universities. This review focuses on these philosophers’ intellectual contributions, with special attention given to the Aristotelian character of their views in the face of an opposing philosophical regimen. We conclude with a brief (...) reflection on Ayn Rand’s moral philosophy in light of the contributions made by these four women philosophers. (shrink)

In this essay, I consider whether the alleged demise of metaphysical realism does actually provide a better way for defending the cognitive status of ethical judgments. I argue that the rejection of a realist ontology and epistemology does not help to establish the claim that ethical knowledge is possible. More specifically, I argue that Hilary Putnam's argument does not succeed in making a case for ethical knowledge. In fact, his account of the procedures by which our valuations are warranted—the criteria (...) of idealized inquiry—ultimately begs the question in a number of crucial ways. Moreover, it prejudices the moral and political discussion in certain ideological respects. Finally, though Putnam has apparently modified to some extent his approach to the issue of realism in recent years, I will point out that these modifications are not fundamental and do not help to advance the case for ethical knowledge. I note also that Martha C. Nussbaum's appeal to Putnam’s argument actually works against her attempt to make a case for an Aristotelian conception of human flourishing. Ultimately, I conclude that metaphysical realism is vital for ethical knowledge. (shrink)