Shanachie and Norm Content Type Journal Article Category Case Studies Pages 1-2 DOI 10.1007/s11673-012-9356-0 Authors MalcolmParker, School of Medicine, The University of Queensland, 288 Herston Road, Herston, QLD 4006, Australia Journal Journal of Bioethical Inquiry Online ISSN 1872-4353 Print ISSN 1176-7529.
In that Case Content Type Journal Article DOI 10.1007/s11673-010-9261-3 Authors MalcolmParker, School of Medicine, University of Queensland, Brisbane, Australia Journal Journal of Bioethical Inquiry Online ISSN 1872-4353 Print ISSN 1176-7529.
Republication: In That Case Content Type Journal Article DOI 10.1007/s11673-010-9264-0 Authors MalcolmParker, School of Medicine, University of Queensland, Brisbane, Australia Journal Journal of Bioethical Inquiry Online ISSN 1872-4353 Print ISSN 1176-7529.
ObjectiveTo increase knowledge of how doctors perceive futile treatments and scarcity of resources at the end of life. In particular, their perceptions about whether and how resource limitations influence end-of-life decision making. This study builds on previous work that found some doctors include resource limitations in their understanding of the concept of futility.SettingThree tertiary hospitals in metropolitan Brisbane, Australia.DesignQualitative study using in-depth, semistructured, face-to-face interviews. Ninety-six doctors were interviewed in 11 medical specialties. Transcripts of the interviews were analysed using thematic (...) analysis.ResultsDoctors’ perceptions of whether resource limitations were relevant to their practice varied, and doctors were more comfortable with explicit rather than implicit rationing. Several doctors incorporated resource limitations into their definition of futility. For some, availability of resources was one factor of many in assessing futility, secondary to patient considerations, but a few doctors indicated that the concept of futility concealed rationing. Doctors experienced moral distress due to the resource implications of providing futile treatment and the lack of administrative supports for bedside rationing.ConclusionsDoctors’ ability to distinguish between futility and rationing would be enhanced through regulatory support for explicit rationing and strategies to support doctors’ role in rationing at the bedside. Medical policies should address the distinction between resource limitations and futility to promote legitimacy in end-of-life decision making. (shrink)
The turn to empirical ethics answers two calls. The first is for a richer account of morality than that afforded by bioethical principlism, which is cast as excessively abstract and thin on the facts. The second is for the facts in question to be those of human experience and not some other, unworldly realm. Empirical ethics therefore promises a richer naturalistic ethics, but in fulfilling the second call it often fails to heed the metaethical requirements related to the first. Empirical (...) ethics risks losing the normative edge which necessarily characterizes the ethical, by failing to account for the nature and the logic of moral norms. I sketch a naturalistic theory, teleological expressivism (TE), which negotiates the naturalistic fallacy by providing a more satisfactory means of taking into account facts and research data with ethical implications. The examples of informed consent and the euthanasia debate are used to illustrate the superiority of this approach, and the problems consequent on including the facts in the wrong kind of way. (shrink)
Over several decades, ethics and law have been applied to medical education and practice in a way that reflects the continuation during the twentieth century of the strong distinction between facts and values. We explain the development of applied ethics and applied medical law and report selected results that reflect this applied model from an empirical project examining doctors’ decisions on withdrawing/withholding treatment from patients who lack decision-making capacity. The model is critiqued, and an alternative “constitutive” model is supported on (...) the basis that medicine, medical law, and medical ethics exemplify the inevitable entanglement of facts and values. The model requires that ethics and law be taught across the medical education curriculum and integrated with the basic and clinical sciences and that they be perceived as an integral component of medical evidence and practice. Law, in particular, would rank as equal in normative authority to the relevant clinical scientific “facts” of the case, with graduating doctors having as strong a basic command of each category as the other. The normalization of legal knowledge as part of the clinician’s evidence base to be utilized in practice may provide adequate consolation for clinicians who may initially resent further perceived incursions on their traditional independence and discretion. (shrink)
The convergence of complementary and alternative medicine (CAM) and evidence-based medicine (EBM) is a prominent feature of healthcare in western countries, but it is currently undertheorised, and its implications have been insufficiently considered. Two models of convergence are described – the totally integrated evidence-based model (TI) and the multicultural-pluralistic model (MP). Both models are being incorporated into general medical practice. Against the background of the reasons for the increasing utilisation of CAM by the public and by general practitioners, TI-convergence is (...) supported and MP-convergence is rejected. MP-convergence is epistemologically and clinically incoherent, and it cannot be regulated. It is also inconsistent with developments in the legal determination of the standard of care for both diagnosis/treatment and disclosure. These claims concerning MP-convergence are justified by the fact that science is not a member of the group of perspectives or world-views which postmodernism treats as equally valid, and this is especially important for healthcare. (shrink)
The relationship between evidence-based medicine (EBM) and clinical judgement is the subject of conceptual and practical dispute. For example, EBM and clinical guidelines are seen to increasingly dominate medical decision-making at the expense of other, human elements, and to threaten the art of medicine. Clinical wisdom always remains open to question. We want to know why particular beliefs are held, and the epistemological status of claims based in wisdom or experience. The paper critically appraises a number of claims and distinctions, (...) and attempts to clarify the connections between EBM, clinical experience and judgement, and the objective and evaluative categories of medicine. I conclude that to demystify clinical wisdom is not to devalue it. EBM ought not be conceived as needing to be limited or balanced by clinical wisdom, since if its language is translatable into terms comprehensible and applicable to individuals, it helps constitute clinical wisdom. Failure to appreciate this constitutive relation will help perpetuate medical paternalism and delay the adoption of properly evidence-based practice, which would be both unethical and unwise. (shrink)
Stewart and DeMarco’s economic theory of patient decision-making applied to the case of diabetes is flawed by clinical inaccuracies and an unrealistic depiction of patients as rational traders. The theory incorrectly represents patients’ struggles to optimize their management as calculated trade-offs against the costs of care, and gives an unrealistic, inflexible account of such costs. It imputes to physicians the view that their patients’ lack of compliance is unreasonable, but physicians are accustomed to the variety of human factors which contribute (...) to suboptimal compliance, and work with patients to minimize their influence. By depicting patients as rational traders rather than human beings with a range of motivations and burdens, the economic theory distorts the proper function of informed consent. (shrink)
It is increasingly asserted that the disagreements of abstract principle between adversaries in the euthanasia debate fail to account for the complex, particular and ambiguous experiences of people at the end of their lives. A greater research effort into experiences, meaning, connection, vulnerability and motivation is advocated, during which the euthanasia 'question' should remain open. I argue that this is a normative strategy, which is felicitous to the status quo and further medicalises the end of life, but which masquerades as (...) a value-neutral assertion about needing more knowledge. (shrink)
Lennard Davis’s Biocultural Critique of the alleged certainty of diagnosis (Davis Journal of Bioethical Inquiry 7:227−235, 2010) makes errors of fact concerning psychiatric diagnostic categories, misunderstands the role of power in the therapeutic relationship, and provides an unsubstantiated and vague alternative to the management of psychological distress via a conceptually outdated model of the relationships between physical and psychological disease and illness. This response demonstrates that diagnostic knowledge vouchsafes legitimate power to physicians, and via them relief to patients who suffer (...) from psychological distress. The history of medicine and psychiatry demonstrates that psychiatric diagnosis shares many features with physical diagnosis, while there is also reason to believe that the two types will continue to be distinct in some respects. Diagnostic categories in psychological medicine, like those in physical medicine, are provisional, probabilistic, and often uncertain. These features do not detract from the dependence on diagnosis of therapeutic efficacy in both domains. (shrink)
The United Nations Convention on the Rights of Persons with Disabilities urges and requires changes to how signatories discharge their duties to people with intellectual disabilities, in the direction of their greater recognition as legal persons with expanded decision-making rights. Australian jurisdictions are currently undertaking inquiries and pilot projects that explore how these imperatives should be implemented. One of the important changes advocated is to move from guardianship models to supported or assisted models of decision-making. A driving force behind these (...) developments is a strong allegiance to the social model of disability, in the formulation of the Convention, in inquiries and pilot projects, in implementation and in the related academic literature. Many of these instances suffer from confusing and misleading statements and conceptual misinterpretations of certain elements such as legal capacity, decision-making capacity, and support for decision-making. This paper analyses some of these confusions and their possible negative implications for supported decision-making instruments and those whose interests these instruments would serve, and advises a more incremental development of existing guardianship regimes. This provides a more realistic balance between neglecting the real limits of those with mental disabilities and thereby ignoring their identity and particularity, and continuing to bring them equally and fully into society. (shrink)
Fulford has argued that (1) the medical concepts illness, disease and dysfunction are inescapably evaluative terms, (2) illness is conceptually prior to disease, and (3) a model conforming to (2) has greater explanatory power and practical utility than the conventional value-free medical model. This ‘reverse’ model employs Hare's distinction between description and evaluation, and the sliding relationship between descriptive and evaluative meaning. Fulford's derivative ‘Values Based Medicine’ (VBM) readjusts the imbalance between the predominance of facts over values in medicine. VBM (...) allegedly responds to the increased choices made available by, inter alia, the progress of medical science itself. VBM attributes appropriate status to evaluative meaning, where strong consensus about descriptive meaning is lacking. According to Fulford, quasi-legal bioethics, while it can be retained as a kind of deliberative framework, is outcome-based and pursues ‘the right answer’, while VBM approximates a democratic, process-oriented method for dealing with diverse values, in partnership with necessary contributions from evidence-based medicine (EBM). I support the non-cognitivist underpinnings of VBM, and its emphasis on the importance of values in medicine. But VBM overstates the complexity and diversity of values, misrepresents EBM and VBM as responses to scientific and evaluative complexity, and mistakenly depicts ‘quasi-legal bioethics’ as a space of settled descriptive meaning. Bioethical reasoning can expose strategies that attempt to reduce authentic values to scientific facts, illustrating that VBM provides no advantage over bioethics in delineating the connections between facts and values in medicine. (shrink)
An Anonymous DeathThe comet, a white haired traveller, hauls its tail behind, thereby hangs its tale. Its particulate history swings away into black time as it skirts you.A million times a million fissions, fires in Andromeda, a surge of ice across a steppe, the moon’s impacted skin. Events escape their birth and move out at the roar of light, hurtling endlessly nowhere and everywhere colliding stray worlds, spinning and groping.At night through cat’s eye domes watchmen on the world’s clearest ranges (...) trap the begetting of suns or discern an ancient death when intercepted at the glass when Diplodocus started the journey into strata or when a hairy thing tottered erect and stretched out tool-seeking fingers. The watchers in the domes live half in a past older than the sun.I tended a white haired man and cry out for a lens to map him. His deeds curve short of my time sputting out in a brown river carrying a wiry oarsman in a sepia photograph. The deeds of friends are buried in a beach wir. (shrink)
I found a manin a roomsprawl awkwardat a dying angletickingat his bed’s endat his life’s endpast the end of his witsand his wife’sin a roomround the end of their lives.He trembled his vows againheld his cachectic bellepast her life’s endtheir last toast the mercy kill.I found himticking slowlyshe colddeliveredwaiting on his life.His survivalobliging inquiryof motiveof methodI hurriedhim off to hergentlest of homicides.Two mounds in a room, coolingpast fear, post suicide.
SenilityCalled from pleasuresI go tap-tapping down an old man’s backdown the skin of eighty summers wastingon a rib-ladder closingon a history of heart and lungs.These narrowly contracting bags I find, proclaim“Today his chest is clear as yours or mine.”This is the news requiredas the tide of vigilancelaps his sheets each surfacing dawn.“He’s doing very well.”He leans his gaze to the voice dintingthe routine of his roombut slides the focal point towards infinitypast those gatheredto the motes of memoryto wherepinned in the (...) windthrough their age and bondher sacrificial flags go flutteringbattered and fastened into the room’s cornerhinged haggard to his unhinging.In this too a workless son and centrelessclock-bound slaveto the incontinent brain and its seepage.Two tight-wire walkerswell talked out by nine each bed-wet daythe backyard hoist their prayer-wheel creaking.The sheets flap up the scent of their detentions.Time in its time will track them round their modest cornernovice at the f. (shrink)
A crescendo of panting to her stiff-lunged yearspressed in on her for three days and a bit before the succumbingno word could be wedged between gasps.A knife twist in her life’s two year tail two years’witness to others’ ministerings at her flesh-raw chestturned outward to the airenforced fluency in the language of lint.From nests of treason in her breastat night the insurgency pushed outinto the bloodlinesoutriders of a black hostthe dreadful propaganda of cellsbridgeheads locked down in bone and braina Reichstag (...) fire flowering in her backherstory crumblingmidnight dominoes along her spine.At the endat the panting postin the room curtained for deathher body spat and crackled with a foreign fevereven past the last breath and her eyes drying.In the bare room a malignant hum.When they came for her a thin smoke hung. (shrink)
They enterin curves and stoopslimping and tappinga file of bare armscreased faces upliftedred eyelids poutingeyes curtained in cataract.The syringes are magazined at his hip.A pinch of skinin a chill autumn morninga stinging spreads outat the borders of shouldersthe grim supplicationfor all his attentionthe trembling smileon his remembering a name.Swabs spent in bucketsthe names all collecteda shifting and amblingacross the lawns to their liveson small porchesand in dim echoing cells.Washing his handsof the short easy morningthose bird-bone armsgrow stars of Davidin the (...) injected whealsand the upturned headspull at his neckfor a sparklet of mercyhe prodding them downinto the frostfrom the stinking trainsat the point of more serious weaponry.They are a herdfanning out to their winding down daysdark-eyed ones shuffling blindto other deaths, gassed and limed. (shrink)
The materials consist of a co-authored, peer-reviewed book, a co-authored, peer-reviewed book chapter, 30 single authored peer-reviewed journal papers, and 15 co-authored peer-reviewed journal papers, of which I was the lead author on 8 papers. There are 32 papers from Australasian journals, at least two of which are also regarded as international. 22 papers are published in international journals. The co-authored book was favourably described in his foreword by Justice Michael Kirby of the High Court of Australia. The refereed chapter (...) is contained in an issue of the Australian Legal Monographs series. The papers constitute a body of work in Australasian and international contexts in a field which is relatively new to academic achievement, broadly understood as philosophy of medicine, medical ethics and health law. The journals in which the papers are published include two of the most highly regarded bioethics journals in the world, Australia’s leading medical journal, the two leading world medical education journals, Australia’s leading journal for health and medical law, and the Torts Law Journal, an Australian journal which is recognized as one of the world’s leading journals in the field of tort law. (shrink)
In April 1939, G. E. Moore read a paper to the Cambridge University Moral Science Club entitled ‘Certainty’. In it, amongst other things, Moore made the claims that: the phrase ‘it is certain’ could be used with sense-experience-statements, such as ‘I have a pain’, to make statements such as ‘It is certain that I have a pain’; and that sense-experience-statements can be said to be certain in the same sense as some material-thing-statements can be — namely in the sense that (...) they can be safely counted on. When Moore later read his paper to Wittgenstein, Wittgenstein took violent exception to it, and the two entered into a heated exchange. The only known notes of this exchange are a previously unpublished verbatim record of part of it, taken by Norman Malcolm. This paper is an edition of Malcolm’s notes. These notes are valuable for both philosophical and scholarly reasons. They give us a glimpse of a sustained exchange between Wittgenstein and a real-life interlocutor; they contain a defence by Wittgenstein of the idea that a word’s use can illuminate its meaning; and they provide evidence of Wittgenstein’s philosophical engagement with the topic of certainty, and with Moore’s thought on it, long before he began to write the notes which make up On Certainty, in 1949. (shrink)
Lloyd (2009) contends that climate models are confirmed by various instances of fit between their output and observational data. The present paper argues that what these instances of fit might confirm are not climate models themselves, but rather hypotheses about the adequacy of climate models for particular purposes. This required shift in thinking—from confirming climate models to confirming their adequacy-for-purpose—may sound trivial, but it is shown to complicate the evaluation of climate models considerably, both in principle and in practice.
Recently some philosophers have proposed that the later philosophy of Wittgenstein tends towards idealism, or even solipsism. The solipsism is said to be of a peculiar kind. It is characterized as a ‘collective’ or ‘aggregative’ solipsism. The solipsism or idealism is also said to be ‘transcendental’. In the first part of this paper I will be examining a recent essay by Professor Bernard Williams, in which he presents what he takes to be the grounds for such an interpretation of Wittgenstein. (...) After that I will try to offer convincing evidence that no tendency towards any form of idealism is to be found in Wittgenstein's later philosophy. (shrink)
The philosophy of memory has been largely dominated by what could be called ‘the representative theory of memory’. In trying to give an account of ‘what goes on in one's mind’ when one remembers something, or of what ‘the mental content of remembering’ consists, philosophers have usually insisted that there must be some sort of mental image, picture, or copy of what is remembered. Aristotle said that there must be ‘something like a picture or impression’; William James thought that there (...) must be in the mind 'an image or copy’ of the original event; Russell said that ‘Memory demands an image’. In addition to the image or copy a variety of other mental phenomena have been thought to be necessary. In order for a memory image to be distinguished from an expectation image, the former must be accompanied by ‘a feeling of pastness’. One has confidence that the image is of something that actually occurred because the image is attended by ‘a feeling of familiarity’. And in order that you may be sure that the past event not merely occurred but that you witnessed it, your image of the event must be presented to you with a feeling of ‘warmth and intimacy’. When all the required phenomena are put together, the mental content of remembering turns out to be, as William James says, ‘a very complex representation’. (shrink)