Members of the Clinical Ethics Consultation Affairs Standing Committee of the American Society for Bioethics and Humanities present a collection of insights and recommendations developed from their collective experience, intended for those engaged in the work of healthcare ethics consultation.

Physicians generally recommend that patients resuscitated with naloxone after opioid overdose stay in the emergency department for a period of observation in order to prevent harm from delayed sequelae of opioid toxicity. Patients frequently refuse this period of observation despiteenefit to risk. Healthcare providers are thus confronted with the challenge of how best to protect the patient’s interests while also respecting autonomy, including assessing whether the patient is making an autonomous choice to refuse care. Previous studies have shown that physicians (...) have widely divergent approaches to navigating these conflicts. This paper reviews what is known about the effects of opioid use disorder on decision-making, and argues that some subset of these refusals are non-autonomous choices, even when patients appear to have decision making capacity. This conclusion has several implications for how physicians assess and respond to patients refusing medical recommendations after naloxone resuscitation. (shrink)

From computerized medical records to databases of pharmacological interactions and automated provisional EKG readings, the emergence of information technology has significantly altered the practice of medicine. Information technology has been widely used to enhance diagnosis and treatment and to improve communication between providers. The advent of the Internet also brings far-reaching implications for patient–physician communication, challenging physicians, patients, and policymakers to consider its impact on the delivery of medical care and the therapeutic relationship. A new set of practices by patients (...) and physicians is unfolding in cyberspace, ranging from the use of e-mail to communicate between physicians and patients in an existing relationship to one-to-one consultations with an anonymous physician and ongoing online treatment, such as psychotherapy. These practices are emerging in both the for-profit and not-for-profit spheres. (shrink)

What term is most appropriate in describing the limits of medicine? That depends on who determines the limits and the bases on which those limits are delineated and communicated. Schneiderman, Jecker, and Jonsen critique two recent policy statements by critical care providers—Bosslet et al. and Nates et al. —for their rejection of the use of the term futile for treatment. Both statements recommend using the adjective inappropriate for the problematic treatment, rather than futile, based on the lack of consensus of (...) just what constitutes futility. Schneiderman, Jecker, and Jonsen also assert that, despite a lack of consensus about the determination of futility, the definitions they have... (shrink)

Civility is an essential feature of health care, as it is in so many other areas of human interaction. The article examines the meaning of civility, reviews its origins, and provides reasons for its moral significance in health care. It describes common types of uncivil behavior by health care professionals, patients, and visitors in hospitals and other health care settings, and it suggests strategies to prevent and respond to uncivil behavior, including institutional codes of conduct and disciplinary procedures. The article (...) concludes that uncivil behavior toward health care professionals, patients, and others subverts the moral goals of health care and is therefore unacceptable. Civility is a basic professional duty that health care professionals should embrace, model, and teach. (shrink)

In this issue, Raphael Cohen-Almagor reviews some of the terms used in the discussion of bioethical issues at the end of a patient's life; he argues that they are “valueladen” and serve “primarily the physicians, at times at the expense of the patients’ best interest.” Each of the following terms comes under scrutiny: “death with dignity,” “persistent vegetative state,” “futility,” “double effect,” and “brain death.” He argues that these concepts, developed in recent decades, “have generated an unhealthy atmosphere for patients, (...) which might lead to undesirable actions at the end of patients’ lives.” He issues a plea to discontinue the use of the term “persistent vegetative state” because it is dehumanizing, to explain “double effect” and “futility” in detail and with sincerity, and to clarify the motivation for using these terms and others. He warns physicians not to use terminology that is offensive to patients and loved ones or that weakens their patients’ will to live. (shrink)

In this issue, Raphael Cohen-Almagor reviews some of the terms used in the discussion of bioethical issues at the end of a patient's life; he argues that they are “valueladen” and serve “primarily the physicians, at times at the expense of the patients’ best interest.” Each of the following terms comes under scrutiny: “death with dignity,” “persistent vegetative state,” “futility,” “double effect,” and “brain death.” He argues that these concepts, developed in recent decades, “have generated an unhealthy atmosphere for patients, (...) which might lead to undesirable actions at the end of patients’ lives.” He issues a plea to discontinue the use of the term “persistent vegetative state” because it is dehumanizing, to explain “double effect” and “futility” in detail and with sincerity, and to clarify the motivation for using these terms and others. He warns physicians not to use terminology that is offensive to patients and loved ones or that weakens their patients’ will to live. (shrink)

The problem of decision-making capacity in patients with dementia, such as those with early stage Alzheimer's, can be vexing, especially when these patients refuse life-sustaining medical treatments. However, these patients should not be presumed to lack decision-making capacity. Instead, an analysis of the patient's decision-making capacity should be made. Patients who have some degree of decision-making capacity may be able to make a choice about life-sustaining medical treatment and may, in many cases, choose to forgo treatment.

Childress and coauthors present a case considering ECMO withdrawal over the objection of the conscious patient who is no longer a candidate for transplantation or other definitive therapeutic inter...

Although clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems, progress in developing standards for quality is challenging. In this article, we describe the results of a pilot project utilizing portfolios as an evaluation tool. We found that this approach is feasible and resulted in a reasonably wide distribution of scores among the 23 submitted portfolios that we evaluated. We discuss limitations and implications of these results, and suggest that this is a significant step (...) on the pathway to an eventual certification process for clinical ethics consultants. (shrink)

It is now a default obligation to provide cardiopulmonary resuscitation (CPR), in the absence of knowledge of a patient’s or surrogate’s wishes to the contrary. We submit that it is time to reevaluate this position. Attempting CPR should be subject to the same scrutiny demanded of other medical interventions that involve balancing a great benefit against grievous harms.

Clinical ethics consultation is largely outside the scope of regulation and oversight, despite its importance. For decades, the bioethics community has been unable to reach a consensus on whether there should be accountability in this work, as there is for other clinical activities that influence the care of patients. The American Society for Bioethics and Humanities, the primary society of bioethicists and scholars in the medical humanities and the organizational home for individuals who perform CEC in the United States, has (...) initiated a two‐step quality attestation process as a means to assess clinical ethics consultants and help identify individuals who are qualified to perform this role. This article describes the process. (shrink)

To examine the ethical duty to patients and families in the setting of the resuscitation bay, we address a case with a focus on providing optimal care and communication to family members. We present a case of nonsurvivable traumatic injury in a minor, focusing on how allowing family more time at the bedside impacts the quality of death and what duty exists to maintain an emotionally optimal environment for family grieving and acceptance. Our analysis proposes tenets for patient and family-centric (...) care that, in alignment with trauma-informed care principles, optimize the long-term well-being of the family, namely valuing family desires and sensitivity to location. (shrink)

Many adoptees face a number of challenges relating to separation from biological parents during the adoption process, including issues concerning identity, intimacy, attachment, and trust, as well as language and other cultural challenges. One common health challenge faced by adoptees involves lack of access to genetic-relative family health history. Lack of GRFHx represents a disadvantage due to a reduced capacity to identify diseases and recommend appropriate screening for conditions for which the adopted person may be at increased risk. In this (...) article, we draw out common features of traditionally understood “health disparities” in order to identify analogous features in the context of adoptees’ lack of GRFHx. (shrink)

For over a decade, managed care has profoundly altered how healthcare is delivered in the United States. There have been concerns that the patient-physician relationship may be undermined by various aspects of managed care, such as restrictions on physician choice, productivity requirements that limit the time physicians may spend with patients, and the use of compensation formulas that reward physicians for healthcare dollars not spent. We have previously published data on the effects of managed care on the physician-patient relationship from (...) the physician's perspective. In 1999, we collected data on the impact of managed care arrangements on the physician-patient relationship from the patient's perspective. This article discusses our collective findings. (shrink)

Over the past several years, healthcare has been profoundly altered by the growth of managed care. Because managed care integrates the financing and delivery of healthcare services, it dramatically alters the roles and relationships among providers, payers, and patients. While analysis of this change has focused on whether and how managed care can control costs, an increasingly important concern among healthcare providers and recipients is the impact of managed care on the physicianpatient relationship, but little data have been collected and (...) analyzed. We designed a survey for distribution to Wisconsin physicians to analyze the prevalence and types of managed care arrangements in the state, and the impact of these arrangements on physicians and their relationships with patients. (shrink)

The field of clinical ethics consultation has matured into a multidisciplinary profession, with clinical ethics consultants (CECs) being trained in bioethics, philosophy, theology, law, medicine, n...

In this article, we develop a non-rights-based argument based on beneficence (i.e., the welfare of individuals and communities) and justice as the disposition to act justly to promote equity in health care resource allocation. To this end, we structured our analysis according to the following main sections. The first section examines the work of Amartya Sen and his equality of capabilities approach and outlines a framework of health care as a fundamental human need. In the subsequent section, we provide a (...) definition of health equity based on the moral imperative to guarantee that every individual ought to have the freedom to pursue health goals and well-being. In the later part of the article, we outline a non-right approach to health care based on three pillars: (1) human flourishing, (2) justice as a disposition not a process, and (3) solidarity. (shrink)

The cosmological and teleological argument both start with some contingent feature of the actual world and argue that the best or only explanation of that feature is that it was produced by an intelligent and powerful supernatural being. The cosmological argument starts with a general feature, such as the existence of contingent being or the presence of motion and uses some version of the Principle of Sufficient Reason to conclude that this feature must have an explanation. The debate then focuses (...) on two points: first, whether the PSR in question is true, and second, whether the explanation must involve God or at least some God-like being. The teleological argument begins with a general feature of the cosmos judged to have value, such as the existence of intelligent life or the presence of order in the universe, and argues, usually inductively but sometimes deductively, that this feature is to be explained by the agency of a powerful supernatural being. Here, the debate tends to focus on whether there are alternate naturalistic explanations, such as Darwinian evolution. (shrink)

What is "critical thinking"? -- What is "law"? : thinking critically about legal perspectives -- Putting critical thinking into legal practice -- Thinking critically about assessments -- Thinking critically in the workplace and beyond.

This article seeks to present a detailed textual analysis of Protagoras’ Great Speech in Plato's Protagoras. I will argue that the concept of ἀρετή as it appears in the Great Speech is whittled down to a vague notion of civic duty. In this respect, Protagoras is bringing himself in line with the democracy, but in doing so the ἀρετή he claims to teach loses much of its initial appeal, particularly in the eyes of his aristocratic clientele. Nevertheless, if thecontentof Protagoras’ (...) Great Speech overlooks the abilities required to rise to political prominence, theformmost assuredly does not. As one would expect from Plato's Protagoras, his speech is replete with just that oratorical prowess his students might expect to acquire from him. This, in turn, has a number of interesting and important implications in the broader context of theProtagoras, in particular regarding the contrast or conflict between long speeches and short-answer dialectic. Moreover, although it has long been noticed that Protagoras neglects rhetoric and personal pre-eminence in his account, as far as I know there has not been any serious attempt to analyse the stylistic aspects of this masterful speech. Accordingly, both this and my attempt to interpret it within the economy of the dialogue are original. (shrink)

BackgroundThe emergence of artificial intelligence (AI) in medicine has prompted the development of numerous ethical guidelines, while the involvement of patients in the creation of these documents lags behind. As part of the European PROFID project we explore patient perspectives on the ethical implications of AI in care for patients at increased risk of sudden cardiac death (SCD).AimExplore perspectives of patients on the ethical use of AI, particularly in clinical decision-making regarding the implantation of an implantable cardioverter-defibrillator (ICD).MethodsSemi-structured, future scenario-based (...) interviews were conducted among patients who had either an ICD and/or a heart condition with increased risk of SCD in Germany (n = 9) and the Netherlands (n = 15). We used the principles of the European Commission’s Ethics Guidelines for Trustworthy AI to structure the interviews.ResultsSix themes arose from the interviews: the ability of AI to rectify human doctors’ limitations; the objectivity of data; whether AI can serve as second opinion; AI explainability and patient trust; the importance of the ‘human touch’; and the personalization of care. Overall, our results reveal a strong desire among patients for more personalized and patient-centered care in the context of ICD implantation. Participants in our study express significant concerns about the further loss of the ‘human touch’ in healthcare when AI is introduced in clinical settings. They believe that this aspect of care is currently inadequately recognized in clinical practice. Participants attribute to doctors the responsibility of evaluating AI recommendations for clinical relevance and aligning them with patients’ individual contexts and values, in consultation with the patient.ConclusionThe ‘human touch’ patients exclusively ascribe to human medical practitioners extends beyond sympathy and kindness, and has clinical relevance in medical decision-making. Because this cannot be replaced by AI, we suggest that normative research into the ‘right to a human doctor’ is needed. Furthermore, policies on patient-centered AI integration in clinical practice should encompass the ethics of everyday practice rather than only principle-based ethics. We suggest that an empirical ethics approach grounded in ethnographic research is exceptionally well-suited to pave the way forward. (shrink)

Adherence to a few basic principles of textbook reading compilation have made this one of the more worthwhile introductory philosophy texts. In the first place, the editors have given lengthy and frequently complete texts. Anselm's Proslogium, Descartes' Meditations, Plato's Phaedo, and Kant's Prolegomena are given complete or nearly complete; there is a ninety-one page extract from Locke's Essay, over fifty pages of James and nearly forty pages from Whitehead. This still leaves room for ample primary material by Leibniz, Hume, and (...) Schopenhauer. The plan of the book is to frame the important primary text with intellectually contemporaneous discussion of the problems treated in the primary text, and then to bracket each section with a prologue and epilogue drawn—except in the final section where Plato has the last word—from twentieth-century literature relevant to the issues under discussion in each section. The authors are thus able to provide an historical and thematic introduction to philosophy, which together cannot help but impress the beginning student with the unity of philosophical experience. Obviously no single textbook will ever escape the need for supplementation; this one in particular will require those who would like their students to be exposed to more phenomenology and existentialism, and, to a lesser degree, analytical philosophy, to introduce additional reading. But Epstein and Kennedy have provided the basic skeleton to which may be added as much flesh as the instructor desires.—E. A. R. (shrink)

There appears to be a wide measure of agreement, both amongst biologists and others, that Darwin's theory of evolution marks a major breakthrough in the science of biology; Darwin has even been called ‘Biology's Newton’, the highest term of praise that could be bestowed on a scientist. A. G. N. Flew, considering the matter from a philosophical point of view, says: ‘Yet one of the most important of all scientific theories is that developed by Darwin in his Origin of Species (...) . Covering the entire range of biological phenomena its scope is enormous. While if any scientific theory is interesting philosophically this one is.’ In spite of the testimony of both biologists and philosophers of science to the importance of the theory, it does not appear to play anything like the same role in biology as does Newton's theory in physics. For modern physics would be. (shrink)

In this paper we conduct an analysis of the critical narratives of Stardew Valley and compare them to other relevant videogames in order to develop new possibilities for an ecological critique of capitalist extractive econo­mies. Critical narratives of this game are aimed primarily at the alienating conditions of labour and deeply devastating modes of production under capitalism that impact and severely damage the environment. Analysing these narratives, we superimpose the immediate messages of the game with the procedural rhetoric and material (...) conditions of their existence. Over the course of our analysis, we highlight a material-narrative disso­nance which, in the case of Stardew Valley, fails to function as a commu­nicative strategy of the game and remains its mere external contradiction. Although the game’s critical narrative may seem overly utopian and its political imaginary a bit underdeveloped, the game elaborates on concrete ways to tackle the alienation of labour and resolve the ecological crisis. In addition to this, the paper covers the history of the interplay between the video game industry and the field of global ecological crisis research. We compare the attempts to raise awareness of the videogames’ own material­ity that preceded Stardew Valley. We conclude that Stardew Valley utilises the language of sustainable co-existence and wasteless local production, expanding this logic both to the sphere of labour and the spectrum of en­vironmental problems. In the case of ecological critique, some gameplay decisions in Stardew Valley enable us to come up with new strategies aimed at creating critical narratives about the environment in videogames. Thus supplementing Stardew Valley’s findings with critical tropes derived from other games (mainly, Rain World), we were able to gather a set of theoretical instruments that could facilitate the creation of games about ecosystems. Following Donna Haraway’s emphasis on the crucial role of narrative fram­ing (“it matters which stories tell stories”), we highlight new opportunities for the entire medium of videogames. (shrink)

When this work was first published in 1960, it immediately filled a void in Kantian scholarship. It was the first study entirely devoted to Kant's _Critique of Practical Reason_ and by far the most substantial commentary on it ever written. This landmark in Western philosophical literature remains an indispensable aid to a complete understanding of Kant's philosophy for students and scholars alike. This _Critique_ is the only writing in which Kant weaves his thoughts on practical reason into a unified argument. (...) Lewis White Beck offers a classic examination of this argument and expertly places it in the context of Kant's philosophy and of the moral philosophy of the eighteenth century. (shrink)