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)

A popular response to the Exclusion Argument for physicalism maintains that mental events depend on their physical bases in such a way that the causation of a physical effect by a mental event and its physical base needn’t generate any problematic form of causal overdetermination, even if mental events are numerically distinct from and irreducible to their physical bases. This paper presents and defends a form of dualism that implements this response by using a dispositional essentialist view of properties to (...) argue that the psychophysical laws linking mental events to their physical bases are metaphysically necessary. I show the advantages of such a position over an alternative form of dualism that merely places more “modal weight” on psychophysical laws than on physical laws. The position is then defended against the objection that it is inconsistent with dualism. Lastly, some suggestions are made as to how dualists might clarify the contribution that mental causes make to their physical effects. (shrink)

The Exclusion Argument for physicalism maintains that since (1) every physical effect has a sufficient physical cause, and (2) cases of causal overdetermination are rare, it follows that if (3) mental events cause physical events as frequently as they seem to, then (4) mental events must be physical in nature. In defence of (1), it is sometimes said that (1) is supported if not entailed by conservation laws. Against this, I argue that conservation laws do not lend sufficient support to (...) (1) to render its denial ‘unscientific’, and that those who accept (3) and deny (4) may consequently respond to the Exclusion Argument by denying (1) without thereby setting themselves at odds with current science. I also argue that conservation laws are compatible with (3) and the negation of (4), and that one can therefore accept conservation laws and (3) while denying both (1) and (4). (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)

In this paper, we examine the lawfulness of a proposal to provide elective ventilation to incompetent patients who are potential organ donors. Under the current legal framework, this depends on whether the best interests test could be satisfied. It might be argued that, because the Mental Capacity Act 2005 (UK) (and the common law) makes it clear that the best interests test is not confined to the patient's clinical interests, but extends to include the individual's own values, wishes and beliefs, (...) the proposal will be in the patient's best interests. We reject this claim. We argue that, as things currently stand, the proposal could not lawfully be justified as a blanket proposition by reference to the best interests test. Accordingly, a modification of the law would be necessary to render the proposal lawful. We conclude with a suggestion about how that could be achieved. (shrink)

Much of the commentary in the wake of the Charlie Gard litigation was aimed at apparent shortcomings of the law. These include concerns about the perceived inability of the law to consider resourcing issues, the vagueness of the best interests test and the delays and costs of having disputes about potentially life-sustaining medical treatment resolved by the courts. These concerns are perennial ones that arise in response to difficult cases. Despite their persistence, we argue that many of these criticisms are (...) unfounded. The first part of this paper sets out the basic legal framework that operates when parents seek potentially life-sustaining treatment that doctors believe is against a child’s best interests, and describes the criticisms of that framework. The second part of the paper suggests an alternative approach that would give decision-making power to parents, and remove doctors’ ability to unilaterally withhold or withdraw life-sustaining treatment that they regard is futile. This proposal is grounded in several values that we argue should guide these regulatory choices. We also contend that the best interests test is justifiable and since the courts show no sign of departing from it, the focus should be on how to better elucidate the underlying values driving decisions. We discuss the advantages of our proposed approach and how it would address some of the criticisms aimed at the law. Finally, we defend the current role that the judiciary plays, as an independent state-sanctioned process with a precedent-setting function. (shrink)

BackgroundThis paper investigates the content of Australian policies that address withholding or withdrawing life-sustaining treatment to analyse the guidance they provide to doctors about the allocation of resources.MethodsAll publicly available non-institutional policies on withholding and withdrawing life-sustaining treatment were identified, including codes of conduct and government and professional organization guidelines. The policies that referred to resource allocation were isolated and analysed using qualitative thematic analysis. Eight Australian policies addressed both withholding and withdrawing life-sustaining treatment and resource allocation.ResultsFour resource-related themes were (...) identified: doctors’ ethical duties to consider resource allocation; balancing ethical obligations to patient and society; fair process and transparent resource allocation; and legal guidance on distributive justice as a rationale to limit life-sustaining treatment.ConclusionOf the policies that addressed resource allocation, this review found broad agreement about the existence of doctors’ duties to consider the stewardship of scarce resources in decision-making. However, there was disparity in the guidance about how to reconcile competing duties to patient and society. There is a need to better address the difficult and confronting issue of the role of scarce resources in decisions about life-sustaining treatment. (shrink)

Theories of phenomenal intentionality have been claimed to resolve certain worries about the indeterminacy of mental content that rival, externalist theories face. Thus far, however, such claims have been largely programmatic. This paper aims to improve on prior arguments in favor of phenomenal intentionality by using attention and Gestalt principles as specific examples of factors that influence the phenomenal character of perceptual experience in ways that thereby help determine perceptual content. Some reasons are then offered for rejecting an alternative interpretation (...) of these examples, according to which the phenomenal effects of attention and Gestalt principles play no role in the determination of perceptual content. (shrink)

Heidegger is perhaps best known for stressing the function of time as temporality on the phenomena of life. There is a sense, however, in which the full significance of these insights can be best understood only through an exploration of the function of space as spatiality in the phenomena of life. At their juxtaposition, there is a privileged perspective on the meaning of life, and most importantly on what is the most meaningful life on the Heideggerian account, thephilosophical life. The (...) following short exploration uncovers this standpoint through an analysis of the word “clearing” as temporally expansive space. Through this device, there is a clear view of the role of philosophy, of truth, and of the meaning of life in Heidegger’s Being and Time. (shrink)

Chalmers’ meta-problem of consciousness is the problem of explaining “problem reports”; i.e. reports to the effect that phenomenal consciousness has the various features that give rise to the hard problem. Chalmers suggests that solving the meta-problem will likely “shed significant light on the hard problem.” Against this, I argue that work on the meta-problem will likely fail to make the hard problem any easier. For each of the main stances on the hard problem can provide an account of problem reports, (...) and we have no way of deciding which of these accounts gives the correct explanation of an individual’s problem reports without presupposing a stance on the hard problem. We thus cannot determine which of the available solutions to the meta-problem is correct without having already solved the hard problem. (shrink)

This article argues that standard causal and functionalist definitions of realization fail to account for the realization of entities that cannot be individuated in causal or functional terms. By modifying such definitions to require that realizers also logically suffice for any historical properties of the entities they realize, one can provide for the realization of entities whose resistance to causal/functional individuation stems from their possession of individuative historical properties. But if qualia cannot be causally or functionally individuated, then qualia can (...) be physically realized only if the thesis that all things are physical or physically realized is insufficient for physicalism. (shrink)