There has been an ongoing appeal in the bioethics literature for a broader understanding and conceptual clarity of the phenomenon of moral distress. Several authors argue that greater conceptual cl...

Let n ≥ 3. The following theorems are proved. Theorem. The theory of the class of strictly upper triangular n × n matrix rings over fields is finitely axiomatizable. Theorem. If R is a strictly upper triangular n × n matrix ring over a field K, then there is a recursive map σ from sentences in the language of rings with constants for K into sentences in the language of rings with constants for R such that $K \vDash \varphi$ if (...) and only if $R \vDash \sigma$. Theorem. The theory of a strictly upper triangular n × n matrix ring over an algebraically closed field is ℵ 1 -categorical. (shrink)

We say that a ring admits elimination of quantifiers, if in the language of rings, {0, 1, +, ·}, the complete theory of R admits elimination of quantifiers. Theorem 1. Let D be a division ring. Then D admits elimination of quantifiers if and only if D is an algebraically closed or finite field. A ring is prime if it satisfies the sentence: ∀ x ∀ y ∃ z (x = 0 ∨ y = 0 ∨ xzy ≠ 0). Theorem (...) 2. If R is a prime ring with an infinite center and R admits elimination of quantifiers, then R is an algebraically closed field. Let A be the class of finite fields. Let B be the class of 2 × 2 matrix rings over a field with a prime number of elements. Let C be the class of rings of the form $GF(p^n) \bigoplus GF(p^k)$ such that either n = k or g.c.d. (n, k) = 1. Let D be the set of ordered pairs (f, Q) where Q is a finite set of primes and f: Q → A ∪ B ∪ C such that the characteristic of the ring f(q) is q. Finally, let E be the class of rings of the form $\bigoplus_{q \in Q}f(q)$ for some (f, Q) in D. Theorem 3. Let R be a finite ring without nonzero trivial ideals. Then R admits elimination of quantifiers if and only if R belongs to E. Theorem 4. Let R be a ring with the descending chain condition of left ideals and without nonzero trivial ideals. Then R admits elimination of quantifiers if and only if R is an algebraically closed field or R belongs to E. In contrast to Theorems 2 and 4, we have Theorem 5. If R is an atomless p-ring, then R is finite, commutative, has no nonzero trivial ideals and admits elimination of quantifiers, but is not prime and does not have the descending chain condition. We also generalize Theorems 1, 2 and 4 to alternative rings. (shrink)

In November 2018, the practice of health care ethics consultation crossed a major threshold when 138 candidates took the inaugural Healthcare Ethics Consultant Certification Examination. This accomplishment, long in the making, has had and continues to have both advocates and critics. The Healthcare Ethics Consultant Certification Commission, a functionally autonomous body created and funded by the American Society for Bioethics and Humanities, was charged with overseeing creation of the certification process, developing the exam, and formulating certification standards and policies to (...) assess candidates’ qualifications. In this essay, as members of the commission, we describe the process of developing, administering, and scoring the certification examination as well as the historical context and the outlook for certification. By detailing the decisions and actions of the commission, we aim to provide a transparent account of the commission's efforts to develop a psychometrically sound, reliable, and secure examination through a deliberative, fair, and data‐driven process. (shrink)

We describe the ethics consultation service (ECS) at the Cleveland Clinic and report on its activities over a 24-month period in which 478 consultations were performed. To our knowledge, this is the largest case series of ethics consultations reported to date. Established more than 25 years ago, the ECS at the Cleveland Clinic is staffed by multiple consultants with advanced training in bioethics. Several of these ethicists work closely with specialized clinical units and research departments, where they participate in multidisciplinary (...) meetings and provide specialized assistance. This combination of historical experience, large numbers of consultation requests, and specialized clinical ethicists suggests that the experience at the Cleveland Clinic may be helpful to ethicists and others who may be considering how to structure and sustain a vibrant ECS. Our results highlight the diversity of activities performed by a high-volume ECS at a tertiary care facility. Our hope in sharing the inner workings of the ECS at the Cleveland Clinic is to promote dialogue on common practices and approaches across medical institutions that support ethics consultation. (shrink)

It is generally accepted that appropriate documentation of activities and recommendations of ethics consultants in patients’ medical records is critical. Despite this acceptance, the bioethics literature is largely devoid of guidance on key elements of an ethics chart note, the degree of specificity that it should contain, and its stylistic tenor. We aim to provide guidance for a variety of persons engaged in clinical ethics consultation: new and seasoned ethics committee members who are new to ethics consultation, students and trainees (...) in clinical ethics, and those who have significant experience with ethics consultation so that they can reflect on their practice. Toward the goal of promoting quality charting practices in ethics consultations, we propose recommendations on a broad array of questions concerning clinical ethics consultation chart notes, including whether and when to write a chart note, and practical considerations for the tenor, purpose, and content of a chart note. Our broader aim is to promote discussion about good charting practices in clinical ethics, with the hope of contributing to clear standards of excellence in clinical ethics consultation. (shrink)

The authors work in a variety of clinical ethics consultation services (CECSs) that employ a range of methods and approaches. This article discusses the approach to ethics consultation at the Center for Medical Ethics and Health Policy at Baylor College of Medicine and describes the development and transformation of the authors’ CECSs. It discusses how one CECS shifted from a nascent program with only fifty consultations a year to a vibrant, heavily staffed service with five hundred ethics consultations a year.

Developing a care plan in a critical care context can be challenging when the therapeutic alliance between clinicians and families is compromised by anger. When these cases occur, clinicians often turn to clinical ethics consultants to assist them with repairing this alliance before further damage can occur. This paper describes five different reasons family members may feel and express anger and offers concrete strategies for clinical ethics consultants to use when working with angry families acting as surrogate decision makers for (...) critical care patients. We reviewed records of consults using thematic analysis between January 2015 and June 2016. Each case was coded to identify whether the case involved a negative encounter with an angry family. In our review, we selected 11 cases with at least one of the following concerns or reasons for anger: perceived or actual medical error, concerns about the medical team’s competence, miscommunication, perceived conflict of interest or commitment, or loss of control. To successfully implement these strategies, clinical ethics consultants, members of the medical team, and family members should share responsibility for creating a mutually respectful relationship. (shrink)

While valuable work has been done addressing clinical ethics within established healthcare systems, we anticipate that the projected growth in acquisitions of community hospitals and facilities by large tertiary hospitals will impact the field of clinical ethics and the day-to-day responsibilities of clinical ethicists in ways that have yet to be explored. Toward the goal of providing clinical ethicists guidance on a range of issues that they may encounter in the systematization process, we discuss key considerations and potential challenges in (...) implementing system-wide ethics consultation services. Specifically, we identify four models for organizing, developing, and enhancing ethics consultation activities within a system created through acquisitions: train-the-trainer, local capacity-building, circuit-riding, and consolidated accountability. We note each model’s benefits and challenges. To our knowledge, this is the first paper to consider the broader landscape of issues affected by consolidation. We anticipate that clinical ethicists, volunteer consultants, and hospital administrators will benefit from our recommendations. (shrink)

Patients who enter the health care system for acute care may become “permanent” patients of the hospital when a lack of resources precludes discharge to the next level of post-acute care. Legal, professional, and ethical norms prohibit physician and acute care hospital “dumping” of these patients. However, limitless use of hospital resources for indefinite stays is untenable. In the absence of hospital policy addressing this specific issue, the availability of financial support will be determined by health care professionals' willingness to (...) advocate for the patient and negotiate with hospital administrators and the ability and willingness of administrators to authorize the use of hospital resources. We propose five mid-level ethical principles to guide advocacy and administrative decision-making about provision of financial support for post-acute care for those patients who cannot afford it. We use two actual, de-identified cases to illustrate how these principles can be used to make reasoned, consistent decisions about the provision of post-acute financial support. (shrink)

Patients who enter the health care system for acute care may become “permanent” patients of the hospital when a lack of resources precludes discharge to the next level of post-acute care. The care of these patients contributes to the rising costs of health care and will remain largely unaffected by the Affordable Care Act. For example, some resources may be available for treatment of undocumented persons, but Medicaid enrollment is unavailable for this population. Even where patients have access to Medicaid, (...) it takes up to three months between applying for and actually receiving Medicaid benefits. During that time, patients may be ready for hospital discharge. However, post-acute care facilities have no financial incentive or legal obligation to accept patients with no insurance or only pending Medicaid coverage. (shrink)

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)

The clinical ethicist met with Ms. H to clarify what information she wants and does not want to know. First, she wants to receive any treatment that could prolong her life, regardless of how the treatment affects her ability to engage in activities of daily living. Second, she wants to be included in the decision‐making process as much as possible, as long as clinicians use only “positive” language. Ms. H considers the words “dying,” “chemotherapy,” “radiation,” and “cancer” to be “bad (...) words.” For conversations in which these words cannot be avoided, she wants her clinicians to talk to her son. Her desired engagement includes hearing about risks, benefits, and alternatives to treatments if clinicians use only “positive” language. Finally, she says that she rarely sees doctors and that she is “very scared” of hospitals, despite exhibiting a comfortable demeanor.Should clinicians honor Ms. H's waiver of specified information and, if so, to what degree? (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)

In their article “Structuring a Written Examination to Assess ASBH Health Care Ethics Consultation Core Competencies” (2014), White, Jankowski, and Shelton argue that a written examination to evalu...

The authors of this article are previous or current members of the Clinical Ethics Consultation Affairs (CECA) Committee, a standing committee of the American Society for Bioethics and Humanities (ASBH). The committee is composed of seasoned healthcare ethics consultants (HCECs), and it is charged with developing and disseminating education materials for HCECs and ethics committees. The purpose of this article is to describe the educational research and development processes behind our teaching materials, which culminated in a case studies book called (...) A Case-Based Study Guide for Addressing Patient-Centered Ethical Issues in Health Care (hereafter, the Study Guide). In this article, we also enumerate how the Study Guide could be used in teaching and learning, and we identify areas that are ripe for future work. (shrink)

Hospital administrators may lack familiarity with what clinical ethicists do (and do not do), and many clinical ethicists report receiving inadequate financial support for their clinical ethics consultation services (CECSs). Ethics consultation is distinct in that it is not reimbursable by third parties, and its financial benefit to the hospital may not be quantifiable. These peculiarities make it difficult for clinical ethicists to resort to tried-and-true outcome-centered evaluative strategies, like cost reduction or shortened length of stay for patients, to show (...) a “need” for ethics consultation. Likewise, it can be difficult for clinical ethicists to “speak the same language” as healthcare administrators and managers, which, in turn, means that CECSs run the risk of being unable to demonstrate value to those who pay for the service. The purpose of this descriptive article is to provide practical guidance to clinical ethicists and program directors on how to cultivate administrative support for a CECS. Specifically, we discuss two elements that clinical ethics leaders must critically appraise and successfully argue to meet the expectations of administrators— the value of a CECS and its fit in clinical workflow. (shrink)

Steven Rose regards oversimplification of biology as the supreme sin, inevitably leading to evil consequences, and requiring an unique distortion of scientific practice to avoid it. To avoid this, he proposes a short-cut to scientific knowledge by defining certain areas of biology that are intrinsically flawed. But this achieves only a subordination of science to politics. There are no general-purpose shortcuts for evaluating the validity of theories, and no substitutes for testing specific theories using relevant evidence.

Apparently, the wall was something of an engineering miracle even prior to the events that exposed it to the light of day. People used to go down to the basement where part of it was visible, and marvel at its ability to resist 3500 pounds per square inch of pressure over 3300 feet. When it was called upon to bear even more it rose to the challenge, anthropomorphically speaking. Now it is being compared to the Liberty Bell,1 a physical (...) object that symbolizes a signature and defining event. This wall, built to hold back the Hudson River from flooding the basement of the World Trade Center, was once the foundation and physical site of a place, but has now itself become a place. It has transformed from site to situation. It is being written retrospectively as a humble and unglamorous object that rose to be a noble, even heroic place, one which because of the “ miracle ” of superior engineering stood when everything else fell. This object which newly defines a place has become the classic American story of triumph over insurmountable odds. It has become personified, narrativized, and valorized - it “held” against the onslaught like a defender protecting a city, saving the lives of people who were rushing out of the building. It is a place of memory, although precisely what is being remembered depends on who faces the wall. It is the Wailing Wall. It is being incorporated into the new design for the site by the architects and the memorial planners, an unlikely remembrance to and representation of horrific events. It is the hypostatization of a narrative of siege, another quintessentially American story about the triumph of the inside over the outside. It is the Alamo, it is Independence Day, it is homeland security. Less literally but no less viscerally than Maya Ying Lin’s Vietnam. (shrink)

The first longevity revolution began in the middle of the 19th century, accelerated through the first half of the 20th century, and led to the first and only quantum leap in human life expectancy.In the 20th century alone, life expectancy at birth in most developed nations rose by about 30 years. The first three quarters of the century were notable for gains made at younger and middle ages, and in the last quarter century, old age mortality declined. Nothing in (...) history has ever come close to the magnitude of this benefit to humanity. The rise in life expectancy occurred swiftly because the primary beneficiaries of advances in public health and... (shrink)

The second edition of The Great Psychotherapy Debate has been updated and revised to include a history of healing practices, medicine, and psychotherapy, an expanded theoretical presentation of the contextual model, an examination of therapist effects, and a thorough review of the research on common factors such as the alliance, expectations, and empathy.

The Great Psychotherapy Debate: Models, Methods, and Findings comprehensively reviews the research on psychotherapy to dispute the commonly held view that the benefits of psychotherapy are derived from the specific ingredients contained in a given treatment (medical model). The author reviews the literature related to the absolute efficacy of psychotherapy, the relative efficacy of various treatments, the specificity of ingredients contained in established therapies, effects due to common factors, such as the working alliance, adherence and allegiance to the therapeutic protocol, (...) and effects that are produced by different therapists. In each case, the evidence convincingly corroborates the contextual model and disconfirms the prevailing medical model. (shrink)

In Against Moral Responsibility, Bruce Waller launches a spirited attack on a system that is profoundly entrenched in our society and its institutions, deeply rooted in our emotions, and vigorously defended by philosophers from ancient times to the present. Waller argues that, despite the creative defenses of it by contemporary thinkers, moral responsibility cannot survive in our naturalistic-scientific system. The scientific understanding of human behavior and the causes that shape human character, he contends, leaves no room for moral responsibility. (...) Waller argues that moral responsibility in all its forms--including criminal justice, distributive justice, and all claims of just deserts--is fundamentally unfair and harmful and that its abolition will be liberating and beneficial. What we really want--natural human free will, moral judgments, meaningful human relationships, creative abilities--would survive and flourish without moral responsibility. In the course of his argument, Waller examines the origins of the basic belief in moral responsibility, proposes a naturalistic understanding of free will, offers a detailed argument against moral responsibility and critiques arguments in favor of it, gives a general account of what a world without moral responsibility would look like, and examines the social and psychological aspects of abolishing moral responsibility. Waller not only mounts a vigorous, and philosophically rigorous, attack on the moral responsibility system, but also celebrates the benefits that would result from its total abolition. (shrink)

Offers a compelling vision of how to achieve and conduct a liberal but democratic society through the ideal of Neutrality--between people and ideas of the good--and using the tool of Neutral dialogue.

Federal law under the Individuals with Disabilities in Education Improvement Act stipulates that services provided to students with diagnosed disabilities must be individualised based on the as...

HIV stigma, a social-medical problem, continues to confound researchers and health professionals, while undermining outcomes. Empathy may reduce stigma; its absence may predict stigma. This research investigates: How does Kafka’s _Metamorphosis_ advance understandings of HIV stigma in medical health education? _Metamorphosis_ amplifies the sociological-relational mechanisms fostering HIV stigma. It offers a multi-disciplinary, responsive space for ethical, humanistic and clinical inquiry to meet: enabling students to consider how social structures shape health inequities, moral, social experience, and their professional identity within. _Metamorphosis_ (...) may ultimately promote medical health humanities’ social mission—allowing literature to unfold such revelations towards greater equity in health. (shrink)

Micheline Sauvage of the French National Scientific Research Centre traces for us the story of this great Athenian and great philosopher, as seen both by his contemporaries and by the European philosophers who followed after him.

Many philosophers have claimed that the folk endorse moral universalism. Some have taken the folk view to support moral universalism; others have taken the folk view to reflect a deep confusion. And while some empirical evidence supports the claim that the folk endorse moral universalism, this work has uncovered intra-domain differences in folk judgments of moral universalism. In light of all this, our question is: why do the folk endorse moral universalism? Our hypothesis is that folk judgments of moral universalism (...) are generated in part by a desire to punish. We present evidence supporting this across three studies. On the basis of this, we argue for a debunking explanation of folk judgments of moral universalism. Our results not only further our understanding of the psychological processes underpinning folk judgments of moral universalism. They also bear on philosophical discussions of folk meta-ethics. (shrink)

Three eminent scientists analyze the scientific, social, and political roots of biological determinism.

Animals today and tomorrow -- What makes an argument? -- Should animals be used in rodeo sports? -- Should animals be kept as pets? -- Should zoos and safari parks be banned?

The Turing Test (TT), as originally specified, centres on theability to perform a social role. The TT can be seen as a test of anability to enter into normal human social dynamics. In this light itseems unlikely that such an entity can be wholly designed in an off-line mode; rather a considerable period of training insitu would be required. The argument that since we can pass the TT,and our cognitive processes might be implemented as a Turing Machine(TM), that consequently a (...) TM that could pass the TT could be built, isattacked on the grounds that not all TMs are constructible in a plannedway. This observation points towards the importance of developmentalprocesses that use random elements (e.g., evolution), but in these casesit becomes problematic to call the result artificial. This hasimplications for the means by which intelligent agents could bedeveloped. (shrink)