In 2012, a U.S. Institute of Medicine report called for a different approach to health care: “Left unchanged, health care will continue to underperform; cause unnecessary harm; and strain national, state, and family budgets.” The answer, they suggested, would be a “continuously learning” health system. Ethicists and researchers urged the creation of “learning health organizations” that would integrate knowledge from patient‐care data to continuously improve the quality of care. Our experience with an ongoing research study on atrial fibrillation—a trial known (...) as IMPACT‐AFib—gave us some insight into one of the challenges that will have to be dealt with in creating these organizations. Although the proposed educational intervention study placed no restrictions on what providers and health plans could do, the oversight team argued that the ethical principle of beneficence did not allow the researchers to be “bystanders” in relation to a control group receiving suboptimal care. In response, the researchers designed a “workaround” that allowed the project to go forward. We believe the experience suggests that what we call “bystander ethics” will create challenges for the kinds of quality improvement research that LHOs are designed to do. (shrink)

Should mental health insurance cover only disorders found in DSM‐IV, or should it be extended to treatment for ordinary shyness, unhappiness, and other responses to life's hard knocks?

How can health plans make fair determinations about when “experimental” (and costly) treatments such as high dose chemotherapy with autologous bone marrow transplantation should be covered despite lack of clear clinical consensus about their benefits? Different models for managing “last chance” therapies evolving in some health plans offer promising examples of how issues of fairness and legitimacy in decisionmaking can be addressed.

In 2012, a U.S. Institute of Medicine report called for a different approach to health care: “Left unchanged, health care will continue to underperform; cause unnecessary harm; and strain national, state, and family budgets.” The answer, they suggested, would be a “continuously learning” health system. Ethicists and researchers urged the creation of “learning health organizations” that would integrate knowledge from patient‐care data to continuously improve the quality of care. Our experience with an ongoing research study on atrial fibrillation—a trial known (...) as IMPACT‐AFib—gave us some insight into one of the challenges that will have to be dealt with in creating these organizations. Although the proposed educational intervention study placed no restrictions on what providers and health plans could do, the oversight team argued that the ethical principle of beneficence did not allow the researchers to be “bystanders” in relation to a control group receiving suboptimal care. In response, the researchers designed a “workaround” that allowed the project to go forward. We believe the experience suggests that what we call “bystander ethics” will create challenges for the kinds of quality improvement research that LHOs are designed to do. (shrink)

Book reviewed in this article: Animal Experimentation: The Moral Issues. Edited by Robert M. Baird and Stuart E. Rosenbaum.

Although “rationing” continues to be a dirty word for the public in health policy discourse, Nir Eyal and colleagues handle the concept exactly right in their article in this issue of the Hastings Center Report. They correctly characterize rationing as an ethical requirement, not a moral abomination. They identify the key health policy question as how rationing can best be done, not whether it should be done at all. They make a cogent defense of what they call “rationing through (...) inconvenience” as a justifiable allocational technique. And they wisely call for research on the effectiveness and fairness of this approach and other methods of rationing. I fully agree with their approach to rationing and with their argument that the process they provocatively label “rationing through inconvenience” should not be rejected out of hand. But I believe they have underestimated two ways in which the practical impacts of rationing through inconvenience limit its potential usefulness: the asymmetry of its effect on patients and physicians and the way in which it reduces the capacity of health systems to learn from experience. (shrink)

"Cluster randomized trials," in which groups of patients are randomly assigned to different therapeutic interventions, provide a powerful way of evaluating drugs. CRTs have not been widely used, in good part because of concerns about whether patients must give informed consent to participate in them. A better understanding of how CRTs fit into clinical practice resolves the concerns.

Book reviewed in this article: Animal Experimentation: The Moral Issues. Edited by Robert M. Baird and Stuart E. Rosenbaum.

This essay introduces a special report from The Hastings Center entitled Democracy in Crisis: Civic Learning and the Reconstruction of Common Purpose, which grew out of a project supported by the John S. and James L. Knight Foundation. This multiauthored report offers wide‐ranging assessments of increasing polarization and partisanship in American government and politics, and it proposes constructive responses to this in the provision of objective information, institutional reforms in government and the electoral system, and a reexamination of (...) cultural and political values needed if democracy is to function well in a pluralistic and diverse society. The essays in the special report explore the norms of civic learning and institutions, social movements, and communal innovations that can revitalize civic learning in practice. This introductory essay defines and explains the notion of civic learning, which is a lynchpin connecting many of the essays in the report. Civic learning pertains to the ways in which citizens learn about collective social problems and make decisions about them that reflect the duties and responsibilities of citizenship. Such learning can occur in many social settings in everyday life, and it can also be facilitated through participation in the processes of democratic governance on many levels. Civic learning is not doctrinaire and is compatible with a range of public goals and policies. It is an activity that increases what might be called the democratic capability of a people. (shrink)

Over email a few days after the death of Daniel Callahan, cofounder of The Hastings Center and for many years its director and then president, Joseph Fins, a longtime Hastings colleague, offered this comfort: “[H]enceforth every issue of the Report is a living memorial to Dan the writer, editor, and institution builder.” In the Hastings Center Report's first issue, published in June 1971, Dan stated, “To say that [the work of the Report] must be multi‐disciplinary is only (...) to say the issues [it will address] are as complex as human beings themselves.” This July–August 2019 issue continues the tradition Dan began. An essay by Laura Guidry‐Grimes expands on the importance of interdisciplinary conversations and problem solving—and attends to the complexity of human beings—in recalling a patient who was failed by multiple social institutions. In the lead article, a team of authors led by James Sabin identifies a challenge to conducting ethical research within learning health organizations, where research and care are integrated with the aid of patient data from health insurance providers. (shrink)

In a recent symposium on Descartes' ontological argument, Norman Malcolm has restated a rather ingenious version of St Anse1m's ontological argument. 1 The purpose of the present paper is to assess the merits of this particular version of the ontological argument.

The purpose of the present paper is to formulate and resolve a certain puzzle surrounding God's existence and the standard attributes traditionally assigned to God.

This essay introduces a special report from The Hastings Center entitled Democracy in Crisis: Civic Learning and the Reconstruction of Common Purpose, which grew out of a project supported by the John S. and James L. Knight Foundation. This multiauthored report offers wide‐ranging assessments of increasing polarization and partisanship in American government and politics, and it proposes constructive responses to this in the provision of objective information, institutional reforms in government and the electoral system, and a reexamination of (...) cultural and political values needed if democracy is to function well in a pluralistic and diverse society. The essays in the special report explore the norms of civic learning and institutions, social movements, and communal innovations that can revitalize civic learning in practice. This introductory essay defines and explains the notion of civic learning, which is a lynchpin connecting many of the essays in the report. Civic learning pertains to the ways in which citizens learn about collective social problems and make decisions about them that reflect the duties and responsibilities of citizenship. Such learning can occur in many social settings in everyday life, and it can also be facilitated through participation in the processes of democratic governance on many levels. Civic learning is not doctrinaire and is compatible with a range of public goals and policies. It is an activity that increases what might be called the democratic capability of a people. (shrink)

One of the contemporary results of Germany’s memorial conundrum is the rise of its “counter-monuments”: brazen, painfully self-conscious memorial spaces conceived to challenge the very premises of their being. On the former site of Hamburg’s greatest synagogue, at Bornplatz, Margrit Kahl has assembled an intricate mosaic tracing the complex lines of the synagogue’s roof construction: a palimpsest for a building and community that no longer exist. Norbert Radermacher bathes a guilty landscape in Berlin’s Neukölln neighborhood with the inscribed light of (...) its past. Alfred Hrdlicka began a monument in Hamburg to counter—and thereby neutralize—an indestructible Nazi monument nearby. In a suburb of Hamburg, Jochen Gerz and Esther Shalev-Gerz have erected a black pillar against fascism and for peace designed to disappear altogether over time. The very heart of Berlin, former site of the gestapo headquarters, remains a great, gaping wound as politicians, artists, and various committees forever debate the most appropriate memorial for this site.4 4. The long-burning debate surrounding projected memorials, to the Gestapo-Gelände in particular, continues to exemplify both the German memorial conundrum and the state’s painstaking attempts to articulate it. For an excellent documentation of the process, see Topographie des Terrors: Gestapo, SS und Reichssicherheitshauptamt auf dem “Prinz-Albrecht-Gelände,” ed. Reinhard Rürup . For a shorter account, see James E. Young, “The Topography of German Memory,” The Journal of Art 1 : 30. James E. Young is assistant professor of English and Judaic studies at the University of Massachusetts, Amherst. He is the author of Writing and Rewriting the Holocaust: Narrative and the Consequences of Interpretation and The Texture of Memory: Holocaust Memorials and Meaning in Europe, Israel, and America , from which this essay is drawn. He is also the curator of “The Art of Memory,” an exhibition at the Jewish Museum of New York. (shrink)

The main thesis of this paper is that it is not possible to determine the nature of epistemic justification apart from scientific psychological investigation. I call this view the strong thesis of methodological psychologism. Two sub-theses provide the primary support for this claim. The first sub-thesis is that no account of epistemic justification is correct which requires for the possession of at least one justified belief a psychological capacity which humans do not have. That is, the correct account of epistemic (...) justification must be psychologically realistic. The second sub-thesis is that it is not possible to determine whether an account of epistemic justification is psychologically realistic apart from scientific psychological investigation. After defending these subtheses, I point out some interesting consequences of the overall thesis which present a challenge to traditional epistemology. (shrink)

Philosophers continue to debate about David Hume’s case against the rationality of belief in miracles. This article clarifies semantic, epistemological, and metaphysical questions addressed in the controversy. It also explains the main premises of Hume’s argument and discusses criticisms of them. The article concludes that one’s evaluation of Hume’s argument will depend on one’s views about (a) the definitions of ’miracle’ and ’natural law’; (b) the type of reasoning one ought to employ to determine the probability that a particular miracle (...) claim is true; and (c) whether reasonable people proportion their beliefs about the occurrence of miracles to their evidence. (shrink)

After reviewing historical aspects of brain evolution, this accessible book provides an enjoyable overview of several general principles of brain evolution, culminating in discussions of mammalian and human brains and a framework for future research.

If connectionist computational models explain the acquisition of complex cognitive skills, errors in such models would also help explain unusual brain activity such as in creativity – as well as in mental illness, including childhood onset problems with social behaviors in autism, the inability to maintain focus in attention deficit and hyperactivity disorder (ADHD), and the lack of motivation of depression disorders.

The essays range from Hegel and Modernism to Marcel Duchamp and the Avant-Garde, postmodern poetics, boredom and Proust, the romance of Arendt and Heidegger, ...

Cancer-related electronic support groups (ESGs) may be regarded as a complement to face-to-face groups when the latter are available, and as an alternative when they are not. Advantages over face-to-face groups include an absence of barriers imposed by geographic location, opportunities for anonymity that permit sensitive issues to be discussed, and opportunities to find peers online. ESGs can be especially valuable as navigation aids for those trying to find a way through the healthcare system and as a guide to the (...) cancer journey. Outcome indicators that could be used to evaluate the quality of ESGs as navigation aids need to be developed and tested. Conceptual models for the navigator role, such as the Facilitating Navigator Model, are appropriate for ESGs designed specifically for research purposes. A Shared or Tacit Model may be more appropriate for unmoderated ESGs. Both conceptual models raise issues in Internet research ethics that need to be address. (shrink)