Partly because physicians can “never say never,” partly because of the seduction of modern technology, and partly out of misplaced fear of litigation, physicians have increasingly shown a tendency to undertake treatments that have no realistic expectation of success. For this reason, we have articulated common sense criteria for medical futility. If a treatment can be shown not to have worked in the last 100 cases, we propose that it be regarded as medically futile. Also, if the treatment fails to (...) restore consciousness or alleviate total dependence on intensive care, we propose such treatment be judged futile. This definition provides clear end points and encourages the profession to review data from the past and perform, prospective clinical studies that not only report treatments that work but also treatments that do not work. We have also argued that, in a variety of settings, physicians have no ordinary ethical obligation to offer futile interventions. Although physicians should inform, and discuss all decisions to withhold or withdraw medical treatments with patients, they need not obtain the patient's permission to desist from futile interventions. (shrink)

The paper explores the ethical and psychological issues that arise when family members request that “everything possible” be done for a particular patient. The paper first illustrates this phenomenon by reviewing the well known case of Helga Wanglie. We proceed to argue that in Wanglie and similar cases family members may request futile treatments as a means of conveying that (1) the loss of the patient is tantamount to losing a part of themselves; (2) the patient should not be abandoned (...) or disvalued in any way; or (3) the patient is owed special obligations by virtue of the special relationship in which the family and the patient stand. We maintain that families can best express these important messages by caring for patients, rather than by making requests for futile interventions. Likewise, when life-sustaining measures are futile, health providers can best fulfill their professional obligations by assuring patients' dignity and comfort, rather than by applying futile interventions. (shrink)

In situations where experience shows that a particular intervention will not benefit a patient, common sense seems to suggest that the intervention should not be used. Yet it is precisely in these situations that a peculiar ethic begins to operate, an ethic that Eddy calls “the criterion of potential benefit.” According to this ethic, “a treatment is appropriate if it might have some benefit.” Thus, the various maxims learned in medical school instruct physicians that “‘an error of commission is to (...) be preferred to an error of omission,’ or ‘when in doubt, cut it out’ or ‘if but one patient is helped, then the treatment is worthwhile.’”. (shrink)

Loss of insight is a prominent clinical manifestation of behavioral variant frontotemporal dementia , but its characteristics are poorly understood. Twelve bvFTD patients were compared with 12 Alzheimer’s disease patients on a structured insight interview of cognitive insight and emotional insight . Compared to the AD patients, the bvFTD patients were less aware and less concerned about their disorder, and they had less appreciation of its effects on themselves and on others. After corrective feedback , the bvFTD patients were just (...) as aware of their disorder as the AD patients but remained unconcerned and unappreciative of its effects. These findings suggest that lack of insight in bvFTD is not due to “anosognosia,” or impaired cognitive and executive awareness of disease, but to “frontal anosodiaphoria,” or lack of emotional concern over having bvFTD and its impact on themselves and others. (shrink)

Should the nation provide expensive care and scarce organs to convicted felons? We distinguish between two fields of justice: Medical Justice and Societal Justice. Although there is general acceptance within the medical profession that physicians may distribute limited treatments based solely on potential medical benefits without regard to nonmedical factors, that does not mean that society cannot impose limits based on societal factors. If a society considers the convicted felon to be a full member, then that person would be entitled (...) to at least a decent minimum level of care — which might include access to scarce life-saving organs. However, if criminals forfeit their entitlement to the same level of medical care afforded to all members of society, they still would be entitled to a kind of rudimentary decent minimum granted to all persons on simple humanitarian grounds. Almost certainly this entitlement would not include access to organ transplants. (shrink)

A referral was made to our Cardiac Transplant Program for a patient who was in the New Jersey Prison System. The Medical Director of the New Jersey Department of Corrections called regarding a 39-year-old inmate who was being treated in a New Jersey hospital that has a unit for prisoners from a nearby cor- rectional facility. The referring physician described the patient to our Medical Director of heart transplantation as a “murderer” who had been incarcerated since 1987 and sentenced to (...) prison for 30 years without eligibility for parole before completion of his 30-year sentence. The patient was being treated in the CCU of the facility and according to preliminary studies, was suffering from a possible dilated cardiomyopathy. There was evidence of a prior cerebrovascular accident (etiology unknown) with a dense hemiplegia of the left side. The patient was alert but unable to care for himself. There were a number of specific tests necessary to evaluate the patient's candidacy for heart transplantation before actually placing him-on a waiting list. However, the transplant director was uncertain about having the patient brought to our facility for further testing and called some members of the Transplant Selection Committee team to discuss the case. (shrink)

D.T. a 35-year-old woman, was found to have breast cancer. At the time of mastectomy axillary lymph nodes were positive and the cancer was classified as adenocarcinoma, grade 4. The patient underwent conventional chemotherapy. When it became apparent the disease was metastatic, the patient's oncologist contacted a well-known cancer center regarding the possibility of treating the patient with high dose chemotherapy and autologous bone marrow transplantation. The patient's health insurance provider informed the patient, however, that the treatment—estimated to cost in (...) the range of $150,000–200,000—was “considered experimental or research in nature” and therefore was not included in coverage. D.T. did not pursue this further. Approximately 2 years later, cancer was detected in the patient's spine. This time she applied to another well-known cancer center for HDC/ABMT. The cancer center agreed to accept her on the condition of proof of ability to pay for the treatment. Again her insurer refused coverage on the same grounds as before. D.T. found another source for the money, underwent treatment, then sued the insurance carrier. She sought a declaratory judgment that the treatment was covered under the insurance policy. The court ruled in favor of D.T. finding the contract phrase “considered experimental” ambiguous. (shrink)

Two recent policy statements by providers of critical care representing the United States and Europe have rejected the concept and language of “medical futility,” on the ground that there is no universal consensus on a definition. They recommend using “potentially inappropriate” or “inappropriate” instead. As Bosslet and colleagues state: The term “potentially inappropriate” should be used, rather than futile, to describe treatments that have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing (...) ethical considerations justify not providing them. Clinicians should explain and advocate for the treatment plan... (shrink)

This paper critically assesses John Danaher’s ‘ethical behaviourism’, a theory on how the moral status of robots should be determined. The basic idea of this theory is that a robot’s moral status is determined decisively on the basis of its observable behaviour. If it behaves sufficiently similar to some entity that has moral status, such as a human or an animal, then we should ascribe the same moral status to the robot as we do to this human or animal. The (...) paper argues against ethical behaviourism by making four main points. First, it is argued that the strongest version of ethical behaviourism understands the theory as relying on inferences to the best explanation when inferring moral status. Second, as a consequence, ethical behaviourism cannot stick with merely looking at the robot’s behaviour, while remaining neutral with regard to the difficult question of which property grounds moral status. Third, not only behavioural evidence ought to play a role in inferring a robot’s moral status, but knowledge of the design process of the robot and of its designer’s intention ought to be taken into account as well. Fourth, knowledge of a robot’s ontology and how that relates to human biology often is epistemically relevant for inferring moral status as well. The paper closes with some concluding observations. (shrink)

In this introductory textbook to Kant's Critique of Pure Reason, Jill Vance Buroker explains the role of this first Critique in Kant's Critical project and offers a line-by-line reading of the major arguments in the text. She situates Kant's views in relation both to his predecessors and to contemporary debates, explaining his Critical philosophy as a response to the failure of rationalism and the challenge of skepticism. Paying special attention to Kant's notoriously difficult vocabulary, she explains the strengths and (...) weaknesses of his arguments, while leaving the final assessment up to the reader. Intended to be read alongside the Critique, this guide is accessible to readers with little background in the history of philosophy, but should also be a valuable resource for more advanced students. (shrink)

Regina R. is a 12-year-old girl with recently diagnosed insulin-dependent diabetes. Before discharging her from the hospital, her family physician and consulting diabetes specialist try to instruct the girl and her parents in the appropriate program of treatment, including diet, insulin, and regular self-monitoring. However, the parents become upset when they learn what is involved in insulin treatment and inform the family physician they plan to employ the services of an alternative healing clinic that promises to cure their daughter with (...) a combination of herbal potions, macrobiotics, aroma therapy, therapeutic touch, Ayurveda, homeopathy, and guided imagery. (shrink)

Jill North offers answers to questions at the heart of the project of interpreting physics. How do we figure out the nature of the world from a mathematically formulated theory? What do we infer about the world when a physical theory can be mathematically formulated in different ways? The notion of structure is crucial to North's answers.

In Wrong Medicine, Lawrence J. Schneiderman, M.D., and Nancy S. Jecker, Ph.D., address issues that have occupied the media and the courts since the time of Karen Ann Quinlan. The authors examine the ethics of cases in which medical treatment is offered--or mandated--even if a patient lacks the capacity to appreciate its benefit or if the treatment will still leave a patient totally dependent on intensive medical care. In exploring these timely issues Schneiderman and Jecker reexamine the doctor-patient (...) relationship and call for a restoration of common sense and reality to what we expect from medicine. They discuss economic, historical, and demographic factors that affect medical care and offer clear definitions of what constitutes futile medical treatment. And they address such topics as the limits on unwanted treatment, the shift from the "Age of Physician Paternalism" to the "Age of Patient Autonomy," health care rationing, and the adoption of new ethical standards. (shrink)

Book reviewed in this article: Wrong Medicine. By Lawrence J. Schneiderman and Nancy S. Jecker.

Plato's entire fictive world is permeated with philosophical concern for Eros, well beyond the so-called erotic dialogues. Several metaphysical, epistemological and cosmological conversations - Timaeus, Cratylus, Parmenides, Theaetetus and Phaedo - demonstrate that Eros lies at the root of the human condition and that properly guided Eros is the essence of a life well lived. This book presents a holistic vision of Eros, beginning with the presence of Eros at the origin of the cosmos and the human soul, surveying four (...) types of human self-cultivation aimed at good guidance of Eros and concluding with human death as a return to our origins. The book challenges conventional wisdom regarding the 'erotic dialogues' and demonstrates that Plato's world is erotic from beginning to end: the human soul is primordially erotic and the well-cultivated erotic soul can best remember and return to its origins, its lifelong erotic desire. (shrink)

Inspired by Jill Kraye's many contributions to European intellectual history, this volume presents a diverse collection of studies in Renaissance philosophy and humanism by leading experts in the field.

In her Dinny Gordon series (1958–1965), junior novelist Anne Emery’s heroine manifests intellectual desire, a passionate engagement in the life of the mind along with the desire to connect with like-minded others. Within a genre which focused on socialization and dating, in Dinny, Emery normalizes a studious, inner-directed, yet feminine heroine, passionate about ancient history rather than football captains. Emery’s endorsement of the pleasure Dinny takes in intellectual work, and the friends and boyfriends Dinny collects, challenge stereotypes of intellectual girls (...) as dateless isolates while suggesting an alternative model of girlhood operating within apparent conformism to postwar “good girl” standards. (shrink)

Prologue: learning to read -- Reading Plato -- Poetry: the measure of truth -- A life without poetry -- The power of persuasion -- Eros: the work of desire -- Dialectics: making sense of logos -- Epilogue: poetic justice.

I argue that the fundamental space of a quantum mechanical world is the wavefunction's space. I argue for this using some very general principles that guide our inferences to the fundamental nature of a world, for any fundamental physical theory. I suggest that ordinary three-dimensional space exists in such a world, but is non-fundamental; it emerges from the fundamental space of the wavefunction.

Book reviewed in this article: The Physician's Covenant: Images of the Healer in Medical Ethics. By William F. May.

Acknowledging the powerful impact that Plato's dialogues have had on readers, Jill Gordon shows how the literary techniques Plato used function philosophically to engage readers in doing philosophy and attracting them toward the philosophical life. The picture of philosophical activity emerging from the dialogues, as thus interpreted, is a complex process involving vision, insight, and emotion basic to the human condition rather than a resort to pure reason as an escape from it. Since the literary features of Plato's writing (...) are what draw the reader into philosophy, the book becomes an argument for the union of philosophy and literature—and against their disciplinary bifurcation—in the dialogues. Gordon construes the relationship of Plato's text to its audience as an analogue of Socrates' relationship with his interlocutors in the dialogues, seeing both as fundamentally dialectic. On this insight she builds her detailed analysis of specific literary devices in chapters on dramatic form, character development, irony, and image-making. In this way Gordon views Plato as not at all the enemy of the poets and image-makers that previous interpreters have depicted. Rather, Gordon concludes that Plato understands the power of words and images quite well. Since they, and not logico-deductive argumentation, are the appropriate means for engaging human beings, he uses them to great effect and with a sensitive understanding of human psychology, wary of their possible corrupting influences but ultimately willing to harness their power for philosophical ends. (shrink)

This essay interprets Hannah Arendt’s concept of the “social question” through a reading of her controversial essay “Reflections on Little Rock.” I argue that Arendt’s social question refers to social climbing and not simply poverty, as she initially suggests. The social-climbing framework illuminates “Little Rock” in two ways. First, it explains why Arendt opposed mandatory school desegregation, which she saw as black social climbing, that is, African American citizens and the NAACP using the US courts and federal government to raise (...) the status of African Americans to the level of whites. Second, and more significant, it provides a framework for criticizing “Little Rock” with Arendt’s own standards and criteria in mind. Reminded by Arendt of the suspect politics of social climbing, we can see something she did not: segregation was not “natural” association but an institution established after the Civil War to protect white social climbing and social advancement. (shrink)

Jacopo Baboni Schilingi’s interactive musical compositions Argo and Terra play with time, space, and material sound to capture a symbiotic relationship between technology and the most intimate process fundamental to life: breathing. Argo reacts to the artist’s respiration in “real time,” generating an “infinite” sequence of diverse musical arrangements that question the relation between the human body and technology and contingency and programming. Noting the egotistical tendencies of artists, Schilingi likens himself to Odysseus, the master of Argo, the name given (...) to his faithful technological invention. This theme of mastery is revisited in Terra where Schilingi’s hands, covered in sensors, manipulate both the musical composition and the dance movements of a female body, a body whose fertile tension both emerges and withdraws in a battle akin to Heidegger’s earth/world strife. This chapter provides a hermeneutic reading of Argo and Terra within a Heideggerian framework that does not, as Luce Irigaray has noted, forget air. Irigaray states, “Air does not show itself. As such, it escapes as (a) being. It allows itself to be forgotten.” Schilingi’s generative music makes air visible and hauntingly audible, as the music can only be stopped when the artist’s life comes to an end. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:A New Graduate Nurse’s StoryJill MountI was taking pre–med courses on the west coast when my mother was diagnosed with acute leukemia. I immediately finished out my classes, packed up my bags and cat and moved back to the town on the east coast where my parents lived. While my mother was fighting the leukemia, I spent many hours in her hospital room and I learned more about the (...) roles of doctors and nurses. Unlike what I had seen on television, where the doctors were always nearby and available to their patients, my mother’s doctors were seldom present. It was the nurses who spent the most time with my mother in the hospital. I wanted to care and be present for my patients like her nurses. So I decided to become a nurse. I didn’t realize that not all cancer units were like my mother’s where the nurses had time to really care for their patients.My mother’s attending doctor would visit her bedside once a day. The doctor would generally stand a few feet away from the foot of my mother’s bed and describe my mother’s latest blood counts. The doctor always seemed to keep her distance at the foot of the bed. As my mother’s series of chemotherapy treatments failed to put her in remission, the doctor would describe the next chemotherapy protocol that my mother would endure. My mother wanted desperately to live and she would keep copies of the blood counts her doctor provided her and would insist on trying the next round of chemotherapy, despite the list of grim side effects each seemed to come with. The doctor generally stayed an average of five minutes during these visits.My mother’s nurses, however, were a constant presence. I had not realized at the time that people are hospitalized primarily for nursing care. My mother was assigned several great nurses, who not only took her vital signs and administered her medications, but who seemed to care about her as a person as well. The nurses seemed to understand how difficult it was for my mother, a very independent person, not to have control over her health. To help her regain control, they provided her with guided visualizations. This was during the mid–eighties so they had her visualize her immune system as Pac–man eating all the cancer cells. My mother liked this because when she did the Pac– man visualizations, she felt she had some control directing her immune system to fight the disease.The nurses also provided my mother with emotional support. We were not a very physically affectionate family and the nurses encouraged us to give my mother hugs when she was not at risk for infections. They also gave her lots of back rubs. One of the nurses gave my mother a relaxation audiotape, which she listened to for hours, others provided her with poetry books. I believe it was partly the nurses’ physical and emotional care that enabled my mother to live as long and to fight the cancer for as long as she did. During the course of my mother’s illness, she received five rounds of chemotherapy over a period of ten months. Unfortunately her efforts to combat the cancer were unsuccessful and she died of complications of the disease and from the cumulative toxic side effects of the chemotherapy.After observing all the ways the nurses cared for my mother, I decided this was what I wanted to do and I decided to go to nursing school instead of medical school. I was able to apply my pre–med prerequisite courses to an accelerated nursing program [End Page E16] and I graduated with my bachelors in nursing after 18 months of nursing school.My nursing program emphasized the importance of viewing the patient as a whole person and not merely viewing them in terms of a particular disease or condition. Nursing school also reinforced how important nurse caring was for patients. I remember one of our exam questions focused on caring. The question was about a nurse walking into a patient’s room and finding the patient... (shrink)

One of the explicit goals of the 1996 welfare reform in the United States was to create conditions that would encourage marriage as a means of reducing poverty and welfare “dependency.” With the exception of a few notable studies that examine reliance on abusive partners and former partners, relatively little scholarly attention has been given to the contours of partnering after welfare reform. Using a feminist lens on data from two qualitative studies, the author examines the partnership experiences of a (...) sample of mostly white women three to four years after they had left welfare. An exploration of women’s views of their transitions into and their experiences with partnering reveals that women align with a logic of heterosexual partnering that holds the potential to complicate their lives. The analysis sounds a precautionary note and provides empirical evidence that partnering in the context of the reduced options of welfare reform can diminish women’s long-term stability and that encouraging partnering is, ultimately, an unsustainable policy direction for the support of lone mothers. (shrink)

Freedom of religious expression is to many a fundamental element of their identity. Yet the jurisprudence of the European Court of Human Rights on the Islamic headscarf issue does not refer to autonomy and identity rights of the individual women claimants. The case law focuses on Article 9 of the European Convention on Human Rights, which provides a legal human right to freedom of religious expression. The way that provision is interpreted is critically contrasted here with the right to personal (...) autonomy and identity now developed by that court in interpreting Article 8 which contains a right to respect one’s private life. (shrink)