Machine intelligence already helps medical staff with a number of tasks. Ethical decision-making, however, has not been handed over to computers. In this proof-of-concept study, we show how an algorithm based on Beauchamp and Childress’ prima-facie principles could be employed to advise on a range of moral dilemma situations that occur in medical institutions. We explain why we chose fuzzy cognitive maps to set up the advisory system and how we utilized machine learning to train it. We report on the (...) difficult task of operationalizing the principles of beneficence, non-maleficence and patient autonomy, and describe how we selected suitable input parameters that we extracted from a training dataset of clinical cases. The first performance results are promising, but an algorithmic approach to ethics also comes with several weaknesses and limitations. Should one really entrust the sensitive domain of clinical ethics to machine intelligence? (shrink)

Good physical experiments conform to the basic methodological standards of experimental design: they are objective, reliable, and valid. But is this also true of thought experiments? Especially problems of personal identity have engendered hypothetical scenarios that are very distant from the actual world. These imagined situations have been conspicuously ineffective at resolving conflicting intuitions and deciding between the different accounts of personal identity. Using prominent examples from the literature, I argue that this is due to many of these thought experiments (...) not adhering to the methodological standards that guide experimental design in nearly all other disciplines. I also show how empirically unwarranted background assumptions about human physiology render some of the hypothetical scenarios that are employed in the debate about personal identity highly misleading. (shrink)

abstractBy appealing to the similarity between pre-vital and post-mortem nonexistence, Lucretius famously tried to show that our anxiety about death was irrational. His so-called Symmetry Argument has been attacked in various ways, but all of these strategies are themselves problematic. In this paper, I propose a new approach to undermining the argument: when Parfit’s distinction between identity and what matters is applied, not diachronically but across possible worlds, the alleged symmetry can be broken. Although the pre-vital and posthumous time spans (...) that we could have experienced are indeed analogous with respect to our identity, they are not analogous with respect to psychological continuity, which forms the basis of prudential concern. Lucretius even anticipated the Parfitian distinction. He did not, however, notice the significance that it has for his Symmetry Argument. (shrink)

Lockean views of personal identity maintain that we are essentially persons who persist diachronically by virtue of being psychologically continuous with our former selves. In this article, I present a novel objection to this variant of psychological accounts, which is based on neurophysiological characteristics of the brain. While the mental states that constitute said psychological continuity reside in the cerebral hemispheres, so that for the former to persist only the upper brain must remain intact, being conscious additionally requires that a (...) structure originating in the brainstem—the ascending reticular activating system—be functional. Hence, there can be situations in which even small brainstem lesions render individuals irreversibly comatose and thus forever preclude access to their mental states, while the neural correlates of the states themselves are retained. In these situations, Lockeans are forced to regard as fulfilled their criterion of diachronic persistence since psychological continuity, as they construe it, is not disrupted. Deeming an entity that is never again going to have any mental experiences to be a person, however, is an untenable position for a psychological account to adopt. In their current form, Lockean views of personal identity are therefore incompatible with human neurophysiology. (shrink)

The COVID-19 pandemic has been overwhelming public health-care systems around the world. With demand exceeding the availability of medical resources in several regions, hospitals have been forced to invoke triage. To ensure that this difficult task proceeds in a fair and organised manner, governments scrambled experts to draft triage guidelines under enormous time pressure. Although there are similarities between the documents, they vary considerably in how much weight their respective authors place on the different criteria that they propose. Since most (...) of the recommendations do not come with ethical justifications, analysing them requires that one traces back these criteria to their underlying theories of distributive justice. In the literature, COVID-19 triage has been portrayed as a value conflict solely between utilitarian and egalitarian elements. While these two accounts are indeed the main antipodes, I shall show that in fact all four classic theories of distributive justice are involved: utilitarianism, egalitarianism, libertarianism, and communitarianism. Detecting these in the documents and classifying the suggested criteria accordingly enables one to understand the balancing between the different approaches to distributive justice—which is crucial for both managing the current pandemic and in preparation for the next global health crisis. (shrink)

Fifty years have passed since brain death was first proposed as a criterion of death. Its advocates believe that with the destruction of the brain, integrated functioning ceases irreversibly, somatic unity dissolves, and the organism turns into a corpse. In this article, I put forward two objections against this assertion. First, I draw parallels between brain death and other pathological conditions and argue that whenever one regards the absence or the artificial replacement of a certain function in these pathological conditions (...) as compatible with organismic unity, then one equally ought to tolerate that function’s loss or replacement in brain death. Second, I show that the neurological criterion faces an additional problem that is only coming to light as life-supporting technology improves: the growing sophistication of the latter gives rise to a dangerous decoupling of the actual performance of a vital function from the retention of neurological control over it. Half a century after its introduction, the neurological criterion is facing the same fate as its cardiopulmonary predecessor. (shrink)

Although machine intelligence is increasingly employed in healthcare, the realm of decision-making in medical ethics remains largely unexplored from a technical perspective. We propose an approach based on fuzzy cognitive maps (FCMs), which builds on Beauchamp and Childress’ prima-facie principles. The FCM’s weights are optimized using a genetic algorithm to provide recommendations regarding the initiation, continuation, or withdrawal of medical treatment. The resulting model approximates the answers provided by our team of medical ethicists fairly well and offers a high degree (...) of interpretability. Possible applications of such a system include informal guidance on medical ethics dilemmas as well as educational purposes. (shrink)

When an individual is comatose while parts of her brain remain functional, the question arises as to whether any mental characteristics are still associated with this brain, that is, whether the person still exists. Settling this uncertainty requires that one becomes clear about two issues: the type of functional loss that is associated with the respective profile of brain damage and the persistence conditions of persons. Medical case studies can answer the former question, but they are not concerned with the (...) latter. Conversely, in the philosophical literature, various accounts of personal identity are discussed, but usually detached from any empirical basis. Only uniting the two debates and interpreting the real-life configurations of brain damage through the lens of the philosophical concepts enables one to make an informed judgment regarding the persistence of comatose persons. Especially challenging are cases in which three mental characteristics that normally occur together—wakefulness, awareness and memory storage—come apart. These shall be the focus of this paper. (shrink)

Can machine intelligence do clinical ethics? And if so, would applying it to actual medical cases be desirable? In a recent target article (Meier et al. 2022), we described the piloting of our advisory algorithm METHAD. Here, we reply to commentaries published in response to our project. The commentaries fall into two broad categories: concrete criticism that concerns the development of METHAD; and the more general question as to whether one should employ decision-support systems of this kind—the debate we set (...) out to ignite with our target article. (shrink)

In their Target Article, Rahimzadeh et al. (2023) discuss the virtues and vices of employing ChatGPT in ethics education for healthcare professionals. To this end, they confront the chatbot with a moral dilemma and analyse its response. In interpreting the case, ChatGPT relies on Beauchamp and Childress’ four prima-facie principles: beneficence, non-maleficence, respect for patient autonomy, and justice. While the chatbot’s output appears admirable at first sight, it is worth taking a closer look: ChatGPT not only misses the point when (...) applying the principle of non-maleficence; its response also fails, in several places, to honour patient autonomy – a flaw that should be taken seriously if large language models are to be employed in ethics education. I therefore subject ChatGPT’s reply to detailed scrutiny and point out where it went astray. (shrink)

When does a human being cease to exist? For millennia, the answer to this question had remained largely unchanged: death had been diagnosed when heartbeat and breathing were permanently absent. Only comparatively recently, in the 1950s, rapid developments in intensive-care medicine called into question this widely accepted criterion. What had previously been deemed a permanent cessation of vital functions suddenly became reversible. -/- A new criterion of death was needed. It was suggested that the destruction of the brain could indicate (...) the death of the organism in the presence of external life support. Soon the so-called brain death became the new worldwide standard. In recent years, however, doubts about this neurological criterion have been growing. Is brain death really our death? -/- This is the question that this thesis seeks to answer. To this end, we shall connect the medical debate about the definition of death to the philosophical debate about personal identity. While we will find that the destruction of its brain does in fact not correspond to an organism’s death, we shall also ask whether the assumption that we are essentially organisms is correct. May brain death be the ceasing to exist of a different entity? -/- Substituting clinical case reports and considerations about human physiology for the use of thought experiments, the thesis takes a novel and philosophically unconventional approach to the problem of what we essentially are. We shall analyse various pathological conditions and their respective effects on the bodily and mental characteristics of our existence. We will conclude that brain death is indeed our death – but for reasons entirely different from those cited in the original justification of this criterion. (shrink)

-/- Zuk et al. (2023) examined researchers’ views on how deep brain stimulation may impact patients’ personality, mood, and behaviour (PMB). The team found that experts vary substantially in the notion of personality they employ. However, despite noting the lack of conceptual precision, no attempt was made at scientifically defining any of the involved concepts, so that the results of the different interviews remain largely incommensurable. In this comment, I am doing the interpretative work that the authors should have undertaken (...) following the descriptive part of the paper: first, disentangling the PMB cluster by defining what exactly constitutes personality, mood, and behaviour; and secondly, conceptualising the notion of personality change. I am arguing that what sets personality changes apart from other modifications is diachronic persistence. (shrink)

For hundreds of years, death had been defined by cardiopulmonary criteria. When heart and respiratory functions were permanently absent, doctors declared their patients dead. Three developments in intensive care medicine called into question these widely-accepted criteria, however: the advent of positive pressure ventilation and the promotion of cardiopulmonary resuscitation, both in the early 1950s, and the first successful heart transplantation in 1967. What had previously been diagnosed as the permanent absence of vital functions, suddenly became reversible. Not only could doctors (...) replace a defective heart with a functioning transplant; patients could also be kept oxygenated in the total absence of spontaneous respiratory function. The traditional boundaries between life and death became blurred. Patients for whom there was not the remotest possibility of regaining consciousness following massive brain damage continued to consume valuable medical resources. Moreover, their organs could not be procured for transplantation. Were those patients still alive or could the ventilators be switched off? A criterion suited to indicate a patient’s death despite the provision of external life support was needed. In 1968 an ad hoc committee of the Harvard Medical School published the first comprehensive definition of what would soon become the new clinical standard: brain death. The brain bears a special relation to other organs; it directs bodily functions without carrying them out. When the brain is destroyed, it was argued, this control mechanism is irreversibly dysfunctional, so that the organism becomes unable to maintain its vital functions, loses its somatic unity and, consequently, ceases to exist. This neurological criterion has been controversial ever since its introduction. Whether brain death is indeed death is what I shall be investigating in this thesis. I will be asking three main questions: What are we? Is brain death the death of an organism? Is brain death the death of a psychological being? The question of personal identity and the question of the appropriate definition of death are intimately related. Only when we have determined what kind of entity we essentially are can we specify what conditions must apply for this entity to persist or to cease to exist. I shall argue that we are essentially psychological beings, which entails that our death is distinct from the death of our organisms. Hence, we need two different criteria – one for the death of each entity. I shall try to establish whether brainstem death and whole-brain death correspond to the irreversible cessation of organismic functioning. I will then determine by which criterion the death of a psychological being can be diagnosed. (shrink)

During the COVID‐19 pandemic, national triage guidelines were developed to address the anticipated shortage of life‐saving resources, should ICU capacities be overloaded. Rationing and triage imply that in addition to individual patient interests, interests of population health have to be integrated. The transfer of theoretical and empirical knowledge into feasible and useful practice models and their implementation in clinical settings need to be improved. This paper analyzes how triage protocols could translate abstract theories of distributive justice into concrete material and (...) procedural criteria for rationing intensive care resources during a pandemic. We reconstruct the development and implementation of a rationing protocol at a German university hospital: describing the ethical challenge of triage, clarifying the aspirational norms, and summarizing specific norms of fair triage and allocation for developing an institutional policy and practice model and implementing it. We reflect on how critical topics are seen by clinicians and what helped manage the perceived burdens of the triage dilemma. We analyze what can be learned from this debate regarding the difficult issues around triage protocols and their potential implementation into clinical settings. Analyzing the ought‐to‐is gap of triage, integrating abstract ethical principles into practical concepts, and evaluating those should clarify the benefits and risks of different allocation options. We seek to inform debates on triage concepts and policies to ensure the best possible treatment and fair allocation of resources as well as to help protect patients and professionals in worst‐case scenarios. (shrink)