Innovative surgery raises four kinds of ethical challenges: potential harms to patients; compromised informed consent; unfair allocation of healthcare resources; and conflicts of interest. Lack of adequate data on innovations and lack of regulatory oversight contribute to these ethical challenges. In this paper these issues and the extent to which problems may be resolved by better evidence-gathering and more comprehensive regulation are explored. It is suggested that some ethical issues will be more resistant to resolution than others, owing to special (...) features of both surgery and innovation. (shrink)

Financial and nonfinancial conflicts of interest in medicine and surgery are troubling because they have the capacity to skew decision making in ways that might be detrimental to patient care and well-being. The recent case of the Articular Surface Replacement (ASR) hip provides a vivid illustration of the harmful effects of conflicts of interest in surgery.

The development and deployment of medical devices, along with most areas of healthcare, has been significantly impacted by the COVID-19 pandemic. This has had variable ethical implications, two of which we will focus on here. First, medical device regulations have been rapidly amended to expedite approvals of devices ranging from face masks to ventilators. Although some regulators have issued cessation dates, there is inadequate discussion of triggers for exiting these crisis standards, and evidence that this may not be feasible. Given (...) the relatively low evidence standards currently required for regulatory approval of devices, this further indefinite reduction in standards raises serious ethical issues. Second, the pandemic has disrupted the usual operations of device representatives in hospitals, providing an opportunity to examine and refine this potentially ethically problematic practice. In this paper we explain and critically analyse the ethical implications of these two pandemic-related impacts on medical devices and propose suggestions for their management. These include an endpoint for pandemic-related adjustments to device regulation or a mechanism for continued refinement over time, together with a review of device research conducted under crisis conditions, support for the removal and replacement of emergency approved devices, and a review of device representative credentialling. (shrink)

Traditionally, physicians and parents made decisions about children’s health care based on western practices. More recently, with legal and ethical development of informed consent and recognition for decision making, children are becoming active participants in their care. The extent to which this is happening is however blurred by lack of clarity about what children — of diverse levels of cognitive development — are capable of understanding. Moreover, when there are multiple surrogate decision makers, parental and professional conflict can arise concerning (...) children’s ‘best interest’. Giving children a voice and offering choice promotes their dignity and quality of life. Nevertheless, it also presents with many challenges. Case studies using pseudonyms and changed situational identities are used in this article to illuminate the complexity of ethical challenges facing nurses in end-of-life care with children and families. (shrink)

A care deficit is clearly evident in global cities such as London and is attributable to an ageing population, the increased employment of native-born women, prevalent gender ideologies that continue to exempt men from much reproductive work, as well as the failure of the state to provide viable alternatives. However, while it is now acknowledged that migrant women, and to a lesser extent, migrant men, step in to provide care in cities such as London, there is less research on how (...) this shapes the nature, politics and ethics of care. Drawing upon empirical research with low-paid migrant workers employed as domiciliary care providers in London, this paper explores the emergence of a distinct migrant ethic of care that is critically shaped by the caring work that migrant women and men perform. (shrink)

Volume 19, Issue 6, June 2019, Page 28-29.

In this paper we argue that surgeons face a particular kind of within-role conflict of interests, related to innovation. Within-role conflicts occur when the conflicting interests are both legitimate goals of professional activity. Innovation is an integral part of surgical practice but can create within-role conflicts of interest when innovation compromises patient care in various ways, such as by extending indications for innovative procedures or by failures of informed consent. The standard remedies for conflicts of interest are transparency and recusal, (...) which are unlikely to address this conflict, in part because of unconscious bias. Alternative systemic measures may be more effective, but these require changes in the culture of surgery and accurate identification of surgical innovation. (shrink)

Buddhisms and Deconstructions considers the connection between Buddhism and Derridean deconstruction, focusing on the work of Robert Magliola. Fourteen distinguished contributors discuss deconstruction and various Buddhisms—Indian, Tibetan, and Chinese —followed by an afterword in which Magliola responds directly to his critics.

In lieu of an abstract, here is a brief excerpt of the content:The Right Thing to DoJane RogersIn stark contrast to getting my graduate degree in bioethics in which I discovered that I am inclined to favor an ethics based on my religious beliefs, in nursing school I learned that I had to take my religion out of nursing care. As a bioethics student, I read in my textbook, Bioethics: A Systematic Approach, that “… just because an action is rationally (...) allowed does not mean that everyone agrees one ought to act in that way.” Yet often in nursing I found that we nurses knew what was best for our patients, even if they did not. At least, we believed that we did. This general paternalistic belief spread into every area of the care we gave except for one, and that was religion. [End Page 208]As student nurses, we learned to separate our religion from our care to focus on the patient’s religion or spiritual needs. Our patients should never know of our religious beliefs or even if we had a lack of them. We needed to be completely neutral on all religious issues and focus solely on the patient’s preference. If our patients needed spiritual care, we would find someone to provide it and we would incorporate it into the nursing plan of care. Providing care of the whole patient including their religious needs was the definition of a good nurse. Certainly I wanted to be a good nurse, so I swore I would always include the spiritual needs of my patients as part of my care, while never expressing my own.As fate would have it, as a new nurse I found myself overwhelmed running around just trying to give medications, admit and discharge patients, start IV’s, insert catheters, note doctor’s orders and get my charting done. My time was engaged in trying to calm confused and combative patients, running to grab an emesis basin for a patient to throw up in or answering the phone, so thinking about religion or spiritual care for my patients most of the time amounted to “God help me and my patients get through this shift.” My goal of being a good nurse was starting to look dismal as I realized I had no idea if I could find the time or means and ways to incorporate religion into the care I gave, or if it even mattered if I did.Fortuitously for me, most of my patients never mentioned religion, although at times they did leave some nonverbal clues. I could see a rosary laying on a bedside table or a bible or prayer book next to them in bed. While I would make sure their religious item was always within reach, I remained respectful yet distant in religious matters, never offering any spiritual care or assistance. I was quite accepting of my first Mormon patient wearing the garment under the traditional hospital gown. I was appalled when an unconscious Jehovah Witness patient was nearly given blood. When a minister or priest came to visit, I’d excuse myself quickly so that the work of their God could do what I could not or should not do. Occasionally I was asked by family members to call in a minister or a priest or chaplain and I did that with a great feeling of satisfaction as I was surely providing the spiritual care they requested.Eventually however I did start to indulge in highly spontaneous and random acts of religion. These were always done secretly. The patient or family must never know. Thinking it would help I once covertly gave a patient a special rosary I had with Lourdes water in it thinking it might heal him. I waited to see a miracle. It never came. Despite the absence of that miracle I was still hopeful that perhaps my prayers or another rosary could heal or at least help some of my patients. After all, as a nurse I witnessed lots of healings that astounded me. People I never thought would get better sometimes did anyway.Although I was cognizant that some healing was the direct result of superb medical intervention and excellent nursing care, there were always... (shrink)

Transnational food retailers expanded to middle-income countries over recent decades responding to supply and demand. Control in new markets diffuses along three axes: socio-economic, geographic, and product category. We used a mixed method approach to study the progression of modern retail in Thailand on these three axes and consumer preferences for food retailing. In Thailand modern retail controls half the food sales but traditional fresh markets remain important. Quantitative questionnaires administered to members of a large national cohort study revealed around (...) half of respondents were primarily traditional shoppers and half either utilized modern and traditional formats equally or primarily shopped at supermarkets. Fresh foods were mainly purchased at traditional retail formats and dry packaged foods at supermarkets. Qualitative interviews found price and quality of produce and availability of culturally important products to be significant reasons for continued support of fresh markets. Our results show socio-economic and geographic diffusion is already advanced with most respondents having access to and utilizing modern retail. Control of the fresh food sector by transnationals faces barriers in Thailand and may remain elusive. The short to mid-term outcome may be a bifurcated food system with modern and traditional retail each retaining market share, but fresh markets longer term survival may require government assistance as supermarkets become more established. Fresh markets supply affordable, healthy foods, and livelihoods for poorer Thais and are repositories of Thai food culture and social networks. If they survive they will confer cultural, social, economic, and health benefits. (shrink)

Despite concerns about the relationships between health professionals and the medical device industry, the issue has received relatively little attention. Prevalence data are lacking; however, qualitative and survey research suggest device industry representatives, who are commonly present in clinical settings, play a key role in these relationships. Representatives, who are technical product specialists and not necessarily medically trained, may attend surgeries on a daily basis and be available to health professionals 24 hours a day, 7 days a week, to provide (...) advice. However, device representatives have a dual role: functioning as commissioned sales representatives at the same time as providing advice on approaches to treatment. This duality raises the concern that clinical decision-making may be unduly influenced by commercial imperatives. In this paper, we identify three key ethical concerns raised by the relationship between device representatives and health professionals: impacts on healthcare costs, the outsourcing of expertise and issues of accountability and informed consent. These ethical concerns can be addressed in part through clarifying the boundary between the support and sales aspects of the roles of device representatives and developing clear guidelines for device representatives providing support in clinical spaces. We suggest several policy options including hospital provision of expert support, formalising clinician conduct to eschew receipt of meals and payments from industry and establishing device registries. (shrink)

Effective communication and interpersonal skills have long been recognized as fundamental to the delivery of quality health care. However, there is mounting evidence that the pressures of communication in high stress work areas such as hospital emergency departments present particular challenges to the delivery of quality care. A recent report on incident management in the Australian health care system cites the main cause of critical incidents, as being poor and inadequate communication between clinicians and patients. This article presents research that (...) describes and analyses spoken interactions between health care practitioners and patients in one ED of a large, public teaching hospital in Sydney, Australia. The research aimed to address the challenges and critical incidents caused by breakdowns in communication that occur between health practitioners and patients and by refining and extending knowledge of discourse structures, to identify ways in which health care practitioners can enhance their communicative practices thereby improving the quality of the patient journey through the ED. The research used a qualitative ethnographic approach combined with discourse analysis of audio-recorded interactions. Some key findings from the analysis of data are outlined including how the absence of information about processes, the pressure of time within the ED, divergent goals of clinicians and patients, the delivery of diagnoses and professional roles impact on patient experiences. Finally, the article presents an in-depth linguistic analysis on interpersonal and experiential patterns in the discursive practices of patients, nurses and doctors. (shrink)

Embryos, cells, genes, and organisms : reflections on the history of evolutionary developmental biology / Manfred D. Laubichler and Jane Maienschein The organismic systems approach : streamlining the naturalistic agenda / Werner Callebaut, Gerd B. Müller, and Stuart A. Newman Complex traits : genetics, development, and evolution / H. Frederik Nijhout Functional and developmental constraints on life-cycle evolution : an attempt on the architecture of constraints / Gerhard Schlosser Legacies of adaptive development / Roger Sansom Evo-devo meets the mind (...) : toward a developmental evolutionary psychology / Paul E. Griffiths Reproducing entrenchments to scaffold culture : the central role of development in cultural evolution / William C. Wimsatt and James R. Griesemer. (shrink)

Nineteenth‐ and twentieth‐century North Atlantic theology has seen a succession of Trinitarian revivals. Some observers take as an index of a theologian's success whether he or she has much interesting to say about the Holy Spirit, and some, including Robert Jenson, have also noted a tendency to announce the Spirit and talk about the Son. While Rogers shares that concern, he qualifies the characterization to note that authors in three traditions sometimes admit the charge and demur, claiming that is (...) how it should be, citing passages in Calvin, Rahner, and Pavel Florensky. Of these the boldest is Florensky, who anticipates Jenson's critique but, writing in 1913, makes it not of Barth but of Eastern Orthodox theology , even in its liturgy. Rogers leaves this puzzle unresolved. (shrink)

Americans have always been divided over whether to welcome or to discourage immigration. But virtually all American leaders have rested their views on notions that the United States has unique providential or world-historical significance-as an asylum for the world's oppressed, as a model to the world, or even as the world's leader. Today, it is normatively desirable for the U.S. to view itself not as the world's "city on a hill" but simply as one worthy political society among many others. (...) Whether such a view can be made politically appealing to most Americans, however, remains in doubt. (shrink)

An international legal agreement governing the global antimicrobial commons would represent the strongest commitment mechanism for achieving collective action on antimicrobial resistance (AMR). Since AMR has important similarities to climate change—both are common pool resource challenges that require massive, long-term political commitments—the first article in this special issue draws lessons from various climate agreements that could be applicable for developing a grand bargain on AMR. We consider the similarities and differences between the Paris Climate Agreement and current governance structures for (...) AMR, and identify the merits and challenges associated with different international forums for developing a long-term international agreement on AMR. To be effective, fair, and feasible, an enduring legal agreement on AMR will require a combination of universal, differentiated, and individualized requirements, nationally determined contributions that are regularly reviewed and ratcheted up in level of ambition, a regular independent scientific stocktake to support evidence informed policymaking, and a concrete global goal to rally support. (shrink)

Antimicrobial resistance (AMR) is an urgent threat to global public health and development. Mitigating this threat requires substantial short-term action on key AMR priorities. While international legal agreements are the strongest mechanism for ensuring collaboration among countries, negotiating new international agreements can be a slow process. In the second article in this special issue, we consider whether harnessing existing international legal agreements offers an opportunity to increase collective action on AMR goals in the short-term. We highlight ten AMR priorities and (...) several strategies for achieving these goals using existing “legal hooks” that draw on elements of international environmental, trade and health laws governing related matters that could be used as they exist or revised to include AMR. We also consider the institutional mandates of international authorities to highlight areas where additional steps could be taken on AMR without constitutional changes. Overall, we identify 37 possible mechanisms to strengthen AMR governance using the International Health Regulations, the Agreement on the Application of Sanitary and Phytosanitary Measures, the Agreement on Trade-Related Aspects of Intellectual Property Rights, the Agreement on Technical Barriers to Trade, the International Convention on the Harmonized Commodity Description and Coding System, and the Basel, Rotterdam, and Stockholm conventions. Although we identify many shorter-term opportunities for addressing AMR using existing legal hooks, none of these options are capable of comprehensively addressing all global governance challenges related to AMR, such that they should be pursued simultaneously with longer-term approaches including a dedicated international legal agreement on AMR. (shrink)

The revival of interest in pragmatism and its practical relevance for democracy has prompted a reconsideration of John Dewey’s political philosophy. Dewey’s _The Public and Its Problems _ constitutes his richest and most systematic meditation on the future of democracy in an age of mass communication, governmental bureaucracy, social complexity, and pluralism. Drawing on his previous writings and prefiguring his later thinking, Dewey argues for the importance of civic participation and clarifies the meaning and role of the state, the proper (...) relationship between the public and experts, and the source of democracy’s legitimacy. These themes remain as important today as they were when Dewey first engaged them, and this is the work to which scholars consistently turn when assessing Dewey’s conception of democracy and what might be imagined for democracy in our own time. In this carefully annotated edition, Melvin L. Rogers provides an introductory essay that elucidates the philosophical and historical background of _The Public and Its Problems_ while explaining the key ideas of the book. He also provides a biographical outline of Dewey’s life and bibliographical notes to assist student and scholar alike. (shrink)

_The Undiscovered Dewey_ explores the profound influence of evolution and its corresponding ideas of contingency and uncertainty on John Dewey's philosophy of action, particularly its argument that inquiry proceeds from the uncertainty of human activity. Dewey separated the meaningfulness of inquiry from a larger metaphysical story concerning the certainty of human progress. He then connected this thread to the way in which our reflective capacities aid us in improving our lives. Dewey therefore launched a new understanding of the modern self (...) that encouraged intervention in social and natural environments but which nonetheless demanded courage and humility because of the intimate relationship between action and uncertainty. Melvin L. Rogers explicitly connects Dewey's theory of inquiry to his religious, moral, and political philosophy. He argues that, contrary to common belief, Dewey sought a place for religious commitment within a democratic society sensitive to modern pluralism. Against those who regard Dewey as indifferent to moral conflict, Rogers points to Dewey's appreciation for the incommensurability of our ethical commitments. His deep respect for modern pluralism, argues Rogers, led Dewey to articulate a negotiation between experts and the public so that power did not lapse into domination. Exhibiting an abiding faith in the reflective and contestable character of inquiry, Dewey strongly engaged with the complexity of our religious, moral, and political lives. (shrink)

Élégamment écrit, l’ouvrage de Barbara Reeves-Ellington raconte une histoire de rencontres improbables entre protestantes américaines et habitant.e.s des Balkans ottomans au xixe siècle. À partir d’une série d’études de cas centrées sur la Bulgarie, avec un dernier chapitre où l’action se situe à Constantinople, l’historienne détaille le rôle des femmes dans l’action missionnaire et l’impact de leur action tant dans les Balkans qu’au sein du mouvement missionnaire aux États-Unis. Puisant dans...