This target article focuses on dynamics that arise in three typical ethically complex cases in which psychiatric consultations are requested by physicians: a dying patient refuses life-prolonging treatment, an uncooperative patient demands to be allowed to go outside and smoke, and an angry patient demands to be admitted to the hospital. The discussion canvasses what is at stake morally and clinically in each of these cases and explores clinician–patient interactions, dynamics in relationships between consulting physicians and consultant psychiatrists, patient transference, (...) and physician countertransference. The article defines legalism and countertransference and argues that an ethically and clinically important consequence of these phenomena for patients is distortion of clinicians' perceptions of patients' decisions and vulnerabilities. The discussion also describes how legalism and countertransference adversely affect how clinicians treat their psychiatrist colleagues. Finally, the article suggests how the effects of legalism and countertransference can be mitigated. (shrink)

Beginning with a discussion of why value neutrality on the part of the genetics counselor does not necessarily preserve autonomy of the counselee, the idea that social values unavoidably underlie the articulation of risks and benefits of genetic testing is made explicit. Despite the best efforts of a counselor to convey value neutral facts, risk assessment by the counselee and family is done according to normative analysis, experience with illness, and definitions of health. Each of these factors must be known (...) by the genetic counselor in order to relate those facts which she acknowledges as relevant to the decisions that will be made by those people seeking the genetic information. (shrink)

This essay describes an example of how we—one professor of the elective course Art, Medicine, and Clinical Moral Perception at Creighton University School of Medicine, one Director of Adult Programs at the Joslyn Museum of Art in Omaha, Nebraska, and fourth year medical students—practice perception skills using art objects. This essay presents one example of the journal assignments to which students respond in written narratives about their own perception habits. We also share questions any health professions educator can use to (...) guide students’ study of their habits of perception using art objects. (shrink)

The term "callous" has not, to this point, been studied empirically or considered philosophically in the context of healthcare professionalism. It should be, however, because its uses seem peculiar. Sometimes "callous" is used to suggest that becoming callous confers a benefit of some protection against emotional distress, which might be considered expedient in the healthcare work environment. But, "callous" also refers to a person's unappealing demeanor of hardened insensitivity. The tension between these different moral connotations of "callous" prompts several empirical, (...) psychological, and moral questions; I introduce and entertain a few here. I also suggest a distinction between callousness and inurement and argue for why this distinction is important to appreciate and uphold in health professions education. (shrink)

In an earlier edition of CambridgeQuarterly, in the section (CQ Vol 9, No 4), Larry Gottlieb sought advice on ethics committee assembly and policy implementation for a community mental health center. One concern mentioned is that staff members frequently encounter ethical issuesregarding the care of clients whose decisionmaking abilities are impaired by chronic mental illness and/or substance abuse. My response offers a suggestion for policy development and implementation, which may be integrated into guiding staff members of community mental health centers (...) toward a model of care planning that is centered on clients' experiences of their treatments and on relationship-building among clients, community members, and mental health professionals. (shrink)

In this paper, we explore best practices for asynchronous discussions in graduate online bioethics education. We explain that online approaches have advantages and challenges in contrast to in-person discussions. Online challenges are lack of visual or auditory cues and technical access. Advantages include extended opportunities for specific focus, thoughtful reflection, and critical review. We found no significant review of related best practices in bioethics. Our more general literature review of graduate education and online approaches, plus experience in our own bioethics (...) graduate program, suggest provisional best practices that we detail. We reason that online graduate discussion provisionally should aim for a “community of inquiry” framework that incorporates cognitive, social, and teaching “presences,” as well as a learning presence. However, we also note unresolved concerns about whether the framework sufficiently addresses learning, is complete, and captures communicative functions. Drawing further on the literature, we also suggest best practices for instructor feedback to students about their discussion performance, including that remarks should be timely and specific. Summaries from two courses in our graduate bioethics program illustrate how we implement discussion strategies. Finally, we review assessment strategies and suggest that embedded formative assessments in discussion support and demonstrate deeper learning. Limitations in generalizability include that our review targets asynchronous and text-based online discussion, our program assessments do not necessarily detail best practices, student expectations and approaches could be rather particular to our program, and specific bioethics content in principle could alter best practices. (shrink)

The distinction between the Bible as literature and the Bible as scripture is largely artificial. The church can properly hear its Bible as scripture only when it reads it as literature.

Background Intestinal transplant in infants with severe short bowel syndrome (SBS) is an emerging therapy, yet without sufficient long-term data or established guidelines, resulting in possible variation in practice. Objectives To assess current attitudes and counselling practices among physicians regarding intestinal transplant in infants with SBS, and to determine whether counselling and management vary between subspecialists or centres. Methods A national sample of practicing paediatric surgeons and neonatologists was surveyed via the American Academy of Paediatrics listserves. Results were analysed by (...) physician subspecialty and again by presence or absence of intestinal transplant at respondent's centre. Results The survey was completed by 433 respondents, consisting of 363 neonatologists and 70 paediatric surgeons. Fifty-seven respondents (13.2%) practiced at a centre that performed intestinal transplants in children. The vast majority of respondents (91% for preterm, 95% for term neonates) felt that maintaining a neonate with SBS on total parenteral nutrition for intestinal transplant was ethically optional (neither impermissible nor obligatory), and that parents should be given an informed choice whether to pursue that option. However, only 33% indicated they often/always offer intestinal transplant as a treatment option to families in this situation. Conclusions There is a marked disparity between individual physicians’ beliefs regarding the acceptability of intestinal transplant for severe SBS and their reported practice. Wide variability exists among physicians with respect to their knowledge, beliefs and practice regarding severe SBS, raising concerns about transparency and justice. Survival data prior to transplant, currently unavailable, are essential to rational decision making and informed parental permission. (shrink)

ABSTRACT Objective: To contrast relief efforts for the 26 December 2004 tsunami with current global HIV/aids relief efforts and analyse possible reasons for the disparity. Methods: Literature review and ethical analysis. Results: Just over 273,000 people died in the tsunami, resulting in relief efforts of more than US$10 bn, which is sufficient to achieve the United Nation’s long‐term recovery plan for South East Asia. In contrast, 14 times more people died from HIV/aids in 2004, with UNAIDS predicting a US$8 bn (...) funding gap for HIV/aids in developing nations between now and 2007. This disparity raises two important ethical questions. First, what is it that motivates a more empathic response to the victims of the tsunami than to those affected by HIV/AIDS? Second, is there a morally relevant difference between the two tragedies that justifies the difference in the international response? The principle of justice requires that two cases similarly situated be treated similarly. For the difference in the international response to the tsunami and HIV/aids to be justified, the tragedies have to be shown to be dissimilar in some relevant respect. Are the tragedies of the tsunami disaster and the HIV/aids pandemic sufficiently different, in relevant respects, to justify the difference in scope of the response by the international community? Conclusion: We detected no morally relevant distinction between the tsunami and the HIV/aids pandemic that justifies the disparity. Therefore, we must conclude that the international response to HIV/aids violates the fundamental principles of justice and fairness. (shrink)

Background Citizen science is increasingly prevalent in the biomedical sciences, including the field of human genomics. Genomic citizen science initiatives present new opportunities to engage individuals in scientific discovery, but they also are provoking new questions regarding who owns the outputs of the research, including intangible ideas and discoveries and tangible writings, tools, technologies, and products. The legal and ethical claims of participants to research outputs become stronger—and also more likely to conflict with those of institution-based researchers and other stakeholders—as (...) participants become more involved, quantitatively and qualitatively, in the research process. It is not yet known, however, how genomic citizen science initiatives are managing the interests of their participants in accessing and controlling research outputs in practice. To help fill this gap, we conducted an in-depth review of relevant policies and practices of U.S.-based genomic citizen science initiatives. Methods We queried the peer-reviewed literature and grey literature to identify 22 genomic citizen science initiatives that satisfied six inclusion criteria. A data collection form was used to capture initiative features, policies, and practices relevant to participants’ access to and control over research outputs. Results This analysis revealed that the genomic citizen science landscape is diverse and includes many initiatives that do not have institutional affiliations. Two trends that are in apparent tension were identified: commercialization and operationalization of a philosophy of openness. While most initiatives supported participants’ access to research outputs, including datasets and published findings, none supported participants’ control over results via intellectual property, licensing, or commercialization rights. However, several initiatives disclaimed their own rights to profit from outputs. Conclusions There are opportunities for citizen science initiatives to incorporate more features that support participants’ access to and control over research outputs, consistent with their specific objectives, operations, and technical capabilities. (shrink)

Understanding the clinical significance of variants associated with hereditary cancer risk requires access to a pooled data resource or network of resources—a “cancer gene variant commons”—incorporating representative, well-characterized genetic data, metadata, and, for some purposes, pathways to case-level data. Several initiatives have invested significant resources into collecting and sharing cancer gene variant data, but further progress hinges on identifying and addressing unresolved policy issues. This commentary provides insights from a modified policy Delphi process involving experts from a range of stakeholder (...) groups involved in the data-sharing ecosystem. In particular, we describe policy issues and options generated by Delphi participants in five domains critical to the development of an effective cancer gene variant commons: incentives, financial sustainability, privacy and security, equity, and data quality. Our intention is to stimulate wider discussion and lay a foundation for further work evaluating policy options more in-depth and mapping them to those who have the power to bring about change. Addressing issues in these five domains will contribute to a cancer gene variant commons that supports better care for at-risk and affected patients, empowers patient communities, and advances research on hereditary cancers. (shrink)

Methods in comparative work -- The sense of justice in Rawls -- The sense of justice in the analects -- Two senses of justice -- The contemporary relevance of a sense of justice.

Is a feminist political liberalism possible? Political liberalism’s regard for a wide range of comprehensive doctrines as reasonable makes some feminists skeptical of its ability to address sex inequality. Indeed, some feminists claim that political liberalism maintains its position as a political liberalism at the expense of securing substantive equality for women. We claim that political liberalism’s core commitments actually restrict all reasonable political conceptions of justice to those that secure genuine substantive equality for all, including women and other marginalized (...) groups. In particular, we argue that political liberalism’s criterion of reciprocity limits reasonable political conceptions of justice to those that eliminate social conditions of domination and subordination relevant to reasonable democratic deliberation among equal citizens and that the criterion of reciprocity requires the social conditions necessary for recognition respect among persons as equal citizens. As a result, we maintain that the criterion of reciprocity limits reasonable political conceptions of justice to those that provide genuine equality for women along various dimensions of social life central to equal citizenship. (shrink)

While Richard Joyce’s moral skepticism might seem to be an extreme metaethical view, it is actually far more moderate than it might first appear. By articulating four challenges facing his approach to moral skepticism, I argue that Joyce’s moderation is, in fact, a theoretical liability. First, the fact that Joyce is not skeptical about normativity in general makes it possible to develop close approximations to morality, lending support to moderate moral revisionism over moral error theory. Second, Joyce relies on strong, (...) contentious conceptual and empirical claims in support of his views. Third, Joyce’s evolutionary debunking argument threatens to backfire, generalizing to all normative judgments. Finally, Joyce fails to offer an adequate account of the normativity of desire. Each of these four challenges can be either sidestepped or embraced by radicalizing and defending a global form of normative skepticism. There are thus several ways in which global normative skepticism appears to be in a more robust dialectical position than Joyce’s moral skepticism. Furthermore, I argue, Joyce’s arguments against global normative skepticism are unconvincing. While this discussion is framed in terms of Joyce’s work, its arguments will apply to other moral skeptics who are not also global normative skeptics. The result is an invitation for Joyce and other moral skeptics to leave these problems behind and join the radical camp. (shrink)

A philosopher and mother mines classic Daoist texts of Chinese philosophy for wisdom relevant to today's parents. The ancient Chinese philosopher Mencius compared children to tender sprouts, shaped by soil, sunlight, water, and, importantly, the efforts of patient farmers and gardeners. At times children require our protection, other times we need to take a step back and allow them to grow. Like sprouts, a child's character, tendencies, virtues, and vices are at once observable and ever-changing. A practical parenting manual, philosophical (...) reflection on the relationship between parent and child, and necessary response to modern stereotypes of Chinese parenting, Little Sprouts reconsiders cultural definitions of success and explores how we might support and nourish young people. Engaging deeply with foundational Daoist and Confucian thinkers, Georgetown philosopher Erin Cline offers accessible, provocative musings on key parenting issues-from family rituals to learning and vocation to challenges and disabilities-and helps us grow into better parents of joyful, fulfilled children. (shrink)

The protection of species ranks highly among environmentalist priorities, and many environmentalists expect the public to respect and support efforts to protect and rehabilitate endangered species. There are a range of instrumental and anthropocentric justifications for these attitudes, yet some environmentalists want more. It is unclear that more is to be had. In particular, it is challenging to justify some environmentalist attitudes without appealing to some version of the claim that species are intrinsically valuable. However, this has been a notoriously (...) difficult thesis to defend, and it is clearly not available to those who doubt the existence of species. In this paper, I show how a number of environmentalist commitments that appear to be about the value of species can be interpreted and defended in a way that is compatible with antirealism about species. According to my proposal, the proper target of environmentalists’ evaluative concern is the irreplaceable design that is embodied by the individuals that make up a (putative) species. This approach can capture and justify many environmentalist attitudes about the value of biological variety without attributing intrinsic value to species, or even requiring a place for species in our ontology. This enables environmentalists to effectively sidestep a number of puzzling issues surrounding the nature and value of species. (shrink)

Adult humans show exceptional relational ability relative to other species. In this research, we trace the development of this ability in young children. We used a task widely used in comparative research—the relational match-to-sample task, which requires participants to notice and match the identity relation: for example, AA should match BB instead of CD. Despite the simplicity of this relation, children under 4 years of age failed to pass this test (Experiment 1), and their performance did not improve even with (...) initial feedback (Experiment 2). In Experiments 3 and 4, we found that two kinds of symbolic-linguistic experience can facilitate relational reasoning in young children. Our findings suggest that children learn to become adept analogical thinkers, and that language fosters this learning in at least two distinct ways. (shrink)

David Enoch has recently proposed that the deliberative indispensability of irreducibly normative facts suffices to support their inclusion in our ontology, even if they are not necessary for the explanation of any observable phenomena. He challenges dissenters to point to a relevant asymmetry between explanation and deliberation that shows why explanatory indispensability, but not deliberative indispensability, is a legitimate guide to ontology. In this paper, I aim to do just that. Given that an entity figures in the actual explanation of (...) some phenomenon, it is not an open question whether that entity exists. Thus, if you can manage to find actual explanations, you can find answers to ontological questions. In contrast, even if some entity is indispensable to deliberation, it still might not exist. For example, even if some form of libertarian free will is deliberatively indispensable, we still might not have libertarian free will. So even if you manage to discover the indispensable commitments of deliberation, there is still more work to do to get to the bottom of things. That additional work is explanatory work, and so deliberative indispensability is not an independent guide to what there is. (shrink)

In the paper, titled ‘Choosing death in unjust conditions: hope, autonomy and harm reduction,’ Wiebe and Mullin argue that people living in unjust social conditions are sufficiently autonomous to request medical assistance in dying (MAiD). The ethical issue is that some people may request MAiD primarily because of unjust social conditions, not their illness, disease, disability or decline in capability. It is easily agreed that people living in unjust social conditions can be autonomous. Nevertheless, Wiebe and Mullin fail to appreciate (...) that autonomy is only a necessary condition for MAiD. In addition to autonomy, one must decide that providing assisted dying to a patient because they are living in unjust social conditions is ethical. Central to making this ethical decision is the principle of non-maleficence, famously articulated as ‘do no harm.’ The authors admit that performing MAiD in response to unjust social circumstances is harmful, but they justify this harmful action by appealing to the principle of harm reduction. A fundamental flaw of their approach is that it relies on the legislative definition of intolerable suffering, which is based on circular reasoning and given that 99.2% of patients that have applied for MAiD satisfied this criterion, it is essentially equivalent to no standard/criterion. Canadian society is struggling with the ethical implications of its permissive MAiD programme, and, fundamental to this debate, will be determining the proper balance between autonomy and non-maleficence for people living in unjust social conditions. (shrink)

This paper argues that a comparative study of the idea of a sense of justice in the work of John Rawls and the early Chinese philosopher Kongzi is mutually beneficial to our understanding of the thought of both figures. It also aims to provide an example of the relevance of moral psychology for basic questions in political philosophy. The paper offers an analysis of Rawls’s account of a sense of justice and its place within his theory of justice, focusing on (...) the features of this capacity and how it develops. It then provides an account of the sense of justice in Kongzi’s thought as it is seen in the Analects. Finally, it shows how examining the similarities and differences between the two accounts can deepen our understanding of both views, as well as our appreciation for the importance of understanding how a sense of justice develops. (shrink)