Although the use of the cluster randomized trial (CRT) design to evaluate vaccines, public health interventions or health systems is increasing, the ethical issues posed by the design are not adequately addressed, especially in low- and middle-income country settings (LMICs). To help reveal ethical challenges, qualitative interviews were conducted with key stakeholders experienced in designing and conducting two selected CRTs in Malawi. The 18 interviewed stakeholders included investigators, clinicians, nurses, data management personnel and community workers who were invited to share (...) their experiences related to implementation of CRTs. Data analysis revealed five major themes with ethical implications: (1) The moral obligation for health care providers to participate in health research and its compensation; (2) Suboptimal care services compromising the integrity of CRT; (3) Ensuring scientific validity and withholding care service; (4) Obtaining valid consent and permission for waiver of consent; and (5) Inadequate risk assessment for trial participation. Understanding key ethical issues posed by CRTs in Malawi could improve ethical review and research oversight of this particular study design. (shrink)

Brain dead organ donors are the principal source of transplantable organs. However, it is controversial whether brain death is the same as biological death. Therefore, it is unclear whether organ removal in brain death is consistent with the ‘dead donor rule’, which states that organ removal must not cause death. Our aim was to evaluate the public9s opinion about organ removal if explicitly described as causing the death of a donor in irreversible apneic coma. We conducted a cross-sectional internet survey (...) of the American public (n=1096). Questionnaire domains included opinions about a hypothetical scenario of organ removal described as causing the death of a patient in irreversible coma, and items measuring willingness to donate organs after death. Some 71% of the sample agreed that it should be legal for patients to donate organs in the scenario described and 67% agreed that they would want to donate organs in a similar situation. Of the 85% of the sample who agreed that they were willing to donate organs after death, 76% agreed that they would donate in the scenario of irreversible coma with organ removal causing death. There appears to be public support for organ donation in a scenario explicitly described as violating the dead donor rule. Further, most but not all people who would agree to donate when organ removal is described as occurring after death would also agree to donate when organ removal is described as causing death in irreversible coma. (shrink)

The controversy over brain death and the dead donor rule continues unabated, with some of the same key points and positions starting to see repetition in the literature. One might wonder whether some of the participants are talking past each other, not all debating the same issue, even though they are using the same words (e.g., “death”). One reason for this is the complexity of the debate: It’s not merely about the nature of human life and death. Interwoven into this (...) debate are deep philosophical issues on realism, the normative/descriptive distinction, the relation of thought and language to the world, the mind–body problem, personhood, moral status, and the ethics of killing. There are also social and legal .. (shrink)

Since at least the 1960s, deontic logicians and ethicists have worried about whether there can be normative systems that allow conflicting obligations. Surprisingly, however, little direct attention has been paid to questions about how we may reason with conflicting obligations. In this paper, I present a problem for making sense of reasoning with conflicting obligations and argue that no deontic logic can solve this problem. I then develop an account of reasoning based on the popular idea in ethics that reasons (...) explain obligations and show that it solves this problem. (shrink)

A traditional picture is that cases of deontic constraints--- cases where an act is wrong (or one that there is most reason to not do) even though performing that act will prevent more acts of the same morally (or practically) relevant type from being performed---form a kind of fault line in ethical theory separating (agent-neutral) consequentialist theories from other ethical theories. But certain results in the recent literature, such as those due to Graham Oddie and Peter Milne in "Act and (...) Value", do not sit well this traditional wisdom. My aim in this paper is to argue that both the traditional wisdom and Oddie and Milne are mistaken. I begin by looking more closely at the traditional wisdom and why it fails (§1). Then I develop my account of this fault line in ethical theory and its importance (§2). Finally I show that a diagnosis of where Oddie and Milne go wrong follows as a corollary of this new account (§3). An important upshot will be that discussions of cases of deontic constraints would do best to focus on the account of the nature and importance of the cases identified in this paper rather than continuing to work with the mistaken traditional picture. (shrink)

In an earlier study by Nair,1 undergraduate national servicemen were interviewed regarding their perceptions on their conscript experience and nation-building. The present study examines the congruent perceptions of military commanders in the context of social psychological theory and research. Twenty senior military commanders were selected to represent a cross-section of formations and appointments in the army. They were individually interviewed with particular reference to their recall of policies, procedures and practices in conscript service that might have a bearing on (...) nation- building. Verbatim transcriptions of each interview were scrutinized and responses coded and tallied. There was clear identification of the unifying effect of common barracks and training regimes across economic, ethnic and religious differences. The findings provide converging evidence for the presence of the psychological effects of superordinate goals,2 the minimal group paradigm, 3 and the contact hypothesis,4 serving to build a cohesive nation. There were also recurrent and converging attributions of the military experience resulting in national servicemen with the qualities of discipline, responsibility, team spiritedness and physical fitness. It was perceived that these acquired positive qualities were carried over to civilian life and characterized the Singapore workforce. (shrink)

ABSTRACT:Organismal superposition holds that the same individual both is and is not an organism, as a consequence of organismal pluralism. When coupled with the assumption that death is the cessation of an organism, this entails that there is no unique answer as to whether brain death is biological death. This essay argues that concerns about organismal pluralism and superposition do not undermine a theory of biological death, nor entail any metaphysical indeterminacy about the biological vital status of a brain-dead individual.

The concept of death and its relationship to organ transplantation continue to be sources of debate and confusion among academics, clinicians, and the public. Recently, an international group of scholars and clinicians, in collaboration with the World Health Organization, met in the first phase of an effort to develop international guidelines for determination of death. The goal of this first phase was to focus on the biology of death and the dying process while bracketing legal, ethical, cultural, and religious perspectives. (...) The next phase of the project will include a broader group of stakeholders in the development of clinical practice guidelines and will use expert consensus on biomedical criteria for death from the first phase as scientific input into normative deliberation about appropriate policies and practices. Surely, science alone cannot resolve the normative and philosophical questions intertwined in debates about moral status, legal and moral rights, the ethics of killing, and personhood and the nature of the self; however, scientific input is necessary for informed moral deliberation. An objective and unbiased investigation of the biology of death is independent of, and should be undertaken prior to, an analysis of the normative questions engendered by debate about determination of death. This strategy is explicitly endorsed by the International Guidelines for Determination of Death and reflects the prevailing view of these issues in the mainstream medical literature. However, this mainstream literature, exemplified by the IGDD group's recent report, does not exhibit any of the characteristics usually associated with a scientifically rigorous investigation, such as making empirically testable and falsifiable claims, a commitment to evidence and logic over authoritative assertion, or a willingness to revise hypotheses and theories in light of new evidence. Indeed, the core claims and methodologies of the mainstream medical literature on death, both of which are represented by the IGDD report, are not merely scientifically unjustified; they are not science at all. This situation creates a problem for the integrity of science and the academy, and it unjustly obscures and prevents legitimate democratic and moral deliberation about issues that, at bottom, are normative, not scientific. (shrink)

A “universalist” policy on brain death holds that brain death is death, and neurologic criteria for death determination are rightly applied to all, without exemptions or opt outs. This essay argues that advocates of a universalist brain death policy defend the same sort of coercive control of end-of-life decision-making as “pro-life” advocates seek to achieve for reproductive decision-making, and both are grounded in an illiberal political philosophy. Those who recognize the serious flaws of this kind of public policy with respect (...) to abortion must apply the same logic to brain death. (shrink)

John P. Lizza has long been a major figure in the scholarly literature on criteria for death. His searching and penetrating critiques of the dominant biological paradigm, and his defense of a theory of death of the person as a psychophysical entity, have both significantly advanced the literature. In this special issue, Lizza reinforces his critiques of a strictly biological approach. In my commentary, I take up Lizza’s challenge regarding a biological concept of death. He is certainly right to point (...) out that science is not value-free; however, this does not imply that there cannot be a characterization of biological death that can be shown to be superior to other concepts. After characterizing and justifying such a theory of biological death, I show that patients who meet the diagnostic criteria for brain death are unequivocally biologically alive. However, with respect to concepts of personhood and related ideas, I urge the acceptance of a pluralism of such concepts for matters of public policy. (shrink)

The dead donor rule, which requires that organ donors not be killed by the process of organ procurement, is thought to protect vulnerable patients from exploitation and from being harmed through organ procurement. In current practice, the majority of transplantable organs are retrieved from patients who are declared dead by neurological criteria, or "brain-dead." Because brain death is considered to be sufficient for death, it is thought that brain-dead donors are neither harmed nor wronged by organ removal.In this essay I (...) argue that this is not the case. Brain-dead donors can be, and many are, harmed and wronged by... (shrink)

Reasons can interact in a variety of ways to determine what we ought to do or believe. And there can be cases where two reasons to do an act or have a belief are individually worse than a reason to not do that act or have that belief, but the reasons together are better than the reason to not do that act or have that belief. So the reasons together―which we can call the accrual of those reasons—can have a strength (...) that is an increasing function of the strengths of the individual reasons. In this paper, we will look at how reasons determine what we ought to do and believe in cases where the accrual of reasons is relevant. Our focus will not primarily be on questions about the nature of individual reasons and their weight. Instead, we will at the outset rely on our pretheoretical grip on what reasons there are and how weighty they are individually and ask the more formal or structural question of how to determine the strength of their accrual based on these facts. In looking at these issues, my goal will not be anything as ambitious as developing a full theory of the accrual of reasons. Rather, my goal will be more modest: I will introducing some of the challenges for providing an adequate model and argue that a promising approach to resolving these challenges involves making use of the familiar distinction in moral philosophy between derivative and non-derivative normative notions. (shrink)

Legally defining “death” in terms of brain death unacceptably obscures a value judgment that not all reasonable people would accept. This is disingenuous, and it results in serious moral flaws in the medical practices surrounding organ donation. Public policy that relies on the whole-brain concept of death is therefore morally flawed and in need of revision.

The didactic proposal of the post-constructivist (Grossi, 2005), takes into account the relationship between the subject, reality, others and the Other interior and considers the learning potential of all students. Its theoretical foundation is, among other things, the principle that learning is a social phenomenon, and that the spatial organization of the class, in groups of adults, promotes the teaching-learning process. Post-constructivism is a didactic proposition that allows us to respond to the purpose of teaching all students. This article on (...) group work in post-constructivism aims to analyze the change in posture of teachers, and the professional development that follows, and which demonstrates a break with the traditional form of education. The trick of the identified researcher is then to take up in a teacher training, through the aulic groups in the Geempa class and the weekly study group, the scientific approach of post-constructivism. (shrink)

How do multiple reasons combine to support a conclusion about what to do or believe? This question raises two challenges: How can we represent the strength of a reason? How do the strengths of multiple reasons combine? Analogous challenges about confirmation have been answered using probabilistic tools. Can reductive and nonreductive theories of reasons use these tools to answer their challenges? Yes, or more exactly: reductive theories can answer both challenges. Nonreductive theories, with the help of a result in confirmation (...) theory, can answer one, and there are grounds for optimism that they can answer the other. (shrink)

One of the popular albeit controversial ideas in the last century of moral philosophy is that what we ought to do is explained by our reasons. And one of the central features of reasons that accounts for their popularity among normative theorists is that they can conflict. But I argue that the fact that reasons conflict actually also poses two closely related problems for this popular idea in moral philosophy. The first problem is a generalization of a problem in deontic (...) logic concerning the existence of conflicting obligations. The second problem arises from a tension between the fact that reasons can conflict and a model of how reasons explain ‘ought’s that has been widely accepted. Having presented each of these problems, I develop a unified solution to them that is informed by results in both ethics and deontic logic. An important implication of this solution is that we must distinguish between derivative and nonderivative reasons and revise our conception how it is that reasons explain ‘ought’s. (shrink)

Business ethics researchers and practitioners are interested in understanding the temporal mechanisms of various managerial activities, processes, and policies. In this direction, I borrow notions of time from Virginia Woolf’s _Mrs. Dalloway_ to examine how social time intersperses with the paid and (unpaid) care work of female employees during the pandemic. I explore how discussions of social time in connection to care work appear in newspaper discourses of “shecession”, i.e. the large-scale job/income losses experienced by women during the COVID-19 pandemic. (...) Since shecession is a byproduct of the pandemic times, exploring the role of time in it is crucial. In fact, my findings show that the macro social time of the pandemic affects working women with care responsibilities who are situated at the intersection of multiple vulnerable social categories by simultaneously being a penalizer and a lost opportunity. Similarly, I also find that the micro social times of working women embed, stratify, and synchronize differently during the pandemic when compared to normal times. Working women with care responsibilities are thus adversely affected by both micro and macro social time changes. My findings, therefore, could be instrumental in developing and implementing inclusive policies and processes in business organizations and labor markets. In so doing, my study also indicates how a consideration of social time enriches the application of care ethics in work contexts. Ultimately, this article is also about developing caring organizations, societies, and families which care for the caregivers (working women), since receiving care is a precondition of giving care. (shrink)

There is consensus among computer scientists, logicians, and philosophers that good reasoning with qualitative beliefs must have the structural property of cumulative transitivity or, for short, cut. This consensus is typically explicitly argued for partially on the basis of practical and mathematical considerations. But the consensus is also implicit in the approach philosophers take to almost every puzzle about reasoning that involves multiple steps: philosophers typically assume that if each step in reasoning is acceptable considered on its own, the whole (...) chain of reasoning must also acceptable. In this paper I focus on whether there are good philosophical reasons for thinking that the consensus that good reasoning must satisfy cut is true. My central claim is that we should not accept the consensus—good reasoning might not satisfy cut. In particular, I consider four arguments for the consensus and explain why they are unpersuasive. (§2-5). I then show that the issue of whether good reasoning is cut turns on a substantive yet until now unnoticed question in epistemology (§6). (shrink)

Some patients who have been diagnosed as “dead by neurologic criteria” continue to exhibit certain brain functions, most commonly, neuroendocrine functions. This preservation of neurologic function after the diagnosis of “brain death” or “brainstem death” is an ongoing source of controversy and concern in the medical, bioethics, and legal literatures. Most obviously, if some brain function persists, then it is not the case that all functions of the entire brain have ceased and hence, declaring such a patient to be “dead” (...) would be a false positive, in any nation with so-called “whole brain death” laws. Furthermore, and perhaps more concerning, the preservation of any brain function necessarily entails the preservation of some amount of brain perfusion, thereby raising the concern as to whether additional areas of neural tissue may remain viable, including areas in the brainstem. These and other considerations cast significant doubt on the reliability of diagnosing either “brain death” or “brainstem death.”. (shrink)

Background Doctors sometimes encounter parents who object to prescribed treatment for their children, and request suboptimal substitutes be administered instead. Previous studies have focused on parental refusal of treatment and when this should be permitted, but the ethics of requests for suboptimal treatment has not been explored. Methods The paper consists of two parts: an empirical analysis and an ethical analysis. We performed an online survey with a sample of the general public to assess respondents’ thresholds for acceptable harm and (...) expense resulting from parental choice, and the role that religion played in their judgement. We also identified and applied existing ethical frameworks to the case described in the survey to compare theoretical and empirical results. Results Two hundred and forty-two Mechanical Turk workers took our survey and there were 178 valid responses. Respondents’ agreement to provide treatment decreased as the risk or cost of the requested substitute increased. More than 50% of participants were prepared to provide treatment that would involve a small absolute increased risk of death for the child and a cost increase of US$<500, respectively. Religiously motivated requests were significantly more likely to be allowed. Existing ethical frameworks largely yielded ambiguous results for the case. There were clear inconsistencies between the theoretical and empirical results. Conclusion Drawing on both survey results and ethical analysis, we propose a potential model and thresholds for deciding about the permissibility of suboptimal treatment requests. (shrink)

Physicians participate in several kinds of activities in their professional lives. Clinical care is the core function of the physician. Medical education is overwhelmingly oriented toward this func...

The context of discovery and collection of Siwalik fossils had far less to do with science than with the ability to effect “translations” that helped bring together a wide range of social worlds, from the Doab Canal engineers working at the foot of the Hills, surgeon-botanists at the Saharanpur Botanic Gardens, other colonial officials, the native “Hindoo” diggers and collectors, to all of whom the Siwalik Hills was a “boundary object,” a common factor that bound their lives together. In this (...) colonial scientific collecting episode pertaining to the discovery of a new field of research, cooperation between different participants is achieved not by using methods of standardization but through an emphasis on greater heterogeneity, both in terms of the “allies” enrolled and fossils collected. Heterogeneity becomes a factor of strength rather than a weakness that deters the practice of science. This essay employs sociological reflection to examine the context of discovery, collection, and justification of a significant group of fossils in India in the 1830s–40s. (shrink)

In this chapter, we begin by sketching in the broadest possible strokes the ideas behind two formal systems that have been introduced with to goal of explicating the ways in which reasons interact to support the actions and conclusions they do. The first of these is the theory of defeasible reasoning developed in the seminal work of Pollock; the second is a more recent theory due to Horty, which adapts and develops the default logic introduced by Reiter to provide an (...) account of reasons. However, the implementations are complex enough, in both cases, to prevent anything more than this sketch. And we would not want to give the impression that we think that work on the logic of reasons must follow the path mapped out in either of these theories—indeed, we feel that the field is wide open. In the remainder of the chapter, therefore, will concentrate on a number of issues bearing on the logic of reasons that are either not treated in the work of Pollock and Horty, or whose treatment there is, we feel, either inadequate or incomplete. These are: first, the question of whether it is necessary to understand logical interactions among reasons themselves, rather than simply between reasons and the actions or conclusions they support, and if so, what principles might govern these interactions; second, priority relations among reasons and the notion of reason accrual; and third, some problems posed by undercutting defeat. (shrink)

Two experiments investigated whether moral evaluations of organ transplantation influence judgments of death and causation. Participants’ beliefs about whether an unconscious organ donor was dead and whether organ removal caused death in a hypothetical vignette varied depending on the moral valence of the vignette. Those who were randomly assigned to the good condition were more likely to believe that the donor was dead prior to organ removal and that organ removal did not cause death. Furthermore, attitudes toward euthanasia and organ (...) donation independently predicted judgments of death and causation, regardless of experimental condition. The results are discussed in light of the framework of motivated reasoning, in which motivation influences the selection of cognitive processes and representations applied to a given domain, as well as Knobe’s person-as-moralist model, in which many basic concepts are appropriately imbued with moral features. On either explanatory framework, these data cast doubt on the psychological legitimacy of the mainstream justification for vital organ procurement from heart-beating donors, which holds that neurological criteria for death are scientifically justified, independently of concerns about organ transplantation. These data suggest that, rather than concluding that organ removal is permissible because the donor is dead, people may believe that the donor is dead because they believe organ removal to be permissible. (shrink)

Behavioural variant frontotemporal dementia (bvFTD) is a subtype of frontotemporal dementia characterized by changes in personality, social behaviour, and cognition. Although neural abnormalities cause bvFTD patients to struggle with inhibiting problematic behaviour, they are generally considered fully autonomous individuals. Subsequently, bvFTD patients demonstrate understanding of right and wrong but are unable to act in accordance with moral norms. To investigate the ethical, legal, and social issues associated with bvFTD, we conducted a scoping review of academic literature with inclusion & exclusion (...) criteria and codes derived from our prior work. Among our final sample of fifty-six articles, four mentioned bvFTD patient-offenders as unfit to stand trial by insanity, and sixteen mentioned the use of dementia evidence in a court of law to better understand the autonomy of bvFTD patients. Additional emergent issues that were discovered include: training police officers to handle situations involving bvFTD patients and educating healthcare providers on how to help caregivers navigate bvFTD. The current literature highlights the inadequacy of traditional applications of medico-legal categories such as autonomy, capacity and competence, in informing cognitive capacity assessments in clinical and legal settings and deserves consideration by neuroethicists. (shrink)

The volume critically analyses the primary drawbacks of the Indian education system-non-enrolment, dropouts, irregular attendance, and inadequate learning. It establishes the need to strongly encourage parents to recognize the importance of education for their children's future. Arguing that supply-side strategies-free education, midday meals, opening more schools-have not proved effective since the problem of inadequate demand is much larger, the authors delineate the measures that are required to boost the demand for education in India.

The established view regarding ‘brain death’ in medicine and medical ethics is that patients determined to be dead by neurological criteria are dead in terms of a biological conception of death, not a philosophical conception of personhood, a social construction or a legal fiction. Although such individuals show apparent signs of being alive, in reality they are dead, though this reality is masked by the intervention of medical technology. In this article, we argue that an appeal to the distinction between (...) appearance and reality fails in defending the view that the ‘brain dead’ are dead. Specifically, this view relies on an inaccurate and overly simplistic account of the role of medical technology in the physiology of a ‘brain dead’ patient. We conclude by offering an explanation of why the conventional view on ‘brain death’, though mistaken, continues to be endorsed in light of its connection to organ transplantation and the dead donor rule. (shrink)