The leading ethical position on placebo-controlled clinical trials is that whenever proven effective treatment exists for a given condition, it is unethical to test a new treatment for that condition against placebo. Invoking the principle of clinical equipoise, opponents of placebo-controlled trials in the face of proven effective treatment argue that they (1) violate the therapeutic obligation of physicians to offer optimal medical care and (2) lack both scientific and clinical merit. We contend that both of these arguments are mistaken. (...) Clinical equipoise provides erroneous ethical guidance in the case of placebo-controlled trials, because it ignores the ethically relevant distinction between clinical trials and treatment in the context of clinical medicine and the methodological limitations of active-controlled trials. Placebo controls are ethically justifiable when they are supported by sound methodological considerations and their use does not expose research participants to excessive risks of harm. (shrink)

A predominant ethical view holds that physician‐investigators should conduct their research with therapeutic intent. And since a physician offering a therapy wouldn't prescribe second‐rate treatments, the experimental intervention and the best proven therapy should appear equally effective. "Clinical equipoise" is necessary. But this perspective is flawed. The ethics of research and of therapy are fundamentally different, and clinical equipoise should be abandoned.

The doctrine of clinical equipoise is appealing because it appears to permit physicians to maintain their therapeutic obligation to offer optimal medical care to patients while conducting randomized controlled trials (RCTs). The appearance, however, is deceptive. In this article we argue that clinical equipoise is defective and incoherent in multiple ways. First, it conflates the sound methodological principle that RCTs should begin with an honest null hypothesis with the questionable ethical norm that participants in these trials should never be randomized (...) to an intervention known to be inferior to standard treatment. Second, the claim that RCTs preserve the therapeutic obligation of physicians misrepresents the patient-centered orientation of medical care. Third, the appeal to clinical equipoise as a basic principle of risk-benefit assessment for RCTs is incoherent. Finally, the difficulties with clinical equipoise cannot be resolved by viewing it as a presumptive principle subject to exceptions. In the final sections of the article, we elaborate on the non-exploitation framework for the ethics clinical research and indicate issues that warrant further inquiry. (shrink)

A special report of The Hastings Center and the Association of American Medical Colleges addressed the ethical oversight of learning health systems, which seek to combine high‐quality patient care with routine data collection aimed at improving patient outcomes. The report contained two position papers, authored by a number of distinguished bioethicists, and several commentaries. The position papers urged two changes. First, they urged a rethinking of our approach to the regulation of human subjects research, so as to make it easier (...) in the future for learning health systems to function well. Second, they argued that the rethinking required dispensing with a strict distinction between research and therapy, which has been a major tenet of bioethics since the Belmont Report, which explicated basic ethical principles governing human subjects research. We fully support the objectives of the authors, and we agree that the learning health system is an important advance that serves patients well. Unnecessary regulatory burden ought not impede this progress. We disagree, however, that the best way to bring about these needed changes in the regulatory environment is to reject the basic distinction between research and treatment. Unfortunately, we find the arguments in favor of that strategy to be, in places, reminiscent of what we take to be basic conceptual errors that hampered the ethical understanding of human subjects research prior to adoption of the Belmont Report. To see why one need not reject the research‐treatment distinction in order to promote learning health systems, we first investigate in some detail the arguments offered for eliminating the distinction. We next turn to an issue not addressed by those authors, namely, the relationship between the physician or investigator and the patient or subject, to illustrate why the distinction is important and what is lost if it is jettisoned. (shrink)

: The "difference position" holds that clinical research and therapeutic medical practice are sufficiently distinct activities to require different ethical rules and principles. The "similarity position" holds instead that clinical investigators ought to be bound by the same fundamental principles that govern therapeutic medicine—specifically, a duty to provide the optimal therapeutic benefit to each patient or subject. Some defenders of the similarity position defend it because of the overlap between the role of attending physician and the role of investigator in (...) a research trial. This overlap is maximal when the same physician occupies both roles with respect to a particular patient-subject. We address the ethical tensions inherent in that role conflict and argue that the tensions are real but manageable. The difference position provides a sound ethical framework within which to manage those tensions, while the similarity position is unsatisfactory because it seeks to deny the existence of the tensions. (shrink)

The practice of voluntary physician‐assisted death as a last resort is compatible with doctors' duties to practice competently, to avoid harming patients unduly, to refrain from medical fraud, and to preserve patients' trust. It therefore does not violate physicians' professional integrity.

Some ethical issues facing contemporary medicine cannot be fully understood without addressing medicine's internal morality. Medicine as a profession is characterized by certain moral goals and morally acceptable means for achieving those goals. The list of appropriate goals and means allows some medical actions to be classified as clear violations of the internal morality, and others as borderline or controversial cases. Replies are available for common objections, including the superfluity of internal morality for ethical analysis, the argument that internal morality (...) is merely an apology for medicine's traditional power and authority, and the claim that there is no single, "core" internal morality. The value of addressing the internal morality of medicine may be illustrated by a detailed investigation of ethical issues posed by managed care. Managed care poses some fundamental challenges for medicine's internal morality, but also calls for thoughtful reflection and reconsideration of some traditionally held moral views on patient fidelity in particular. (shrink)

Cosmetic surgery is a fast-growing medical practice. In 1997 surgeons in the United States performed the four most common cosmetic procedures443,728 times, an increase of 150% over the comparable total for 1992. Estimated total expenditures for cosmetic surgery range from $1 to $2 billion. As managed care cuts into physicians' income and autonomy, cosmetic surgery, which is not covered by health insurance, offers a financially attractive medical specialty.

*The opinions expressed are the views of the author and do not necessarily reflect the policy of the National Institutes of Health, the Public Health Service, or the U.S. Department of Health and Human Services.

A basic question of medical ethics is whether the norms governing medical practice should be understood as the application of principles and rules of the common morality to medicine or whether some of these norms are internal or proper to medicine. In this article we describe and defend an evolutionary perspective on the internal morality of medicine that is defined in terms of the goals of clinical medicine and a set of duties that constrain medical practice in pursuit of these (...) goals. This perspective is developed by means of a critical examination of the essentialist conception of the internal morality of medicine advocated by Edmund Pellegrino and the critique of internal morality approaches by Robert Veatch and Tom Beauchamp. (shrink)

With breathtalung speed, traditional criminal prohibitions against assisted suicide have been declared unconstitutional in twelve states, including California and New York. This poses great promise and great peril. The promise is that competent terminally ill patients, as a compassionate measure of last resort, will have the option of putting an end to their suffering by physician-assisted suicide. More sigmficant, legally permitting this controversial option may be a catalyst for doctors, health care institutions, and society to improve the care of the (...) dying. PAS should be limited only to those relatively few competent patients who continue to suffer intolerably despite unrestrained efforts to palliate and who face a continued existence that they regard as worse than death. When dying patients know they will not be abandoned to miserable and pointless suffering if palliative care fails, they will be fortified to cope better with the process of dying.The immediate peril is that PAS will become a quick fix, available on demand to any patient diagnosed as terminally ill, thus bypassing palliative care and producing premature deaths. (shrink)

This is a review of James Franklin's book, What Science Knows and How It Know It.

The American Philosophers contains papers by current leading philosophers and political theorists that explore the work of the major American philosophers from the colonial period to the present, from Jonathan Edwards to David Kaplan. Contains a philosophically and historically broad exploration of the major schools of American philosophy Examines both the pragmatists and the later Twentieth Century analytic philosophers, as well as such shapers of the political and philosophical American scene as Franklin, Jefferson, Madison, Emerson, and Jane Addams.

In The Healer's Power, Howard Brody placed the concept of power at the heart of medicine's moral discourse. Struck by the absence of “power” in the prevailing vocabulary of medical ethics, yet aware of peripheral allusions to power in the writings of some medical ethicists, he intuited the importance of power from the silence surrounding it. He formulated the problem of the healer's power and its responsible use as “the central ethical problem in medicine.” Through the prism of power (...) he refracted a wide range of ethical problems, from informed consent to truth-telling, from confidentiality to futility, from the physician's fantasies to the physician's virtues. At times this prism shed new light on old problems, enabling us to see from an unexpected angle the elements of which the problem was composed. At other times it exposed issues of ethical significance that had been neglected in the bioethics literature. (shrink)

This book (edited by Jonathan Y. Tsou, Jamie Shaw, and Carla Fehr) offers eighteen original historical and philosophical essays focused on values in science, scientific pluralism, and pragmatism. These themes have been central in the work of Matthew J. Brown, and the book frames these topics through an engagement with Brown’s broadly ranging work on values in science. The themes of this book are integrated and unified in the pragmatic and value-laden ideal of science defended by Professor Brown in (...) his fascinating 2020 book, Science and Moral Imagination. Brown's ideal of moral imagination prescribes that scientists should recognize the contingencies in their work as unforced choices, examine morally salient aspects of these decisions, recognize the various interests of relevant stakeholders, explore and construct alternative options, and exercise fair and warranted value judgments to guide those decisions. The interdisciplinary essays in this volume engage with different aspects of Brown's philosophical research on scientific values as well as his historical research on figures such as John Dewey and Paul K. Feyerabend. The international contributors to this volume include distinguished and familiar voices from the values in science literature (e.g., Kevin Elliott, Janet Kourany, and Don Howard) as well as newer voices. The resulting book showcases some of the latest innovative research being done on values, pluralism, and pragmatism, and it will be an important resource for researchers working on values in science. Specific topics addressed in the book include: moral imagination, inductive risk, epistemic priority, the value free ideal of science, values in the contexts of artificial intelligence and medicine, varieties of pluralism (e.g., epistemic, ethical, and cultural), and the structure of scientific communities. The book also features novel historical research on important figures in the traditions of pragmatism, pluralism, and values in science, such as John Dewey, John Stuart Mill, Paul Feyerabend, W. V. O. Quine, Ludwig Fleck, among others. The contributions to the volume represent a broad range of contemporary history and philosophy of science perspectives, which have guided Brown's own work, including socially relevant philosophy of science (SRPoiSE), history of philosophy of science (HOPOS), feminist philosophy of science, and philosophy of science in practice (SPSP). The book will be of interest to a broad audience of researchers working in philosophy of science, philosophy of medicine, history and philosophy of science, and science and technology studies. (shrink)

Among both the defenders and adversaries of orthodox Trinitarian dogma, the so-called “kenosis hymn” of Philippians 2 was of the utmost importance, whether in refuting opponents’ teachings or articulating one’s own. While historical theologians have extensively investigated its place in the works of Sts. Hilary and Augustine—each the leading Latin pro-Nicene authority of his time—a comparative examination of the two has not yet been undertaken. This article seeks to trace and account for Augustine’s noteworthy improvement upon his predecessor’s thought in (...) the closely related realms of exegesis and Christology. It first summarizes the most relevant points of continuity and discontinuity in the Latin bishops’ uses of the Pauline language of forma dei–forma serui. From there, it turns to the role of Phil. 2 in countering subordinationist readings of hotly contested scriptural texts, arguing that Augustine more ably responds to the challenges at hand. Finally, it argues that his employment of the forma dei–forma serui paradigm is closely linked to his teaching on the revelatory capacity of Christ’s human nature. With regard to both, Augustine’s teaching marks a bona fide development of Hilary’s and thus of the Latin tradition more broadly. (shrink)

Mathematicians often speak of conjectures as being confirmed by evidence that falls short of proof. For their own conjectures, evidence justifies further work in looking for a proof. Those conjectures of mathematics that have long resisted proof, such as the Riemann hypothesis, have had to be considered in terms of the evidence for and against them. In recent decades, massive increases in computer power have permitted the gathering of huge amounts of numerical evidence, both for conjectures in pure mathematics and (...) for the behavior of complex applied mathematical models and statistical algorithms. Mathematics has therefore become (among other things) an experimental science (though that has not diminished the importance of proof in the traditional style). We examine how the evaluation of evidence for conjectures works in mathematical practice. We explain the (objective) Bayesian view of probability, which gives a theoretical framework for unifying evidence evaluation in science and law as well as in mathematics. Numerical evidence in mathematics is related to the problem of induction; the occurrence of straightforward inductive reasoning in the purely logical material of pure mathematics casts light on the nature of induction as well as of mathematical reasoning. (shrink)

In this volume of essays, Howard Wettstein explores the foundations of religious commitment. His orientation is broadly naturalistic, but not in the mode of reductionism or eliminativism. This collection explores questions of broad religious interest, but does so through a focus on the author's religious tradition, Judaism. Among the issues explored are the nature and role of awe, ritual, doctrine, religious experience; the distinction between belief and faith; problems of evil and suffering with special attention to the Book of (...) Job and to the Akedah, the biblical story of the binding of Isaac; the virtue of forgiveness. One of the book's highlights is its literary approach to theology that at the same time makes room for philosophical exploration of religion. Another is Wettstein's rejection of the usual picture that sees religious life as sitting atop a distinctive metaphysical foundation, one that stands in need of epistemological justification. (shrink)

ABSTRACT The article reflects on the natural scientific variant of the philosophical essay, with discussions of the essays of James Clerk Marxwell, Steven Jay Gould, and Carlo Rovelli. It suggests that the natural scientific essay is an important source of the philosophical essay eclipsed by the prominence of the essay form in art and literary criticism. It assesses the role of chance and improvisation in the natural scientific essay and considers its potential as an avenue both of scientific research and (...) of the wider dissemination of scientific thought. (shrink)

This essay examines neoconservative criticisms of equity planning, and the challenges against the right of government to regulate local development and land use. The specific concern of this essay is how, or if, local development administrators (equity planners), should use their discretionary powers to ensure that city officials and private developers promote and protect the interests of urban residents, particularly the poor and disadvantaged. The essay begins by discussing the alleged conflict said to exist between needy urban residents and the (...) more secure urban taxpayers. The contrary views of equity planners are then reviewed, and the tensions within the neoconservative arguments are exposed and critiqued. Finally, the dispute between equity planners and neoconservatives is further explored by examining the dispute over the voucher system to address the problem of equal educational opportunity in urban communities. (shrink)

Perspectives on teaching values and applied ethics in tertiary level education with an emphasis on the importance of bridging the gap between moral philosophy ...

Socrates.--Plato.--Aristotle.--Aquinas.--Descartes.--Spinoza.--Locke.--Voltaire.--Kant.--Hegel.--Dew ey.--Russell.

Let L be a computable vocabulary, let X_L be the space of L-structures with universe ω and let f:2^\omega \rightarrow X_L be a hyperarithmetic function such that for all x,y \in 2^\omega, if x \equiv _h y then f(x) \cong f(y). One of the following two properties must hold. (1) The Scott rank of f(0) is \omega _1^{CK} + 1. (2) For all x \in 2^\omega, f(x) \cong f(0).

Recently, there has been an upsurge of attention focused on bias and its impact on specialized artificial intelligence applications. Allegations of racism and sexism have permeated the conversation as stories surface about search engines delivering job postings for well-paying technical jobs to men and not women, or providing arrest mugshots when keywords such as “black teenagers” are entered. Learning algorithms are evolving; they are often created from parsing through large datasets of online information while having truth labels bestowed on them (...) by crowd-sourced masses. These specialized AI algorithms have been liberated from the minds of researchers and startups, and released onto the public. Yet intelligent though they may be, these algorithms maintain some of the same biases that permeate society. They find patterns within datasets that reflect implicit biases and, in so doing, emphasize and reinforce these biases as global truth. This paper describes specific examples of how bias has infused itself into current AI and robotic systems, and how it may affect the future design of such systems. More specifically, we draw attention to how bias may affect the functioning of a robot peacekeeper, a self-driving car, and a medical robot. We conclude with an overview of measures that could be taken to mitigate or halt bias from permeating robotic technology. (shrink)

In this dialogue, we discuss the contrast between inexorable physical laws and the semiotic freedom of life. We agree that material and symbolic structures require complementary descriptions, as do the many hierarchical levels of their organizations. We try to clarify our concepts of laws, constraints, rules, symbols, memory, interpreters, and semiotic control. We briefly describe our different personal backgrounds that led us to a biosemiotic approach, and we speculate on the future directions of biosemiotics.

In 1964, anesthesiologists at Harvard Medical School studied a group of patients about to undergo major abdominal surgery. Half the patients got the standard preoperative visit. The other half received an enhanced visit dealing with postoperative pain. That half were told that pain is normal and expected, that they would receive medications as ordered by their physicians, that they could also use several self-help techniques to relieve pain, and that nurses and physicians would be standing by to assist them if (...) needed. The enhanced-visit group ended up requesting half as many opioid analgesics as the other group, and they were discharged an average of two days earlier, despite successful blinding (Egbert et al.... (shrink)

Pylyshyn's argument is very similar to one made in the 1960s to the effect that vision may be influenced by spatial selective attention being directed to distinctive stimulus features, but not by mental set for meaning or membership in an ill-defined category. More recent work points to a special role for spatial attention in determining the contents of perception.