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)

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)

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)

Populist protests against Coronavirus-related restrictions in the US appear paradoxical in three respects. Populism is generally hostile to expertise, yet it has flourished at a moment when expertise has seemed more indispensable than ever. Populism thrives on crisis and indeed often depends on fabricating a sense of crisis, yet it has accused mainstream politicians and media of overblowing and even inventing the Corona crisis. Populism, finally, is ordinarily protectionist, yet it has turned anti-protectionist during the pandemic and challenged the allegedly (...) overprotective restrictions of the nanny-state. I address each apparent paradox in turn before speculating in conclusion about how populist distrust of expertise, antipathy to government regulation, and skepticism toward elite overprotectiveness may come together – in the context of intersecting medical, economic, political, and epistemic crises – in a potent and potentially dangerous mix. (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)

In _influx & efflux_ Jane Bennett pursues a question that was bracketed in her book _Vibrant Matter_: how to think about human agency in a world teeming with powerful nonhuman influences? “Influx _& _efflux”—a phrase borrowed from Whitman's "Song of Myself"—refers to everyday movements whereby outside influences enter bodies, infuse and confuse their organization, and then exit, themselves having been transformed into something new. How to describe the human efforts involved in that process? What kinds of “I” and “we” (...) can live well and act effectively in a world of so many other lively materialities? Drawing upon Whitman, Thoreau, Caillois, Whitehead, and other poetic writers, Bennett links a nonanthropocentric model of self to a radically egalitarian pluralism and also to a syntax and style of writing appropriate to the entangled world in which we live. The book tries to enact the uncanny process by which we “write up” influences that pervade, enable, and disrupt us. (shrink)

Can human beings be free and responsible if there is an all-powerful God? Anselm of Canterbury offers viable answers to questions which have plagued religious people for at least two thousand years. Katherin Rogers examines Anselm's reconciliation of human free will and divine omnipotence in the context of current philosophical debates.

The work of literary structuralists, particularly Roland Barthes, provides sharper insights into ethnomethodology than symbolic interactionism, labeling theory, or phenomenology. Further, it suggests that the metaphor of text may be fruitful for analysts of everyday life. Greater theoretical benefits derive from that metaphor, however, if one applies it using the ideas of literary theorists outside the structuralist tradition.

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)

_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)

A methodical study of the primitive cultures of the hunting-gathering peoples which focuses on their social structures and economic relations.