While COVID-19 has generated a massive burden of illness worldwide, healthcare workers (HCWs) have been disproportionately exposed to SARS-CoV-2 coronavirus infection. During the so-called ‘first wave’, infection rates among this population group have ranged between 10% and 20%, raising as high as one in every four COVID-19 patients in Spain at the peak of the crisis. Now that many countries are already dealing with new waves of COVID-19 cases, a potential competition between HCW and non-HCW patients for scarce resources can (...) still be a likely clinical scenario. In this paper, we address the question of whether HCW who become ill with COVID-19 should be prioritised in diagnostic, treatment or resource allocation protocols. We will evaluate some of the proposed arguments both in favour and against the prioritisation of HCW and also consider which clinical circumstances might warrant prioritising HCW and why could it be ethically appropriate to do so. We conclude that prioritising HCW’s access to protective equipment, diagnostic tests or even prophylactic or therapeutic drug regimes and vaccines might be ethically defensible. However, prioritising HCWs to receive intensive care unit (ICU) beds or ventilators is a much more nuanced decision, in which arguments such as instrumental value or reciprocity might not be enough, and economic and systemic values will need to be considered. (shrink)

This is the second paper in a two-part series describing subject and family perspectives from the CENTURY-S (CENtral Thalamic Deep Brain Stimulation for the Treatment of Traumatic Brain InjURY-Safety) first-in-human invasive neurological device trial to achieve cognitive restoration in moderate to severe traumatic brain injury (msTBI). To participate, subjects were independently assessed to formally establish decision-making capacity to provide voluntary informed consent. Here, we report on post-operative interviews conducted after a successful trial of thalamic stimulation. All five msTBI subjects met (...) a pre-selected primary endpoint of at least a 10% improvement in completion time on Trail-Making-Test Part B, a marker of executive function. We describe narrative responses of subjects and family members, refracted against that success. Interviews following surgery and the stimulation trial revealed the challenge of adaptation to improvements in cognitive function and emotional regulation as well as altered (and restored) relationships and family dynamics. These improvements exposed barriers to social reintegration made relevant by recoveries once thought inconceivable. The study’s success sparked concerns about post-trial access to implanted devices, financing of device maintenance, battery replacement, and on-going care. Most subjects and families identified the need for supportive counseling to adapt to the new trajectory of their lives. (shrink)

Patient narratives from two investigational deep brain stimulation trials for traumatic brain injury and obsessive‐compulsive disorder reveal that injury and illness rob individuals of personal identity and that neuromodulation can restore it. The early success of these interventions makes a compelling case for continued post‐trial access to these technologies. Given the centrality of personal identity to respect for persons, a failure to provide continued access can be understood to represent a metaphorical identity theft. Such a loss recapitulates the pain of (...) an individual's initial injury or illness and becomes especially tragic because it could be prevented by robust policy. A failure to fulfill this normative obligation constitutes a breach of disability law, which would view post‐trial access as a means to achieve social reintegration through this neurotechnological accommodation. (shrink)

As improvements in neuroscience have enabled a better understanding of disorders of consciousness as well as methods to treat them, a hurdle that has become all too prevalent is the denial of coverage for treatment and rehabilitation services. In 2011, a settlement emerged from a Vermont District Court case, Jimmo v. Sebelius, which was brought to stop the use of an “improvement standard” that required tangible progress over an identifiable period of time for Medicare coverage of services. While the use (...) of this standard can have deleterious effects on those with many chronic conditions, it is especially burdensome for those in the minimally conscious state, where improvements are unpredictable and often not manifested through repeatable overt behaviors. Though the focus of this paper is on the challenges of brain injury and the minimally conscious state, which an estimated 100,000 to 200,000 individuals suffer from in the United States, the post-Jimmo arguments presented can and should have a broad impact as envisioned by the plaintiffs who brought the case on behalf of multiple advocacy groups representing patients with a range of chronic care conditions. (shrink)

When the COVID-19 surge hit New York City hospitals, the Division of Medical Ethics at Weill Cornell Medical College, and our affiliated ethics consultation services, faced waves of ethical issues sweeping forward with intensity and urgency. In this article, we describe our experience over an eight-week period (16 March through 10 May 2020), and describe three types of services: clinical ethics consultation (CEC); service practice communications/interventions (SPCI); and organizational ethics advisement (OEA). We tell this narrative through the prism of time, (...) describing the evolution of ethical issues and trends as the pandemic unfolded. We delineate three phases: anticipation and preparation, crisis management, and reflection and adjustment. The first phase focused predominantly on ways to address impending resource shortages and to plan for remote ethics consultation, and CECs focused on code status discussions with surrogates. The second phase was characterized by the dramatic convergence of a rapid increase in the number of critically ill patients, a growing scarcity of resources, and the reassignment/ redeployment of staff outside their specialty areas. The third phase was characterized by the recognition that while the worst of the crisis was waning, its medium- and long-term consequences continued to pose immense challenges. We note that there were times during the crisis that serving in the role of clinical ethics consultant created a sense of dis-ease as novel as the coronavirus itself. In retrospect we learned that our activities far exceeded the familiar terrain of clinical ethics consultation and extended into other spheres of organizational life in novel ways that were unanticipated before this pandemic. To that end, we defined and categorized a middle level of ethics consultation, which we have termed service practice communication intervention (SPCI). This is an underappreciated dimension of the work that ethics consult services are capable of in times of crisis. We believe that the pandemic has revealed the many enduring ways that ethics consultation services can more robustly contribute to the ethical life of their institutions moving forward. (shrink)

This is the first article in a two-part series describing subject and family perspectives from the central thalamic deep brain stimulation for the treatment of traumatic brain injury using the Medtronic PC + S first-in-human invasive neurological device trial to achieve cognitive restoration in moderate to severe traumatic brain injury, with subjects who were deemed capable of providing voluntary informed consent. In this article, we report on interviews conducted prior to surgery wherein we asked participants about their experiences recovering from (...) brain injury and their perspectives on study enrollment and participation. We asked how risks and benefits were weighed, what their expectations and fears were, and how decisions were reached about trial participation. We found that informed consent and enrollment decisions are fraught. Subjects and families were often split, with subjects more focused on putative benefits and families concerned about incremental risk. Both subjects and families viewed brain injury as disruptive to personal identity and relationships. As decisions were made about study enrollment, families struggled with recognizing the re-emergent agency of subjects and ceding decision-making authority to subjects who had previously been dependent upon them for protection and guidance. Subjects and family members reported a hope for the relief of cognitive disabilities, improved quality of life, normalization of interpersonal interactions, and a return to work or school as reasons for study participation, along with altruism and a desire to advance science. Despite these aspirations, both subjects and families appreciated the risks of the intervention and did not suffer from a therapeutic misconception. A second essay to be published in the next issue of Cambridge Quarterly of Healthcare Ethics—Clinical Neuroethics will describe interviews conducted after surgery, the effects of cognitive restoration for subjects, families, and challenges presented to the social structures they will call upon to support them through recovery. This subsequent article will be available online prior to its formal publication in October 2023. (shrink)

Objective Although patients exercise greater autonomy than in the past, and shared decision making is promoted as the preferred model for doctor-patient engagement, tensions still exist in clinical practice about the primary locus of decision-making authority for complex, scarce, and resource-intensive medical therapies: patients and their surrogates, or physicians. We assessed physicians’ attitudes toward decisional authority for adult venoarterial extracorporeal membrane oxygenation (VA-ECMO), hypothesizing they would favor a medical locus. Design, Setting, Participants A survey of resident/fellow physicians and internal medicine (...) attendings at an academic medical center, May to August 2013. Measurements We used a 24-item, internet-based survey assessing physician-respondents’ demographic characteristics, knowledge, and attitudes regarding decisional authority for adult VA-ECMO. Qualitative narratives were also collected. Main Results A total of 179 physicians completed the survey (15 percent response rate); 48 percent attendings and 52 percent residents/ fellows. Only 32 percent of the respondents indicated that a surrogate’s consent should be required to discontinue VA-ECMO; 56 percent felt that physicians should have the right to discontinue VA-ECMO over a surrogate’s objection. Those who self-reported as “knowledgeable” about VA-ECMO, compared to those who did not, more frequently replied that there should not be presumed consent for VA-ECMO (47.6 percent versus 33.3 percent, p = 0.007), that physicians should have the right to discontinue VAECMO over a surrogate’s objection (76.2 percent versus 50 percent, p = 0.02) and that, given its cost, the use of VA-ECMO should be restricted (81.0 percent versus 54.4 percent, p = 0.005). Conclusions Surveyed physicians, especially those who self-reported as knowledgeable about VA-ECMO and/or were specialists in pulmonary/ critical care, favored a medical locus of decisional authority for VA-ECMO. VA-ECMO is complex, and the data may (1) reflect physicians’ hesitance to cede authority to presumably less knowledgeable patients and surrogates, (2) stem from a stewardship of resources perspective, and/or (3) point to practical efforts to avoid futility and utility disputes. Whether these results indicate a more widespread reversion to paternalism or a more circumscribed usurping of decisional authority occasioned by VA-ECMO necessitates further study. (shrink)

ABSTRACT:Daniel Callahan died on July 16, 2019, just short of his 89th birthday. In the years since, we have seen the overturning of abortion rights, a concern central to his scholarship and musings about the place of religion in American civic life. Callahan’s journey from lay Catholic journalist and commentator at Commonweal to a co-founder of the Hastings Center, during his decade of doubt, is especially relevant today as America revisits established precedent governing a woman’s right to choose. His life-long (...) struggle with faith and the secularization of bioethics is a story worth telling, as it may foster dialogue across a divide between religious and laical thinkers that has fractured our political discourse. We recall Callahan’s misgivings about the marginalization of religious perspectives in public life; he sought not the denial of complexity nor of difference in views, but rather the importance of free and honest debate around deeply held beliefs, contextualized in the realities of the contemporary world. Callahan’s ambivalence about his faith remains a part of the fabric of American life, a story that Callahan chronicled to our collective benefit for over a half-century. (shrink)

Research in education and cognitive development suggests that explaining plays a key role in learning and generalization: When learners provide explanations—even to themselves—they learn more effectively and generalize more readily to novel situations. This paper proposes and tests a subsumptive constraints account of this effect. Motivated by philosophical theories of explanation, this account predicts that explaining guides learners to interpret what they are learning in terms of unifying patterns or regularities, which promotes the discovery of broad generalizations. Three experiments provide (...) evidence for the subsumptive constraints account: prompting participants to explain while learning artificial categories promotes the induction of a broad generalization underlying category membership, relative to describing items (Exp. 1), thinking aloud (Exp. 2), or free study (Exp. 3). Although explaining facilitates discovery, Experiment 1 finds that description is more beneficial for learning item details. Experiment 2 additionally suggests that explaining anomalous observations may play a special role in belief revision. The findings provide insight into explanation’s role in discovery and generalization. (shrink)

Let’s face it, the humanities are in trouble. Last year, in The Chronicle of Higher Education, Thomas H. Benton warned prospective graduate students to avoid doctoral studies in the humanities. His rationale: a job market down 40%, the improbability of tenure, the more certain prospect of life as an adjunct, and eventual outright exile from one’s chosen field. Benton, the pen name of William Pannapacker, an associate professor of English at Hope College in Holland, Michigan, pulled no punches. His piece (...) was entitled, “Graduate School in the Humanities: Just Don’t Go.”. (shrink)

If ever I summon before me my highest ideals of men and medicine, I find them sprung from the spirit of Osler. —Wilder Penfield, M.D. Neuroethics is a recently coined term that is shaping our cultu...

Jacques Rancière: An Introduction offers the first comprehensive introduction to the thought of one of today's most important and influential theorists. Joseph Tanke situates Rancière's distinctive approach against the backdrop of Continental philosophy and extends his insights into current discussions of art and politics. Tanke explains how Rancière's ideas allow us to understand art as having a deeper social role than is customarily assigned to it, as well as how political opposition can be revitalized. The book presents Rancière's body (...) of work as a coherent whole, tracing key notions such as the distribution of the sensible, the aesthetics of politics, and the supposition of equality from his earliest writings through to his most recent interventions. Tanke concludes with a series of critical questions for Rancière's work, indicating how contemporary thought might proceed after its encounter with him. The book provides readers new to Rancière with a clear overview of his enormous intellectual output. Engaging with many un-translated and unpublished sources, the book will also be of interest to Rancière's long-time readers. (shrink)

As scholars envision a new regulatory or statutory neurorights schema it is important to imagine unintended consequences if reforms are implemented before their implications are fully understood. This paper critically evaluates provisions proposed for a new Chilean Constitution and evaluates this movement against efforts to improve the diagnosis of, and treatment for, individuals with disorders of consciousness within the broader context of disability law, international human rights, and a capabilities approach to health justice as advanced by Amartya Sen and Martha (...) Nussbaum. Framed in this way, any neurorights regime would need to satisfy several criteria. First it would be obliged to balance both positive and negative rights in the furtherance of human capabilities. Second, it would need to be future oriented and informed about the science it sought to regulate and not fall prey to science fiction fantasies that remain ungrounded in reality. Third, it would need to be specific and avoid generalizations that would lead to conceptual confusion and litigation that could delay scientific progress. Finally, it would need to harmonize novel neurorights with long-established norms in international disability and human rights law. A failure to meet these criteria will destine any novel neurorights regime to the periphery. At this juncture Chile’s nascent constitutional venture into neurorights fails to satisfy these criteria. While there yet may be a role for a more capacious and bivalent articulation of neurorights that account for capabilities and precedent, the current Chilean neurorights reforms are vague and premature. As such they should undergo additional scholarly scrutiny and should not be adopted by other jurisdictions. (shrink)

"This fine work's ample documentation should gladden the scholarly reader while its accessible prose & well-organized presentation will make it useful for ...

Hastings Center Report, Volume 52, Issue 2, Page 21-31, March‐April 2022.

In this essay an effort is made to answer the question of what function psychology and psychiatry have in merleau-ponty's ``the structure of behavior and phenomenology of perception''. it is argued that in his first book merleau-ponty tried to present a philosophical critique of the behaviorist and gestaltist interpretations of empirical psychology, whereas ``phenomenology of perception'' attempts to make a contribution to philosophical anthropology which in many instances employs analyses which belong to phenomenological psychology, the regional ontology of psychic phenomena.

Introduction -- The stirrings of modernity -- Rupture -- Non-affirmative painting -- Anti-platonism -- The cynical legacy.

While we share many of the views on emotion research put forth in Kagan’s article “Once More into the Breach,” our commentary focuses on two points of disagreement. First, we argue for the importance of a priori principles. In particular, emotions cannot be understood without reference to final and formal cause, and the related principles of equifinality and equipotentiality. Secondly, although we agree the term “basic emotions” is misleading, we maintain that the emotions traditionally called “basic” should still be seen (...) as a distinct set of emotions by virtue of their being constitutive for other, derived emotions. In conclusion we argue for moving beyond the strict empiricist approach proposed by Kagan and many thinkers before him. (shrink)

Pickering & Garrod's interactive alignment account corresponds directly with the account Skinner gave in his book Verbal Behavior. This correspondence becomes evident when “properties of verbal stimuli” substitutes for “channels of alignment.” Skinner 's account appears to have the dual advantages of requiring fewer basic terms and integrating the field of verbal behavior with the whole field of human behavior.

In lieu of an abstract, here is a brief excerpt of the content:Minding Brain Injury, Consciousness, and Ethics: Discourse and DeliberationsJoseph J. Fins (bio) and James Giordano (bio)The annual John Collins Harvey Lecture at the Georgetown University’s Pellegrino Center for Clinical Bioethics is a forum for addressing contemporary topics at the intersection of medicine and bioethics. This year, in marking the decadal anniversary of the launch of the Brain Research through Advancing Innovative Neurotechnology (BRAIN) Initiative, the Harvey Lecture provided an (...) interactive discussion with renowned clinician, researcher, scholar, and author, Joseph J. Fins, MD—who is the E. William Davis, Jr., MD Professor of Medical Ethics, Chief of the Division of Medical Ethics, and a Professor of Medicine at Weill Cornell Medical College—conducted by James Giordano, PhD, MPhil—who is a Professor of Neurology and Biochemistry, and Chief of the Pellegrino Center’s Neuroethics Studies Program at the Georgetown University Medical Center. The discourse focused upon the topic of covert consciousness, and the ways in which current and developing brain science technologies, together with revised practices of medicine, in general, may afford new opportunities in patient care, but may also give rise to issues, questions, challenges, and opportunities for neuroethics.Prof. James GIORDANO:Prof. Fins, your most recent book, Rights Come to Mind: Brain Injury, Ethics, and the Struggle for Consciousness (Fins 2015), addresses your ongoing work to employ current and emerging neurological approaches to reveal conscious functions in patients with profound brain injury and disease. To be sure, the destination—if you will—is to talk about covert consciousness. But in commencing this discussion, I’d like to propose a route, which traces your professional journey to this point in your career, and how it led you on your search to reveal consciousness in those patients who lack expressive capability. You went into palliative care first, and that brought you to where you are today. [End Page 227]Prof. Joseph J. FINS:First, let me thank you and the Pellegrino Center for the honor of giving the John Harvey Collins Lecture in such an interactive manner. The forefront of neurological care—and the neuroethical issues and methods focal to such practice—wasn’t what I initially intended to do professionally, but I think that therein is a good lesson for young people’s career aspirations. Simply put, one doesn’t always know where they’ll end up at the beginning of the journey, and as Kierkegaard said, life is lived forward, but is understood backwards (Kierkegaard 1843).In the nineties and the early 2000s, I was trying to help improve the quality of care of people at the end of life, and I wrote a book, entitled The Palliative Ethic of Care: Clinical Wisdom at Life’s End (Fins 2006), in which I addressed notions of phronesis—practical wisdom—in integrating theory and practice toward improving how people die. I became interested in the Quinlan case (Quinlan 1976), and the right to die, and around the same time, I ran into a colleague of mine at Cornell: Dr. Nicholas D. Schiff. Dr. Schiff is a neurologist, who was a protégé of Fred Plum, who was the originator of the concept of the vegetative state with Bryan Jennett, back in 1972. Fred was both of our teachers here at Cornell. Niko (Dr. Schiff) was interested in patients with disorders of consciousness, and was beginning to envision doing work—that ultimately, we did—using deep brain stimulation (DBS) to try to treat patients in the minimally conscious state, a category that was subsequently codified in 2002.I realized that a whole population of people—with these disorders of consciousness—had been somewhat marginalized, and their neglect essentially devolves back to the considerations of the right to die. The right to die was established in the Quinlan case because Judge Hughes—the presiding chief judge of the New Jersey Supreme Court—talked about Ms. Quinlan’s loss of a cognitive, sapient state as being the moral warrant for her right to die, given the fact that it was viewed as a futile situation. I recognized, over the ensuing years—from my background in palliative and end-of-life care—[1] that we had over-generalized notions of futility... (shrink)

I would like to share some reflections on how bioethics fosters dialogue between the sciences and humanities by talking a bit about my work as a physician-ethicist collaborating with neuroscientists studying severe brain injury and mechanisms of recovery. If I am successful in this Pilgrim's Progress, I hope I will convince you that the injured brain can teach us much about ourselves. It is not something I was prepared to believe as a medical student, when I was more certain of (...) things than I am now. (shrink)

The purpose of this essay is to indicate the extent to which there is a privileged relationship between the experience of the death of a friend and an understanding of what it means to be a self or a subject. In particular this claim is raised against Heidegger who in ¶47 of _Being and Time_ seems to have raised and explicitly denied any such connection but on closer review turns out to have in fact ignored it altogether. This essay aims (...) to wrestle back from Heidegger the irreducible significance of an other’s death by casting light on a specific kind of intersubjectivity that Heidegger fails to consider: friendship. Drawing on the recently published course materials from Heidegger’s tenure in Freiburg, and in particular the 1921 lectures on Augustine’s _Confessions_, this essays points to a decisive turning point in Heidegger’s theory of Mitsein, if only by exposing a road not taken. The argument is that it is precisely because Heidegger, in fact, considers only the death of a “random stranger” rather than anybody that one actually cares for, that he has an easy time dismissing the significance of the death of another. Against Heidegger this essay will argue that when a friend dies one loses not only her friend’s presence but also something of her own. In so suggesting, this essay departs from the otherwise familiar critiques of Heidegger styled after Fichte, Hegel, or Levinas. (shrink)

Heyman s analysis of the relevant complex behavioral variables associated with addiction is evaluated in relation to identifying the appropriate variables in behavior analysis. The model of behavioral allocation and choice known as melioration, discussed by Heyman as a way to understand the complexities of addiction, is examined and contrasted with another model of matching called ratio invariance, which is offered in this commentary as another behavioral account with a significant potential for resolving the contradictions of addiction.

This paper builds on previous work by Sirgy, M. J., Journal of Business Ethics 19, 193–206, dealing with issues of code of conduct of marketing educators. Sirgy developed a discussion document outlining a semblance of what might be construed as a code of ethics for marketing educators. The discussion document was debated and accompanied by three commentaries. One conclusion derived from the discussion document and the commentaries is the need to develop a code of ethics involving behaviors that most marketing (...) educators find morally unacceptable. The current paper reports on a descriptive study involving a survey of marketing educators in which survey respondents were asked to rate the extent to which certain behaviors are deemed acceptable or unacceptable. The results of the survey identified certain behaviors deemed unacceptable by the vast majority of survey respondents. This evidence of hypernorms within the community of marketing educators was used to propose an initial code of ethics. (shrink)

Although Shanker & King disregard the behavioral paradigm, their arguments are reminiscent of those in Skinner 's Verbal Behavior. Like S&K, Skinner maintained that communication is not appropriately characterized as the transmission of information between individuals. In contrast to the paradigm advocated by S&K, however, the behavioral paradigm emphasizes prediction and control as important scientific goals.

The paper presents Henry More’s doctrine of the Spirit of Nature. Through a thorough analysis of both his earlier and later work, it shows in which regards he draws from traditional Neo-Platonic notions of a soul of the world and in which regards he transforms it in order to fi t it into the framework of early modern natural philosophy. The guideline is an attempt to map possible parallels between the functions of imagination on a microcosmic scale and the Spirit (...) of Nature on a macrocosmic one. Although this parallel cannot be pushed through to its ultimate consequences within More’s system, it nevertheless proves to be fruitful. Both the Spirit of Nature and the imagination are for More something ambivalent, both noble and gross, on the edge between body and soul. As such, however, they are remnants of More’s early gradualism that are in confl ict with the psycho-physical dualism he endorsed in his later work. (shrink)

Incapacitated adults with a legally appointed guardian or conservator may be recruited for or involved with medical, behavioral, or social science research. Much of the research in which such persons participate is aimed at evaluating medical interventions for them, or contributing to general knowledge about disorders from which they may suffer. In this paper we will consider how the appointment of guardians for patients with disorders of consciousness —severe brain injuries that affect a patient’s level of arousal and ability to (...) interact —impacts such patients’ access to research.Such persons may be under guardianship because they have lost decisional capacity (i.e., those in a coma or... (shrink)

Spiritualist ethics: The problem of evil, by L. Lavelle. On conscience, or On the pain of having-done-it, by V. Jankélévitch. Value and immortality; and, Dangerous situation of ethical values, by G. Marcel. The concept of fallibility, by P. Ricoeur.--Axiological ethics: Ethics and metaphysics, by R. Le Senne. Good and evil, by H. Reiner. Values and truths, by R. Polin. Values as principles of action, by G. Gusdorf.--Three contemporary conceptions of humanism: Jean-Paul Sartre: Sartre on humanism, by J. J. Kockelmans. Moral (...) perspectives in Sartre's thought, by F. Jeanson. Ambiguity, by S. de Beauvoir. Albert Camus: Albert Camus and the ethic of absurdity, by H. Hochberg. On humanism, by M. Heidegger. Existentialism's basic ethical position, by O. Bollnow.--Situation ethics: Systematic essentialist ethics and existential situation ethics, by T. Steinbüchel. The question of the Single One, by M. Buber. What is a Christian ethic? By D. Bonhoeffer. Meaning and analysis of the borderline situation, by H. Thielicke. (shrink)