The coronavirus disease-2019 (COVID-19) has caused shortages of life-sustaining medical resources, and future waves of the virus may cause further scarcity. The Yale New Haven Health System developed a triage protocol to allocate scarce medical resources during the COVID-19 pandemic, with the primary goal of saving the most lives possible, and a secondary goal of making triage assessments and decisions consistent, transparent, and fair. We outline the process of developing the protocol, summarize the protocol, and discuss the major ethical challenges (...) encountered, along with our answers to the challenges. These challenges include (1) the role of age and chronic comorbidities; (2) evaluating children and pregnant patients; (3) racial, ethnic, and socioeconomic disparities in health; (4) prioritization of healthcare workers; and (5) balancing clinical judgment versus protocolized assessments.We conclude with a review of the limitations of our protocol and the lessons learned. We hope that a robust public discussion of such protocols and the ethical challenges they raise will result in the fairest possible processes, less need for triage, and more lives saved during future waves of the pandemic and similar public health emergencies. (shrink)

It is argued that the primary aim of institutional management is to protect the moral integrity of health professionals without significantly compromising other important values and interests. Institutional policies are recommended as a means to promote fair, consistent, and transparent management of conscience-based refusals. It is further recommended that those policies include the following four requirements: (1) Conscience-based refusals will be accommodated only if a requested accommodation will not impede a patient’s/surrogate’s timely access to information, counseling, and referral. (2) Conscience-based (...) refusals will be accommodated only if a requested accommodation will not impede a patient’s timely access to health care services offered within the institution. (3) Conscience-based refusals will be accommodated only if the accommodation will not impose excessive burdens on colleagues, supervisors, department heads, other administrators, or the institution. (4) Whenever feasible, health professionals should provide advance notification to department heads or supervisors. Formal review may not be required in all cases, but when it is appropriate, several recommendations are offered about standards and the review process. A key recommendation is that when reviewing an objector’s reasons, contrary to what some have proposed, it is not appropriate to adopt an adversarial approach modelled on military review boards’ assessments of requests for conscientious objector status. According to the approach recommended, the primary function of reviews of objectors’ reasons is to engage them in a process of reflecting on the nature and depth of their objections, with the objective of facilitating moral clarity on the part of objectors rather than enabling department heads, supervisors, or ethics committees to determine whether conscientious objections are sufficiently genuine. (shrink)

What is conscientious objection? -- Should conscientious objectors be accommodated? -- Assessing objectors' beliefs and reasons -- Accommodation and conscientious provision.

Consensus is growing among ethicists and lawyers that medical decision making for incompetent patients who were previously competent should be made in accordance with that person's prior wishes and desires. Moreover, this legal and ethical preference for the substituted judgment standard has found its way into the daily practice of medicine. However, what appears on the surface to be an agreement between jurists, bioethicists, and clinicians obscures the very real differences between disciplines regarding the actual implementation of the sub stituted (...) judgment standard. Ethicists and judges have carefully outlined how substituted judgments ought to be made and evaluated. Although differences arise, especially at the state court level, regarding the scope of the substituted judgment standard and its relation to other standards of surrogate decision making, agreement is fairly widespread on the priority of substituted judgment and on the necessity of sufficient evidence being available in order to support a particular substituted judgment. (shrink)

The American Journal of Bioethics, Volume 11, Issue 11, Page 17-18, November 2011.

While the importance of mechanisms in determining causality in medicine is currently the subject of active debate, the role of mechanistic reasoning in clinical practice has received far less attention. In this paper we look at this question in the context of the treatment of a particular individual, and argue that evidence of mechanisms is indeed key to various aspects of clinical practice, including assessing population-level research reports, diagnostic as well as therapeutic decision making, and the assessment of treatment effects. (...) We use the pulmonary condition bronchiectasis as a source of examples of the importance of mechanistic reasoning to clinical practice. (shrink)

: This paper examines informed consent in relation to research involving the newly dead. Reasons are presented for facilitating advance decision making in relation to postmortem research, and it is argued that the informed consent of family members should be sought when the deceased have not made a premortem decision. Regardless of whether the dead can be harmed, there are two important respects in which family consent can serve to protect the dead: (1) protecting the deceased's body from being used (...) for research that is incompatible with the person's premortem preferences and values and (2) protecting the deceased's body from being subject to disrespectful treatment. These claims are explained and justified, and several objections are critically examined. Additional reasons for securing family consent are presented including to protect them from additional emotional distress, to respect their wishes about wanting to have a say, and to maintain public trust in the medical profession and medical research. The paper also examines the scope of disclosure in relation to postmortem research. (shrink)

Evidence-based medicine (EBM) has thus far failed to adequately account for the appropriate incorporation of other potential warrants for medical decision making into clinical practice. In particular, EBM has struggled with the value and integration of other kinds of medical knowledge, such as those derived from clinical experience or based on pathophysiologic rationale. The general priority given to empirical evidence derived from clinical research in all EBM approaches is not epistemically tenable. A casuistic alternative to EBM approaches recognizes that five (...) distinct topics, 1) empirical evidence, 2) experiential evidence, 3) pathophysiologic rationale, 4) patient goals and values, and 5) system features are potentially relevant to any clinical decision. No single topic has a general priority over any other and the relative importance of a topic will depend upon the circumstances of the particular case. The skilled clinician must weigh these potentially conflicting evidentiary and non-evidentiary warrants for action, employing both practical and theoretical reasoning, in order to arrive at the best choice for an individual patient. (shrink)

In response to physicians who refuse to provide medical services that are contrary to their ethical and/or religious beliefs, it is sometimes asserted that anyone who is not willing to provide legally and professionally permitted medical services should choose another profession. This article critically examines the underlying assumption that conscientious objection is incompatible with a physician’s professional obligations (the “incompatibility thesis”). Several accounts of the professional obligations of physicians are explored: general ethical theories (consequentialism, contractarianism, and rights-based theories), internal morality (...) (essentialist and non-essentialist conceptions), reciprocal justice, social contract, and promising. It is argued that none of these accounts of a physician’s professional obligations unequivocally supports the incompatibility thesis. (shrink)

Physicians are expected to engage patients as partners in identifying the possible benefits and harms associated with treatment options and selecting from among medically appropriate treatment options, rather than simply dictating what treatments patients will and will not receive. This collaborative model reflects the recognition that citizens in multicultural societies have diverse values and are likely to have different views about whether the possible benefits of a medical intervention outweigh the possible harms. However, there are circumstances in which the collaborative (...) process breaks down due to irresolvable disagreement. Especially challenging are cases in which patients are expected to die if they do not receive a treatment and either the patients or their surrogates insist on the treatment despite the physician's belief that providing it is ill advised. The source of disagreement is often differing appraisals of the risks and potential benefits. In such cases, physicians generally judge that there is insufficient likelihood or magnitude of benefit to justify the burdens or expense of treatment, while patients or surrogates believe that the small chance of preventing the patient's death is sufficient to justify the costs and potential burdens to the patient.There is a perception that surgeons enjoy considerable discretion in deciding when the risks of a procedure outweigh the expected benefits. An important contrast can be drawn between surgeons and intensivists—physicians who specialize in the medical management of critically ill patients. We will argue that there are good reasons for subjecting the decisions of both surgeons and intensivists to some oversight. We begin by showing that, for many cases, major professional society guidelines for intensivists recommend oversight via a procedural mechanism rather than unilateral decision‐making by individual clinicians. Next, we present reasons for adopting a procedural approach to dispute resolution, and we argue that these reasons apply to situations in which intensivists believe that patients or surrogates are requesting inappropriate life support as well as to many disagreements between surgeons and surrogates. Finally, we present and respond to several objections. (shrink)

: Research involving the dead, especially heart-beating cadavers, may facilitate the testing of potentially revolutionary and life-saving medical treatments. However, to ensure that such research is conducted ethically, it is essential to: (1) identify appropriate standards for this research and (2) assign institutional responsibility and a mechanism for oversight. Protocols for research involving the dead should be reviewed by a special committee and assessed according to nine standards intended to ensure scientific merit, to protect deceased patients and their families, and (...) to promote institutional integrity and responsibility. Federal regulation of research involving the dead will foster appropriate standards and, equally importantly, help establish the acceptability of such research. (shrink)

Typically, a refusal to provide a medical service is an instance of conscientious objection only when the medical service is legal, professionally accepted, and clinically appropriate. That is, conscientious objection typically occurs only when practitioners reject prevailing norms or practices. Insofar as refusing to provide antibiotics for a viral infection does not violate prevailing clinical norms, there is no need for the physician in Case 1 to justify his refusal to provide antibiotics by appealing to his conscience.1 By contrast, insofar (...) as emergency contraception is legal and does not violate prevailing norms of good medical practice, the physician in Case 6 cannot justify his refusal to provide EC by... (shrink)

This special issue of HEC Forum includes articles on a wide range of specific topics that make significant contributions to conscientious objection scholarship. In this commentary, it is not feasible to provide a comprehensive analysis of each of the articles; and I have not attempted to do so. Instead, for each article, I have selected specific issues and arguments on which to comment.

Unemployment has been at historically high rates for an extended period, and while it has recently improved in certain countries, the unemployment that remains may be becoming structural. Aside from inequality, unemployment is accordingly the problem that is most likely to put critical pressure on our political institutions, disrupt the social fabric of our way of life, and even threaten the continuation of liberalism itself. Despite the obvious importance of the problem of unemployment, however, there has been a curious lack (...) of attention paid to this issue by contemporary non-Marxist political philosophers. Non-Marxists typically view unemployment as a technical matter, and doing something about it a question of means not ends, with the solution to this question depending on the kind of empirical determinations about what causes what that are best left to economists, not political philosophers. But I think this is a mistake. Because work is a major part of our social life, as well as something that for a great many people grounds their sense of who they are and provides the basis of their sense of self-respect, those unable to find work are missing out on a great deal of what makes for a meaningful life, and not just the economic benefits that social cooperation has to offer. Those who are unemployed accordingly have something to complain about, even if we do not let them starve, and the rest of us (or at least the institutions that represent us) may have some sort of moral obligation to take action to increase the number of employment opportunities currently available regardless of any uncertainty surrounding the effects that any actions open to us might have. The nature and extent of this moral obligation is what On Unemployment is dedicated to exploring. (shrink)

Terrorism is commonly viewed as a form of war, and as a form of war, the morality of terrorism seems to turn on the usual arguments regarding the furtherance of political objectives through coercive means. The terrorist argues that his options for armed struggle are limited, and that the use of force against civilians is the only way he can advance his cause. But this argument is subject to a powerful response. There is the argument from consequences, which asserts that (...) terrorism is almost always counterproductive, even assuming the terrorist’s political objectives are legitimate. There is the argument from rights, which claims that terrorism violates the basic human rights of (at least) its civilian victims, and is therefore morally objectionable regardless of its consequences. And there is the argument from virtue, which notes that slaughtering civilians requires no skill or courage and therefore generates no honor or glory, making the terrorist not a virtuous warrior but a vicious one. But terrorism is not only a means of political coercion. It is also, in the view of many terrorists, a means of retribution. It is a means of exacting punishment on a political community the terrorist believes is collectively responsible for grievous wrongs certain members of that community have committed. And viewed as a means of retribution, the usual arguments made against terrorism-as-coercion have no moral force. To explain why terrorism-as-retribution is morally wrong, we must attack the notion of collective responsibility on which the terrorist relies. (shrink)

The reality of resource limitation during the Coronavirus Disease 2019 pandemic has deeply challenged established approaches to healthcare system emergency response. Early preparation du...

Those who provide medical care for infants born extremely prematurely, at what is often referred to as borderline viability, have long grown accustomed to working with the parent(s) to reach a deci...

In “Disentangling Conscience Protections,” in this issue of the Hastings Center Report, Nadia Sawicki offers a taxonomy of conscience protection laws (conscience clauses) that highlights the expansive protections they can offer to health professionals who refuse to provide a medical service for reasons of conscience. Conscience clauses can protect health professionals from adverse actions by public actors (such as administrative agencies, prosecutors, and government funders) or private actors (such as employers, private professional associations, and injured patients), and they can also (...) protect health professionals from being subject to adverse actions for their beliefs, their conduct, or harm that results from their conduct. This taxonomy provides an accurate description of the broad range of protections conscience clauses can offer and thereby is a valuable contribution to the scholarly literature on conscientious objection in health care. But it remains to consider whether the distinctions Sawicki identifies disentangle conscience protections beyond merely providing a taxonomy. In particular, does the taxonomy identify relevant distinctions in relation to determining whether a conscience clause is justified? (shrink)

Recognition of conscientious objection seems reasonable in relation to controversial and contentious issues, such as physician assisted suicide and abortion. However, physicians also advance conscience‐based objections to actions and practices that are sanctioned by established norms of medical ethics, and an account of their moral force can be more elusive in such contexts. Several possible ethical justifications for recognizing appeals to conscience in medicine are examined, and it is argued that the most promising one is respect for moral integrity. It (...) is also argued that an appeal to conscience has significant moral weight only if the core ethical values on which it is based correspond to one or more core values in medicine. Finally, several guidelines pertaining to appeals to conscience and their ethical evaluation are presented. (shrink)

This paper examines the varied cultural meanings of computer game play in competitive and professional computer gaming and live-streaming. To do so it riffs off Andrew Feenberg’s 1994 work exploring the changing meanings of the ancient board game of Go in mid-century Japan. We argue that whereas Go saw a de-aestheticization with the growth of newspaper reporting and a new breed of ‘westernized’ player, the rise of professionalized computer gameplay has upset this trend, causing a re-aestheticization of professional game competition (...) as a result of the many informal elements that contribute to the successes, and public perceptions, of professional players. In doing so we open up the consideration of the aesthetics of broadcasted gameplay, how they reflect back upon the players and the game, and locate this shift historically and culturally within the last two decades of computer games as a creative industry, entertainment industry, a media form, and as an embodied practice. (shrink)

In a provocative 1974 article entitled “Harvesting the Dead,” Willard Gaylin explored potential uses of “neomorts,” or what are currently referred to as “heart-beating cadavers”—that is, humans determined to be dead by neurological criteria and whose cardiopulmonary function is medically maintained by ventilators, vasopressors, and so forth. Medical research was one of the potential uses Gaylin identified. He pointed out that tests of drugs and medical procedures that would have unacceptable health risks if performed on living human subjects could be (...) performed on neomorts without any health risks. According to Gaylin, the potential benefits of such research could be enormous, including not subjecting patients to ineffective or harmful medical procedures and eliminating delays in providing effective therapies to dying patients. (shrink)

Ethical particularists allege that there are, on account of epistemological limitations, no such things as general moral principles. This paper defends the existence of general moral principles by adapting and appropriating Polanyi’s epistemology of science to this problem in moral philosophy.

This paper will demonstrate that the distinction between arguments and adverbials is reflected in initial phrase-structure, pace Larson (1988), rather than simply in the lexical entries of verbs.

Childbearing is an increasingly complicated matter, which has evolved significantly over the past several decades. Treatment options for infertility have expanded. Prenatal testing and treatment have led to an evolution in obstetrical decision-making, wherein the risks and benefits to the fetus and future child are better understood and more strongly considered in medical management of the pregnant woman. Obstetrics appears to be increasingly interventional; one in three babies in the United States is now born by cesarean section. Neonatal intensive care (...) has markedly improved outcomes for premature babies. A pregnant woman may now be presented with many options— obstetrician or midwife, home or hospital delivery, choices among prenatal testing and monitoring, early induction of labor, cesarean delivery. Health care professionals face similar decisions with regard to what they recommend and the boundaries of safe and responsible care they should make available. Preterm Babies, Fetal Patients, and Childbearing Choices, by John D. Lantos and Diane S. Lauderdale, provides an excellent overview of the available information relevant to these questions. (shrink)

According to the conventional view, causal and moral responsibility have a strict hierarchical relationship. Determining causal responsibility comes first; then we sort through the factors to which we have assigned causal responsibility and determine which, if any, should be assigned moral responsibility too. Moral inquiry accordingly stands not only apart but also above causal inquiry. But I am going to argue that this way of looking at causal and moral responsibility is a mistake. Rather than being separate and independent inquires (...) with different purposes and concerns, I am going to argue that finding causal responsibility actually entails finding moral responsibility even when there is no evidence of what we would call traditional fault. Indeed, I am going to argue we cannot find someone causally responsible without finding them morally responsible too. (shrink)

The persistent failure of public schooling in low-income communities constitutes one of our nation's most pressing civil rights and social justice issues. Many school reformers recognize that poverty, racism, and a lack of power held by these communities undermine children's education and development, but few know what to do about it. A Match on Dry Grass argues that community organizing represents a fresh and promising approach to school reform as part of a broader agenda to build power for low-income communities (...) and address the profound social inequalities that affect the education of children. Based on a comprehensive national study, the book presents rich and compelling case studies of prominent organizing efforts in Chicago, New York City, Los Angeles, Denver, San Jose, and the Mississippi Delta. The authors show how organizing groups build the participation and leadership of parents and students so they can become powerful actors in school improvement efforts. They also identify promising ways to overcome divisions and create the collaborations between educators and community residents required for deep and sustainable school reform. Identifying the key processes that create strong connections between schools and communities, Warren, Mapp, and their collaborators show how community organizing builds powerful relationships that lead to the transformational change necessary to advance educational equity and a robust democracy. (shrink)