This article argues that while the presence and influence of “futility” as a concept in medical decision-making has declined over the past decade, medicine is seeing the rise of a new concept with similar features: suffering. Like futility, suffering may appear to have a consistent meaning, but in actuality, the concept is colloquially invoked to refer to very different experiences. Like “futility,” claims of patient “suffering” have been used (perhaps sometimes consciously, but most often unconsciously) to smuggle value judgments about (...) quality of life into decision-making. And like “futility,” it would behoove us to recognize the need for new, clearer terminology. This article will focus specifically on secondhand claims of patient suffering in pediatrics, but the conclusions could be similarly applied to medical decisions for adults being made by surrogate decision-makers. While I will argue that suffering, like futility, is not sufficient wholesale justification for making unilateral treatment decisions, I will also argue that claims of patient suffering cannot be ignored, and that they almost always deserve some kind of response. In the final section, I offer practical suggestions for how to respond to claims of patient suffering. (shrink)

Our aim in this article is to bring some clarity to the clinical ethics expertise debate by critiquing and replacing the taxonomy offered by the Core Competencies report. The orienting question for our taxonomy is: Can clinical ethicists offer justified, normative recommendations for active patient cases? Views that answer “no” are characterized as a “negative” view of clinical ethics expertise and are further differentiated based on (a) why they think ethicists cannot give justified normative recommendations and (b) what they think (...) ethicists can offer, if they cannot offer recommendations. Views that answer “yes” to the orienting question are characterized as a “positive” view of clinical ethics expertise. Positive views are distinguished according to four additional questions. First (P1), how are those recommendations generated? Second (P2), what is the nature of the recommendations? Third (P3), we ask, how are the recommendations justified? And finally (P4), how are the recommendations communicated? (shrink)

This article describes the process engaged by 17 expert scholars in the development of a set of six consensus recommendations about the normative foundations of pediatric decision-making. The process began with a robust pre-reading assignment, followed by three days of in-person symposium discussions that resulted in a publication in _Pediatrics_ entitled “Pediatric Decision-Making: Consensus Recommendations” (Salter et al. 2023). This article next compares the six recommendations to existing statements about pediatric decision-making (specifically those developed by the American Academy of (...) Pediatrics), highlighting similarities and differences. Finally, the article discusses the value of finding consensus in the field of pediatric bioethics. (shrink)

In this paper we suggest a revisionist perspective on two significant figures in early modern life science and philosophy: William Harvey and John Locke. Harvey, the discoverer of the circulation of the blood, is often named as one of the rare representatives of the ‘life sciences’ who was a major figure in the Scientific Revolution. While this status itself is problematic, we would like to call attention to a different kind of problem: Harvey dislikes abstraction and controlled experiments (aside from (...) the ligature experiment in De Motu Cordis), tends to dismiss the value of instruments such as the microscope, and emphasizes instead the privileged status of ‘observed experience’. To use a contemporary term, Harvey appears to rely on, and chiefly value, ‘tacit knowledge’. Secondly, Locke’s project is often explained with reference to the image he uses in the Epistle to the Reader of his Essay, that he was an “underlabourer” of the sciences. In fact, despite the significant medical phase of his career, Locke’s ‘empiricism’ turns out to be above all a practical (i.e. ‘moral’) project, which focuses on the delimitation of our powers in order to achieve happiness, and rejects the possibility of naturalizing knowledge. When combined, these two cases suggest a different view of some canonical moments in early modern natural philosophy. (shrink)

Whether adolescents should be allowed to make their own medical decisions has been a topic of discussion in bioethics for at least two decades now. Are adolescents sufficiently capacitated to make their own medical decisions? Is the mature-minor doctrine, an uncommon legal exception to the rule of parental decision-making authority, something we should expand or eliminate? Bioethicists have dealt with the curious liminality of adolescents—their being neither children nor adults—in a variety of ways. However, recently there has been a trend (...) to rely heavily, and often exclusively, on emerging neuroscientific and psychological data to answer these questions. Using data from magnetic resonance imaging and functional MRI studies on the adolescent brain, authors have argued both that the adolescent brain isn't sufficiently mature to broadly confer capacity on this population and that the adolescent brain is sufficiently mature to assume adolescent capacity. Scholars then accept these data as sufficient for concluding that adolescents should or should not have decision-making authority. Two critical mistakes are being made here. The first is the expectation that neuroscience or psychology is or will be able to answer all our questions about capacity. The second, and more concerning, mistake is the conflation of decision-making capacity with decision-making authority. (shrink)

The global development of human embryonic stem cell science and its therapeutic applications are dependent on the nature of its engagement at national and international levels with key cultural values and beliefs concerning the moral status of the early human embryo. This article argues that the political need to reconcile the promise of new health technologies with the cultural costs of scientific advance, dependent in this case on the use of the human embryo, has been met by the evolution of (...) bioethics as a political community, transnational network, and bureaucratic device. Bioethics has become the political means for the creation of a global moral economy where the trading and exchange of values is normalized and legitimated. As a result of such trading, value compromises are produced capable of legitimizing the regulatory policies necessary for maintaining public trust in the new science. (shrink)

Originally published in 1933, this book presents the content of the Alfred Marshall Lectures for that year, which were delivered by Sir Arthur Salter at Cambridge University. The text sets out Salter's vision regarding the fundamental components of an ordered society. This book will be of value to anyone with an interest in political philosophy and the nature of statehood.

This article addresses, from a Frankfurt School perspective on law identified with Franz Neumann and more recently Habermas, the attack upon the principles of war criminality formulated at the Nuremberg trials by the increasingly influential legal and political theory of Carl Schmitt. It also considers the contradictions within certain of the defence arguments that Schmitt himself resorted to when interrogated as a possible war crimes defendant at Nuremberg. The overall argument is that a distinctly internal, or “immanent”, form of critique (...) is required of Schmitt's position, in which its is found wanting even on its own terms. In principle, the application of this dialectical mode of critique can allow a genuine debate to emerge between those seeking to continue both the Schmittian and critical theory traditions, whilst safeguarding the latter from the dangers of formulating polemical interventions that are, in effect, counterproductive to their own intentions. (shrink)

In a contribution to this journal Amos Witzum has challenged a common interpretation of Adam Smith's theory of justice, according to which Smith ‘employed a concept of justice – in the tradition of natural laws theories – whereby rights are related to guarding what is one's own rather than to what is one's due’ (Witzum, 1997, p. 242). Witzum claims that not only does Smith's conception of justice include one's due, and hence, distributional considerations, but the right to one's own (...) ‘stems from the right to what is one's due’ (p. 244). Furthermore, he asserts that ‘as all members of society own their natural faculties, which presumably were given to them to enable them to survive, the fruits of their labour up to subsistence level belong to them by virtue of their ownership of their own faculties’ (p. 259). This leads him to the conclusion that property acquisition gives rise to a duty, on the part of property holders, to ‘distribute subsistence’ and that when wages fall below the subsistence level, the rights of workers have been violated ‘in exactly the same sense that taking an acquired asset away from its owner constitutes a violation of justice’ (p. 244). (shrink)

In “Acquiescence is Not Agreement,” Caruso Brown (2022) offers a comprehensive framework for identifying and empowering marginalized voices in pediatric decision-making. She does so through both a...

From growth attenuation therapy for severely developmentally disabled children to the post-natal management of infants with trisomy 13 and 18, pediatric treatment decisions regularly involve assessments of the probability and severity of a child’s disability. Because these decisions are almost always made by surrogate decision-makers and because these decision-makers must often make decisions based on both prognostic guesses and potentially biased quality of life judgments, they are among the most ethically complex in pediatric care. As the introduction to HEC Forum’s (...) special thematic issue on Childhood and Disability, this article orients the reader to the history of bioethics’ relationship to both pediatric ethics and disability studies and introduces the issue’s five manuscripts. As clinicians, disability scholars, philosophers and clinical ethicists writing on various aspects of pediatric disability, the articles’ authors all invite readers to dig beneath an overly-simplified version of what disability might mean to children and families and instead embrace a posture of genuine humility, recognizing both the limits and harms of traditional medical and bioethical responses to the disabled child. (shrink)

This paper considers the question of whether journalism can be considered to be a social practice. After considering some of the goods of journalism the paper moves to investigate how external goods can corrupt the practice and make it somewhat ineffective. The paper therefore looks to consider ways in which the goods claimed have been better served in ‘radical’ journalism. Bristol Independent Media Centre is then evaluated as an example of an active project in which the goods of community are (...) pursued through an inclusive form of participatory journalism. (shrink)

I will argue in what follows that the reading of Smith which attributes to him a theory of the transition from feudalism to capitalism, and the implications which follow from it, are unfounded. There are three key aspects of the interpretation which I will challenge. First, that Smith's account of the destruction of feudal power by the progress of commerce is related to an explanation of the transition to the commercial stage; second, that the decline in baronial power incorporates Smith's (...) account of the ending of serfdom and a change in relations of production in the Marxian sense; and third, that the rise of international commerce -- the �prime-mover� in the whole process, is a force which is external to European feudalism. (shrink)

The siren call of individualism is compelling. And although we have recognized its dangerous allure in the realm of adult decision-making, it has had profound and yet unnoticed dangerous effects in pediatric decision-making as well. Liberal individualism as instantiated in the best interest standard conceptualizes the child as independent and unencumbered and the goal of child rearing as rational autonomous adulthood, a characterization that is both ontologically false and normatively dangerous. Although a notion of the individuated child might have a (...) place in establishing a threshold of care obligated and enforced by the state, beyond this context we should turn our attention more explicitly to the relational interests of children. (shrink)

This article critically examines, and ultimately rejects, the best interest standard as the predominant, go-to ethical and legal standard of decision making for children. After an introduction to the presumption of parental authority, it characterizes and distinguishes six versions of the best interest standard according to two key dimensions related to the types of interests emphasized. Then the article brings three main criticisms against the best interest standard: (1) that it is ill-defined and inconsistently appealed to and applied, (2) that (...) it is unreasonably demanding and narrow, and (3) that it fails to respect the family. Finally, it argues that despite the best interest standard’s potent rhetorical power, it is irreparably encumbered by too much inconsistency and confusion and should be rejected. (shrink)

Objectives To characterize the prevalence and content of pediatric triage policies.Methods We surveyed and solicited policies from U.S. hospitals with pediatric intensive care units. Policies were analyzed using qualitative methods and coded by 2 investigators.Results Thirty-four of 120 institutions (28%) responded. Twenty-five (74%) were freestanding children’s hospitals and 9 (26%) were hospitals within a hospital. Nine (26%) had approved policies, 9 (26%) had draft policies, 5 (14%) were developing policies, and 7 (20%) did not have policies. Nineteen (68%) institutions shared (...) their approved or draft policy. Eight (42%) of those policies included neonates. The polices identified 0 to 5 (median 2) factors to prioritize patients. The most common factors were short- (17, 90%) and long- (14, 74%) term predicted mortality. Pediatric scoring systems included Pediatric Logistic Organ Dysfunction-2 (12, 63%) and Score for Neonatal Acute Physiology and Perinatal Extensions-II (4, 21%). Thirteen (68%) policies described a formal algorithm. The most common tiebreakers were random/lottery (10, 71%) and life cycles (9, 64%). The majority (15, 79%) of policies specified the roles of triage team members and 13 (68%) precluded those participating in patient care from making triage decisions.Conclusions While many institutions still do not have pediatric triage policies, there appears to be a trend among those with policies to utilize a formal algorithm that focuses on short- and long-term predicted mortality and that incorporates age-appropriate scoring systems. Additional work is needed to expand access to pediatric-specific policies, to validate scoring systems, and to address health disparities. (shrink)

This paper introduces Leo Strauss’s thematic question, “Progress or return?” to the context of psychoanalysis. the conversation within psychoanalysis. Progress signifies development or advancement, a mode that Freud embraced wholeheartedly. Strauss’s pursuit of a return questions the presumption of the goodness of progress. Freud’s thinking forecloses critical considerations within religion and metaphysics, circumscribing his consideration to adaptation within a given particular time and place. By contrast, a return transcends the particular setting. I address the question, “Progress or Return?” to historical (...) and individual development. If a life of progress points away from nature toward civilization, the life of return points away from civilization and toward nature. Freud epitomizes the idea of progress and pathologizes the notion of return, consequently foreclosing the questioning of authority as well as the quest for a natural law that would supersedes authority. True progress, I argue, is not linear but dependent on return. (shrink)

Introduction : up against Carl Schmitt -- An afterlife for Carl Schmitt? -- On politics, law and ideology -- Mobilising direct political action: Sorel, myths and counter-myths -- Myths of parliamentarism -- Leviathan : a political myth misfired? -- Hamlet as an instructive prototype of a political myth? -- Political myths underpinning democracy.

This article examines the role of context in the development and deployment of standards of medical decision-making. First, it demonstrates that bioethics, and our dominant standards of medical decision-making, developed out of a specific historical and philosophical environment that prioritized technology over the person, standardization over particularity, individuality over relationship and rationality over other forms of knowing. These forces de-contextualize the patient and encourage decision-making that conforms to the unnatural and contrived environment of the hospital. The article then explores several (...) important differences between the home health care and acute care settings. Finally, it argues that the personalized, embedded, relational and idiosyncratic nature of the home is actually a much more accurate reflection of the context in which real people make real decisions. Thus, we should work to “re-contextualize” patients, in order that they might be better equipped to make decisions that harmonize with their real lives. (shrink)

The governments of China, India, and the United Kingdom are unanimous in their belief that bioinformatics should supply the link between basic life sciences research and its translation into health benefits for the population and the economy. Yet at the same time, as ambitious states vying for position in the future global bioeconomy they differ considerably in the strategies adopted in pursuit of this goal. At the heart of these differences lies the interaction between epistemic change within the scientific community (...) itself and the apparatus of the state. Drawing on desk-based research and thirty-two interviews with scientists and policy makers in the three countries, this article analyzes the politics that shape this interaction. From this analysis emerges an understanding of the variable capacities of different kinds of states and political systems to work with science in harnessing the potential of new epistemic territories in global life sciences innovation. (shrink)

The political context of the conversion of the Historic Tramway Bridge, adjacent to Sandon Point in Bulli (NSW, Australia), and how this was exploited to serve predetermined ends, illustrates that technologies can be designed to have particular social (and political) effects. Through reflection on this relatively small engineering project, this paper provides a concrete example of what Langdon Winner (1986) attempted to expose in his (in)famous and contested analysis of “the low bridges of Robert Moses”. The means through which this (...) project reflected specific political and economic interests, and how such interests were largely unmarked and unquestioned, locate issues of concerns for the broader public and the engineering profession as a whole. In reflecting on the Tramway Bridge conversion, consideration is given to how far the project of creating the new engineer has progressed in seeking to address the great social, economic, environmental and cultural challenges of our time (Johnson, 1996). (shrink)

In 1988 I began a report on the accuracy of expert testimony in child sexual abuse cases utilizing Ralph Underwager and Hollida Wakefield as a case study (Wakefield & Underwager, 1988). In response, Underwager and Wakefield began a campaign of harassment and intimidation, which included multiple lawsuits; an ethics charge; phony (and secretly taped) phone calls; and ad hominem attacks, including one that I was laundering federal grant monies. The harassment and intimidation failed as the author refused demands to retract. (...) In addition, the lawsuits and ethics charges were dismissed. Lessons learned from the experience are discussed. (shrink)