Goodness and Human Life
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2015-09-01 03:00:00 AM
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2015-09-01 03:00:00 AM
Abstract
The presence of a human being/organism—a living human ‘whole’, with the defining tendency to promote its own welfare—has value in itself, as do the functions which compose it. Life is inseparable from health, since without some degree of healthy functionality (if not in all cases active functioning) the living whole would not exist. The value of life differs both within a single life (in different periods or possible situations) and between lives (lives that vary in length, health or even physical maturity are not all equally fulfilled). As with any other form of human flourishing, the value of life-and-health must be distinguished from the moral importance of human beings: less fulfilled means not less important morally, but more in need of being fulfilled. That said, to say that life and health has value is not to say exactly what—if anything—that value requires by way of active promotion at a given time. Many factors must be taken into account in making health care decisions, even if the worth of all lives, and the dignity of all human beings, must in every case be acknowledged.
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2015-09-01 03:00:00 AM
Abstract
The “disability paradox” is the idea that for those who become severely disabled, their own quality of life (QoL) assessment remains at or slightly below the QoL assessments of normal controls. This is a source of skepticism regarding third-person QoL judgments of the disabled. I argue here that this skepticism applies as well to those who are in the minimally conscious state (MCS). For rather simple means of sustaining an MCS patient’s life (for example, tube feeding), the cost of being wrong that the patient would not want further support is high. Pair this cost with the reason to be skeptical of third-person judgments, and my argument suggests not withholding food and water from MCS patients.
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2015-09-01 03:00:00 AM
Abstract
Many believe that moral value is—at least to some extent—dependent on the developmental states necessary for supporting rational activity. My paper rejects this view, but does not aim simply to register objections to it. Rather, my essay aims to answer the following question: if a human being’s developmental state and occurrent capacities do not bequeath moral standing, what does? The question is intended to prompt careful consideration of what makes human beings objects of moral value, dignity, or (to employ my preferred term) goodness. Not only do I think we can answer this question, I think we can show that nascent human life possesses goodness of precisely this sort. I appeal to Aquinas’s metaethics to establish the conclusion that the goodness of a human being—even if that being is an embryo or fetus—resides at the substratum of her existence. If she possesses goodness, it is because human existence is good.
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2015-09-01 03:00:00 AM
Abstract
In the health care professions, the meaning of—and implications for—‘dignity’ and ‘value’ are progressively more important, as scholars and practitioners increasingly have to make value judgments when making care decisions. This paper looks at the various arguments for competing sources of human value that medical professionals can consider—human rights, autonomy, and a higher-order moral value—and settles upon a foundational model that is related to (though distinct from) the Kantian model that is popular within the medical community: human value is foundational; human dignity, autonomy, and rights derive from the relational quality of human dignity. Moral dignity is expressed though the relationships we cultivate, the communal ends we pursue, and the rights we enjoy. Correlatively, human dignity is inseparable from its ground (i.e., morality), and the relationship between these two is best represented for Kant in the humanities formulation. The foundational model of dignity ensures that human value is non-circularly derived, but is ultimately tied to expressions of individual human dignity that comes from the dignity of morality. Linking Kant’s dignity of humanity to the dignity of morality affords a unique and efficacious response to the discussion of human value. In one sense, dignity is amplificatory, since its worth is inextricable with that of autonomy and the rights afforded to the autonomous. But that isn’t to say that the worth of dignity is merely amplificatory. Rather, human dignity indicates the absolute inner value (MM 6:435) found in each individual in virtue of being human (MM 6:435, 462). That inner worth engenders certain universal rights—derivable from the dignity and fundamental rational appeal of morality—just as it provides for the possibility for a community of beings to seek to live the moral life.
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2015-08-07 03:00:00 AM
Abstract
How may clinical ethics committees (CECs) inspire ethical reflection among healthcare professionals? How may they deal with organizational ethics issues? In recent years, Norwegian CECs have attempted different activites that stretch or go beyond the standard trio of education, consultation, and policy work. We studied the novel activities of Norwegian CECs by examining annual reports and interviewing CEC members. Through qualitative analysis we identified nine categories of novel CEC activities, which we describe by way of examples. In light of the findings, we argue that some novel working methods may be well suited to promote ethical reflection among clinicians, and that the CEC may be a suitable venue for discussing issues of organizational ethics.
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2015-08-02 03:00:00 AM
Abstract
This paper argues that substantive ethical rules serve a critical ethical function, even in those cases where we should deviate from those rules. Assuming that the rules are valid provides decision-makers with the context essential to reaching a well-justified decision. Recognizing this helps to reconcile two attractive but incompatible positions regarding the evaluation of healthcare ethics consultants. The first position is that ethical rules can validly be used to evaluate the quality of consultants’ advice, ensuring conformity to standards promoted by a significant portion of medical ethicists. The second position—the message of ethical particularism—is that we should not evaluate consultants according to strict rules, since good ethical advice may deviate from even the most carefully wrought moral rules. Steering a path between these extremes, I argue that we should evaluate the quality of consultations by examining whether consultants have communicated the relevant ethical rules to participants as ethical presumptions. In communicating presumptions, a consultant provides an indispensable ingredient to ethical decision-making, while leaving open the possibility that the ethical course of action involves violating the very ethical rules that one should presume.
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2015-07-30 03:00:00 AM
Abstract
An individual’s right to refuse life-sustaining treatment is a fundamental expression of patient autonomy; however, supporting this right poses ethical dilemmas for healthcare providers when the patient has attempted suicide. Emergency physicians encounter patients who have attempted suicide and are likely among the first medical providers to face the dilemma of honoring the patient’s DNR or intervening to reverse the effects of potentially fatal actions. We illustrate this issue by introducing a case example in which the DNR of a terminally ill woman was not honored because the cause of her cardiac arrest was suicide. We argue that although a terminal diagnosis should change the way health care providers respond to a suicide attempt, many of the theoretical underpinnings for how one should treat suicide attempts—especially the criterion of external reasonability, that is the action to withhold or withdraw life-sustaining measures is reasonable independent of the precipitating event—are common to all situations (Brown et al. in Am J Bioeth 13(3):3–12, 2013). The presumption that patients who attempt suicide lack capacity due to acute mental illness is flawed because it fails to account for a competent individual’s reasonable preference to not be forced to live in an unbearable, terminal condition. In states without legislation allowing physician aid in dying, patients and providers must grapple with these limitations on a case-by-case basis. In cases where the patient has a limited life expectancy and there is not concern for psychiatric illness as the primary cause of the suicidal action, we argue that the negative right to refuse life-sustaining treatment should prevail.
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2015-06-23 03:00:00 AM
Abstract
In this essay, I argue that the Commodification Objection (suitably redescribed), locates a phenomenon of real moral significance. In defending the Commodification Objection, I review three common criticisms of it, which claim firstly, that commodification doesn’t always lead to instrumentalization; secondly, that commodification isn’t the only route to such an outcome; and finally, that the Commodification Objection applies only to persons, and human organs (and, therefore, blood products) are not persons. In response, I conclude that (i) moral significance does not require that an undesirable outcome be a necessary consequence of the phenomenon under examination; (ii) the relative likelihood of an undesirable mode of regard arising provides a morally-relevant distinguishing marker for assessing the comparative moral status of social institutions and arrangements; and (iii) sales in blood products (and human organs more generally) are sufficiently distinct from sales of everyday artefacts and sufficiently close to personhood to provide genuine grounds for concern. Accordingly, criticisms of the Commodification Objection do not provide grounds for rejecting the claim that human organ sales in general and compensation for blood plasma donation in particular can have morally pernicious ‘commodificatory effects’ upon our attitudes, for what human organ sales provide is a distinctive ethical hazard.
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2015-06-18 03:00:00 AM
Abstract
The central claim of this paper is that American states’ use of so-called “triggering conditions” to regulate surrogate decision-making authority in end-of-life care leaves unresolved a number of important ethical and legal considerations regarding the scope of that authority. The paper frames the issue with a case set in a jurisdiction in which surrogate authority to withdraw life-sustaining treatment is triggered by two specific clinical conditions. The case presents a quandary insofar as the clinical facts do not satisfy the triggering conditions, and yet both the appropriate surrogates and the care team agree that withdrawal of life-sustaining treatment is in the best interest of the patient. The paper surveys applicable law across the 50 states and weighs the arguments for and against the inclusion of such triggering conditions in relevant legal regimes. The paper concludes by assessing the various legal and policy options states have for regulating surrogate decision-making authority in light of the moral considerations (including epistemic difficulties), and notes the possibility for conflict within ethics teams arising from the potential tension between prudence, risk-aversion, and moral obligation.
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2015-06-09 03:00:00 AM
Abstract
Standardizing consultation processes is increasingly important as clinical ethics consultation (CEC) becomes more utilized in and vital to medical practice. Solid organ transplant represents a relatively nascent field replete with complex ethical issues that, while explored, have not been systematically classified. In this paper, we offer a proposed taxonomy that divides issues of resource allocation from viable solutions to the issue of organ shortage in transplant and then further distinguishes between policy and bedside level issues. We then identify all transplant related ethics consults performed at the Cleveland Clinic (CC) between 2008 and 2013 in order to identify how consultants conceptually framed their consultations by the domains they ascribe to the case. We code the CC domains to those in the Core Competencies for Healthcare Consultation Ethics in order to initiate a broader conversation regarding best practices in these highly complex cases. A discussion of the ethical issues underlying living donor and recipient related consults ensues. Finally, we suggest that the ethical domains prescribed in the Core Competencies provide a strong starting ground for a common intra-disciplinary language in the realm of formal CEC.
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2015-06-09 03:00:00 AM
Abstract
Ethics networks have emerged over the last few decades as a mechanism for individuals and institutions over various regions, cities and states to converge on healthcare-related ethical issues. However, little is known about the development and nature of such networks. In an effort to fill the gap in the knowledge about such networks, a survey was conducted that evaluated the organizational structure, missions and functions, as well as the outcomes/products of ethics networks across the country. Eighteen established bioethics networks were identified via consensus of three search processes and were approached for participation. The participants completed a survey developed for the purposes of this study and distributed via SurveyMonkey. Responses were obtained from 10 of the 18 identified and approached networks regarding topic areas of: Network Composition and Catchment Areas; Network Funding and Expenses; Personnel; Services; and Missions and Accomplishments. Bioethics networks are designed primarily to bring ethics education and support to professionals and hospitals. They do so over specifically defined areas—states, regions, or communities—and each is concerned about how to stay financially healthy. At the same time, the networks work off different organizational models, either as stand-alone organizations or as entities within existing organizational structures.
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2015-06-01 03:00:00 AM
Abstract
The American Society for Bioethics and Humanities promulgated standards for clinical ethics consultants and is currently developing a national Quality Attestation in Clinical Ethics Consultation to assist facilities in ensuring that those performing clinical ethics consultations meet minimum standards. As the field moves towards such professionalization, there is a need to provide access to qualified clinical ethicists at a broad range of medical facilities. Currently, however, there are insufficient numbers of trained clinical ethicists to staff all healthcare facilities, and many facilities lack the necessary resources to hire staff clinical ethicists. In this review, we describe several models for providing expert clinical ethics support to remote facilities that lack access to qualified clinical ethicists. Based on this analysis, we recommend telemedicine as the optimal model providing expert support to local ethics committee members tasked with providing clinical ethics consultation services.
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2015-06-01 03:00:00 AM
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2015-06-01 03:00:00 AM
Abstract
In this paper, I will argue that there is a deep connection between home-based care, technology, and the self. Providing the means for persons (especially older persons) to receive care at home is not merely a kindness that respects their preference to be at home: it is an important means of extending their selfhood and respecting the unique selves that they are. Home-based technologies like telemedicine and robotic care may certainly be useful tools in providing care for persons at home, but they also have important implications for sustaining selfhood in ways that are of value to individuals and those who care for them. I will argue, by appealing to Hilde Lindemann’s notion of “holding” persons’ identities in place, that technological interventions are not only useful tools for improving and sustaining health and good care at home, but that they may also help to extend our personal identities and relational capacities in ways that are practically and ethically good. Because of these important goods, I will claim that there is a prima facie moral duty to do this “holding” work and that it is best done by family members and loved ones who are well suited to the job because of their history and relationship with the individual that needs to be “held” in place.
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2015-06-01 03:00:00 AM
Abstract
This study examines elderly residential life in long-term care settings, focusing on the ways residents interact with their physical and social environments. It further proposes that the residential environment is an important player for everyday ethics in long-term care settings, and is also an important factor in enhancing the quality of life for residents. By employing the theories of place identity and environmental meanings and listening to the voices of the elderly collected through an ethnographic field study in elderly homes of life care, the study reveals the residents’ experiences of going through declining health and moving through the stages of care. Two major themes were identified. The first theme of liminal life portrays the elders’ fears as they move through the stages of care. This theme includes four sub-themes: (1) the loss of home and the loss of autonomy; (2) impending loss and its constant reminders; (3) the social classification of “us” and “them”; (4) the irreversibility of moving. The second theme of relational life describes the keys to successful transitions as experienced and told by the residents. The second theme includes three sub-themes: (1) shifting identity and the acceptance of old age; (2) human interdependence and building trust; (3) an accompanied death. Study implications are further discussed, including specific suggestions for social programs and revisions to the physical environments. A more fundamental question about place-based staged care is also raised so as to serve as a point of departure for reflections and discussions amongst health professionals, planners and designers, and other decision-makers.
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2015-06-01 03:00:00 AM
Abstract
The ethical standard for informed consent is fostered within a shared decision-making (SDM) process. SDM has become a recognized and needed approach in health care decision-making. Based on an ethical foundation, the approach fosters the active engagement of patients, where the clinician presents evidence-based treatment information and options and openly elicits the patient’s values and preferences. The SDM process is affected by the context in which the information exchange occurs. Rural settings are one context that impacts the delivery of health care and SDM. Rural health care is significantly influenced by economic, geographical and social characteristics. Several specific distinctive features influence rural health care decision-making—poverty, access to health care, isolation, over-lapping relationships, and a shared culture. The rural context creates challenges as well as fosters opportunities for the application of SDM as a natural dynamic within the rural provider–patient relationship. To fulfill the ethical requirements of informed consent through SDM, it is necessary to understand its inherent challenges and opportunities. Therefore, rural clinicians and ethicists need to be cognizant of the impact of the rural setting on SDM and use the insights as an opportunity to achieve SDM.
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2015-06-01 03:00:00 AM
Abstract
Over the past 20 years, clinical research has migrated from academic medical centers to community-based settings, including rural settings. This evolving research environment may present some moral hazards or challenges that could undermine traditionally accepted standards for the protection of human subjects. The study described in this article was designed to explore the influence of motives driving the decisions to conduct clinical trial research in rural community settings. The researchers conducted semi-structured interviews with 80 participants who conducted clinical trials with rural subjects. The interviews provided a way to examine the influence of budgetary factors when deciding to conduct a clinical study, how information about the budget and the purpose of the study is conveyed to research participants, and the potential willingness of clinicians and coordinators to enroll in the kinds of studies they offer. The findings suggest that clinical trial research in rural communities may challenge clinicians’ abilities to balance the needs of the patient with the needs of the research enterprise. Few respondents seemed to recognize the traditionally recognized hazards of a dual relationship, specifically the moral risks of trying to attend to the interests of both patient and industry. It seems important to re-examine how we protect human subjects and what such protection should look like as research becomes part of the way medical care is provided, even in very rural areas.
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2015-06-01 03:00:00 AM
Abstract
This paper examines the meaning of space and its relationship to value. In this paper, I draw on Henri Lefebvre to suggest that our ethics produce and are produced by spaces. Space is not simply a passive material container or neutral geographic location. Space includes the ideas on which buildings are modeled, the ordering of objects and movement patterns within the space, and the symbolic meaning of the space and its objects. Although often unrecognized, space itself is value-laden, and its values are suggested as people interact within that space. By reflecting on the spaces of health care, we will see that we not only must attend to the quandaries caused by the delivery of health care in non-acute places, but also to the values that produce and are produced by spaces. These values influence our moral imagination and shape us as people.
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2015-06-01 03:00:00 AM
Abstract
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.
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