Withholding and withdrawing treatment are widely regarded as ethically equivalent in medical guidelines and ethics literature. Health care personnel, however, widely perceive moral differences between withholding and withdrawing. The proponents of equivalence argue that any perceived difference can be explained in terms of cognitive biases and flawed reasoning. Thus, policymakers should clear away any resistance to accept the equivalence stance by moral education. To embark on such a campaign of changing attitudes, we need to be convinced that the ethical analysis (...) is correct. Is it? In this article, I take a closer look at the moral relation between withholding and withdrawing. My conclusion is that withholding and withdrawing are not in general ethically equivalent. Thus, medical guidelines should be rewritten, and rather than being “educated” away from their sound judgments, medical professionals and patients should have nuanced medico-ethical discussions regarding withholding and withdrawing treatment. (shrink)

Contains an overall account of morality in its philosophical format particularly with regard to problems of observation, evidence, and truth.

Suppose that we develop a medically safe and affordable means of enhancing human intelligence. For concreteness, we shall assume that the technology is genetic engineering (either somatic or germ line), although the argument we will present does not depend on the technological implementation. For simplicity, we shall speak of enhancing “intelligence” or “cognitive capacity,” but we do not presuppose that intelligence is best conceived of as a unitary attribute. Our considerations could be applied to specific cognitive abilities such as verbal (...) fluency, memory, abstract reasoning, social intelligence, spatial cognition, numerical ability, or musical talent. It will emerge that the form of argument that we use can be applied much more generally to help assess other kinds of enhancement technologies as well as other kinds of reform. However, to give a detailed illustration of how the argument form works, we will focus on the prospect of cognitive enhancement. (shrink)

Ethical notions such as good and bad, are often treated as though they were ?symmetric? in the sense of having the same moral ?weight?, one in a positive the other in a negative sense. I argue that they are in fact ?asymmetric? and that the negative members of such pairs of notions are more fundamental and definite, logically speaking, and operationally more important than the positive members. Detailed arguments are given to show this for some non?moral notions, such as life (...) and death, health and illness; some semi?moral notions such as pleasure and pain; and finally for the moral notions of happiness, benevolence, right, and good and their negative counterparts. One of the intentions of the article is to show that a systematic view of such asymmetries may have consequences for one's view of the proper or desirable structure of a general theory of ethics: norms stating prohibitions and norms stating permissions will be seen to be, in a sense defined in the text, more fundamental and important than norms stating ('positive') obligations. (shrink)

Ethical analyses, professional guidelines and legal decisions support the equivalence thesis for life-sustaining treatment: if it is ethical to withhold treatment, it would be ethical to withdraw the same treatment. In this paper we explore reasons why the majority of medical professionals disagree with the conclusions of ethical analysis. Resource allocation is considered by clinicians to be a legitimate reason to withhold but not to withdraw intensive care treatment. We analyse five arguments in favour of non-equivalence, and find only relatively (...) weak reasons to restrict rationing to withholding treatment. On the contrary, resource allocation provides a strong argument in favour of equivalence: non-equivalence causes preventable death in critically ill patients. We outline two proposals for increasing equivalence in practice: (1) reduction of the mortality threshold for treatment withdrawal, (2) time-limited trials of intensive care. These strategies would help to move practice towards more rational treatment limitation decisions. (shrink)