Volume 20, Issue 3, March 2020, Page 71-73.

Seit wenigen Jahren erfreuen sich in den Lebenswissenschaften mehrere Theorien eines immer weitergehenden Einflusses, die unter Etikettierungen wie Systembiologie, Netzwerktheorie oder Signalomics nur scheinbar unabhängige Herangehensweisen an komplexe Zusammenhänge darstellen. Navigation ist der übergreifende Gedanke, der so unterschiedliche Gebiete wie Regelungstheorie, Entscheidungstheorie und Systemwissenschaft verbindet. Navigation als Lage- und Kursbestimmung nebst den zugehörigen Signalverarbeitungsprozessen und Steuerkommandos ist die Grundlage dessen, was lebende Organismen von der blo§en Ansammlung materieller Ingredienzien unterscheidet – von der molekularen Ebene bis zum Sozialverhalten. Denn stets stellen (...) sich Prozesse des Lebens als solche des Suchens, Kommunizierens, Disponierens und Vervollkommnens dar, ob es sich nun um die Regulation der Sauerstoffspannung im Blut oder die Organisation eines Ameisenvolkes handelt. Navigationsaufgaben sind damit schließlich auch Fragestellungen ärztlicher Entscheidungsfindung, die sich in einem komplexen Raum aus individuellen, sozialen und ethischen Anforderungen entfalten. (shrink)

Nancy Jecker and Andrew Ko (2017) wish to present an account of personal identity which captures what matters to the patient and places the patient at the center of medical decisions. They focus particularly on medical interventions in the brain that can cause drastic changes in personality; under what circumstances should we say the patient has 'survived' these changes? More specifically, how can we best understand the notion of survival in a way that captures what is of concern (...) to the patient? This goal is laudable, however, their chosen account of narrative identity is ill-suited to this task for one reason in particular; it does not give sufficient guidance in predicting which medical decisions are likely to be experienced as disruptive to identity. (shrink)

Recently, bioethicists and the UNCRPD have advocated for supported medical decision-making on behalf of patients with intellectual disabilities. But what does supported decision-making really entail? One compelling framework is Anita Silvers and Leslie Francis’ mental prosthesis account, which envisions supported decision-making as a process in which trustees act as mere appendages for the patient’s will; the trustee provides the cognitive tools the patient requires to realize her conception of her own good. We argue (...) that supported decision-making would be better understood as a collaborative process, giving patients with intellectual disabilities the opportunity to make decisions in a respectful relationship with trusted others. We offer an alternative account of supported decision-making where the primary constraint is to protect the patient from domination by the trustee. This is advantageous in its preservation of the prospects for genuine collaboration, for the mental prosthesis approach ultimately reinforces a problematic ideal of isolated patient self-determination. (shrink)

Decision-making capacity (DMC) plays an important role in clinical practice—determining, on the basis of a patient’s decisional abilities, whether they are entitled to make their own medical decisions or whether a surrogate must be secured to participate in decisions on their behalf. As a result, it’s critical that we get things right—that our conceptual framework be well-suited to the task of helping practitioners systematically sort through the relevant ethical considerations in a way that reliably and transparently delivers (...) correct verdicts about who should and should not have the authority to make their own medical decisions. Unfortunately, however, the standard approach to DMC does not get things right. It is of virtually no help in identifying and clarifying the relevant ethical considerations. And, embedded in the prevailing anti-paternalist paradigm, DMC assessments obfuscate and distort the underlying ethical justification for granting or withholding decisional authority. Here, we describe the core commitments of the standard approach to DMC and then highlight three problems with it. We then argue that these problems are significant enough that they call for more than merely tinkering and fine tuning—variations of the standard approach cannot adequately address them. Instead, we should ditch DMC. (shrink)

Albert Jonsen and Stephen Toulmin have argued that the best way to resolve complex “moral” issues in clinical settings is to focus on the details of specific cases. This approach to medical decision-making, labeled ‘casuistry’, has met with much criticism in recent years. In response to this criticism, Carson Strong has attempted to salvage much of Jonsen’s and Toulmin’s version of casuistry. He concludes that much of their analysis, including Jonsen’s further elaboration about the casuistic methodology, is (...) on the mark. In this essay, the details of Jonsen’s and Toulmin’s version of casuistry and the major criticisms against their approach to clinical decision-making are explicated. Furthermore, it is argued that Strong’s salvage efforts fail to deflect these criticisms. The upshot of this analysis, which includes a few additional criticisms, is that Jonsen’s and Toulmin’s version of casuistry is not an appropriate framework from which to resolve complex “moral” issues in clinical settings. (shrink)

Machine intelligence already helps medical staff with a number of tasks. Ethical decision-making, however, has not been handed over to computers. In this proof-of-concept study, we show how an algorithm based on Beauchamp and Childress’ prima-facie principles could be employed to advise on a range of moral dilemma situations that occur in medical institutions. We explain why we chose fuzzy cognitive maps to set up the advisory system and how we utilized machine learning to train it. (...) We report on the difficult task of operationalizing the principles of beneficence, non-maleficence and patient autonomy, and describe how we selected suitable input parameters that we extracted from a training dataset of clinical cases. The first performance results are promising, but an algorithmic approach to ethics also comes with several weaknesses and limitations. Should one really entrust the sensitive domain of clinical ethics to machine intelligence? (shrink)

Shared decision-making involves health professionals and patients/clients working together to achieve true person-centred health care. However, this goal is infrequently realized, and most barriers are unknown. Discussion between philosophers, clinicians, and researchers can assist in confronting the epistemic and moral basis of health care, with benefits to all. The aim of this paper is to describe what shared decision-making is, discuss its necessary conditions, and develop a definition that can be used in practice to support excellence (...) in maternity care. Discussion between the authors, with backgrounds in philosophy, clinical maternity care, health care management, and maternity care research, assisted the team to confront established norms in maternity care and challenge the epistemic and moral basis of decision-making for caesarean section. The team concluded that shared decision-making must start in pregnancy and continue throughout labour and birth, with equality in discourse facilitated by the clinician. Clinicians have a duty of care for the adequacy of women's knowledge, which can only be fulfilled when relevant knowledge is offered freely and when personal beliefs and biases that may impinge on decision-making (defeaters) are disclosed. Informed consent is not shared decision-making. Key barriers include existing cultural norms of “the doctor knows best” and “patient acquiescence” that prevent defeaters being acknowledged and discussed and can lead to legal challenges, overuse of medical intervention and, in some areas, obstetric violence. Shared decision-making in maternity care can thus be defined as an enquiry by clinician and expectant woman aimed at deciding upon a course of care or none, which takes the form of a dialogue within which the clinician fulfils their duty of care to the client's knowledge by making available their complete knowledge (based on all types of evidence) and expertise, including an exposition of any relevant and recognized potential defeaters. Research to develop measurement tools is required. (shrink)

Shared Decision Making (‘SDM’) is one of the most significant developments in Western health care practices in recent years. Whereas traditional models of care operate on the basis of the physician as the primary medical decision maker, SDM requires patients to be supported to consider options in order to achieve informed preferences by mutually sharing the best available evidence. According to its proponents, SDM is the right way to interpret the clinician-patient relationship because it fulfils the (...) ethical imperative of respecting patient autonomy. However, there is no consensus about how decisions in SDM contexts relate to the principle of respect for autonomy. In response, I demonstrate that in order to make decisions about what treatment they will or will not receive, patients will be required to meet different conditions depending on the approach proponents of SDM take to understanding personal autonomy. Due to the fact that different conceptions of autonomy yield different obligations, I argue that if physicians and patients satisfied all the conditions described in standard accounts of SDM, then SDM would undermine patient autonomy. (shrink)

According to many of its proponents, shared decision making ("SDM") is the right way to interpret the clinician-patient relationship because it respects patient autonomy in decision-making contexts. In particular, medical ethicists have claimed that SDM respects a patient's relational autonomy understood as a capacity that depends upon, and can only be sustained by, interpersonal relationships as well as broader health care and social conditions. This paper challenges that claim. By considering two primary approaches to relational (...) autonomy, this paper argues that standard accounts of SDM actually undermine patient autonomy. It also provides an overview of the obligations generated by the principle of respect for relational autonomy that have not been captured in standard accounts of SDM and which are necessary to ensure consistency between clinical practice and respect for patient autonomy. (shrink)

Advanced AI systems are rapidly making their way into medical research and practice, and, arguably, it is only a matter of time before they will surpass human practitioners in terms of accuracy, reliability, and knowledge. If this is true, practitioners will have a prima facie epistemic and professional obligation to align their medical verdicts with those of advanced AI systems. However, in light of their complexity, these AI systems will often function as black boxes: the details of (...) their contents, calculations, and procedures cannot be meaningfully understood by human practitioners. When AI systems reach this level of complexity, we can also speak of black-box medicine. In this paper, we want to argue that black-box medicine conflicts with core ideals of patient-centered medicine. In particular, we claim, black-box medicine is not conducive for supporting informed decision-making based on shared information, shared deliberation, and shared mind between practitioner and patient. (shrink)

Jennifer Hawkins (2024) offers two cases that challenge traditional accounts of decision-making capacity, according to which respect for a medical decision turns on an individual’s cognitive capacities at the time the decision is made (Hawkins 2024; Appelbaum and Grisso 1988). In each of her described cases (involving anorexia nervosa and grief, respectively), a patient makes a decision that—although instrumentally rational at the time—does not reflect the patient’s longer-term values due to being in a particular (...) psychological state. Importantly, this state does not impair the patient’s cognition, but rather predisposes them to make a decision that conflicts with their own broader values, beliefs, or desires. (shrink)

Phenomenology gives rise to certain ontological considerations that have far-reaching implications for standard conceptions of patient autonomy in medical ethics, and, as a result, the obligations of and to patients in clinical decision-making contexts. One such consideration is the phenomenological reduction in classical phenomenology, a core feature of which is the characterisation of our primary experiences as immediately and inherently meaningful. This paper builds on and extends the analyses of the phenomenological reduction in the works of Husserl, (...) Heidegger, and Merleau-Ponty in order to identify and explain its implications for our current understanding of the principle of respect for patient autonomy and the norms of clinical decision making. (shrink)

This article is about the information relevant to decision-making capacity in refusal of life-prolonging medical treatment cases. We examine the degree to which the phenomenology of the options available to the agent—what the relevant states of affairs will feel like for them—forms part of the capacity-relevant information in the law of England and Wales, and how this informational basis varies across adolescent and adult medical treatment cases. We identify an important doctrinal phenomenon. In the leading authorities, (...) the courts appear to count the first-personal phenomenology of the available options among the information that adolescents seeking to refuse life-prolonging treatment must understand and appreciate in order to possess capacity; adults are not held to this (higher) standard. We evaluate this differential treatment in light of philosophical work on transformative choice—decisions involving options whose sensory character, and effect on our values and preferences, are grasped only through experience itself. (shrink)

In this paper, we define correlation coefficient measure between any two rough neutrosophic sets. We also prove some of its basic properties.. We develop a new multiple attribute group decision making method based on the proposed correlation coefficient measure. An illustrative example of medical diagnosis is solved to demonstrate the applicability and effecriveness of the proposed method.

In this chapter, it is argued that some animal shelters fulfill the conditions that make triage protocols necessary, namely, the operation with limited financial budgets, space, medical resources, and staff. It is suggested that requirements presented for triage in humans can be fruitfully applied to the context of animal shelters. The focus lies on the criteria of maximizing benefit, justice, medical criteria, life-span considerations, fair decision-making, patient will, re-evaluation of triage decisions and changes in the therapeutic (...) goal, and burden of triage and staff support. The establishment of triage protocols for shelters will make the decision-making process less arbitrary, fairer, and more transparent. Furthermore, it is argued that, in situations where disagreement persist among shelter staff, an external Ethics Board could be called in to help analyze and potentially resolve some of the remaining ethical issues. (shrink)

“Bodily autonomy” has received significant attention in bioethics, medical ethics, and medical law in terms of the general inviolability of a patient’s bodily sovereignty and the rights of patients to make choices (e.g., reproductive choices) that concern their own body. However, the role of the body in terms of how it can or does contribute to a patient’s capacity for, or exercises of their autonomy in clinical decision-making situations has not been explicitly addressed. The approach to (...) autonomy in this paper is aligned with traditional theories that conceive autonomy in terms of an individual’s capacities for, and exercises of rational reflection. However, at the same time, this paper extends these accounts by arguing that autonomy is, in part, embodied. Specifically, by drawing on phenomenological conceptions of the experience of autonomy, we argue that, in principle, the body is a necessary component of the capacity for autonomy. Secondly, through the presentation of two different cases, we highlight ways in which a patient’s body can contribute to the autonomy of treatment choices. Ultimately, we hope to encourage others to explore additional conditions under which a concept of embodied autonomy should be employed in medical decision making, how its underlying principles might be operationalised in clinical situations, and its consequences for approaches to patient autonomy in healthcare practice, policy, and law. (shrink)

Forms of Artificial Intelligence (AI) are already being deployed into clinical settings and research into its future healthcare uses is accelerating. Despite this trajectory, more research is needed regarding the impacts on patients of increasing AI decision making. In particular, the impersonal nature of AI means that its deployment in highly sensitive contexts-of-use, such as in healthcare, raises issues associated with patients’ perceptions of (un) dignified treatment. We explore this issue through an experimental vignette study comparing individuals’ perceptions (...) of being treated in a dignified and respectful way in various healthcare decision contexts. Participants were subject to a 2 (human or AI decision maker) x 2 (positive or negative decision outcome) x 2 (diagnostic or resource allocation healthcare scenario) factorial design. We found evidence of a “human bias” (i.e., a preference for human over AI decision makers) and an “outcome bias” (i.e., a preference for positive over negative outcomes). However, we found that for perceptions of respectful and dignified interpersonal treatment, it matters more who makes the decisions in diagnostic cases and it matters more what the outcomes are for resource allocation cases. We also found that humans were consistently viewed as appropriate decision makers and AI was viewed as dehumanizing, and that participants perceived they were treated better when subject to diagnostic as opposed to resource allocation decisions. Thematic coding of open-ended text responses supported these results. We also outline the theoretical and practical implications of these findings. (shrink)

The aim of this paper is to argue that intuitive methods of moral decision making are objective tools on the grounds that they are reasons based. First, I will conduct a preliminary analysis in which I highlight the acceptance of methodological pluralism in the practice of medical ethics. Here, the point is to show the possibility of using intuitive methods given the pluralism framework. Second, I will argue that the best starting point of elaborating such methods is (...) a bottom-up perspective. Third, I will address the worry of subjectivism. Under the influence of certain rationalist positions and recent developments in cognitive science and moral psychology, one might think that intuitive methods of moral decision making are essentially subjective and emotion based. If moral intuitions are the result of emotional reactions and intuitive reasoning is emotionally driven, then there are reasons to believe intuitive methods are subjective and relative to particular psychological constitution. Against this picture, I will argue that intuitive methods of moral decision making are essentially reasons-based. A Wittgensteinian approach will show that intuitive methods of moral decision making are conceptually linked with criteria of morality. (shrink)

The dominant approach to assessing decision-making capacity in medicine focuses on determining the extent to which individuals possess certain core cognitive abilities. Critics have argued that this model delivers the wrong verdict in certain cases where patient values that are the product of mental disorder or disordered affective states undermine decision-making without undermining cognition. I argue for a re-conceptualization of what it is to possess the capacity to make medical treatment decisions. It is, I argue, (...) the ability to track one’s own personal interests at least as well as most people can. Using this idea, I demonstrate that it is possible to craft a solution for the problem cases—one that neither alters existing criteria in dangerous ways (e.g. does not open the door to various kinds of abuse) nor violates the spirit of widely accepted ethical constraints on decision-making assessment. (shrink)

Three common ethical principles for establishing the limits of parental authority in pediatric treatment decision making are the harm principle, the principle of best interest, and the threshold view. This paper consider how these principles apply to a case of a premature neonate with multiple significant comorbidities whose mother wanted all possible treatments, and whose health care providers wondered whether it would be ethically permissible to allow him to die comfortably despite her wishes. Whether and how these principles (...) help to understand what was morally right for the child is questioned. The paper concludes that the principles were of some value in understanding the moral geography of the case, but that the case reveals common bioethical principles for medical decision making are problematically value-laden because they are inconsistent with the widespread moral value of medical vitalism. (shrink)

The Substituted Judgment Standard for surrogate decision-making dictates that a surrogate, when making medical decisions on behalf of an incapacitated patient, ought to make the decision that the patient would have made if the patient had decisional capacity. Despite its intuitive appeal, however, SJS has been the target of a variety of criticisms. Most objections to SJS appeal to epistemic difficulties involved in determining what a patient would have decided in a given case. In this (...) article, I offer an alternative standard for surrogate decision-making that avoids these difficulties. I then offer an account of its theoretical underpinnings which shows that it preserves the central moral justification for SJS, namely, respect for patient autonomy. (shrink)

A crucial question in relation to support designed to enable the legal capacity of people with mental disabilities concerns when support constitutes undue influence. This article addresses this question in order to facilitate the development of law and policy in England and Wales, by providing a normative analysis of the different approaches to undue influence across decisions about property, contracts, health, finances, and accommodation. These are all potential contexts for supporting legal capacity, and, in doing so, the article compares approaches (...) to undue influence that are rarely considered together. -/- Drawing on the UN Convention on the Rights of Persons with Disabilities, third sector and public body documents, and law in England and Wales, the analysis identifies six models that conceptualise undue influence in terms of: modes of influence; an overborne will; an inference from the situation; an overborne will understood as a mental incapacity; an overborne will in connection with vulnerability; and impaired discursive control. This final approach is a novel proposal for understanding undue influence. The analysis highlights key policy-relevant issues that distinguish the models, and generates a deliberative framework for navigating them, with the ‘overborne will’, ‘inference-based’, and ‘discursive control’ models identified as potentially fitting for the support context. (shrink)

Qualitative evidence concerning the relationship between QoL and a wide range of disabilities suggests that subjective judgments regarding other people’s QoL are wrong more often than not and that such judgments by medical practitioners in particular can be biased. Guided by their desire to do good and avoid harm, surgeons often rely on "the eyeball test" to decide whether a patient will or will not benefit from surgery. But the eyeball test can easily harbor a range of implicit judgments (...) and biases against patients with disabilities, including erroneous assumptions about QoL. We critique the use of the "eyeball" test and offer suggestions to reduce bias and ensure that patients’ values are more consistently prioritized in surgical decision-making. (shrink)

While most of healthcare research and practice fully endorses evidence-based healthcare, a minority view borrows popular themes from philosophy of science like underdetermination and value-ladenness to question the legitimacy of the evidence-based movement’s philosophical underpinnings. While the feminist origins go unacknowledged, those critics adopt a feminist reading of the “gap argument” to challenge the perceived objectivism of evidence-based practice. From there, the critics seem to despair over the “subjective elements” that values introduce to clinical reasoning, demonstrating that they do not (...) subscribe to feminist science studies’ normative program——where contextual values can enable good science and justified decisions. In this paper, I investigate why it is that the critics of evidence-based medicine adopt feminist science’s characterization of the problem but resist the productive solutions offered by those same theorists. I suggest that the common feminist empiricist appeal to idealized epistemic communities is impractical for those working within the current biomedical context and instead offer an alternate stream of feminist research into the empirical content of values (found in the work of Elizabeth Anderson and Sharyn Clough) as a more helpful recourse for facilitating the important task of legitimate and justified clinical decision-making. I use a case study on clinical decision-making to illustrate the fruitfulness of the latter feminist empiricist framework. -/- See response by Sharyn Clough: http://wp.me/p1Bfg0-1aN See reply by Maya Goldenberg: http://wp.me/p1Bfg0-1oY. (shrink)

Because an increasing number of patients have medical conditions that render them incompetent at making their own medical choices, more and more medical choices are now made by surrogates, often patient family members. However, many studies indicate that surrogates often do not discharge their responsibilities adequately, and in particular, do not choose in accordance with what those patients would have chosen for themselves, especially when it comes to end-of-life medical choices. This chapter argues that a (...) significant part of the explanation of such surrogate failure is that family surrogates are likely to undergo anticipatory grief when making end-of-life decisions. After clarifying both the emotional structure and object of grief, I propose that the pending death of a loved one induces an emotional conflict in surrogates between the care demanded by their responsibility as surrogates and the attachment surrogates feel toward their dying loved one, an attachment surrogates "resolve" in the direction of attachment rather than care. This hypothesis helps to explain both surrogates' general inability to exercise "substituted judgment" on behalf of their loved ones and a wide swath of the particular data regarding this inability (e.g., that surrogates more often err by choosing overtreatment). I conclude by considering possible clinical and philosophical responses to this hypothesis. (shrink)

In a context of imperfect risk protection, households may protect against the impact of a health shock by employing various financial and non-financial coping mechanisms, such as foregoing or reducing needed medical care, labor substitution, consumption reduction, borrowing money, dissaving, and selling assets. However, leveraging certain coping mechanisms may reduce future productivity, potentially trapping households in chronic or persistent poverty. Resources and risk are not necessarily shared equitably within a household; the ability and willingness of the household to leverage (...) coping mechanisms, or the choice of coping mechanism may depend on the social protection policy context, household socioeconomic status, and type of intrahousehold risk sharing. Vietnam has been making policy changes aimed towards achieving Universal Health Coverage for the past several decades, culminating in a 2015 change mandating universal insurance coverage. This can potentially influence both providers in making decisions around service delivery and households around financing care. This research aims to contribute to the literature exploring the relationships among direct and indirect health care costs, potentially maladaptive coping mechanisms, and household living standards, within the particular health financing and social protection environment in Vietnam. (shrink)

Philosophers of science have insisted that evidence of underlying mechanisms is required to support claims about the effects of medical interventions. Yet evidence about mechanisms does not feature on dominant evidence-based medicine “hierarchies.” After arguing that only inferences from mechanisms (“mechanistic reasoning”)—not mechanisms themselves—count as evidence, I argue for a middle ground. Mechanistic reasoning is not required to establish causation when we have high-quality controlled studies; moreover, mechanistic reasoning is more problematic than has been assumed. Yet where the problems (...) can be overcome, mechanistic reasoning can and should be used as evidence. (shrink)

In the domain of medical science, factual evidence is usually considered as the criterion on which to base decisions and construct hypotheses. Evidence-based medicine is the translation of this approach into the field of patient care, and it means providing only the type of care that is based on evidence that proves its effectiveness and appropriateness. However, while the literature has focused on the types and force of evidence used to establish the recommendation and treatment guidelines, the problem of (...) how evidence is used in doctor–patient interactions to motivate, or refuse, treatment or habit change has been almost completely neglected. In this specific context, characterized by the epistemic unbalance between the interlocutors and a specific conversational goal, the scientific categories of evidence are often irrelevant. The goal of this paper is to address this challenge by analyzing the role evidence plays in doctor–patient interactions in diabetes care. After introducing an analytical distinction between the epistemic and the pragmatic aspect of evidence, we will propose a classification of the types and functions of evidence in chronic care communication, and illustrate its possible uses through its application to our corpus of diabetes-care consultations. From our qualitative analyses, it is possible to observe how in this communicative context a crucial role is played by the conflicts of evidence, in which providers correct patients’ uses of evidence leading them to using less defeasible levels of evidence. (shrink)

Thesis --University of Stellenbosch, 2004 Acceptance of the concept of medical futility facilitates a paradigm shift from curative to palliative medicine, accommodating a more humane approach and avoiding unnecessary suffering in the course of the dying process. This should not be looked upon as abandoning the patient but rather as providing the patient and family with an opportunity to come to terms with the dying process. It also does not entail withdrawal or passivity on the part of the health (...) care professional. In addition to medical skills, the treating physician is responsible for guiding this process by demonstrating sensitivity and compassion, respecting the values of patients, their families and the medical staff. The need for training to equip medical staff to take responsibility as empathetic participants in end-of-life decision-making is underscored. S Afr Med J 2008; 98: 284-286. (shrink)

Artificial intelligence (AI) is expected to revolutionise the practice of medicine. Recent advancements in the field of deep learning have demonstrated success in variety of clinical tasks: detecting diabetic retinopathy from images, predicting hospital readmissions, aiding in the discovery of new drugs, etc. AI’s progress in medicine, however, has led to concerns regarding the potential effects of this technology on relationships of trust in clinical practice. In this paper, I will argue that there is merit to these concerns, since AI (...) systems can be relied on, and are capable of reliability, but cannot be trusted, and are not capable of trustworthiness. Insofar as patients are required to rely on AI systems for their medical decision-making, there is potential for this to produce a deficit of trust in relationships in clinical practice. (shrink)

Nowadays, healthcare and medical education is qualified by test scores and competitiveness. This article considers its quality in terms of improving the moral competence of future healthcare providers. Objectives. Examining the relevance of moral competence in medico-clinical decision-making despite the paradigm shift and discussing the up-to-date findings on healthcare students. Design and method. N=115 participants were surveyed with a standard Moral Competence Test to examine how their moral competence development was affected by the learning environment and further (...) important factors. Results. The sample allowed the identification of a regress in moral competence during students’ pre-clinical curriculum, and progress during their clinical curriculum. A gender-related bias, a segmentation effect, and a pronunciation effect were noticed. Explanations. Scholarly literature usually reports a linear decrease of medical students’ C-scores resulting from, e.g., competitive trends in education. We identified such trends in terms of gender-specific competitive tactics. Religious and ethical affiliations were discussed to explain the unexpected gender bias and the related segmentation and pronunciation effects. The findings can be regarded as predictive for similar developments in educational institutions regardless of cultural contexts as the sample examined in this article represents medical education in a country facing a transition from a non-competitive to competitive tertiary education model, and between presecular and monocultural to secular and pluralist social ethics. (shrink)

Most medical research and a substantial amount of non-medical research, especially that involving human participants, is governed by some kind of research ethics committee (REC) following the recommendations of the Declaration of Helsinki for the protection of human participants. The role of RECs is usually seen as twofold: firstly, to make some kind of calculation of the risks and benefits of the proposed research, and secondly, to ensure that participants give informed consent. The extent to which the role (...) of the REC includes the former is not uncontroversial. Indeed, the most prevalent debate on the role of RECs sees liberals and strong paternalists arguing over the importance of informed consent given by competent agents versus the significance of making benevolent decisions on behalf of others. On the one hand, liberals argue for the rights of competent adults to decide for themselves the kinds and extents of risks to which they wish to expose themselves. On the other hand, proponents of strong paternalism raise concerns about the likelihood of participants being able to truly understand the complex data involved in research. They support a role for RECs in which they exercise duties of benevolence towards patients and participants by limiting the extent to which they can be exposed to significant, permanent and irreversible harms. In this paper, we will argue that when it comes to decisions about risk it is neither possible nor desirable for RECs to adopt either role. (shrink)

: The Islamic jurists utilized the discipline of maqāṣid al-sharīʿah,in its capacity as the philosophy of Islamic law, in their legal and ethicalinterpretations, with added interest in addressing the issues of modern times.Aphoristically subsuming the major themes of the Sharīʿah, maqāṣid play apivotal role in the domain of decision-making and deduction of rulings onunprecedented ethical discourses. Ethics represent the infrastructure of Islamiclaw and the whole science of Islamic jurisprudence operates in the lightof maqāṣid to realize the ethics in (...) people’s lives. Scrutinizing the key themesof maqāṣid-based ijtihād and scope of ethics in maqāṣid, this article delvesinto the discourse on the application of maqāṣid to medical ethics. As a casestudy, this research analyses the extent of medical confidentiality in the light ofmaqāṣid and arrives at the conclusion that limited confidentiality goes more inline with the maxims of maqāṣid. (shrink)

Default positions, predetermined starting points that aid in complex decision-making, are common in clinical medicine. In this article, we identify and critically examine common default positions in clinical ethics practice. Whether default positions ought to be held is an important normative question, but here we are primarily interested in the descriptive, rather than normative, properties of default positions. We argue that default positions in clinical ethics function to protect and promote important values in medicine—respect for persons, utility, and (...) justice. Further, default positions in clinical ethics may also guard against harm. Where default positions exist, there are epistemic burdens to overturn them. The person wishing to reject the default position, rather than the person endorsing it, bears this burden. The person who bears the burden of meeting the epistemic requirements must provide evidence proportional to the degree of harm the default position protects against. Default positions that protect against significant harm impose significant epistemic requirements to overturn. This asymmetry not only makes medical decision-making more economical but also serves to promote and protect certain values. The identification and analysis of common and recognizable default positions can help to identify other default positions and the conditions under which their associated epistemic requirements are met. The article concludes with considerations of potential problems with the use of default positions in clinical ethics. (shrink)

The objective of the paper is to implement and validate diagnosis in the medical field via refined neutrosophic fuzzy logic (RNFL). As such, we have proposed a Max-Min composition (MMC) method in RNFL. This method deals with the diagnosis under certain constraints like uncertainty and indeterminacy. Further, we have considered the diagnosis problems to validate the sensitivity analysis of the novel multi attribute decision-making technique. Finally, we gave the graphical representations and compared the obtained results with other (...) existing measures in refined neutrosophic fuzzy sets. (shrink)

In medical settings, machines are in close proximity with human beings: with patients who are in vulnerable states of health, who have disabilities of various kinds, with the very young or very old, and with medical professionals. Machines in these contexts are undertaking important medical tasks that require emotional sensitivity, knowledge of medical codes, human dignity, and privacy. -/- As machine technology advances, ethical concerns become more urgent: should medical machines be programmed to follow a (...) code of medical ethics? What theory or theories should constrain medical machine conduct? What design features are required? Should machines share responsibility with humans for the ethical consequences of medical actions? How ought clinical relationships involving machines to be modeled? Is a capacity for empathy and emotion detection necessary? What about consciousness? -/- The essays in this collection by researchers from both humanities and science describe various theoretical and experimental approaches to adding medical ethics to a machine, what design features are necessary in order to achieve this, philosophical and practical questions concerning justice, rights, decision-making and responsibility, and accurately modeling essential physician-machine-patient relationships. -/- This collection is the first book to address these 21st-century concerns. (shrink)

I discuss an influential argument put forward by Hatherley in theJournal of Medical Ethics. Drawing on influential philosophical accounts of interpersonal trust, Hatherley claims that medical artificial intelligence is capable of being reliable, but not trustworthy. Furthermore, Hatherley argues that trust generates moral obligations on behalf of the trustee. For instance, when a patient trusts a clinician, it generates certain moral obligations on behalf of the clinician for her to do what she is entrusted to do. I make (...) three objections to Hatherley’s claims: (1) At least one philosophical account of interagent trust implies that medical AI is capable of being trustworthy. (2) Even if this account should ultimately be rejected, it does not matter much because what we care mostly about is that medical AI is reliable. (3) It is false that trust in itself generates moral obligations on behalf of the trustee. (shrink)

In a recent Response published in the Journal of Medical Ethics,1 Buturovic provides two criticisms of my argument in ‘Is the exclusion of psychiatric patients from access to physician-assisted suicide discriminatory?’2 First, Buturovic argues that my argument effectively ‘erases the distinction between healthy adults and patients (whether somatic or psychiatric) essentially implying that PAS [physician-assisted suicide] should be available to all, for all reasons or, ultimately no reason’ (Buturovic,1 pg. 1). Second, Buturovic argues that opening the doors to (...) class='Hi'>medical assistance in dying (MAID) for psychiatric patients could have a number of undesirable implications. In particular, Buturovic highlights the potential negative implications for relations of trust in medicine—psychiatry in particular—along with potential effects on the rate of organ donation. I would here like to respond to these two criticisms. In short, my response to Buturovic’s first argument is that the slope is not nearly as slippery as Buturovic suggests. The reason for this is that the plausibility of Buturovic’s argument rests on a significant misinterpretation of my argument, along with an important equivocation in her own. Buturovic argues that, under the three criteria that I propose for the provision of MAID—sufficient decision-making capacity, demonstrated treatment resistance, and a lack of substantially negative implications for existing standards of psychiatric treatment and research—the provision of MAID for trivial reasons, even no reason at all, is justifiable. The main problem with this argument is that I propose no such positive criteria. My argument is that none of the three arguments addressed in my previous paper are sufficient to justify the exclusion of any and all psychiatric patients from access to MAID. I do not claim, in other words, that any individual …. (shrink)

Patient centred diagnosis is best practised through shared decision making; an iterative dialogue between doctor and patient, whichrespects a patient’s needs, values, preferences, and circumstances. -/- Shared decision making for diagnostic situations differs fundamentally from that for treatment decisions. This has important implications when considering its practical application. -/- The nature of dialogue should be tailored to the specific diagnostic decision; scenarios with higher stakes or uncertainty usually require more detailed conversations.

This paper argues that the concept of paternalism is currently overextended to include a variety of actions that, while resembling paternalistic actions, are importantly different. I use the example of Japanese physicians’ non-disclosures of cancer diagnoses directly to patients, arguing that the concept of maternalism better captures these actions. To act paternalistically is to substitute one's own judgement for that of another person and decide in place of that person for his/her best interest. By contrast, to act maternalistically is to (...) decide for another person based on a reasonable understanding of that person's own preferences. The concept of maternalism allows for a more thorough assessment of the moral justification of these types of actions. I conclude that it is possible, at least in principle, to justify Japanese physicians’ non-disclosures, and that this justification must be based on an understanding of these actions as maternalistic. (shrink)

The studies of ethics had long been under-dealt although it is the kind of primary in sustaining a civility. It is hardly deniable that the concept of efficiency and productivity has hailed on the mindedness and interest of academic community. The narrative of ethics or social justice would be ridiculed as the kind of Greek juggle on philosophy or put to be on neglect for its lacking or default on the modern disciplinary frame in the academics. A cure, however, seems (...) not to be from a juggernaut of modern capitalistic civilization and its supportive paradigm of understanding so that alternative way for any more realistic solution can be made exploitative from the ethics or similar tools of motivation. Now we talk about noblesse oblige or benevolent capitalism as one important dose for the new paradigm of social promise or reformed capitalism. The ethics studies have increasingly made its way as focused in the discipline of business and public administration. Typically, it is profiled in combination of leadership studies, and the civility tends to accept this narrative, beyond the liberal competition and fairness school, as one of important element when we consider the concept of social justice. The modern professionals, for example, bar members, medical doctors, and many of licensees for their business operation, also clone to carry their responsibility under a specific ethical code. This would be the kind of safety code from the abusive or madly profit-driven capitalism. More importantly, I believe that a sheer understanding of ethics and social justice would be assets and equipment for the ruling class in the contemporary society. In this context, the paper would survey an ethical theory or decision making model, history of Korea as well as a recent episode involving the chief prosecutor of South Korea. Korean leadership, typically for the powerful cores or inner circle princelings, can be revisited in purview of ethics studies, such as Cooper‟s design and ethical decision making model. (shrink)

We aim to establish the following claim: other factors held constant, the relative weights of the epistemic burdens of competing treatment options serve to determine the options that patient surrogates pursue. Simply put, surrogates confront an incentive, ceteris paribus, to pursue treatment options with respect to which their knowledge is most adequate to the requirements of the case. Regardless of what the patient would choose, options that require more knowledge than the surrogate possesses (or is likely to learn) will either (...) be neglected altogether or deeply discounted in the surrogate’s incentive structure. We establish this claim by arguing that the relation between epistemic burdens and incentives in decision-making is a general feature of surrogate decision-making. After establishing the claim, we draw out some of the implications for surrogate decision-making in medicine and offer philosophical and psychological explanations of the phenomenon. (shrink)

In this article, we focus on the definition and application of the sliding scale of capacity. We show that the current interpretations of the sliding scale confound distinct features of the medical decision, such as its urgency, its severity, or its complexity, that do not always covary.We propose that the threshold for assessing capacity should be adjusted based solely on the cognitive complexity of the decision at hand. We further suggest that the complexity of a decision (...) should be identified based on a patient’s particular cognitive deficits. We utilize the current research on the types of deficits that characterize amnestic dementias and examine which types of medical decisions might be most complex for patients with that type of dementia. We conclude that applying the sliding scale based on individualized judgments of cognitive complexity will improve accuracy of assessment of capacity and enable capable patients to participate in medical decision making. (shrink)

This is a very short textbook on probabilistic reasoning, expected utility decision-making, cognitive biases, and self-correction, especially in application to medical examples. It also includes a chapter on concepts of health.

Integrating medical imaging with computing technologies, such as Artificial Intelligence (AI) and its subsets: Machine learning (ML) and Deep Learning (DL) has advanced into an essential facet of present-day medicine, signaling a pivotal role in diagnostic decision-making and treatment plans (Huang et al., 2023). The significance of medical imaging is escalated by its sustained growth within the realm of modern healthcare (Varoquaux and Cheplygina, 2022). Nevertheless, the ever-increasing volume of medical images compared to the availability (...) of imaging experts. Biomedical experts and radiologists have resulted in a widening disparity, causing an excess and overwhelming workload on these healthcare professionals (Chen et al., 2021). Several studies indicate that the present-day biomedical radiologist is now saddled with the daunting task of interpreting an image almost every 10 seconds to keep pace with the burgeoning clinical demands (McDonald et al., 2015; Hosny et al., 2018; Lantsman et al., 2022). This cognitive drain has invariably led to inevitable consequences such as delays in diagnosis and an amplified risk of diagnostic errors – thus, the biomedical imaging aspect is in dire need of methods that would aid accurate diagnostics and analytics for improved decision making. In this review, the importance of AI-related technologies such as ML and/or DL methods are reviewed in relation to the processing of medical or biomedical images along with their potentials, challenges, and possible suggestions for future studies in the health landscape. The focus will be on machine learning methods associated with the medical field of image classification. (shrink)

This paper concerns the double standard debate in the ethics of AI literature. This debate essentially revolves around the question of whether we should subject AI systems to different normative standards than humans. So far, the debate has centered around the desideratum of transparency. That is, the debate has focused on whether AI systems must be more transparent than humans in their decision-making processes in order for it to be morally permissible to use such systems. Some have argued (...) that the same standards of transparency should be applied across the board, for AI systems and humans alike. Others have argued that we should hold AI systems to higher standards than humans in terms of transparency. In this paper, we first point out that there are structurally similar double standard debates to be had about other desiderata besides transparency, such as predictive accuracy. Second, we argue that when we focus on predictive accuracy, there are at least two reasons for holding AI systems to a lower standard than humans. (shrink)

Background: Current practice frequently fails to provide care consistent with the preferences of decisionally-incapacitated patients. It also imposes significant emotional burden on their surrogates. Algorithmic-based patient preference predictors (PPPs) have been proposed as a possible way to address these two concerns. While previous research found that patients strongly support the use of PPPs, the views of surrogates are unknown. The present study thus assessed the views of experienced surrogates regarding the possible use of PPPs as a means to help make (...) treatment decisions for decisionally-incapacitated patients. -/- Methods: This qualitative study used semi-structured interviews to determine the views of experienced surrogates [n=26] who were identified from two academic medical centers and two community hospitals. The primary outcomes were respondents’ overall level of support for the idea of using PPPs and the themes related to their views on how a PPP should be used, if at all, in practice. -/- Results: Overall, 21 participants supported the idea of using PPPs. The remaining five indicated that they would not use a PPP because they made decisions based on the patient’s best interests, not based on substituted judgment. Major themes which emerged were that surrogates, not the patient’s preferences, should determine how treatment decisions are made, and concern that PPPs might be used to deny expensive care or be biased against minority groups. -/- Conclusions: Surrogates, like patients, strongly support the idea of using PPPs to help make treatment decisions for decisionally-incapacitated patients. These findings provide support for developing a PPP and assessing it in practice. At the same time, patients and surrogates disagree over whose preferences should determine how treatment decisions are made, including whether to use a PPP. These findings reveal a fundamental disagreement regarding the guiding principles for surrogate decision-making. Future research is needed to assess this disagreement and consider ways to address it. (shrink)