The Journal Of Medicine And Philosophy[JOURNAL]
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200 papers
Expanding the Use of Continuous Sedation Until Death and Physician-Assisted Suicide.
LiPuma SH, Demarco JP
J Med Philos · 2024 Apr · PMID 38538066 · Publisher ↗
The controversy over the equivalence of continuous sedation until death (CSD) and physician-assisted suicide/euthanasia (PAS/E) provides an opportunity to focus on a significant extended use of CSD. This extension, sugge...
The controversy over the equivalence of continuous sedation until death (CSD) and physician-assisted suicide/euthanasia (PAS/E) provides an opportunity to focus on a significant extended use of CSD. This extension, suggested by the equivalence of PAS/E and CSD, is designed to promote additional patient autonomy at the end-of-life. Samuel LiPuma, in his article, "Continuous Sedation Until Death as Physician-Assisted Suicide/Euthanasia: A Conceptual Analysis" claims equivalence between CSD and death; his paper is seminal in the equivalency debate. Critics contend that sedation follows proportionality protocols for which LiPuma's thesis does not adequately account. Furthermore, sedation may not eliminate consciousness, and as such LiPuma's contention that CSD is equivalent to neocortical death is suspect. We not only defend the equivalence thesis, but also expand it to include additional moral considerations. First, we explain the equivalence thesis. This is followed by a defense of the thesis against five criticisms. The third section critiques the current use of CSD. Finally, we offer two proposals that, if adopted, would broaden the use of PAS/E and CSD and thereby expand options at the end-of-life.
The Social Epistemology of Clinical Placebos.
Rees M
J Med Philos · 2024 Apr · PMID 38531824 · Publisher ↗
Many extant theories of placebo focus on their causal structure wherein placebo effects are those that originate from select features of the therapy (e.g., client expectations or "incidental" features like size and shape...
Many extant theories of placebo focus on their causal structure wherein placebo effects are those that originate from select features of the therapy (e.g., client expectations or "incidental" features like size and shape). Although such accounts can distinguish placebos from standard medical treatments, they cannot distinguish placebos from everyday occurrences, for example, when positive feedback improves our performance on a task. Providing a social-epistemological account of a treatment context can rule out such occurrences, and furthermore reveal a new way to distinguish clinical placebos from standard medical treatments.
The Altruism Requirement as Moral Fiction.
Semrau L
J Med Philos · 2024 Apr · PMID 38530655 · Publisher ↗
It is widely agreed that living kidney donation is permitted but living kidney sales are not. Call this the Received View. One way to support the Received View is to appeal to a particular understanding of the conditions...
It is widely agreed that living kidney donation is permitted but living kidney sales are not. Call this the Received View. One way to support the Received View is to appeal to a particular understanding of the conditions under which living kidney transplantation is permissible. It is often claimed that donors must act altruistically, without the expectation of payment and for the sake of another. Call this the Altruism Requirement. On the conventional interpretation, the Altruism Requirement is a moral fact. It states a legitimate constraint on permissible transplantation and is accepted on the basis of cogent argument. The present paper offers an alternative interpretation. I suggest the Altruism Requirement is a moral fiction-a kind of motivated falsehood. It is false that transplantation requires altruism. But the Requirement serves a purpose. Accepting it allows kidney donation but not kidney sale. It, in short, rationalizes the Received View.
Psychopathology and Metaphysics: Can One Be a Realist About Mental Disorder?
Iliadi S
J Med Philos · 2024 Apr · PMID 38530639 · Full text
Metaphysical realism about mental disorder is the thesis that mental disorder exists mind-independently. There are two ways to challenge metaphysical realism about mental disorder. The first is by denying that mental dis...
Metaphysical realism about mental disorder is the thesis that mental disorder exists mind-independently. There are two ways to challenge metaphysical realism about mental disorder. The first is by denying that mental disorder exists. The second is by denying that mental disorder exists mind-independently. Or, differently put, by arguing that mental disorder is mind-dependent. The aim of this paper is three-fold: (a) to examine three ways in which mental disorder can be said to be mind-dependent (namely, by being causally dependent on the human mind, by being weakly dependent on human attitudes, and by being strongly dependent on human attitudes), (b) to clarify their differences, and (c) to discuss their implications regarding metaphysical realism about mental disorder. I argue that mental disorder being mind-dependent in the first two senses is compatible with metaphysical realism about mental disorder, whereas mental disorder being mind-dependent in the third sense is not.
A Fictionalist Account of Open-Label Placebo.
Hardman D
J Med Philos · 2024 Apr · PMID 38530636 · Publisher ↗
The placebo effect is now generally defined widely as an individual's response to the psychosocial context of a clinical treatment, as distinct from the treatment's characteristic physiological effects. Some researchers,...
The placebo effect is now generally defined widely as an individual's response to the psychosocial context of a clinical treatment, as distinct from the treatment's characteristic physiological effects. Some researchers, however, argue that such a wide definition leads to confusion and misleading implications. In response, they propose a narrow definition restricted to the therapeutic effects of deliberate placebo treatments. Within the framework of modern medicine, such a scope currently leaves one viable placebo treatment paradigm: the non-deceptive and non-concealed administration of "placebo pills" or open-label placebo (OLP) treatment. In this paper, I consider how the placebo effect occurs in OLP. I argue that a traditional, belief-based account of OLP is paradoxical. Instead, I propose an account based on the non-doxastic attitude of pretence, understood within a fictionalist framework.
Beyond Conceptual Analysis: Social Objectivity and Conceptual Engineering to Define Disease.
Gagné-Julien AM
J Med Philos · 2024 Mar · PMID 38422236 · Publisher ↗
In this article, I side with those who argue that the debate about the definition of "disease" should be reoriented from the question "what is disease" to the question of what it should be. However, I ground my argument...
In this article, I side with those who argue that the debate about the definition of "disease" should be reoriented from the question "what is disease" to the question of what it should be. However, I ground my argument on the rejection of the naturalist approach to define disease and the adoption of a normativist approach, according to which the concept of disease is normative and value-laden. Based on this normativist approach, I defend two main theses: (1) that conceptual analysis is not the right method to define disease and that conceptual engineering should be the preferred method and (2) that the method of conceptual engineering should be implemented following the principles of Alexandrova's account of social objectivity in the context of the definition of disease.
The Disease Loophole: Index Terms and Their Role in Disease Misclassification.
Roberts AN
J Med Philos · 2024 Mar · PMID 38418099 · Publisher ↗
The definitions of disease proffered by philosophers and medical actors typically require that a state of ill health be linked to some known bodily dysfunction before it is classified as a disease. I argue that such defi...
The definitions of disease proffered by philosophers and medical actors typically require that a state of ill health be linked to some known bodily dysfunction before it is classified as a disease. I argue that such definitions of disease are not fully implementable in current medical discourse and practice. Adhering to the definitions would require that medical actors keep close track of the current state of knowledge on the causes and mechanisms of particular illnesses. Yet, unaddressed problems in medical terminology can make this difficult to do. I show that unrecognized misuse of "heterogeneous," "biomarker," and other important health terms-which I call index terms-can misrepresent the current empirical evidence on illness pathophysiology, such that unvalidated illness constructs become mistaken for diseases. Thus, implementing common definitions of disease would require closing this "loophole" in medical discourse. I offer a simple rule that, if followed, could help do just that.
Interventionism and Intelligibility: Why Depression Is Not (Always) a Brain Disease.
Gibson QH
J Med Philos · 2024 Mar · PMID 38418097 · Publisher ↗
Major depressive disorder (MDD) is a serious condition with a large disease burden. It is often claimed that MDD is a "brain disease." What would it mean for MDD to be a brain disease? I argue that the best interpretatio...
Major depressive disorder (MDD) is a serious condition with a large disease burden. It is often claimed that MDD is a "brain disease." What would it mean for MDD to be a brain disease? I argue that the best interpretation of this claim is as offering a substantive empirical hypothesis about the causes of the syndrome of depression. This syndrome-causal conception of disease, combined with the idea that MDD is a disease of the brain, commits the brain disease conception of MDD to the claim that brain dysfunction causes the symptoms of MDD. I argue that this consequence of the brain disease conception of MDD is false. It incorrectly rules out genuine instances of content-sensitive causation between adverse conditions in the world and the characteristic symptoms of MDD. Empirical evidence shows that the major causes of depression are genuinely psychological causes of the symptoms of MDD. This rules out, in many cases, the "brute" causation required by the brain disease conception. The existence of cases of MDD with non-brute causes supports the reinstatement of the old nosological distinction between endogenous and exogenous depression.
The Phenomenology of the Face-to-Facetime: A Levinasian Critique of the Virtual Clinic.
O'Brien DC
J Med Philos · 2024 Mar · PMID 38418092 · Publisher ↗
In order to promote social distancing during the recent COVID-19 pandemic, physicians and healthcare systems have made efforts to replace in-person with virtual clinic visits when feasible. While these efforts have been...
In order to promote social distancing during the recent COVID-19 pandemic, physicians and healthcare systems have made efforts to replace in-person with virtual clinic visits when feasible. While these efforts have been well received and seem compatible with sound clinical practice, they do not perfectly replicate the experience of a face-to-face exchange between doctor and patient. This essay attempts to describe features of the virtual visit that distinguish it from its face-to-face analog and considers the phenomenological work of Emmanuel Levinas in arguing that these differences may limit the force of the ethical summons a provider would otherwise experience before the face of a patient. The diminishment of this signal therapeutic experience may engender vocational as well as clinical consequences, which should be weighed against the practical benefits of the virtual visit as we consider whether our enthusiasm for this mode of practice should continue.
Reference-Class Problems Are Real: Health-Adjusted Reference Classes and Low Bone Mineral Density.
Binney N
J Med Philos · 2024 Mar · PMID 38418083 · Full text
Elselijn Kingma argues that Christopher Boorse's biostatistical theory (the BST) does not show how the reference classes it uses are objective and naturalistic. Recently, philosophers of medicine have attempted to rebut...
Elselijn Kingma argues that Christopher Boorse's biostatistical theory (the BST) does not show how the reference classes it uses are objective and naturalistic. Recently, philosophers of medicine have attempted to rebut Kingma's concerns. I argue that these rebuttals are theoretically unconvincing, and that there are clear examples of physicians adjusting their reference classes according to their prior knowledge of health and disease. I focus on the use of age-adjusted reference classes to diagnose low bone mineral density in children. In addition to using the BST's age, sex, and species, physicians also choose to use other factors to define reference classes, such as pubertal status, bone age, body size, and muscle mass. I show that physicians calibrate the reference classes they use according to their prior knowledge of health and disease. Reference classes are also chosen for pragmatic reasons, such as to predict fragility fractures.
Unfreedom or Mere Inability? The Case of Biomedical Enhancement.
Lee JY
J Med Philos · 2024 Mar · PMID 38418080 · Publisher ↗
Mere inability, which refers to what persons are naturally unable to do, is traditionally thought to be distinct from unfreedom, which is a social type of constraint. The advent of biomedical enhancement, however, challe...
Mere inability, which refers to what persons are naturally unable to do, is traditionally thought to be distinct from unfreedom, which is a social type of constraint. The advent of biomedical enhancement, however, challenges the idea that there is a clear division between mere inability and unfreedom. This is because bioenhancement makes it possible for some people's mere inabilities to become matters of unfreedom. In this paper, I discuss several ways that this might occur: first, bioenhancement can exacerbate social pressures to enhance one's abilities; second, people may face discrimination for not enhancing; third, the new abilities made possible due to bioenhancement may be accompanied by new inabilities for the enhanced and unenhanced; and finally, shifting values around abilities and inabilities due to bioenhancement may reinforce a pre-existing ableism about human abilities. As such, we must give careful consideration to these potential unfreedom-generating outcomes when it comes to our moral evaluations of bioenhancement.
Patient Expertise and Medical Authority: Epistemic Implications for the Provider-Patient Relationship.
Watson JC
J Med Philos · 2024 Jan · PMID 37874696 · Publisher ↗
The provider-patient relationship is typically regarded as an expert-to-novice relationship, and with good reason. Providers have extensive education and experience that have developed in them the competence to treat con...
The provider-patient relationship is typically regarded as an expert-to-novice relationship, and with good reason. Providers have extensive education and experience that have developed in them the competence to treat conditions better and with fewer harms than anyone else. However, some researchers argue that many patients with long-term conditions (LTCs), such as arthritis and chronic pain, have become "experts" at managing their LTC. Unfortunately, there is no generally agreed-upon conception of "patient expertise" or what it implies for the provider-patient relationship. I review three prominent accounts of patient expertise and argue that all face serious objections. I contend, however, that a plausible account of patient expertise is available and that it provides a framework both for further empirical studies and for enhancing the provider-patient relationship.
The "Risks of Routine Tests" and Analogical Reasoning in Assessments of Minimal Risk.
Kwek A
J Med Philos · 2024 Jan · PMID 37804082 · Publisher ↗
Research risks have to meet minimal risk requirements in order for the research to qualify for expedited ethics review, to be exempted from ethics review, or to be granted consent waivers. The definition of "minimal risk...
Research risks have to meet minimal risk requirements in order for the research to qualify for expedited ethics review, to be exempted from ethics review, or to be granted consent waivers. The definition of "minimal risk" in the Common Rule (45 CFR 46) relies on the risks-of-daily-life and risks-of-routine-tests as comparators against which research activities are assessed to meet minimal risk requirements. While either or both comparators have been adopted by major ethics codes, they have also been criticized. In response to criticisms, elaborations, and alternative comparators have been proposed. In this paper, I approach the search for workable comparators from the point of view that ethical reasoning about minimal risk involves analogical reasoning using comparators. In this regard, I develop two necessary conditions for an adequate minimal risk conception, which I use to assess three comparators. I conclude that the risks-of-routine-tests best fits the analogical reasoning operating in minimal risk assessments.
How to Exercise Integrity in Medical Billing: Don't Distort Prices, Don't Free-Ride on Other Physicians.
Langston C
J Med Philos · 2024 Jan · PMID 37804081 · Full text
This paper proposes that billing gamesmanship occurs when physicians free-ride on the billing practices of other physicians. Gamesmanship is non-universalizable and does not exercise a competitive advantage; consequently...
This paper proposes that billing gamesmanship occurs when physicians free-ride on the billing practices of other physicians. Gamesmanship is non-universalizable and does not exercise a competitive advantage; consequently, it distorts prices and allocates resources inefficiently. This explains why gamesmanship is wrong. This explanation differs from the recent proposal of Heath (2020. Ethical issues in physician billing under fee-for-service plans. J. Med. Philos. 45(1):86-104) that gamesmanship is wrong because of specific features of health care and of health insurance. These features are aggravating factors but do not explain gamesmanship's primary wrong-making feature, which is to cause diffuse harm not traceable to any particular patient or insurer. This conclusion has important consequences for how medical schools and professional organizations encourage integrity in billing. To avoid free-riding, physicians should ask themselves, "could all physicians bill this way?" and if not, "does the patient benefit from the distinctive service I am providing under this code?" If both answers are "no," physicians should refrain from the billing practice in question.
Intentions at the End of Life: Continuous Deep Sedation and France's Claeys-Leonetti law.
Farrelly-Jackson S
J Med Philos · 2024 Jan · PMID 37804077 · Publisher ↗
In 2016, France passed a major law that is unique in giving terminally ill and suffering patients the right to the controversial procedure of continuous deep sedation until death (CDS). In so doing, the law identifies CD...
In 2016, France passed a major law that is unique in giving terminally ill and suffering patients the right to the controversial procedure of continuous deep sedation until death (CDS). In so doing, the law identifies CDS as a sui generis clinical practice, distinct from other forms of palliative sedation therapy, as well as from euthanasia. As such, it reconfigures the ethical debate over CDS in interesting ways. This paper addresses one aspect of this reconfiguration and its implications for the intentions at work in this complex time at the end of life. The concept of intention is often considered central to the ethics of end-of-life care, but its role is recognized to be problematic, with charges of elusiveness and ambiguity. I aim to show that consideration of the French law affords a new understanding of the intentionality of CDS, and that in addition to the obvious importance of this for clarifying the ethics of the practice, it may suggest new ways of addressing the wider problem of ambiguous clinical intentions at end of life.
The Relational Care Framework: Promoting Continuity or Maintenance of Selfhood in Person-Centered Care.
Tieu M, Matthews S
J Med Philos · 2024 Jan · PMID 37776569 · Full text
We argue that contemporary conceptualizations of "persons" have failed to achieve the moral goals of "person-centred care" (PCC, a model of dementia care developed by Tom Kitwood) and that they are detrimental to those r...
We argue that contemporary conceptualizations of "persons" have failed to achieve the moral goals of "person-centred care" (PCC, a model of dementia care developed by Tom Kitwood) and that they are detrimental to those receiving care, their families, and practitioners of care. We draw a distinction between personhood and selfhood, pointing out that continuity or maintenance of the latter is what is really at stake in dementia care. We then demonstrate how our conceptualization, which is one that privileges the lived experiences of people with dementia, and understands selfhood as formed relationally in connection with carers and the care environment, best captures Kitwood's original idea. This conceptualization is also flexible enough to be applicable to the practice of caring for people at different stages of their dementia. Application of this conceptualization into PCC will best promote the well-being of people with dementia, while also encouraging respect and dignity in the care environment.
Moral Distress, Conscientious Practice, and the Endurance of Ethics in Health Care through Times of Crisis and Calm.
Kaldjian LC
J Med Philos · 2024 Jan · PMID 37769334 · Publisher ↗
When health professionals experience moral distress during routine clinical practice, they are challenged to maintain integrity through conscientious practice guided by ethical principles and virtues that promote the dig...
When health professionals experience moral distress during routine clinical practice, they are challenged to maintain integrity through conscientious practice guided by ethical principles and virtues that promote the dignity of all human beings who need care. Their integrity also needs preservation during a crisis like the COVID-19 pandemic, especially when faced with triage protocols that allocate scarce resources. Although a crisis may change our ability to provide life-saving treatment to all who need it, a crisis should not change the ethical values that should always be guiding clinical care. Enduring ethical commitments should encourage clinicians to base treatment decisions on the medical needs of individual patients. This approach contrasts with utilitarian attempts to maximize selected aggregate outcomes by using scoring systems that use short-term and possibly long-term prognostic estimates to discriminate between patients and thereby treat them unequally in terms of their eligibility for life-sustaining treatment. During times of crisis and calm, moral communication allows clinicians to exercise moral agency and advocate for their individual patients, thereby demonstrating conscientious practice and resisting influences that may contribute to compartmentalization, moral injury, and burnout.
Phenomenological Interview and Gender Dysphoria: A Third Pathway for Diagnosis and Treatment.
Dierckxsens G, Baron TR
J Med Philos · 2024 Jan · PMID 37758478 · Publisher ↗
Gender dysphoria (GD) is marked by an incongruence between a person's biological sex at birth, and their felt gender (or gender identity). There is continuing debate regarding the benefits and drawbacks of physiological...
Gender dysphoria (GD) is marked by an incongruence between a person's biological sex at birth, and their felt gender (or gender identity). There is continuing debate regarding the benefits and drawbacks of physiological treatment of GD in children, a pathway, beginning with endocrine treatment to suppress puberty. Currently, the main alternative to physiological treatment consists of the so-called "wait-and-see" approach, which often includes counseling or other psychotherapeutic treatment. In this paper, we argue in favor of a "third pathway" for the diagnosis and treatment of GD in youths. To make our case, we draw on a recent development in bioethics: the phenomenological approach. Scholars such as Slatman and Svenaeus have argued that the extent to which the body can (or should be) manipulated or reconstructed through medical intervention is not only determined by consideration of ethical frameworks and social and legal norms. Rather, we must also take account of patients' personal experience of their body, the personal and social values associated with it, and their understanding of its situation in their life: their narrative identities. We apply this phenomenological approach to medicine and nursing to the diagnosis and treatment of GD in youth. In particular, we discuss Zahavi and Martiny's conception of the phenomenological interview, in order to show that narrative techniques can assist in the process of gender identification and in the treatment of youth presenting with GD. We focus on two case studies that highlight the relevance of a narrative-based interview in relations between patients, HCPs, and family, to expose the influence of social ideologies on how young people presenting with GD experience their bodies and gender.
Civil Liberties in a Lockdown: The Case of COVID-19.
Director S, Freiman C
J Med Philos · 2023 Nov · PMID 37665953 · Publisher ↗
In response to the spread of COVID-19, governments across the world, with very few exceptions, have enacted sweeping restrictive lockdown policies that impede citizens' freedom to move, work, and assemble. This paper cri...
In response to the spread of COVID-19, governments across the world, with very few exceptions, have enacted sweeping restrictive lockdown policies that impede citizens' freedom to move, work, and assemble. This paper critically responds to the central arguments for restrictive lockdown legislation. We build our critique on the following assumption: public policy that enjoys virtually unanimous support worldwide should be justified by uncontroversial moral principles. We argue that the virtually unanimous support in favor of restrictive lockdowns is not adequately justified by the arguments given in favor of them. Importantly, this is not to say that states ought not impose restrictive lockdown measures, but rather that the extent of the acceptance of these measures is not proportionate to the strength of the arguments for lockdowns.
Disability, Transition Costs, and the Things That Really Matter.
Ness T, Barclay L
J Med Philos · 2023 Nov · PMID 37421413 · Full text
This article develops a detailed, empirically driven analysis of the nature of the transition costs incurred in becoming disabled. Our analysis of the complex nature of these costs supports the claim that it can be wrong...
This article develops a detailed, empirically driven analysis of the nature of the transition costs incurred in becoming disabled. Our analysis of the complex nature of these costs supports the claim that it can be wrong to cause disability, even if disability is just one way of being different. We also argue that close attention to the nature of transition costs gives us reason to doubt that well-being, including transitory impacts on well-being, is the only thing that should determine the wrongness of causing or removing disability. Non-welfare considerations also defeat the claim that it is always wrong to cause disability. The upshot of these conclusions is that closer attention to the nature of transition costs supports disabled people who strenuously contest the assumption that their well-being is lower than nondisabled people. It also suggests that, in addition, disabled people should contest their opponents' narrow account of how we should make ethical decisions regarding causing or failing to prevent disability.
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