When Religious Language Blocks Discussion About Health Care Decision Making.

There is a curious asymmetry in cases where the use of religious language involves a breakdown in communication and leads to a seemingly intractable dispute. Why does the use of religious language in such cases almost always arise on the side of patients and their families, rather than on the side of clinicians or others who work in healthcare settings? I suggest that the intractable disputes arise when patients and their families use religious language to frame their problem and the possibilities of solution. Unlike clinicians, they are not bilingual and thus lack the capacity to understand and negotiate differences in terms that are responsive to those who work in healthcare settings. After considering a representative case, I explore whether an ethics consultant or chaplain can function as a translator and suggest that, at best, such efforts at mediation depend on contingent aspects of a case and will only be partially successful. To appreciate limits on the role for bilingual translators, I consider a futility dispute where a parent using religious language demands that everything be done for a permanently unconscious child. I challenge the traditional interpretation that says the parent values "mere duration of biological life irrespective of quality." From a religious perspective, human life is never "merely biological." This effort to slot the dispute into standard philosophical schemas misses what is crucial in the dispute. I suggest that a better interpretation views the dispute at a meta-level as one about whether withholding and withdrawing care is morally distinguishable from killing. Curiously, this interpretation makes the advocate of futile care into an ally of those "quality of life" advocates who also challenge this distinction. The crux of their dispute now rests on the normative ethics of killing. While I think my interpretation comes much closer to the views of many who demand 'futile care,' I suggest that it still falls short because of the way it reconstructs the religious concerns in nonreligious terms. I close by considering an analogy between the language of suffering and the language of faith, suggesting that both require a much richer understanding of the narratives that orient the lives of patients and their families.

A framework for understanding medical epistemologies.

What clinicians, biomedical scientists, and other health care professionals know as individuals or as groups and how they come to know and use knowledge are central concerns of medical epistemology. Activities associated with knowledge production and use are called epistemic practices. Such practices are considered in biomedical and clinical literatures, social sciences of medicine, philosophy of science and philosophy of medicine, and also in other nonmedical literatures. A host of different kinds of knowledge claims have been identified, each with different uses and logics of justification. A general framework is needed to situate these diverse contributions in medical epistemology, so we can see how they fit together. But developing such a framework turns out to be quite tricky. In this survey, three possible frameworks are considered along with the difficulties associated with each of them. The essay concludes with a fourth framework, which considers any epistemology as part of a practice that is oriented toward overcoming errors that emerge in antecedently given practices where knowledge is developed and used. As medicine indirectly advances health by directly mitigating disease, so epistemology indirectly advances knowledge by directly mitigating error.

Developing an ethical framework-guided instrument for assessing bias in EHR-based Big Data studies: a research protocol.

INTRODUCTION: The emergence of Big Data health research has exponentially advanced the fields of medicine and public health but has also faced many ethical challenges. One of most worrying but still under-researched aspects of the ethical issues is the risk of potential biases in data sets (eg, electronic health records (EHR) data) as well as in the data curation and acquisition cycles. This study aims to develop, refine and pilot test an ethical framework-guided instrument for assessing bias in Big Data research using EHR data sets. METHODS AND ANALYSIS: Ethical analysis and instrument development (ie, the EHR bias assessment guideline) will be implemented through an iterative process composed of literature/policy review, content analysis and interdisciplinary dialogues and discussion. The ethical framework and EHR bias assessment guideline will be iteratively refined and integrated with preliminary summaries of results in a way that informs subsequent research. We will engage data curators, end-user researchers, healthcare workers and patient representatives throughout all iterative cycles using various formats including in-depth interviews of key stakeholders, panel discussions and charrette workshops. The developed EHR bias assessment guideline will be pilot tested in an existing National Institutes of Health (NIH) funded Big Data HIV project (R01AI164947). ETHICS AND DISSEMINATION: The study was approved by Institutional Review Boards at the University of South Carolina (Pro00122501). Informed consent will be provided by the participants in the in-depth interviews. Study findings will be disseminated with key stakeholders, presented at relevant workshops and academic conferences, and published in peer-reviewed journals.

A matter of respect: a defense of the dead donor rule and of a "whole-brain" criterion for determination of death.

Many accounts of the historical development of neurological criteria for determination of death insufficiently distinguish between two strands of interpretation advanced by advocates of a "whole-brain" criterion. One strand focuses on the brain as the organ of integration. Another provides a far more complex and nuanced account, both of death and of a policy on the determination of death. Current criticisms of the whole-brain criterion are effective in refuting the first interpretation, but not the second, which is advanced in the 2008 President's Council report on the determination of death. In this essay, I seek to further develop this second strand of interpretation. I argue that policy on determination of death aligns moral, biological, and ontological death concepts. Morally, death marks the stage when respect is no longer owed. Biologically, death concerns integrated functioning of an organism as a whole. But the biological concepts are underdetermined. The moral concerns lead to selection of strong individuality concepts rather than weak ones. They also push criteria to the "far side" of the dying process. There is a countervailing consideration associated with optimizing the number of available organs, and this pushes to the "near side" of death. Policy is governed by a conviction that it is possible to align these moral and biological death concepts, but this conviction simply lays out an agenda. There is also a prescription-integral to the dead donor rule-that lexically prioritizes the deontic concerns and that seeks to balance the countervailing tendencies by using science-based refinements to make the line between life and death more precise. After showing how these concerns have been effectively aligned in the current policy, I present a modified variant of a "division" scenario and show how an "inverse decapitation problem" leads to a conclusive refutation of the nonbrain account of death.

Importance of a midterm time horizon for addressing ethical issues integral to nanobiotechnology.

There is a consensus emerging on the importance of upstream ethical engagement in nanobiotechnology. Such a preventive ethic would anticipate downstream concerns that might arise and mitigate them as part of the research and development process. However, there is an unappreciated tension between the time horizon of upstream ethics and that assumed by most bioethical research. Current standards of high-quality research on ethical issues biases the research in favor of near-term, science-based, results-oriented work. A near-term focus would miss many of the important ethical issues integral to nanobiotechnology and undermine the goals integral to upstream ethical engagement. However, if we move to a far-term time horizon, the ethical debates tend to get too speculative and are no longer disciplined by existing research trajectories. This paper addresses the link between the midterm time horizon necessary for upstream ethics and the form, content, and style of ethical reflection. New paradigm cases, standards, and criteria will be needed for high-quality upstream ethics work in the area of nanobiotechnology.

The social conditions for nanomedicine: disruption, systems, and lock-in.

Here we consider two ways that nanomedicine might be disruptive. First, low-end disruptions that are intrinsically unpredictable but limited in scope, and second, high end disruptions that involve broader societal issues but can be anticipated, allowing opportunity for ethical reflection.

Systems theory and the ethics of human enhancement: a framework for NBIC convergence.

Representatives from government and the private sector recommend a major, cooperative initiative directed toward using NBIC (nano-, bio-, info-, and cogno-) technologies for human enhancement. By appropriately seeding the convergence of NBIC domains, they believe that the rate of development can be both accelerated and simultaneously channeled to avoid adverse risk and advance human good. However, to accomplish these goals, leaders of the convergence efforts identified as a major intellectual barrier the "development of a hierarchical architecture for integrating science across many scales, disciplines, and data modalities." Such a holistic framework requires a radical rethinking of the nature of science and engineering, and, beyond this, is also necessary for addressing their normative ethical and societal implications. In the first part of this essay, I consider the claim that a new view of science and engineering is needed. After reviewing the central features of a classical view of science, I consider aspects of the nano-revolution, showing why the classical conception is inappropriate and how a systems-oriented perspective is responsive to the character of this new science. I then consider how both science and engineering are transformed, calling into question older dichotomies between pure and applied domains. With the reworking of this distinction comes opportunities for rethinking the relation between science and the humanities more generally, which is necessary if we are to more appropriately address normative ethical aspects of the convergence initiative. After providing this groundwork for the needed hierarchical architecture, I consider a useful example of how a systems perspective might guide NBIC convergence. In the 1960s-1990s George Engel advocated a systems-theoretic model as an alternative to a more reductionistic "biomedical model" in medicine, and he did it for the exact same reasons as those advocated by the leaders of the NBIC convergence; namely, it embodies a more appropriate notion of science and enables one to address ethical aspects of medicine that were insufficiently addressed in the older model. By reviewing Engel's "biopsychosocial model" we can learn important lessons for developing the needed NBIC framework. I close by extending Engel's model so that it addresses all areas of enhancement envisioned as a part of NBIC convergence, and then identify areas where future research is still needed.

Illness, the problem of evil, and the analogical structure of healing: on the difference Christianity makes in bioethics.

A Christian bioethic needs to place the medical approach to sickness, suffering, and death within the context of redemption and the renewal of humanity in the image of God. This can be done by accounting for the way in which the disruptions of the human life-world that attend the illness experience manifest the structure of the problem of evil and point toward an answer that transcends the individual and the medical community. Further, the disease-oriented approach to medicine, when understood in the context of the analogia entis, can be taken as an analogy for a deeper spiritual healing, and can thus become a vehicle through which one can minister to the disruptions of a patient's life-world. An appreciation of the analogical structure of healing provides the basis for a Christian ethic of care.

Thinking theologically about reproductive and genetic enhancements: the challenge.

Current philosophical and legal bioethical reflections on reprogenetics provides little more than a rationalization of the interests of science. There are two reasons for this. First, bioethicists attempt to address ethical issues in a "language of precision" that characterizes science, and this works against analogical and narratological modes of discourse that have traditionally provided guidance for understanding human nature and purpose. Second, the current ethical and legal debate is framed by a public/private distinction that banishes robust norms to the private realm, and leaves a minimalist public discourse of harm avoidance that is insuffucient for regulating the science. In this essay, I argue that Mark Hanson's account of anxiety provides a valuable starting point for addressing deficiencies in the current philosophical and legal debate, and it highlights the need for a theological discourse on genetic enhancements. Through an assessment of Joel Shuman's criticism of the public/private distinction, I show how the needed theological discourse should be situated in the context of robust communities, and how such a communitarian inter-ethic is compatible with a variant of liberalism. Finally, I critically assess James Keenan's account of virtue and perfection, in order to outline what a sufficient discourse on reproductive and genetic enhancements requires.

Beware of mereologists bearing gifts: prolegomena to a medical metaphysics.

This essay considers implications of formal mereologies and ontologies for medical metaphysics. Edward Fried's extensional mereological account of the human body is taken as representative of a prominent strand in analytic metaphysics that has close affinities with medical positivism. I show why such accounts fail. First, I consider how Fried attempts to make sense of the medical case of Barney Clark, the first recipient of an artificial heart, and show that his analytic metaphysical categories do not have the right kind of fit with the case. A proper medical metaphysic should involve a richer two way dialogue with medicine, and it should not just "apply" formal accounts worked out in other settings. Second, I argue that any effort to account for real wholes with extensional mereological sums requires all sorts of ad hoc, supplementary mechanisms that do the real work, and the full repertoire of these mechanisms involves inconsistencies and semantic shifts. Finally, I consider an alternative strand of work on non-extensional whole/part relations that is closer to medicine and that can deepen reflection on some core problems in bioethics, for example, associated with the determination of death when an organism ceases to function as a whole. In addition to the utility such formal ontologies have for addressing traditional problems such as the determination of death, philosophers of medicine should appreciate the increasingly influential role such formal tools are playing in the development of data system ontologies. Assumptions integral to these ontologies have far reaching implications for the way future research and practice in medicine will be conducted, and much greater critical reflection is needed on the full range of issues associated with the development and use of such medical ontologies.

What is unique about nanomedicine? The significance of the mesoscale.

Unlike drugs and medical devices, for which long standing and continuously improving quality assurance/quality control infrastructures exist, many nano-based products lack well-defined standards that are useful to manufacturers and regulators. Inherent variabilities in nanoparticle sizes and shapes, their large surface-to-volume ratios, and their mesoscale interactions with subcellular structures, suggest new complexities and challenges that must be met before widespread application of nanomedicines can be expected.

Recommendations for nanomedicine human subjects research oversight: an evolutionary approach for an emerging field.

The nanomedicine field is fast evolving toward complex, "active," and interactive formulations. Like many emerging technologies, nanomedicine raises questions of how human subjects research (HSR) should be conducted and the adequacy of current oversight, as well as how to integrate concerns over occupational, bystander, and environmental exposures. The history of oversight for HSR investigating emerging technologies is a patchwork quilt without systematic justification of when ordinary oversight for HSR is enough versus when added oversight is warranted. Nanomedicine HSR provides an occasion to think systematically about appropriate oversight, especially early in the evolution of a technology, when hazard and risk information may remain incomplete. This paper presents the consensus recommendations of a multidisciplinary, NIH-funded project group, to ensure a science-based and ethically informed approach to HSR issues in nanomedicine, and to integrate HSR analysis with analysis of occupational, bystander, and environmental concerns. We recommend creating two bodies, an interagency Human Subjects Research in Nanomedicine (HSR/N) Working Group and a Secretary's Advisory Committee on Nanomedicine (SAC/N). HSR/N and SAC/N should perform 3 primary functions: (1) analysis of the attributes and subsets of nanomedicine interventions that raise HSR challenges and current gaps in oversight; (2) providing advice to relevant agencies and institutional bodies on the HSR issues, as well as federal and federal-institutional coordination; and (3) gathering and analyzing information on HSR issues as they emerge in nanomedicine. HSR/N and SAC/N will create a home for HSR analysis and coordination in DHHS (the key agency for relevant HSR oversight), optimize federal and institutional approaches, and allow HSR review to evolve with greater knowledge about nanomedicine interventions and greater clarity about attributes of concern.

Health as intra-systemic integrity: rethinking the foundations of systems biology and nanomedicine.

In current research on systems biology and nanomedicine, we often find an ideal of a new science-based preventive medicine. I consider how disease, cause, explanation, diagnosis, and treatment are understood within this ideal, with special attention to the role of nanoscience and technology in elucidating the "circuit diagram" of a healthy system. I argue that the developmental systems theory that informed George Engel's biopsychosocial model addresses some deficiencies in the current systems ideal, but it needs to be integrated with an ethical analysis that is more attentive to the socioeconomic, cultural, and institutional factors that condition how we understand and manage disease. We also need a richer account of top-down causal paths if we are to appropriately understand diseases as disruptions of inter- and intra-systemic integrity.