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PubMed2002

Risk filtering, ranking, and management framework using hierarchical holographic modeling.

This paper contributes a methodological framework to identify, prioritize, assess, and manage risk scenarios of a large-scale system. Qualitative screening of scenarios and classes of scenarios is appropriate initially, while quantitative assessments may be applied once the set of all scenarios (hundreds) has been prioritized in several phases. The eight-phase methodology is described in detail and is applied to operations other than war. The eight phases are as follows: Phase I, Scenario Identification-A hierarchical holographic model (HHM) is developed to describe the system's "as planned" or "success" scenario. Phase II, Scenario Filtering-The risk scenarios identified in Phase I are filtered according to the responsibilities and interests of the current system user. Phase III, Bi-Criteria Filtering and Ranking. Phase IV, Multi-Criteria Evaluation. Phase V, Quantitative Ranking-We continue to filter and rank scenarios based on quantitative and qualitative matrix scales of likelihood and consequence; and ordinal response to system resiliency, robustness, redundancy. Phase VI, Risk Management is performed, involving identification of management options for dealing with the filtered scenarios, and estimating the cost, performance benefits, and risk reduction of each. Phase VII, Safeguarding Against Missing Critical Items--We examine the performance of the options selected in Phase VI against the scenarios previously filtered out during Phases II to V. Phase VIII, Operational Feedback-We use the experience and information gained during application to refine the scenario filtering and decision processes in earlier phases. These eight phases reflect a philosophical approach rather than a mechanical methodology. In this philosophy, the filtering and ranking of discrete scenarios is viewed as a precursor to, rather than a substitute for, consideration of the totality of all risk scenarios.

Journal Article↗
PubMed1997

Liberal rationalism and medical decision-making.

I contrast Robert Veatch's recent liberal vision of medical decision-making with a more rationalist liberal model. According to Veatch, physicians are biased in their determination of what is in their patient's overall interests in favour of their medical interests. Because of the extent of this bias, we should abandon the practice of physicians offering what they guess to be the best treatment option. Patients should buddy up with physicians who share the same values -- 'deep value pairing'. The goal of choice is maximal promotion of patient values. I argue that if subjectivism about value and valuing is true, this move is plausible. However, if objectivism about value is true -- that there really are states which are good for people regardless of whether they desire to be in them -- then we should accept a more rationalist liberal alternative. According to this alternative, what is required to decide which course is best is rational dialogue between physicians and patients, both about the patient's circumstances and her values, and not the seeking out of people, physicians or others, who share the same values. Rational discussion requires that physicians be reasonable and empathic. I describe one possible account of a reasonable physician.

Coercion↗
PubMed2000

Reefer madness: legal & moral issues surrounding the medical prescription of marijuana.

California, Arizona, and several other states have recently legalized medical marijuana. My goal in this paper is to demonstrate that even if one grants the opponents of legalization many of their contentious assumptions, the federal government is still obligated to take several specific steps toward the legalization of medical marijuana. I defend this claim against a variety of objections, including the claims: that marijuana is unsafe, that marijuana cannot be adequately tested or produced as a drug, that the availability of synthetic THC makes marijuana superfluous, and especially that legalizing medical marijuana will increase recreational use by 'sending the wrong message.' I then go on to argue that given the intransigent position of the federal government on this issue, state governments are justified in unilaterally legalizing medical marijuana as an act of civil disobedience. A large portion of this paper consists of an extensive response to the objection that legalizing medical marijuana will 'send the wrong message'--which I take to be the primary impediment to legalization. This objection basically claims that the consequences of withholding legalization (especially preventing increased recreational use) are superior to those of legalizing medical marijuana. I argue that legalization is justified even if one were to grant both that the harms of legalization outweighed its benefits and that utilitarianism is true. This requires a subtle and somewhat extended discussion of utilitarian moral and political theory.

Cannabis↗
PubMed2002

Human death--a view from the beginning of life.

This paper presents a simple argument against definitions of the death of a human being in terms of death, or the cessation of functioning, of its brain: a human being is alive, and is capable of dying, before it acquires a brain. Although a more accurate definition is sketched, it is stressed that it should not be taken for granted that it is ethically urgent to work out such a definition. What morally matters more than the death of a human being may be something for which its death is sufficient, but not necessary, namely the irreversible loss of its capacity for consciousness. It is when we lose this capacity that we lose our moral standing, as subjects who can be benefited and harmed, and who can have rights. But, as is also suggested, the loss of this capacity is ill suited to be what the death of a human being definitionally consists of.

Beginning of Human Life↗
PubMed2003

The conjoined twins and the limits of rationality in applied ethics.

In this article I consider the case of the surgical separation of conjoined twins resulting in the immediate and predictable death of the weaker one. The case was submitted to English law by the hospital, and the operation permitted against the parents' wishes. I consider the relationship between the legal decision and the moral reasons adduced in its support, reasons gaining their force against the framework of much mainstream normative ethical theory. I argue that in a few morally dilemmatic situations, such a legalistic-theoretical approach cannot plausibly accommodate certain irreducible and ineliminable features of the ethical experience of any concrete individual implicated in the situation, and that this failure partly undermines its self-appointed role of guiding such an individual's conduct. For example, the problem as experienced by the judge and by the parents might not be the same problem at all, and some of their respective reasons may be mutually unintelligible or impotent. I certainly do not argue for a rejection of law or of moral theory; I merely challenge their implicit claim to comprehensiveness and their fixation with an idealised and putatively universal rationality modelled on converging scientific enquiry. Finally, I claim that at least in the twins' case there may be insufficient normative robustness to the conclusions reached, or indeed reachable, by the court in a situation where intuitions and moral reasons pull in fundamentally incommensurable directions; as such, there may be room for an acknowledgement of the spiritual, through a humble abstention from making a decision--which is not to be confused with deciding to do nothing.

Bioethical Issues↗
PubMed2005

Understanding end-of-life caring practices in the emergency department: developing Merleau-Ponty's notions of intentional arc and maximum grip through praxis and phronesis.

The emergency department (ED) is a fast-paced, highly stressful environment where clinicians function with little or suboptimal information and where time is measured in minutes and hours. In addition, death and dying are phenomena that are often experienced in the ED. Current end-of-life care models, based on chronic illness trajectories, may be difficult to apply in the ED. A philosophical approach examining end-of-life care may help us understand how core medical and nursing values are embodied as care practices and as ethical comportment. The integration of Aristotle's notions of phronesis and praxis with Merleau-Ponty's ontological notions of intentional arc and maximum grip in the context of the culture and practices of the ED offers a unique view of clinical and ethical practice at the end-of-life in the emergency setting. Caring for people at the end-of-life calls us to act virtuously based on previous experience, meanings and local practices. The maximum grip of the ultimate particulars of the situation combined with one's experiential and theoretical knowledge opens up situated possibilities for the expert clinician.

Adaptation, Psychological↗
PubMed2006

The phenomenology of life phenomena--in a nursing context.

The purpose of this article is to describe and develop knowledge about life phenomena in a life-philosophical and nursing context. Knowledge about life phenomena is part of a care-ethical understanding with a focus on relations. Life phenomena are to be understood as a generalized label for the various phenomena which are given with human existence. The Danish life philosophical tradition with the perspective of life as experienced has something to say in relation to a further refinement of the phenomenology of life phenomena. The refinement will be described as an ethical and existential understanding of the phenomena of nursing. The first part of the article takes a philosophical approach to the phenomenology of life phenomena. It attempts to locate life phenomena in relation to, respectively, needs, senses, and feelings. In order to maintain an overview, the attempt is made to separate needs, senses, and feelings, although in real life these are closely interwoven. The article also describes philosophy and life phenomena in relation to nursing as an empirical field. In nursing there is a risk that life phenomena become invisible to those whose task is to help the ill person adjust to a new life situation. For the nurse, it will be a continuing task, never completed, to develop a sensory-based, situation-determined attention to the patient. And the nurse must be continually aware of whether mere 'need-oriented' nursing is controlling her professional actions as a nurse. Taking a point of departure in the nurse's sensory, situationally determined attention, the last part of the article focuses on needs, senses, and feelings in connection with the nurse being able to direct her attention to the patient's life phenomena.

Attention↗
PubMed1991

Decisionmaking competence and risk.

Mark Wicclair criticizes Allen Buchanan's and my claim that determining an appropriate level of competence (Wicclair substitutes "decisional capacity" for "competence", the import of which I note briefly below) for health care treatment decisionmaking involves balancing respecting a patient's self-determination and protecting his or her well-being. The most important implication of this balancing is that a standard of competence should vary in significant part with the effects for the patient's well-being of accepting his or her choice. Wicclair's criticisms take two main forms. First, he considers and rejects four of the positive reasons we offer in support of a risk-related standard. Second, in rejecting our fourth reason he argues that a risk-related standard leads to faulty competence determinations -- too high a standard in some cases and too low a standard in others. If he is correct, there are no positive reasons for adopting a risk-related standard and there are as well specific reasons not to adopt such a standard in order to avoid mistaken competence determinations. My response will address both sorts of criticisms in turn.

Altruism↗
PubMed2005

Are patients' decisions to refuse treatment binding on health care professionals?

When patients refuse to receive medical treatment, the consequences of honouring their decisions can be tragic. This is no less true of patients who autonomously decide to refuse treatment. I distinguish three possible implications of these autonomous decisions. According to the Permissibility Claim, such a decision implies that it is permissible for the patient who has made the autonomous decision to forego medical treatment. According to the Anti-Paternalism Claim, it follows that health-care professionals are not morally permitted to treat that patient. According to the Binding Claim it follows that these decisions are binding on health-care professionals. My focus is the last claim. After arguing that it is importantly different from each of the first two claims, I give two arguments to show that it is false. One argument against the Binding Claim draws a comparison with cases in which patients autonomously choose perilous positive treatments. The other argument appeals to considered judgments about cases in which disincentives are used to deter patients from refusing sound treatments.

Beneficence↗