Daniel Sulmasy

The dead donor rule (DDR) originally stated that organ donors must not be killed by and for organ donation. Scholars later added the requirement that vital organs should not be procured before death. Some now argue that the DDR is breached in donation after circulatory determination of death (DCDD) programs. DCDD programs do not breach the original version of the DDR because vital organs are procured only after circulation has ceased permanently as a consequence of withdrawal of life-sustaining therapy. We hold that the original rendition of the DDR banning killing by and for organ donation is the fundamental norm that should be maintained in transplantation ethics. We propose separating the DDR from two other fundamental normative rules: the duties to prevent harm and to obtain informed consent.

A number of practices at the end of life can causally contribute to diminished consciousness in dying patients. Despite overlapping meanings and a confusing plethora of names in the published literature, this article distinguishes three types of clinically and ethically distinct practices: double-effect sedation, parsimonious direct sedation, and sedation to unconsciousness and death. After exploring the concept of suffering, the value of consciousness, the philosophy of therapy, the ethical importance of intention, and the rule of double effect, these three practices are defined clearly and evaluated ethically. It is concluded that, if one is opposed to euthanasia and assisted suicide, double-effect sedation can frequently be ethically justified, that parsimonious direct sedation can be ethically justified only in extremely rare circumstances in which symptoms have already completely consumed the patient’s consciousness, and that sedation to unconsciousness and death is never justifiable. The special case of sedation for existential suffering is also considered and rejected.

Dear Norm,Thank you for sharing such a personal and heartfelt essay. I have been asked by the editors to comment. Reading it inspires me to do so in a similarly heartfelt way. Although I don't know you well, I thought I'd write to you as if you were my patient.I share your sense that Alzheimer disease is a terrible scourge. I've seen much of this disease over a lifetime of practice, and I deeply understand its ravages and the debility and suffering it causes. But what you propose is not a good solution for the problems that Alzheimer disease poses for patients, families, and society. It will ultimately do far more harm than good. Please let me try to explain.

Shortly after the Presidential Commission for the Study of Bioethical Issues was constituted in 2010 and days before the commission members were to join a conference call to discuss possible topics for their deliberation, Craig Venter held a press conference announcing that his lab had created a synthetic chromosome for a species of mycoplasma and had inserted this genetic material into organisms of another species of mycoplasma (the genes of which had been deactivated), transforming the host species into the donor species. While not overtly claiming to have “created life in the test tube,” Venter's publicity seemed cleverly designed to provoke the media into reporting his discovery in just that way. The resulting uproar caused President Obama to give his new bioethics commission the assignment of investigating the ethics of the emerging field of synthetic biology. The commission went right to work. It formed working groups to deliberate about parts of the report, feeding ideas and language to the staff members who would do the actual writing, and then present the working group suggestions to the commission as a whole for public deliberation at open meetings. One of those working groups was charged with coming up with ethical principles that would guide the analysis. Having served as a member of that working group, I report here on the process by which these principles emerged and reflect upon the suitability of that process for the work of public bioethics commissions.

Purpose Recent research has found unrealistic optimism among patient-subjects in early-phase oncology trials. Our aim was to investigate the cognitive and motivational factors that evoke this bias in this context. We expected perceptions of control to be a strong correlate of unrealistic optimism. Methods A study of patient-subjects enrolled in early-phase oncology trials was conducted at two sites in the USA. Respondents completed questionnaires designed to assess unrealistic optimism and several risk attribute variables that have been found to evoke the bias in other contexts. Results One hundred and seventy-one patient-subjects agreed to be interviewed for our study. Significant levels of perceived controllability were found with respect to all nine research-related questions. Perceptions of control were found to predict unrealistic optimism. Two other risk attribute variables, awareness of indicators and mental image, were correlated with unrealistic optimism. However, in multivariate regression analysis, awareness and mental image dropped out of the model and perceived controllability was the only factor independently associated with unrealistic optimism. Conclusion Patient-subjects reported that they can, at least partially, control the benefits they receive from participating in an early-phase oncology trial. This sense of control may underlie unrealistic optimism about benefiting personally from trial participation. Effective interventions to counteract unrealistic optimism may need to address the psychological factors that give rise to distorted risk/benefit processing.

Important discussions about limiting care based on professional judgment often devolve into heated debates over the place of physicians in bedside rationing. Politics, loaded rhetoric, and ideological caricature from both sides of the rationing debate obscure precise points of disagreement and consensus, and hinder critical dialogue around the obligations and boundaries of professional practice. We propose a way forward by reframing the rationing conversation, distinguishing between the scale of the decision and its context avoiding the word “rationing.” We propose to shift the terminology, using specific, descriptive words to defuse conflict and re-focus the debate towards substantive issues. These distinctions can clarify the real ethical differences at stake and facilitate a more constructive conversation about the clinical and social responsibilities of physicians to use resources ethically at the bedside and their role in allocating medical resources at a societal level.

Important discussions about limiting care based on professional judgment often devolve into heated debates over the place of physicians in bedside rationing. Politics, loaded rhetoric, and ideological caricature from both sides of the rationing debate obscure precise points of disagreement and consensus, and hinder critical dialogue around the obligations and boundaries of professional practice. We propose a way forward by reframing the rationing conversation, distinguishing between the scale of the decision and its context avoiding the word “rationing.” We propose to shift the terminology, using specific, descriptive words to defuse conflict and re-focus the debate towards substantive issues. These distinctions can clarify the real ethical differences at stake and facilitate a more constructive conversation about the clinical and social responsibilities of physicians to use resources ethically at the bedside and their role in allocating medical resources at a societal level.

Francis W. Peabody, MDDepartment of MedicineBoston City Hospital and Harvard Medical SchoolBoston, MassachusettsMarch 19, 2017Dear Dr. Peabody,Thank you for giving us the opportunity to review your manuscript "The Care of the Patient." It has been carefully considered by the editors and two external reviewers. We regret to inform you that it cannot be considered further for publication in the Prestigious Journal of Medicine.Chief among our reasons is that it is overly long. Opinion pieces—especially non-data driven articles about topics like ethics—should be no longer than 1,000 words. Compounding matters, the lack of graphics or tables makes the paper difficult to digest efficiently. We also agree with the...

In this dissertation, I defend the view that the distinction between killing and allowing to die is coherent and morally important. ;I first review the history of the distinction from Hippocrates to the early 20th century. I next show that contemporary accounts of the distinction do not reflect the intuitions of those who employ it. I dismiss accounts based on acts and omissions, causing and allowing, harming and benefitting, double effect, the movements of agents, social expectations, and causal responsibility. ;Because of the confusing ways in which the words 'killing' and 'allowing to die' are used, I introduce neologisms. Gribbing is an act in which an agent creates a new, non-therapeutic, lethal pathophysiological state intending that a human being should die by way of that act. Alting is an act in which an agent removes or refrains from initiating an intervention that stops or delays the natural history of an underlying lethal state, either intending that a human being should die by way of that act, or not so intending. The form of the distinction I defend is that all Gribbing is wrong, except in cases of self-defense or rescue. Some Alting is wrong, and some is not. ;I then present a theory of intention to support the thesis that what all Gribbing has in common with the bad cases of Alting is the agent's intention that a human being should die by way of the agent's act. This gives the distinction practical moral importance, since the burden of proof is upon the Gribber to show that death was not the intention. ;Finally, I apply this formulation in a variety of cases, showing that it leads to judgments that generally coincide with those of people who employ the unexamined distinction. If what one means by 'the distinction between killing and allowing to die' is a distinction between Gribbing and Alting, then the distinction is coherent and morally meaningful. The remaining task is to justify the premise that acting with the intention that a human being should die by way of one's act is always morally wrong

The National Conference of Catholic Bishops has argued for significant government involvement in health care in order to assure respect for what they regard as the right to health care. Critics charge that the bishops are wrong because health care is not a right. In this article, it is argued that these critics are correct in their claim that health care is not a right. However, it is also argued that the premise that health care is not a right does not imply that the market is the most equitable and just system for providing health care. Natural law arguments in the tradition of Roman Catholic social teaching lead to the conclusion that a just and prosperous society has a moral obligation to provide health care even if there is no such right. Further, there are strong moral grounds for concluding that the bishops are correct in their claim that health care ought not to be considered a market commodity. It is argued that if health care ought not to be considered a commodity, then national health insurance is the best available alternative for fulfilling the social obligation to distribute health care resources justly and fairly at this time in American history. The bishops' case for government involvement can be made on the strength of the Catholic tradition in theological argumentation, independent of the claim that health care is a right

We report the results of a randomized trial to assess the impact of an innovative ethics curriculum on the knowledge and confidence of 85 medical house officers in a university hospital programme, as well as their responses to a simulated clinical case. Twenty-five per cent of the house officers received a lecture series, 25 per cent received lectures and case conferences, with an ethicist in attendance, and 50 per cent served as controls. A post-intervention questionnaire was administered. Knowledge scores did not differ among the groups. Confidence regarding ethical issues was significantly greater in the aggregate intervention group compared to the control group. Confidence regarding procedural issues related to ethics was significantly higher for the EI group than for the controls. Responses to a simulated case showed that significantly fewer house officers in the EI group would intubate a patient for whom such therapy would be futile. We conclude that ethics education can have an impact on house officers' confidence and their responses to a simulated case, and that the EI was more effective than the LI. Such results have implications regarding the implementation of ethics education during residency.

Many medical ethicists accept the thesis that there is no moral difference between withholding and withdrawing life-sustaining therapy. In this paper, we offer an interesting counterexample which shows that this thesis is not always true. Withholding is distinguished from withdrawing by the simple fact that therapy must have already been initiated in order to speak coherently about withdrawal. Provided that there is a genuine need and that therapy is biomedically effective, the historical fact that therapy has been initiated entails a claim to continue therapy that cannot be attributed to patients who have not yet received therapy. This intrinsic difference between withholding and withdrawing therapy is of moral importance. In many instances, patients will waive this claim. But when one considers withdrawing therapy from one patient to help another in a setting of scarce resources, this intrinsic moral difference comes into sharp focus. In an era of shrinking medical resources, this difference cannot be ignored

OBJECTIVE: To examine the long-term effects of an innovative curriculum on medical house officers' (HOs') knowledge, confidence, and attitudes regarding medical ethics. DESIGN: Long term cohort study. The two-year curriculum, implemented by a single physician ethicist with assistance from other faculty, was fully integrated into the programme. It consisted of monthly sessions: ethics morning report alternating with didactic conferences. The content included topics such as ethics vocabulary and principles, withdrawing life support, informed consent, and justice. Identical content was offered simultaneously at the largest affiliated community hospital. SETTING: A multi-hospital university training programme from July, 1992 to June, 1994. PARTICIPANTS: Thirty-nine HOs responded in 92. Thirty HOs from the same cohort responded in 94 (response rates = 83% v 71%; P = 0.19). RESULTS: The curriculum was well received, with 96% of HOs finding the sessions stimulating. Previously validated scales of knowledge and confidence were administered at baseline and at follow-up. The average knowledge score improved 14% (P < 0.001). Confidence also improved, rising from 3.3 to 3.8 on a 5-point Likert scale (P < 0.001). These findings were independent of age, gender, religion, and prior education. The only attitudinal change was an increase in the proportion of residents who thought that ethics should be a required part of residency training (57% v 80%, P = 0.05). CONCLUSION: This curriculum appears practical, popular, and effective. It should be readily transferable to other institutions

Introduction: The use of human samples in genomic research has increased ethical debate about informed consent (IC) requirements and the information that subjects should receive regarding the results of the research. However, there are no quantitative data regarding researchers’ attitudes about these issues. Methods: We present the results of a survey of 104 US and 100 Spanish researchers who had published genomic epidemiology studies in 61 journals during 2006. Results: Researchers preferred a broader IC than the IC they had actually obtained in their published papers. US authors were more likely than their Spanish colleagues to support obtaining a broad IC, covering either any future research project or any projects related to a group of diseases (67.6% vs 43%; adjusted OR = 4.84, 95% CI, 2.32 to 10.12). A slight majority of researchers (55.8%) supported informing participants about individual genomic results only if the reliability and clinical validity of the information had been established. Men were more likely than women to believe that patients should be informed of research results even if these conditions were not met (adjusted OR = 2.89, 95% CI = 1.46 to 5.72). Conclusions: This study provides evidence of a wide range of views among scientists regarding some controversial ethical issues related to genomic research, suggesting the need for more study, debate and education. In the interim, journals might consider including the investigators’ policies regarding these ethical issues in the papers they publish in the field of genomic epidemiology

Purpose: Physicians are often reluctant to discuss “Do Not Resuscitate” orders with patients. Although perceived self-efficacy is a known prerequisite for behavioural change, little is understood about the confidence of physicians regarding DNR discussions.Subjects and methods: A survey of 217 internal medicine attendings and 132 housestaff at two teaching hospitals about their attitudes and confidence regarding DNR discussions.Results: Participants were significantly less confident about their ability to discuss DNR orders than to discuss consent for medical procedures , and this was true for both attendings and housestaff . In a multivariate logistic model of confidence regarding DNR discussions, women were less confident than men ; house officers were less confident than attendings , those who were less confident of their ability to discuss medical procedures were less confident discussing DNR , and those who found talking to patients about DNR orders very difficult reported less confidence than those who did not .Conclusion: We conclude that physicians’ confidence regarding DNR discussions is low compared with their confidence regarding other medical discussions and that confidence varies by sex and perceived difficulty of the task. Efforts to improve DNR discussions should explore the need to tailor educational interventions to fit these characteristics

David Thomasma called for the development of a medical ethics based squarely on the philosophy of medicine. He recognized, however, that widespread anti-essentialism presented a significant barrier to such an approach. The aim of this article is to introduce a theory that challenges these anti-essentialist objections. The notion of natural kinds presents a modest form of essentialism that can serve as the basis for a foundationalist philosophy of medicine. The notion of a natural kind is neither static nor reductionistic. Disease can be understood as making necessary reference to living natural kinds without invoking the claim that diseases themselves are natural kinds. The idea that natural kinds have a natural disposition to flourish as the kinds of things that they are provides a telos to which to tether the notion of disease – an objective telos that is broader than mere survival and narrower than subjective choice. It is argued that while nosology is descriptive and may have therapeutic implications, disease classification is fundamentally explanatory. Sickness and illness, while referring to the same state of affairs, can be distinguished from disease phenomenologically. Scientific and diagnostic fallibility in making judgments about diseases do not diminish the objectivity of this notion of disease. Diseases are things, not kinds. Injury is a concept parallel to disease that also makes necessary reference to living natural kinds. These ideas provide a new possibility for the development of a philosophy of medicine with implications for medical ethics.

The word ‘dignity’ is used in a variety of ways in bioethics, and this ambiguity has led some to argue that the term must be expunged from the bioethical lexicon. Such a judgment is far too hasty, however. In this article, the various uses of the word are classified into three serviceable categories: intrinsic, attributed, and inflorescent dignity. It is then demonstrated that, logically and linguistically, the attributed and inflorescent meanings of the word presuppose the intrinsic meaning. Thus, one cannot conclude that these meanings are arbitrary and unrelated. This categorization and logical and linguistic analysis helps to unravel what seem to be contradictions in discourse about dignity and bioethics, and provides a hierarchy of meaning that has potential normative implications.

Pellegrino was there at the beginning of the field. In the 1950s and 60s, before there was a Kennedy Institute of Ethics or a Hastings Center; before the word ‘bioethics’ itself was coined, Pellegrino was writing articles such as "Ethical Considerations in the Practice of Medicine and Nursing," published in 1964. He was among those who started the Society for Health and Human Values—a precursor organization to the American Society for Bioethics and Humanities. He was the founding editor of the Journal of Medicine and Philosophy at a time when the notion that there was a relationship between philosophy and medicine was foreign to both physicians and philosophers. The authors of the articles published in the very ..