George Khushf

In our first section, we make the prior engagement between artificial intelligence (AI) and medicine explicit and show how pervasively AI (broadly conceived) has already influenced and been integrated into medicine and clinical care. There has been ethical reflection on these developments since the early 1960s, and many of the concerns articulated today (about impact on the physician-patient relation, explainability, bias and so on) have already been considered in some form long ago. In our second section, we briefly consider ML and what may be distinctive about diagnostic support systems utilizing ML. We also consider in very broad strokes some of the ethical challenges and technical tools offered within AI for addressing these challenges. Within this broader horizon, we consider in our third section the contributions made by the essays in the issue. We close with some summary thoughts on how reading these essays together sharpens our appreciation of ongoing ethical challenges for integrating diagnostic support systems into clinical practice.

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.

Nanomedicine is yielding new and improved treatments and diagnostics for a range of diseases and disorders. Nanomedicine applications incorporate materials and components with nanoscale dimensions where novel physiochemical properties emerge as a result of size-dependent phenomena and high surface-to-mass ratio. Nanotherapeutics and in vivo nanodiagnostics are a subset of nanomedicine products that enter the human body. These include drugs, biological products, implantable medical devices, and combination products that are designed to function in the body in ways unachievable at larger scales. Nanotherapeutics andin vivonanodiagnostics incorporate materials that are engineered at the nanoscale to express novel properties that are medicinally useful. These nanomedicine applications can also contain nanomaterials that are biologically active, producing interactions that depend on biological triggers. Examples include nanoscale formulations of insoluble drugs to improve bioavailability and pharmacokinetics, drugs encapsulated in hollow nanoparticles with the ability to target and cross cellular and tissue membranes and to release their payload at a specific time or location, imaging agents that demonstrate novel optical properties to aid in locating micrometastases, and antimicrobial and drug-eluting components or coatings of implantable medical devices such as stents.

Current philosophical and legal bioethical reflection 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 insufficient 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 Shumann'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.

Germund Hesslow has argued that concepts of health and disease serve no important scientific, clinical, or ethical function. However, this conclusion depends upon the particular concept of disease he espouses; namely, on Boorse's functional notion. The fact/value split embodied in the functional notion of disease leads to a sharp split between the "science" of medicine and bioethics, making the philosophy of medicine irrelevant for both. By placing this disease concept in the broader context of medical history. I shall show self-contradictory notion. By making explicit the value desiderate of medical nosologies, a reconfiguration of the relation between medicine, bioethics, and the philosophy of medicine is initiated. This, in turn, will involve a recovery of the caring dimensions of medicine, and thus a more humane practice.

”Merely fact-minded sciences make merely factminded people.”“ …the positivistic concept of science in our time is, historically speaking, a residual concept. It has dropped all the questions which had been considered under the now narrower, now broader concepts of metaphysics….all these ‘metaphysical’ questions, taken broadly – commonly called specifically philosophical questions – surpass the world understood as the universe of mere facts. They surpass it precisely as being questions with the idea of reason in mind. And they all claim a higher dignity than questions of fact, which are subordinated to them even in the order of inquiry. Positivism, in a manner of speaking, decapitates philosophy.”Edmund HusserlIn ethical literature associated with controversies at the beginning and end of human life, there is often a two-part structure: first, basic facts about the topic are presented in a more or less descriptive format, then there is the ethics or policy.

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

In prominent funding and policy statements, a particle with at least one dimension in the 1-300 nm size range must have novel physicochemical properties to count as a “nanoparticle.” Size is thus only one factor. Novelty of a particle's properties is also essential to its “nano” classification. When particles in this size range are introduced into living systems, they often interact with their host in novel ways that require some modification of existing methods and models used by pharmaceutical scientists and toxicologists for assessing their efficacy and safety. It is not clear, however, whether the novelty of the intended physicochemical properties is in any way related to the novel behavior of those particles when their toxicity is evaluated. In fact, when considering toxicity, much of the concern about nanoparticles relates to the unanticipated or poorly understood interactions.

Many believe that nanotechnology will be disruptive to our society. Presumably, this means that some people and even whole industries will be undermined by technological developments that nanoscience makes possible. This, in turn, implies that we should anticipate potential workforce disruptions, mitigate in advance social problems likely to arise, and work to fairly distribute the future benefits of nanotechnology. This general, somewhat vague sense of disruption, is very difficult to specify – what will it entail? And how can we responsibly anticipate and mitigate any problems? We can't even clearly state what the problems are anticipated to be. In fact, when we move from sweeping policy statements to more concrete accounts, nanotechnology seems to bifurcate into two divergent streams: one is fairly continuous with current developments, extending extant science in a quantitative way; the other is radically new, and includes science fiction-like dreams of molecular manufacturing and assemblers, with their utopian scenarios of absolute plenty. In these cases, “disruption” takes on the valence of Huxley's brave new world.

The Hyde Amendment and Roman Catholic attempts to put restrictions on Title X funding have been criticized for being intolerant. However, such criticism fails to appreciate that there are two competing notions of tolerance, one focusing on the limits of state force and accepting pluralism as unavoidable, and the other focusing on the limits of knowledge and advancing pluralism as a good. These two types of tolerance, illustrated in the writings of John Locke and J.S. Mill, each involve an intolerance. In a pluralistic context f where the free exercise of religion is respected, John Locke's account of tolerance is preferable. However, it (in a reconstructed form) leads to a minimal state. Positive entitlements to benefits like artificial contraception or nontherapeutic abortions can legitimately be resisted, because an intolerance has already been shown with respect to those that consider the benefit immoral, since their resources have been coop ted by taxation to advance an end that is contrary to their own. There is a sliding scale from tolerance (viewed as forbearance) to the affirmation of communal integrity, and this scale maps on to the continuum from negative to positive rights. Keywords: church and state, Hyde Amendment, Locke, Mill, religious liberty, Title X funding, toleration CiteULike Connotea Del.icio.us What's this?

Conflicts of interest serve as a cipher for a radical rupture in the Flexnerian paradigm of medicine, and they can only be addressed if we recognize that health care is now practiced by institutions, not just individual physicians. By showing how "appropriate utilization of services" or "that which is medically indicated" is a function of socioeconomic factors related to institutional responsibilities, I point toward an administrative and organizational ethic as a needed component for addressing conflicts of interest. The argument is developed by reviewing three important books. First, I consider Mark Rodwin's attempt to configure the economic structures of medicine so that classical fiduciary and scientific ideals can be fostered. Second, I consider E. Haavi Morreim's attempt to modify the classical ideals in order to account for new economic realities. Finally, by considering essays in a recent volume on conflicts of interest edited by Spece, Shimm, and Buchanan, I argue for a constructive dialectic between the approaches of Rodwin and Morreim. In order to properly address conflicts of interest, there must be a radical reassessment of medicine that accounts for the interrelation between scientific, ethical, and economic concerns. Until institutions come into view and professional ethics is developed to account for their role, legitimate interests and obligations of diverse parties cannot be harmonized.

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

Three basic political positions on embryo research will be identified as libertarian, conservative, and social-democratic. The Human Embryo Research Panel will be regarded as an expression of the social-democratic position. A taxonomy of the ethical issues addressed by the Panel will then be developed at the juncture of political and ethical modes of reflection. Among the arguments considered will be those for the separability of the abortion and embryo research debates; arguments against the possibility of the preembryo being a person, especially arguments associated with totipotency and the significance of the primitive streak; and the various reasons for regulating embryo research, including those associated with respect for the preembryo, the protection of traditional views of human procreation, and the prevention of commercialization

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

Germund Hesslow has argued that concepts of health and disease serve no important scientific, clinical, or ethical function. However, this conclusion depends upon the particular concept of disease he espouses; namely, on Boorse's functional notion. The fact/value split embodied in the functional notion of disease leads to a sharp split between the science of medicine and bioethics, making the philosophy of medicine irrelevant for both. By placing this disease concept in the broader context of medical history, I shall show that it does capture an essential part of modern medical ideology. However, it is also a self-contradictory notion. By making explicit the value desiderata of medical nosologies, a reconfiguration of the relation between medicine, bioethics, and the philosophy of medicine is initiated. This, in turn, will involve a recovery of the caring dimensions of medicine, and thus a more humane practice.