Peter Koch

Governments standardly deploy a distinction between goods and services in assessing economic health and tracking national income statistics, of which medical goods and services carry significant importance. In what follows we draw on Basic Formal Ontology (BFO) to introduce a third kind of entity called patterns, which help capture the various ways in which goods and services are intertwined and help also to show how many services generate a new kind of non-goods-related products. Patterns are an overlooked yet essential features of many economic sectors including medicine. Studying patterns offers new insights into various components of economic analysis, including outcomes-oriented evaluations of medical services and the value of human capital in the medical sphere.

In clinical ethics, there remains a great deal of uncertainty regarding the appropriateness of attempting cardiopulmonary resuscitation (CPR) for certain patients. Although the issue continues to receive ample attention and various frameworks have been proposed for navigating such cases, most discussions draw heavily on the notion of harm as a central consideration. In the following, I use emerging philosophical literature on the notion of harm to argue that the ambiguities and disagreement about harm create important and oft-overlooked challenges for the ethics of CPR. I begin by elucidating the standard account of harm, called the Counterfactual Comparative Account (CCA). I then show that three challenges to the CCA—preemptive harms, the harm of death, and non-experiential harms—are particularly salient when assessing potential harms for candidates of CPR and likely impact-related decision-making and communication. I extend this argument to explore how the ambiguities of harm might extend to other realms of clinical decision-making, such as the use and limitations of life-sustaining treatments. To address these challenges, I propose two strategies for identifying and minimizing the impact of such uncertainty: first, clinicians and ethicists ought to promote pluralistic conversations that account for different understandings of harm; second, they ought to invoke harm-independent considerations when discussing the ethics of CPR in order to reflect the nuances of such conversations. These strategies, coupled with a richer philosophical understanding of harm, promise to help clinicians and ethicists navigate the prevalent and difficult cases involving patient resuscitation and many other harm-based decisions in the clinical setting.

When governments collect data relating to economic activity they commonly employ a distinction between goods and services. Both goods and services have economic value. Goods (cars, houses, bottles of milk) are, very roughly, independent continuants which can be alienated (sold, gifted, rented, and so forth). Services (hairdressing, gardening, teaching) are, again very roughly, occurrents. They are occurrents which are further often said to be marked by the fact that production and consumption coincide. Social services under both headings typically involve combinations of service provision. The patterns in question are primarily those of the family (where the patterns to be maintained or restored are, roughly, those characteristic of a healthy family life) and of the child (patterns characteristic of healthy development, provided by child protective services, who work to prevent child abuse).

The promotion of patient welfare is a central goal of medical professionals and serves as a fundamental principle of medical professionalism. Despite its importance, however, it is unclear what is meant by patient welfare. In my dissertation, I explore patient welfare by analyzing the ordinary notion of welfare and applying this analysis to the patient population. I argue that welfare is best understood and expressed in terms of capabilities, which I define using the structure and vocabulary of Basic Formal Ontology. I conclude that patient welfare is a multi-dimensional quality of the human organism corresponding to the degree to which that patient has realized the array of capabilities typical of the human kind. I then identify certain important implications for this view on the practice of medicine.

We propose a definition of capability as a class intermediate between function and disposition as the latter are defined in Basic Formal Ontology (BFO). A disposition inheres in a material entity and is realized in a certain kind of process. An example is the disposition of a glass to break when struck, which is realized when it shatters. A function is a disposition which is (simply put) the rationale for the existence of its bearer. To say for example that a water pump has the function to pump water is to say that the pump exists because something was needed that would pump water. Capabilities are a special sort of disposition in that that, like functions, they can be evaluated on the basis of how well they are realized. They differ from functions in that their realizations are not the rationale – not the primary reason – for the existence of their bearers. Thus, a water pump may have many capabilities, including to be weatherproof, to run without lubricant, and so forth, but only one function. All functions are capabilities on the view we defend, but not all capabilities are functions. We develop a series of axioms to distinguish capabilities formally from both dispositions and functions and provide examples of the use of ‘capability’ in a variety of domains.

In the continuing debate about the role of the Clinical Ethics Consultant in performing clinical ethics consultations, it is often assumed that consultants should operate within ethical and legal standards. Recent scholarship has focused primarily on clarifying the consultant's role with respect to the ethical standards that serve as parameters of consulting. In the following, however, I wish to address the question of how the ethics consultant should weigh legal standards and, more broadly, how consultants might weigh authoritative directives, whether legal, institutional, or professional, against other normative considerations. I argue that consultants should reject the view that authoritative directives carry exclusionary reason for actions and, further, ethicists should interpret directives as lacking any moral weight qua authoritative directive. I then identify both implications and limitations of this view with respect to the evolving role of the ethics consultant in an institutional setting, and in doing so propose the kinds of considerations the ethicist should weigh when presented with an authoritative directive.

The use of decision-making capacity assessments in clinical medicine is an underdeveloped yet quickly growing practice. Despite the ethical and clinical importance of these assessments as a means of protecting patient autonomy, clinicians, philosophers, and ethicists have identified a number of practical and theoretical hurdles which remain unresolved. One ethically important yet largely unaddressed issue is whether, and to what extent physicians ought to inform and obtain consent from patients prior to initiating a capacity assessment. In what follows, I address the following question: Must, or should, physicians obtain consent for capacity assessments? I argue that physicians have an ethical obligation to obtain express patient consent for capacity assessments, and in doing so, I challenge the predominant view which requires physicians to merely inform patients without obtaining consent. I then identify an underlying philosophical paradox that complicates the clinician's duty to obtain consent: in short, consent is needed for an assessment of one's ability to consent. Finally, I recommend a practical solution to this paradox of consent for capacity assessments by proposing a model of double consent from both the patient and health care representative.

Although shared decision-making is a standard in medical care, unilateral decisions through process-based conflict resolution policies have been defended in certain cases. In patients who do not stand to receive proportional clinical benefits, the harms involved in interventions such as cardiopulmonary resuscitation seem to run contrary to the principle of non-maleficence, and provision of such interventions may cause clinicians significant moral distress. However, because the application of these policies involves taking choices out of the domain of shared decision-making, they face important ethical and legal problems, including a recent challenge to their constitutionality. In light of these concerns, we suggest a re-conceptualization of informed non-dissent as an alternative approach in cases where the application of process-based policies is being considered. This clinician-directed communication model still preserves what is valuable in such policies and salvages professional integrity, while minimising ethical and legal challenges.

The authors work in a variety of clinical ethics consultation services (CECSs) that employ a range of methods and approaches. This article discusses the approach to ethics consultation at the Center for Medical Ethics and Health Policy at Baylor College of Medicine and describes the development and transformation of the authors’ CECSs. It discusses how one CECS shifted from a nascent program with only fifty consultations a year to a vibrant, heavily staffed service with five hundred ethics consultations a year.

In this paper I will provide a hylomorphic critique of Jeff McMahan’s “An Alternative to Brain Death.” I will evaluate three puzzles—the dicephalus, the braintransplant, and the split-brain phenomenon—proposed by McMahan which allow him to deny that a human being is identical to an organism. I will contend thatMcMahan’s solution entails counterintuitive consequences that pose problems to organ transplant cases. A Thomistic hylomorphic metaphysics not only avoids these unwelcome consequences and provides solutions to the three puzzles but in doing so allows for an alternative definition of death. Since McMahan has constructed his definition of death around his own metaphysics, alternative metaphysics, in this case a hylomorphic metaphysics, allow for an alternative definition of death.

In this paper I will provide a hylomorphic critique of Jeff McMahan’s “An Alternative to Brain Death.” I will evaluate three puzzles—the dicephalus, the braintransplant, and the split-brain phenomenon—proposed by McMahan which allow him to deny that a human being is identical to an organism. I will contend thatMcMahan’s solution entails counterintuitive consequences that pose problems to organ transplant cases. A Thomistic hylomorphic metaphysics not only avoids these unwelcome consequences and provides solutions to the three puzzles but in doing so allows for an alternative definition of death. Since McMahan has constructed his definition of death around his own metaphysics, alternative metaphysics, in this case a hylomorphic metaphysics, allow for an alternative definition of death.