FUTILITY AND THE VARIETIES OF MEDICAL JUDGMENT

Pellegrino has argued that end-of-life decisions should be based upon the physician's assessment of the effectiveness of the treatment and the patient's assessment of its benefits and burdens. This would seem to imply that conditions for medical futility could be met either if there were a judgment of ineffectiveness, or if the patient were in a state in which he or she were incapable of a subjective judgment of the benefits and burdens of the treatment. I argue that a theory of futility according to Pellegrino would deny that latter but would permit some cases of the former. I call this the “circumspect” view. I show that Pellegrino would adopt the circumspect view because he would see the medical futility debate in the context of a system of medical ethics based firmly upon a philosophy of medicine. The circumspect view is challenged by those who would deny that one can distinguish objective from subjective medical judgments. I defend the circumspect view on the basis of a previously neglected aspect of the philosophy of medicine -- an examination of varieties of medical judgment. I then offer some practical applications of this theory in clinical practice.     

Retrospective and prospective metacognitive judgments in rhesus macaques (Macaca mulatta)

A growing body of research suggests that some non-human animals are capable of making accurate metacognitive judgments. In previous studies, non-human animals have made either retrospective or prospective judgments (about how they did on a test or how they will do on a test, respectively). These two types of judgments are dissociable in humans. The current study tested the abilities of two rhesus macaque monkeys to make both retrospective and prospective judgments about their performance on the same memory task. Both monkeys had been trained previously to make retrospective confidence judgments. Both monkeys successfully demonstrated transfer of retrospective metacognitive judgments to the new memory task. Furthermore, both monkeys transferred their retrospective judgments to the prospective task (one, immediately, and one, following the elimination of a response bias). This study is the first to demonstrate both retrospective and prospective monitoring abilities in the same monkeys and on the same task, suggesting a greater level of flexibility in animals’ metacognitive monitoring abilities than has been reported previously.     

Research report: A preliminary analysis of medical futility decisionmaking: law and professional attitudes

Judicial decisions reviewed in this article indicate that courts have taken two disparate approaches to disputes over futility of treatment. To explore whether a consensus on medical futility is developing among hospitals, the authors conducted a nationwide survey of health care professionals at hospitals. Respondents assigned importance ratings to factors used in recent futility decisions made at their institutions. The resulting importance ratings showed significant variation by characteristics of the institution (comparing respondents from for-profit, not-for-profit, and government hospitals) and by profession of the respondent (comparing physicians and nurses). The respondents' judgments endorsed three distinct strategies for making futility decisions (i.e., emphasis on the patient's decision preferences, providing for the patient and family, and adhering to objective medical and social norms). © 1998 John Wiley & Sons, Ltd.     

Futility in Chronic Anorexia Nervosa: A Concept Whose Time Has Not Yet Come

Comparatively little scholarly attention has been given to the question of futility in chronic psychiatric disorders, with the exception of a small body of work on so-called end-stage anorexia nervosa (AN). A review of this literature provides the background for a critical examination of whether the concept of futility has any clinically meaningful, ethically justifiable, and legally defensible application to AN. In this article, the arguments for and against futility judgments in AN are analyzed with special emphasis on determinations of capacity in this serious mental illness. Parallels between the futility disputes in medical and psychiatric disorders, where applicable, will be drawn to further illuminate whether or not the concept that continued psychiatric treatment for AN is ever truly futile.     

The demands of an ongoing activity influence the success of event-based prospective memory

Four experiments were conducted to evaluate whether event-based prospective memory would be sensitive to the concurrent demands of the ongoing activity in which intention-related cues were embedded. In Experiments 1 and 2, random alternation between two judgments in the ongoing task reduced prospective memory as compared with having a single task throughout. In Experiment 3, participants' making two binary judgments on every trial resulted in worse prospective memory than did their making single four-alternative judgments. In Experiment 4, participants' making two related judgments resulted in better prospective memory than did their making two unrelated judgments. The results are consistent in spirit with a production rule account of the processing resources that are available when intention-related cues are encountered. Therefore, event-based prospective memory can inversely covary with the cognitive demands of the ongoing activity.     

An analysis of the structure of justification of ethical decisions in medical intervention

The most important distinction in value theory is the subjective-objective distinction which determines the epistemological status of value judgments about medical intervention. Ethical decisions in medical intervention presuppose one of three structures of justification — namely, an inductive approach, a deductive approach which can be either consequentialist or non-consequentialist, and a uniquely ethical approach. Inductivism and deductivism have been discussed extensively in the literature and are only briefly described here. The uniquely ethical approach which presupposes value objectivism is analyzed in detail. This method involves a purely ethical inference which moves from facts to values directly with an emphasis on reason which involves a non-logical justification (as opposed to illogical). It involves the use of natural practical arguments which have an imperative conclusion but no imperative premise and exhibit a value-requiredness between two states of affairs.     

A study of the foundations of ethical decision making of clinical medical ethicists

A study of clinical medical ethicists was conducted to determine the various philosophical positions they hold with respect to ethical decision making in medicine and their various positions' relationship to the subjective-objective controversy in value theory. The study consisted of analyzing and interpreting data gathered from questionnaires from 52 clinical medical ethicists at 28 major health care centers in the United States. The study revealed that most clinical medical ethicists tend to be objectivists in value theory, i.e., believe that value judgments are knowledge claims capable of being true or false and therefore expressions of moral requirements and normative imperatives emanating from an external value structure or moral order in the world. In addition, the study revealed that most clinical medical ethicists are consistent in the philosophical foundations of their ethical decision making, i.e., in decision making regarding values they tend not to hold beliefs which are incompatible with other beliefs they hold about values.     

The Effect of Inference Order and Experience-Related Knowledge on Diagnostic Conjunction Probabilities

Ideally, a decision maker′s diagnostic probability judgments should not be affected by making predictive judgments before making diagnostic inferences. The purpose of this study is to investigate how experience-related knowledge and the inference presentation order affect a decision maker′s diagnostic conjunction probability judgments. Specifically, when decision makers are asked to make diagnoses in different judgment domains with which they have different levels of experience, we examine how making predictions first affects their subsequent diagnostic judgments in a standard conjunction paradigm. Professional auditors with experience in the auditing domain and MBA students with little or no auditing experience participated in the experiment. The results indicate that when the task involves a domain with which people have experience, making predictions prior to diagnoses has a significant influence on their subsequent diagnostic conjunction probabilities. When auditors made diagnoses in a familiar audit task situation, they were strongly influenced by whether or not they were asked to make predictions in advance. However, there was no influence of inference order on auditors′ diagnoses in a medical task, with which they do not have experience-related knowledge. Similarly, MBA students, having no experience-related knowledge in either audit or medical domains, were not affected by the inference order in making diagnoses. In the discussion of these exploratory results, we suggest that this inference order effect may be due to subjects′ anchoring on the predictive probability and insufficiently adjusting it to yield the diagnostic probability judgment.     

Patients' rights and physician accountability: Problems with PSROs

The author examines the ethical underpinnings of the Professional Standard Review Organizations (PSROs). Four normative problems are explored in order of their importance: the problem of bureaucracy incapable of responding sensitively to individual cases; the problem of cost consciousness overcoming the commitment to quality; the problem of commitment to highest quality interfering with other social values and goals; and the problem of value judgments being made by professionals rather than patients whose rights and interests are most directly at stake. Though physicians may indeed be able to balance qualitative and cost considerations with prudence, they, nevertheless, approach medical problems with their own value system. Deciding between marginal health care and alternative courses with a given amount of funds involves subtle value judgments that will vary depending on the value systems of the decision-makers. Because of their unique composition, PSROs cannot adequately reflect the social consensus about what constitutes a reasonable limit to health care.     

Meaning,Expression, and the Interpretation of Literature

I argue that when we interpret a literary work, we engage with at least two different kinds of meaning, each requiring a distinct mode of interpretation. These kinds of meaning are literary varieties of what Paul Grice called nonnatural and natural meaning. The long‐standing debate that began with Beardsley and Wimsatt's attack on the intentional fallacy is, I argue, really a debate about nonnatural meaning in literature. I contend that natural meaning has been largely neglected in our theorizing about literary interpretation and that this comes at a serious cost, resulting in an inadequate account of what interpretation involves. I argue, first, that by recognizing that literary meaning includes both nonnatural and natural meaning, we are better placed to understand the interpreter's relationship with the author, and, second, that recognition of the distinction between nonnatural and natural meaning advances the established debate about literary meaning, offering support for actual intentionalism. The more inclusive view of literary meaning helps resolve an apparent difficulty raised by Noël Carroll.     

Cognitive biases in moral judgments that affect political behavior

Cognitive biases that affect decision making may affect the decisions of citizens that influence public policy. To the extent that decisions follow principles other than maximizing utility for all, it is less likely that utility will be maximized, and the citizens will ultimately suffer the results. Here I outline some basic arguments concerning decisions by citizens, using voting as an example. I describe two types of values that may lead to sub-optimal consequences when these values influence political behavior: moralistic values (which people are willing to impose on others regardless of the consequences) and protected values (PVs, values protected from trade-offs). I present evidence against the idea that voting is expressive, i.e., that voters aim to express their moral views rather than to have an effect on outcomes. I show experimentally that PVs are often moralistic. Finally, I present some data that citizens’ think of their duty in a parochial way, neglecting out-groups. I conclude that moral judgments are important determinants of citizen behavior, that these judgments are subject to biases and based on moralistic values, and that, therefore, outcomes are probably less good than they could be.     

Good Moral Judgment and Decision‐Making Without Deliberation

It is widely accepted in psychology and cognitive science that there are two “systems” in the mind: one system (System 1) is characterized as quick, intuitive, perceptive, and perhaps more primitive, while the other (System 2) is described as slower, more deliberative, and responsible for our higher‐order cognition. I use the term “reflectivism” to capture the view that conscious reflection—in the “System 2” sense—is a necessary feature of good moral judgment and decision‐making. This is not to suggest that System 2 must operate alone in forming our moral decisions, but that it plays a normatively ineliminable role. In this paper, I discuss arguments that have been offered in defense of reflectivism. These arguments fit into two broad categories; let us think of them as two sides of a coin. On the first side are arguments about the efficaciousness of conscious reasoning—for example, without conscious deliberation we will make bad moral judgments and decisions. On the other side of the coin are arguments about the centrality of conscious deliberation to normative actions—for example, without conscious deliberation we are no more agential than animals or automatons. Despite their attractiveness, I argue that these arguments do not successfully establish that reflection is a necessary component of good moral judgment and decision‐making. If I am right, the idea that good moral judgment and decision‐making can result from entirely automatic and subconscious processes gains traction. My goal in this paper is to show that reflectivism fails to include the full range of cases of moral decision‐making and that a theory of automaticity may do a better job. I briefly discuss at the end of the paper how an account of successful automatic moral judgment and decision‐making might begin to take shape.     

Ethical issues in diagnosis

The ways in which ethical issues arise in making clinical judgments are briefly discussed. By showing the topography of the role of value judgments in medical diagnostics it is suggested why clinical medicine remains inextricably a value-infected science.     

Judgment Internalism: an Argument from Self-Knowledge

One of the most important metaethical debates concerns the relationship between evaluative judgments and motivation. The so-called judgment internalists claim that there is an internal modal connection between our evaluative judgments and motivation, whereas the so-called externalists believe that evaluative judgments are connected to desires only through contingent external facts. This debate has reached a standoff. My aim is to introduce a completely new argument for internalism, which does not rely on our intuitions about individual cases. I argue that the truth of internalism explains best why the so-called transparency method yields self-knowledge of what we desire.     

Explaining Practical Normativity

Ethical non-naturalists often charge that their naturalist competitors cannot adequately explain the distinctive normativity of moral or more broadly practical concepts. I argue that the force of the charge is mitigated, because non-naturalism is ultimately committed to a kind of mysterianism about the metaphysics of practical norms that possesses limited explanatory power. I then show that focusing on comparative judgments about the explanatory power of various metaethical theories raises additional problems for the non-naturalist, and suggest grounds for optimism that a naturalistic realist about practical normativity will ultimately be able to explain the distinctive normativity of practical norms. I then show that radical pluralism or particularism about the structure of normative ethics would complicate the naturalistic strategy that I defend. This suggests a perhaps surprising way in which the resolution of the debate between ethical naturalists and non-naturalists may rest in part on the answers to substantive normative questions.     

Intrinsic Value,Alternative Possibilities,and Reason

I address three issues in this paper: first, just as many have thought that there is a requirement of alternative possibilities for the truth of judgments of moral responsibility, is there reason to think that the truth of judgments of intrinsic value also presupposes our having alternatives? Second, if there is this sort of requirement for the truth of judgments of intrinsic value, is there an analogous requirement for the truth of judgments of moral obligation on the supposition that obligation supervenes on goodness? Third, if the truth of judgments of intrinsic value and those of moral obligation do presuppose our having access to alternatives, what should be said about whether determinism imperils the truth of such judgments? I defend an affirmative answer to the first question, a more guarded answer to the second, and a yet more restrained answer to the third.     

Moral realism and moral judgments

For moral realists moral judgments will be a kind of factual judgment that involves the basically reliable apprehension of an objective moral reality. I argue that factual judgments display at least some degree of conceptual sensitivity to error, while moral judgments do not. Therefore moral judgments are not a kind of factual judgment.     

Can cognitive psychological research on reasoning enhance the discussion around moral judgments?

In this article we will demonstrate how cognitive psychological research on reasoning and decision making could enhance discussions and theories of moral judgments. In the first part, we will present recent dual-process models of moral judgments and describe selected studies which support these approaches. However, we will also present data that contradict the model predictions, suggesting that approaches to moral judgment might be more complex. In the second part, we will show how cognitive psychological research on reasoning might be helpful in understanding moral judgments. Specifically, we will highlight approaches addressing the interaction between intuition and reflection. Our data suggest that a sequential model of engaging in deliberation might have to be revised. Therefore, we will present an approach based on Signal Detection Theory and on intuitive conflict detection. We predict that individuals arrive at the moral decisions by comparing potential action outcomes (e.g., harm caused and utilitarian gain) simultaneously. The response criterion can be influenced by intuitive processes, such as heuristic moral value processing, or considerations of harm caused.     

The Moral Dilemmas Debate, Deontic Logic, and the Impotence of Argument

In this paper I argue for modesty concerning what theoretical reason can accomplish in the moral dilemmas debate. Specifically, I contend that philosophers' conclusions for or against moral dilemmas are driven less by rational argument and more by how the moral world intuitively appears to them.I support this thesis by first considering an argument against moral dilemmas, the argument from deontic logic, and showing that its persuasive force depends on one's having already accepted its conclusion. I then make a different, and general, case that any argument in the moral dilemmas debate concerning the defeasibility of conflicting obligations can be marginalized by making not-unreasonable adjustments in the conditions for wrongdoing.These two strands of argument are related by the notion of inescapable wrongdoing. It is our standing intuitions about inescapable wrongdoing which make the relevant deontic logical principles plausible or implausible to us. And whether wrongdoing can be inescapable is central to deciding what the conditions for wrongdoing are. My conclusion is that the arguments in the moral dilemmas debate merely implement whatever standing intuition we have concerning inescapable wrongdoing, and that apart from any such intuition the arguments are unpersuasive.     

Disability versus futility in rationing health care services: defining medical futility based on permanent unconsciousness--PVS,coma, and anencephaly

All societies must ration health care services in the face of unlimited demand. The concept of medical futility may appear to be an uncontroversial means by which to ration services. Depending upon how it is applied, however, limiting services based on alleged medical futility may violate prohibitions against disability-based discrimination. In particular, use of medical futility to require removal of life-sustaining interventions has been held to violate the Americans with Disabilities Act. The ADA protects both people with disabilities who are conscious and people in unconscious states, such as permanent vegetative state (PVS), coma, and anencephaly. Ultimately, as the number of people in permanently unconscious states increases, our society will have to recognize that consciousness is an essential characteristic defining human beings and determining whether a legal right to unlimited life-sustaining intervention should apply. This article proposes to define medical futility to preclude life-sustaining interventions after a stated period of permanent unconsciousness and to redefine the end of life consistently as neocortical death.