Revisiting the best interest standard: uses and misuses

The best interest standard is the threshold most frequently employed by physicians and ethics consultants in challenging a parent's refusal to provide consent for a child's medical care. In this article, I will argue that the best interest standard has evolved to serve two different functions, and that these functions differ sufficiently that they require separate standards. While the best interest standard is appropriate for choosing among alternative treatment options for children, making recommendations to parents, and making decisions on behalf of a child when the legal decision makers are either unable to make a decision or are in dispute, a different standard is required for deciding when to seek state interference with parental decision-making authority. I will suggest that the harm principle provides a more appropriate threshold for determining when to seek state intervention than the best interest standard.     

The Harm Principle Cannot Replace the Best Interest Standard: Problems With Using the Harm Principle for Medical Decision Making for Children

For many years the prevailing paradigm for medical decision making for children has been the best interest standard. Recently, some authors have proposed that Mill’s “harm principle” should be used to mediate or to replace the best interest standard. This article critically examines the harm principle movement and identifies serious defects within the project of using Mill’s harm principle for medical decision making for children. While the harm principle proponents successfully highlight some difficulties in present-day use of the best interest standard, the use of the harm principle suffers substantial normative and conceptual problems. A medical decision-making framework for children is suggested, grounded in the four principles. It draws on the best interest standard, incorporates concepts of harm, and provides two questions that can act as guide and limit in medical decision making for children.     

Dual-relationship prohibitions: A concept whose time never should have come

The concept of dual-relationship prohibitions has limited value in that it creates confusion and leads to unfair results in ethics and licensing actions. It serves little purpose because it does not assist psychologists in analyzing situations. Neither does it provide much help in assisting psychologists in deciding how to act in a particular situation, such that the client's best interest is considered. This article addresses the problems with dual-relationship prohibitions. It also focuses on the constitutional problems of dual-relationship restrictions. Finally, a new standard is offered, that of substantial conflict of interest. In addition, an analytical model is proposed to guide psychologists in making decisions regarding whether a substantial conflict of interest exists where multiple-role relationships are involved. Finally, several suggestions are presented to make the entire process connected with ethics complaints fairer and more constitutionally sound.     

Forgoing life-sustaining treatment: limits to the consensus. Part 2

While substantial progress has been made in reaching a moral and policy consensus regarding forgoing life-sustaining treatment, several holes exist in that consensus where more public discussion and moral analysis is needed. First, among patients who have not been found to be legally incompetent there is controversy over whether certain treatments can be refused. Controversies also remain over damages for treatment without consent, limits based on third-party interests and the ethical integrity of the medical profession, and cases where it cannot be agreed whether the patient is competent. Even greater dispute exists over care of incompetent patients. Perhaps the greatest gap in the consensus arises over limits to the use of the best interests standard. This article proposes replacing it with a "reasonableness standard" that takes into account disputes about what is literally the best for the patient and conflicts of interest between the patient and others.     

Ethical Responsibilities in Child Custody Evaluations: Implications for Evaluation Methodology

Child custody evaluators frequently encounter 3 complex problems: (a) assessment of highly contested cases; (b) how to help the court, attorneys, and clients struggle with the ambiguity of the "best interest" standard; and (c) ethical issues in assessing the children's preferences for their primary custodial parent. The purpose of this article is to describe the methodological implications of recent custody evaluation guidelines and recent research. Recommendations include reliance on family-process oriented diagnostic approaches and functional assessment methods, use of evaluation methods in which relevant parties have an opportunity to state their views and rationale concerning the children's best interests, and understanding of the content areas relevant to assessing children's custodial preferences at different developmental levels.     

The best interest standard: both guide and limit to medical decision making on behalf of incapacitated patients

In this issue of JCE, Douglas Diekema argues that the best interest standard (BIS) has been misemployed to serve two materially different functions. On the one hand, clinicians and parents use the BIS to recommend and to make treatment decisions on behalf of children. On the other hand, clinicians and state authorities use the BIS to determine when the government should interfere with parental decision-making authority. Diekema concedes that the BIS is appropriately used to "guide" parents in making medical treatment decisions for their children. But he argues that the BIS is inappropriately used as a "limiting" standard to determine when to override those decisions. Specifically, Diekema contends that the BIS "does not represent the best means for determining when one must turn to the state to limit parental action." He argues that this limiting function should be served by the harm principle instead of by the BIS. I contend that we should not reassign the BIS's limiting function to the harm principle. In this article I make two arguments to support my position. First, the BIS has effectively served, and can serve, both guiding and limiting functions. Second, the harm principle would be an inadequate substitute. It cannot serve the limiting function as well as the more robust BIS.     

Child psychoanalysis and obsessive-compulsive symptoms: the treatment of a ten-year-old boy

Obsessive-compulsive symptoms have long held interest for psychoanalysts. Currently, pharmacological and behavioral treatments are commonly viewed as the standard of care, and psychoanalytic clinicians are often uncertain of how best to approach these patients. The successful two-year psychoanalytic treatment of a ten-year-old boy with obsessivecompulsive disorder, who remained symptom-free eight years after termination, is reported. While this is but a single case, its outcome implies that for some patients psychoanalysis may be the treatment of choice.     

When Parents Refuse: Resolving Entrenched Disagreements Between Parents and Clinicians in Situations of Uncertainty and Complexity

When shared decision making breaks down and parents and medical providers have developed entrenched and conflicting views, ethical frameworks are needed to find a way forward. This article reviews the evolution of thought about the best interest standard and then discusses the advantages of the harm principle (HP) and the zone of parental discretion (ZPD). Applying these frameworks to parental refusals in situations of complexity and uncertainty presents challenges that necessitate concrete substeps to analyze the big picture and identify key questions. I outline and defend a new decision-making tool that includes three parts: identifying the nature of the disagreement, checklists for key elements of the HP and ZPD, and a “think list” of specific questions designed to enhance use of the HP and ZPD in clinical decision making. These tools together will assist those embroiled in complex disagreements to disentangle the issues to find a path to resolution.     

On General Education as a Discipline

The article highlights what is referred to by the concept of generaleducation (Allgemeine Pädagogik). It is seen as a foundational part ofeducation as a discipline dealing with Bildung and Erziehung philosophicallyand it has traditionally constituted the kernel of the discipline ofeducation. Today it seems as if the interest towards the philosophyand theory of education (i.e. general education) is increasing.     

Parental refusals of medical treatment: the harm principle as threshold for state intervention

Minors are generally considered incompetent to provide legally binding decisions regarding their health care, and parents or guardians are empowered to make those decisions on their behalf. Parental authority is not absolute, however, and when a parent acts contrary to the best interests of a child, the state may intervene. The best interests standard is the threshold most frequently employed in challenging a parent's refusal to provide consent for a child's medical care. In this paper, I will argue that the best interest standard provides insufficient guidance for decision-making regarding children and does not reflect the actual standard used by medical providers and courts. Rather, I will suggest that the Harm Principle provides a more appropriate threshold for state intervention than the Best Interest standard. Finally, I will suggest a series of criteria that can be used in deciding whether the state should intervene in a parent's decision to refuse medical care on behalf of a child.     

Trapping the Metasemantic Metaphilosophical Deflationist?

Some philosophers are metaphilosophical deflationists for metasemantic reasons. These theorists take standard philosophical assertions to be defective in some manner. There are various versions of metasemantic metaphilosophical deflationism, but a trap awaits any global version of it: metasemantics itself is a part of philosophy, so in deflating philosophy these theorists have thereby deflated the foundation of their deflationism. The present article discusses this issue and the prospects for an adequate response to the trap. Contrary to most historical responses (some of which it discusses), the article argues that the best response to the trap is to adopt a local but still pervasive metasemantic deflationism. Such a response might seem ad hoc, but the article argues that the human activity of philosophy isn't a natural kind, and that a heterogeneous metaphilosophy of the appropriate kind is well motivated.     

Reproduction,Ethics, and the Law: Feminist Perspectives (Book)

It is often claimed that if technology becomes too intrusive it can be reigned in by better technologies and laws that restrict access. This article argues through a series of propositions and observations why these standard solutions will invariably fall short, and why civility--and the placed communities out of which civility arises--is our best hope against technological assaults on privacy. The article ends with a brief discussion of what sorts of personal and professional commitments a civil culture entails.     

Picking up the pace: effects of global temporal context on sensitivity to the tempo of auditory sequences

This article continues a line of research examining factors affecting listeners' auditory tempo sensitivities. Of particular interest is the question of whether listeners are sensitive to the overall (global) pace of their auditory environment and how this sensitivity may affect their perceptions of sequence timing. To address this question, we manipulated the set of sequence tempi (between 300 and 700 msec) that listeners experienced over the course of a 1-h period (i.e., the global temporal context) while they performed a tempo-discrimination task involving standard-comparison pairs of isochronous tone sequences. Overall findings show systematic distortions in perceived tempo that are consistent with the view that listeners adapt to the global pace of their auditory environments. Moreover, general support was found for the hypothesis that increasing the number of equal intervals in a standard sequence produces greater improvements in tempo sensitivity when the standard sequence tempo is different from the global pace than when it is at the global pace. Implications of these findings for models of timing and temporal processing are discussed.     

rethinking domestic violence in theory and practice

Drawing on the author's previous work, this article suggests that conceptual advantages result from envisioning domestic violence on a larger continuum of “normalized” to “extreme” sadomasochistic interactions (including gendered interactions that can also range from “ordinary” to “deviant” in how they are perceived). Thereafter, it may be harder to ignore how redressing social inequities involving gender as well as racial and class imbalances can amount, at least in terms of prevention, to anti-domestic violence measures of one important kind. More concretely, proceeding from the assumption that domestic violence remains disturbingly common (even though its exact scope is difficult to ascertain), this article contrasts how this social problem would best be approached in theory and how it often continues to be dealt with in practice. In making this comparison, a cursory review of recent policy developments in this area, from mandatory arrest policies and laws (and the criticisms these have engendered) to more recent interest in restorative justice and collaborative empowerment, is presented and incorporated into the paper's larger argument.     

Death by non-feeding: Not in the baby's best interests

It has recently been suggested that doctors have a duty to act in their patient's best interest and that this duty demands that life-sustaining treatment—including food and fluids—should sometimes be withheld or withdrawn and the patient allowed to die. In this article, the author explores the scope of the ‘best interests principle’ in the context of treatment decisions for seriously handicapped newborn infants. She argues that those who hold that it is permissible to starve or dehydrate an infant to death are mistaken to think that this course of action is in the infant's best interests. While it may be true that there are times whendeath is, everything considered, in an infant's best interests, a slow and distressingmethod of bringing death about is not. Since death by dehydration and starvation is not benign, the withholding of food and fluids is generally not in an infant's best interests. The author concludes by suggesting thatwhenever the withdrawal or non-employment of life-sustaining means imposes a heavy burden on the infant, the ‘best interests principle’ would demand that the infant be killed rather than allowed to die.     

Reactions to uncertainty: A comparison of three motivational theories

This study attempted to explicate some of the variables underlying preference, pleasure, and reward. In order to accomplish this, Jones's (1966, 1969) information drive theory, Berlyne's (1967, 1971, 1973, 1978) optimal arousal potential theory, Helson's (1964, 1966, 1971, 1973) adaptation-level theory, and McClelland and Clark's (1953) discrepancy hypothesis were experimentally contrasted. Subjects (316) rated the hedonic tone, perceived uncertainty, arousing properties, and interest value of two series of visual stimuli of specified uncertainty. Regression analyses revealed that immediately prior experience with stimuli varying in uncertainty affected rating of perceived uncertainty and arousing properties but had no major effects on ratings of hedonic tone and interest value. The results did not support Jones's and McClelland and Clark's models. Berlyne's model seemed to account for the affective hedonic tone and interest results, while Helson's model best explained the nonaffective perceived uncertainty and arousal data. It was concluded that nonaffective variables are affected by short-term experience with uncertainty while affective variables are not. Speculations concerning the phenomenon of interest value were then offered.Jewish Child Care AssociationThis article is based on a dissertation submitted to the New School for Social Research in partial fulfillment of the Ph.D. requirements. I would like to thank Drs. Nathan Brody and Nathan Kogan for their help in conducting this experiment and preparing this article.     

The case for characterising type-2 blindsight as a genuinely visual phenomenon

Type-2 blindsight is often characterised as involving a non-visual form of awareness that blindsight subjects experience under certain presentation conditions. This paper evaluates the claim that type-2 awareness is non-visual and the proposal that it is a cognitive form of awareness. It is argued that, contrary to the standard account, type-2 awareness is best characterised as visual both because it satisfies certain criteria for being visual and because it can accommodate facts about the phenomenon that the cognitive account cannot. The conclusion is made that type-2 blindsight is best characterised as involving a form of abnormal, degraded visual awareness.     

A Closer Look at Manifest Consequence

Fine (2007) argues that Frege’s puzzle and its relatives demonstrate a need for a basic reorientation of the field of semantics. According to this reorientation, the domain of semantic facts would be closed not under the classical consequence relation but only under a stronger relation Fine calls “manifest consequence.” I examine Fine’s informally sketched analyses of manifest consequence, showing that each can be amended to determine a class of strong consequence relations. A best candidate relation emerges from each of the two classes, and I prove that the two candidates extensionally coincide. The resulting consequence relation is of independent interest, for it might be held to constitute a cogent standard of reasoning that proceeds under a deficient grasp on the identity of objects.     

When a good fit can be bad

How should we select among computational models of cognition? Although it is commonplace to measure how well each model fits the data, this is insufficient. Good fits can be misleading because they can result from properties of the model that have nothing to do with it being a close approximation to the cognitive process of interest (e.g. overfitting). Selection methods are introduced that factor in these properties when measuring fit. Their success in outperforming standard goodness-of-fit measures stems from a focus on measuring the generalizability of a model's data-fitting abilities, which should be the goal of model selection.