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.     

Negotiating Responsibility: Case Studies of Reproductive Decision-Making and Prenatal Genetic Testing in Families Facing Huntington Disease

Three case studies are presented to further our understanding of how responsibility is negotiated in families when making decisions about genetic risk. These draw on a model of responsibility generated in a study of reproductive decision-making in families facing Huntington disease (HD) to illustrate the impact of prenatal testing on this process. This involves analyzing: how people present themselves as acting responsibly whether or not they utilize genetic testing; who they feel responsible to in their family and elsewhere; the impact that testing has on these relationships; and, how negotiating responsibility changes over time with repeated use of prenatal testing, changing risk status and maturational changes. Two key findings are: how decision-making is perceived can become as important as what is decided; and, how responsibility is negotiated depends on which of these relationships are prioritized. Implications of the findings for clinical practice are noted and suggestions made for further applications of the model.     

Emotional engagement in professional ethics

Recent results from two different studies show evidence of strong emotional engagement in moral dilemmas that require personal involvement or ethical problems that involve significant inter-personal issues. This empirical evidence for a connection between emotional engagement and moral or ethical choices is interesting because it is related to a fundamental survival mechanism rooted in human evolution. The results lead one to question when and how emotional engagement might occur in a professional ethical situation. However, the studies employed static dilemmas or problems that offered only two choices whose outcome was certain or nearly so, whereas actual problems in professional ethics are dynamic and typically involve considerable uncertainty. The circumstances of three example cases suggest that increasing personal involvement and uncertainty could have been perceived as changes, threats, or opportunities and could therefore have elicited an emotional response as a way to ensure the reputation, integrity or success of oneself or a group to which one belongs. Such emotional engagement is only suggested and more studies and experiments are required to better characterize the role of emotional engagement in professional ethics.     

从儿童赌博任务看热执行功能的发展

为考察热执行功能的发展,本研究通过儿童赌博任务检测了60名3～4岁儿童(男女各半)的情感决策。实验结果表明,3岁和4岁儿童在此任务上存在显著的年龄差异,4岁组在各试验组的分数呈上升趋势,他们在试验组2、尤其在试验组4和5中选择有利纸牌的次数显著多于3岁儿童,这反映出情感决策在3～4岁期间发展迅速。此外,儿童在此任务上的成绩存在很多可变性,可能掩盖了性别差异,因而,尽管男孩在最后两个试验组的成绩优于女孩,但性别差异在统计上并不显著。     

Risk-Reduction Surgery Decisions in High-Risk Women Seen for Genetic Counseling

Women at greatest risk for hereditary breast and ovarian cancer may consider prophylactic removal of breasts or ovaries as a risk-reduction measure. This report describes uptake of risk-reduction mastectomy (RRM), risk-reduction oophorectomy (RRO), and related factors in 62 high-risk women who received genetic counseling. Seven (11%) participants underwent RRM and 13 (21%) underwent RRO. Of these women, 37% did not have BRCA testing, suggesting other factors influence decisions to undergo surgery. Women who had indicated (pre-genetic counseling) their intent not to have surgery chose not to have surgery. Information received during genetic counseling that women perceived as being most important for influencing risk-reduction surgery decisions was BRCA test result (positive or negative), followed by discussion of family cancer history. Reasons for indecision about risk-reduction surgery included genetic testing results, concerns about surgery, timing in life, and early menopause. The findings enhance our understanding of information that is helpful to women considering this surgery.     

Alibi believability: Corroborator certainty,cooperativeness and relationship with the defendant

Alibi believability can be affected by characteristics of the alibi corroborator, including the relationship between the defendant and corroborator, which has been studied extensively by researchers. The corroborator's certainty that they were together at the time of the crime may also influence alibi believability, but only a few studies have examined this. Another factor that may affect believability is the corroborator's cooperativeness with the police, which is yet to be studied in the alibi context. Online U.S. participants recruited from CloudResearch (N = 280) acted as mock jurors and evaluated a mock arson case where the defendant used an alibi defence. The alibi corroborator's relationship to the defendant (brother/neighbour), the certainty that they were together at the time (65%/100%) and cooperativeness with police (cooperative/uncooperative) were manipulated between participants. The participants were evenly split when it came to verdict (p > .05) but were more likely to vote guilty when the corroborator was a brother rather than a neighbour (p < .01) and when the brother was uncooperative versus cooperative (p < .05). As expected, alibis were more believable when they were corroborated by a neighbour rather than a brother and when the corroborator was 100% certain that they were together versus 65% certain (ps < .01). Alibis were also more believable when the corroborator cooperated than when he was uncooperative (p < .01). Cooperative (vs. uncooperative) corroborators led to more positive defendant and corroborator views on all six character trait measures (ps < .01). Implications and future directions are discussed.     

Adolescent decision-making: Giving weight to age-specific values

Adults who give proxy consent for medical treatment for adolescents must decide how much weight to give to adolescents' own preferences. There is evidence that some adolescents choose treatments different from what adults see as most reasonable. It is argued that adolescents choose according to age-specific values, i.e. values they hold, as adolescents, and which fulfil important developmental needs. Because not fulfilling these needs may do serious psychological damage, it is urged that proxies give weight to these values, up to the limit where it would endanger or profoundly limit future life.A very brief version of this article has been published as Chapter 3 of Forman EN, Ladd RE.Ethical Dilemmas in Pediatrics: A Case Study Approach. New York: Springer-Verlag. 1991, reprinted by University Press of America, 1995.     

Ethical questions in the age of the new eugenics

As a result of the publicly funded Human Genome Project (HGP), and an increasing number of private enterprises, a new form of eugenic theory and practice has emerged, differing from previous manifestations. Genetic testing has become a consumer service that may now be purchased at greatly reduced cost. While the old eugenics was pseudoscientific, the new eugenics is firmly based on DNA research. While the old eugenics focused on societal measures against the individual, the new eugenics emphasizes the family as a control agent. Eugenics is now voluntary, with the promise of abortion for those afraid of producing genetically damaged children. The ethical concepts of beneficence, avoidance of maleficence, autonomy, and equity are discussed in terms of aspects of the HGP. One major issue is the need for an ethical system available to health consumers that will empower them and assist in their biogenic decisions. “The concentration on the genes implicated in cancer is only a special case of a general genomania (emphasis added) that surfaces in ... the weekly announcements in The New York Times of the location of yet another gene for another disease. The revealing rhetoric of this publicity is always the same; only the blanks need to be filled in: ‘It was announced today by scientists at [Harvard, Vanderbilt, Stanford] Medical School that a gene responsible for [some, many, a common form of] [schizophrenia, Alzheimer’s, arteriosclerosis, prostate cancer] has been located and its DNA sequence determined. This exciting research, say scientists, is the first step in what may eventually turn out to be a possible cure for this disease.’” Lewontin ¹ Portions of this paper were presented at the Eighth National Conference on Applied Ethics, Long Beach, CA, February 27, 28 and March 1, 1997.     

The Political Manipulation of Group Composition: Engineering the Decision Context

Group decisions are not made solely by evaluating the merits of the contending positions. Instead, actors may engage in manipulation to increase the fortunes of their policy preference. Actors may manipulate information, group procedures, or group composition. Using a model of group socialization, this paper argues that a manipulator may seek to alter the group composition as to access and/or status. In doing so, the manipulator seeks to create a more favorable decision environment. This political perspective maintains that the dynamic nature of group composition provides an opportunity for a manipulator to engineer the decision context, potentially affecting the group's decisional output. Strategies and tactics of composition manipulation are presented and then utilized to analyze the American decision process during the Iranian revolution.     

Deciding, Planning, and Practical Reasoning: Elements towards a Cognitive Architecture

I intend to show some of the limits of the decision-theoretic model in connection with the analysis of cognitive agency. Although the concept of maximum expected utility can be helpful for explaining the decision-making process, it is certainly not the primary motor that moves agents to action. Moreover, it has been noticed elsewhere that this model is inadequate to the analysis of single cases of practical reasoning. A theory is proposed that introduces a plan-structure as a basic idea. In order to know its very conceptual scope, we need to accommodate that theory to a cognitive architecture whereby the rational and autonomous agent makes choices and deliberates between courses of action to achieve specific goals that are of its interest. The paper endeavours also to clarify the relationship between the different modules that should constitute the architecture of an agent to accomplish the requisites of efficiency and autonomy in a changeable and dynamic world.