Search

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 afar 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. Keywords: dead donor rule, determination of death, inverse decapitation problem, whole brain death doi: 10.1093/jmp/jhq023

After historically situating NBIC Convergence in the context of earlier bioethical debate on genetics, ten questions are raised in areas related to the ethics of Convergence, indicating where future research is needed. Keywords: human enhancement, human/machine interface, NBIC Convergence, upstream ethics

The arguments against managed care can be divided into two general clusters. One cluster concerns the way managed care undermines the ethical ideals of medical professionalism. Since those ideals largely focus on the physician-patient relation, the first cluster comes under the rubric of micro-ethics; namely, the ethics of individual-individual relations. The second cluster of criticisms focuses on macro-ethical issues, primarily on issues of justice and policy. By reviewing these arguments, it becomes clear that managed care does not easily fit within traditional modes of ethical analysis. It poses a radical challenge to current medical and socio-political norms, and even resists the distinction between micro- and macro-ethical domains, a distinction that reflects the private/public distinction. Managed care organizations call for a third way, an inter-ethic for middle level organizations. The essays in this Journal provide a first step in this radical reassessment, laying the foundation for an organizational ethic that is responsive to the realities and promise of managed care. Key words: ethics of managed care, organizational ethics, inter-ethics

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. Key words: conflicts of interest, fiduciary obligation, medical economics, organizational ethics.