The moral distinction between killing and letting die in medical cases

In some medical cases there is a moral distinction between killing and letting die, but in others there is not. In this paper I present an original and principled account of the moral distinction between killing and letting die. The account provides both an explanation of the moral distinction and an explanation for why the distinction does not always hold. If these explanations are correct, the moral distinction between killing and letting die must be taken seriously in medical contexts.
Defeasibly, when an agent kills she takes responsibility, but when an agent lets die she does not take responsibility. Therein lies the moral distinction between killing and letting die. The distinction, however, is defeated when an agent is already responsible for the surrounding situation. In such cases, killing does not involve taking any further responsibility and letting die does not avoid taking any responsibility. Medical examples are frequently complicated because patients' autonomous choices impact upon medical practitioners' surrounding responsibility.     

Killing, letting die and the bare difference argument

I believe that there is no intrinsic moral difference between killing and letting die. That is, there is no difference that depends solely on the distinction between an act and an omission. I also believe that we can reasonably establish this thesis by appeal to the Bare Difference Argument. The form of this argument involves considering two imaginary cases in which there are no morally relevant differences present, save the bare difference that one is a case of killing and one a case of letting die. But in the pair of cases under consideration this bare difference makes no moral difference. Hence it cannot be that the bare difference between killing and letting die is in itself a morally important difference.
Winston Nesbitt has recently argued that the Bare Difference Argument fails because "the examples produced typically possess a feature which makes their use in this context illegitimate, and that when modified to remove this feature, they provide support for the view which they were designed to undermine". I argue that Nesbitt misunderstands the logic of the Bare Difference Argument and that accordingly his objections are mistaken.     

Recombinant Identities: Biometrics and Narrative Bioethics

In recent years, there has been a growing interest in finding stronger means of securitising identity against the various risks presented by the mobile globalised world. Biometric technology has featured quite prominently on the policy and security agenda of many countries. It is being promoted as the solution du jour for protecting and managing the uniqueness of identity in order to combat identity theft and fraud, crime and terrorism, illegal work and employment, and to efficiently govern various domains and services including asylum, immigration and social welfare. In this paper, I shall interrogate the ways in which biometrics is about the uniqueness of identity and what kind of identity biometrics is concerned with. I argue that in posing such questions at the outset, we can start delimiting the distinctive bioethical stakes of biometrics beyond the all-too-familiar concerns of privacy, data protection and the like. I take cue mostly from Cavarero’s Arendt-inspired distinction between the “what” and the “who” elements of a person, and from Ricoeur’s distinction between the “idem” and “ipse” versions of identity. By engaging with these philosophical distinctions and concepts, and with particular reference to the example of asylum policy, I seek to examine and emphasise an important ethical issue pertaining to the practice of biometric identification. This issue relates mainly to the paradigmatic shift from the biographical story (which for so long has been the means by which an asylum application is assessed) to bio-digital samples (that are now the basis for managing and controlling the identities of asylum applicants). The purging of identity from its narrative dimension lies at the core of biometric technology’s overzealous aspiration to accuracy, precision and objectivity, and raises one of the most pressing bioethical questions vis-à-vis the realm of identification.     

Sexes,species, and genomes: why males and females are not like humans and chimpanzees

This paper describes, analyzes, and critiques the construction of separate “male” and “female” genomes in current human genome research. Comparative genomic work on human sex differences conceives of the sexes as like different species, with different genomes. I argue that this construct is empirically unsound, distortive to research, and ethically questionable. I propose a conceptual model of biological sex that clarifies the distinction between species and sexes as genetic classes. The dynamic interdependence of the sexes makes them “dyadic kinds” that are not like species, which are “individual kinds.” The concept of sex as a “dyadic kind” may be fruitful as a remedy to the tendency to conceive of the sexes as distinct, binary classes in biological research on sex more generally.     

Substance,rights, value,and abortion

Most serious contemporary opposition to abortion is grounded on the belief that human fetuses are members of the same moral category as beings like us, and that the loss of any such life is one of the worst possible losses. Substance view theorists oppose abortion for this reason: in their view beings like us are essentially rational substances with inherent moral worth, and those who perform induced abortion fail to recognize this moral worth. In a recent series of articles, Rob Lovering presents reductio‐style arguments against the substance view, in part arguing that it is inconsistent with our intuitions in rescue and spontaneous abortion cases. In a recent reply, Henrik Friberg‐Fernros argues that the substance view can evade these problematic implications because of a distinction between killing and letting die. According to this argument, the fetus’s right to life is a negative right not to be killed, not a positive right to be rescued, thus the anti‐abortion theorist who lets fetuses die acts acceptably. I argue this stance fails to recognize the inherent moral worth that the substance view contends fetuses possess. One who refrains from saving a person, or doesn’t care how many people she saves, cannot reasonably claim to value life. Furthermore, this stance is at odds with most contemporary anti‐abortion views that oppose induced abortions of both the killing and letting die variety.     

Criminal Law as It Pertains to Patients Suffering from Psychiatric Diseases

The McNaughton rules for determining whether a person can be successfully defended on the grounds of mental incompetence were determined by a committee of the House of Lords in 1843. They arose as a consequence of the trial of Daniel McNaughton for the killing of Prime Minister Sir Robert Peel’s secretary. In retrospect it is clear that McNaughton suffered from schizophrenia. The successful defence of McNaughton on the grounds of mental incompetence by his advocate Sir Alexander Cockburn involved a profound shift in the criteria for such a defence, and was largely based on the then recently published “scientific” thesis of the great US psychiatrist Isaac Ray, entitled A Treatise on the Medical Jurisprudence of Insanity. Subsequent discussion of this defence in the House of Lords led to the McNaughton rules, still the basis of the defence of mental incompetence in the courts of much of the English-speaking world. This essay considers one of these rules in the light of the discoveries of cognitive neuroscience made during the 160 years since Ray’s treatise. A major consideration is the relationship between “the power of self-control” and “irresistible impulse” as conceived by Cockburn on the one hand, and by cognitive neuroscience on the other. The essay concludes with an analysis of the notion of “free will” and of the extent to which a subject can exert restraint in the absence of particular synaptic connections in the brain.     

Neurosemantics,neurons and system theory

Following the concept of internal representations, signal processing in a neuronal system has to be evaluated exclusively based on internal system characteristics. Thus, this approach omits the external observer as a control function for sensory integration. Instead, the configuration of the system and its computational performance are the effects of endogenous factors. Such self-referential operation is due to a strictly local computation in a network and, thereby, computations follow a set of rules that constitute the emergent behaviour of the system. These rules can be shown to correspond to a “logic” that is intrinsic to the system, an idea which provides the basis for neurosemantics.     

Facing Death,Gazing Inward: End-of-Life and the Transformation of Clinical Subjectivity in Thailand

In this article, I describe a new form of clinical subjectivity in Thailand, emerging out of public debate over medical care at the end of life. Following the controversial high-tech death of the famous Buddhist monk Buddhadasa, many began to denounce modern death as falling prey to social ills in Thai society, such as consumerism, technology-worship, and the desire to escape the realities of existence. As a result, governmental and non-governmental organizations have begun to focus on the end-of-life as a locus for transforming Thai society. Moving beyond the classic outward focus of the medical gaze, they have begun teaching clinicians and patients to gaze inward instead, to use the suffering inherent in medicine and illness to face the nature of existence and attain inner wisdom. In this article, I describe the emergence of this new gaze and its major conceptual components, including a novel idea of what it means to be ‘human,’ as well as a series of technologies used to craft this humanity: confession, “facing suffering,” and untying “knots” in the heart. I also describe how this new subjectivity has begun to change the long-stable Buddhist concept of death as taking place at a moment in time, giving way for a new concept of “end-of-life,” an elongated interval to be experienced, studied, and used for inner wisdom.     

Mathematical biology of social behavior

When an individual grows up in a society, he learns certain behavior patterns which are “accepted” by that society. He may in general have a tendency toward behavior patterns other than those which are “accepted” by the society. This tendency toward such unaccepted behavior may be due to a process of cerebration which results in doubt as to the “correctness” of the accepted behavior. Thus, on the one hand, the individual learns to follow the accepted rules almost automatically; on the other hand, he may tend to consciously break those rules. Using a neural circuit, suggested by H. D. Landahl in his theory of learning, a neurobiophysical interpretation of the above situation is outlined. Mathematical expressions are derived which describe the social behavior of an individual as a function of his age, social status, and some neurobiophysical parameters.     

Inventory, differentiation, and proportional diversity: a consistent terminology for quantifying species diversity

Almost half a century after Whittaker (Ecol Monogr 30:279–338, 1960) proposed his influential diversity concept, it is time for a critical reappraisal. Although the terms alpha, beta and gamma diversity introduced by Whittaker have become general textbook knowledge, the concept suffers from several drawbacks. First, alpha and gamma diversity share the same characteristics and are differentiated only by the scale at which they are applied. However, as scale is relative––depending on the organism(s) or ecosystems investigated––this is not a meaningful ecological criterion. Alpha and gamma diversity can instead be grouped together under the term “inventory diversity.” Out of the three levels proposed by Whittaker, beta diversity is the one which receives the most contradictory comments regarding its usefulness (“key concept” vs. “abstruse concept”). Obviously beta diversity means different things to different people. Apart from the large variety of methods used to investigate it, the main reason for this may be different underlying data characteristics. A literature review reveals that the multitude of measures used to assess beta diversity can be sorted into two conceptually different groups. The first group directly takes species distinction into account and compares the similarity of sites (similarity indices, slope of the distance decay relationship, length of the ordination axis, and sum of squares of a species matrix). The second group relates species richness (or other summary diversity measures) of two (or more) different scales to each other (additive and multiplicative partitioning). Due to that important distinction, we suggest that beta diversity should be split into two levels, “differentiation diversity” (first group) and “proportional diversity” (second group). Thus, we propose to use the terms “inventory diversity” for within-sample diversity, “differentiation diversity” for compositional similarity between samples, and “proportional diversity” for the comparison of inventory diversity across spatial and temporal scales. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

The Ethical Basis for Sustainable Human Security: A Place for Anthropocentrism?

The deep and lasting changes to human behaviour that are required to address the global environmental crisis necessitate profound shifts in moral foundations. They amount to a change in what individuals and societies conceive of as progress. This imperative raises important questions about the justification, ends, and means of large-scale changes in people’s ethics. In this essay I will focus on the ends—the direction of moral change as prescribed by the goal of sustainable human flourishing. I shall present a meta-ethical critique of anthropocentrism and propose that only an ecocentric ethic can support the sustainable flourishing of humanity. This proposition does not necessarily contradict itself. My claim will be that the values subsumed under the broad concept of anthropocentrism are categorically counterproductive, informing an undesirable concept of “progress”. I support this claim with two lines of argument. On the one hand, the end values of anthropocentrism are shallow and the “flourishing of humanity” is ill-defined. The conceptual constraints of anthropocentrism itself preclude a more concise definition which would take into account the utter dependence of the flourishing of humanity on the health of ecological support structures. On the other hand, pursuing the values that inform the actions of anthropocentrists (which may be identical with the “flourishing of humanity”) leads to unintended and undesirable outcomes, even from the view of the anthropocentrist herself. Those problems are not encountered with an ecocentric ethic, and the conceptual steps necessary to adopt it are not insurmountable.     

“Not <Emphasis Type="Italic">Here</Emphasis>”: Making the Spaces and Subjects of “Global Health” in Botswana

This essay argues that what makes “global health” “global” has more to do with configurations of space and time, and the claims to expertise and moral stances these configurations make possible, than with the geographical distribution of medical experts or the universal, if also uneven, distribution of threats to health. Drawing on a study of public–private partnerships supporting Botswana’s HIV/AIDS treatment program, this essay demonstrates ethnographically the processes by which “global health” and its quintessential spaces, namely “resource-limited” or “resource-poor settings,” are constituted, reinforced, and contested in the context of medical education and medical practice in Botswana’s largest hospital. Using Silverstein’s work on orders of indexicality, I argue that the terms of “global health” are best understood as chronotopic, and demonstrate how actors orient themselves and others spatio-temporally, morally, and professionally by using or refuting those terms. I conclude by arguing that taking “global health” on its own terms obscures the powerful forces by which it becomes intelligible. At stake are the frames within which medical anthropologists understand their objects of study, as well as the potential for the spaces of “global health” intervention to expand ever outward as American medical personnel attempt to calibrate their experiences to their expectations.     

Why is ‘incommensurability’ a problem?

The origins of the ‘incommensurability problem’ and its central aspect, the ‘meaning variance thesis’ are traced to the successive collapse of several distinctions maintained by the standard empiricist account of meaning in scientific theories. The crucial distinction is that between a conceptual structure and a theory. The ‘thesis’ and the ‘problem’ follow from critiques of this distinction by Duhem, Quine and Feyerabend. It is maintained that, rather than revealing the ‘problem’, the arguments leading to it simply show the inadequacy of the reductionist theory of meaning. The genuine remaining problem is that of the development of a new theory of meaning in science. This paper was written while I was Visiting Fulbright Research Scholar at the University of Leiden and the Museum Boerhaave, Leiden.     

Variation of coloration in <Emphasis Type="Italic">Lycodes yamatoi</Emphasis> Toyoshima, 1985 (Pisces: Zoarcidae) in the northern Sea of Japan

Specimens of eelpouts were found in the northern Sea of Japan that were externally similar to Lycodes yamatoi Toyoshima, 1985, but their coloration differed from the coloring known for this species. Comparative analysis of meristic characters and sequence comparison of mtDNA COI and cytb gene fragments did not reveal distinctions between specimens with different types of coloration. All studied specimens belong to L. yamatoi. The live color pattern of L. yamatoi is characterized by high variation, with two main types of coloration, “dark” and “bright.”     

Moral agency,moral worth and the question of double standards in medical research in developing countries

International regulations governing medical research, healthcare and medical practice, are, obviously, meant to be guidelines and not detailed procedural rules of thumb that can be applied unreflectively without any danger of doing moral wrong. Moreover, such regulations are meant to apply internationally, and no set of straight-jacketed rules of thumb can conceivably apply to all societies and communities of the world, extremely diverse and differently situated as they are. The mark of a good international guideline or regulation, in my view, is that it should provide a clear principle of action that applies equally to all global communities and societies without seeking to foist the particular or momentary moral dilemmas, quandaries, obsessions and preoccupations of some on all. In this paper, I propose to argue that, because moral obligations are obligations only from the point of view of a particular moral agent, we should avoid making the peculiar problems of any particular moral agent(s) the obsessive concern of all moral agents, and that we need, in particular, to make appropriate distinctions between the ethics of developed world research in the developing world, collaborative or cooperative research between the developed and developing worlds, developed world research in the developed world and developing world research in the developing world. A consequence of looking at things this way is that, while it should be clear that there are ethical concerns, imperatives and obligations at all levels, different standards may and, in fact, cannot but be applied in different contexts at different levels, without resorting to the use of double standards, which can never be morally justified. Finally, I venture to propose a formula for a solemn pledge of moral integrity and noble intent, from the perspective of the agent, that is to say, the investigator, sponsor and funder of any research, to complement and balance the widely accepted informed consent requirement, from the perspective of the patient, the subject of any biomedical research.     

Dealing With Death in the Jewish Legal Tradition

The main theme of the article is the tension between the obligation to preserve life, and the value of timely death. This tension is resolved by distinguishing between precipitating death, which is prohibited, and merely removing an impediment to it, which is permitted. In contemporary Jewish law, a distinction is made between therapy, which may be discontinued, and life-support, which must be maintained until the establishment of death. Another theme is that of “soft” patient autonomy, and its role in dealing with the dying in both traditional Jewish law and Israel’s Terminal Patient Law, 2005. Preventing suffering in relation to a dying person, and praying for his or her death are also discussed in the article.     

The Moral Aesthetics of Simulated Suffering in Standardized Patient Performances

Standardized patient (SP) performances are staged clinical encounters between health-professional students and people who specialize in role-playing the part of patients. Such performances have in recent years become increasingly central to the teaching and assessment of clinical skills in U.S. medical schools. SP performances are valued for being both “real” (in that they involve interaction with a real person, unlike written examinations) and “not real” (in that the SP does not actually suffer from the condition portrayed, unlike an actual patient). This article considers how people involved in creating SP performances reconcile a moral commitment to avoid suffering (to keep it “not real”), with an aesthetic commitment to realistically portray it (to keep it “real”). The term “moral aesthetic” is proposed, to indicate a sensibility that combines ideas about what is morally right with ideas about what is aesthetically compelling. Drawing on ethnographic research among SPs and SP program staff and medical faculty who work closely with them, this article argues that their work of creating “realism” in simulated clinical encounters encompasses multiple different (and sometimes conflicting) understandings and practices of realism, informed by three different moral aesthetics: (1) a moral aesthetic of induction, in which an accurate portrayal with a well-documented provenance serves to introduce experientially distant forms of suffering; (2) a moral aesthetic of inoculation, in which the authenticity and emotional impact of a performance are meant to inoculate students against the impact of future encounters with suffering; (3) a moral aesthetic of presence, generating forms of voice and care that are born out of the embodied presence of suffering individuals in a clinical space. All are premised on the assumption that risk and suffering can be banished from SP performances. This article suggests, however, that SP performances necessarily raise the same difficult, important, fundamentally ethical questions that are always involved in learning from and on human beings who are capable of suffering, and who need and deserve recognition and respect as well as care.     

The cancer cell’s “power plants” as promising therapeutic targets: An overview

This introductory article to the review series entitled “The Cancer Cell’s Power Plants as Promising Therapeutic Targets” is written while more than 20 million people suffer from cancer. It summarizes strategies to destroy or prevent cancers by targeting their energy production factories, i.e., “power plants.” All nucleated animal/human cells have two types of power plants, i.e., systems that make the “high energy” compound ATP from ADP and P _i . One type is “glycolysis,” the other the “mitochondria.” In contrast to most normal cells where the mitochondria are the major ATP producers (>90%) in fueling growth, human cancers detected via Positron Emission Tomography (PET) rely on both types of power plants. In such cancers, glycolysis may contribute nearly half the ATP even in the presence of oxygen (“Warburg effect”). Based solely on cell energetics, this presents a challenge to identify curative agents that destroy only cancer cells as they must destroy both of their power plants causing “necrotic cell death” and leave normal cells alone. One such agent, 3-bromopyruvate (3-BrPA), a lactic acid analog, has been shown to inhibit both glycolytic and mitochondrial ATP production in rapidly growing cancers (Ko et al., Cancer Letts., 173, 83–91, 2001), leave normal cells alone, and eradicate advanced cancers (19 of 19) in a rodent model (Ko et al., Biochem. Biophys. Res. Commun., 324, 269–275, 2004). A second approach is to induce only cancer cells to undergo “apoptotic cell death.” Here, mitochondria release cell death inducing factors (e.g., cytochrome c). In a third approach, cancer cells are induced to die by both apoptotic and necrotic events. In summary, much effort is being focused on identifying agents that induce “necrotic,” “apoptotic” or apoptotic plus necrotic cell death only in cancer cells. Regardless how death is inflicted, every cancer cell must die, be it fast or slow.     

Direct use values and passive use values: implications for conservation of large carnivores

We made a quantitative analysis of the responses of urban and rural residents in Sweden to arguments supporting and opposing conservation of large carnivores. The most important arguments in favour of conservation were: “I want them [the large carnivores] to exist in Sweden, even if I will never see any of them”, “Sweden should share the responsibility of conserving the large carnivores” and “We owe it [conservation of large carnivores] to future generations”. We found only small differences between rural and urban residents. For arguments opposing conservation, the difference between rural and urban areas was slightly greater. The most important arguments opposing conservation of large carnivores were: “They may have serious negative impact on livestock farming”, “They may have serious negative impact on reindeer husbandry” and “May inflict suffering on injured livestock”. We conclude that there seems to be less support for direct use values such as hunting, ecotourism or just experiencing large carnivores, this may imply that the minimum viable population size can be used as a long-term management goal for large carnivore populations, possibly with an exception for bears. We also conclude that a separate conservation or management plan is needed for each species, since the conflicts with human interests vary greatly between the different carnivore species.