Ethics is the branch of philosophy that deals with issues of right and wrong in human affairs.

4 Definitions of Key Terms

Aesthetics. A branch of philosophy that inquires into the nature, meaning, and value of art; or any critical reflection about art, culture, and nature.

Aesthetic point of view. A distinctive stance taken toward phenomena, e.g., works of art and nature, for the purpose of inducing aesthetic experience.

Aesthetic experience. A type of experience that manifests the savoring of phenomena for their inherent values, in contrast to practical activities and values.

Aesthetic value. A type of value, in contrast, e.g., to economic value, etc.; also the capacity of something by virtue of its manifold of qualities to induce aesthetic experience.

Aesthetic literacy. A cluster of capacities that enables engagements of phenomena, especially works of art, with prerequisite percipience.

Aesthetic culture. A distinctive domain of society, in contrast, e.g., to its political culture, and, normatively, sensitivity in matters of art and culture, as in a person's aesthetic culture.

Interrelatedness of the arts. Implies features that different kinds of art have in common; or programs that group the arts together for purposes of study.

Abstract

Ethics is the branch of philosophy that deals with moral issues, including questions about what is right (or wrong) to do and other intangibles, such as whether the intentions behind an action determine its goodness, or whether the actual outcome is what is important. The objective of this chapter is to provide a framework for ethical thinking and conduct in science, especially as applied to translational research and clinical investigation. Science, as a discipline of inquiry, endeavors to understand, or to better understand, how the natural world works. The tools of science generate evidence as the basis for that understanding. These tools include observation of the natural world and/or behavior of living creatures, and experimentation, a method of studying events under controlled conditions that can reduce variability and ambiguity of interpretation. Among scientists, certain attitudes, beliefs, and values have traditionally fostered virtuous behavior—hard work, perseverance, respect for others, collegiality, objectivity, and honesty, to name but a few. All of these contribute to the ethical dimensions of science. Today's scientist is a highly trained professional who acquires not only the necessary knowledge and skills to pursue the complex questions that arise, but also who understands and accepts the responsibility to ensure the validity and integrity of one's work, to ensure proper design and conduct of the research, and to ensure that the data are properly recorded, analyzed, and reported.

7.3 What Is an Ontology?

Ontology is a branch of philosophy concerned with the study of what exists. “Ontology” is often used by philosophers as a synonym for “metaphysics” [4]. Philosophical ontology is a descriptive enterprise. It is distinguished from the special sciences not only in its radical generality but also in its primary goal or focus: it seeks no predication or explanation but rather taxonomy. Formal ontologies have been proposed since the eighteenth century, including recent ones such as those by Carnap [5] and Bunge [6].

It was McCarthy [7] who first recognized the overlap between work done in philosophical ontology and the activity of building the logical theories of artificial intelligence (AI) systems. McCarthy affirmed in 1980 that builders of logic-based intelligent systems must first “list everything that exists, building an ontology of our world.” According to Gruber [8], an ontology is a “specification of a conceptualization,” while Guarino [9] argued that “an ontology is a logical theory accounting for the intended meaning of a formal vocabulary.” Ontologies are essential for developing and using knowledge-based systems. Every knowledge model has an ontological commitment [10], i.e., a partial semantic account of the intended conceptualization of a logical theory. Ontologies form the foundation for major projects in knowledge representation such as CYC [11], TOVE [12], KACTUS [13], and SENSUS [14]. Medicine has been the active ontology research and construction area for large knowledge bases. There are several distinguished efforts in medical terminology systems like SNOMED-RT [15] and “Canon group” [16]. The semantic network in unified medical language system (UMLS) [17] is also considered a distinguished terminological ontology [18]. GALEN [19] is a project developing medical terminology servers and data entry systems based on ontology, the common reference model, which is formulated in a specialized description logic, GRAIL [20]. Also, reusable medical ontologies are strongly recommended by Schreiber and Musen [21,22] in intelligent systems.

Van Heijst et al. [23,24] have a case study in the construction of a library of reusable ontologies and they proposed several important and useful principles to address the corresponding hugeness problem and the interaction problem. TCM is a specific domain with a large amount of knowledge. The goal of TCM ontology development is to facilitate the development of TCM terminological knowledge-based system (KBS) by providing a reusable core generic ontology and relevant skeleton subontologies.

Ethics

Ethics is the branch of philosophy that concerns itself with the good and evil nature (morality) of actions and seeks to guide behavior in a way that increases good actions in society. For the most part, the practice of ethics in the medical setting is a nonsectarian activity based on secular principles and beliefs. That being said, the religious beliefs of a particular patient influence ethical decision-making for that patient, religious tenets often inform ethical decision-making in hospitals and healthcare systems that have religious sponsorship, and the physician should be aware of his or her own belief system. A variety of guides to ethics within major faith traditions are available (Steinberg, 2003; Muramoto, 2008; O’Rourke and Boyle, 2011).

A number of terms are used to describe subdisciplines within ethics. Biomedical ethics (bioethics) deals with the ethical implications of biology in patient care, research, and policy development. Neuroethics are the ethical, legal, and social policy implications of neurosciences, including clinical care and neuroscience research (Illes and Bird, 2006). Clinical ethics is a subset of bioethics. Bernat has defined clinical ethics as “the identification of morally correct actions and the resolution of ethical dilemmas in medical decision-making through the application of moral concepts and rules to medical situations” (Bernat, 2008, p. 5). Jonsen et al. (2010, p. 2) define clinical ethics as a structured approach to ethical questions in clinical medicine. Most of the ethical issues that the neurologist will encounter fall within the classification of clinical ethics, although some issues will extend beyond traditional medical situations.

Although the moral conduct and character of the physician have been the subject of discussion for centuries, the disciplines of bioethics, clinical ethics, and neuroethics have been defined and developed over the past 50 years (Pellegrino, 1993; Beauchamp and Childress, 2009). The development of these disciplines has been coincident with the emergence of new and effective medical treatments, the escalation of costs in medical care, the movement of U.S. society away from paternalistic practices generally and in healthcare particularly, and the exposure of ethical abuses in medicine and research.

Ethical reasoning is usually grounded in one of two broad approaches: utilitarianism and deontology. Each approach analyzes the morality of an action and proposes an appropriate course of action from its unique perspective. The utilitarian approach focuses on the consequences of an act. The greater the number of positive consequences (e.g., happiness, health) that result from an action, the more “right” (moral) that action. Conversely, actions that result in negative consequences (unhappiness, disability, and poor health) are considered “wrong” (immoral). The second approach, deontology, considers a person’s duty and focuses on the intent and reasons behind an individual’s actions. Deontologists hold that persons have a duty to act in the manner in which they would like others to act toward them and in the manner in which society, in general, would choose to have people behave. A deontologic approach may lead to the conclusion that, if the intent behind an action is good, the action is morally acceptable even it produces negative consequences. Both the utilitarian and the deontologic approaches are used to develop solutions to specific problems and also to develop guidelines and rules of behavior. Many ethical arguments use a combination of the two approaches. In spite of the differences in approach, the conclusions of the two approaches often overlap and may even be the same.

Other approaches to ethical decision-making include virtue-based ethics, narrative ethics, casuistry, and feminist ethics (Jonson and Toulmin, 1989; Pellegrino and Thomasma, 1993; Charon and Montello, 2002; Held, 2006). Each of these approaches can add depth to ethical analysis and decision-making. For the neurologist, virtue-based ethics, with its emphasis on the moral character of the physician, may be of particular interest. Virtue-based ethics focuses attention on the motivations behind and the behaviors that make up a physician’s practice of medicine. The virtuous physician is habitually disposed to act in conformity with virtues such as integrity, empathy, courage, temperance, and wisdom. Activities that enhance the physician’s virtuous behavior will result in greater good for the patient. The virtue framework is of particular value to the physician who is self-reflective and disposed to consider his or her personal behavior within an ethical construct.

Several systematic methods have been proposed for clinical ethics problem-solving. The method of principlism applies four ethical principles that have particular importance in clinical medicine – nonmaleficence, beneficence, respect for autonomy, and justice – and their related rules to the ethical question in an attempt to reach a well-reasoned decision that would be consistent across similar cases (Beauchamp and Childress, 2009). The principle of nonmaleficence requires that physicians do no harm to their patients. The principle of beneficence states the physician’s affirmative obligation to act for the good of the patient. The principle of respect for autonomy requires a physician to foster and honor an individual patient’s right of self-determination, whereas the principle of justice requires equitable distribution of society’s resources and like treatment of similar circumstances.

Another approach to clinical ethics in decision-making was developed by Jonsen and colleagues (2010) and is referred to as the “four topics” model (or “four boxes” model). This approach provides a practical method for incorporating clinical data, organizing information, and evaluating an ethical problem in the patient care setting. The four topics are medical indications, patient preferences, quality of life, and contextual features; for each topic a number of questions and considerations are applied to the case at hand. The four topics model incorporates analysis of the ethics principles and rules as part of its evaluation of each topic.

Many resources related to ethics are available to the neurologist, including several books focusing on ethical decision-making in the clinical setting (Bernat, 2008; Fletcher et al., 2005; Jonsen et al., 2010). Codes of ethics have been compiled by several key medical organizations, including the American Medical Association (AMA), the American Academy of Neurology (AAN), the American College of Physicians, many neurologic subspecialty societies, and the neurosurgical societies (American Academy of Neurology, 2009; Council on Ethical and Judicial Affairs, American Medical Association, 2010; Leonard et al., 2010; Snyder, 2012). Other helpful resources include the Physician Charter on Professionalism prepared by three medical organizations, the AAN Case-based Ethics Curriculum for Residents, opinions rendered by the Council on Ethical and Judicial Affairs of the AMA, and articles from the AAN Ethics, Law, and Humanities Committee (Ethics, Law and Humanities Committee, American Academy of Neurology, 2000; American Board of Internal Medicine Foundation, 2002).

Its Usefulness

The type-token distinction is important to other branches of philosophy besides philosophy of language and logic. In philosophy of mind, it yields two significantly different versions of the identity theory: one identifies types of mental events with types of physical events (suggesting that the best way to understand mental activity is through neurology); the other merely says that every mental event is some physical event or other (but not necessarily a biological physical event, leaving the door open to an understanding of mental activity in terms of, say, programming) (see Block, 1980). In aesthetics, it is customary to distinguish works of art such as Mozart's Prague symphony (a type) from its many actual performances (tokens) (and also from its many interpretations, recordings, playings of recording, etc.) (see Wollheim, 1968; Wolterstorff, 1975). In ethics, actions are said to be right/wrong, but there is a dispute as to whether there are general principles that prescribe which types of actions are right/wrong or no general principles and only action tokens that are right/wrong.

Outside of philosophy, type talk is ubiquitous. That is, in scientific and everyday discourse we often speak in ways that apparently refer to types. When, for example, we read that the mountain lion disappeared from Iowa in 1867, but now is making a comeback there in the suburbs, we know no particular cat disappeared; rather, a type of cat, a species, did so. Similarly, to say the ivory-billed woodpecker is extinct, or that the banded bog skimmer is rare is not to be referring to one particular organism. The first gene that scientists found linked to an ordinary human personality trait (novelty seeking) is obviously a type of gene. These are examples of sentences where a singular term apparently refers to a type. But we also quantify over types with great regularity, as when a study claims that of 20 481 species examined, two-thirds were secure, 7% were critically imperiled, and 15% were vulnerable. Often we do both, as when it was claimed (in the 60s) that there are 30 particles, yet all but the electron, neutrino, photon, graviton, and proton are unstable. As with art (above), so with artifacts: when we read that the personal computer is more than 30 years old and is only now beginning to reveal its true potential, we do not think there is a particular dusty 30-year-old PC that is somehow improving. The chess move, we are told, of accepting the Queen's Gambit with 2…dc has been known since 1512, but Black must be careful in this opening – the pawn snatch is too risky. For a comprehensive treatment of reference to the many sorts of abstract objects we make in discourse, see Asher (1993).

What is the Philosophy of Neuroscience?

The so-called “philosophy of neuroscience” can be considered a branch of philosophy of science representing the ongoing trend to move from very general questions about science to more detailed discussions of particular issues of specialized disciplines. It applies classical concepts and questions from the general philosophy of science to the field of neuroscience. Research questions of the philosophy of neuroscience include: Is there a specific scientific method in neuroscience (Machamer, McLaughlin, & Grush, 2001)? Are there special kinds of explanations in neuroscience that differ from the types of explanations in other fields of science (Bechtel, 1994)? What is the impact of neuroscience on theories of human agency (Runyan, 2014)? Which concepts of causality or reduction are involved in neuroscientific explanation (Bickle, 2003)?b

One way of pursuing those questions is purely descriptive. If done that way, the agenda of the philosophy of neuroscience equals the approach of other specialized branches of the philosophy of science, e.g., like the philosophy of biology, physics, or psychology. In all those cases the main aim of philosophical investigation is to illuminate the field-specific ways of research and argumentation of an empirical discipline. Regarding neuroscience, one famous debate is the discussion about reductionism (see, e.g., Bickle, 2008; Craver, 2005; Schouten & Looren de Jong, 2007).

Generally speaking, the task of the philosophy of neuroscience is threefold:

First, it is the philosopher’s job to discover and explicate the theoretical assumptions that are often more or less implicitly “woven into the fabric of empirical research” (Hyman, 1989, p. XIV). For example, Max Bennett and Peter Hacker state in their seminal work Philosophical Foundations of Neuroscience, “Many brain-neuroscientists have an implicit belief in reductionism. Few try to articulate what exactly they mean by this term of art” (Bennett & Hacker, 2003, p. 355).

Some philosophers of neuroscience see it as their task to make such implicit beliefs explicit in order to make them an object of investigation in the philosophy of science. This kind of explication work on background concepts can be considered a manifestation of the philosopher’s general aim to dissolve conceptual puzzles and to confront others with their unquestioned or unconscious beliefs and assumptions. As in other fields of empirical research, neuroscientists mostly do not regard such basic questions as a matter of concern for themselves as they do not feel that these issues belong to their empirical core business. Therefore one main task of the philosophy of neuroscience in this context is to show that the proposed distinction between empirical core business and nonempirical sideline work is illusive as it ignores the fact that concepts, theoretical framework, and empirical investigation are intimately connected.

The second task is the distinction of different meanings of concepts that are either explicitly stated or implicitly used by neuroscientists. One example is the difference between ontological and explanatory reductionism in neuroscientific theories (Bennett & Hacker, 2003, pp. 355–366). Another one concerns the distinction between different meanings of “decision,” which is one of the key terms in the debate about the freedom of human will (Walter, 2001, pp. 28–37). In those cases, the philosopher’s job is to clarify the meaning of terms and the different ways of using concepts in order to make sure that discussions are really based on common concepts and not just circling around mock debates due to conceptual confusion. The heated free will debate between some neuroscientists and philosophers shows that many misunderstandings and fruitless debates are due to conceptual confusion and could be avoided by clarification of concepts and by creating a common conceptual ground for fruitful interdisciplinary discussion.c

Finally, the third task of the philosophy of neuroscience is to discuss the plausibility of conclusions drawn from empirical data. For philosophers of science, one of the most irritating assumptions defended by some neuroscientists is the idea that far-reaching conclusions about human thinking and behavior can be more or less directly drawn from measurement results or brain imaging studies. Therefore it is the philosopher’s task to analyze the structure of neuroscientific arguments and theories and to identify conclusions that are logically unsound or not supported by the presented data. Recent neuroscientific claims, among others made by Francis Crick, Gerald Edelman, or Antonio Damasio, offer plenty of examples (see Bennett & Hacker, 2003, pp. 68–74). One of them is the mereological fallacy that consists of ascribing mental states or complex abilities like deciding, believing, interpreting, perceiving, or thinking to the human brain as a part of a person instead of the person as a whole. In The Astonishing Hypothesis, Francis Crick gives a good example of this kind of fallacy: “What you see is not really there; it is what your brain believes is there […]. Your brain makes the best interpretation it can according to its previous experience […]. The brain combines the information provided by the many distinct features of the visual scene […] and settles on the most plausible interpretation of all these various clues taken together” (Crick, 1995, p. 30). Philosophical analysis shows that this kind of ascription of psychological attributes to the brain simply does not make any sense. As Bennett and Hacker state, “The brain is not a logically appropriate subject for psychological predicates” (Bennett & Hacker, 2003, p. 72).

By categorizing such neuroscientific claims as confusing or even senseless, the philosopher is not just making a descriptive statement about neuroscience. In contrast to, for example, the reconstruction and description of theory formation in neuroscience, he takes a normative position toward his object of investigation. In a similarly normative way, he could try to show that certain correlations gained by neuroimaging studies do not reveal anything interesting about causal relations between brain states and behavior. The focus of the philosophy of neuroscience thereby switches from describing the structure of neuroscience to judging certain claims and eventually proposing alternative interpretations or models of explanation.

A survey of possible points of criticism concludes the characterization of the philosophy of neuroscience: Firstly, neuroscientists might complain that the philosophy of neuroscience represents exactly the kind of pointless “armchair philosophy” that tries to criticize empirical research from the outside without really knowing anything about its contents or methods.

Secondly, one could object that, while tackling foundational issues like explanatory strategies or concepts of representation, the actual research topics and empirical results are not at the center of attention. Instead of discussing current findings and helping to analyze, interpret, and consolidate the outcome of neuroscientific research, the philosophy of neuroscience only takes an interest in abstract conceptual and logical analysis. Moreover, it tends to lecture empirical scientists about issues that are remote from their core business or even completely irrelevant to their factual doing.

Thirdly, and finally, one could point at the one-sidedness of the philosophy of neuroscience. While it aims at analyzing and sometimes criticizing neuroscience, there is no attempt to consider neuroscience as a potential enrichment for philosophy, especially for the philosophy of mind. This ignorance, so the objection goes, inhibits productive interdisciplinary cooperation that is necessary for extensive research on the human mind and brain.

1 THE PHILOSOPHY OF PHYSICS TODAY

In the last forty years, philosophy of physics has become a large and vigorous branch of philosophy, and so has amply won its place in a series of Handbooks in the philosophy of science. The reasons for its vigour are not far to seek. As we see matters, there are two main reasons; the first relates to the formative years of analytic philosophy of science, and the second to the last forty years.

First, physics had an enormous influence on the early phase of the analytic movement in philosophy. This influence does not just reflect the fact that for the logical positivists and logical empiricists, and for others such as Russell, physics represented a paradigm of empirical knowledge. There are also much more specific influences. Each of the three main pillars of modern physics — thermal physics, quantum theory and relativity — contributed specific ideas and arguments to philosophical debate. Among the more obvious influences are the following.

Thermal physics and the scientific controversy about the existence of atoms bore upon the philosophical debate between realism and instrumentalism; and the rise of statistical mechanics fuelled the philosophy of probability. As to quantum theory, its most pervasive influence in philosophy has undoubtedly been to make philosophers accept that a fundamental physical theory could be indeterministic. But this influence is questionable since, as every philosopher of science knows (or should know!), indeterminism only enters at the most controversial point of quantum theory: viz., the alleged “collapse of the wave packet”. In any case, the obscurity of the interpretation of quantum theory threw not only philosophers, but also the giants of physics, such as Einstein and Bohr, into vigorous debate: and not only about determinism, but also about other philosophical fundamentals, such as the nature of objectivity. Finally, relativity theory, both special and general, revolutionized the philosophy of space and time, in particular by threatening neo-Kantian doctrines about the nature of geometry.

These influences meant that when the analytic movement became dominant in anglophone philosophy, the interpretation of modern physics was established as a prominent theme in its sub-discipline, philosophy of science. Accordingly, as philosophy has grown, so has the philosophy of physics.

But from the 1960s onwards, philosophy of physics has also grown for a reason external to philosophy. Namely, within physics itself there has been considerable interest in foundational issues, with results that have many suggestive repercussions for philosophy. Again, there have been various developments within physics, and thereby various influences on philosophy. The result, we believe, is that nowadays foundational issues in the fundamental physical theories provide the most interesting and important problems in the philosophy of physics. We have chosen the topics for this volume in accord with this conviction. In the next Subsection, we will articulate some of these foundational issues, and thereby introduce the Chapters of the volume.

What Is Personal Epistemology?

Epistemology, the study of knowledge and knowing, has absorbed philosophers from ancient times. As a branch of philosophy, epistemology concerns the nature, origins, and limitations of knowledge, as well as the justification of truth claims. Recently, educational researchers have become interested in the theories and conceptions of knowledge and knowing that students hold, with the term personal or folk epistemology used to distinguish the lay person's view about knowledge and knowing from the trained philosopher's view (Hofer and Pintrich, 2002; Kitchener, 2002). Thus, personal epistemology essentially refers to the theories or beliefs that students (and other individuals) hold about knowledge and the process of knowing (Hofer and Pintrich, 1997, 2002). Likewise, epistemic theories or beliefs refer to individuals' views about knowledge and knowing (i.e., the epistemic).

Moral Theory

Medical ethics does not constitute a completely independent field. Most persons think of medical ethics as an applied discipline of the wider branch of philosophy that is ethics. Like most other intellectual pursuits, ethics has developed according to several theoretical traditions. In Western ethics, two particular ways of thinking have dominated for some time. Because these approaches may yield rather different perspectives on some questions, they deserve mention.

Consequentialism

One tradition, known as consequentialism, examines the correctness of an action according to what effects the act will likely have on the real world. Good actions produce the most favorable ratio of happiness, pleasure, or some similar value to unhappiness or a similarly disvalued result. The utilitarian philosophers Bentham and Mill enjoined us to seek the greatest happiness for the greatest number of individuals possible. These theories emphasize the social nature of human moral action, requiring calculation of the consequences of an act. Only after determining the impact of an action for those directly and remotely involved can a person pronounce ethical judgment.

Deontology

The other main approach to moral theory proceeds from different premises. Deontology (from the Greek word for duty) holds that some actions have intrinsic moral worth. Many religious moral rules conform to this view. Hence the Ten Commandments pronounce that we should not kill. Other approaches, such as Kant’s categorical imperative, also proclaim universal truths and rules that persons should honor irrespective of the consequences.

A consequentialist might claim that removal of organs from persons in a persistent vegetative state does not harm the individuals because they can no longer experience meaningful life, or even hunger or thirst. The consequentialist also might assert that harvesting the organs best serves the class of patients in a persistent vegetative state because, overall, transplantation fosters the well-being (and by implication, happiness) of humans who can actually benefit from continued treatment. Some deontologists, however, surely would argue that the killing that necessarily results from the removal of vital organs, no matter what the intent, undermines human dignity and is morally impermissible.

Prevailing Principles

Despite the “opposing” traditions of ethics, most persons in medical ethics agree on a small number of important principles that should guide medical behavior. The reader should note, however, that narrow adherence to these notions encourages an oversimplified approach. Medical ethics neither begins with nor ends with the principles named here. A more nuanced view includes many more considerations and a clear sense of how different ideas interact, especially how some moral duties conflict with others. Nevertheless, a few guideposts may help intensivists understand that medical ethics, like clinical medicine, uses formal logic and has a recognizable structure.

Beneficence

The first principle, beneficence, demands that physicians provide care that benefits the patient. This principle may seem self-evident until you remember that many potential conflicts of interest can influence medical decisions. For example, parents of children may face tragic choices about the support of a sick child whose survival could endanger the economic or psychological integrity of the rest of their family. Other conflicts may involve doctors, especially those in a fee-for-service system, who benefit financially from providing services that promise only marginal, if any, additional benefit.

Nonmaleficence

Beneficence contrasts with nonmaleficence. According to this notion, doctors have a duty to avoid harming patients. Again, the idea may seem obvious, but the practical application involves considerable complexity. For example, when deciding whether to use extracorporeal membrane oxygenation for a desperately ill infant with a diaphragmatic hernia, you must consider the possibility that the technology will extend the life of the baby only by several days but may cause discomfort to implement and maintain; that is, no long-term benefit will accrue to balance the burden of the procedure. Similar reasoning might apply to cases of malignancy for which chemotherapy and other treatments have no or little likelihood of producing a cure or substantial life prolongation, whereas the treatments impose burdens, such as nausea, itching, extreme fatigue, and high risk of infection. The principle of nonmaleficence reminds us to take potential pain and suffering seriously before recommending no-holds-barred medical intervention.

Autonomy

When considering which medical treatments will best help a patient and what harms to avoid, a natural question arises: whose perspective should we use? The principle of autonomy suggests that we must respect individual human differences. To the extent possible, persons should decide for themselves what is in their own best interests. In pediatrics, respecting autonomy can present difficult questions about when children develop the capacity and independence to accept or refuse recommended treatment. The autonomy principle reminds us that individuals or their families often have different values and goals from those of their physicians. Medical decisions usually should be in accordance with the patient’s or family’s perspective.

Justice

The fourth principle, justice, provides some of the most pressing and challenging dilemmas for modern medical care. Put simply, this principle exhorts us to use our services fairly, that is, to avoid decisions that accept or reject candidates for treatment based on factors that are irrelevant to their medical situation, such as poverty. The application of the justice principle runs into two major obstacles today. First, members of our society seem to have a great deal of difficulty agreeing on what constitutes just or fair allocation of medical resources. Second, we have not yet decided exactly how considerations of justice should affect the medical care system.

Medical goods can be distributed, assuming not everyone can have everything, according to a number of different schemes: based on the likelihood of success; by some definition of need (urgency, desperation); as a reward (for past achievement, for waiting the longest, for future contribution); by equal shares; by random assignment until the goods run out; or, as we often do in our society, by ability to pay. Different philosophical and political traditions support each of these approaches, and we seem far from agreeing on which is best.

With respect to the second issue, some persons urge physicians to ignore financial constraints to do everything “medically indicated” for patients, regardless of the economic consequences.1 The argument is that, at least for decisions about individual patients, physicians discharge their fiduciary responsibility only by advocating the best, even if most expensive, care. Macroeconomic concerns, regional and institutional issues, and microeconomics challenge this view.

From a macroeconomic perspective, our society resists increasing medical spending as an ever-increasing proportion of total social expenditure (such as percent of gross domestic product). Most Western industrial countries spend on average 9% of gross domestic product on health care. Does the United States get incrementally better outcomes for its 15% or larger outlay?2 By many measures of public health (e.g., infant mortality and longevity), the well-being of the U.S. population does not reflect our high medical expenses.2 Similarly, does the way we spend our health care dollar make the most sense? Should we spend great sums of money on expensive intensive care at the end of life for patients with little likelihood of benefit? In pediatrics, we have reason to believe that preventive measures (e.g., immunization and accident prevention) reduce morbidity and mortality rates3-5 and, in some cases, save money.3,4

Regional and institutional economic questions involve matters such as consolidation of care to increase economic efficiency and medical efficacy. However, political and psychosocial factors often lead to duplication of services and diffusion of experience. Certain programs may even create conflicts of interest. For instance, a hospital could offer a particularly scarce and expensive service (e.g., extracorporeal membrane oxygenation or pediatric organ transplantation). The costs of the service might be so high that just a few patients treated “free,” that is, without charge to the family, might threaten the economic stability of the enterprise. Such fiscal concerns surely help shape what services institutions offer and the way those services become available (are “marketed”) to those in need.

With respect to microallocation, intensivists frequently engage in decisions about the distribution of specific services to particular patients, sometimes with clear awareness that competition exists under conditions of scarcity. With a nearly full ICU and a large demand for postoperative care for the cases on the next day’s operating room schedule, intensivists often must negotiate and juggle, trying to meet varying claims about who should occupy scarce beds and receive nursing attention. Even the decision to use one vasoactive drug or antibiotic instead of a far more or less expensive agent requires an attempt to balance expected benefit against drains on resources. It seems inappropriate to demand that physicians ignore such actual conflicts. Intensivists, like other practitioners, rarely enjoy the luxury of having a single duty to a single patient with an unlimited ability to pay for services. Although doctors might prefer to leave economic considerations to policymakers and the marketplace, justice issues do find their way into ICU routines.

The challenge for the pediatric intensivist involves applying the various ethical principles and perspectives to individual cases and to policies that affect how the unit operates. The following sections focus on a few topics where ethical concerns arise frequently.