Cheryl Misak

An Official Multi-Society Statement: The Role of Clinical Research Results in the Practice of Critical Care Medicine

BACKGROUND While the results of clinical research are clearly valuable in the care of critically ill patients, the limitations of such information and the role of other forms of medical knowledge for clinical decision making have not been carefully examined. METHODS The leadership of three large professional societies representing critical care practitioners convened a diverse group representing a wide variety of views regarding the role of clinical research results in clinical practice to develop a document to serve as a basis for agreement and a framework for ongoing discussion. RESULTS Consensus was reached on several issues. While the results of rigorous clinical research are important in arriving at the best course of action for an individual critically ill patient, other forms of medical knowledge, including clinical experience and pathophysiologic reasoning, remain essential. No single source of knowledge is sufficient to guide clinical decisions, nor does one kind of knowledge always take precedence over others. Clinicians will find clinical research compelling for a variety of reasons that go beyond study design. While clinical practice guidelines and protocols based upon clinical research may improve care and decrease variability in practice, clinicians must be able to understand and articulate the rationale as to why a particular protocol or guideline is used or why an alternative approach is taken. Making this clinical reasoning explicit is necessary to understand practice variability. CONCLUSIONS Understanding the strengths and weaknesses of different kinds of medical knowledge for clinical decision making and factors beyond study design that make clinical research compelling to clinicians can provide a framework for understanding the role of clinical research in practice.

ICU-acquired weakness: obstacles and interventions for rehabilitation.

There is growing evidence that ventilated, critically ill patients incur systemic muscle injury (1–3). This ICU-acquired weakness is often disabling and long lasting (1, 2). To make matters worse, the diminishment of exercise capacity may have devastating effects on neurocognitive outcomes (4, 5). Hence the vital importance of this new topic in outcomes research. In 1998, I survived serious multiple organ failure. I will draw on that experience and speak to obstacles in the way of recovering from ICU-acquired weakness and to interventions that might help patients overcome those obstacles.

Compromised Autonomy and the Seriously Ill Patient

Respect for patient autonomy has become the preeminent principle of medical ethics, to the point that tools have been developed, such as instructive directives, in an attempt to preserve a semblance of autonomy even when it has become clearly and irretrievably lost. Much of the practice around the respect for autonomy, however, mistakenly supposes that the capacity for autonomous choice is an all-or-nothing proposition. But seriously ill patients may retain some ability to participate in discussions of medical care yet have their autonomy profoundly compromised by physical duress, cognitive dysfunction, or delirium. The choices of individuals with compromised autonomy do not carry the same moral weight as those of the fully autonomous. Clinicians, therefore, cannot rely on such choices for guiding medical decisions and are obligated to evaluate them more fully before acting. We argue that clinicians should compare the choices of individuals with compromised autonomy to a medical assessment of the patients best interest. When the patients choice and the best-interests assessment are discordant, acting in the patients best interest may, at times, rightly override the requests of the patient. Such an approach, under a tightly constrained set of circumstances, would permit both the provision and the withholding of medical interventions despite patient requests to the contrary.

The Oxford Handbook of American Philosophy

1. Jonathan Edwards and 18th Century Religious Philosophy 2. Emerson, Romanticism and Classical American Pragmatism 3. Peirce and Pragmatism: American Connections 4. William James 5. John Dewey: Inquiry, Ethics and Democracy 6. Josiah Royce: Idealism, Transcendentalism, Pragmatism 7. George Santayana: Ordinary Reflection Systematized 8. A Pragmatist Wordview: George Herbert Meads Philosophy of the Act 9. W.E.B. Dubois: Double-Consciousness, Jamesian Sympathy and the Critical Turn 10. The Pragmatist Family Romance 11. The Reception of Early American Pragmatism 12. Whiteheads Metaphysical System 13. Thorstein Veblen and American Social Criticism 14. Pragmatism and the Cold War 15. Pragmatism and the Given: C.I. Lewis, Quine and Peirce 16. W. V. Quine 17. Philosophy of Science in America 18. The Influence of Wittgenstein on American Philosophy 19. Placing in a Space of Norms: Neo-Sellarsian Philosophy in the 21st Century 20. Rorty, Davidson and the Future of Metaphysics in America 21. Analytic Philosophy in America 22. Logic and the Foundations of Mathematics 23. Liberal Equality: What, Where and Why 24. Legal Philosophy in America 25. American Moral Philosophy 26. Essences, Intersections and American Feminism

ICU Psychosis and Patient Autonomy: Some Thoughts from the Inside

I shall draw on my experience of being an ICU patient to make some practical, ethical, and philosophical points about the care of the critically ill. The recurring theme in this paper is ICU psychosis. I suggest that discharged patients ought to be educated about it; I discuss the obstacles in the way of accurately measuring it; I argue that we must rethink autonomy in light of it; and I suggest that the self disintegrates in the face of it.

Narrative evidence and evidence‐based medicine

I argue that evidence-based medicine (EBM) imposes methodological limits that constrain the practice and study of medicine in unfortunate ways. EBM attempts to rid the study of medicine of the subjectivity of individual judgements, while in fact, any use of any kind of evidence requires judgement. On this basis, I argue that there are compelling reasons to broaden the range of evidence employed in EBM, and in particular, to include both straightforward and evaluative narratives. This would mark a shift from the current focus of EBM on purely quantitative data to the inclusion of qualitative data as well. I conclude by emphasizing that objectivity in medicine must come not from the exclusion of wide swaths of potentially valuable evidence, but from the careful application of our critical practices.

Medical Futility: A New Look at an Old Problem

Efforts to answer the question of whether or when physicians may unilaterally refuse to provide treatments they deem medically futile, but that are nonetheless demanded by patients or their surrogates, have been characterized as intractable failures. We propose a new look at this old problem and suggest reframing the debate in terms of the implicit social contract, in healthy democracies, between the medical profession and the society it serves. This ever-evolving contract is predicated upon providing patients with beneficial and desired medical care within the constraints of scarce resources and the characteristics of our health-care system. The contract ranges over a continuum of decisions, from those that do not need an explicit negotiated agreement with the patient or surrogate, to those that do. Between these two poles lies a contentious gray area, where the rights and obligations of patients and physicians are being shaped continuously by the many forces that are at play in a democratic society, including professional guidelines, social advocacy, legislation, and litigation. We provide examples of how this gray area has been and is negotiated around rights to refuse and demand a variety of life-sustaining treatments, and anticipate conflicts likely to arise in the future. Reframing the futility debate in this way reveals that the issue is not a story of intractable failure, but rather, a successful narrative about how democracies balance the legitimate perspectives of patients and physicians against a backdrop of societal constraints and values.

A Culture of Justification: The Pragmatist's Epistemic Argument for Democracy

The pragmatist view of politics is at its very heart epistemic, for it treats morals and politics as a kind of deliberation or inquiry, not terribly unlike other kinds of inquiry. With the exception of Richard Rorty, the pragmatists argue that morals and politics, like science, aim at the truth or at getting things right and that the best method for achieving this aim is a method they sometimes call the scientific method or the method of intelligence – what would now be termed deliberative democracy. Hence, the pragmatists offer an argument for democracy which appeals to the quality of the decisions supplied by democratic procedure. Why should we value decisions that are the products of voting after open debate over private decision-making and then voting, over bargaining, or over elimination of those who disagree with us? We should value them because the deliberative democratic method is more likely to give us true or right or justified answers to our questions. Rorty, of course, thinks that no inquiry aims at the truth and that nothing about pragmatism speaks in democracy’s favor. This paper will show how his brand of pragmatism betrays what is good and deeply interesting in the pragmatist tradition.

Experience, Narrative, and Ethical Deliberation*

David Velleman, in “A Right of Self-Termination?” opens with a story. While undergoing treatment for cancer, he gave a talk at a philosophy department and found himself reacting severely to a conversation at dinner. One of his hosts had lit a cigarette and waxed lyrical about his right to choose whether to live and die smoking or to quit and merely survive. Velleman felt that “a few months with cancer taught me that a tumor rarely invades a region smaller than an extended family. . . . Listening to my host laugh at his future cancer, I wondered if he realized how many others would share it.” He resented his host’s taking his right to be a right to make his own life shorter in order to make it better, for this accounting failed to consider harms and benefits to others. He also resented his host’s assumption that only accounting for harms and benefits was relevant. He thought that his host had failed to see that what is of value in a human life cannot be entirely captured by cost-benefit talk. If a life is to be more than a mere instrument, there must be something that makes a claim on us—something that we try to live up to. Velleman questions whether “one may end one’s life simply because one isn’t getting enough out of it” and urges the consideration of whether one is doing justice to one’s life. In “ICU Psychosis and Patient Autonomy,” I also recount personal experience—my month-long encounter with multiple organ failure, full

Reflections on Inquiry and Truth Arising from Peirce's Method for the Fixation of Belief

My paper of November 1877, setting out from the proposition that the agitation of a question ceases when satisfaction is attained with the settlement of belief. . . goes on to consider how the conception of truth gradually develops from that principle under the action of experience, beginning with willful belief or self-mendacity, the most degraded of all mental conditions; thence arising to the imposition of beliefs by the authority of organized society; then to the idea of settlement of opinion as the result of fermentation of ideas; and finally reaching the idea of truth as overwhelmingly forced upon the mind in experiences as the effect of an independent reality. CP 5.564, “Basis of Pragmatism.” 1906. (italics not in original)