James Lindemann Nelson

Moral teachings from unexpected quarters. Lessons for bioethics from the social sciences and managed care.

On the usual account of moral reasoning, social science is often seen as able to provide “just the facts,” while philosophy attends to moral values and conceptual clarity and builds formally valid arguments. Yet disciplines are informed by epistemic values—and bioethics might do well to see social scientific practices and their attendant normative understandings about what is humanly important as a significant part of ethics generally.

The OHRP and SUPPORT - Another view

A group of physicians, bioethicists, and scholars in allied fields agrees with the Office for Human Research Protections about the informed-consent documents in SUPPORT.

Bioethics education. Expanding the circle of participants.

Bioethics education now takes place outside universities as well as within them. How should clinicians, ethics committee members, and policymakers be taught the ethics they need, and how may their progress best be evaluated?

Slow cures and bad philosophers : essays on Wittgenstein, medicine, and bioethics

Slow Cures and Bad Philosophers uses insights from the philosophy of Ludwig Wittgenstein to rethink bioethics. Although Wittgenstein produced little formal writing on ethics, this volume shows that, in fact, ethical issues permeate the entirety of his work. The scholars whom Carl Elliott has assembled in this volume pay particular attention to Wittgenstein’s concern with the thick context of moral problems, his suspicion of theory, and his belief in description as the real aim of philosophy. Their aim is not to examine Wittgenstein’s personal moral convictions but rather to explore how a deep engagement with his work can illuminate some of the problems that medicine and biological science present. As Elliott explains in his introduction, Wittgenstein’s philosophy runs against the grain of most contemporary bioethics scholarship, which all too often ignores the context in which moral problems are situated and pays little attention to narrative, ethnography, and clinical case studies in rendering bioethical judgments. Such anonymous, impersonal, rule-writing directives in which health care workers are advised how to behave is what this volume intends to counteract. Instead, contributors stress the value of focusing on the concrete particulars of moral problems and write in the spirit of Wittgenstein’s belief that philosophy should be useful. Specific topics include the concept of “good dying,” the nature of clinical decision making, the treatment of neurologically damaged patients, the moral treatment of animals, and the challenges of moral particularism. Inspired by a philosopher who deplored “professional philosophy,” this work brings some startling insights and clarifications to contemporary ethical problems posed by the realities of modern medicine. Contributors. Larry Churchill, David DeGrazia, Cora Diamond, James Edwards, Carl Elliott, Grant Gillett, Paul Johnston, Margaret Olivia Little, James Lindemann Nelson, Knut Erik Tranoy

Serum and Glucocorticoid-Regulated Kinase 1 Promotes Vascular Smooth Muscle Cell Proliferation via Regulation of β-catenin Dynamics

In response to arterial intimal injury vascular smooth muscle cells (VSMCs) within the vessel wall proliferate upon exposure to growth factors, accumulate, and form a neointima that can occlude the vessel lumen. Serum and glucocorticoid inducible kinase 1 (SGK1) is a growth factor-responsive kinase; however its role in VSMC proliferation is not fully understood. Here, we examined growth factor-dependent regulation of SGK1 and defined a molecular role for SGK1 in stimulation of VSMC proliferation. We found that stimulation of VSMCs with the pro-proliferative growth factor, platelet-derived growth factor BB (PDGF) significantly increased SGK1 mRNA, protein, and kinase activity in aortic VSMCs in vitro. To test the hypothesis that activation of SGK1 activity promotes VSMC proliferation, we examined the effects of stable expression of constitutively active (S422D) and kinase-defective (S422A) mutants of SGK1 on VSMC growth. We found that activation of SGK1 increased, whereas interference of SGK1 signaling inhibited VSMC growth in vitro. Consistent with these findings, expression of the S422D mutant augmented both basal and PDGF-induced BrdU uptake in VSMCs. Conversely, PDGF-induced BrdU uptake was attenuated in VSMCs expressing S422A. Furthermore, we determined that activated SGK1 enhanced basal and PDGF-dependent G1→S cell cycle transition, whereas dominant-negative SGK1 abrogated G1→S cell cycle transition under similar conditions. Downstream signaling by active SGK1 induced basal and PDGF-induced phosphorylation of glycogen synthase kinase 3β, an effect which was attenuated when SGK1 activity was blocked by expression of the kinase-defective mutant, S422A. We also found that transfection of S422D enhanced β-catenin-nuclear localization and activation of the TOP/Flash and cyclin D1 transcriptional reporters. These effects were significantly blunted in VSMCs transfected with the S422A mutant. Our results provide compelling evidence of a role for SGK1 in stimulation of arterial VSMC growth via regulation of β-catenin dynamics and implicate SGK1 in the progression of intimal narrowing following arterial injury. Hence, the findings presented here point to inhibition of SGK1 activity as a novel therapeutic approach for the treatment of occlusive vascular diseases.

Critical Interests and Sources of Familial Decision‐Making Authority for Incapacitated Patients

H ow ought we to understand the sources and limits of the authority of family members to make health care decisions for their decisiondy incapacitated relatives? This question is becoming increasingly crucial as the population ages and the power of medical technology waxes. It is also becoming increasingly contested, as faith in advance directives shows signs of waning,’ and the moral complexities of intimate relationship become more theoretically patent.2 This last point-the newly visible moral richness of intimate relationship-provides this paper with its field. I am interested in probing the images of the relationship between self and other, particularly self and intimate other, that seem presupposed by some leading attempts to determine the basis for proxy decision-making authority, and what constraints it must observe. In the light of both recent work in the philosophy of mind and considerations closer to common experience, the reigning images seem too slight to support the weight of current practices and beliefs about proxy authority; supplanting them with images more faithful to our experience will have implications for our practice with proxies.

Harming the Dead and Saving the Living

“brain death”—such as many traditional Jews—the shift from “death” to “cessation of (relevant) humanity” must surely appear as question begging. Interestingly, some proponents of halakhah (the Jewish tradition of normative discourse) have endorsed “brain death,” arguing that death of the whole brain, including speciacally the brain stem, fulalls the traditional pulmonary criterion since the capacity for autonomous breathing has been permanently lost. Within the framework of a vitalist position, these supporters of vital-organ transplants are in dispute with a more conservative faction that insists “brain-dead” patients are still alive as long as their heart is still beating. Both sides of that debate, however, subscribe to a vitalist idea of “sanctity of life,” holding that it is human life as such that must be cherished and protected, regardless of any capacity for consciousness. Many vitalists might agree that death is hard to deane, both theoretically and clinically, but would rightly fail to be impressed by Koppelman’s assertion that death does not matter. Her stance depends on the complementary supposition that there is something else that matters very much, namely, the cessation of humanity. It is hard to see how this deanitional sleight of hand can supplant a serious discussion of the metaphysics of personhood.3 It seems that Koppelman’s position would be better served by claiming outright that this cessation of humanity should be recognized as death, as eloquently advocated by Veatch (2003). Realizing that this would not convince true vitalists, Veatch would allow individuals to block retrieval of their organs under his “higher brain” deanition of death. But I suspect that the widespread resistance toward this broader deanition of death reoects a prevalent quasi-vitalist stance. There are those who are prepared to accept whole brain death as a relatively rare determination that a person who seems alive is actually dead—yet who recoil at the suggestion that many thousands of (biologically) alive humans be declared dead solely because they are no longer sentient. If there is any public policy merit in allowing donation of vital organs from such persons, I surmise it is more likely to succeed through the path indicated by Koppelman—that is, admitting that they are alive and relying on their (formerly recorded) consent to give up their organs (and their life) for the sake of others. But, unlike Koppelman, I believe this would have to build on a more fundamental shift toward allowing competent patients to nobly choose death for the sake of others.4 ■

Everything Includes Itself in Power: Power and Coherence in Engelhardt’s Foundations of Bioethics

A way of understanding an important theme in the history of ethics, at least since the Enlightenment, is to see it as an attempt to chain Shakespeare’s universal wolf. Somehow, power must be kept from dissolving without residue into will and appetite. Otherwise, we run the risk of various kinds of war, which few regard as an efficient way of achieving their ends, and fewer still desire for its own sake. Further, we lose what strikes me as a deep human hope: that there are ways of living that are legitimate. By this I mean that the circumstances and projects that form our lives are not merely expressions of a purely contingent play of historical forces with which we will have to either put up if we must or pull down if we can. Rather, we hope that our lives can be made to reflect, even if darkly, something that is true about the way things ought to be, quite independently of whatever you or I or anyone else might think or wish. The way things ought to be, according to this hope, will at least constrain and perhaps even guide our power, turning it to ends other than whatever we or others just might happen to desire, steering it toward what in fact we should yearn for. Should this hope fail, we face not only Hobbes’ prospect of the war of each against all, but an even pro founder threat: the loss of a deeply important feature of our notion of ourselves as agents. For if there is only power, and only will and appetite to guide it, if there is nothing to be said for any goal or end or form of life that would distinguish it as more worth pursuing than any other, then what is to prevent us from slipping into a kind of inertness, in which all pursuits are comparatively indifferent, and any pursuit seems ultimately vain?

Duties of Patients to Their Caregivers

At least in its more abstract guises, morality is a great leveler. Both the broad notions that are typically touted as constitutive of ethical theory, such as “universalizability” and “impartiality,” and the deliberative strategies that make up the heart of many particular theories — “the original position” in Rawls, or Bentham’s ringing slogan, “each counts for one, no one for more than one” — suggest that, at base, all moral beings are peers, and that a large part of living a moral life involves a quest to weaken the hold of ethically insignificant differences on our attitudes and behavior.

Making peace in gestational conflicts.

Mary Anne Warrens claim that “there is room for only one person with full and equal rights inside a single human skin” ([1], p. 63) calls attention to the vast range of moral conflict engendered by assigning full basic moral rights to fetuses. Thereby, it serves as a goad to thinking about conflicts between pregnant women and their fetuses in a way that emphasizes relationships rather than rights. I sketch out what a ‘care orientation’ might suggest about resolving gestational conflicts. I also argue that the care orientation, with its commitment to the significance of the partial and the particular, cannot be absorbed within standard, impartialist moral theory.