Papers by Elisa Rapaport
Fields such as medical ethics have long suffered from a disconnect between theory and application... more Fields such as medical ethics have long suffered from a disconnect between theory and application. “Real-world” practitioners understand the day-to-day realities that inspire and inhibit their actions, and “ivory tower” scholars sometimes fall into the trap of presuming that non-scholars cannot understand theory or, worse yet, that ethical theory need not be informed by practical experience. There are plenty of applied ethicists across disciplines bridging this divide, yet problems persist amongst faculty who underestimate the interest and capacity of medical and nursing students, and even amongst academic administrators who presume ethics is too obscure a topic to warrant seminar-style discussion. For many nurses, philosophy is intimidating. Yet with each new semester I find that most of my nursing students need not have worried about how they might grasp what are foreign-sounding terms like deontology, teleology, and utilitarianism. They already understand the concepts and have employed them in their lives — usually both personally and professionally. I have also found that most nurses could themselves populate a textbook with true-life examples demonstrating every such concept I challenge them to consider. Like most philosophers, I bring a blend of critical analysis, theory, and logical consistency to the courses I teach. My goal is to expose medical professionals to the processes that guide their decision-making, to the historical context of patient autonomy, and to potential dilemmas that await them in their careers as they strive for professional excellence. It is not enough to memorize cases, dates, theorists, and terminology. For the experience to truly be transformative – to successfully equip and empower students to reflect on the implications of their actions on patients, colleagues, and the profession in general – the union of theory and practice is essential. The process is most effective when students are encouraged to share and reflect on their experiences in the context of improving their moral decision-making. With such input, those scholars tweaking the theoretical approaches to today’s problems can better grasp the feasibility of their theories. The theories can evolve and as originally hoped, influence behavior, when given the opportunity to be taken seriously in the lives of the moral agents. The field of bioethics and philosophy in particular could benefit from listening to the professionals who are living ethical dilemmas every day. This paper will provide a series of brief excerpts from student stories demonstrating the relevancy of moral theory as typically applied to issues in health care. It is an example of an on-going conversation amongst disciplines that we must engage in at the academic level in order to truly appreciate and fulfill the promise of humanity in medicine.
bu.edu, Apr 29, 2011
As technology makes possible the saving of human life, medical ethics has intensified its concern... more As technology makes possible the saving of human life, medical ethics has intensified its concern for the patient’s right to forgo life-saving treatment. Autonomy may be the most important consideration in end-of-life decision-making. But narrow presumptions about personhood and the ‘good’ life — and their perceived incommensurability with disability — have the power to hijack autonomy, such as by presuming that a debilitating existence is worse than no existence at all. This essay explores Ronald Dworkin’s classic distinction between ‘critical’ and ‘experiential’ interests, the former setting the ability to envision one’s overall life as a requisite for competence. When physicians or others even subtly impose their own preferences in their recommendations to patients, they inadvertently negate the value of experiential interests, eroding the essence of autonomy. One solution is the selection of a ‘partner’ health care proxy, someone whose familiarity and emotional investment can best respect the patient’s interests as a person.
The basis what is often called “feminist ethics” considers the traditional ways males and females... more The basis what is often called “feminist ethics” considers the traditional ways males and females have responded to ethical dilemmas, with the recognition that males make decisions clearly, quickly, and decisively while females weigh the implications for interpersonal relationships much more heavily into their decisions. Most ethicists sympathetic to this view acknowledge the danger in perpetuating generalizations according to gender. Nonetheless the theory attempts to move from this foundation to a broader and progressive ethic. From the presumption of gender differences in ethical decision-making emerges the emphasis on women’s values being strengths rather than weaknesses; to be conscious of a capacity to care about other people is itself, according to this theory, an ethical position. I seek to further this discussion in two ways with this project. I shall argue that (1) the capacity to care is related to empathy and as such, indicates the beginning of ethics. (2) The word “feminist” to describe any theory of ethics is detrimental to the goal because (a) political connotations effectively exclude rather than attract enthusiasts and (b) the word misrepresents the entire concept. Acknowledging gender differences leads to appreciating care-centered priorities traditionally associated with females. This does not necessitate that caring is uniquely female, however. Nor does it follow that a traditionally-viewed male approach to decision-making is flawed or in any way inferior. The attractiveness of care ethics is its potential to represent voiceless members of society, with the example that women’s decision-making offers more advantage than disadvantage. My position is that this is a humanistic view that sees value in all people regardless of gender, class, or other demographics that have categorized oppression in the past. The feminist label does damage by ostracizing the alleged oppressor and by discrediting the very theory that potentially offers hope for all people.
In medical ethics the issue of autonomy has produced interesting questions about how to resolve c... more In medical ethics the issue of autonomy has produced interesting questions about how to resolve conflicts, such as how to ensure that a patient‘s wishes are respected when he is no longer able to speak for himself. The choice of a health care proxy (a.k.a. health care power of attorney) is perhaps one of the single most important decisions that can be specified in advance directive planning. I confront here three main concerns. (1) A handful of ethicists (e.g., Buchanan) have argued that advance directives violate autonomy, because the incapacitated patient‘s interests are no longer those of the earlier 'pre-patient‘ who anticipated his future preferences. The idea is that one person has no authority to make decisions for another, and that the later 'self‘ of the incapacitated patient is effectively a different 'self‘ than the former person. (2) Some legal experts (e.g., Cebuhar) purport that a living will trumps a living proxy and that the more specifically detailed the preferences provided in a living will, the better. (3) There remains a push amongst some ethicists and medical professionals (e.g., Savulescu; Ardagh), for a modern, modified 'paternalism‘ whereby physicians and emergency rescuers make decisions for their incapacitated patients, rather than involving the patients‘ family, friends, or designated health care proxies. Loved ones, this approach claims, are too emotionally involved and medically uninformed to serve as effective proxies.
I argue against these claims in this dissertation. It is precisely their emotional involvement that makes intimate acquaintances (or what we might call 'partner‘ proxies) the appropriate choice: who better could understand a patient‘s life-long values and anticipate the sorts of decisions he would make? For many patients, their social circles matter more than do ideological concepts like self-determination; it may be (as in a communitarian critique) that the well-being of patients‘ loved ones is integral to their own personal interests. Furthermore,
reliance on overly-specific, binding living wills is problematic from an epistemological point of view. Despite our best efforts, we can guarantee neither the details of our future predicaments nor our reactions to them, but the proxy has the benefit of weighing contemporaneous information into medical decisions. The concern about directives being problematic for autonomy is avoided when the patient, while still competent, (a) appoints a benevolent acquaintance or partner proxy and (b) gives her the discretionary authority to make decisions in real time and in a manner that respects the general spirit of the patient‘s expressed values. An appropriately-chosen proxy is more useful than binding directives that cannot accommodate technological advancement, prognostic considerations, and experiential interests on behalf of the patient. Examinations of de Sousa‘s emotion theory and of Goldie‘s analysis of the ways in which we can understand and appreciate the emotions of others, both further demonstrate the unique advantage of partner proxies in ethically carrying through the decision-making process that is demanded of them.
Works in Progress by Elisa Rapaport
Much of philosophy has sought to understand the ways we experience the world, assess our percepti... more Much of philosophy has sought to understand the ways we experience the world, assess our perceptions, and reflect, develop, and communicate ideas. Phenomenologists such as Edmund Husserl have focused on the experiential aspects of consciousness — what it is like to be a conscious being in the world — whereas philosophers of language have attempted to define and safeguard language, syntax, logical form, etc. Ludwig Wittgenstein famously argued there is no such thing as a ‘private’ language, because communication necessarily involves another person. At best, the babblings frequently referred to as ‘baby talk’ are usually reduced to a proto-language or an early developmental stage of common linguistic forms to come. Yet there is a persisting sense in which all expression is private, insofar as it attempts to articulate first-person perspective, thoughts, emotions, experience, ideas, etc. This paper argues that in the process of trying to find what we might call their ‘public voice’ infants and toddlers faithfully reside within a pure phenomenology of being. That is, they are free of the self-imposed constraints, self-consciousness, and adherence to rules imposed by most language analysis. Our reactions to early communication are perhaps too one-dimensional, as we correct, measure, and even judge the reinforcement of baby babble, for fear of hindering language development. Rather, by validating his or her experience there is an opportunity to contribute positively to a child’s emerging sense of self. Children are in a Husserlean sense better phenomenologists than most adults are. Even — or perhaps especially — if they are speaking to an audience of one.
The standard of informed consent is being violated. With more than 38 million American women util... more The standard of informed consent is being violated. With more than 38 million American women utilizing birth control each year, both the expected success rate and consequent implications of failure are significant. Most patients understand the approximate pregnancy rate to be around one percent for popular options like hormonal birth control pills and intrauterine devices, and they are told that the rare event of failure usually results from inconsistent usage or slippage of the device, respectively. Most birth control decisions center on variables like ease of use, cost, and reliability, for obvious reasons. What is left out of the doctor-patient discussion, however, are the consequences of being amongst the one percent whose birth control fails. Research on potential harm to the fetus exposed to estrogen and progesterone — the hormones typically found in oral contraceptives — is inclusive. Nevertheless it is easy enough for a woman to stop taking the pills once she discovers she is pregnant. With IUDs the potential harm to the fetus and even to the woman herself is significant. As many as half of IUD pregnancies are ectopic, a life-threatening condition usually necessitating an abortion (compared to just one percent of pregnancies overall). Furthermore, hormone-releasing devices like Mirena® and even non-hormonal IUDs like ParaGard® significantly increase the risks of miscarriage, premature birth, and infection in otherwise normal uterine pregnancies. The IUD literature disclosed to patients mentions such possibilities in the small print attachments included in the packaging — which the patient may or may not see, as most gynecologists directly order and insert the devices. Information-seeking patients might find this information on their own, such as through the manufacturers’ websites, which heavily emphasize an impressive success rate and gloss over the FDA-required warnings of serious harm. ParaGard® attempts to remove themselves from responsibility for such tragedies, assuring readers that nothing printed there can serve as a substitute for advice given by one’s medical doctor. As in many situations, the issue of informed consent rests with the information that is exchanged between doctor and patient: does the patient fully understand the potential harm to herself, and in the event of pregnancy, to potential others? I propose that at least in some cases, this standard is not being met. Furthermore, IUDs pose a problem oral contraceptives do not. In the event that the device cannot be located or otherwise removed, continuing a pregnancy is incredibly dangerous both to the fetus and the mother. One might say that a woman using birth control wasn’t interested in having another child, anyway, implying that aborting should be a reasonable if not simple solution. Because of increased risk for sterility following infection as a result of an IUD, use is typically only suggested for women who already have children. Once removed, an IUD’s birth control properties cease, so not surprisingly, the reversibility aspect is a heavily-marketed feature — suggesting that women using IUDs may be interested in having more children in the future (thus they might not be inclined to abort if accidentally pregnant, despite the preference not to become pregnant at the moment). All of this is to say becoming pregnant, with an IUD in place is a far more complicated matter than a game of chance, betting on being in the 99 percent. When a woman who is already a mother becomes pregnant with an IUD that doctors are unable to remove, there are greater considerations than those accurately represented in downplaying the likelihood of the risks becoming reality. She might be disinclined to abort, impacted by the positives of the experience of already having children. She might not be prepared emotionally for the heartbreak that could result in deciding to continue a pregnancy that ends tragically. She could unintentionally be inflicting the hazards of a life with severe disabilities on her child if born prematurely. She could be threatening her own life with an infection that turns septic in an effort to maintain the life of the offspring that was conceived despite 99 percent odds. The doctor-patient conversation needs to focus more on these one percent possibilities — even at the risk of the patient ultimately deciding against the IUD as a form of birth control so highly touted for its success rate. This is by no means intended to be representational of the inclinations of women in general; but because any woman could potentially be thus affected, the onus is on physicians to discuss such possibilities. Without this discussion, the ethical standard has not been met for informed consent.
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Papers by Elisa Rapaport
I argue against these claims in this dissertation. It is precisely their emotional involvement that makes intimate acquaintances (or what we might call 'partner‘ proxies) the appropriate choice: who better could understand a patient‘s life-long values and anticipate the sorts of decisions he would make? For many patients, their social circles matter more than do ideological concepts like self-determination; it may be (as in a communitarian critique) that the well-being of patients‘ loved ones is integral to their own personal interests. Furthermore,
reliance on overly-specific, binding living wills is problematic from an epistemological point of view. Despite our best efforts, we can guarantee neither the details of our future predicaments nor our reactions to them, but the proxy has the benefit of weighing contemporaneous information into medical decisions. The concern about directives being problematic for autonomy is avoided when the patient, while still competent, (a) appoints a benevolent acquaintance or partner proxy and (b) gives her the discretionary authority to make decisions in real time and in a manner that respects the general spirit of the patient‘s expressed values. An appropriately-chosen proxy is more useful than binding directives that cannot accommodate technological advancement, prognostic considerations, and experiential interests on behalf of the patient. Examinations of de Sousa‘s emotion theory and of Goldie‘s analysis of the ways in which we can understand and appreciate the emotions of others, both further demonstrate the unique advantage of partner proxies in ethically carrying through the decision-making process that is demanded of them.
Works in Progress by Elisa Rapaport
I argue against these claims in this dissertation. It is precisely their emotional involvement that makes intimate acquaintances (or what we might call 'partner‘ proxies) the appropriate choice: who better could understand a patient‘s life-long values and anticipate the sorts of decisions he would make? For many patients, their social circles matter more than do ideological concepts like self-determination; it may be (as in a communitarian critique) that the well-being of patients‘ loved ones is integral to their own personal interests. Furthermore,
reliance on overly-specific, binding living wills is problematic from an epistemological point of view. Despite our best efforts, we can guarantee neither the details of our future predicaments nor our reactions to them, but the proxy has the benefit of weighing contemporaneous information into medical decisions. The concern about directives being problematic for autonomy is avoided when the patient, while still competent, (a) appoints a benevolent acquaintance or partner proxy and (b) gives her the discretionary authority to make decisions in real time and in a manner that respects the general spirit of the patient‘s expressed values. An appropriately-chosen proxy is more useful than binding directives that cannot accommodate technological advancement, prognostic considerations, and experiential interests on behalf of the patient. Examinations of de Sousa‘s emotion theory and of Goldie‘s analysis of the ways in which we can understand and appreciate the emotions of others, both further demonstrate the unique advantage of partner proxies in ethically carrying through the decision-making process that is demanded of them.