In some jurisdictions there is a puzzling asymmetry between consent and refusal, where, for some kinds of treatment, the adolescent patient has the power to permit her own treatment but her refusal does not have the same kind of normative significance as refusal of treatment by a competent adult. In this journal I recently offered a clarification and defence of this asymmetry in terms of a paternalistic justification of the sharing of normative powers between adolescents and other (...) parties. Lawlor offers a number of objections to this account. Three of his objections can be dealt with quickly. But one of them is much more challenging: the asymmetry of consent and refusal entails a practice of making sham offers. They do not really offer a choice at all. Genuine offers seem to require a commitment to be symmetrically responsive to whatever decision outcome is reached by the recipient of the offer. When we reflect upon the way that offers can be made in complex social contexts, where different parties have a ‘say’ in what ought to be done, the symmetry of responsiveness need not apply. Offers can be genuine, without being symmetrically responsive. Contrary to the seemingly plausible objection, the asymmetry of consent and refusal does not entail sham offers, or the offer of ‘sham choices’. (shrink)

In some jurisdictions there is a puzzling asymmetry between consent and refusal, where, for some kinds of treatment, the adolescent patient has the power to permit her own treatment but her refusal does not have the same kind of normative significance as refusal of treatment by a competent adult. In this journal I recently offered a clarification and defence of this asymmetry in terms of a paternalistic justification of the sharing of normative powers between adolescents and other (...) parties. Lawlor (2016) offers a number of objections to this account. Three of his objections can be dealt with quickly. But one of them is much more challenging: the asymmetry of consent and refusal entails a practice of making sham offers (offers that purport to be responsive to the patient's choices, but which, in fact, are not). They do not really offer a choice at all. Genuine offers seem to require a commitment to be symmetrically responsive to whatever decision outcome is reached by the recipient of the offer. When we reflect upon the way that offers can be made in complex social contexts, where different parties have a ‘say’ in what ought to be done, the symmetry of responsiveness need not apply. Offers can be genuine, without being symmetrically responsive. Contrary to the seemingly plausible objection, the asymmetry of consent and refusal does not entail sham offers, or the offer of ‘sham choices’. (shrink)

John Harris claims that is it ‘palpable nonsense’ to suggest that ‘a child might competently consent to a treatment but not be competent to refuse it.’ In ‘Transitional Paternalism: How Shared Normative Powers Give Rise to the Asymmetry of Adolescent Consent and Refusal’ Neil Manson aims to explain away the apparent oddness of this asymmetry of consent and refusal, by appealing to the idea of shared normative powers, presenting joint bank accounts as an example. In (...) this article, I will argue that Manson's account fails to explain away the oddness. Rather, I will argue that there are ambiguities to which Manson has not paid sufficient attention. In fact, as odd as it may sound, I argue that Manson actually agrees with Harris. He fails to recognize that he agrees with Harris because he is not careful enough to distinguish between different asymmetries, which I have labelled the asymmetries of choice, permissibility and competence. (shrink)

John Harris claims that is it ‘palpable nonsense’ to suggest that ‘a child might competently consent to a treatment but not be competent to refuse it.’ In ‘Transitional Paternalism: How Shared Normative Powers Give Rise to the Asymmetry of Adolescent Consent and Refusal’ Neil Manson aims to explain away the apparent oddness of this asymmetry of consent and refusal, by appealing to the idea of shared normative powers, presenting joint bank accounts as an example. In (...) this article, I will argue that Manson's account fails to explain away the oddness. Rather, I will argue that there are ambiguities to which Manson has not paid sufficient attention. In fact, as odd as it may sound, I argue that Manson actually agrees with Harris. He fails to recognize that he agrees with Harris because he is not careful enough to distinguish between different asymmetries, which I have labelled the asymmetries of choice, permissibility and competence. (shrink)

The paper examines the attainment and adequacy of informed consent in an ethnographic–discursive study on gynecological visits involving doctors, patients, and nurses. Starting from a theoretical discussion on informed consent and the principles upon which it relies, the paper highlights the changes and the adjustments that these principle undergo in practice, from the planning of the research till later stages of the researcher’s fieldwork and data recording. Analyses first focus on the informed consent as a written artifact (...) and show how the description of the study indexes the prospective participants’ identity, as well as, it works in favor of the researcher’s (or, other institutional representatives such as the managers of the Hospital) accountability. Then, the authors focus on instances of audio and video recorded doctor–patient–nurse interactions in which information is reformulated by the doctors, in such a way as to anticipate and/or respond to the nurses’ and patients’ concerns with regards the project (such as, the risk of exposure to the public). The analysis of these episodes carry ethical implications, in that they alert that patients, nurses, and doctors may be not equally knowledgeable about the project and that they can be conceded unequal opportunities to have their interpretations and identity performances acknowledged and inscribed on the tape. (shrink)

The recent #metoo movement has turned public attention to the problem of sex under conditions of power inequality. Is consent impaired, when you have plenty to lose (e.g. a great professional opportunity) from saying “no” to a sexual advance? And even if consent is valid, is this a morally acceptable situation, especially if one party is aware that their position of relative power will influence the other’s decision to have sex? Such situations bring to the fore not only (...) the issues of coerced sex and quid pro quo harassment (asking for sex in exchange for benefits), but the much more controversial question of whether sex between unequal but otherwise competent consenting adult partners is in principle OK—and whether institutions such as companies, universities, or the state itself should be in the business of regulating such relations. In what follows, I will outline the central concept of power asymmetry and its ethical relevance (section 2). I will then distinguish two main views about the ethics of sexual interaction under conditions of power asymmetry: a Kantian view, which categorically condemns such interactions, and a Millian view, which justifies at least some such interactions (section 3). I then briefly consider three contexts, which raise difficult questions about sex between unequals: the workplace, the university (section 4), and voluntary prostitution (section 5). Section 6 provides a short conclusion. (shrink)

ContextIn many cases, informed consent of participants is considered a prerequisite even for exclusively data-based medical research. In this context, a model of broad consent is being discussed. In Germany, the Medizininformatik-Initiative (Medical Informatics Initiative) has developed a proposal for broad consent for German hospitals which suggests a validity period of 30 years.Definition of the problemAgainst this background, the article discusses how the claim of consent beinginformedhas to be regarded in a temporal perspective. The practice of (...) consent is here understood to be oriented towards the realization of well-being, personal sovereignty, and trust. In the context of medical research, an asymmetry of access to information between research participants, researchers, and data-storing institutions has to be assumed.Argument and conclusionThe article argues that in order to appropriately address this information asymmetry, a continuous dissemination of comprehensibly prepared information to research participants is necessary to enable personal sovereignty. (shrink)

Background Conducting clinical trials with pre-term or sick infants is important if care for this population is to be underpinned by sound evidence. Yet, approaching the parents of these infants at such a difficult time raises challenges to obtaining valid informed consent for such research. In this study, we asked, What light does the analytical literature cast on an ethically defensible approach to obtaining informed consent in perinatal clinical trials? -/- Methods In a systematic search, we identified 30 (...) studies. We began our analysis by applying philosophical frameworks, which were then refined as concepts emerged from the analytical studies, to present a coherent picture of a broad literature. -/- Results Between them, the studies addressed four themes. The first three were the ethical basis for parental informed consent for neonatal and/or perinatal research, the validity of parental consent in this context, and the range of possible options in methods for gaining consent. The last was the issue of risk and the possibility of a double-standard or asymmetry in the current approaches to the requirement for consent for research and consent for clinical treatment. -/- Conclusions In addressing these issues, the analysed studies showed that, whilst there are a variety of possible defences for seeking parental ‘consent’ to neonatal and/or perinatal clinical trials, these are all consistent with the strongly and widely held view that it is important that parents do give (or decline) consent for such research. So far as the method of obtaining consent is concerned, none of the existing consent processes reviewed by the research is satisfactory, and there are philosophical reasons for supposing that at least some parents will fail to give valid consent in a neonatal context. Furthermore, in giving parental ‘consent’ in a perinatal context, parents are authorising infant participation, not giving ‘proxy consent’. Finally, there are reasons for giving weight to both parental ‘consent’ and the infant’s best interests in both research and clinical treatment. However, there are also reasons to treat these factors differently in the two contexts, and this may be partly due to the differing relevance of risk in each case. A significant gap is the lack of any detailed discussion of a process of emergency and/or urgent ‘assent’, in which parents assent or refuse their baby’s participation as best they can during the emergency and later give full consent to continuing participation and follow-up. (shrink)

Information on the risks and benefits related to surgical procedures is essential for patients in order to obtain their informed consent. Some disciplines, such as sociolinguistics, offer insights that are helpful for patient—professional communication in both written and oral consent. Communication difficulties become more acute when patients make decisions through an informed consent document because they may sign this with a lack of understanding and information, and consequently feel deprived of their freedom to make their choice about (...) different treatments or surgery. This article discusses findings from documentary analysis using the sociolinguistic SPEAKING model, which was applied to the general and specific informed consent documents required for laparoscopic surgery of the bile duct at Torrecárdenas Hospital, Almería, Spain. The objective of this procedure was to identify flaws when information was provided, together with its readability, its voluntary basis, and patients’ consent. The results suggest potential linguistic communication difficulties, different languages being used, cultural clashes, asymmetry of communication between professionals and patients, assignment of rights on the part of patients, and overprotection of professionals and institutions. (shrink)

Argumentation theory has much to offer our understanding of the doctor-patient relationship as it plays out in the context of seeking and obtaining consent to treatment. In order to harness the power of argumentation theory in this regard, I argue, it is necessary to take into account insights from the legal and bioethical dimensions of informed consent, and in particular to account for features of the interaction that make it psychologically complex: that there is a fundamental asymmetry (...) of authority, power and expertise between doctor and patient; that, given the potential for coercion, it is a challenge to preserve the interactive balance presumed by the requirement of informed consent; and finally that the necessary condition that patients be ‘competent to consent’ may undermine the requirement of respecting patient autonomy. I argue argumentation theory has the resources to deal with these challenges and expand our knowledge, and appreciation, of the informed consent interaction in health care. Keywords: argumentation theory, informed consent, doctor-patient interaction, competency to consent, autonomy, medical paternalism. (shrink)

The starting point of this article is that employees’ chances of securing reasonable expectations of privacy at work must be better protected. A dependency asymmetry between employer and job-applicant implies that prospective employees are in a disadvantaged position vis à vis the employer regarding the chances of defending their reasonable interests. Since an increased usage of work related surveillance will, to a larger extent, require of job-applicants that they negotiate their privacy interests in employment contracting, it is important to (...) consider means of strengthening employees’ negotiating power. This article emphasizes the importance of contextualizing consent for contractual agreements to be ethically acceptable. (shrink)

In many jurisdictions, adolescents acquire the right to consent to treatment; but in some cases their refusals – e.g. of life-saving treatment – may not be respected. This asymmetry of adolescent consent and refusal seems puzzling, even incoherent. The aim here is to offer an original explanation, and a justification, of this asymmetry. Rather than trying to explain the asymmetry in terms of a variable standard of competence – where the adolescent is competent to (...) class='Hi'>consent to, but not refuse, certain interventions – the account offered here focuses more closely on the normative power to render actions permissible. Where normative powers are shared they can readily give rise to an asymmetry between consent and refusal. We then turn to why it is justifiable that normative powers be shared in adolescence. Transitional paternalism holds that the acquisition of normative powers by competent adolescents should not be an instant one, achieved in a single step, but that there should be a transitional period where paternalistic protection is rolled back, but not entirely withdrawn until a later date. Transitional paternalism could be implemented without generating the asymmetry between consent and refusal but, it is argued, the asymmetric version of transitional paternalism is to be preferred insofar as it offers a greater respect for the adolescent's decisions than the symmetrical alternative. (shrink)

The author argues for a theory of responsibility for outcomes of imposed risk, based on whether it was permissible to impose the risk. When one tries to apply this persuasive model of responsibility for outcomes of risk imposition to procreation, which is a risk imposing act, one finds that it doesn’t match one’s intuitions about responsibility for outcomes of procreative risk. This mismatch exposes a justificatory gap for procreativity, namely, that procreation cannot avail itself of the shared vulnerability to risks (...) and their constraints—to the balance one is forced to strike between one’s interest in being free to impose risks on others and one’s interest in being safe from harm resulting from the risk imposed by others—which serves to justify risk imposition, generally. Whereas most risk impositions involve trade-offs of liberty and security among people who share the vulnerabilities associated with the taking, imposing, or being constrained from imposing risks, procreation involves the introduction of people into that position of vulnerability in the first place. Thus, when one procreates, one imposes risks in the absence of the shared vulnerability that usually serves as a justification for risk imposition. Procreative risks may not be wrongfully imposed, but they aren’t permissibly imposed in a manner fully comparable to other permissibly imposed risks. This makes procreation a unique form of risk imposition, with unique implications for its justification and for one’s responsibility for its outcomes. This insight can help explain several puzzling procreative asymmetries. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Convention for Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Biomedicine: Convention on Human Rights and BiomedicineCouncil of EuropePreambleThe Member States of the Council of Europe, the other States and the European Community signatories hereto,Bearing in mind the Universal Declaration of Human Rights proclaimed by the General Assembly of the United Nations on 10 December 1948;Bearing in mind the (...) Convention for the Protection of Human Rights and Fundamental Freedoms of 4 November 1950;Bearing in mind the European Social Charter of 18 October 1961;Bearing in mind the International Covenant on Civil and Political Rights and the International Covenant on Economic, Social and Cultural Rights of 16 December 1966;Bearing in mind the Convention for the Protection of Individuals with Regard to Automatic Processing of Personal Data of 28 January 1981;Bearing also in mind the Convention on the Rights of the Child of 20 November 1989;Considering that the aim of the Council of Europe is the achievement of a greater unity between its members and that one of the methods by which that aim is to be pursued is the maintenance and further realisation of human rights and fundamental freedoms;Conscious of the accelerating developments in biology and medicine;Convinced of the need to respect the human being both as an individual and as a member of the human species and recognising the importance of ensuring the dignity of the human being; [End Page 277]Conscious that the misuse of biology and medicine may lead to acts endangering human dignity;Affirming that progress in biology and medicine should be used for the benefit of present and future generations;Stressing the need for international co-operation so that all humanity may enjoy the benefits of biology and medicine;Recognising the importance of promoting a public debate on the questions posed by the application of biology and medicine and the responses to be given thereto;Wishing to remind all members of society of their rights and responsibilities;Taking account of the work of the Parliamentary Assembly in this field, including Recommendation 1160 (1991) on the preparation of a Convention on bioethics;Resolving to take such measures as are necessary to safeguard human dignity and the fundamental rights and freedoms of the individual with regard to the application of biology and medicine;Have agreed as follows:Chapter IGeneral provisionsArticle 1. (Purpose and object)Parties to this Convention shall protect the dignity and identity of all human beings and guarantee everyone, without discrimination, respect for their integrity and other rights and fundamental freedoms with regard to the application of biology and medicine.Each Party shall take in its internal law the necessary measures to give effect to the provisions of this Convention.Article 2. (Primacy of the human being)The interests and welfare of the human being shall prevail over the sole interest of society or science.Article 3. (Equitable access to health care)Parties, taking into account health needs and available resources, shall take appropriate measures with a view to providing, within their jurisdiction, equitable access to health care of appropriate quality. [End Page 278]Article 4. (Professional standards)Any intervention in the health field, including research, must be carried out in accordance with relevant professional obligations and standards.Chapter IIConsentArticle 5. (General rule)An intervention in the health field may only be carried out after the person concerned has given free and informed consent to it.This person shall beforehand be given appropriate information as to the purpose and nature of the intervention as well as on its consequences and risks.The person concerned may freely withdraw consent at any time.Article 6. (Protection of persons not able to consent)1. Subject to Articles 17 and 20 below, an intervention may only be carried out on a person who does not have the capacity to consent, for his or her direct benefit.2. Where, according to law, a minor does not have the capacity to consent to an intervention, the intervention may only be carried out with the authorisation of his or her representative or an authority or a person or... (shrink)

Part of the standard protection of decisionally incapacitated research subjects is a prohibition against enrolling them unless surrogate decision makers authorize it. A common view is that surrogates primarily ought to make their decisions based on what the decisionally incapacitated subject would have wanted regarding research participation. However, empirical studies indicate that surrogate predictions about such preferences are not very accurate. The focus of this article is the significance of surrogate accuracy in the context of research that is not expected (...) to benefit the research subject. We identify three morally relevant asymmetries between being enrolled and not being enrolled in such non-beneficial research, and conclude that when there is a non-negligible probability that surrogates’ predictions are wrong, it will generally be better to err on the side of not authorizing enrollment. (shrink)

In 2016, this Journal published an article by Rob Lawlor1 on what we might call the acceptance-refusal asymmetry in competence requirements. This is the view that there can be cases in which a patient is sufficiently competent to accept a treatment ( viz., to give consent to it), but not sufficiently competent to refuse it ( viz., to withhold consent to it). Though the main purpose of Lawlor’s paper was to distinguish this asymmetry from various other (...) asymmetries with which it has sometimes been confused,1 Lawlor also presented a brief case in favour of it. Developing an earlier argument of Ian Wilks’,2 3 Lawlor argued that, when the risks associated with refusing a treatment are graver than those associated with accepting it, a higher level of competence may be required to refuse a treatment than to accept it. This claim could have important implications for the law, since determinations of competence often play a central role in determining the lawfulness of refusing or imposing a treatment (eg, in England and Wales under the Mental Capacity Act 2005). Indeed, the acceptance-refusal asymmetry in competence requirements, or something close to it, has played an important role in court judgments.2 However, Lawlor himself suggests that his conclusion will have practical implications only in a narrow range of cases.3 In this issue, Pickering, Giles Newton-Howes and Simon Walker (henceforth ‘the authors’) respond to Lawlor’s piece.4 They deny that competence requirements should depend on the level of risk associated with a decision, and thus that there is any basis for the acceptance-refusal asymmetry in competence requirements. Part of the authors’ argument involves contesting the way in which Lawlor uses cases to support his view. In one case cited by Lawlor—and drawn from Wilks—we are invited to consider a whether …. (shrink)

Adolescents, in many jurisdictions, have the power to consent to life saving treatment but not necessarily the power to refuse it. A recent defence of this asymmetry is Neil Manson's theory of ‘transitional paternalism’. Transitional paternalism holds that such asymmetries are by-products of sharing normative powers. However, sharing normative powers by itself does not entail an asymmetry because transitional paternalism can be implemented in two ways. Manson defends the asymmetry-generating version of transitional paternalism in the clinical (...) context, arguing that it maximizes respect for adolescent autonomy. This article offers an alternative argument in favour of the asymmetry-generating form of transitional paternalism, one that makes appeal to obligations that individuals have to develop self-governance in others. We should share normative powers asymmetrically in the clinical context for three reasons. First, the asymmetric version of transitional paternalism takes seriously duties to support adolescents’ developing autonomy, alongside other duties that adults have to young people. It does so by enabling young people to be involved in important decisions that they would otherwise be excluded from. This is of value because participation of this sort is central to the cultivation of their self-governance. Second, only the asymmetric version gives young people a voice in respect of all clinical actions, and only the asymmetric version leaves open the possibility that the coarse lines of legislation might be ‘fine-tuned’ in individual cases. Third, the asymmetric sharing of normative powers is consistent with the kind of social arrangements that best support autonomy. (shrink)

If a person is competent to consent to a treatment, is that person necessarily competent to refuse the very same treatment? Risk relativists answer no to this question. If the refusal of a treatment is risky, we may demand a higher level of decision-making capacity to choose this option. The position is known as asymmetry. Risk relativity rests on the possibility of setting variable levels of competence by reference to variable levels of risk. In an excellent 2016 article (...) inJournal of Medical Ethics(JME), Rob Lawlor defends asymmetry of this kind by defending risk relativity, using and developing arguments and approaches found in earlier work such as that of Wilks. He offers what we call the two-scale approach: a scale of risk is to be used to set a standard of competence on a scale of decision-making difficulty. However, can this be done in any rational way? We argue it cannot, and in this sense, and to this extent, risk relativity is a nonsense. (shrink)

I do not disagree with the argument that human-population right-handedness may in some way be a consequence of the population-level left-lateralization of language. But I suggest that the human functional lateralization is not dependent on the structural left-right brain asymmetries to which Corballis refers.

An explanation of our seeming inability to influence the past.

Background:Moral courage is defined as courage to act according to one’s own ethical values and principles even at the risk of negative consequences for the individual. In a complex nursing practice, ethical considerations are integral. Moral courage is needed throughout nurses’ career.Aim:To analyse graduating nursing students’ moral courage and the factors associated with it in six European countries.Research design:A cross-sectional design, using a structured questionnaire, as part of a larger international ProCompNurse study. In the questionnaire, moral courage was assessed with (...) a single question (visual analogue scale 0–100), the questionnaire also covered several background variables.Participants and research context:The sample comprised graduating nursing students (n = 1796) from all participating countries. To get a comprehensive view about graduating nursing students’ moral courage, the views of nurse managers (n = 538) and patients (n = 1327) from the same units in which the graduating nursing students practised were also explored, with parallel questionnaires.Ethical considerations:Ethical approvals and research permissions were obtained according to national standards in every country and all participants gave their informed consent.Results:The mean of graduating nursing students’ self-assessed moral courage was 77.8 (standard deviation 17.0; on a 0–100 scale), with statistically significant differences between countries. Higher moral courage was associated with many factors, especially the level of professional competence. The managers assessed the graduating nursing students’ moral courage lower (66.5; standard deviation 18.4) and the patients slightly higher (80.6; standard deviation 19.4) than the graduating nursing students themselves.Discussion and conclusions:In all countries, the graduating nursing students’ moral courage was assessed as rather high, with differences between countries and populations. These differences and associations between moral courage and ethics education require further research. (shrink)

Philosophical work on the concept of consent in the past few decades has got to grips with it as a rich notion. We are increasingly sensitive to consent not as a momentary, atomic, transactional thing, but as a complex idea admitting of various qualities and dimensions. In this paper we note that the recognition of this complexity demands a theoretical framework quite different to those presently extant, and we suggest that the enactive approach is one which offers significant (...) value in this regard. In consonance with arguments made by Laurie Penny about how consent is a continuous and dynamic process, we outline how an enactive approach identifies consent as temporally extended (rather than momentarily transactional), and as affected by the skilfulness of the agents involved, the fitness of community provided resources to negotiate the consensual relationship over time, and the unfolding of circumstances in the situation in which the joint action is taking place. We argue that the value of an enactive perspective on consent is in highlighting these complexities, and providing resources to articulate and theorise them in ways that are not open to other current approaches. (shrink)

Population ethics is widely considered to be exceptionally important and exceptionally difficult. One key source of difficulty is the conflict between certain moral intuitions and analytical results identifying requirements for rational (in the sense of complete and transitive) social choice over possible populations. One prominent such intuition is the Asymmetry, which jointly proposes that the fact that a possible child’s quality of life would be bad is a normative reason not to create the child, but the fact that a (...) child’s quality of life would be good is not a reason to create the child. This paper reports a set of questionnaire experiments about the Asymmetry in the spirit of economists’ empirical social choice. Few survey respondents show support for the Asymmetry; instead respondents report that expectations of a good quality of life are relevant. Each experiment shows evidence (among at least some participants) of dual-process moral reasoning, in which cognitive reflection is statistically associated with reporting expected good quality of life to be normatively relevant. The paper discusses possible implications of these results for the economics of population-sensitive social welfare and for the conflict between moral mathematics and population intuition. (shrink)

Adolescents are routinely treated differently to adults, even when they possess similar capacities. In this article, we explore the justification for one case of differential treatment of adolescents. We attempt to make philosophical sense of the concurrent consents doctrine in law: adolescents found to have decision-making capacity have the power to consent to—and thereby, all else being equal, permit—their own medical treatment, but they lack the power always to refuse treatment and so render it impermissible. Other parties, that is, (...) individuals who exercise parental responsibility or a court, retain the authority to consent on an adolescent’s behalf. We explore four defences of the doctrine. We reject two attempts to defend the asymmetry in the power to consent to and refuse medical treatment by reference to transitional paternalism. We then consider and reject a stage of life justification. Finally, we articulate a justification based on the distinctiveness of adolescent well-being. (shrink)

How do we distinguish between cause and effect? The main argument of this paper is that if a realist account of the meaning of causal statements is adopted, then two clear distinctions between cause and effect emerge. By realist account is meant conceiving a cause as something with a power to act. Since a realist approach to causality is not widely accepted among philosophers, two arguments against a realist approach to causality are countered. The asymmetry of causality is defended (...) against the claim that physics, in the main, describes a symmetrical universe. (shrink)

Während der größte Teil der Bevölkerung die kieferorthopädische Therapie, also die Veränderung der Zahn- bzw. Kieferstellung, als eine Behandlung betrachtet, die vor allem auf eine Verbesserung des Erscheinungsbildes zielt, sehen der kieferorthopädische und zahnärztliche Berufsstand sowie auch private und öffentliche Kostenträger in bestimmten Abweichungen von Zahn- oder Kieferstellungen eine Gefährdung der oralen Gesundheit und der Funktionsfähigkeit des Gebisses. Letztere Auffassung bestimmt das ärztliche Handeln in der Kieferorthopädie und begründet auch die Übernahme zumindest bestimmter Leistungen durch die gesetzlichen Krankenkassen. Anhand aktueller (...) wissenschaftlicher Erkenntnisse lassen sich jedoch in vielen Fällen keine (akuten oder potentiellen) gesundheitlichen oder essentiellen funktionellen Beeinträchtigungen und Risiken abweichender Zahnstellungen nachweisen. Ziel dieses Aufsatzes ist es, diesem Widerspruch nachzugehen. Im Folgenden werden wir aufzeigen, welche Faktoren die Anbieter kieferorthopädischer Leistungen beeinflussen, welches die entscheidenden Gründe und Grundlagen für die Behandlung sind und an welchen Kriterien sich die Leistungsübernahme durch die Krankenkassen orientiert. Dabei wird deutlich werden, dass die formalen Kriterien von Behandlung und Kostenübernahme, die tatsächliche Behandlungs- und Kostenerstattungspraxis, die Erwartungen derjenigen, die Behandlungsleistungen in Anspruch nehmen und der aktuelle Stand der Forschung zu erwartbaren Funktionsbeeinträchtigungen durch Zahnstellungsvariationen nicht zwanglos zu vereinbaren sind. Erforderlich erscheint ein interdisziplinärer normativer Diskurs über die Frage, wie die diagnostizierten Spannungen aufzulösen wären. Als Anregung für einen solchen Diskurs werden wir im Ausblick alternative Lösungsstrategien vorstellen. (shrink)

This paper suggests a novel reinterpretation of the mathematical core of Wheeler-Feynman absorber theory, and hence a new route to the conclusion that the temporal asymmetry of classical electromagnetic radiation has the same origin as that of thermodynamics. The argument begins (Sec. 2) with a careful analysis of what the apparent asymmetry of radiation actually involves. Two major flaws in the standard version of the Wheeler-Feynman treatment of radiative asymmetry are then identified (Secs. 4–5), and the proposed (...) reinterpretation is described (Sec. 6). This avoids the two flaws previously mentioned, and also the problematic dependence of radiation on cosmological structure. (shrink)

Sam signaled a turn by extending his arm out the window. Difficulties in explaining the asymmetry of the by-relation in such examples by reference to acceptable and unacceptable counterfactual conditionals are explored by Hugh McCann in "The Trouble with Level-Generation" ("Mind", October 1982). I refine and defend the following alternative account of one-way dependence of y on x: not only is x necessary for y, but something else, independent from x, is also necessary for y; but there is nothing (...) independent from y such that it and y are each necessary for x. (shrink)

The scope of someone's consent is the range of actions that they permit by giving consent. The Scope of Consent investigates the under-explored question of which normative principle governs the scope of consent. To answer this question, the book's investigation involves taking a stance on what constitutes consent. By appealing to the idea that someone can justify their behaviour by appealing to another person's consent, Dougherty defends the view that consent consists in behaviour (...) that expresses a consent-giver's will for how a consent-receiver behaves. The ultimate conclusion of the book is that the scope of consent is determined by certain evidence that bears on the appropriate interpretation of the consent. (shrink)

Cell line immortalisation is a growing component of African genomics research and biobanking. However, little is known about the factors influencing consent to cell line creation and immortalisation in African research settings. We contribute to addressing this gap by exploring three questions in a sample of Xhosa participants recruited for a South African psychiatric genomics study: First, what proportion of participants consented to cell line storage? Second, what were predictors of this consent? Third, what questions were raised by (...) participants during this consent process? 760 Xhose people with schizophrenia and 760 controls were matched to sex, age, level of education and recruitment region. We used descriptive statistics to determine the proportion of participants who consented to cell line creation and immortalization. Logistic regression methods were used to examine the predictors of consent. Reflections from study recruiters were elicited and discussed to identify key questions raised by participants about consent. Approximately 40% of participants consented to cell line storage. The recruiter who sought consent was a strong predictor of participant’s consent. Participants recruited from the South African Eastern Cape, and older participants, were more likely to consent; both these groups were more likely to hold traditional Xhosa values. Neither illness nor education were significant predictors of consent. Key questions raised by participants included two broad themes: clarification of what cell immortalisation means, and issues around individual and community benefit. These findings provide guidance on the proportion of participants likely to consent to cell line immortalisation in genomics research in Africa, and reinforce the important and influential role that study recruiters play during seeking of this consent. Our results reinforce the cultural and contextual factors underpinning consent choices, particularly around sharing and reciprocity. Finally, these results provide support for the growing literature challenging the stigmatizing perception that people with severe mental illness are overly vulnerable as a target group for heath research and specifically genomics studies. (shrink)

By an argument form I shall mean a schema consisting of a string of symbols that are place-­‐holders for either logical terms or non-­‐logical (descriptive/content) terms: substituting terms of the appropriate kind for the symbols yields an argument. A substitution instance of an argument form is an argument that arises as a result of such a substitution. By a valid argument I shall mean an argument such that it is impossible for the premises to be true and the conclusion false. (...) Thus, an invalid argument is an argument such that it is possible for the premises to be true and the conclusion false. (shrink)

also as a theory of interpretation, and extending it with a bidirectional pragmatic component that is closely related to existing ideas about natural language interpretation. The paper argues for the priority of the direction from content to form, develops the..

This contribution explores disability rights protection in Inter-American States within the framework of the OAS and in the context of the obligations established under the CIADDIS and the CRPD. Following the classical division between ‘primary’ and ‘secondary’ rules, the contribution first sketches key regulatory initiatives in the area of disability rights and second considers compliance and enforcement mechanisms. Along these lines, the first section illustrates similarities and differences between the CIADDIS and the CRPD and, within this framework, essential regional regulatory (...) initiatives. The second section assesses disability rights in select countries, based on periodic reports under the CIADDIS and CRPD. The section examines the four largest countries by population in the region, notably, the United States of America (US), Mexico, Brazil and Colombia. The third section explores the enforcement of disability rights via key cases before the Inter-American Commission on Human Rights (IAComHR) and the Inter-American Court of Human Rights (IACtHR). The purpose is providing a comprehensive understanding of disability rights in the region and identifying key regulatory problems and ways forward. (shrink)

Causes always seem to come prior to their effects. What might explain this asymmetry? Causation's temporal asymmetry isn't straightforwardly due to a temporal asymmetry in the laws of nature—the laws are, by and large, temporally symmetric. Nor does the asymmetry appear due to an asymmetry in time itself. This Element examines recent empirical attempts to explain the temporal asymmetry of causation: statistical mechanical accounts, agency accounts and fork asymmetry accounts. None of these accounts (...) are complete yet and a full explanation of the temporal asymmetry of causation will likely require contributions from all three programs. (shrink)

Voluntariness of consent to research has not been sufficiently explored through empirical research. The aims of this study were to develop a more comprehensive approach to assessing voluntariness and to generate preliminary data on the extent and correlates of limitations on voluntariness. We developed a questionnaire to evaluate subjects’ reported motivations and constraints on voluntariness. 88 subjects in five different areas of clinical research—substance abuse, cancer, HIV, interventional cardiology, and depression—were assessed. Subjects reported a variety of motivations for participation. (...) Offers of financial incentives were common but not influential, pressures from others were rare, and no threats were reported. However, certain financial incentives and—paradoxically—altruistic motivations led some subjects to feel more constrained. Consistent with previous studies, no one pattern of motivation was common to all research subjects. There was little evidence of constrained voluntariness, but some suggestion of areas of concern. Voluntariness appears to be susceptible to systematic empirical investigation. (shrink)

I propose that we interpret Kant’s argument from incongruent counterparts in the 1768 article ‘Concerning the Ultimate Ground of the Differentiation of Directions in Space’ in light of a theory of dynamic absolute space that he accepted throughout the 1750s and 1760s. This force-based or material conception of space was not an unusual interpretation of the Newtonian notion of absolute space. Nevertheless, commentators have continually argued that Kant’s argument is an utter failure that shifts from the metaphysics of space to (...) its epistemology, because he has no way to connect ‘directionality’ and ‘handedness’ to absolute space. This supposed failure is based on an understanding of absolute space in purely mathematical terms and as an absolute void that lacks any qualitative or dynamic features. If we recognize that Kant held that space had an intrinsic directional asymmetry then his argument successfully connects incongruent counterparts to absolute space. The presence of this notion in Kant’s pre-Critical thought is rarely noted, and its necessity in understanding his incongruence argument is novel. (shrink)

One of the most striking features of causation is that causes typically precede their effects – the causal arrow is strongly aligned with the temporal arrow. Why should this be so? We offer an opinionated guide to this problem, and to the solutions currently on offer. We conclude that the most promising strategy is to begin with the de facto asymmetry of human deliberation, characterised in epistemic terms, and to build out from there. More than any rival, this subjectivist (...) approach promises to demystify the asymmetry, temporal orientation, and deliberative relevance of causal judgements. (shrink)

We analyzed the patients’ perception of prenatal diagnosis of fetal cardiac pathology, and the reasons for choosing to continue with pregnancy despite being eligible to receive a medical termination of pregnancy. We also identified the challenges, the motives interfering in decision-making, and the consequences of the decisions on pregnancy, child and mother. This descriptive, prospective and longitudinal study was conducted in France, amongst pregnant women who wished to continue their pregnancy despite an unfavorable medical advice. Socio-demographic data were collected through (...) a questionnaire. Such questionnaire covered information assessing the parents/mother’s perception of prenatal diagnosis, and medical termination of pregnancy, their interpretation of the established diagnosis and their motives for not considering pregnancy termination. 72 eligible patients were analyzed over one year: mean age 33 ± 6.89 years, 47 patients had already given birth to ≥1 healthy child. Mean gestational age at the detection of fetal cardiac pathologies was 30 ± 4.37 weeks of amenorrhea. Patients decided to keep the child after 3 ± 1.25 consultations. 56 patients made their decision with their husbands and 16 made their decision alone. Reasons for declining the medical termination were culpability and responsibility, ideologies and convictions, mistrust and hope. Newborns of 67 patients died with a mean survival duration of 38 days. Patient informed consent should be sought before any decision in neonatology, even if conflicting with the medical team’s knowledge and the pregnant mother’s benefits. Decisions to accept or decline pregnancy termination depend on the patients’ psychological character, ideologies, convictions, and mistrust in the diagnosis/prognosis, or hope in the fetus survival. (shrink)

The paper analyzes the philosophical consequences of the recent discovery of direct violations of the time–reversal symmetry of weak interactions. It shows that although we have here an important case of the time asymmetry of one of the fundamental physical forces which could have had a great impact on the form of our world with an excess of matter over antimatter, this asymmetry cannot be treated as the asymmetry of time itself but rather as an asymmetry (...) of some specific physical process in time. The paper also analyzes the consequences of the new discovery for the general problem of the possible connections between direction of time and time-asymmetric laws of nature. These problems are analyzed in the context of Horwich’s Asymmetries in time: problems in the philosophy of science argumentation, trying to show that existence of a time–asymmetric law of nature is a sufficient condition for time to be anisotropic. Instead of Horwich’s sufficient condition for anisotropy of time, it is stressed that for a theory of asymmetry of time to be acceptable it should explain all fundamental time asymmetries: the asymmetry of traces, the asymmetry of causation, and the asymmetry between the fixed past and open future. It is so because the problem of the direction of time has originated from our attempts to understand these asymmetries and every plausible theory of the direction of time should explain them. (shrink)

A certain type of counterfactual is thought to be intimately related to causation, control, and explanation. The time asymmetry of these phenomena therefore plausibly arises from a time asymmetry of counterfactual dependence. But why is counterfactual dependence time asymmetric? The most influential account of the time asymmetry of counterfactual dependence is David Albert’s account, which posits a new, time-asymmetric fundamental physical law, the so-called “past hypothesis.” Albert argues that the time asymmetry of counterfactual dependence arises from (...) holding fixed the past hypothesis when evaluating counterfactuals. In this paper, I argue that Albert’s account misconstrues the time asymmetry of counterfactual dependence. (shrink)