There is a wind of change about to affect the training of all house officers in the United States. The Accreditation Council of Graduate Medical Education has promulgated a set of general competencies for all U.S.-trained residents, with a major thrust focused on bioethics and professionalism that will likely catch residency directors unaware. The ACGME's General Competencies document globally addresses many relationship-based ethical roles and responsibilities of house officers in healthcare. Of note, this document contains a specific section on professionalism. (...) However, the entire document is woven with a sustained thread of medical ethics throughout its other sections. The intent is to imbue each physician with those skills, rules, and aspects of character that will be a foundation for humane, ethical, professional conduct. Professionalism does indeed go beyond ethical principles, accounting for competency and commitment to excellence and, most of all, implying a virtue ethics account of medical practice. The need to address the central place of virtue ethics in house-staff education is apparent, and we now have the right tool for the job—the ACGME General Competencies. (shrink)

The physician-patient relationship has changed over the last several decades, requiring a systematic reevaluation of the competing demands of patients, physicians, and families. In the era of genetic testing, using a model of patient care known as the family covenant may prove effective in accounting for these demands. The family covenant articulates the roles of the physician, patient, and the family prior to genetic testing, as the participants consensually define them. The initial agreement defines the boundaries of autonomy and benefit (...) for all participating family members. The physician may then serve as a facilitator in the relationship, working with all parties in resolving potential conflicts regarding genetic information. The family covenant promotes a fuller discussion of the competing ethical claims that may come to bear after genetic test results are received. (shrink)

The emergence of the ethics consultation as a means to resolve moral crises in clinical medicine has revealed the need for a worksheet that would facilitate intake and analysis. The author developed the Bioethics Consultation Form as an attempt to remedy this need. The form is arranged in an outline format and is a useful asset to ethics committee discussions and record keeping. The first section covers basic intake data concerning the patient's medical and personal information, advance directives, and values, (...) as well as the values of the physician and family. After the intake section is completed with the above data, the ethics consultant then turns to the analysis section. This second section allows for (1) the discussion of conflicting values, (2) the identification of priorities, and (3) the elucidation of ethical norms relevant to the case.The Bioethics Consultation Form was adopted by the Patient Care Advisory committee of the Franklin Square Hospital Center in Baltimore, Maryland in 1986. The methodology in the use of the form will be discussed. Further, the potential spectrum of consultative cases that can be analyzed using the form will be highlighted. (shrink)

Physicians and families need to interact more meaningfully to clarify the values and preferences at stake in advance care planning. The current use of advance directives fails to respect patient autonomy. This paper proposes using the family covenant as a preventive ethics process designed to improve end-of-life planning by incorporating other family members—as agreed to by the patient and those family members—into the medical care dialogue. The family covenant formulates advance directives in conversation with family members and with the assistance (...) of a physician, thereby making advance directives more acceptable to the family, and more intelligible to other physicians. It adds the moral force of a promise to the obligation of respecting a patient’s preferences about end-of-life care. These negotiations between patient, family, and physician, from early planning phases through implementation, should greatly reduce the incidence of family disagreements on what the patient would have wanted. The family covenant ensures advance directive discussions within the family, promotes and respects the autonomy of other family members, and might even spur others in the family to complete advance directives through additional covenants. The family covenant holds the potential to transform moral quagmires into meaningful moral conversation. J Am Geriatr Soc 51:1155–1158, 2003. (shrink)

Abstract:Respect for persons protects patients regarding their own healthcare decisions. Patient informed choice for altruism (PICA) is a proposed means for a fully autonomous patient with decisionmaking capacity to limit his or her own treatment for altruistic reasons. An altruistic decision could bond the patient with others at the end of life. We contend that PICA can also be an advance directive option. The proxy, family, and physicians must be reminded that a patient’s altruistic treatment refusal should be respected.

The development of the Values History instrument for use in advance directive decision making has raised the question of the importance of values in eliciting advance directives. This pilot study examines the relationship between the domains of values and advance directives drawn from the Values History in three generation intrafamily triads. Significant correlations between values and advance directives were found primarily within the youngest generation. Results reveal a relatively high familiarity by the participants of the various established forms of advance (...) directives. Also, a significant percentage of parents and grand- parents was found to have signed some form of advance directive. (shrink)

While I concur that the conclusions reached in the target article by Burger and Kass (2009) in this issue are essentially on target, the authors glossed over an important consideration in ethics an...

A collection of personal narratives and essays, Living Professionalism is designed to help medical students and residents understand and internalize various aspects of professionalism. These essays are meant for personal reflection and above all, for thoughtful discussion with mentors, with peers, with others throughout the health care provider community who care about acting professionally.

Medical school curricula, although traditionally and historically dominated by science, have generally accepted, appreciated, and welcomed the inclusion of literature over the past several decades. Recent concerns about medical professional formation have led to discussions about the specific role and contribution of literature and stories. In this article, we demonstrate how professionalism and the study of literature can be brought into relationship through critical and interrogative interactions based in the literary skill of close reading. Literature in medicine can question the (...) meaning of “professionalism” itself, thereby resisting standardization in favor of diversity method and of outcome. Literature can also actively engage learners with questions about the human condition, providing a larger context within which to consider professional identity formation. Our fundamental contention is that, within a medical education framework, literature is highly suited to assist learners in questioning conventional thinking and assumptions about various dimensions of professionalism. (shrink)

Doctors’ strikes are legally permissible in the UK, with the situation differing in other countries. But are they morally permissible? Doug McConnell and Darren Mann have systematically attempted to dismiss the arguments for the moral impermissibility of doctors’ strikes and creatively attempted to provide further moral justification for them. Unfortunately for striking doctors, they fail to achieve this. Meanwhile, junior doctors’ strikes have continued in the UK through 2023 and have now extended into 2024. In this response, which focuses on (...) the UK situation and specifically junior doctors’ strikes in the National Health Service (NHS) in England, I will demonstrate a central problem with their arguments—namely that they underplay the harms caused by prolonged doctors’ strikes by ignoring the harms to patients with cancer. This weakens their conclusion that strikes are morally permissible in terms of the conditions and thresholds they set. I then provide a psychological critique of their justification for strikes in terms of the interests of the public. It follows that invoking the controversial concept of supererogatory action is ungrounded but also absurd when you consider time-critical cancer care. If those representing striking doctors wish to maintain a modicum of moral respectability, they should mitigate for patients with cancer and negotiate reasonably and with urgency. (shrink)

The book is an extended study of the problem of consciousness. After setting up the problem, I argue that reductive explanation of consciousness is impossible , and that if one takes consciousness seriously, one has to go beyond a strict materialist framework. In the second half of the book, I move toward a positive theory of consciousness with fundamental laws linking the physical and the experiential in a systematic way. Finally, I use the ideas and arguments developed earlier to defend (...) a form of strong artificial intelligence and to analyze some problems in the foundations of quantum mechanics. (shrink)

I argue that virtual reality is a sort of genuine reality. In particular, I argue for virtual digitalism, on which virtual objects are real digital objects, and against virtual fictionalism, on which virtual objects are fictional objects. I also argue that perception in virtual reality need not be illusory, and that life in virtual worlds can have roughly the same sort of value as life in non-virtual worlds.

[This is an edited version of a keynote talk at the conference on Neural Information Processing Systems (NeurIPS) on November 28, 2022, with some minor additions and subtractions.] -/- There has recently been widespread discussion of whether large language models might be sentient or conscious. Should we take this idea seriously? I will break down the strongest reasons for and against. Given mainstream assumptions in the science of consciousness, there are significant obstacles to consciousness in current models: for example, their (...) lack of recurrent processing, a global workspace, and unified agency. At the same time, it is quite possible that these obstacles will be overcome in the next decade or so. I conclude that while it is somewhat unlikely that current large language models are conscious, we should take seriously the possibility that successors to large language models may be conscious in the not-too-distant future. (shrink)

There is a long tradition in philosophy of using a priori methods to draw conclusions about what is possible and what is necessary, and often in turn to draw conclusions about matters of substantive metaphysics. Arguments like this typically have three steps: first an epistemic claim , from there to a modal claim , and from there to a metaphysical claim.

The philosophical interest of verbal disputes is twofold. First, they play a key role in philosophical method. Many philosophical disagreements are at least partly verbal, and almost every philosophical dispute has been diagnosed as verbal at some point. Here we can see the diagnosis of verbal disputes as a tool for philosophical progress. Second, they are interesting as a subject matter for first-order philosophy. Reflection on the existence and nature of verbal disputes can reveal something about the nature of concepts, (...) language, and meaning. In this article I first characterize verbal disputes, spell out a method for isolating and resolving them, and draw out conclusions for philosophical methodology. I then use the framework to draw out consequences in first-order philosophy. In particular, I argue that the analysis of verbal disputes can be used to support the existence of a distinctive sort of primitive concept and that it can be used to reconstruct a version of an analytic/synthetic distinction, where both are characterized in dialectical terms alone. (shrink)

Is conceptual analysis required for reductive explanation? If there is no a priori entailment from microphysical truths to phenomenal truths, does reductive explanation of the phenomenal fail? We say yes . Ned Block and Robert Stalnaker say no.

Does consciousness collapse the quantum wave function? This idea was taken seriously by John von Neumann and Eugene Wigner but is now widely dismissed. We develop the idea by combining a mathematical theory of consciousness (integrated information theory) with an account of quantum collapse dynamics (continuous spontaneous localization). Simple versions of the theory are falsified by the quantum Zeno effect, but more complex versions remain compatible with empirical evidence. In principle, versions of the theory can be tested by experiments with (...) quantum computers. The upshot is not that consciousness-collapse interpretations are clearly correct, but that there is a research program here worth exploring. (shrink)

This chapter analyzes aspects of the relationship between consciousness and intentionality. It focuses on the phenomenal character and the intentional content of perceptual states, canvassing various possible relations among them. It argues that there is a good case for a sort of representationalism, although this may not take the form that its advocates often suggest. By mapping out some of the landscape, the chapter tries to open up territory for different and promising forms of representationalism to be explored in the (...) future. In particular, it argues for a nonreductive, narrow, and Fregean variety of representationalism, which contrasts strongly with more widely explored varieties. It concludes with some words about the fundamental relationship between consciousness and intentionality. (shrink)

A content of a subject's mental state is narrow when it is determined by the subject's intrinsic properties: that is, when any possible intrinsic duplicate of the subject has a corresponding mental state with the same content. A content of a subject's mental state is..

In the Garden of Eden, we had unmediated contact with the world. We were directly acquainted with objects in the world and with their properties. Objects were simply presented to us without causal mediation, and properties were revealed to us in their true intrinsic glory.

Why is two-dimensional semantics important? One can think of it as the most recent act in a drama involving three of the central concepts of philosophy: meaning, reason, and modality. First, Kant linked reason and modality, by suggesting that what is necessary is knowable a priori, and vice versa. Second, Frege linked reason and meaning, by proposing an aspect of meaning (sense) that is constitutively tied to cognitive signi?cance. Third, Carnap linked meaning and modality, by proposing an aspect of meaning (...) (intension) that is constitutively tied to possibility and necessity. (shrink)

The basic question of ontology is “What exists?”. The basic question of metaontology is: are there objective answers to the basic question of ontology? Here ontological realists say yes, and ontological anti-realists say no. (Compare: The basic question of ethics is “What is right?”. The basic question of metaethics is: are there objective answers to the basic question of ethics? Here moral realists say yes, and moral anti-realists say no.) For example, the ontologist may ask: Do numbers exist? The Platonist (...) says yes, and the nominalist says no. The metaontologist may ask: is there an objective fact of the matter about whether numbers exist? The ontological realist says yes, and the ontological anti-realist says no. Likewise, the ontologist may ask: Given two distinct entities, when does a mereological sum of those entities exist? The universalist says always, while the nihilist says never. The metaontologist may ask: is there an objective fact of the matter about whether the mereological sum of two distinct entities exists? The ontological realist says yes, and the ontological anti-realist says no. Ontological realism is often traced to Quine (1948), who held that we can determine what exists by seeing which entities are endorsed by our best scientific theory of the world. In recent years, the practice of ontology has often presupposed an ever-stronger ontological realism, and strong versions of ontological realism have received explicit statements by Fine (this volume), Sider (2001; this volume), van Inwagen (1998; this volume), and others. (shrink)

What happens when machines become more intelligent than humans? One view is that this event will be followed by an explosion to ever-greater levels of intelligence, as each generation of machines creates more intelligent machines in turn. This intelligence explosion is now often known as the “singularity”. The basic argument here was set out by the statistician I.J. Good in his 1965 article “Speculations Concerning the First Ultraintelligent Machine”: Let an ultraintelligent machine be defined as a machine that can far (...) surpass all the intellectual activities of any man however clever. Since the design of machines is one of these intellectual activities, an ultraintelligent machine could design even better machines; there would then unquestionably be an “intelligence explosion”, and the intelligence of man would be left far behind. Thus the first ultraintelligent machine is the last invention that man need ever make. The key idea is that a machine that is more intelligent than humans will be better than humans at designing machines. So it will be capable of designing a machine more intelligent than the most intelligent machine that humans can design. So if it is itself designed by humans, it will be capable of designing a machine more intelligent than itself. By similar reasoning, this next machine will also be capable of designing a machine more intelligent than itself. If every machine in turn does what it is capable of, we should expect a sequence of ever more intelligent machines. This intelligence explosion is sometimes combined with another idea, which we might call the “speed explosion”. The argument for a speed explosion starts from the familiar observation that computer processing speed doubles at regular intervals. Suppose that speed doubles every two years and will do so indefinitely. Now suppose that we have human-level artificial intelligence 1 designing new processors. Then faster processing will lead to faster designers and an ever-faster design cycle, leading to a limit point soon afterwards. The argument for a speed explosion was set out by the artificial intelligence researcher Ray Solomonoff in his 1985 article “The Time Scale of Artificial Intelligence”.1 Eliezer Yudkowsky gives a succinct version of the argument in his 1996 article “Staring at the Singularity”: “Computing speed doubles every two subjective years of work.. (shrink)

Is there progress in philosophy? A glass-half-full view is that there is some progress in philosophy. A glass-half-empty view is that there is not as much as we would like. I articulate a version of the glass-half-empty view, argue for it, and then address the crucial question of what explains it.

The term ‘emergence’ often causes confusion in science and philosophy, as it is used to express at least two quite different concepts. We can label these concepts _strong_ _emergence_ and _weak emergence_. Both of these concepts are important, but it is vital to keep them separate.

A natural way to think about epistemic possibility is as follows. When it is epistemically possible (for a subject) that p, there is an epistemically possible scenario (for that subject) in which p. The epistemic scenarios together constitute epistemic space. It is surprisingly difficult to make the intuitive picture precise. What sort of possibilities are we dealing with here? In particular, what is a scenario? And what is the relationship between scenarios and items of knowledge and belief? This chapter tries (...) to make sense of epistemic space. It explores different ways of making sense of scenarios and of their relationship to thought and language. It discusses some issues that arise and outlines some applications to the analysis of the content of thought and the meaning of language. (shrink)

When I say ‘Hesperus is Phosphorus’, I seem to express a proposition. And when I say ‘Joan believes that Hesperus is Phosphorus’, I seem to ascribe to Joan an attitude to the same proposition. But what are propositions? And what is involved in ascribing propositional attitudes?

What is involved in the meaning of our expressions? Frege suggested that there is an aspect of an expression.

Hilary Putnam has argued that computational functionalism cannot serve as a foundation for the study of the mind, as every ordinary open physical system implements every finite-state automaton. I argue that Putnam's argument fails, but that it points out the need for a better understanding of the bridge between the theory of computation and the theory of physical systems: the relation of implementation. It also raises questions about the class of automata that can serve as a basis for understanding the (...) mind. I develop an account of implementation, linked to an appropriate class of automata, such that the requirement that a system implement a given automaton places a very strong constraint on the system. This clears the way for computation to play a central role in the analysis of mind. (shrink)

Slavery has long stood as a mirror image to the conception of a free person in republican theory. This essay contends that slavery deserves this central status in a theory of freedom, but a more thorough examination of slavery in theory and in practice will reveal additional insights about freedom previously unacknowledged by republicans. Slavery combines imperium and dominium in a way that both destroys freedom today and diminishes opportunities to achieve freedom tomorrow. Dominium and imperium working together are a (...) greater affront to freedom than either working alone. However, an examination of slavery in practice, focusing on the experiences of American slaves, demonstrates that republicanisms’ acknowledged strategies for freedom-seeking, acquiring insulation from domination through law and through norms, do not encompass the full range of options. Slaves also seek freedom through physical absence, economic activity, and culture. The account of slavery and freedom developed here suggests republican accounts of freedom should either give up their focus on thresholds of freedom, or consider the possibility of a plural conception of freedom that extends beyond just freedom as non-domination to include freedom as collective world-making, or both. (shrink)

The search for neural correlates of consciousness (or NCCs) is arguably the cornerstone in the recent resurgence of the science of consciousness. The search poses many difficult empirical problems, but it seems to be tractable in principle, and some ingenious studies in recent years have led to considerable progress. A number of proposals have been put forward concerning the nature and location of neural correlates of consciousness. A few of these include.

Confronted with the apparent explanatory gap between physical processes and consciousness, there are many possible reactions. Some deny that any explanatory gap exists at all. Some hold that there is an explanatory gap for now, but that it will eventually be closed. Some hold that the explanatory gap corresponds to an ontological gap in nature.

Two-dimensional approaches to semantics, broadly understood, recognize two "dimensions" of the meaning or content of linguistic items. On these approaches, expressions and their utterances are associated with two different sorts of semantic values, which play different explanatory roles. Typically, one semantic value is associated with reference and ordinary truth-conditions, while the other is associated with the way that reference and truth-conditions depend on the external world. The second sort of semantic value is often held to play a distinctive role in (...) analyzing matters of cognitive significance and/or context-dependence. (shrink)

The Matrix presents a version of an old philosophical fable: the brain in a vat. A disembodied brain is floating in a vat, inside a scientist’s laboratory. The scientist has arranged that the brain will be stimulated with the same sort of inputs that a normal embodied brain receives. To do this, the brain is connected to a giant computer simulation of a world. The simulation determines which inputs the brain receives. When the brain produces outputs, these are fed back (...) into the simulation. The internal state of the brain is just like that of a normal brain, despite the fact that it lacks a body. From the brain’s point of view, things seem very much as they seem to you and me. (shrink)

Cartesian arguments for global skepticism about the external world start from the premise that we cannot know that we are not in a Cartesian scenario such as an evil-demon scenario, and infer that because most of our empirical beliefs are false in such a scenario, these beliefs do not constitute knowledge. Veridicalist responses to global skepticism respond that arguments fail because in Cartesian scenarios, many or most of our empirical beliefs are true. Some veridicalist responses have been motivated using verificationism, (...) externalism, and coherentism. I argue that a more powerful veridicalist response to global skepticism can be motivated by structuralism, on which physical entities are understood as those that play a certain structural role. I develop the structuralist response and address objections. (shrink)

This appeared in Philosophy and Phenomenological Research 59:473-93, as a response to four papers in a symposium on my book The Conscious Mind . Most of it should be comprehensible without having read the papers in question. This paper is for an audience of philosophers and so is relatively technical. It will probably also help to have read some of the book. The papers I’m responding to are: Chris Hill & Brian McLaughlin, There are fewer things in reality than are (...) dreamt of in Chalmers’ philosophy Brian Loar, David Chalmers’ The Conscious Mind Sydney Shoemaker, On David Chalmers’ The Conscious Mind Stephen Yablo, Concepts and consciousness Contents. (shrink)

One of the enduring concerns of moral philosophy is deciding who or what is deserving of ethical consideration. Much recent attention has been devoted to the "animal question" -- consideration of the moral status of nonhuman animals. In this book, David Gunkel takes up the "machine question": whether and to what extent intelligent and autonomous machines of our own making can be considered to have legitimate moral responsibilities and any legitimate claim to moral consideration. The machine question poses a (...) fundamental challenge to moral thinking, questioning the traditional philosophical conceptualization of technology as a tool or instrument to be used by human agents. Gunkel begins by addressing the question of machine moral agency: whether a machine might be considered a legitimate moral agent that could be held responsible for decisions and actions. He then approaches the machine question from the other side, considering whether a machine might be a moral patient due legitimate moral consideration. Finally, Gunkel considers some recent innovations in moral philosophy and critical theory that complicate the machine question, deconstructing the binary agent--patient opposition itself. Technological advances may prompt us to wonder if the science fiction of computers and robots whose actions affect their human companions could become science fact. Gunkel's argument promises to influence future considerations of ethics, ourselves, and the other entities who inhabit this world. (shrink)

In Philosophy Without Intuitions, Herman Cappelen focuses on the metaphilosophical thesis he calls Centrality: contemporary analytic philosophers rely on intuitions as evidence for philosophical theories. Using linguistic and textual analysis, he argues that Centrality is false. He also suggests that because most philosophers accept Centrality, they have mistaken beliefs about their own methods.To put my own views on the table: I do not have a large theoretical stake in the status of intuitions, but unreflectively I find it fairly obvious that (...) many philosophers, including myself, appeal to intuitions. Cappelen’s arguments make a provocative challenge to this unreflective background conception. So it is interesting to work through the arguments to see what they might and might not show.In what follows I aim to articulate a minimal notion of intuition that captures something of the core everyday philosophical usage of the term, and that captures the sense .. (shrink)

There are two versions of the language-of-thought hypothesis (LOT): Representational LOT (roughly, structured representation), introduced by Ockham, and computational LOT (roughly, symbolic computation) introduced by Fodor. Like many others, I oppose the latter but not the former. Quilty-Dunn et al. defend representational LOT, but they do not defend the strong computational LOT thesis central to the classical-connectionist debate.