The COVID-19 pandemic has raised a host of ethical challenges, but key among these has been the possibility that health care systems might need to ration scarce critical care resources. Rationing p...

A comprehensive analysis of ethical topics in palliative care, combining clinical experience and philosophical rigor. A broad array of topics are explored from historical, legal, clinical, and ethical perspectives, offering both the seasoned clinician and interested lay reader a thorough examination of the complex ethical issues facing patients suffering from life-threatening illness.

As the population in the United States gets older, more people suffer from dementia, which often causes neuropsychiatric symptoms such as agitation and paranoia. This can lead patients to refuse medications, prompting consideration of covert administration (that is, concealing medication in food or drink). While many condemn this practice as paternalistic, deceptive, and potentially harmful, the end result of assuming the “moral high ground” can be increased suffering for patients and families. This article addresses common criticisms of covert medication and (...) presents a detailed algorithm by which to determine whether the practice is ethically permissible in specific cases. It also explores why so little attention has been paid in the U.S. to this presumably common practice, and reviews professional statements from Europe that endorse the practice. Finally, it presents a compelling argument for the role of Ulysses clauses in advance care planning, not only for patients with psychiatric illness but also for those who may suffer from dementia, which is far more common. (shrink)

For all of the emphasis on quality improvement—as well as the acknowledged overlap between assessment of the quality of healthcare services and clinical ethics—the quality of clinical ethics consultation has received scant attention, especially in terms of empirical measurement. Recognizing this need, the second edition of Core Competencies for Health Care Ethics Consultation identified four domains of ethics quality: (1) ethicality, (2) stakeholders’ satisfaction, (3) resolution of the presenting conflict/dilemma, and (4) education that translates into knowledge. This study is the (...) first, to our knowledge, to directly measure all of these domains. Here we describe the quality improvement process undertaken at a tertiary care academic medical center, as well as the tools developed to measure the quality of ethics consultation, which include post-consultation satisfaction surveys and weekly case conferences. The information gained through these tools helps to improve not only the process of ethics consultation, but also the measurement and assurance of quality. (shrink)

Clinical simulation using standardized patients has become standard in medical education—and is now being incorporated into some graduate programs in bioethics—for both formative and summative evaluation. In most hospitals, though, clinical ethics consultation is done by the ethics committee (or a subset of it). This study is the first, to our knowledge, to examine the effectiveness of standardized patient simulation in training hospital ethics committees to deal with ethically complex and emotionally fraught clinical situations. Following a substantial revision of the (...) institution’s nonbeneficial treatment policy, ethics committee members underwent a simulation to determine whether a specific requested treatment should be withheld on the basis of futility. Pre- and postintervention surveys showed improvement in all domains, although the small sample size limited the power of the study, with only one measure showing a statistically significant difference. An interesting incidental finding was that one-quarter of committee members voted against a determination of futility, even though the case clearly met the definition set forth in the policy. This highlights the emotional challenges in implementing an ethically rigorous, unanimously accepted policy that ultimately determines the timing and manner of a patient’s death. (shrink)

Given narrow operating margins, health care organizations are increasingly relying on philanthropy to fund operations. Since individuals provide the majority of philanthropic support, many organizations have expanded their “grateful patient fundraising” programs to include current inpatients, both established donors as well as persons of wealth. While this is legally permissible under HIPAA, it raises substantial ethical concerns for potential coercion of vulnerable patients, as well as unequal care stemming from preferential treatment and provided “amenities.” While some have drawn the analogy (...) to the additional comforts provided to first-class airline passengers, this analogy is flawed because of the potential clinical impact of the opportunities and services provided, especially to merely potential donors. From an ethical perspective, such programs should only provide non-clinical amenities to established donors, and at the same time strive for maximal transparency whereby all patients are assured of equal care and are fully informed of the specific benefits associated with any potential donation. (shrink)

: Health care reform is bottled up. Socially responsible physicians, forced to curtail care to uninsured patients, should respond with organized, open defiance, by billing the costs of the care to the accounts of patients covered under Medicaid or Medicare. Reverse cost-shifting: maybe it could work, certainly it would be justified.

Health care reform is bottled up. Socially responsible physicians, forced to curtail care to uninsured patients, should respond with organized, open defiance, by billing the costs of the care to the accounts of patients covered under Medicaid or Medicare. Reverse cost‐shifting: maybe it could work, certainly it would be justified.

Typically, the determination of death by neurological criteria follows a very specific protocol. An apnea test is performed with further confirmation as necessary, and then mechanical ventilation is withdrawn with the consent of the family after they have had an opportunity to “say goodbye,” and at such a time to permit organ retrieval (with authorization of the patient or consent of the next of kin). Such a process maximizes transparency and ensures generalizability. In exceptional circumstances, however, it may be necessary (...) to deviate from this protocol in order to spare family members unnecessary suffering and to reduce moral distress felt by clinical staff. It may also be appropriate, we argue, to refrain from even inquiring about organ donation when the next-of-kin is not only certain to refuse, but lacks the decision-making capacity to potentially consent. The case described in this article calls into question generally reliable assumptions about determination of death by neurological criteria, where the best the clinical team could do for the patient and his family was “the least bad option.”. (shrink)

Background Because opioids can suppress respiratory drive, the principle of double effect (PDE) has been used to justify their use for terminally ill patients. Recent studies, however, suggest that the risk of respiratory depression in typical end-of-life (EOL) situations may be overstated and that heightened concern for this rare occurrence can lead to inadequate treatment of pain. The purpose of this study is to examine the role of the PDE in medical school ethics education, with specific reference to its potential (...) impact on pain management at EOL. Method After obtaining institutional review board approval, an electronic survey was sent to ethics educators at every allopathic medical school in the USA. Results One-third of ethics educators felt that opioids were ‘likely’ to cause significant respiratory depression that could hasten death. Educators' opinions of opioid effects did not influence their view of the relevance of the PDE, with approximately 70% deeming it relevant to EOL care. Only 15% of ethics educators believed that associating the PDE with opioid use might discourage clinicians from optimally treating pain, out of concern for respiratory depression. Conclusion This study demonstrates that a significant minority of ethics educators believe, contrary to current evidence, that opioids are ‘likely’ to cause significant respiratory depression that could hasten death in terminally ill patients. Yet, many of those who do not feel this is likely still rely on the PDE to justify this possibility, potentially (and unknowingly) contributing to clinical misperceptions and underutilisation of opioids at EOL. (shrink)

Many patients believe that cardiopulmonary resuscitation is more likely to be successful than it really is in clinical practice. Even when working with accurate information, some nevertheless remain resolute in demanding maximal treatment. They maintain that even if survival after cardiac arrest with CPR is extremely low, the fact remains that it is still greater than the probability of survival after cardiac arrest without CPR. Without realising it, this line of reasoning is strikingly similar to Pascal’s Wager, a Renaissance-era argument (...) for accepting the proposition for God’s existence. But while the original argument is quite logical—if not universally compelling—the modern variant makes several erroneous assumptions. The authors here present a case of a patient who unwittingly appeals to Pascal’s Wager to explain his request for maximal treatment, in order to highlight the crucial divergences from the original Wager. In understanding the faulty assumptions inherent in the application of Pascal’s Wager to code status decisions—and identifying the underlying motivations which the Wager serves to confirm—providers can better ensure that the true values and preferences of patients are upheld. (shrink)

The semantic paradoxes are often associated with self-reference or referential circularity. Yablo (Analysis 53(4):251–252, 1993), however, has shown that there are infinitary versions of the paradoxes that do not involve this form of circularity. It remains an open question what relations of reference between collections of sentences afford the structure necessary for paradoxicality. In this essay, we lay the groundwork for a general investigation into the nature of reference structures that support the semantic paradoxes and the semantic hypodoxes. We develop (...) a functionally complete infinitary propositional language endowed with a denotation assignment and extract the reference structural information in terms of graph-theoretic properties. We introduce the new concepts of dangerous and precarious reference graphs, which allows us to rigorously define the task: classify the dangerous and precarious directed graphs purely in terms of their graph-theoretic properties. Ungroundedness will be shown to fully characterize the precarious reference graphs and fully characterize the dangerous finite graphs. We prove that an undirected graph has a dangerous orientation if and only if it contains a cycle, providing some support for the traditional idea that cyclic structure is required for paradoxicality. This leaves the task of classifying danger for infinite acyclic reference graphs. We provide some compactness results, which give further necessary conditions on danger in infinite graphs, which in conjunction with a notion of self-containment allows us to prove that dangerous acyclic graphs must have infinitely many vertices with infinite out-degree. But a full characterization of danger remains an open question. In the appendices we relate our results to the results given in Cook (J Symb Log 69(3):767–774, 2004) and Yablo (2006) with respect to more restricted sentences systems, which we call $\mathcal{F}$ -systems. (shrink)

The abstract structure of inquiry - the process of acquiring and changing beliefs about the world - is the focus of this book which takes the position that the "pragmatic" rather than the "linguistic" approach better solves the philosophical problems about the nature of mental representation, and better accounts for the phenomena of thought and speech. It discusses propositions and propositional attitudes (the cluster of activities that constitute inquiry) in general and takes up the way beliefs change in response to (...) potential new information, suggesting that conditional propositions should be understood as projections of epistemic policies onto the world.Robert C. Stalnaker is a professor in the Sage School of Philosophy at Cornell University. A Bradford Book. (shrink)

Winner of the 1975 National Book Award, this brilliant and widely acclaimed book is a powerful philosophical challenge to the most widely held political and social positions of our age--liberal, socialist, and conservative.

Robert B. Brandom is one of the most original philosophers of our day, whose book Making It Explicit covered and extended a vast range of topics in metaphysics, epistemology, and philosophy of language--the very core of analytic philosophy. This new work provides an approachable introduction to the complex system that Making It Explicit mapped out. A tour of the earlier book's large ideas and relevant details, Articulating Reasons offers an easy entry into two of the main themes of Brandom's (...) work: the idea that the semantic content of a sentence is determined by the norms governing inferences to and from it, and the idea that the distinctive function of logical vocabulary is to let us make our tacit inferential commitments explicit. Brandom's work, making the move from representationalism to inferentialism, constitutes a near-Copernican shift in the philosophy of language--and the most important single development in the field in recent decades. Articulating Reasons puts this accomplishment within reach of nonphilosophers who want to understand the state of the foundations of semantics. Table of Contents: Introduction 1. Semantic Inferentialism and Logical Expressivism 2. Action, Norms, and Practical Reasoning 3. Insights and Blindspots of Reliabilism 4. What Are Singular Terms, and Why Are There Any? 5. A Social Route from Reasoning to Representing 6. Objectivity and the Normative Fine Structure of Rationality Notes Index Displaying a sovereign command of the intricate discussion in the analytic philosophy of language, Brandom manages successfully to carry out a program within the philosophy of language that has already been sketched by others, without losing sight of the vision inspiring the enterprise in the important details of his investigation ' Using the tools of a complex theory of language, Brandom succeeds in describing convincingly the practices in which the reason and autonomy of subjects capable of speech and action are expressed. --J'rgen Habermas. (shrink)

Winner of the Los Angeles Times Book Prize With a new preface by the author In his most powerful and important book, renowned psychiatrist Robert Jay Lifton presents a brilliant analysis of the crucial role that German doctors played in the Nazi genocide. Now updated with a new preface, The Nazi Doctors remains the definitive work on the Nazi medical atrocities, a chilling exposé of the banality of evil at its epitome, and a sobering reminder of the darkest side (...) of human nature. (shrink)

In a new retelling of the romantic rationalist adventure of ideas that is Hegel's classic The Phenomenology of Spirit, Robert Brandom argues that when our self-conscious recognitive attitudes take Hegel's radical form of magnanimity and trust, we can overcome a troubled modernity and enter a new age of spirit.

This paper revisits some foundational questions concerning the abstract representation of a discourse context. The context of a conversation is represented by a body of information that is presumed to be shared by the participants in the conversation – the information that the speaker presupposes a point at which a speech act is interpreted. This notion is designed to represent both the information on which context-dependent speech acts depend, and the situation that speech acts are designed to affect, and so (...) to be a representation of context that is appropriate for explaining the interaction of context and the contents expressed in them. After reviewing the motivating ideas and the outlines of the apparatus, the paper responds to a criticism of the framework, and considers the way it can help to clarify some phenomena concerning pronouns with indefinite antecedents. (shrink)

This collection of papers (including three completely new ones) by one of the foremost philosophers in epistemology transcends two of the most widely misunderstood positions in philosophy--foundationalism and coherentism. Audi proposes a distinctively moderate, internalist foundationalism that incorporates some of the virtues of both coherentism and reliabilism. He develops important distinctions between positive and negative epistemic dependence, substantively and conceptually naturalistic theories, dispositional beliefs and dispositions to believe, episodically and structurally inferential beliefs, first and second order internalism, and rebutting as (...) opposed to refuting skepticism. These contrasts are applied not only to rational belief, but to rational action and the rationality of desires and intentions. The overall position is a pluralist, moderately rationalistic, internalist theory of justification and a partly externalist conception of knowledge. However, by virtue of offering a theory of rationality as well as an account of knowledge and justified belief, it will interest philosophers of ethics, science, and the social sciences and teachers and students of epistemology. (shrink)

_Explores the ancient and perennial notion of the four elements as environmental ideas._.

Robert John Ackermann deals decisively with the problem of relativism that has plagued post-empiricist philosophy of science. Recognizing that theory and data are mediated by data domains (bordered data sets produced by scientific instruments), he argues that the use of instruments breaks the dependency of observation on theory and thus creates a reasoned basis for scientific objectivity. Originally published in 1985. The Princeton Legacy Library uses the latest print-on-demand technology to again make available previously out-of-print books from the distinguished (...) backlist of Princeton University Press. These editions preserve the original texts of these important books while presenting them in durable paperback and hardcover editions. The goal of the Princeton Legacy Library is to vastly increase access to the rich scholarly heritage found in the thousands of books published by Princeton University Press since its founding in 1905. (shrink)

What kind of mental state is episodic memory? I defend the claim that it is, in key part, imagining the past, where the imagining in question is experiential imagining. To remember a past episode is to experientially imagine how things were, in a way controlled by one’s past experience of that episode. Call this the Inclusion View. I motive this view by appeal both to patterns of compatibilities and incompatibilities between various states, and to phenomenology. The bulk of the paper (...) defends the account against four objections. Imagining and remembering seem to differ in whether they are active or passive, in the forms of singular content they involve, in their relations to observation and in their relations to belief. I argue that these differences can be accommodated, and some even explained, once we flesh out what else is involved in episodic memory, in addition to imagining the past. (shrink)

The second edition of Doing Ethics in Media continues its mission of providing an accessible but comprehensive introduction to media ethics, with a theoretical grounding in moral philosophy, to help students think clearly and systematically about dilemmas in the rapidly changing media environment. Each chapter highlights specific considerations, cases, and practical applications for the fields of journalism, advertising, digital media, entertainment, public relations, and social media. Six fundamental decision-making questions - the "5Ws and H" around which the book is organized (...) - provide a path for students to articulate the issues; understand applicable law and ethics codes; consider the needs of stakeholders; work through conflicting values; integrate philosophic principles; and pose a "test of publicity." Students are challenged to be active ethical thinkers through the authors' reader-friendly style and use of critical early-career examples. While most people will change careers several times during their lives, all of us are life-long media consumers, and Doing Ethics in Media prepares readers for that task. Doing Ethics in Media is aimed at undergraduate and graduate students studying media ethics in mass media, journalism, and media studies. It also serves students in rhetoric, popular culture, communication studies, and interdisciplinary social sciences. The book's companion website-doingethicsin.media, or www.doingmediaethics.com-provides continuously updated real-world media ethics examples and collections of essays from experts and students. The site also hosts ancillary materials for students and for instructors, including a test bank and instructor's manual. (shrink)

_A moving meditation on recent geopolitical crises, viewed through the lens of ancient and modern tragedy__ “Spare, elegant and poignant.... If there is a single contemporary book that should be pressed into the hands of those who decide issues of war and peace, this is it.”—John Gray, _New Statesman_ “It is tragic that Robert D. Kaplan’s luminous _The Tragic Mind_ is so urgently needed.”—George F. Will_ Some books emerge from a lifetime of hard-won knowledge. Robert D. Kaplan has (...) learned, from a career spent reporting on wars, revolutions, and international politics in Europe, the Middle East, and East Asia, that the essence of geopolitics is tragedy. In _The Tragic Mind_, he employs the works of ancient Greek dramatists, Shakespeare, German philosophers, and the modern classics to explore the central subjects of international politics: order, disorder, rebellion, ambition, loyalty to family and state, violence, and the mistakes of power. The great dilemmas of international politics, he argues, are not posed by good versus evil—a clear and easy choice—but by contests of good versus good, where the choices are often searing, incompatible, and fraught with consequences. A deeply learned and deeply felt meditation on the importance of lived experience in conducting international relations, this is a book for everyone who wants a profound understanding of the tragic politics of our time. (shrink)

Philosophers, Henri Bergson once observed, "seem to philosophize as if they were sealed in the privacy of their study and did not live on a planet surrounded by the vast organic world of animals, plants, insects, and protozoa." Providing a solid overview of ecological philosophy and original insights into this developing field, Minding Nature focuses on some of the most influential thinkers who, in fact, have emphasized our natural relations to the earth, our social creations, and each other. Combining philosophy, (...) ecology, and political theory, chapters thoroughly examine, critique, and build upon the ideas of such luminaries as Thomas Hobbes, Martin Heidegger, Ernst Bloch, Hannah Arendt, Herbert Marcuse, Barry Commoner, Rachel Carson, and Jurgen Habermas, among others. Each thinker considered has contributed significantly to both contemporary discussion and historical understanding of political, epistemological, or social aspects related to nature and, with several exceptions, stimulated constructive dialogue within progressive, democratic, and radical left circles. By challenging the notion that conservation is inherently politically conservative or that our oikos (home) must be rendered uniformly economic where ecology is concerned, they enable us to rethink the possibility of creating a more democratic and ecological society. (shrink)

It is almost unanimously accepted that Kant denies resultant moral luck—that is, he denies that the lucky consequence of a person’s action can affect how much praise or blame she deserves. Philosophers often point to the famous good will passage at the beginning of the Groundwork to justify this claim. I argue, however, that this passage does not support Kant’s denial of resultant moral luck. Subsequently, I argue that Kant allows agents to be morally responsible for certain kinds of lucky (...) consequences. Even so, I argue that it is unclear whether Kant ultimately endorses resultant moral luck. The reason is that Kant does not write enough on moral responsibility for consequences to determine definitively whether he thinks that the lucky consequence for which an agent is morally responsible can add to her degree of praiseworthiness or blameworthiness. The clear upshot, however, is that Kant does not deny resultant moral luck. (shrink)

Our primary focus is on analysis of the concept of voluntariness, with a secondary focus on the implications of our analysis for the concept and the requirements of voluntary informed consent. We propose that two necessary and jointly sufficient conditions must be satisfied for an action to be voluntary: intentionality, and substantial freedom from controlling influences. We reject authenticity as a necessary condition of voluntary action, and we note that constraining situations may or may not undermine voluntariness, depending on the (...) circumstances and the psychological capacities of agents. We compare and evaluate several accounts of voluntariness and argue that our view, unlike other treatments in bioethics, is not a value-laden theory. We also discuss the empirical assessment of individuals? perceptions of the degrees of noncontrol and self-control. We propose use of a particular Decision Making Control Instrument. Empirical research using this instrument can provide data that will help establish appropriate policies and procedures for obtaining voluntary consent to research. (shrink)

This paper provides an overview of the history of the notion of essence in 20th century analytic philosophy, focusing on views held by influential analytic philosophers who discussed, or relied on essence or cognate notions in their works. It in particular covers Russell and Moore’s different approaches to essence before and after breaking with British idealism, the (pre- and post-)logical positivists’ critique of metaphysics and rejection of essence (Wittgenstein, Carnap, Schlick, Stebbing), the tendency to loosen the notion of logical necessity (...) to accommodate certain metaphysical truths in Wittgenstein and others, Quine’s logical rehabilitation of metaphysics and criticism of de re modality, the modal view of essence promoted by the development of quantified modal logic (C. I. Lewis, Barcan Marcus, Kripke) and direct reference theory (Barcan Marcus, Kripke, Putnam), and the emergence of the notion of metaphysical necessity (Kneale, Kripke), and finally Fine’s re-establishment of a Neo-Aristotelian, hyperintensional notion of essence in contemporary metaphysics. (shrink)

In this essay I sketch some vices of virtue ethics, draw on inference about the philosophical source of the vices, and conclude with a recommendation concerning future efforts in moral theory construction. The source of the vices, I argue, lies in a mononomic or single-principle strategy within normative theory construction, a reductionist conceptual scheme which distorts certain integral aspects of our moral experience. My recommendation is that this strategy be abandoned, for the moral field is not unitary -- mononomic methods (...) are not the best tools for moral theorists. (shrink)

In the Western world it is usually taken as given that we all want happiness, and our educational arrangements tacitly acknowledge this. Happiness, Hope, and Despair argues, however, that education has an important role to play in deepening our understanding of suffering and despair as well as happiness and joy. Education can be uncomfortable, unpredictable, and unsettling; it can lead to greater uncertainty and unhappiness. Drawing on the work of Søren Kierkegaard, Miguel de Unamuno, Fyodor Dostoevsky, Simone Weil, Paulo Freire, (...) and others, Peter Roberts shows why these features of educational life need not be feared; to the contrary, they can be seen as a source of hope and human fulfilment. After years of negotiating an education system dominated by the language of competition, performance, and economic advancement, students and teachers often long for something different; they seek not just measurable success but also opportunities to ask searching questions of themselves and the world they encounter. Happiness, Hope, and Despair makes an important contribution toward meeting this need. It fosters a rethinking of the nature, purpose, and value of education, and opens up possibilities for further scholarly and professional inquiry. (shrink)

Philosophers often consider problems of free will and moral luck in isolation from one another, but both are about control and moral responsibility. One problem of free will concerns the difficult task of specifying the kind of control over our actions that is necessary and sufficient to act freely. One problem of moral luck refers to the puzzling task of explaining whether and how people can be morally responsible for actions permeated by factors beyond their control. This chapter explicates and (...) assesses skeptical, compatibilist, and libertarian approaches to moral luck. First, I argue that what makes the above problems of free will and moral luck distinct is largely their emphasis on different kinds of luck. Second, I describe and evaluate skeptical arguments from constitutive and circumstantial luck that it is impossible to act freely. Third, I explicate and assess various support and implication relationships between various kinds of compatibilism and libertarianism, on the one hand, and causal, constitutive, circumstantial, and resultant moral luck, on the other. (shrink)

How important is luck in economic success? No question more reliably divides conservatives from liberals. As conservatives correctly observe, people who amass great fortunes are almost always talented and hardworking. But liberals are also correct to note that countless others have those same qualities yet never earn much. In recent years, social scientists have discovered that chance plays a much larger role in important life outcomes than most people imagine. In Success and Luck, bestselling author and New York Times economics (...) columnist Robert Frank explores the surprising implications of those findings to show why the rich underestimate the importance of luck in success--and why that hurts everyone, even the wealthy. Frank describes how, in a world increasingly dominated by winner-take-all markets, chance opportunities and trivial initial advantages often translate into much larger ones--and enormous income differences--over time; how false beliefs about luck persist, despite compelling evidence against them; and how myths about personal success and luck shape individual and political choices in harmful ways. But, Frank argues, we could decrease the inequality driven by sheer luck by adopting simple, unintrusive policies that would free up trillions of dollars each year--more than enough to fix our crumbling infrastructure, expand healthcare coverage, fight global warming, and reduce poverty, all without requiring painful sacrifices from anyone. If this sounds implausible, you'll be surprised to discover that the solution requires only a few, uncontroversial steps. Compellingly readable, Success and Luck shows how a more accurate understanding of the role of chance in life could lead to better, richer, and fairer economies and societies. (shrink)

Robert C. Stalnaker presents a set of essays on the structure of inquiry. First he focuses on the concepts of knowledge, belief, and partial belief, and on the rules and procedures we ought to use to determine what to believe. Then he explores the relations between conditionals and causal and explanatory concepts.

This paper examines some of the key ways in which water is mediated by technology and human artifacts. I show how the modes in which we conceive and experience this vital fluid are affected deeply by the techniques and instruments we use to interact with it. I argue that a notion of the domestication of water enables us to better grasp our relations with the environment given that vast volumes of water are now neither completely natural nor artificial in the (...) conventional senses of the terms. Instead, water is often filtered through an expansive technological network that not merely changes its flows and phenomenal forms but greatly alters or multiplies its meanings. As examples of this process, I investigate the practical engagement with water by the first Western philosopher; the construction of several large hydrological projects; efforts at river management in the aesthetic landscape; and the emergence of bottled water. (shrink)