Euthanasia and assisted suicide was openly permitted but not technically legal in the Netherlands for decades. In 2002, it was formally legalised through the Termination of Life on Request and Assisted Suicide Review Procedures Act, subject to two main criteria: the patient had to be capable of making voluntary decisions and the patient had to experience unbearable suffering without prospect of improvement. Within the Netherlands, EAS has wide acceptance, and the public in general seems to favour a liberal interpretation of (...) both of these requirements. Physicians are expected to use ‘their own moral compass’ to decide about personal participation, and it is generally possible and permissible to find a substitute physician if the patient meets the legally required criteria but the physician is not comfortable assisting. Over the years, multiple quantitative and qualitative studies have explored the Dutch practice of EAS,1–3 but relatively little is known about the edges of what counts as meeting these criteria and how acceptable the practice is for physicians who participate. The study by Snijdewind et al gives a glimpse of these boundaries and suggests that at least sometimes the criteria are being stretched and adapted to meet the perceived needs of patients, and some participating physicians are relatively uncomfortable with some of the requests with which they are faced.4 Just how rare or common these ‘edgy’ cases are within the larger practice of EAS in the Netherlands cannot be answered by …. (shrink)

Palliative care and hospice should be the standards of care for all terminally ill patients. The first place for clinicians to go when responding to a request for assisted death is to ensure the adequacy of palliative interventions. Although such interventions are generally effective, a small percentage of patients will suffer intolerably despite receiving state-of-the-art palliative care, and a few of these patients will request a physician-assisted death. Five potential “last resort” interventions are available under these circumstances: (1) accelerating opioids (...) for pain or dyspnea; (2) stopping potentially life-prolonging therapies; (3) voluntarily stopping eating and drinking; (4) palliative sedation (potentially to unconsciousness); and (5) physician-assisted death. Patient, family, and clinicians should search for the least harmful way to respond to intolerable end-of-life suffering in ways that are effective and also respect the values of the major participants. A system that allows an open response to such cases ultimately protects patients by ensuring a full clinical evaluation and search for alternative responses, while reinforcing the need to be responsive and to not abandon. (shrink)

Cultural narratives shape how we think about the world, including how we decide when the end of life begins. Hospice care has become an integral part of the end‐of‐life care in the United States, but as it has grown, its policies and practices have also imposed cultural narratives, like those associated with the “six‐month rule” that the majority of the end of life takes place in the final six months of life. This idea is embedded in policies for a range (...) of care practices and reimbursement processes, even though six months is not always a meaningful marker. In the case of people living with advanced dementia, six months is both too early in the trajectory to facilitate conversations and too late in the trajectory to ensure decision‐making capacity. This essay encourages scholars and policy‐makers to consider how cultural narratives may limit what they think is possible in care for people living with dementia. (shrink)

In my career as a primary care physician and as a palliative care consultant, I have assisted many patients to die with their full consent. None of them wanted to die, and all would have chosen other paths had their disease not been so severe and irreversible. To a person, none of these patients thought of themselves as “suicidal,” and they would have found that label preposterous and demeaning. In fact, the kind of personal disintegration that the label implies is (...) just what is trying to be prevented by those choosing this possibility. So on behalf of patients who have chosen this option, I reject the title of this debate as it unnecessarily tars the discussion with the suggestion of mental illness. In my primary care practice, I have also met many patients who were “suicidal” in the mental health sense of the word, and rest assured I have assisted none of them to die. In fact, I have at times had them involuntarily hospitalized to prevent them from carrying out their wishes. (shrink)

Voluntary active euthanasia and physician-assisted suicide remain technically illegal in the Netherlands, but the practices are openly tolerated provided that physicians adhere to carefully constructed guidelines. Harsh criticism of the Dutch practice by authors in the United States and Great Britain has made achieving a balanced understanding of its clinical, moral, and policy implications very difficult. Similar practice patterns probably exist in the United States, but they are conducted in secret because of a more uncertain legal and ethical climate. In (...) this manuscript, we plan to compare end-of-life care in the United States and the Netherlands with regard to underlying values, justifications, and practices. We will explore the risks and benefits of each system for a real patient who was faced with a common end-of-life clinical dilemma, and close with challenges for public policies in both countries. (shrink)

Voluntary active euthanasia (VAE) and physician-assisted suicide (PAS) remain technically illegal in the Netherlands, but the practices are openly tolerated provided that physicians adhere to carefully constructed guidelines. Harsh criticism of the Dutch practice by authors in the United States and Great Britain has made achieving a balanced understanding of its clinical, moral, and policy implications very difficult. Similar practice patterns probably exist in the United States, but they are conducted in secret because of a more uncertain legal and ethical (...) climate. In this manuscript, we plan to compare end-of-life care in the United States and the Netherlands with regard to underlying values, justifications, and practices. We will explore the risks and benefits of each system for a real patient who was faced with a common end-of-life clinical dilemma, and close with challenges for public policies in both countries. (shrink)

Hospice is the premiere end of life program in the United States, but its requirement that patients forgo disease-directed therapies and that they have a prognosis of 6 months or less means that it serves less than half of dying patients and often for very short periods of time. Palliative care offers careful attention to pain and symptom management, added support for patients and families, and assistance with difficult medical decision making alongside any and all desired medical treatments, but it (...) does not include a comprehensive system of care as is provided by hospice. The practice of palliative care and hospice is filled with sometimes overt (requests for hastened death in an environment where such acts are legally prohibited) and other times covert (the delay in palliative care referral because the health care team believes it will undermine disease directed treatment) ethical issues. The contributors to this volume use a series of case presentations within each chapter to illustrate some of the palliative care and hospice challenges with significant ethical dimensions across the three overarching domains: 1) care delivery systems; 2) addressing the many dimensions of suffering; and 3) difficult decisions near the end of life. The contributors are among the most experienced palliative care, hospice and ethics scholars in North America and Western Europe. Each has been given relatively free reign to address what they feel are the most pressing ethical challenges within their domain, so a wide range of positions and vantage points are represented. As a result, the volume provides a very diverse ethical exploration of this relatively young field that can deepen, stretch, and at times confront any simple notion of the challenges facing patients, their families, professional caregivers, and policy makers. (shrink)

According to the biopsychosocial model, developed by the late Dr. George Engel, how physicians approach patients and the problems they present is very much ...

Book reviewed in this article: Death and Dignity: Making Choices and Taking Charge. By Timothy E. Quill.

Some individuals facing dementia contemplate hastening their own death: weighing the possibility of living longer with dementia against the alternative of dying sooner but avoiding the later stages of cognitive and functional impairment. This weighing resonates with an ethical and legal consensus in the United States that individuals can voluntarily choose to forgo life‐sustaining interventions and also that medical professionals can support these choices even when they will result in an earlier death. For these reasons, whether and how a terminally (...) ill individual can choose to control the timing of their death is a topic that cannot be avoided when considering the dementia trajectory. With a focus on the U.S. context, this landscape review considers the status of provisions that would legally permit people facing dementia to hasten death with appropriate support from medical professionals. This review can be used to plan and guide clinical and legal practitioner discussion and policy development concerning evolving questions not fully covered by existing medical decision‐making provisions. (shrink)

With breathtalung speed, traditional criminal prohibitions against assisted suicide have been declared unconstitutional in twelve states, including California and New York. This poses great promise and great peril. The promise is that competent terminally ill patients, as a compassionate measure of last resort, will have the option of putting an end to their suffering by physician-assisted suicide. More sigmficant, legally permitting this controversial option may be a catalyst for doctors, health care institutions, and society to improve the care of the (...) dying. PAS should be limited only to those relatively few competent patients who continue to suffer intolerably despite unrestrained efforts to palliate and who face a continued existence that they regard as worse than death. When dying patients know they will not be abandoned to miserable and pointless suffering if palliative care fails, they will be fortified to cope better with the process of dying.The immediate peril is that PAS will become a quick fix, available on demand to any patient diagnosed as terminally ill, thus bypassing palliative care and producing premature deaths. (shrink)

Our autonomy can be compromised by limitations in our capacities, or by the power relationships within which we are embedded. If we insist that real consent requires full autonomy, then virtually no sex will turn out to be consensual. I argue that under conditions of compromised autonomy, consent must be socially and interpersonally scaffolded. To understand consent as an ethically crucial but nonideal concept, we need to think about how it is related to other requirements for ethical sex, such as (...) the ability to exit a situation, trust, safety, broader social support, epistemic standing in the community, and more. (shrink)

City Living is about urban spaces, urban dwellers, and how these spaces and people make, shape, and change one another. More people live in cities than ever before: more than 50% of the earth's people are urban dwellers. As downtown cores gentrify and globalize, they are becoming more diverse than ever, along lines of race, ethnicity, socioeconomic class, sexuality, and age. Meanwhile, we are in the early stages of what seems sure to be a period of intense civil unrest. During (...) such periods, cities generally become the primary sites where tensions and resistance are concentrated, negotiated, and performed. For all of these reasons, understanding cities and contemporary city living is pressing and exciting from almost any disciplinary and political perspective. Quill R Kukla offers the first systematic philosophical investigation of the nature of city life and city dwellers. The book draws on empirical and ethnographic work in geography, anthropology, urban planning, and several other disciplines in order to explore the impact that cities have on their dwellers and that dwellers have on their cities. It begins with a philosophical exploration of spatially embodied agency and of the specific forms of agency and spatiality that are distinctive of urban life. It explores how gentrification is enacted and experienced at the level of embodied agency, arguing that gentrifying spaces are contested territories that shape and are shaped by their dwellers. The book then moves to an exploration of repurposed cities, which are cities materially designed to support one sociopolitical order, but in which that order collapsed, leaving new dwellers to use the space in new ways. Through detailed original ethnography of the repurposed cities of Berlin and Johannesburg, Kukla makes the case that in repurposed cities, we can see vividly how material spaces shape and constrain the agency and experience of dwellers, while dwellers creatively shape the spaces they inhabit in accordance with their needs. The book concludes with a reconsideration of the right to the city, asking what would be involved in creating a city that enabled the agency and flourishing of all its diverse inhabitants. (shrink)

When I say “I know Sarah,” or “I know Berlin,” what sort of knowledge am I claiming? Such knowledge of a particular is, I claim, not reducible to either propositional knowledge-that or to traditional physical know-how. Mere, bare knowledge by acquaintance also does not capture the kind of knowledge being claimed here. Using knowledge of a place as my central example, I argue that this kind of knowledge-of, or “objectual knowledge” as it is sometimes called, is of a distinctive epistemological (...) sort. It is a genre of inherently first-personal aesthetic knowledge, but it also, like know-how, involves active skill. I end by exploring a couple of classic problems in aesthetic epistemology, applied to the case of knowledge-of as active aesthetic knowledge. (shrink)

When I say “I know Sarah,” or “I know Berlin,” what sort of knowledge am I claiming? Such knowledge of a particular is, I claim, not reducible to either propositional knowledge-that or to traditional physical know-how. Mere, bare knowledge by acquaintance also does not capture the kind of knowledge being claimed here. Using knowledge of a place as my central example, I argue that this kind of knowledge-of, or “objectual knowledge” as it is sometimes called, is of a distinctive epistemological (...) sort. It is a genre of inherently first-personal aesthetic knowledge, but it also, like know-how, involves active skill. I end by exploring a couple of classic problems in aesthetic epistemology, applied to the case of knowledge-of as active aesthetic knowledge. (shrink)

The author argues that all forms of life are interconnected and that no being, construct, or object can exist independently from the ecological entanglement, nor does "nature" exist as an entity separate from the uglier or more synthetic elements of life. Realizing this interconnectedness is what the author calls the ecological thought. He investigates the philosophical, political, and aesthetic implications of this interconnectedness.

At any given time, a subject has a multiplicity of conscious experiences. A subject might simultaneously have visual experiences of a red book and a green tree, auditory experiences of birds singing, bodily sensations of a faint hunger and a sharp pain in the shoulder, the emotional experience of a certain melancholy, while having a stream of conscious thoughts about the nature of reality. These experiences are distinct from each other: a subject could experience the red book without the singing (...) birds, and could experience the singing birds without the red book. But at the same time, the experiences seem to be tied together in a deep way. They seem to be unified, by being aspects of a single encompassing state of consciousness. (shrink)

Two opposing tendencies in the philosophy of language go by the names of ‘referentialism’ and ‘inferentialism’ respectively. In the crudest version of the contrast, the referentialist account of meaning gives centre stage to the referential semantics for a language, which is then used to explain the inference rules for the language, perhaps as those which preserve truth on that semantics (since a referential semantics for a language determines the truth-conditions of its sentences). By contrast, the inferentialist account of meaning gives (...) centre stage to the inference rules for the language, which are then used to explain its referential semantics, perhaps as the semantics on which the rules preserve truth. On pain of circularity, we cannot combine both directions of explanation. (shrink)

When I take off my glasses, the world looks blurred. When I put them back on, it looks sharpedged. I do not think that the world really was blurred; I know that what changed was my relation to the distant physical objects ahead, not those objects themselves. I am more inclined to believe that the world really is and was sharp-edged. Is that belief any more reasonable than the belief that the world really is and was blurred? I see more (...) accurately with my glasses on than off, so visual appearances when they are on have some cognitive priority over visual appearances when they are off. If I must choose which kind of visual appearance to take at face value, I will choose the sharp-edged look. But what should I think when I see a mist, which looks very blurred however well I am seeing? Indeed, why choose to take any of the looks at face value? Why not regard all the choices as illegitimate projections of ways of seeing the world onto the world itself? (shrink)

This paper discusses the nature and the status of inference to the best explanation. We outline the foundational role given IBE by its defenders and the arguments of critics who deny it any place at all ; argue that, on the two main conceptions of explanation, IBE cannot be a foundational inference rule ; sketch an account of IBE that makes it contextual and dependent on substantive empirical assumptions, much as simplicity seems to be ; show how that account avoids (...) the critics ' complaints and leaves IBE an important role ; and sketch how our account can clarify debates over IBE in arguments for scientific realism. (shrink)

I argue that the concept of disease serves such radically different strategic purposes for different kinds of stakeholders that coming up with a unified philosophical definition of disease is hopeless. Instead, I defend a radically pluralist, pragmatist account of when it is appropriate to mobilize the concept of disease. I argue that it is appropriate to categorize a condition as a disease when it serves legitimate strategic goals to at least partially medicalize that condition, and when the condition is pathological (...) from inside the epistemology and metaphysics of medicine. While some conditions, like pancreatic cancer, are legitimate diseases from all stakeholders’ points of view and in any context, and while other conditions, like homosexuality, are not diseases from any legitimate point of view, there is a range of interesting, messy cases—including Deafness, autism, pre-hypertension, infertility, and ADHD, for example—whose disease status is irreducibly context-dependent and under contest. (shrink)

Previous research has suggested that bodily signals from internal organs are associated with diverse cortical and subcortical processes involved in sensory-motor functions, beyond homeostatic reflexes. For instance, a recent study demonstrated that the preparation and execution of voluntary actions, as well as its underlying neural activity, are coupled with the breathing cycle. In the current study, we investigated whether such breathing-action coupling is limited to voluntary motor action or whether it is also present for mental actions not involving any overt (...) bodily movement. To answer this question, we recorded electroencephalography (EEG), electromyography (EMG), and respiratory signals while participants were conducting a voluntary action paradigm including self-initiated motor execution (ME), motor imagery (MI), and visual imagery (VI) tasks. We observed that the voluntary initiation of ME, MI, and VI are similarly coupled with the respiration phase. In addition, EEG analysis revealed the existence of readiness potential (RP) waveforms in all three tasks (i.e., ME, MI, VI), as well as a coupling between the RP amplitude and the respiratory phase. Our findings show that the voluntary initiation of both imagined and overt action is coupled with respiration, and further suggest that the breathing system is involved in preparatory processes of voluntary action by contributing to the temporal decision of when to initiate the action plan, regardless of whether this culminates in overt movements. -/- . (shrink)

In Games: Agency as Art, Thi Nguyen has given us a deep and compelling picture of agency as much more layered, volatile, environment-dependent and discontinuous than it appears in most philosophical accounts. Games ‘inscribe … forms of agency into artifactual vessels’.1 1 When we play a game, we take up a form of agency, including a set of motivations, values and goals, which has been artificially provided by the game. Our purpose in playing, in the kinds of gameplay that interest (...) Nguyen, is to have the aesthetic experience of first-personally exercising the kind of agency sculpted by the game. As we move in and out of gameplay, we take up and drop values, motives, and goals that are provided to us by the game. Games can expand our autonomy and the richness of life by allowing us to practice different forms of agency, taking on different ends for the aesthetic experience of striving to meet them. While I am on board with these central moves of Nguyen’s book, in this essay I will argue that the situation is substantially messier than Nguyen portrays it as being. Game play, I will claim, is inextricably embedded and entangled in its larger social, material and cultural context. Conversely, I will argue, everyday life is routinely sculpted in ways Nguyen claims are distinctive of games. (shrink)

Traditional moral explorations of sexual violation are dyadic: they focus on the relationship between the perpetrator and the victim, considered in relative isolation. We argue that the moral texture of sexual violation and its fallout only shows up once we see acts of sexual violation as acts that occur within an ecosystem. An ecosystem is made up of dwellers and an environment embedded in a broad, thick, interdependent, and relatively stable web of norms, practices, environments, material and institutional structures. We (...) argue that many of the important and interesting harms wrought by sexual violation can only be understood as ecological harms. To illustrate this, we focus on sexual violations that occur within a specific type of ecosystem, namely an academic department with a graduate program. We examine the possible damaging effects of sexual violation on the ecology of a department. We also consider what makes an ecosystem resilient and relatively able to self-repair, and how sexual violation within an ecosystem may weaken its self-repairing resources. We show that looking at sexual violation through this ecological lens lets us identify harms that are otherwise obscured or difficult to locate. (shrink)

Discussions of uptake in the philosophy of language focus our attention on what role other people have in fixing the import, success, influence and social life of a speech act. The general idea in most discussions of uptake, despite their differences and disagreements, is whether and how an audience is cooperative or uncooperative when a speaker plays a critical role in how speech acts function. This essay is primarily concerned with “refusals”, or uncooperative uptakes. The essay analyzes the varieties of (...) refusal; when refusal is possible why it might be challenging and when it is ethical. It examines how and when the uptake of a speech act can constitute the pragmatic form and force of the original speech act. (shrink)

Disorders of volition are often accompanied by, and may even be caused by, disruptions in the phenomenology of agency. Yet the phenomenology of agency is at present little explored. In this paper we attempt to describe the experience of normal agency, in order to uncover its representational content.

In this chapter, we turn our attention to the effects of the attention economy on our ability to act autonomously as a group. We begin by clarifying which sorts of groups we are concerned with, which are structured groups (groups sufficiently organized that it makes sense to attribute agency to the group itself). Drawing on recent work by Purves and Davis (2022), we describe the essential roles of trust (i.e., depending on groups to fulfill their commitments) and trustworthiness (i.e., the (...) property of a group that makes trusting them fitting) in autonomous group action, with particular emphasis on democratic institutions (which we view as group agents) and democratic legitimacy (which depends on trust and trustworthiness). We then explain how engagement maximization promotes polarization, which is detrimental to trust and trustworthiness and, in turn, democratic legitimacy and democratic institutions. We close by considering what groups might do to protect themselves from the threat posed to them by the attention economy. (shrink)

Medical practice is ideally based on robust, relevant research. However, the lack of disease-modifying treatments for Alzheimer’s disease has motivated “innovative practice” to improve patients’ well-being despite insufficient evidence for the regular use of such interventions in health systems treating millions of patients. Innovative or new non-validated practice poses at least three distinct ethical questions: first, about the responsible application of new non-validated practice to individual patients ; second, about the way in which data from new non-validated practice are communicated (...) via the scientific and lay press ; and third, about the prospect of making new non-validated interventions widely available before more definitive testing. We argue that the authors of metabolic enhancement protocols for Alzheimer’s disease have overstated the evidence in favor of these interventions within the scientific and lay press, failing to communicate weaknesses in their data and uncertainty about their conclusions. Such unmeasured language may create false hope, cause financial harm, undermine informed consent, and frustrate the production of generalizable knowledge necessary to face the societal problems posed by this devastating disease. We therefore offer more stringent guidelines for responsible innovation in the treatment of Alzheimer’s disease. (shrink)

To desire something is a condition familiar to everyone. It is uncontroversial that desiring has something to do with motivation, something to do with pleasure, and something to do with reward. Call these "the three faces of desire." The standard philosophical theory at present holds that the motivational face of desire presents its unique essence--to desire a state of affairs is to be disposed to act so as to bring it about. A familiar but less standard account holds the hedonic (...) face of desire to reveal to true nature of desire. In this view, to desire something is to tend to pleasure if it seems that the desired state of affairs has been achieved, or displeasure if it seems otherwise, thus tying desire to feelings instead of actions. In Three Faces of Desire, Schroeder goes beyond actions and feelings to advance a novel and controversial theory of desire that puts the focus on desire's neglected face, reward. Informed by contemporary science as much as by the philosophical tradition, Three Faces of Desire discusses recent scientific discoveries that tell us much about the way that actions and feelings are produced in the brain. In particular, recent experiments reveal that a distinctive system is responsible for promoting action, on the one hand, and causing feelings of pleasure and displeasure, on the other. This system, the brain's reward system, is the causal origin of both action and feeling, and is the key to understanding the nature of desire. (shrink)

In this paper we defend the doxastic conception of delusions against the metacognitive account developed by Greg Currie and collaborators. According to the metacognitive model, delusions are imaginings that are misidentified by their subjects as beliefs: the Capgras patient, for instance, does not believe that his wife has been replaced by a robot, instead, he merely imagines that she has, and mistakes this imagining for a belief. We argue that the metacognitive account is untenable, and that the traditional conception of (...) delusions as beliefs should be retained. (shrink)

The most promising contemporary form of epistemic scientific realism is based on the following intuition: Belief should be directed, not toward theories as wholes, but toward particular theoretical constituents that are responsible for, or deployed in, key successes. While the debate on deployment realism is quite fresh, a significant degree of confusion has already entered into it. Here I identify five criteria that have sidetracked that debate. Setting these distractions aside, I endeavor to redirect the attention of both realists and (...) non-realists to the fundamental intuition above. In more detail: I show that Stathis Psillos (1999) has offered an explicit criterion for picking out particular constituents, which, contrary to Kyle Stanford’s (2006a) criticisms, neither assumes the truth of theories nor requires hindsight. I contend, however, that, in Psillos’s case studies, Psillos has not successfully applied his explicit criterion. After clarifying the various alternative criteria at work (in those case studies and in a second line of criticism offered by Stanford), I argue that, irrespective of Stanford’s criticisms, the explicit criterion Psillos does offer is not an acceptable one. Nonetheless, the deployment realist’s fundamental intuition withstands all of these challenges. In closing, I point in a direction toward which I’ve elsewhere focused, suggesting that, despite the legitimacy and applicability of the deployment realist’s intuition, the historical threat that prompted it remains. (shrink)

Colburn (computer science, U. of Minnesota-Duluth) has a doctorate in philosophy and an advanced degree in computer science; he's worked as a philosophy professor, a computer programmer, and a research scientist in artificial intelligence. Here he discusses the philosophical foundations of artificial intelligence; the new encounter of science and philosophy (logic, models of the mind and of reasoning, epistemology); and the philosophy of computer science (touching on math, abstraction, software, and ontology).

The harms associated with wireless mobile devices (e.g. smartphones) are well documented. They have been linked to anxiety, depression, diminished attention span, sleep disturbance, and decreased relationship satisfaction. Perhaps what is most worrying from a moral perspective, however, is the effect these devices can have on our autonomy. In this article, we argue that there is an obligation to foster and safeguard autonomy in ourselves, and we suggest that wireless mobile devices pose a serious threat to our capacity to fulfill (...) this obligation. We defend the existence of an imperfect duty to be a ‘digital minimalist’. That is, we have a moral obligation to be intentional about how and to what extent we use these devices. The empirical findings already justify prudential reasons in favor of digital minimalism, but the moral duty is distinct from and independent of prudential considerations. (shrink)