Unrepresented patients lack the capacity to make medical decisions for themselves, have no clear documentation of preferences for medical treatment, and have no surrogate decision maker or obvious candidate for that role. There is no consensus about who should serve as the decision maker for these patients, particularly regarding whether to continue or to limit life-sustaining treatment. Several authors have argued that ethics committees should play this role rather than the patient's treating physician, a common current default. We argue that (...) concerns about the adequacy of physicians as surrogates are either empirically unfounded or apply equally to ethics committees. We suggest that physicians should be the primary decision maker for the unrepresented because of their fiduciary duties toward their patients. As part of the process of fulfilling these duties, they should seek the advice of third parties such as ethic committees; but final end-of-life decision-making for the unrepresented should rest with the treating physician. (shrink)

In 2015, the major critical care societies issued guidelines outlining a procedural approach to resolving intractable conflict between healthcare professionals and surrogates over life-sustaining treatments (LST). We report our experience with a resolving conflict procedure. This was a retrospective, single-centre cohort study of ethics consultations involving intractable conflict over LST. The resolving conflict process was initiated eleven times for ten patients over 2,015 ethics consultations from 2000 to 2020. In all cases, the ethics committee recommended withdrawal of the contested LST. (...) In seven cases, the patient died or was transferred or a legal injunction was obtained before completion of the process. In the four cases in which LST was withdrawn, the time from ethics consultation to withdrawal of LST was 24.8 ± 12.2 days. Healthcare provider and surrogate were often distressed during the process, sometimes resulting in escalation of conflict and legal action. In some cases, however, surrogates appeared relieved that they did not have to make the final decision regarding LST. Challenges regarding implementation included the time needed for process completion and limited usefulness in emergent situations. Although it is feasible to implement a due process approach to conflict over LST, there are factors that limit the procedure’s usefulness. (shrink)

Critical care society guidelines recommend that ethics committees mediate intractable conflict over potentially inappropriate treatment, including Do Not Resuscitate status. There are, however, limited data on cases and circumstances in which ethics consultants recommend not offering cardiopulmonary resuscitation despite patient or surrogate requests and whether physicians follow these recommendations. This was a retrospective cohort of all adult patients at a large academic medical center for whom an ethics consult was requested for disagreement over DNR status. Patient demographic predictors of ethics (...) consult outcomes were analyzed. In 42 of the 116 cases, the patient or surrogate agreed to the clinician recommended DNR order following ethics consultation. In 72 of 74 of the remaining cases, ethics consultants recommended not offering CPR. Physicians went on to write a DNR order without patient/surrogate consent in 57 of those cases. There were no significant differences in age, race/ethnicity, country of origin, or functional status between patients where a DNR order was and was not placed without consent. Physicians were more likely to place a DNR order for patients believed to be imminently dying. The median time from DNR order to death was 4 days with a 90-day mortality of 88.2%. In this single-center cohort study, there was no evidence that patient demographic factors affected ethics consultants’ recommendation to withhold CPR despite patient/surrogate requests. Physicians were most likely to place a DNR order without consent for imminently dying patients. (shrink)

The lung allocation score system in the United States and several European countries gives more weight to risk of death without transplantation than to survival following transplantation. As a result, centers transplant sicker patients, leading to increased length of initial hospitalization. The care of patients who have accumulated functional deficits or additional organ dysfunction during their prolonged stay can be ethically complex. Disagreement occurs between the transplant team, patients and families, and non-transplant health care professionals over the burdens of ongoing (...) intensive intervention. These cases highlight important ethical issues in organ transplantation, including the nature and requirements of transplant informed consent, the limits of physician prognostication, patient autonomy and decision-making capacity following transplant, obligations to organ donors and to other potential recipients, and the impact of program metrics on individualized recipient care. We outline general ethical principles for the care of lung transplant recipients with prolonged hospitalization and give regulatory, research, and patient-centered recommendations for these cases. (shrink)

In June 2015, the major North American and European critical care societies released new joint guidelines that delineate a process-based approach to resolving intractable conflicts over the appropriateness of providing or continuing LST.2 This article frames the new guidelines within the history, ethical arguments, legal landscape, and empirical evidence regarding limitation of LST without surrogate consent in cases of intractable conflict.

A study of American Indian youths illustrates competing pressures between research and ethics. A stakeholder-researcher team developed three plans to protect participants. The first allowed participants to skip potentially upsetting interview sections. The second called for participants flagged for abuse or suicidality to receive referrals, emergency 24-hr clinical backup, or both. The third, based on the community's desire to promote service access, included giving participants a list of service resources. Interviewers gave referrals to participants flagged as having mild problems, and (...) reported participants with serious problems to supervisors for clinical backup. Participants seldom chose to skip sections, so data integrity was not compromised. However, participants did have more problems than expected (e.g., 1 in 3 had thought about suicide, 1 in 5 had attempted suicide, and 1 in 4 reported abuse), so service agencies were not equipped to respond. Researchers must accept the competing pressures and find ethically appropriate compromises that will not undermine research integrity. (shrink)

In this issue of American Journal of Bioethics, Childress et al. address one of the most challenging modern clinical ethical dilemmas: the awake, competent patient dependent on extracorporeal membr...

Systematic study of the intersection of ethics consultation services and solid organ transplants and recipients can identify and illustrate ethical issues that arise in the clinical care of these patients, including challenges beyond resource allocation. This was a single-centre, retrospective cohort study of all adult ethics consultations between January 1, 2007, and December 31, 2017, at a large academic medical centre in the north-eastern United States. Of the 880 ethics consultations, sixty (6.8 per cent ) involved solid organ transplant, thirty-nine (...) (65.0 per cent) for candidates and twenty-one (35.0 per cent ) for recipients. Ethics consultations were requested for 4.3 per cent of heart, 4.9 per cent of lung, 0.3 per cent of liver, and 0.3 per cent of kidney transplant recipients over the study period. Nurses were more likely to request ethics consultations for recipients than physicians (80.0 per cent vs 20.0 per cent, p = 0.006). The most common reason for consultation among transplant candidates was discussion about intensity of treatment or goals of care after the patient was not or was no longer a transplant candidate. The most common reason for ethics consultation among transplant recipients was disagreement between transplant providers and patients/families/non-transplant healthcare professionals over the appropriate intensity of treatment for recipients. Very few consultations involved questions about appropriate resource allocation. Ethics consultants involved in these cases most often navigated communication challenges between transplant and non-transplant healthcare professionals and patients and families. (shrink)

"Dr. Rubin has brought cognitive psychology into a wholly unprecedented dialogue with studies in oral tradition. The result is a truly new perspective on memory and the processes of oral tradition." --John Miles Foley, University of Missouri.

"Dr. Rubin has brought cognitive psychology into a wholly unprecedented dialogue with studies in oral tradition. The result is a truly new perspective on memory and the processes of oral tradition." --John Miles Foley, University of Missouri.

There is increasing interest in determining what impact having women in management positions may have on corporate social responsibility initiatives. Various authors suggest that gender equality practices should be factored into the broader framework of CSR. This paper examines how the presence of women on corporate boards, in top and middle management and as heads of CSR departments, influences gender equality practices in the field of CSR. Using information collected from companies that have signed up to Women's Empowerment Principles in (...) Spain, we show that the presence of women in the aforesaid posts has a positive impact on CSR activities with gender equality objectives. We thus supplement the justice, business and moral arguments with further arguments in support of the incorporation of women into not only corporate boards but all management positions. Finally, we provide a view of how gender equality can be included in the broader framework of CSR. (shrink)

In recent years, firms have greatly increased the amount of resources allocated to activities classified as Corporate Social Responsibility (CSR). While an increase in CSR expenditure may be consistent with firm value maximization if it is a response to changes in stakeholders' preferences, we argue that a firm's insiders (managers and large blockholders) may seek to overinvest in CSR for their private benefit to the extent that doing so improves their reputations as good global citizens and has a "warm-glow" effect. (...) We test this hypothesis by investigating the relation between firms' CSR ratings and their ownership and capital structures. Employing a unique data set that categorizes the largest 3000 U. S. corporations as either socially responsible (SR) or socially irresponsible (SI), we find that on average, insiders' ownership and leverage are negatively related to the firm's social rating, while institutional ownership is uncorrelated with it. Assuming that higher CSR ratings is associated with higher CSR expenditure level, these results support our hypothesis that insiders induce firms to over-invest in CSR when they bear little of the cost of doing so. (shrink)

Viewed this way, the texts yield striking examples of language and notation that are irreducibly ambiguous and productive because they are ambiguous.

Emily Brady provides a systematic account of aesthetics in relation to the natural environment, offering a critical understanding of what aesthetic appreciation ...

A structure has a (finite-string) automatic presentation if the elements of its domain can be named by finite strings in such a way that the coded domain and the coded atomic operations are recognised by synchronous multitape automata. Consequently, every structure with an automatic presentation has a decidable first-order theory. The problems surveyed here include the classification of classes of structures with automatic presentations, the complexity of the isomorphism problem, and the relationship between definability and recognisability.

Strengthening the abilities of smallholder farmers in developing countries, particularly women farmers, to produce for both home and the market is currently a development priority. In many contexts, ownership of assets is strongly gendered, reflecting existing gender norms and limiting women’s ability to invest in more profitable livelihood strategies such as market-oriented agriculture. Yet the intersection between women’s asset endowments and their ability to participate in and benefit from agricultural interventions receives minimal attention. This paper explores changes in gender relations (...) and women’s assets in four agricultural interventions that promoted high value agriculture with different degrees of market-orientation. Findings suggest that these dairy and horticulture projects can successfully involve women and increase production, income and the stock of household assets. In some cases, women were able to increase their control over production, income and assets; however in most cases men’s incomes increased more than women’s and the gender-asset gap did not decrease. Gender- and asset-based barriers to participation in projects as well as gender norms that limit women’s ability to accumulate and retain control over assets both contributed to the results. Comparing experiences across the four projects, especially where projects implemented adaptive measures to encourage gender-equitable outcomes, provides lessons for gender-responsive projects targeting existing and emerging value chains for high value products. Other targeted support to women farmers may also be needed to promote their acquisition of the physical assets required to expand production or enter other nodes of the value chain. (shrink)

For early modern metaphysician Anne Conway, the world comprises creatures. In some sense, Conway is a monist about creatures: all creatures are one. Yet, as Jessica Gordon-Roth has astutely pointed out, that monism can be understood in very different ways. One might read Conway as an ‘existence pluralist’: creatures are all composed of the same type of substance, but many substances exist. Alternatively, one might read Conway as an ‘existence monist’: there is only one created substance. Gordon-Roth has done the (...) scholarship a great favor by illuminating these issues in Conway. However, this article takes issue with Gordon-Roth's further view that Conway ‘oscillates’ between the extremes of existence pluralism and monism. In its place, I argue we should read Conway as a priority monist: the whole of creation is ontologically prior to its parts. (shrink)

Quantum mechanics is an extraordinarily successful scientific theory. But more than 100 years after it was first introduced, the interpretation of the theory remains controversial. This Element introduces some of the most puzzling questions at the foundations of quantum mechanics and provides an up-to-date and forward-looking survey of the most prominent ways in which physicists and philosophers of physics have attempted to resolve them. Topics covered include nonlocality, contextuality, the reality of the wavefunction and the measurement problem. The discussion is (...) supplemented with descriptions of some of the most important mathematical results from recent work in quantum foundations, including Bell's theorem, the Kochen-Specker theorem and the PBR theorem. (shrink)

The laws of nature have come a long way since the time of Newton: quantum mechanics and relativity have given us good reasons to take seriously the possibility of laws which may be non-local, atemporal, ‘all-at-once,’ retrocausal, or in some other way not well-suited to the standard dynamical time evolution paradigm. Laws of this kind can be accommodated within a Humean approach to lawhood, but many extant non-Humean approaches face significant challenges when we try to apply them to laws outside (...) the time evolution picture. Thus for proponents of non-Humean approaches to lawhood there is a clear need for a novel non-Humean account which is capable of accommodating these sorts of laws. In this paper we propose such an account, characterizing lawhood in terms of constraints, which are understood as a form of modal structure. We demonstrate that our proposed realist account can indeed accommodate a large variety of laws outside the time evolution paradigm, and describe some possible applications to important philosophical problems. (shrink)

In The Sublime in Modern Philosophy: Aesthetics, Ethics, and Nature, Emily Brady takes a fresh look at the sublime and shows why it endures as a meaningful concept in contemporary philosophy. In a reassessment of historical approaches, the first part of the book identifies the scope and value of the sublime in eighteenth-century philosophy, nineteenth-century philosophy and Romanticism, and early wilderness aesthetics. The second part examines the sublime's contemporary significance through its relationship to the arts; its position with respect (...) to other aesthetic categories involving mixed or negative emotions, such as tragedy; and its place in environmental aesthetics and ethics. Far from being an outmoded concept, Brady argues that the sublime is a distinctive aesthetic category which reveals an important, if sometimes challenging, aesthetic-moral relationship with the natural world. (shrink)

Standpoint theorists have long been clear that marginalization does not make better understanding a given. They have been less clear, though, that social dominance does not make ignorance a given. Indeed, many standpoint theorists have implicitly committed themselves to what I call the strong epistemic disadvantage thesis. According to this thesis, there are strong, substantive limits on what the socially dominant can know about oppression that they do not personally experience. I argue that this thesis is not just implausible but (...) politically pernicious; it is an excuse for ignorance and silence that stifles our ability to address many injustices. Moreover, I argue that if we are to avoid lending support to the SEDT while working within a standpoint theory framework, we must hold that the socially dominant can achieve marginalized standpoints. So, we must hold that men can achieve feminist standpoints, that white women (and men) can achieve black feminist standpoints, and so on. (shrink)

Relational quantum mechanics (RQM) is an interpretation of quantum mechanics based on the idea that quantum states do not describe an absolute property of a system but rather a relationship between systems. There have recently been some criticisms of RQM pertaining to issues around intersubjectivity. In this article, we show how RQM can address these criticisms by adding a new postulate which requires that all of the information possessed by a certain observer is stored in physical variables of that observer (...) and thus is accessible by measurement to other observers. This makes it possible for observers to reach intersubjective agreement about quantum events that have occurred in the past. We suggest a possible ontology for a version of RQM employing this postulate; this ontology upholds the principle that quantum states are always relational, but it also postulates a set of quantum events that are not strictly relational. We show that the new postulate helps address the preferred basis problem in RQM. (shrink)

There is a long tradition, in the history and philosophy of science, of studying Kant’s philosophy of mathematics, but recently philosophers have begun to examine the way in which Kant’s reflections on mathematics play a role in his philosophy more generally, and in its development. For example, in the Critique of Pure Reason , Kant outlines the method of philosophy in general by contrasting it with the method of mathematics; in the Critique of Practical Reason , Kant compares the Formula (...) of Universal Law, central to his theory of moral judgement, to a mathematical postulate; in the Critique of Judgement , where he considers aesthetic judgment, Kant distinguishes the mathematical sublime from the dynamical sublime. This last point rests on the distinction that shapes the Transcendental Analytic of Concepts at the heart of Kant’s Critical philosophy, that between the mathematical and the dynamical categories. These examples make it clear that Kant's transcendental philosophy is strongly influenced by the importance and special status of mathematics. The contributions to this book explore this theme of the centrality of mathematics to Kant’s philosophy as a whole. This book was originally published as a special issue of the Canadian Journal of Philosophy. (shrink)

Dementia patients in the moderate-late stage of the disease can, and often do, express different preferences than they did at the onset of their condition. The received view in the philosophical literature argues that advance directives which prioritize the patient’s preferences at onset ought to be given decisive moral weight in medical decision-making. Clinical practice, on the other hand, favors giving moral weight to the preferences expressed by dementia patients after onset. The purpose of this article is to show that (...) the received view in the philosophical literature is inadequate and is out of touch with real clinical practice. I argue that having dementia is a cognitive transformative experience and that preference changes which result from this are legitimate and ought to be given moral weight in medical decision-making. This argument ought to encourage us to reduce our confidence in the moral weight of advance directives for dementia patients. (shrink)

This paper attempts to show how certain approaches in Values Based Practice duplicate key moves in liberal political theory.

This book draws its inspiration from Hilbert, Wittgenstein, Cavaillès and Lakatos and is designed to reconfigure contemporary philosophy of mathematics by making the growth of knowledge rather than its foundations central to the study of mathematical rationality, and by analyzing the notion of growth in historical as well as logical terms. Not a mere compendium of opinions, it is organised in dialogical forms, with each philosophical thesis answered by one or more historical case studies designed to support, complicate or question (...) it. The first part of the book examines the role of scientific theory and empirical fact in the growth of mathematical knowledge. The second examines the role of abstraction, analysis and axiomatization. The third raises the question of whether the growth of mathematical knowledge constitutes progress, and how progress may be understood. Readership: Students and scholars concerned with the history and philosophy of mathematics and the formal sciences. (shrink)

Standpoint epistemology has been linked with increasing calls for deference to the socially marginalized. As we understand it, deference involves recognizing someone else as better positioned than we are, either to investigate or to answer some question, and then accepting their judgment as our own. We connect contemporary calls for deference to old objections that standpoint epistemology wrongly reifies differences between groups. We also argue that while deferential epistemic norms present themselves as a solution to longstanding injustices, habitual deference prevents (...) the socially dominant from developing for themselves the skills necessary to expand their capacity for empathy, to deftly probe for evidence, and to ask critical questions. Consequently, we argue that standpoint epistemology must be understood as calling for inclusion, not deference. (shrink)

As out-of-hospital emergencies become more commonplace, so does the call for a “doctor in the house”. New York City paediatrician Mitchell Rubin has responded to numerous such crises over the past 25 years. He explores reactions on all sides of this peculiar physician–victim relationship, his growing concerns and fears, and possible reasons why many doctors hesitate to act. His thoughts and experiences instigate the discussion about the need for a universal system of Good Samaritan physician respondersWhile flying to Italy (...) last spring, the pilot’s voice came over the loudspeaker: “Is there a doctor on board”? How many times have I heard this request in the last 25 years? A passenger had fainted. As I began caring for her, the pilot asked me, “Should we take the plane down?”. Surprised to be given this responsibility, I took my best guess and answered “no”. After a stressful landing, while I gave oxygen to the prostrate woman, we were met by an ambulance on the tarmac. The woman was appreciative and gracious, the pilot scarcely offered thanks, and I began my vacation exhausted.Having been trained as a paediatrician, I have responded to nearly two dozen “Good Samaritan” scenarios, where a person was injured or became critically sick in a public setting. Perhaps I have had more than my fair share, but I wonder if this is an important and mounting phenomenon. With America growing older and more and more people with serious, chronic illnesses remaining active in the community, we should not be surprised to see increasing numbers of out-of-hospital emergencies. And, as this becomes more commonplace, I become less and less certain of the role I—and other physicians like me—should have.When I was young, cocky and fearless, the call to meet an emergency was exciting. Shortly after training, an …. (shrink)

There is an undeniable tendency to dismiss women’s sexual assault allegations out of hand. However, this tendency is not monolithic—allegations that black men have raped white women are often met with deadly seriousness. I argue that contemporary rape culture is characterized by the interplay between rape myths that minimize rape, and myths that catastrophize rape. Together, these two sets of rape myths distort the epistemic resources that people use when assessing rape allegations. These distortions result in the unjust exoneration of (...) people we cannot conceive of as monstrous, while making it too easy to believe that some marginalized people could be rapists. I also argue that rape myths enable a novel kind of epistemic injustice. This injustice concerns how our assessments of trustworthiness and our assessments of plausibility interact. I argue that rape myths can result in runaway credibility deflations that can explain both why people fail to believe most women, and also why people may unjustly believe false allegations that white women have been raped by black men. (shrink)

Semantic Scholar extracted view of "Environmental Policy and Environmental Thought: Commoner and Ruckelshaus" by Charles T. Rubin.

East Asians and Westerners differ in various aspects of perception and cognition. For example, visual memory for East Asians is believed to be more influenced by the contextual aspects of a scene than is the case for Westerners (Masuda & Nisbett, 2001). There are also differences in visual search: for Westerners, search for a long line among short is faster than for short among long, whereas this difference does not appear to hold for East Asians (Ueda et al., submitted). However, (...) it is unclear how these group-level differences originate. To investigate the extent to which they depend upon environment, we tested visual search and visual memory in East Asian immigrants who had lived in Canada for different amounts of time. Recent immigrants were found to exhibit no search asymmetry, unlike Westerners who had spent their lives in Canada. However, immigrants who had lived in Canada for more than two years showed performance comparable to that of Westerners. These differences could not be explained by the general analytic/holistic processing distinction believed to differentiate Westerners and East Asians, since all observers showed a strong holistic tendency for visual recognition. Results instead support the suggestion that exposure to a new environment can significantly affect the particular processes used to perceive a given stimulus. (shrink)

What kinds of issues does the global crisis of climate change present to aesthetics, and how will they challenge the field to respond? This paper argues that a new research agenda is needed for aesthetics with respect to global climate change (GCC) and outlines a set of foundational issues which are especially pressing: (1) attention to environments that have been neglected by philosophers, for example, the cryosphere and aerosphere; (2) negative aesthetics of environment, in order to grasp aesthetic experiences, meanings, (...) and dis/values in light of the catastrophic effects of GCC; (3) bringing intergenerational thinking into aesthetics through concepts of temporality and 'future aesthetics' (4) understanding the relationship between aesthetic and ethical values as they arise in regard to GCC. (shrink)

An epistemic account of constitutive relevance lists the criteria by which scientists can identify the components of mechanisms in empirical practice. Three prominent claims from Craver form a promising basis for an account. First, constitutive relevance is established by means of interlevel experiments. Second, interlevel experiments are executions of interventions. Third, there is no interlevel causation between a mechanism and its components. Currently, no account on offer respects all three claims. I offer my causal situationist account of constitutive relevance that (...) respects the claims. By situating a part of a mechanism on the causal chain between the mechanism’s input and output, components can be identified with interventions, without the interventions suggesting interlevel causation. The causal situationist account is the only account on offer so far that clearly fits within Craver’s framework. (shrink)

Any successful interpretation of quantum mechanics must explain how our empirical evidence allows us to come to know about quantum mechanics. In this article, we argue that this vital criterion is not met by the class of ‘orthodox interpretations,’ which includes QBism, neo-Copenhagen interpretations, and some versions of relational quantum mechanics. We demonstrate that intersubjectivity fails in radical ways in these approaches, and we explain why intersubjectivity matters for empirical confirmation. We take a detailed look at the way in which (...) belief-updating might work in the kind of universe postulated by an orthodox interpretation, and argue that observers in such a universe are unable to escape their own perspective in order to learn about the structure of the set of perspectives that is supposed to make up reality according to these interpretations. We also argue that in some versions of these interpretations it is not even possible to use one’s own relative frequencies for empirical confirmation. Ultimately we conclude that it cannot be rational to believe these sorts of interpretations unless they are supplemented with some observer-independent structure which underwrites intersubjective agreement in at least certain sorts of cases. (shrink)