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...

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)

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)

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.

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)

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)

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)

This important book charts the development of philosophical thinking about history over the past 250 years, combining extracts from key texts with new explanatory and critical discussion. The book is designed to make the work of thinkers such as Hume, Herder, Hegel, Dilthey, Nietzsche, Heidegger and Foucault accessible to students with no prior knowledge of Western philosophy. An introductory section is followed by nine further chapters exploring contrasting schools of thought. The volume reveals the origins of contemporary trends in the (...) discipline and relates wider philosophical reflections to the study of history itself. It also points to connections between philosophy of history and literary and cultural theory which have developed in recent decades. (shrink)

Theories of discourse bring to realism new ideas about how knowledge develops and how representations of reality are influenced. We gain an understanding of the conceptual aspect of social life and the processes by which meaning is produced. This collection reflects the growing interest realist critics have shown towards forms of discourse theory and deconstruction. The diverse range of contributions address such issues as the work of Derrida and deconstruction, discourse theory, Eurocentrism and poststructuralism. What unites all of the contributions (...) is a sense that it is essential to provide a realist alternative to the hitherto dominance of social constructionism, hermeneutics and postmodernism, over many of the issues discussed. By developing a realist perspective the different authors attempt to embed discourse within the structured nature of the reality of the world. Realism can situate language, discourse and ideology within context specific, or 'causally efficacious' circumstances. Realism can help to uncover issues of power, representation, and subjectivity and how discursive and other social practices produce real effects. This can help us understand the manner in which social structures are reproduced through various forms of ideology and discourse. And by knowing this, we can start to address questions concerning human emancipation and how the world is to be transformed. (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.

This is a paradigmatic work of contemporary philosophy.

Robert Stern investigates how scepticism can be countered by using transcendental arguments concerning the necessary conditions for the possibility of experience, language, or thought. He shows that the most damaging sceptical questions concern neither the certainty of our beliefs nor the reliability of our belief-forming methods, but rather how we can justify our beliefs.

Robert Hanna presents a fresh view of the Kantian and analytic traditions that have dominated continental European and Anglo-American philosophy over the last two centuries, and of the connections between them. But this is not just a study in the history of philosophy, for out of this emerges Hanna's original approach to two much-contested theories that remain at the heart of contemporary philosophy. Hanna puts forward a new 'cognitive-semantic' interpretation of transcendental idealism, and a vigorous defense of Kant's theory (...) of analytic and synthetic necessary truth, making this compelling reading for all who are interested in these fundamental philosophical issues. (shrink)

Permissivism says that for some propositions and bodies of evidence, there is more than one rationally permissible doxastic attitude that can be taken towards that proposition given the evidence. Some critics of this view argue that it condones, as rationally acceptable, sets of attitudes that manifest an untenable kind of arbitrariness. I begin by providing a new and more detailed explication of what this alleged arbitrariness consists in. I then explain why Miriam Schoenfield’s prima facie promising attempt to answer the (...) Arbitrariness Objection, by appealing to the role of epistemic standards in rational belief formation, fails to resolve the problem. Schoenfield’s strategy is, however, a useful one, and I go on to explain how an alternative form of the standards-based approach to Permissivism – one that emphasizes the significance of the relationship between people’s cognitive abilities and the epistemic standards that they employ – can respond to the arbitrariness objection. (shrink)

Although the seasons have been a perennial theme in literature and art, their significance for philosophy and environmental theory has remained largely unexplored. This pioneering book demonstrates the ways in which inquiry into the seasons reveals new and illuminating perspectives for philosophy, environmental thought, anthropology, cultural studies, aesthetics, poetics, and literary criticism. The Seasons opens up new avenues for research in these fields and provides a valuable resource for teachers and students of the environmental humanities. The innovative essays herein address (...) a wide range of seasonal cultures and geographies, from the traditional Western model of the four seasons––spring, summer, fall, and winter––to the Indigenous seasons of Australia and the Arctic. Exemplifying the crucial importance of interdisciplinary research, The Seasons makes a compelling case for the relevance of the seasons to our daily lives, scientific understanding, diverse cultural practices, and politics. (shrink)

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

One of our great behavioral scientists, the bestselling author of Behave, plumbs the depths of the science and philosophy of decision-making to mount a devastating case against free will, an argument with profound consequences Robert Sapolsky's Behave, his now classic account of why humans do good and why they do bad, pointed toward an unsettling conclusion: We may not grasp the precise marriage of nature and nurture that creates the physics and chemistry at the base of human behavior, but (...) that doesn't mean it doesn't exist. Now, in Determined, Sapolsky takes his argument all the way, mounting a brilliant (and in his inimitable way, delightful) full-frontal assault on the pleasant fantasy that there is some separate self telling our biology what to do. Determined offers a marvelous synthesis of what we know about how consciousness works-the tight weave between reason and emotion and between stimulus and response in the moment and over a life. One by one, Sapolsky tackles all the major arguments for free will and takes them out, cutting a path through the thickets of chaos and complexity science and quantum physics, as well as touching ground on some of the wilder shores of philosophy. He shows us that the history of medicine is in no small part the history of learning that fewer and fewer things are somebody's "fault"; for example, for centuries we thought seizures were a sign of demonic possession. Yet, as he acknowledges, it's very hard, and at times impossible, to uncouple from our zeal to judge others and to judge ourselves. Sapolsky applies the new understanding of life beyond free will to some of our most essential questions around punishment, morality, and living well together. By the end, Sapolsky argues that while living our daily lives recognizing that we have no free will is going to be monumentally difficult, doing so is not going to result in anarchy, pointlessness, and existential malaise. Instead, it will make for a much more humane world. (shrink)

Classical American pragmatism: the pragmatist -- Enlightenment-and its problematic semantics -- Analyzing pragmatism: pragmatics and pragmatisms -- A Kantian rationalist pragmatism: pragmatism -- Inferentialism, and modality in Sellars's arguments against -- Empiricism -- Linguistic pragmatism and pragmatism about norms: an arc of -- Thought from Rorty's eliminative materialism to his pragmatism -- Vocabularies of pragmatism: synthesizing naturalism and -- Historicism -- Towards an analytic pragmatism: meaning-use analysis -- Pragmatism, expressivism, and anti-representationalism: -- Local and global possibilities.

In his influential article ‘Essence and Modality’, Fine proposes a definition of necessity in terms of the primitive essentialist notion ‘true in virtue of the nature of’. Fine’s proposal is suggestive, but it admits of different interpretations, leaving it unsettled what the precise formulation of an Essentialist definition of necessity should be. In this paper, four different versions of the definition are discussed: a singular, a plural reading, and an existential variant of Fine’s original suggestion and an alternative version proposed (...) by Correia which is not based on Fine’s primitive essentialist notion. The first main point of the paper is that the singular reading is untenable. The second that given plausible background assumptions, the remaining three definitions are extensionally equivalent. The third is that, this equivalence notwithstanding, Essentialists should adopt Correia’s version of the definition, since both the existential variant, which has de facto been adopted as the standard version of the definition in the literature, and the plural reading suffer from problems connected to Fine’s primitive essentialist notion. (shrink)

Epistemic Sentimentalism is the view that emotional experiences such as fear and guilt are a source of immediate justification for evaluative beliefs. For example, guilt can sometimes immediately justify a subject’s belief that they have done something wrong. In this paper I focus on a family of objections to Epistemic Sentimentalism that all take as a premise the claim that emotions possess a normative property that is apparently antithetical to it: epistemic reason-responsiveness, i.e., emotions have evidential bases and justifications can (...) be demanded of them. I respond to these objections whilst granting that emotions are reason-responsive. This is not only dialectically significant vis-à-vis the prospects for Epistemic Sentimentalism, but also supports a broader claim about the compatibility of a mental item’s being reason-responsive and its being a generative source of epistemic justification. (shrink)

A sourcebook for developing and facilitating collaborative groups capable of continuously adapting to anticipate the evolving learning needs of students. Based on a theoretical foundation of schools as complex systems in which linear management models are no longer sufficient.

This paper concerns the applications of two-dimensional modal semantics to the explanation of the contents of speech and thought. Different interpretations and applications of the apparatus are contrasted. First, it is argued that David Kaplan's two-dimensional semantics for indexical expressions is different from the use that I made of a formally similar framework to represent the role of contingent information in the determination of what is said. But the two applications are complementary rather than conflicting. Second, my interpretation of the (...) apparatus is contrasted with that of David Chalmers, Frank Jackson, and David Lewis. It is argued that this difference reflects a contrast between internalist and externalist approaches to the problem of intentionality. (shrink)

The Joy of Philosophy is a return to some of the perennial questions of philosophy--questions about the meaning of life; about death and tragedy; about the respective roles of rationality and passion in the good life; about love, compassion, and revenge; about honesty, deception, and betrayal; and about who we are and how we think about who we are. Recapturing the heart-felt confusion and excitement that originally brings us all to philosophy, internationally renowned teacher and lecturer Robert C. Solomon (...) offers both a critique of contemporary philosophy and an invitation to engage in philosophy in a different way. He attempts to save philosophy from itself and its self-imposed diet of thin arguments and logical analysis to recover the richness and complexity of life in thought. Solomon defends the passionate life in contrast to the life of thoughtful contemplation idealized by so many philosophers, attempting to recapture the kind of philosophy that Nietzsche celebrated as a "joyful wisdom.". (shrink)

This paper examines two recent contributions to the hate speech literature – by Steven Heyman and Jeremy Waldron – which seek a justification for the legal restriction of hate speech in an account of the way that hate speech infringes against people’s dignity. These analyses look beyond the first-order hurts and disadvantages suffered by the immediate targets of hate speech, and consider the prospect of hate speech sustaining complex social structures whose wide-scale operations lower the social status of members of (...) targeted groups. In Heyman’s and Waldron’s accounts we find plausible insights into the nature of identity-based social hierarchies, and the harms that redound to subordinated people under the operations of such hierarchies. I argue, however, that both analyses are unsuccessful as justifications for the restriction of hate speech, because they do not ultimately provide reason to think that hate speech is responsible for creating or sustaining identity-based social hierarchies. (shrink)

What, if anything, do we epistemically owe to each other? Various “traditional” views of epistemology might hold either that we don’t epistemically owe anything to each other, because “what we owe to each other” is the realm of the moral, or that what we epistemically owe to each other is just to be epistemically responsible agents. Basu (2019) has recently argued, against such views, that morality makes extra-epistemic demands upon what we should believe about one another. So, what we owe (...) to each other is not just a matter of word and deed, but also of belief. And in fact, Basu argues, sometimes those moral demands require us to believe in ways that cut against orthodox epistemic norms. This paper has three aims. First, to offer two strategies for accommodating the kinds of cases Basu discusses while nonetheless holding that only epistemic normativity makes demands on belief. Second, to offer an alternative account of what we owe to each other that does not hold that morality demands that we sometimes believe against our evidence or in violation of epistemic norms. And third, to give a brief diagnosis of why it seems intuitive that morality makes extra-epistemic doxastic demands on us. Ultimately, I argue that what we epistemically owe to each other does not require us to violate orthodox, invariantist epistemic norms. Morality demands that we have a proper regard for others, not that we sometimes believe against our evidence. (shrink)

Comprehensie collection of historical and contemporary philosophies of technology, including Plato, Aristotle, St. Simon, Comte, Marx, Heidegger, Mumford, Foucault.

Exponents and critics of semantic presupposition have almost invariably based their discussion on the ('Standard') definition of presupposition implied by Frege and Strawson. In this study Noel Burton-Roberts argues convincingly against this definition, that leads it to a three-valued semantics. He presents a very simple semantic definition which is weaker, more general and leads to a semantics more easily interpreted as two-valued with gaps. The author shows that a wide range of intuitive facts that eluded the Standard definition follow directly (...) from this ('Revised') definition itself: facts about the presuppositions of compound sentences and modal sentences, about presuppositional conflict and about differences in the logical status of simple sentences suffering from presupposition failure. The book includes a detailed argument that an ambiguity of natural language negation, generally assumed to be necessary to the defence of semantic presupposition, is neither possible nor necessary in a presuppositional semantics. Noel Burton-Roberts has made an authoritative contribution to a debate which has involved philosophers and linguists for many years. His command of the issues, his clarity of exposition and his theoretical insight may well serve to change the boundaries of that debate. (shrink)

We make the case that the Prisoner’s Dilemma, notwithstanding its fame and the quantity of intellectual resources devoted to it, has largely failed to explain any phenomena of social scientific or biological interest. In the heart of the paper we examine in detail a famous purported example of Prisoner’s Dilemma empirical success, namely Axelrod’s analysis of WWI trench warfare, and argue that this success is greatly overstated. Further, we explain why this negative verdict is likely true generally and not just (...) in our case study. We also address some possible defenses of the Prisoner’s Dilemma. (shrink)

In disagreements about trivial matters, it often seems appropriate for disputing parties to adopt a ‘middle ground’ view about the disputed matter. But in disputes about more substantial controversies (e.g. in ethics, religion, or politics) this sort of doxastic conduct can seem viciously acquiescent. How should we distinguish between the two kinds of cases, and thereby account for our divergent intuitions about how we ought to respond to them? One possibility is to say that ceding ground in a trivial dispute (...) is appropriate because the disputing parties are usually epistemic peers within the relevant domain, whereas in a more substantial disagreement the disputing parties rarely, if ever, qualify as epistemic peers, and so ‘sticking to one’s guns’ is usually the appropriate doxastic response. My aim in this paper is to explain why this way of drawing the desired distinction is ultimately problematic, even if it seems promising at first blush. (shrink)

This paper explores the relationship between eugenics, disability, and dehumanization, with a focus on forms of eugenics beyond Nazi eugenics.