Qu'est-ce que l'individualité? Sommes-nous faits que de matière? Comment fonctionne notre esprit? Comment prend-on une décision? Quelle est la place de la politique dans la vie humaine? Quelle frontière entre politique et morale? Comment peut-on mobiliser l'opinion publique? Qu'est-ce que l'émotion? Quelle est sa place dans la société? De quelle nature est la conscience? Comprendre 1'homme d'aujourd'hui dans toute sa complexité, tel est le but de cet ouvrage, qui fait dialoguer le droit, la génétique, la médecine, les neurosciences, la philosophie, (...) la morale, les sciences politiques. (shrink)

This essay argues that in linguistic communication, nothing corresponds to a linguistic competence as summarized by the three principles of first meaning in language: that first meaning is systematic, first meanings are shared, and first meanings are governed by learned conventions or regularities. There is no such a thing as a language, not if a language is anything like what many philosophers and linguists have supposed. We must give up the idea of a clearly defined shared structure which language users (...) acquire and then apply to cases, as well as the attempt to illuminate how we communicate by appeal to conventions. (shrink)

Includes bibliographical references and index. isbn 0-226-97861-3 (alk. paper) — isbn 0-226-97862-1 (pbk. : alk. paper) 1. Science — Philosophy. 2. Science — History. 3. Progress. I. Title. Q175 .Z25 2004 501 — dc2i 200301 1970 ...

The National Institute for Health and Care Excellence, the UK’s main healthcare priority-setting body, recently reaffirmed a longstanding claim that in recommending technologies to the National Health Service it cannot apply the ‘rule of rescue’. This paper explores this claim by identifying key characteristics of the rule and establishing to what extent these are also features of NICE’s approach to evaluating ultra-orphan drugs through its highly specialised technologies programme. It argues that although NICE in all likelihood does not act because (...) of the rule in prioritising these drugs, its actions in relation to HSTs are nevertheless in accordance with the rule and are not explained by the full articulation of any alternative set of rationales. That is, though NICE implies that its approach to HSTs is not motivated by the rule of rescue, it is not explicit about what else might justify this approach given NICE’s general concern with overall population need and value for money. As such, given NICE’s reliance on notions of procedural justice and its commitment to making the reasons for its priority-setting decisions public, the paper concludes that NICE’s claim to reject the rule is unhelpful and that NICE does not currently meet its own definition of a fair and transparent decision-maker. (shrink)

The UK’s National Institute for Health and Care Excellence is responsible for conducting health technology assessment on behalf of the National Health Service. In seeking to justify its recommendations to the NHS about which technologies to fund, NICE claims to adopt two complementary ethical frameworks, one procedural—accountability for reasonableness —and one substantive—an ‘ethics of opportunity costs’ that rests primarily on the notion of allocative efficiency. This study is the first to empirically examine normative changes to NICE’s approach and to analyse (...) whether these enhance or diminish the fairness of its decision-making, as judged against these frameworks. It finds that increasing formalisation of NICE’s approach and a weakening of the burden of proof laid on technologies undergoing HTA have together undermined its commitment to EOC. This implies a loss of allocative efficiency and a shift in the balance of how the interests of different NHS users are served, in favour of those who benefit directly from NICE’s recommendations. These changes also weaken NICE’s commitment to AfR by diminishing the publicity of its decision-making and by encouraging the adoption of rationales that cannot easily be shown to meet the relevance condition. This signals a need for either substantial reform of NICE’s approach, or more accurate communication of the ethical reasoning on which it is based. The study also highlights the need for further empirical work to explore the impact of these policy changes on NICE’s practice of HTA and to better understand how and why they have come about. (shrink)

Recent work in cognitive and computational neuroscience depicts human brains as devices that minimize prediction error signals: signals that encode the difference between actual and expected sensory stimulations. This raises a series of puzzles whose common theme concerns a potential misfit between this bedrock informationtheoretic vision and familiar facts about the attractions of the unexpected. We humans often seem to actively seek out surprising events, deliberately harvesting novel and exciting streams of sensory stimulation. Conversely, we often experience some wellexpected sensations (...) as unpleasant and to-be-avoided. In this paper, I explore several core and variant forms of this puzzle, using them to display multiple interacting elements that together deliver a satisfying solution. That solution requires us to go beyond the discussion of simple information-theoretic imperatives and to recognize the essential role of species-specific prestructuring, epistemic foraging, and cultural practices in shaping the restless, curious, novelty-seeking human mind. (shrink)

NICE, the draft fertility guideline and dodging the big question: should fertility treatment be provided by the NHS?In August of this year the National Institute for Clinical Excellence made its draft guideline on fertility treatment available for consultation.1 As has been widely reported in the media the draft guideline recommends that the National Health Service should provide publicly funded fertility treatment in a consistent way across England and Wales. The guideline recommends that three cycles of IVF should be available when (...) “The woman is within the optimal range for in vitro fertilisation and there is an appropriately diagnosed cause of infertility of any duration, or unexplained infertility of at least three years’ duration .Those who need fertility treatment will celebrate the guideline, as will many fertility clinics. The guideline does not, however, address key questions that will be obvious to many. Is fertility treatment the kind of thing that ought to be available on the NHS? Will the inevitable increase in demand mean that resources are directed away from other services? Is fertility treatment really the same kind of intervention as heart or hip replacement surgery?My view is that there are good reasons for doing what we can to help people access fertility services. Most of us will start a family and for those of us who do it is probably the most important of all of our life projects. Given that social status and wealth can be significant obstacles to many of the things that people would like to do with their lives, the fact that most of us are able to pursue this important life project is good from an egalitarian …. (shrink)

It is shown that a set of semi-recursive logics, including many fragments of CL, can be embedded within CL in an interesting way. A logic belongs to the set iff it has a certain type of semantics, called nice semantics. The set includes many logics presented in the literature. The embedding reveals structural properties of the embedded logic. The embedding turns finite premise sets into finite premise sets. The partial decision methods for CL that are goal directed with respect to (...) CL are turned into partial decision methods that are goal directed with respect to the embedded logics. (shrink)

Michael Rawlins and Andrew Dillon start their defence of Nice in fine polemical style, unfortunately polemics is all they have to offer. They totally fail to justify the Nice proposals on dementia treatments nor do they make any more plausible than formerly their use of the notorious QALY. They say:"Harris’s recent editorial, It’s not NICE to discriminate, is long on both polemic and invective – but short on scholarship. He offers nothing to illuminate the debate about allocating healthcare in circumstances (...) of finite resources; he has no understanding of the quality adjusted life year and its use in health economic evaluation; and he makes ill-researched, unsubstantiated and offensive charges against the Institute and its advisory bodies."Accusations are easy to make, difficult to substantiate. There are a number of claims here, only one of which is true. It is true that my editorial was robust, polemical if you like, but editorials are not the same as research papers and these are important issues which deeply affect real lives. Although Rawlins and Dillon affect to take the high ground their own article contains even more vigorous and much more personal invective than my editorial, I make no complaints. But as to the rest of what they say, well, let’s just see!They claim I offer nothing to illuminate resource allocation and that I have no understanding of the QALY. Both of these claims may well be true, but nothing they say goes any way to support these claims or even towards making them plausible. I have studied and written about the QALY for almost 20 years1,2,3,4,5,6,7,8,9,10,11,12,13,14,15 and Rawlins and Dillon show no evidence of any awareness or indeed any understanding of the issues, whether …. (shrink)

The authors refute Harris’s criticism of the work of NICE and in turn criticise his description of the institute’s positionHarris’s recent editorial,1It’s not NICE to discriminate, is long on both polemic and invective but short on scholarship. He offers nothing to illuminate the debate about allocating health care in circumstances of finite resources; he has no understanding of the quality adjusted life year and its use in health economic evaluation; and he makes ill researched, unsubstantiated charges against the institute and (...) its advisory bodies.ALLOCATING HEALTHCARE RESOURCESThe British National Health Service , like every other healthcare system in the world, has finite resources. How the NHS’s budget should be most appropriately allocated is a very specific example of the more general problem of distributive justice.2The NHS, with its requirement3 to provide all care that is “necessary and appropriate”, was founded with an egalitarian purpose. Yet despite its laudable emphasis on fairness, the implementation of the NHS’s egalitarian approach remains uncertain. What is necessary? What is appropriate? How should the tensions between the service’s egalitarian aspirations, and the need to provide health care from finite resources, be resolved? On what principles should these allocative decisions be made?Utilitarianism, with its goal to maximise overall good, is another approach. Yet experience with the original Oregon plan demonstrated that, when rigidly applied, it can yield solutions that most find unacceptable—for example, tooth capping taking precedence over emergency appendectomy.4 Moreover, some versions of utilitarianism can allow the interests of minorities to be overridden by the majority; and it has next to nothing to offer in eradicating health inequalities.There is no single, broadly accepted, theory of distributive justice …. (shrink)

Correspondence to: John Harris The Centre for Social Ethics and Policy, Institute of Medicine Law and Bioethics, School of Law, University of Manchester, Williamson Building, Oxford Road, Manchester M13 0JH, UK; [email protected] and Culyer1 have written an interesting and considered response, as people intimately connected to the National Institute for Health and Clinical Excellence , to the two editorials that I wrote on recent NICE decisions. Before commenting on their response, I would like to consider a point they made, which (...) echoes a point already made by Rawlins and Dillon,2 about the tone of my editorials. Claxton and Culyer accuse me of making “personally abusive charges”. In my original editorial, I criticised an institution, NICE, in robust terms, but in doing so I was continuing a long and respected tradition in English philosophy. Consider the following extract from Jeremy Bentham:" In English law, fiction is a syphilis, which runs in every vein, and carries into every part of the system the principle of rottenness...Fiction of use to justice? Exactly as swindling is to trade...It affords presumptive and conclusive evidence of moral turpitude in those by whom it was invented and first employed.3"My remarks were not an ad hominem criticism of anyone but directed at the published, but anonymous statements of an institution—a body corporate. In robustly criticising NICE, I no more attacked any individual associated with NICE than I attacked Tony Blair or the various ministers of state who are ultimately responsible for NICE. And, contra Claxton and Culyer’s claims, I have not denigrated the views of people who beg to differ from me.i If the apologists for NICE, whether they are Tony Culyer or Tony Blair, choose to identify themselves with criticism of NICE, that is entirely a matter for them. The only ad hominem remarks in this entire exchange have been made by Rawlins and Dillon, and Claxton and Culyer. The idea that criticism of the anonymously authored publications of …. (shrink)

The Socratic method is a paradoxical one. On the one hand, to practice it you must admit that you do not know the truth. On the other hand, you must act as if you were sure you knew the truth.

A brain emulation would be a one‐to‐one simulation where every causal process in the brain is represented, behaving in the same way as the original. Opponents of animal testing often argue that much of it is unnecessary and could be replaced with simulations. Personal identity is going to be a major issue with brain emulations, both because of the transition from an original unproblematic single human identity to successor identity/identities that might or might not be the same, and because software (...) minds can potentially have multiple realizability. The process might produce distressed minds that have rights yet have an existence not worth living, or that lack the capacity to form or express their wishes. Emulations will experience and behave on a timescale set by the speed of their software. Brain emulations would not be self‐contained, and their survival would depend upon hardware over which they might not have any control. (shrink)

Attacks similar to those in Nice and Munich could happen in any other Western city in the near future. Discussion about the political culture that grounds liberal democracies should not be delayed.

In the target article, human cruelty is linked to intrinsic reinforcement from engaging in the behavior without any recommendations for a research program to validate or test for such reinforcement and its independence from ultimate adaptive outcomes. Suggestions are offered in this commentary for such a program.

The introduction of National Institute for Health and Clinical Excellence (NICE) guidance on Alzheimer's medication in November 2006 will have a significant effect on the treatment of patients, and is opposed by the Royal College of Psychiatrists and many charities dealing with the elderly. The use of the Quality-Adjusted Life Year (QALY) in the guidance formulation is much debated due to questions of ageism. This article seeks to examine the basis of these accusations and whether NICE can be justified using (...) a utilitarian calculation in a principally egalitarian system such as the NHS. (shrink)

A response is given to the claim by Claxton and Culyer, who stated that the policies of the National Institute for Health and Clinical Excellence (NICE) do not evaluate patients rather than treatments. The argument is made that the use of values such as quality of life and life-years is ethically dubious when used to choose which patients ought to receive treatments in the National Health Service (NHS).

The manifesto presented in Philip Kitcher's exhaustive appraisal of contemporary American education—and the case for its potential reform—is so wide-ranging that it is not possible to do justice to its every component. Instead, I will speak to one of its parts in an attempt to recognize what I take to be the value of the whole. My aim is to address the section on the role of the arts in formal education, and the nature of aesthetic experience within that, to (...) test whether we can take the arts from their current state of being subject to Adam Smith's model of market utility, to being appreciated for their necessary and organic vitality. Kitcher provides strong arguments for exposure to the arts as leading to invaluable aesthetic experiences for young people. By extension—and at times by contrast—I will explore the possibility that the ‘aesthetic’ in aesthetic education does not just come into force with the student's encounter with art works or creative activity in the classroom, but should be integral also to the development of a particular sensibility amongst educators (i.e. the aesthetic education of the educators) for the shape and form of a ‘good’ education, according to its context and circumstance. It is through this sensibility that we might rediscover the necessity of the arts in schools at a time when their importance has been significantly devalued. (shrink)

During the last several years, philosophers of religion have witnessed a long-drawn debate between Nelson Pike and John Fischer on the problems of theological fatalism, Fischer claiming in his most recent contribution to have proved that even if God's past beliefs are ‘nice soft facts’, still theological fatalism cannot be averted. Unfortunately, this debate has not – at least it seems to this observer – served substantially either to clarify the issues involved or to move toward a resolution of the (...) question, but has instead confused matters by its use of misleading terminology and diverted the discussion into unpromising side roads. (shrink)

Two experiments investigated subliminal semantic and form priming in a word-completion task. Visual gap-words with a dominant and a subordinate solution were preceded by form-related or by semantically related words, which were briefly presented and sandwich-masked. Priming of the subordinate solution was assessed in Experiment 1, relative to a neutral condition. Both solutions were primed in Experiment 2. In the absence of conscious prime recognition, both semantic and form primes reliably increased the probability with which the primed solution was given. (...) With our variant of fragment-completion, response priming can be ruled out as explanation. Moreover, effects were already present at first presentation, excluding an interpretation in terms of partial awareness due to massive repetition. The data demonstrate automatic activation at both form and semantic levels in the absence of conscious awareness. (shrink)

The bottom line is that Claxton and Culyer believe, and are on record as saying, that a therapy or procedure is not cost effective if “the health benefits that it is estimated could be gained from the technology are less than those estimated to be forgone by other patients as other procedures are necessarily curtailed or not undertaken. It is this comparison of health gained and health forgone that is at the heart of the rationale of cost-effectiveness analysis”. To estimate (...) whether the gains made …. (shrink)

NICE must not say people are not worth treatingThe National Institute for Health and Clinical Excellence has proposed that drugs for the treatment of dementia be banned to National Health Service patients on the grounds that their cost is too high and “outside the range of cost effectiveness that might be considered appropriate for the NHS”i.1This is despite NICE’s admission that these drugs are effective in the treatment of Alzheimer’s disease and despite NICE having approved even more expensive treatments. The (...) effect is that thousands of Alzheimer’s patients will be denied the only treatment available. It is difficult to think of this as anything but wickedness or folly or more likely both. At the same time, and with no apparent sense of irony, NICE has launched a public consultation document3 on its guidelines on social value judgments. As we shall see these guidelines are ethically illiterate as well as socially divisive.Assuming permanently scarce resources it is clearly crucial that such healthcare resources as are available are not wasted. This point is often made in terms of cost effectiveness and it is argued, not implausibly, that to talk of cost effectiveness implies that we are able to measure just how cost effective each treatment is. To do so of course we need a standard of measurement. NICE has adopted the ubiquitous, but justly infamous QALY, the Quality Adjusted Life Year.The QALY combines life expectancy after treatment with measures of the expected quality of that life. There are two ways in which QALYS can be used. They might be used to determine which of rival therapies to give to a particular patient or which procedure to use to treat a particular condition, in short which of two different treatments is the more …. (shrink)

One of the key roles of the English National Institute for Health and Clinical Excellence (NICE) is technology appraisal. This essentially involves evaluating the cost effectiveness of pharmaceutical products and other technologies for use within the National Health Service. Based on a content analysis of key documents which shed light on the nature of appraisals, this paper draws attention to the multiple layers of uncertainty and complexity which are latent within the appraisal process, and the often socially constructed mechanisms for (...) tackling these. Epistemic assumptions, bounded rationality and more explicitly relational forms of managing knowledge are applied to this end. These findings are discussed in the context of the literature highlighting the inherently social process of regulation. A framework is developed which posits the various forms of uncertainty, and responses to these, as potential conduits of regulatory bias—in need of further research. That NICE’s authority is itself regulated by other actors within the regulatory regime, particularly the pharmaceutical industry, exposes it to the threat of regulatory capture. Following Lehoux, it is concluded that a more transparent and reflexive format for technological appraisals is necessary. This would enable a more robust, defensible form of decision-making and moreover enable NICE to preserve its legitimacy in the midst of pressures which threaten this. (shrink)

This article examines the intrinsic and instrumental value of higher education, in relation to jobs that do not exist anymore and jobs that do not exist yet.