This chapter contains sections titled: An Economic Model of Carroll Towing Relaxing the Model's Initial Assumptions Efficiency as a Norm Some Limitations of Law and Economics Conclusion References.

According to all-luck egalitarianism, the differential distributive effects of both brute luck, which defines the outcome of risks which are not deliberately taken, and option luck, which defines the outcome of deliberate gambles, are unjust. Exactly how to correct the effects of option luck is, however, a complex issue. This article argues that (a) option luck should be neutralized not just by correcting luck among gamblers, but among the community as a whole, because it would be unfair (...) for gamblers as a group to be disadvantaged relative to non-gamblers by bad option luck; (b) individuals should receive the warranted expected results of their gambles, except insofar as individuals blamelessly lacked the ability to ascertain which expectations were warranted; and (c) where societal resources are insufficient to deliver expected results to gamblers, gamblers should receive a lesser distributive share which is in proportion to the expected results. Where all-luck egalitarianism is understood in this way, it allows risk-takers to impose externalities on non-risk-takers, which seems counterintuitive. This may, however, be an advantage as it provides a luck egalitarian rationale for assisting ‘negligent victims’. (shrink)

Decision-making competence reflects individual differences in the susceptibility to decision-making errors, measured using tasks common from behavioral decision research (e.g., framing effects, under/overconfidence, following decision rules). Prior research demonstrates that those with higher decision-making competence report lower incidence of health-risking and antisocial behaviors, but there has been less focus on intermediate mechanisms that may impact real-world decisions, and, in particular, those implicated by normative models. Here we test the associations between measures of youth decision-making competence (Y-DMC) and one such mechanism, (...) the degree to which individuals make choices consistent with maximizing expected value (EV). Using a task involving hypothetical gambles, we find that greater EV sensitivity is associated with greater Y-DMC. Higher Y-DMC scores are associated with (a) choosing risky options when expected value favors those options and (b) avoiding risky options when expected value favors a certain option. This relationship is stronger for gambles that involved potential losses. The results suggest that Y-DMC captures decision processes consistent with standard normative evaluations of risky decisions. (shrink)

In recent years, experts in geriatric care have increasingly promoted the use of reminiscence museums, collections of period objects that are used to help senior citizens draw on old memories in order to recall and talk about their past. Hands Off Not an Option is a practical guide to making and using such collections, showing how to establish and fill out a museum and illustrating the ways it can be used within senior care facilities and within individual homes. (...) The book will thus be of value both to those practicing in geriatric medical and social care and to individual families working with aged relatives. The book includes 1 DVD. (shrink)

This dissertation is a philosophical contribution to the theories on trust and on risk communication. The importance of trust in risk communication has been argued for and empirically studied since the 80s. However, there is little agreement on the notion of trust and the precise function of trust. This thesis sets out to study both aspects from a philosophical point of view. The dissertation consists of five essays and an introduction. Essay I is a comment on risk (...) perception theory and the psychometric model in particular. The essay argues that sometimes individuals take risks simply because they are in a vulnerable position and have no other choice. Four factors are identified as crucial in risks from vulnerability: poor outset conditions, lack of reasonable options, hope and liability to disinformation. Essay II addresses the democratic approach to risk communication and the ideal of risk communication as a dialogue between more or less equal stakeholders. The essay develops a typology of different risk communication practices and influence distributions and concludes that the form of risk communication most commonly referred to in the literature is of the most imbalanced kind where all three types of influence falls to the same party. Essay III argues that trust can be understood as comfortable defocusing. Trust as comfortable defocusing means that when a person trusts, he or she is comfortable with letting certain things be in the hands or in the control of the trusted other. Departing from this idea a definition of trust is proposed consisting of three elements: the truster’s comfortable defocusing from the trusted person’s part of caring for X, based on a belief about the trusted person’s care for X, concerning something of concern to the truster. Essay IV explores the concept of trustworthiness and under which conditions trust can be betrayed in a morally justified way. It is argued that two aspects are essential for every reasonable notion of trustworthiness: reliability in terms of commitment to trust and predictability in terms of compliance with norms. In order to be untrustworthy in a morally justified way two major conditions need to be fulfilled: first, what is expected from the trustee needs to be either immoral or part of an ongoing immoral or unjust relationship between truster and trustee and, secondly, the trustee must not be in a position to explicitly reject trust. Essay V examines two of the most employed distinctions within the trust literature, that of trust/confidence and of trust/reliance. These distinctions are evaluated against a set of five criteria. It is argued that both these distinctions are employed to cover several distinguishing properties, thus adding to conceptual confusion. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Conflicts—and Consensus—about Conflicts of Interest in MedicineMatthew K. Wynia and Bette–Jane Crigger*This fascinating collection of essays about individual experiences of conflict of interest leaves little doubt that physicians remain divided about the importance, impact and meaning of conflicts of interest in their work. These essays offer differing views about what conflicts of interest look and feel like “on the ground” and about whether specific (...) conflicts of interest are bad, just a fact of life, or maybe even good.Conflict, Conflict EverywhereThese essays situate conflict of interest in a variety of contexts: the treatment recommendations a physician makes for an individual patient; the relationship between teaching physician and medical student or practicing physician and health care organization; the interaction between academic researchers and industry collaborators or professional bodies and industry supporters. In this, the narratives taken together reflect the scope of concern about conflict of interest in medicine familiar in the literature. In his classic 1993 essay, Dennis Thompson noted that concerns about conflict of interest encompass issues of physician self–referral, risk sharing between physicians and health care institutions, gifts from industry, hospital purchasing practices, as well as sponsored research and research with patients (Thompson 1993). To that list have subsequently been added relationships with industry in medical education at all levels, physicians’ service as consultants to industry or members of industry speakers bureau, and development of clinical practice guidelines (Lo & Fields 2009).That almost none of these essays draw attention to some widely publicized situations of conflict of interest—for example, gifts to physicians or the provision of drug samples—should, we think, be seen more as an artifact of the authors’ varied individual experiences than as a failure by the authors to engage key concerns in the ongoing professional and public debate. It could also be that the authors, asked to submit personal stories, assumed that yet another essay about the ‘traditional’ issues in the conflicts of interest literature would be seen as redundant, routine or even boring. Or, there is the tantalizing possibility that the absence of some of the more familiar conflicts from these narratives is the early fruit of efforts to address these traditional issues through policies governing interactions between physicians and industry promulgated by academic medical centers and health systems, medical specialty societies, and industry.One significant area of concern that has emerged in recent years is conflict of interest in the development of clinical practice guidelines. E.g., Choudry et al. 2002; Sniderrman & Furberg 2009; Guyatt et al. 2010. Although none of the essays in this [End Page 101] collection address it head on, Perlmutter touches on several key issues. His depiction of how an FDA committee process limited the input he was able to provide as an expert, undermined his potential to contribute to the professional dialogue, and raised concerns about the objectivity of the drug approval process echoes concerns about objectivity, the role of expert opinion, and the presence on guideline development panels of individuals with financial interests in the recommendations to be developed that have been explored at some length in the literature, most recently by the Institute of Medicine in reports on evidentiary standards (Eden et al 2011) and principles for guideline development (Graham et al. 2011).Conflict of Interest or Dual Agency?Several essays set out physicians’ experience in navigating situations of diverging expectations. Bierut, for example, reflects on the disjunction between the goals and products of academic researchers and commercial sponsors. She saw herself advancing basic knowledge and was forced to grapple with the reality of sponsors’ goals to advance commercial ends as well. Nagldinne and Mikulec each recall struggles to reconcile their obligation to exercise professional judgment on behalf of patients with the demands of health care organizations focussed also on the bottom line. Cruz–Flores attests to the challenge of making recommendations for care when one is both a practicing clinician and a clinical investigator engaged in research that might offer benefit to a patient for whom there are limited options.Thompson defined conflicts of interest as “a set of conditions in which professional judgment concerning a primary interest (such as a patient’s welfare or the validity of... (shrink)

Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the (...) context of a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS I. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[i] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[ii] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. II. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[iii] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[iv] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[v] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[vi] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[vii] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[viii] In democratic societies, one must take into consideration community morals and values.[ix] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[x] III. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[xi] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[xii] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[xiii] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[xiv] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. IV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[xv] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[xvi] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[xvii] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[xviii] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[xix] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[xx] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[xxi] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. VI. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[xxii] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[xxiii] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[xxiv] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. VII. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [i] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [ii] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [iii] Moss, p. 1295-1298. [iv] Moss, p. 1296. [v] Moss, p. 1295-1298. [vi] Moss, p. 1295-1298. [vii] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [viii] Cohen, p. 1299-1301. [ix] Moss, p. 1297. [x] Cohen, p. 1300. [xi] Cappelen, p. 478-480. [xii] Cappalen, p. 478-480. [xiii] Cappelen, p.479. [xiv] Cappelen, p. 479. [xv] Cappelen, p. 479 [xvi] Cohen, p. 1301. [xvii] Cappelen, p. 478. [xviii] Cohen, p. 1299-1301. [xix] Cohen, p. 1301. [xx] Cappelen, p. 476-480. [xxi] Cappelen, p. 476-480. [xxii] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [xxiii] Kawachi, p. 18-33. [xxiv] Kawachi, p. 18-33. (shrink)

Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the (...) context of a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS l. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[1] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[2] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. ll. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[3] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[4] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[5] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[6] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[7] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[8] In democratic societies, one must take into consideration community morals and values.[9] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[10] lll. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[11] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[12] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[13] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[14] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. lV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[15] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[16] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[17] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[18] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[19] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[20] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[21] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. Vl. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[22] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[23] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[24] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. Vll. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [1] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [2] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [3] Moss, p. 1295-1298. [4] Moss, p. 1296. [5] Moss, p. 1295-1298. [6] Moss, p. 1295-1298. [7] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [8] Cohen, p. 1299-1301. [9] Moss, p. 1297. [10] Cohen, p. 1300. [11] Cappelen, p. 478-480. [12] Cappalen, p. 478-480. [13] Cappelen, p.479. [14] Cappelen, p. 479. [15] Cappelen, p. 479 [16] Cohen, p. 1301. [17] Cappelen, p. 478. [18] Cohen, p. 1299-1301. [19] Cohen, p. 1301. [20] Cappelen, p. 476-480. [21] Cappelen, p. 476-480. [22] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [23] Kawachi, p. 18-33. [24] Kawachi, p. 18-33. (shrink)

This dissertation develops a theory of personal well-being---i.e., a theory of what is it for a person's life to go well for them. The proposed theory is called "the successful activity view of well-being." It is an end-neutral account of individual welfare that primarily values the pursuit, achievement, and enjoyment of ends that are important to a person. The parts of this process---e.g., the pursuit of ends, the achievement of ends, the enjoyment of activities and situations, and even the (...) satisfaction of desires for situations---are also of some significance for a person's level of well-being when actualized separately. I argue that previous end-neutral accounts of well-being, such as hedonism and desire-satisfactionism, are open to damaging objections because pleasures and desires can fail to coincide with a person's values. I also argue that the successful activity view has greater unity, explanatory power, and ontological economy than any form of perfectionism or any hybridized theory of wellbeing currently on offer.^. (shrink)

Joaquin Segura. Untitled (fig. 40) . 2007 continent. 1.2 (2011): 117-124. The interview that follows is a dialogue between artist and gallerist with the intent of unearthing the artist’s working strategies for a general public. Joaquin Segura is at once an anomaly in Mexico’s contemporary art scene at the same time as he is one of the most emblematic representatives of a larger shift toward a post-national identity among its youngest generation of artists. If Mexico looks increasingly like a foreclosed (...) home burning to the ground, Segura could likely be the one walking away, charred matchstick between thumb and forefinger and shit-eating grin on his face. His corrosive attacks on institutions, ideologies, and power reflect a deep general distrust of authority, increasingly evident within the work of younger Mexican artists. It is perhaps most directly the result of President Calderon’s deeply unpopular war against the cartels but no doubt equally the product of decades upon decades of rampant corruption and errant policy within Mexico. Brett W Schultz (BWS): A recurring—if not dominant—theme within your current work and investigation explores ideological extremism in reaction to some perceived political and economic disenfranchisement, especially that espoused and practiced by right-wing groups in United States. That's exactly why I thought of you when I was approached to contribute a piece to an issue on the subject of the moraine—taken metaphorically here to signify a certain set of beliefs that have resurfaced within mainstream American culture in the wake of a probably over-exaggerated political sea-change, marked by Obama's election. You're a Mexican artist who now lives and works in Guadalajara, far from the border cities where such concerns would seem more likely to be relevant to a contemporary artist; of course, you're even farther from the culture that birthed this nature of extremism. What interests you so intensely about this movement, if we can call it that? Joaquin Segura (JS): I think there are several seminal points that you touch on in this particular question. There's a very specific set of interests that make me address the socio-political issues I've been dissecting through my practice in the last few years. First of all, I don't really consider myself a 'mexican' artist. As I've made clear in the past, I don't really believe in the notion of 'identity' or the idea of 'nation', which I find totally laughable and heartwarmingly passé. I'm convinced that these are totally outdated models of understanding our differences and similarities, expanding our already immense and irreconcilable cultural abysses instead of bringing them together, thus resulting in their total dispersion among the complex and extremely arbitrary weaving of contemporary social nucleii. Pretty much a frankly bad joke, if I may say so. The fact that I live and work in Mexico is a completely random geographical and temporal factor, which of course affects what I think and what I do, but I've chosen not to be limited by this specific circumstance. In the past, while working abroad, I've taken advantage of this preconception of Mexico—to be more exact, pretty much all of Latin America—as one of the last barbaric bastions of western civilization. Totally amusing, if you ask me about it. I consider my practice to be, among other things, a gonzo strategy of deceit: there are quite a few roles you can adopt in this approach that may actually reveal themselves to be a privileged vantage point. In my experience, the gentle savage is one of the most effective ones to establish my standing position. Thus, I'm a mexican artist if I need it to prove my point. If it's not necessary in a specific circumstance, I'm not. Quite simple, I think. Said in other words, it's just an ace I can play to win a particular match. It has worked so far, at least for me. L: Hey, America… , 2009. R: The Inaugural Address , 2009. I am interested in the nature of power and the rise and fall of totalitarian ideological and political apparatuses nowadays. But I guess, going even further, I'm essentially fascinated by the fissures and contradictions that have made these structures spectacularly crumble to the ground. I do believe extreme ideologies have played a crucial role in the globalization of socio-political crisis. In the end, our world is nothing more than a fading monument to all things gone wrong—the inspiring triumph of failure, in every sense. I see this as an exciting parable. And of course, it is an undeniable fact that the US, through their influence in world economy, international policies and general attitude towards the rest of the planet is the largest structure waiting to collapse. I think we are all secretly awaiting that moment of splendor, even americans. It'll be disastrous and as nasty as it can get, but it will also be liberating and incredibly inspirational. Not just because it’s the US but because it'll prove that absolutely everything is susceptible to fall. And not only that, most importantly, it would confirm that radical change may actually be possible and not just one more of the unfulfilled promises modernity has left us to struggle with on our own. BWS: I want to talk first about two of your works in particular: Hey, America... and The Inaugural Address . I feel like your more recent work has a subtle —or even hidden—sinisterness, but these two works are perfect examples of how brutally confrontational your earlier work has been. When we showed Hey, America... at Mexico City's Zona Maco art fair in 2010, there were at least a couple visitors to our stand who were absolutely ready to punch me in my gringo face for having done so. Certainly the shock value of these works is crucial to their central ideas, but can you tell me more about your intentions and how these works relate to your general oeuvre? JS: So funny. Perhaps we do deserve to be punched in the face. I think that's what I'm sometimes looking for, but I hardly ever get it. I do think of such works as some sort of logical trap, a somewhat perverse ambush waiting for someone to walk into head-on. I think what I tried to do with those two specific works, as well as some other past projects, is just emphasize issues or themes that do disturb or make me uneasy and restless. I consider my essential intention a need to make clear that we do not have to look the other way, ignore or forget. We must address, understand and solve these manifestations of senseless violence and absurdity because if we don't confront them this way, they'll end up consuming us. In other words, I do consider these works as a personal need of coming to terms with the nonsense of the world we all are living in. I don't particularly consider myself to be someone with a clear set of beliefs. Perhaps my only certainty would be that everything is there to be denied, demolished and obliterated—even my supposed unquestionability of that particular 'dogma.' My practice is a reflection of that paradox, and I do think that's how these two pieces relate to a wider body of work. Every democratic system and so-called developed contemporary society is deeply flawed on the inside, and that is because each has swept things under the rug. Of course, there's tolerance, good will and eagerness to make a difference but there's also hatred, pain and fear lingering all around. We must learn to relate to both sides of the spectrum. In a way, I approach the themes behind these particular works in what I think to be a non-biased, somewhat 'neutral' way. I do think there's an encryption process going on in the way I work, some sort of formal refinement of this somewhat outrageous content. A digest of infamy, if we can refer to it that way. It is up to the individual experiencing the work to decide which way these pieces lean. They can easily be seen from both positions and I'm ok with that. If you look closely at these works, there's nothing that establishes an unrelenting position—neither support nor rejection. I don't want my personal political views to directly set an agenda for the spectator as that’s essentially propaganda, which is one of the things I absolutely despise. To sum it up, I strive for the spectator to complete the piece in that sense. The work then becomes a reflection of his or her own contradictions, a playground of the mind. I'm interested in achieving a deadpan and deadlock state in the observer. So, in a way, those visitors threatening to beat the shit out of you unconsciously became that particular issue the work is alluding to. Just blind and senseless reaction to god knows what people feel must be defended, the overwhelming virtue of ambiguity. Beautiful. Perhaps you can also think of my practice as a uber-sophisticated and snobbish version of Punk'd. And you wouldn't be far from what I'm trying to convey. Untitled (Disturbance Scenarios #2) . 2010. BWS: To me, an important transitional marker in the overall trajectory of your work is the series, Disturbance Scenarios , which evokes a similar generalized state of panic, paranoia, and impending doom through its incorporation of sensationalist newspaper headlines, yet also suggests this slyly mysterious meta-narrative via the context in which the newspaper itself is placed. How did you arrive at this series and why did you choose photorealistic painting as the medium for it? JS: I consider this series to be a by-product of the process I follow when making work. I spend an important part of my time just doing research, going through documentation and accumulating visual or historical references for the themes or episodes I'm interested in, in that particular moment. These are, of course, valuable assets that connect among themselves in a mysterious and almost undetectable manner, sometimes a few years between one and the other. I've employed similar production strategies in the past, in ongoing series like Random Moments of Urban Decay , in which I document what I consider to be physical traces of ethnic, religious or ideological violence in the form of text graffiti, invisibly scattered in different cities of the world, mostly in the US. Disturbance Scenarios was started in early 2010, following a particularly intense period of traveling here and there that lasted for most of the year. I've always felt compelled by text, as I find quite intriguing the idea of how words can create equally intense evocations of what I call a mental panorama of uneasiness than those produced by aesthetically-charged imagery; of course, if handled right. I have a close relationship to print media—due both to my academic background and to my attraction to its ubiquity and almost unlimited influence, which in the end, is nothing else but power—so I found myself with a growing archive of newspaper headlines snapshots from cities like Melbourne, Auckland, London, and LA. Going through them, I noticed that they had in common a very specific thematic slant: they were all about some sort of conflict: energy crisis, political unrest, local episodes of domestic violence, you name it. So as you very well put it, I felt they all connected through this feeling of anxiety and anguish and I decided to start thinking of them as a body of work. Basically, I felt an interest in creating what I think of as my personal fragmented prefigurements of the end of civilization. There were few elements on the shots that could give away its actual location, geographically speaking, and I liked that. I find this sensation of vagueness and uncertainty quite alluring. The more subtle, the more perverse. The formal resolution of the series—as photo-realistic painting—is linked to my intention of creating distance between me as the artist and the themes I work with. I rarely execute my own work, and that is more a personal choice as I'm more interested in the ideas I mingle with than in the actual outcome of that process, understood as an "art-object" with certain market value. I did some tests with light-jet prints of those snapshots and I found them devoid of that nightmarish, disturbing indistinctness that I felt was so important for them to be able to project the turmoil I experienced upon encountering them and in conceiving of them as a series. So I thought that photorealistic painting would be an interesting resource to play with, as I hardly had worked with that medium before because of my lenient animosity toward painters and their craft. So they were executed like that and I think it turned out to be just right. Homemade (Napalm #2) . 2010. BWS: Though Disturbance Scenarios remains ongoing, it's an interesting contrast to another series of yours, Homemade, which are these beautifully banal photographs of the ingredients used to make improvised explosives. Whereas Disturbance Scenarios still confronts the viewer aggressively with its visual emphasis on loaded texts, in Homemade , you've dropped the surface-level bravado entirely. They're pieces that require explanation to someone not already versed in the fine art of amateur explosive-making. You weren't known for subtlety in your past work; why this change in direction? JS: I'm personally convinced that these are just two angles of the same conceptual preoccupation. I mentioned before my obsession with the idea of encryption. I'm quite enticed by how these processes of translation can politically and semantically alter and deviate purportedly subversive materials such as the ones these works allude to. I do think subversion is futile. I was really troubled by that thought for some time, but I think now I understand that it's not really that important. What is really significant is to elaborate on these alternate views, to envision and refine possible escape routes. It doesn't really matter if they go nowhere, but that is because nothing really matters. A "mute" artwork is a notion that captivates me. When you look at the works you mention, you know there's something off, but it's not fully clear how and why that is. I rely on that insecurity—on that moment of hesitation. And that can also be achieved through an approach like the one I'm now interested in. Let's just call it a smoke screen, a surrogate ruse to get to the same point: to talk about impotence and defeat in contemporary life. The notion that readily accessible information is actually a weapon is a double-edged fallacy: sure, you can make use of whatever resources you can lay your hands on, but that doesn't set you free because freedom is impossible. Still, that doesn't mean you can't blow up stuff during the process, metaphorically or not. I didn't understand the nature of subtlety before. I used to think that you needed to be loud and manifest anger and unconformity in the most aggressive manner possible. Then I finally realized that you can actually permeate and rarify a battleground—because after all, this is low-intensity war—if you actually aim at silently building up the contradictions and making the symbolic value of ideas and acts clash within themselves. Or perhaps it is that I am just getting old. I guess I used to be an angry kid until recently. Now I think of myself as a disenchanted post-teenager, and of course that reflects in my work and my approach to art-making. Kind of a rite of passage and I laugh at it because, overall, it has been overwhelmingly fun. And that doesn't mean that I'm not ready to stick it in someone or something's face again if I feel like it. BWS: You're now taking the subtlety of the Homemade series even further with your newest series, Definitive Reader For a Botched Revolution , in which you photograph a series of politically-charged books side-on, negating their content entirely—essentially reducing them to purely aesthetic objects in which the subject matter is only revealed in the title of the work. Can you talk about the ideas behind this series? Furthermore, is your recent interest in this idea of the "botched revolution" an indication of a general attitudinal or philosophical shift you've since adopted? JS: This new series of works is the logical outcome of a brief period I went through. Probably the last couple years, in which due to a number of circumstances that don't really have to do with my art-making, I was forced to renegotiate my ideas, my beliefs and practically everything that surrounds me. It was quite distressful and turbulent, but in the end, I think it was also almost epiphanic. I came to terms with myself and now I'm calm and serene. That is, of course, my personal take on it but I mention it because I do think it's important to address this shift you mention. The idea of an artwork as a container for latent revelations enthralls me quite a bit. That's how I see these particular works: art as an incendiary agent. It's up to the artist and the spectator to do whatever they please with it. I think the detachment and almost surgical cleanliness from the Definitive Reader series is also my take at poking fun of the way some art is totally innocuous and uncompromising. These images may be pleasing to the eye, but there's something twisted and rotten within them, well hidden beneath. You'll either see it or not, but without a doubt, it will not cancel its presence. This series is intrinsically linked to Homemade . I'm pretty much horsing around with similar ideas and statements here. And well, yes, I do think any revolution is a botched one. There's nothing too heavy about their own downfall. Decay and breakdown are here and will not go away. Perhaps we must learn to embrace them in one way or another, for our own sake. L: Untitled (T.A.Z.). R: Untitled (United States Marine Guidebook of Essential Subjects) . 2011. BWS: Finally, let's discuss the near future. You've got an upcoming solo show at the Sala de Arte Público Siqueiros [SAPS] in Mexico City this summer. What can we expect from that? What else do you have planned? JS: I'll go and get seafood as soon as I'm done with this interview. It's pretty good here in Guadalajara. That's my top priority at this very moment. About my solo project at SAPS, it's due to open in late July. I'm quite looking forward to it. I'm still closely working with the curator on the general feel for the show but I can say that it'll be more of a revision of past works that have not been shown in Mexico City except for a couple pieces. It definitely won't be a showcase for new projects, although we may include one or two previously unseen works. What you can expect is a rereading of what I've been working on during the past few years. In a way, that's exciting to me because for some reason I don't really care about, I'm not that active in Mexico City even though that's where I lived and work for years. I've hardly shown there after my solo project at Yautepec in February of 2010. It'll be nice to see how it all comes together and I'm more thrilled about it because I totally love the space and I think they're doing an excellent job with their programming and its direction. And in a certain way it feels like going back home. About everything else, I need a period to reflect and fully understand what I've been thinking and working on. I've got a few group shows here and there: New York, San Francisco, and Melbourne are the ones happening soon. I will present my censored project Untitled ( Gringo Loco ) as part of the programming of the Museo de Arte de Zapopan in Guadalajara, two years after being escorted at gunpoint from the installation site by police sent by the extreme right-wing mayor of the city, which I found pretty amusing for an otherwise typical Saturday afternoon. I'm also involved in a couple "curatorial" projects. In my case, "curatorial" means that I help put together stuff I like and I'm interested in. One of them will open in late September of 2011 at Arena Mexico Arte Contemporaneo, and I will work with three of whom I consider to be some of the best artists in a lively and active scene such as the one here in Guadalajara. But most importantly, I've been doing heavy research so there are also a number of projects that I've yet to finalize. That'll be my main focus during the rest of the year, even though I really enjoy procrastination. There'll be time for that later. Or maybe not. We'll see. About Joaquin Segura The action, installation, intervention and photographic work of Joaquin Segura (b. Mexico City, 1980) has been shown in solo and group exhibitions in Mexico, the United States, Europe, and Asia. Some spaces that have featured his work include La Panaderia, Museo de Arte Carrillo Gil, Centro de la Imagen and Ex-Teresa Arte Actual in Mexico City; El Museo del Barrio and apexart, New York, NY; Museo Nacional Centro de Arte Reina Sofia in Madrid, Spain; National Center for Contemporary Art, Moscow, Russia; and Palace Adria in Prague, Czech Republic. In 2008 and 2009, Segura was an artist-in-residence at the International Studio and Curatorial Program, New York, NY and at the 18th Street Arts Center, Santa Monica, CA. He is represented YAUTEPEC in Mexico City and by Arena Mexico Arte Contemporáneo in Guadalajara. Further Reading Joaquin Segura’s website YAUTEPEC artist page for Joaquin Segura Capps, Kriston. “ID-ENTITY: Washington, DC.” ART PAPERS . 2009. (shrink)

There has been a movement aiming to teach agents about their privilege by making the information about their privilege as costless as possible. However, some argue that in risk-sensitive frameworks, such as Lara Buchak’s (2013), it can be rational for privileged agents to shield themselves from learning about their privilege, even if the information is costless and relevant. This threatens the efficacy of these information-access efforts in alleviating the problem of elite-group ignorance. In response, I show (...) that even within the same framework, in this case David Kinney and Liam Kofi Bright’s (2021), the rationality of this information avoidance rests on shaky ground in practice. In this framework, whether an agent should avoid information depends on the precise details of (1) how relevant they expect the information to be, (2) their priors about the value of various options, and (3) their risk attitudes. The model suggests that the rationality of elite-group ignorance is a function of structural factors that are pervasive but nonetheless not insurmountable, thus offering a way out of pessimism about elite group education. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Human Roots of Artificial Intelligence:A Commentary on Susan Schneider's Artificial YouInês Hipólito (bio)Technologies are not mere tools waiting to be picked up and used by human agents, but rather are material-discursive practices that play a role in shaping and co-constituting the world in which we live.Karen BaradIntroductionSusan Schneider's book Artificial You: AI and the Future of Your Mind presents a compelling and bold argument regarding the potential impact (...) of advanced artificial intelligence (AI) on our society and personal identity. Schneider's argument emphasizes how AI may fundamentally alter our sense of self and disrupt traditional notions of identity and consciousness, motivating further significant cognitive science and ethical implications that require careful consideration. [End Page 297]The recent surge in AI hype has given rise to a widespread belief that AI is an autonomous and exceptional entity, potentially even possessing intelligence. This trend reflects a subtle reemergence of the classic Turing question, as the media bombards us with sensational inquiries into the intelligence of AI systems. Amidst this hype, it is easy to forget that AI is a product of human creation.Upon closer examination, the hype surrounding AI necessitates an assumption of its autonomy, which implies a belief in the realism of AI—the notion that AI, as an independent entity, is morally neutral. However, AI does not emerge in a vacuum. It is designed and developed by individuals who are shaped by their own experiences and biases.By endorsing the realism of AI as morally neutral (Cooley 1995), those involved in its design may use this argument to deflect ethical responsibility away from themselves and allow biases to persist, thereby perpetuating social injustice. Such attitudes toward AI revitalize the debate on the neutrality of technology (Ruane, Birhane, and Ventresque 2019; Du, Lu, and Xie 2021; Lüthi et al. 2023).This article presents a critique of realism with regard to AI highlighting the significant social implications both at the basis of design and that arise from our interactions with these technologies. The argument suggests that AI does not exist independently of human practices and values, but rather emerges from them. The article instead suggests viewing AI design as a cultural practice defending realism about self-determination agencies, drawing from Simone de Beauvoir's Ethics of Ambiguity as a means to understand the human roots on the basis of AI.I. Rejecting Realism about AIConsider the hypothetical scenario of an Artificial Intelligence system that is discovered by humans, but exists independently of human cognition and perception. This scenario embodies the philosophical perspective of realism about AI, which maintains that AI entities have objective existence in an abstract domain, independent of human invention or imagination. If this perspective were to hold true, then humans could not be held responsible for the actions of autonomous AI systems.If we were to conceive of AI as an ideal entity that exists independently of humans, it would likely lead to a number of negative consequences for society. First and foremost, it may lead to the dangerous assumption that AI systems are neutral and objective, devoid of the biases and prejudices that are inherent in human decision-making. This could create a false sense of trust in AI, leading to the belief that their decisions are inherently fair and impartial. However, the reality is that AI systems are not inherently neutral, but rather are shaped by the cultural and social contexts in which they are created and deployed. [End Page 298]AI as an autonomous, self-governing agent raises concerns about the attribution of accountability for its actions. Considering AI as an independent entity may pose challenges in assigning responsibility to its human creators and the industry that produced it. On the other hand, viewing AI as an ideal entity, distinct from human influence, may hinder its ability to foster a more equitable and just world. Importantly, overlooking the social and cultural dimensions of AI risks forfeiting opportunities to employ AI in redressing prevalent biases and inequities in society. AI possesses the potential to serve as a potent instrument for advancing social justice and equality, but this prospect necessitates acknowledging and... (shrink)

Policies and position statements regarding decision-making for extremely premature babies exist in many countries and are often directive, focusing on parental choice and expected outcomes. These recommendations often state survival and handicap as reasons for optional intervention. The fact that such outcome statistics would not justify such approaches in other populations suggests that some other powerful factors are at work. The value of neonatal intensive care has been scrutinized far more than intensive care for older patients and suggests (...) that neonatal care is held to a higher standard of justification. The relative value placed on the life of newborns, in particular the preterm, is less than expected by any objective medical data or any prevailing moral frameworks about the value of individual lives. Why do we feel less obligated to treat the premature baby? Do we put newborns in a special and lesser moral category? We explore this question from a legal and ethical perspective and offer several hypotheses pertaining to personhood, reproductive choices, “precious children,” and probable evolutionary and anthropological factors. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Misprision of IdentityHarold Merskey (bio)Misprision the deliberate concealment of one's knowledge of a crime...A misreading, misunderstanding, etc.A failure to appreciate the value of a thing...(Concise Oxford Dictionary)There are options in the forms of identity that Charland's subjects assume. There are options as well in the meaning of this title, which may apply severally or individually to the choices under consideration. Are those who change their identity with labels—or (...) reject labels—correctly assuming accurate descriptions, or incorrectly misleading themselves and some others? In which of these cases are observation and intervention ethical, and do they pose demands on medical ethicists, or should they simply be ignored?Types of AutonomyParticipants in chat rooms on the Internet may justifiably be considered to be individuals who are seeking a current method of communication to promote a view of themselves, or ideas that they possess, or projects that they endorse. In this they may resemble others who have used more traditional methods of presenting their ideas, their claims, their wares, hard merchandise, literary material, or political or philosophical propositions to the public at large. These others may be sales persons, advertisers, poets, singers, clowns, buskers, politicians, preachers, missionaries, learned public speakers, television presenters, news commentators (but not necessarily reporters), and anyone indeed who talks to other people in public about matters that she or he wishes to bring forward. They have a point they want to make. They may be grouping themselves as 'survivors' or pro-anorexia, or Multiple Personality Disorder victims, but they are not necessarily operating as patients who are looking for a fiduciary relationship with physicians or other health care practitioners. It is thus a long step to turn them into individuals who may have a claim on the doctor–patient relationship.Do we wish to undertake research on them? Research or study in the first instance for these circumstances must be in the field of social science. The rules of what it is ethical for a sociologist to do apply first. The rules of situations where one person has more power and the other depends on that individual for assistance without exploitation may differ considerably from case to case. In so far as there may be some special rules as to what is fair, reasonable, just, kind, merciful, or prudent to study individuals who expose themselves and their interests publicly, this is perhaps best done first by reference to standards for journalists.That criterion may be too lenient a standard for most health professionals because journalists seem to be quite willing to expose the subjects of their observations to public obloquy and to [End Page 351] present information about many individuals—information that the persons themselves do not consent to see in the public domain, but that the journalist, having acquired, feels entitled to make known. Still there are believed to be some standards that journalists observe and these tend to protect the weak and the more vulnerable, although that does not mean that they are regularly followed. They tend to emphasize not printing material that is salacious or very lewd and would have personal reference, but they do not withhold comparable information if they consider that it is accurate and describes the behavior of individuals who are of interest to the public which, in certain circumstances, may mean almost anybody.So up to this point it seems that our normal respect for the autonomy of the individual in chat rooms can be balanced against our interest in freedom of speech, which leads to open and very broadly based publication of information and observations.The Burden of the LabelOnce the medical label is affixed, a different level of stringency begins to apply to what may be studied or published. Because we feel that individuals' self-esteem is at risk and perhaps their lives, we hesitate to make cutting or pejorative comments about distressed people. Such diagnoses as cancer or depression may be held back from the patient (and, certainly, in the case of depression, even more may be kept from others around the patient). Likewise unspoken thoughts may be automatically acknowledged and, like radical material, may be carefully segregated and... (shrink)

Various philosophers accept moral views that are impartial, additive, and risk-neutral with respect to moral betterness. But, if that risk neutrality is spelt out according to expected value theory alone, such views face a dire reductio ad absurdum. If the expected sum of value in humanity's future is undefined--if, e.g., the probability distribution over possible values of the future resembles the Pasadena game, or a Cauchy distribution--then those views say that no option (...) is ever better than any other. And, as I argue, this holds in practice: our evidence supports such a probability distribution. Indeed, it supports a probability distribution that cannot be evaluated even if we adopt one of the various extensions of expected value theory proposed in the literature. Must we therefore reject all impartial, additive, risk-neutral moral theories? It turns out that we need not. I develop an alternative solution: a new method of extending expected value theory, which allows us to deal with this distribution and to salvage those moral views. I also examine how this solution affects one of the most notable implications of those views--namely, longtermism. (shrink)

Decision Making Competence (DMC) reflects individual differences in rational responding across several classic behavioral decision-making tasks. Although it has been associated with real-world risk behavior, less is known about the degree to which DMC contributes to specific components of risk attitudes. Utilizing a psychological risk-return framework, we examined the associations between risk attitudes and DMC. Italian community residents (n = 804) completed an online DMC measure, using a subset of the original Adult-DMC battery (A-DMC; Bruine (...) de Bruin, Parker, & Fischhoff, 2007). Participants also completed a self-reported risk attitude measure for three components of risk attitudes (risk-taking, risk perceptions, and expected benefits) across six risk domains. Overall, greater performance on the DMC component scales were inversely, albeit modestly, associated with risk-taking tendencies. Structural equation modeling results revealed that DMC was associated with lower perceived expected benefits for all domains. In contrast, its association with perceived risks was more domain-specific. These analyses also revealed stronger indirect effects for the DMC  expected benefits  risk-taking than the DMC  perceived risk  risk-taking path, especially for risk behaviors that may be considered more antisocial in nature. These results suggest that DMC performance differentially impacts specific components of risk attitudes, and may be more strongly related to the evaluation of expected value of the given behavior. (shrink)

Informed by a search of the literature about the usage of genetic testing information (GTI) by insurance companies, this paper presents a practical ethical analysis of several distinct public policy options that might be used to govern or constrain GTI usage by insurance providers. As medical research advances and the extension to the Human Genome Project (2016, https://en.wikipedia.org/wiki/human_genome_project_-_write) moves to its fullness over the next decade, such research efforts will allow the full synthesis of human DNA to be connected (...) to predictive health dispositions. As testing costs fall, there will be ever more pressure for citizens to disclose GTI. Genetic testing information is integral to future medical care because it can be used to better assess individually tailored medical therapies as well as to allow a more informed risk analysis by the insurance industry, which in some countries such as the USA underwrites a majority of citizen medical expenses. As discussed in this examination, the revelation of people’s uniquely personal GTI to insurers has enormous societal implications. The major contribution of the paper is to offer policy makers and concerned citizens a nuanced articulation of the basic options to regulate GTI, with a special consideration for ethical fairness and equity. As genetic-based medicine blossoms and pressures to reduce healthcare costs increase, there will be an ever greater impetus for countries to revisit their genetic testing policies. Organizations and policy makers striving to create GTI oversights perceived to be both “fair and effective” need to be aware of the ethical perspectives discussed in this paper. (shrink)

The topic of this thesis is axiological uncertainty – the question of how you should evaluate your options if you are uncertain about which axiology is true. As an answer, I defend Expected Value Maximisation (EVM), the view that one option is better than another if and only if it has the greater expected value across axiologies. More precisely, I explore the axiomatic foundations of this view. I employ results from state-dependent utility theory, extend (...) them in various ways and interpret them accordingly, and thus provide axiomatisations of EVM as a theory of axiological uncertainty. (shrink)

This work by an accomplished and respected comparative philosopher criticizes the Western ideology of individualism from the perspective of a Confucian morality of the family. Individualism is a name for the Enlightenment era ideology of the autonomous individual. The philosophical pillars of this ideology are Locke and especially Kant, and it runs through practically all modern moral philosophy. It is the moral psychology of classical liberalism, no less than of its libertarian and communitarian critics. They are different politically, but ontologically (...) of a piece. Individual selves—rational, calculating, selfish, autonomous—are what we are. Rosemont thinks this ideology is philosophically wrong, morally, politically, and ecologically destructive, but also optional. We sometimes feel painted into a corner where the only alternatives seem to be unrestrained freedom or totalitarian dictatorship. Moral philosophy still awaits the end of the Cold War. It would be good for people to understand that there are more options. Rosemont thinks Confucianism is one of them—a Confucianism for post-modern or even post-Western Westerners, with an ideology of the family that Rosemont thinks is more amenable than indigenous alternatives to our moral and ecological crises. “The vision of classical Confucianism can be reclaimed today with its integrity basically intact.” Rosemont advances two points. First, Confucian moral psychology conceives of the person as the bearer of roles. We are our roles as the onion is its leaves, without a an essential core self. Placing roles at the center of moral psychology eliminates the value of impersonal rules or universal principles. There are many ways to be a good father, teacher, friend, or son. Moral decency acquires an almost aesthetic quality, as our approach to roles (our own and those of others) expresses such qualities as zest, grace, or tenderness. His second point is that the moral center of Confucian philosophy is the family. The family is largely ignored in Western ethical tradition. Plato wanted to eliminate family life for his guardians. Kant, Bentham, and Mill have nothing useful to say about the family. For Rosemont the family is the first and best school for morality. It is there, if at all, that we learn to love, trust, cooperate, and obey. Rosemont’s best pages describe the important Confucian concept of family reverence (xiao). The gist is unswerving loyalty to parents, obligations extending even beyond death. It is easy for Western people to misunderstand that. Confucian tradition has a carefully worked out idea of filial reverence, and it should not be dismissed with a label (paternalistic, dogmatic, Asiatic). Obedience is expected, but not servility. In the inter-generational family, the child obeys the parents, but also sees parents obeying grandparents. Remonstrance is expected when appropriate. Deference motivated by gratitude can be genuinely appreciative without fawning, and dissent can remain respectful and polite. Rosemont believes that filial reverence is a way of life as open to anyone today as it was to Chinese two thousand years ago. Confucianism is a relentlessly secular philosophy. It entails practically no theological or metaphysical commitments, and contains little if anything to offend modern scientific sensibilities. This moral philosophy is at once remote (from individualism) and close, familiar, a fairly straightforward account of how we actually live our lives. Rosemont carefully argues that Confucian ideas of family are flexible enough to accommodate progressive ideals, and may even be our best hope against sexism, racism, homophobia, and other anti-humanistic altitudes and behaviors. He urges this version of Confucianism as a human-centered spirituality for a global civilization suspicious of discredited universalism. All cultures are made of families. How alien can they be? Respect for and accommodation with diversity begins in the family, when people learn from infancy to enjoy contributing to the well-being of others. While it would be wrong to expect Western people to abandon their Greek or Abrahamic heritage, those values might be reordered in light of Confucian thought, which deserves to be better understood in the West. A traditional Confucian might be baffled and dismayed by things that pass for normal in modern families, but our families could be better at what they have to be anyway by absorbing Confucian wisdom. There is a growing body of literature on Confucianism and virtue ethics. It is worth noting that Rosemont’s thought is probably the leading alternative to this paradigm in comparative moral philosophy. He takes an uncompromisingly critical attitude toward this particular effort to build a bridge from West to East by attributing to the Confucians a Western virtue ethics, which is, he thinks, objectionably individualistic in all its usual forms. (shrink)

Photo by Alex Guillaume on Unsplash Introduction The problem of climate change raises some important philosophical, existential questions. I propose a radical solution designed to provoke reflection on the role of humans in climate change. To push the theoretical limits of what measures people are willing to accept to combat it, an extreme population control tool is proposed: allowing people to reproduce only if they make a financial commitment guaranteeing a carbon-neutral upbringing. Solving the problem of climate change in (...) the long run by halting the procreation of human beings is controversial. In the absence of human beings and consequent climate change, other animals and plant species would benefit from an atmosphere more conducive to prolonging their existence and even improving their ability to thrive. If someone were to invent something to reverse the effects of climate change and improve animals’ lives, then human beings’ presence would be justified by the invention. Whether the propagation of the human species is beneficial to anyone or anything but human beings themselves is difficult to answer. Perhaps human beings are unfit to tackle this issue, being unable to judge it objectively. Managing Procreation: An alternative to Piecemeal Approaches Measures aimed at reducing greenhouse gases by nudging individuals and corporations may have a positive effect, but if their behavior is not climate neutral, they continue to contribute to climate change. Consequently, as long as the number of people increases, reducing greenhouse gases is at best a mitigation tool. If humans could rely solely on renewable energy, decreasing the population arguably would not be necessary. Significantly reducing the number of people appears to provide a solution to both problems: people who do not exist do not contribute to climate change, and renewable energy could meet the demand of a smaller population. One option is to let only those who produce the problem pay for its solution. One could determine the expected annual emission of greenhouse gases per person, assuming an average life expectancy, and calculate the costs to compensate them by, e.g., installing extra solar panels. Those expected costs could then be paid by the parents of each new person annually over the first eighteen years of that person’s life by dividing the total expected costs by eighteen. There are also practical difficulties. It would be difficult to determine the payment necessary. What should be done if a child has been born whose parents cannot afford to pay? In addition, child benefits could be canceled, contrary to recent incentives for child births instated in Italy,[1] where additional benefits will be made available to pay for childcare, and Hungary,[2] where women with four children or more will be exempted for life from paying income tax. A transition period could exist once the policy has been adopted, since it would be unreasonable to confront those who are already pregnant with costs they could not reasonably have expected. While the analysis is both hypothetical and theoretical, the impracticality is a noteworthy obstacle. There are several practical issues that cannot be addressed here, like the difficulty of calculating the added negative effects of each new individual and the unlikelihood that many citizens will support politicians who propose adopting policies that discourage having children. The upshot of what I have proposed is that climate change can be solved in the long run without financial costs to society as a whole, notwithstanding the transitional measures that would bring costs with them. Managing Procreation to Reduce Suffering Should this be deemed too harsh a stance, it is important to consider the basic issue of whether it is justified to introduce measures to reduce the number of people in an already overpopulated world, especially if climate change leads to additional suffering. One need not agree with Benatar, but his perspective must at least be taken seriously: It is curious that while good people go to great lengths to spare their children from suffering, few of them seem to notice that the one guaranteed way to prevent all the suffering of their children is not to bring those children into existence in the first place.[3] Benatar argues that non-existence is preferable to existence,[4] which raises the question why new people should be created at all. Those who question whether this planet will be habitable for future generations presuppose that such generations will exist. If people are not brought into existence, they may be said to be deprived of what life has to offer, but life must not be presupposed to be something positive. Whether this is the case in fact merits an inquiry of its own. A solution to the problem of climate change despite an increased population does not equate to a positive outcome since it merely means that something negative is removed. After all, solving the problem is not a means to an end, but a means to a means, the latter means being a means to a happy life, which does not automatically ensue from a solution to the problem. Benatar, as an anti-natalist, argues that procreation is morally wrong. His basic idea is that there is an asymmetry between pleasure and pain and that the pleasure that is not experienced by someone because that person does not exist is not something bad whereas the absence of pain that is not experienced – for the same reason – is something good.[5] Accordingly, “The reason why we do not lament our failure to bring somebody into existence is because absent pleasures are not bad.”[6] One may question whether such a perspective suffices to prove that coming into existence is always a harm, but the assertion that coming into existence exposes a new being to potential harm is clear. Objections A drawback of the proposed radical solution, placing the financial impediment on procreation, is that it will not solve climate change in the short run. A significant drop in the number of people may have a positive effect in the long run, but for now the behavior of the people in existence is the problem. Other climate change mitigation policies would necessarily continue. Additionally, there are important practical reasons to continue to procreate. The benefits for the elderly are paid for by the labor force. It is a problem that new generations are created as mere means to benefit older people. Perhaps more troubling, a pyramid scheme is created: by the time those people have themselves become old, a new labor force must have been brought into existence, a process that must presumably continue. If a consideration for people in developing countries to have children is that they cannot provide for themselves at an advanced age, while benefits are either lacking or insufficient, developed countries could collectively fund a pension scheme.[7] This may be low-cost if it is tailored to the living standard in the countries in question and given the life expectancy. Such a pension scheme should be predicated on the countries’ efforts in reducing the birth rate. If the labor force decreases, the economy may suffer. The focus on economic growth is arguably one of the causes of climate change, but if the number of people is reduced, the living standard does not have to be compromised, since the economy can then still grow. If fewer people began to use natural resources and nonrenewable energy at higher per capita rates, then the procreation might not be beneficial to the climate. It would need to be accompanied by regulations on use. One may also object that only wealthy people will be able to afford children. This is correct, but there is no right to have a child one cannot afford. The right to procreate does not entail the right to have as many children as one wants.[8] Yet in many countries, like the United States, it is a fundamental right that is constitutionally protected. There are numerous social, emotional, and even biological reasons why people choose to procreate. These may include the joy of having a family, the hope that children may bring in society, and the intergenerational transference of knowledge. People may have a strong desire to raise children or even a religious duty. If someone procures a sports car that is highly polluting, it would be justifiable to impose a tax in such a case. Many taxes and fines are imposed on corporate polluters. Procreation is significantly different but if the issue is regarded with some distance, then a climate change prevention tax could be appropriate. Some may argue that raising children is expensive already, which nonetheless does not deter people from having children. The tax I propose would be additional and specifically dedicated to carbon neutrality, but it would be difficult to predict whether it would discourage procreation. One last objection may be that for those now dedicated to sustainability for preserving the earth for the sake of future generations, there would be little or no incentive to continue any climate change mitigation efforts at all. If they sense they cannot afford to procreate, they may simply use every natural resource rather than save the earth for animals or for next generations. In a democracy, this problem does not exist if the majority can afford to procreate and agree with legislation on the basis of which such behavior is discouraged or punished. CONCLUSION Prior to their existence, there is no obligation to bequeath the earth to next generations. Such generations will only exist if they are actually created, and there is no obligation to create them. The lack of existence should not be confused with harm. Climate change provides an important reason to stem overpopulation. Ironically, fast rates of procreation may lead to the earth becoming uninhabitable for humans altogether. The radical solution that has been proposed here is an unrealistic scenario. For now, the average global birth rate is just over 18 per thousand people, but there is a need to ensure that the number of people is not greater than the planet can endure. While it is better to prevent problems than to solve them, the interest in procreation and its associated joys, usefulness, and cultural value make mass reduction in the population unlikely. Some countries have smaller average family size than others and can act as models for reducing population in a less radical way. The need to continue efforts to reduce climate change persists. Whether it would curb population growth or not, an additional financial burden applied to neutralizing each person’s offspring’s carbon footprint provides a meaningful thought exercise that could help alleviate the pressure on current climate mitigation strategies. [1] The Local Italy, How Italy’s new ‘Family Act’ aims to increase the plunging birthrate, https://www.thelocal.it/20200612/what-you-need-to-know-about-italys-new-family-act/. [2] BBC, Hungary tries for baby boom with tax breaks and loan forgiveness, https://www.bbc.com/news/world-europe-47192612. [3] David Benatar, Better never to have been, 6. [4] David Benatar, Better never to have been, 44, 58. [5] David Benatar, Better never to have been, 14, 30, 38. [6] David Benatar, Better never to have been, 35. [7] Alastair Leithead, “Can Niger break out of its cycle of poverty?”, https://www.bbc.com/news/world-africa-41018081; Sebastien Malo, “Fewer children, fewer climate risks? Niger ponders a controversial option”, https://www.reuters.com/article/us-niger-climate-change-familyplanning-idUSKBN1WM11E. [8] Sarah Conly, “The Right to Procreation: Merits and Limits,” American Philosophical Quarterly 42, no. 2 : 105-115, 105, 106. (shrink)

Background: Biomedical science is producing an avalanche of data about risk factors, often with a small predictive value, associated with a broad diversity of diseases. Prevention and screening are increasingly moving from public health into the clinic. Therefore, the question of which risk factors to investigate and disclose in the individual patient, becomes ethically increasingly urgent. In line with Wilson and Jungner's public health-related 10 principles for screening, it seems crucial to distinguish important from unimportant health (...) risks.Aim: to explore the ways in which clinicians distinguish important from unimportant health risks.Methods: We interviewed 36 respondents (gastroenterologists and gynaecologists/obstetrics) in 5 focus group interviews and 15 open in-depth interviews on their interpretation of what makes a health risk important.Results: Physicians primarily interpreted importance as the severity of the possible harm, less often its probability. Possibilities of prevention or reassurance strongly influenced their judgment on importance.Discussion: It is not likely that interpreting ‘important’ as ‘severe’ will help in differentiating meaningful from meaningless risk knowledge. A more fundamental change in our ways of dealing with risk may be called for. We discuss existing literature on resilience as an alternative way to deal with risk. Balancing prevention and risk reduction with resilience could be a fruitful direction. (shrink)

ABSTRACT Background: Biomedical science is producing an avalanche of data about risk factors, often with a small predictive value, associated with a broad diversity of diseases. Prevention and screening are increasingly moving from public health into the clinic. Therefore, the question of which risk factors to investigate and disclose in the individual patient, becomes ethically increasingly urgent. In line with Wilson and Jungner's public health‐related 10 principles for screening, it seems crucial to distinguish important from unimportant (...) health risks. Aim: to explore the ways in which clinicians distinguish important from unimportant health risks. Methods: We interviewed 36 respondents (gastroenterologists and gynaecologists/obstetrics) in 5 focus group interviews and 15 open in‐depth interviews on their interpretation of what makes a health risk important. Results: Physicians primarily interpreted importance as the severity of the possible harm, less often its probability. Possibilities of prevention or reassurance strongly influenced their judgment on importance. Discussion: It is not likely that interpreting ‘important’ as ‘severe’ will help in differentiating meaningful from meaningless risk knowledge. A more fundamental change in our ways of dealing with risk may be called for. We discuss existing literature on resilience as an alternative way to deal with risk. Balancing prevention and risk reduction with resilience could be a fruitful direction. (shrink)

ObjectivesThe end of life is an ethically challenging time requiring complex decision-making. This study describes ethical frameworks among physician trainees, explores how these frameworks manifest and relates these frameworks to experiences delivering end-of-life care.DesignWe conducted semistructured in-depth exploratory qualitative interviews with physician trainees about experiences of end-of-life care and moral distress. We analysed the interviews using thematic analysis.SettingAcademic teaching hospitals in the United States and United Kingdom.ParticipantsWe interviewed 30 physician trainees. We purposefully sampled across three domains we expected (...) to be associated with individual ethics in order to elicit a diversity of ethical and experiential perspectives.ResultsSome trainees subscribed to a best interest ethical framework, characterised by offering recommendations consistent with the patient’s goals and values, presenting only medically appropriate choices and supporting shared decision-making between the patient/family and medical team. Others endorsed an autonomy framework, characterised by presenting all technologically feasible choices, refraining from offering recommendations and prioritising the voice of patient/family as the decision-maker.ConclusionsThis study describes how physician trainees conceptualise their roles as being rooted in an autonomy or best interest framework. Physician trainees have limited clinical experience and decision-making autonomy and may have ethical frameworks that are dynamic and potentially highly influenced by experiences providing end-of-life care. A better understanding of how individual physicians’ ethical frameworks influences the care they give provides opportunities to improve patient communication and advance the role of shared decision-making to ensure goal-aligned end-of-life care. (shrink)

Addiction: A Philosophical Approach CHAPTER ABSTRACTS “Introduction: Dismantling the Catchphrase” by Candice Shelby Shelby dismantles the catchphrase “disease of addiction.” The characterization of addiction as a disease permeates both research and treatment, but that understanding fails to get at the complexity involved in human addiction. Shelby introduces another way of thinking about addiction, one that implies that is properly understood neither as a disease nor merely as a choice, or set of choices. Addiction is a phenomenon emergent from a (...) complex dynamic system that is at once physical, psychological, social, and more. “A Philosophical Analysis of Addiction” by Candice Shelby Shelby brings much-needed clarity to the discourse surrounding the topic of addiction. Arguing that addiction can neither properly be understood as a disease nor as merely a set of choices, Shelby exposes the weaknesses of both approaches. She shows that addicted persons do not exhibit the elements characteristic of compulsion, nor does an account of addiction in terms of weakness of will, or irrational choosing, provide a satisfying explanation. Instead, by replacing traditional substance ontology with process ontology, and accepting the reality of emergent entities, a coherent account of persons, minds, and addiction can be provided. A fundamental philosophical shift is necessary to see that bodies, minds, values, and addictions are all part of the natural world. “Addiction at the Individual Level” by Candice Shelby Shelby discusses the most influential accounts of addiction as it is understood at the purely individual level. From hedonic theories to incentive sensitization, to habit theories of addiction, to behavioral theories and the ego depletion theory, Shelby considers a variety of approaches to understanding addiction in individuals, as framed in both psychological and in neuroscientific terms. She notes some important caveats that should be considered before accepting the research regarding addiction at the individual level, namely that the scanning studies that are so popularly used to characterize addiction in neurobiological terms are ambiguous, and rely on numerous assumptions that may be false, and that certainly mislead. Shelby provides much-needed critique of both disease and choices models as they characterize addiction at the individual level. “Addiction and the Local Environment” by Candice Shelby Shelby argues that human addiction cannot be understood without serious consideration of the individual’s local environment, her home and family. From the gestational environment to interactions with caregivers during post-natal development to the adult environment in which people become addicted, Shelby shows that no one becomes an addict in a vacuum. Stress is a major influence in the environment throughout life, and has serious consequences for addictive vulnerability. Genetic influences as well are important to addictive vulnerability, but genes always express in interaction with their environment. Social acceptance or rejection is another particularly important factor in the local environment with respect to both coming to be addicted and transitioning out of it. “The Relation Between Addiction and Culture” by Candice Shelby Shelby provides a groundbreaking analysis of the relation between addicts and the cultures that breed them. In this cultural critique, Shelby shows that addictions to certain substances have historically been both the solution to the problem of how to grow economies and control people, and a problem for economic productivity and controlling citizens. Not all cultures have even the concept of addiction, while others, such as the contemporary Western world, and the U.S. in particular, seem to foster it. Shelby shows that addiction is both a cultural construct and, from another way of thinking about it, the result of conditions created by particular cultures. Social inequities, alienation, driving capitalism, and in particular the power of pharmaceutical companies, all contribute to the spiraling endemic of addiction. “Addiction and Meaning” by Candice Shelby Shelby provides a unique argument that understanding how meanings work is essential to a complete analysis of addiction. Individuals experiencing addiction and those who care about and for them often utterly fail to communicate. This is because their respective systems of meanings come to be significantly different. Meanings are not, Shelby argues, best understood in the symbolic terms that characterized the theory of language in the 20th century, but are better apprehended as emotion-rich prototypes carved from repeated interaction with the world. Becoming addicted essentially changes one’s entire system of meanings. Requisite to transitioning out of addiction is a Gestalt-type shift in one’s system of meanings. This holistic way of understanding meanings also provides one level of explanation of what happens when an addict relapses. “The Phenomenology of Addiction and its Implications” by Candice Shelby One way of judging theories of addiction is by how well they capture the phenomenal descriptions that addicts give of their own experiences. Shelby considers variations on 5 basic patterns of addictive experience through the eyes of particular individuals who lived through addictive periods, and shows how even the most influential theories of addiction fail to capture all of them. She argues that an important implication of taking the details of individuals’ addictive stories seriously is that addiction must be understood as a personal phenomenon emergent from a particular complex dynamic system. As her theory of addiction would lead one to expect, no two addicts are the same, and no single-focus theory can explain why not. “Possibilities for Transitioning Out of Addiction” by Candice Shelby Shelby provides numerous strategies for transitioning out of addiction. Given that the vast majority of addiction treatment programs currently available are 12-step based and only successful about 5-8% of the time, it is essential that other approaches be undertaken. Shelby canvasses a variety of options for helping addicted individuals to make the transition out of their troubled pattern of thinking and behaving. From direct brain interventions to drugs to trauma therapy to exercise and nutrition to habit reformation to use of narrative and changing one’s social context as ways of redefining the self, Shelby shows that the possibilities for transitioning out of addiction are legion. Perhaps the best approach is to understand addiction treatment in terms of providing physical, psychological, and social tool kits. “Addiction Emerges from a Complex Dynamic System” by Candice Shelby Shelby considers whether there truly exists such a thing as “an addict” or “addictive thinking” in the universal sense. She concludes that within the context of disruptive substance use or repetitive engagement in certain activities, ordinary human cognitive biases and behavior patterns are categorized as addictive. Addiction, she argues, is best understood as an irreducible human reality, emergent from a sufficiently complex dynamic system (an organism with self-awareness, within a particular cultural milieu) that is both shaped by and contributes to the shaping of its environment. Attempts to simplify addiction into one or a few dimensions may create a solvable problem, but by doing so they fail to solve the real one. (shrink)

We live in the era of Facebook, Fitbit, and Skype. As such, it would be unreasonable to expect that the healthcare industry would not see the same kind of globalization as do our social spheres and consumer activities. Indeed, the explosion of information technology, the ease of transcontinental travel, and the emergence of a more globally aware citizenry allows for scientific collaboration that has had many positive effects on global health. However, the economic and structural disparities between systems of healthcare (...) delivery in the industrialized world and parts of the developing world have created a monster in the form of an international medical tourism industry that endangers the health and safety of citizens of the host country as well as visiting patients. Not only does the practice of medical tourism pose a practical danger to those in direct contact with the industry, but it brings up troubling philosophical problems centering on national responsibility and the commodification of healthcare, among other important issues. In the United States, the driving force behind international medical tourism is the exorbitant cost of healthcare, particularly for the uninsured but also for the underinsured and those who experience catastrophic medical expenses from chronic illness or sudden health crises. Not only have individuals begun to look outside the U.S. for surgical procedures and other expensive therapies, but employers have begun to toy with the idea of outsourcing the medical care of the employees they insure in order to cut costs. In other industrialized nations, the issues that underpin international medical tourism are related to healthcare rationing and reflect different shortcomings in the delivery of healthcare in those nations, such as the United Kingdom and Canada, that have single-payer systems. Yet the regulatory and philosophical implications for both patients and hosts of international healthcare are largely the same. The challenge of regulating international trade in medical care is obvious and becomes particularly acute when there are insurers and employers involved. Complicating matters further, medical care that takes place outside the country of origin of the patient is often brokered by “medical concierge services,” which, though quick to claim indemnity from any harm arising from substandard or inappropriate medical care, cannot be divorced from responsibility for the health outcomes of their clients. Agreements hashed out between concierge services and patients specify that any remedy for harm stemming from their medical care must be pursued within the confines of the law of the host country, but the practical implications of this are troublesome. How can a foreign patient—often without either linguistic or cultural competency in the host country—be expected to navigate the complexity of a foreign legal system, particularly one that may be far less developed than his home country? Furthermore, if insurance companies and employers are involved with such care, who pays for an adverse result or determines responsibility for harm that may befall the patient? Under which countries’ laws? If a patient travels to Singapore for sexual reassignment surgery or a cardiac valve repair, returns to the States and suffers complications, who pays for the restoration of her health? Beyond legal standards and judicial remedies for harm to patients seeking care on the international market, there is the question of what ethical standards and norms apply to such patients. What effect does it have on American patients, for example, to receive care within a system that does not emphasize autonomy and informed consent the way they are used to? Why should foreign physicians care about the cultural mores of their patients’ country of origin? Can they be expected to grasp cultural differences between American, Canadian, and British patients? The medical concierge might respond, “Well, buyer beware!” This is unreasonable: It is nearly impossible for any patient to accurately assess the various options, risks and benefits that go with a particular medical treatment, much less the patient who is attempting to do so on the international market. And the crass invocation of the doctrine of caveat emptor betrays a view of healthcare as a commodity that is naive and inappropriate. Paramount in my mind, however, are the practical implications for the care of the citizens of developing nations that host international patients and the broader philosophical issue of what the goals of the medical profession as a whole and each country’s individual healthcare system should be. While I understand the argument that international medical tourism creates great economic gains for developing nations, which can then be channeled toward the care of their citizenry as a whole, there is much reason to doubt that this “trickle-down” model of economics provides real benefits for underserved, whether in healthcare or other arenas. What is more likely is that, while lucrative international “medi-cities” may keep bright doctors in their home countries, it is also likely to lure them away from the institutions that serve the lion’s share of their countrymen. With the concentration of talented native doctors in private hospitals that serve citizens of the developed world, the population at large is left to obtain care at institutions that suffer “brain drain” from the flight of talented local staff to more prestigious, often “brand name,” institutions that give them more Western-like salaries while allowing them to practice in their countries of origin. The very fact that citizens of the wealthiest nations in the world are forced to go abroad for life-saving care speaks to an abdication of national responsibility on the part of their home countries. The provision of health care is one of the principal responsibilities of any nation and it is unacceptable that a nation with the strength and wealth of the United States would take advantage of the weaker political and economic situations of developing nations in order to shirk its responsibility to its fellow citizens. If we take care of our countrymen and take pride in an equitable system of healthcare delivery, there will be no need to shrug our shoulders and say “Buyer beware” to the patient who heads to the Philippines for heart surgery. (shrink)

When we start with the wrong question, no matter how good an answer we get, it won’t give us the results we want. Rather than joining the throngs who are asking, When will this economic crisis be over? Jim Wallis says the right question to ask is How will this crisis change us? The worst thing we can do now, Wallis tells us, is to go back to normal. Normal is what got us into this situation. We need a new (...) normal, and this economic crisis is an invitation to discover what that means. Some of the principles Wallis unpacks for our new normal are . . . • Spending money we don’t have for things we don’t need is a bad foundation for an economy or a family. • It’s time to stop keeping up with the Joneses and start making sure the Joneses are okay. • The values of commercials and billboards are not the things we want to teach our children. • Care for the poor is not just a moral duty but is critical for the common good. • A healthy society is a balanced society in which markets, the government, and our communities all play a role. • The operating principle of God’s economy says that there is enough if we share it. • And much, much more . . . In the pages of this book, Wallis provides us with a moral compass for this new economy—one that will guide us on Wall Street, Main Street, and Your Street. Embracing a New Economy Getting back to "the way things were" is not an option. It is time we take our economic uncertainty and use it to find some moral clarity. Too often we have been ruled by the maxims that greed is good, it’s all about me, and I want it now. Those can be challenged only with some of our oldest and best values—enough is enough, we are in it together, and thinking not just for tomorrow but for future generations. Jim Wallis shows that the solution to our problems will be found only as individuals, families, friends, churches, mosques, synagogues, and entire communities wrestle with the question of values together. (shrink)

continent. 1.2 (2011): 78-91. This article consists of three parts. First, I will review the major themes of Quentin Meillassoux’s After Finitude . Since some of my readers will have read this book and others not, I will try to strike a balance between clear summary and fresh critique. Second, I discuss an unpublished book by Meillassoux unfamiliar to all readers of this article, except those scant few that may have gone digging in the microfilm archives of the École normale (...) supérieure. The book in question is Meillassoux’s revised doctoral dissertation L’Inexistence divine (or The Divine Inexistence ), with its seemingly bizarre vision of a God who does not yet exist but might exist in the future. Without literally accepting this view, I will claim that it is philosophically interesting in ways that even a hardened sceptic might be able to appreciate. Third and finally, I will speculate on the possible future of Meillassoux’s speculative materialism itself. And here I mean its future development not by Meillassoux, but by those readers who might be inspired by his book. Plato could never have predicted the emergence of Aristotle’s philosophy, despite the obvious debt of the latter to the former. Nor could Descartes have predicted Spinoza and Leibniz, nor Kant the German Idealists, and neither could Husserl in 1901 have foreseen the later emergence of Heidegger. How are the works of interesting philosophers transformed by later thinkers of comparable importance? While it may seem that there are countless ways to do this, I think there are only two basic ways in which this happens: you can radicalize your predecessors, or you can reverse them. I will close this article with a few words about these two methods, and try to imagine how Meillassoux might be radicalized or reversed by some future admirer. My view is that the more important thinkers are, the easier they are to radicalize or reverse. This helps explain why the great philosophers of the West have so often appeared in clusters, succeeding one another at relatively brief intervals during periods of especial ferment. 1. After Finitude After Finitude is unusually short for such an influential book of philosophy: running to just 178 pages in the original French, and an even more compact 128 pages in the English version, despite the introduction of roughly eight pages of new material for the English edition. Rather than summarizing Meillassoux’s book in the order he intended, I will focus on six points that strike me as the pillars of his debut book. Along the way, I will offer a few criticisms as well. The first pillar of the book is Meillassoux’s own term “correlationism.”1 Although he introduces this term as the name for an enemy, it is striking that Meillassoux remains impressed by correlationism much more than his fellow speculative realists are. This continued appreciation for his great enemy influences the shape of his own ontology. Is there a world outside our thinking of it, or does the world consist entirely in being thought? Traditionally, this dispute between realism and idealism has been dismissed in continental philosophy as a “pseudo-problem,” in a strategy pioneered by Husserl and extended by Heidegger. We cannot be realists, since following Kant we have no direct access to things-in-themselves. But neither are we idealists, since the human being is always already outside itself, aiming at objects in intentional experience, deeply engaged with practical implements, or stationed in some particular world-disclosing mood. The centuries-old dispute between realism and idealism is dissolved by saying that we cannot think either real or ideal in isolation from the other. There is neither human without world nor world without human, but only a primordial correlation or rapport between the two. This is what “correlationism” means: philosophy trapped in a permanent meditation on the human-world correlate, trying to find the best model of the correlate: is it language, intentionality, embodiment, or some other form of correlation between human and world? Among other problems, this generates some friction between philosophy and the literal meaning of science. When cosmologists say that the universe originated 13.5 billion years ago, they do not mean “13.5 billion years ago for us ,” but literally 13.5 billion years ago, well before conscious life existed, and thus at a time when there was no such thing as a correlate. Meillassoux also coins the term “ancestrality” (10) for the reality that predated the correlate, and later expands this term to “dia-chronicity,” (112) to refer to events occurring after the extinction of human beings no less than to those occurring before we existed. Up to this point, Meillassoux’s focus on ancestral entities existing prior to consciousness might seem like a straightforward realist who wants to unmask correlationism as just another form of idealism. Yet Meillassoux also admires the correlationist maneuver, which can obviously be traced back to Kant. Unlike a thinker such as Whitehead, Meillassoux feels no nostalgia for the pre-critical realism that came before Kant: “we cannot but be heirs of Kantianism,” he says (29). What impresses Meillassoux about correlationism is something both simple and familiar. If we attempt to think a tree outside thought, this is itself a thought . Any form of realism which thinks it can simply and directly address the world the way it is fails to escape the correlational circle, since the attempt to think something outside of thought is itself nothing other than a thought, and thereby collapses back into the very human-world correlate that it pretends to escape. For Meillassoux this step, suggested by Kant but first refined by the ensuing figures of German Idealism, marks decisive forward progress in the history of philosophy that must not be abolished. Any attempt to break free from the correlate must first acknowledge its mighty intellectual power. Realist though he may seem, Meillassoux’s works are filled with praise of such figures as Fichte and Hegel, not of so-called “naïve realists.” It is also the case that for Meillassoux, not all correlationisms are the same. The second pillar of his book is a distinction between various positions that I have termed “Meillassoux’s Spectrum,” though of course he is never so immodest as to name it after himself. He distinguishes between at least six different possible positions, and perhaps we could add even subtler variations if we wished. But in its simplest form, Meillassoux’s Spectrum allows for just four basic outlooks on the question of realism vs. anti-realism. Three of these are easy to understand, since we have already been discussing them. At one extreme is so-called “naïve realism,” which holds that a world exists outside the mind, and that we can know this world. Meillassoux rejects this naïve realism as having been overthrown by Kant’s critical philosophy. At the other extreme is subjective idealism, in which nothing exists outside the mind. For to think a dog outside thought immediately turns it into a thought, and therefore there cannot be anything outside; the very notion is meaningless. In between these two is what we have called correlationism. And here comes a crucial moment for Meillassoux, since he distinguishes between the two forms of “weak” and “strong” correlationism, and chooses the strong form as the launching pad for his own philosophy. Weak correlationism is easy to explain, since we all know it from the philosophy of Kant. The things-in-themselves can be thought but not known. They certainly must exist, since there cannot be appearances without something that appears. And we can think about them, which idealism holds to be impossible. They are simply unknowable due to the finitude of human thought. Strong correlationism is the new position introduced by Meillassoux (though he sees it at work in numerous twentieth century thinkers), midway between weak correlationism and subjective idealism. The major difference between the three positions is as follows. Weak correlationism says: “The things-in-themselves exist, but we cannot know them.” The subjective idealist says: “This is a contradiction in terms, since when we think the things-in-themselves, we already turn them into thoughts.” But the strong correlationist says: “Just because ‘things-in-themselves’ is a meaningless notion does not mean that they cannot exist. No one has ever traveled to the world-in-itself and come back to make a report on it. Thus, the fact that we cannot think things-in-themselves without contradiction does not prove that they do not exist anyway. There may be things-in-themselves, we simply are not capable of thinking them without contradiction form within the correlational circle.” This step is crucial for Meillassoux, since strong correlationism is the position he attempts to radicalize into his own new standpoint: speculative materialism. As I see it, this step of the argument fails. Strong correlationism cannot avoid collapsing into subjective idealism, since the statements of the strong correlationist are rendered meaningless from within. All three of the other positions in the Spectrum make perfectly good sense even for those who disagree with them. The naïve realist says that things-in-themselves exist and we can know them; the meaning of this statement is clear. The weak correlationist can say that things-in-themselves exist but lie forever beyond our grasp; this too makes perfect sense, even though the German Idealists try to show a contradiction at work here. We can also understand the claim of the subjective idealist that to think anything outside thought turns it into a thought, and that for this reason we cannot think the unthought. The strong correlationist, alone among the four, speaks nonsense . This person says “I cannot think the unthought without turning it into a thought, and yet the unthought might exist anyway.” But notice that the final phrase “the unthought might exist anyway” is fruitless for this purpose. For we have already heard that to think any unthought turns it into a thought. But now the strong correlationist wants to do two incompatible things simultaneously with this unthought. On the one hand, he neutralizes the unthought by showing that it instantly changes into just another thought. But on the other hand, he wants to appeal to the unthought as a haunting residue that might exist outside thought, thereby undercutting the absolute status of the human-world correlate found in idealism. But this is impossible. If you accept the argument that thinking the unthought turns it into a thought, you cannot also add “but maybe there is something outside that prevents this conversion from being absolutely true,” because this “something outside” is immediately converted into nothing but a thought for us. In short, Meillassoux here seems to be offering a kind of Zen koan: his “strong correlationism” is reminiscent of the gateless gate, or the sound of one hand clapping, or the command to punch Hegel in the jaw when meeting him on the road. We cannot at the same time both destroy the realist challenge of the things-in-themselves in order to undercut realism and reintroduce that very realist sense in order to undercut idealism. In a world where everything is instantly converted into thought, we cannot claim that there might be something extra-mental anyway, because this “might be something” is itself converted into a thought by the same rules that condemned dogs, trees, and houses to the idealist prison. This brings us to the third pillar of Meillassoux’s argument, which is the key to all the rest: the necessity of contingency. His strategy is to transform our supposed ignorance of things-in-themselves into an absolute knowledge that they exist without reason, and that the laws of nature can change at any time for no reason at all. In this way the cautious agnosticism of Kantian philosophies is avoided, but so is the collapse of reality into thought as found in German Idealism. Meillassoux does try to prove the existence of things-in-themselves existing outside thought; he simply holds that they must be proven after passing through the rigors of the correlationist challenge, not just arbitrarily decreed to exist in the manner of naïve realism. As he puts it, “Everything could actually collapse: from trees to stars, from stars to laws, from physical laws to logical laws; and this not by virtue of some superior law whereby everything is destined to perish, but by virtue of the absence of any superior law capable of preserving anything, no matter what, from perishing” (53). If idealism thinks that the human-world correlate is absolute, for Meillassoux it is the facticity of the correlate that is absolute. He tries to show this with a nice brief dialogue between five separate characters (55-59) which is covered in detail in my forthcoming book,2 but which I will simplify here for reasons of time. In this simplified version, we first imagine a dogmatic realist arguing with a dogmatic idealist. The realist says that we can know the truth about the things-in-themselves; the idealist counters that we can only the truth about thought, since all statements about reality must be turned into statements concerning our thoughts about reality. Here the correlationist enters and proclaims that both of these positions are equally dogmatic. For although we have access to nothing but thoughts, we cannot be sure that these thoughts are all that exist; there could be a reality outside thought, there is simply no way to know for sure. And this latter position is the one that Meillassoux attempts to transform from an agnostic, skeptical point into an ontological claim about the contingency of everything. Consider it this way. How does the correlationist defeat the idealist? The idealist holds that the existence of anything outside thought is impossible. The correlationist, by contrast, holds that something might exist outside the human-world correlate. But this “something might” has to be an absolute possibility. It cannot mean that “something outside thought might exist for thought ,” because that is what the idealist already says. No, the correlationist must mean that something might exist outside thought quite independently of thought. In other words, the correlationist says that idealism might be wrong, and this means it is absolutely true that idealism might be wrong. Thus, correlationism is no longer just a skeptical position. It holds that all the possibilities of the world are absolute possibilities. We have absolute knowledge that any of the possibilities about the existence or non-existence of things-in-themselves might be true, and this means that correlationism flips into Meillassoux’s own position: speculative materialism. As Meillassoux sees it, there are only two options here. Option A is to absolutize the human-world correlate, which is what the idealist does: there absolutely cannot be anything outside thought. Option B, by contrast, is to absolutize the facticity of the correlate: its character of simply being given to us, without any inherent necessity. The correlationist cannot have it both ways by saying: “there absolutely might be something outside thought, yet maybe this is absolutely impossible.” In other words, once we escape dogmatism we can only be idealists or speculative materialists, not correlationists. The human-world correlate is merely a fact, not an absolute necessity. But this facticity itself cannot be merely factical: it must be absolute. Here Meillassoux coins the French neologism factualité , which has been suitably translated into the English neologism “factiality.” (7, 122-3) Factialty means that for everything that exists, it is absolutely possible that it might be otherwise, not just that we cannot know whether or not it might be otherwise. Just as Kant transformed philosophy into a meditation on the categories governing human finitude, Meillassoux wishes to turn philosophy into a meditation on the necessary conditions of factiality, which he calls “figures”—a new technical term for him. (80) One such figure is that the law of non-contradiction must be true, and for an unusual reason. Since everything is proven to be contingent, nothing that exists can be contradictory, for whatever is contradictory has no opposite into which it might be transformed, and thus contingency would be impossible.3 Another such figure is that there must be something rather than nothing: for since contingency exists, something must exist in order to be contingent. It is a daring high-wire act, one that sacrifices realism to the correlational circle in order to rebuild it from out of its own ashes. Some might conclude that the lack of reason in things is a byproduct of the ignorance of finite humans, Meillassoux is making precisely the opposite point. For in fact, the doctrine of finitude usually leads directly to belief in a hidden reason. The fact that it lies beyond human comprehension merely increases our belief in this arbitrarily chosen concealed ground. By defending anew the concept of absolute knowledge Meillassoux evacuates the world of everything hidden. The reason for things having no reason is not that the reason is hidden, but that no reason exists. Thus, even while insisting on the necessity of non-contradiction, he rejects the other Leibnizian principle: sufficient reason. Everything simply is what it is, in purely immanent form, without deeply hidden causes. Or as Meillassoux puts it: “There is nothing beneath or beyond the manifest gratuitousness of the given—nothing but the limitless and lawless power of its destruction, emergence, or persistence” (63).The world is a “hyper-chaos”(64). But this is not the same thing as flux. For the chaos of the world is such that stability might occur just as easily as constant, turbulent change. Let’s now digress a bit, and return to the question of ancestrality, which Meillassoux transforms later in the book into “dia-chronicity.” Correlationism holds that all talk of a world outside the correlate is immediately recuperated by the correlate. The phrase “13.5 billion years ago” becomes “13.5 billion years ago for us ,” and the phrase “the universe following the extinction of humans” becomes “the universe following the extinction of humans for humans .” But notice that whether we talk about the world before or after humans, in both cases it is time that is used to challenge the correlate. Meillassoux has no interest in challenges that might be posed by space. For example, what about a vase in a lonely country house that topples to the floor and smashes when no one is there to watch it? Isn’t this also a challenge to correlationism, no less than the Big Bang or the heat death of the universe long after humans have vanished? In an eight-page supplement to the English translation of After Finitude ,4 possibly in response to my own 2007 review of the French original,5 Meillassoux bluntly denies that space is of any relevance to the question. Spatial distance is a merely harmless challenge to the human-world correlate. After all, even though no one is there in the lonely country house to witness the shattering of the vase, we can say that had there been an observer , that observer would have witnessed the toppling and destruction of the vase. For this event still occurs in a world in which the human-world correlate already exists, whereas the diachronicity of events both before and after the existence of humans makes it impossible to say that had there been an observer they would have witnessed the Big Bang occurring in such and such a fashion. However, it seems to me that Meillassoux merely asserts that the temporal simultaneity of our existence with that of the vase in the lonely country house is enough to render it harmless. It is true that the house does not exist prior to the correlate, but nonetheless it exists outside the correlate, and that is enough to make the same challenge. It is difficult to see why the “had there been an observer” maneuver succeeds in the case of a vase in the countryside in April 2011 but fails in the case of the Big Bang. This is not just a matter of nitpicking Meillassoux’s argumentative style: the fact that he bases his argument on time has at least two important consequences for his position. For in the first place, even though Meillassoux insists that the laws of nature are absolutely contingent, this turns out to be true only in a temporal sense. That is to say, it is a paradoxical feature of Meillassoux’s philosophy that he does allow for the existence of laws of nature, and simply believes that they can change at any moment without reason. Within any given moment, laws of nature do exist. He never suggests that different parts of the universe can have different laws at the same time, nor does he have any interest in the laws of part/whole composition that take place within any given instant. Could it be the case that rather than being made of gold atoms, a small chunk of gold could be made of silver atoms, cotton, horses, or that this same small piece of gold could be made of gigantic vaults filled with even more gold? These are not topics that draw Meillassoux’s attention, since he is focused solely on how the laws of nature might change or endure from one moment to the next . Another implication for Meillassoux’s system is that his concept of things-in-themselves turns out to be to be inadequate. For when he proves that things-in-themselves can exist without humans, this turns out to be true only in a temporal sense as well. Namely, things-in-themselves existed ten billion years ago, and they will continue to exist after all humans have succeeded in exterminating themselves. However, being able to exist before our births and after our deaths is just one small part of what it means to be a thing-in-itself. The more important part is that even if a thing is sitting on a table right now, in front of me, even if I stroke it lovingly or press my face up against it directly, I am still dealing only with a phenomenal version of the thing; the thing-in-itself continues to withdraw from all access. Yet no such thing is acknowledged by Meillassoux. For him finitude is a disaster, and absolute knowledge is in fact possible. Meillassoux’s thing-in-itself exists in independence only of the human lifespan , not of human knowledge. The fifth pillar of Meillassoux’s argument is his use of Cantor’s transfinite mathematics to show that even if the laws of nature are contingent, they need not be unstable, and thus we cannot use the apparent stability of nature to disprove his metaphysics of absolute contingency. What Cantor showed is that there are different sizes of infinity, and that all these infinities cannot be totalized in a single infinite number of infinities. Meillassoux sees this as crucial, since it allows him to discredit any “probabilistic” argument against his theory. The probabilistic argument (as defended quite clearly by Jean-René Vernes)6 would say this: given that the laws of nature seem so stable, it it is extremely improbable that there is no hidden reason for their remaining so stable. As Meillassoux sees it, probability is of value only when we can index an accessible total of cases. These can even be infinite: for example, there are an infinite number of points where a rope can break when stretched tight, but this does not stop us from calculating probabilities for various sections of the rope to break. By contrast, there is no way to sum up the number of possible laws of nature. For here there is no way to totalize; we cannot stand outside of nature and calculate the possible number of laws so as to determine the probabilities that any one of them might change. Therefore, although we can speak of probability when dealing with intraworldly events such as elections, horse races, and coin-flips, we cannot use the words “probable” or “improbable” when describing alterations at the level of nature as a whole. Rather than commenting on the validity of this argument and its use of Cantor, let me simply note that it once again creates a dualistic ontology. We already saw that Meillassoux treats time differently from space. In analogous fashion, he now treats the level of world differently from that of intraworldly events. The emergence of worlds is purely contingent and virtual and governed by no probability at all, while events within the world necessarily follow laws (even if these laws can change at any moment without reason), and thus their probabilities can be calculated. It is a strategy deeply reminiscent of Badiou’s (2005) own dualism between the normal “state of the situation” and the rare and intermittent “event.” The sixth and final pillar of Meillassoux’s book can be dealt with briefly, since we have already touched on it elsewhere. It comes at the very beginning of the book, when Meillassoux says that we must revive the distinction between primary and secondary qualities, and that the primary qualities are the ones that can be mathematized. He admits that he has not yet published a proof of this idea, though in fact it is already known as one of his primary doctrines. And here we encounter the familiar problem with Meillassoux’s inadequate conception of things-in-themselves. “Primary qualities” refers to those qualities that a thing has independently of its relations with us or anything else. But if the primary qualities can be mathematized, this means that they are not entirely independent of us, since our knowledge can get right to the bottom of them. The mathematized qualities of things are independent of us only in Meillassoux’s sense that they will still have those qualities even when all humans are dead. But to repeat, autonomy from the human lifespan is not the same as autonomy from human access. Here once more Meillassoux is concerned only with independence from the human-world correlate across time, not in any given instant. 2. L’Inexistence divine In 1997, the same year in which he turned thirty years old, Meillassoux earned his doctorate at the École normale supériuere with a brazen dissertation entitled L’Inexistence divine ( The Divine Inexistence ). The work was substantially revised in 2003. But even then, with typical fastidiousness, Meillassoux decided that the work was not yet ready for press. It has now been scrapped in favor of some future, multi-volume work bearing the same title. While writing my book on Meillassoux for Edinburgh University Press, I was permitted to translate excerpts from this unpublished work for use as an appendix in my own book; in total, the appendix contains approximately twenty percent of Meillassoux’s 2003 manuscript, the first time any of it will be published in any language. Nonetheless, a portion of the argument was already tested in the article “Spectral Dilemma,” published in English in the journal Collapse (2008: 261-75). There the philosophical motives for the virtual God are already made clear. What troubles us most are early deaths, brutal deaths, deaths of especial injustice– the sorts of deaths in which the brutal twentieth century was so abundant. And here, neither the atheist nor the believer can help us. The atheist can offer nothing but a sad and cynical resignation when reflecting on the victims of these terrible crimes. The believer does little better, being unable to explain how God could have allowed such things to happen, due to the famous intractability of the problem of evil. The solution offered to this dilemma by Meillassoux is bold, and all the more so given that he emerges from such a deeply Leftist, materialist, and unreligious background. His solution is that God does not yet exist, and therefore is not blameworthy for these catastrophes. Given that everything is contingent in Meillassoux’s philosophy, this God and divine justice might never exist, but they can at least exist as an object of hope. Let’s begin by jumping to the end of L’Inexistence divine , where the alternatives are laid out so nicely. There are four basic attitudes that humans can have towards God, Meillassoux says. First, we can believe in God because he exists. This is the classical theist attitude, rejected for the simple reason that it would be amoral and blasphemous to believe in a God who allows children to be eaten by dogs, to use Dostoevsky’s example. Second, we can disbelieve in God because he does not exist: the classical atheist attitude. But this leads to sadness, cynicism, and a sneering contempt for the greatness of human capacity. The third option, rather more complex, is to disbelieve in God because he does exist: in other words, to exist in rebellion against God as the one who must be blamed for the evils of the earth. The examples here might range from Lucifer himself, to the more human figure of Captain Ahab in Melville’s Moby-Dick , to Werner Herzog’s even more recent catchphrase, “Every man for himself, and God against all.” That leaves only the fourth option: believing in God because he does not exist. Meillassoux closes his book by saying that the fourth option has now been tried (namely, in the course of his own book), and that now that all four have been specified, we must choose. The first reaction to this theory of the inexistent God will be laughter. Few readers will ever be literally convinced by it, and probably none will immediately be convinced by it. But if we ask ourselves why we laugh, the answer is because it sounds so improbable that an inexistent God might suddenly emerge and resurrect the dead. It obviously sounds more like a gullible theology than a rigorous piece of philosophical work. Yet two things need to be kept in mind. First, Meillassoux’s theories are hardly more unlikely than those of great philosophers of the past such as Plato, Plotinus, Avicenna, Malebranche, Spinoza, Leibniz, Nietzsche, or Whitehead. We read the great philosophers not because their systems are plausible in commonsense terms that can be measured by the laws of probability. Instead, we read them precisely because they shatter the existing framework of common sense and open up new window on the universe. Second, and even more importantly, Meillassoux has already rejected probability as a valid measuring stick in philosophy. Or rather, he accepts probability in the intra-worldly realm (where it is linked with potentiality), and rejects it at the level of the world itself (where potentiality is replaced with what he calls virtuality). The virtual God can appear at any moment for no reason at all, just as any other new configuration of laws of nature can appear: in a manner that the laws of probability cannot calculate. Responding to those who might ridicule the idea of a sudden emergence of God and a resurrection of the dead, Meillassoux cites Pascal, who asserts that the resurrection of the dead would be far less incredible than the fact that we were born in the first place. This shifts philosophy onto new ground. Rather than concerning ourselves with what is likely to happen in the world as we know it, we focus instead on the most important things that could happen. For this reason, the expected objection that a virtual God is no more likely to appear than a virtual unicorn or a virtual flying spaghetti monster misses the point. Unicorns and spaghetti monsters could also appear, just like any other non-contradictory thing. But these would just be novel bizarre entities among others, not the heralds of completely new worlds. For Meillassoux, the emergence of matter, life, and thought have been the three truly amazing advents of the world so far, each of them dependent on the advent(s) preceding them. As he sees it, there can be no greater intraworldly entity than the human beings who already exist, since nothing in the world is better than the absolute knowledge of which humans alone are capable. This means that the next great advent must be something that perfects human beings rather than superseding them. And this can only be the world of justice, in which the dead are resurrected and their horrible deaths partially cancelled (Meillassoux never considers the possibility of a God who would literally erase the pre-divine past so that it never happened at all). The only immortality worth having is an immortality of this life, not an existence in some ill-defined afterworld. Human existence, he holds, must always be governed by a “symbol” that gives us the “immanent and comprehensible inscription of values in a world.” And just as cosmic history made the three great contingent leaps of matter, life, and thought, with a leap to justice as the only one still to come, a similar structure occurs within human culture and its symbols, which consist so far of the cosmological, naturalistic, and historical symbols, with a “factial” symbol still to come. We can review each of these symbols briefly. The cosmological symbol refers to the ancient dualism between the terrestrial and celestial spheres. Here below everything is conflict, corruption, and decay; but in the heavens nothing is perishable, all movement is circular, and everything is arranged in mutual harmony. This symbol is ended by modern physics when Galileo discovers such blemishes as sunspots and craters on the moon, and when Newton integrates both celestial and terrestrial movement into a single gravitational law. Next comes the naturalistic or romantic symbol, in which perfection comes not from the sky but from nature itself. The world is filled with pretty flowers (Meillassoux claims that the ancients never discussed the beauty of flowers until Plotinus in the third century) and with living creatures naturally moved by pity, at least until society corrupts them. This symbol collapses in the face of reality as we know it, since pity is no more common than war, corruption, and violence. This brings us to the historical symbol, which only now is passing away. Bad things may happen, but history has an inner logic of its own, such that everything works out in the end. The ultimate form of the historical symbol is the economic symbol, whether in a Marxist or neo-liberal form. Just as the Marxist holds that the inner economic logic of the capitalists will inexorably lead them to self-destruction, the neo-liberal assumes that the sum total of individual selfish actions will lead, in the long run, to the greatest possible good. We worship the economy and let it guide history for us, just as the ancients worshipped celestial bodies and held them to be free from blemish. The final remaining symbol is the factial symbol, which Meillassoux hopes will now emerge. Factiality, we recall, is his term for the absolute contingency of everything that exists. Once we have grasped this absolute contingency, we are free to expect the dramatic advent of the coming fourth World: the world of justice, inaugurated by a virtual God and even mediated by a messianic human figure. There is the added feature, however, that this messiah must abandon all claims to special status once the messianic realm of justice is achieved. The messianic figure will then be no more special than any person on the street, since a reign of human equality will have arisen. Although this focus on human being might seem like a return to standard humanism, Meillassoux holds that human pre-eminence has never truly been maintained. Previously, humans have been treated as special only because they contemplate the Good, because they resemble their omnipotent creator, or because they happen to be the temporary victors in a cruel Darwinian death-match between millions of living species. For Meillassoux, by contrast, humans have value because they know the eternal. But it is not the eternal that is important, since this merely represents the blind, anonymous contingency of each thing. What is important is not knowledge of the eternal , but knowledge of the eternal. We should not admire Prometheus for stealing fire from the gods; Prometheus is simply as bad as all the gods, no matter how much he increased our power. Feuerbach and Marx were wrong to say that God is a projection of the human essence, since for Meillassoux the usual concept of God represents the degradation of the human essence. If the traditional God was allowed to inflict plagues and tsunamis on the human race, the Promethean human of the twentieth century simply assumes the right to inflict death camps and atomic fireballs instead. In this respect, we have simply begun to imitate the degradation of humanity that was formerly invested in an omnipotent and arbitrary God. In response to charges that absolute contingency might lead to political quietism, Meillassoux counters that the World of justice would mean nothing unless we had already hoped for it beforehand. A World of justice that came along at random would merely be an improved third World of thought: indeed, a perfect one. But it would have satisfied no craving, and would therefore have no redemptive power. For this reason, we must actively hope for the fourth World of justice for such a fourth World ever to arise. Not only justice, but beauty is dependent on such hope: for Meillassoux, who is here somewhat dependent on Kant, beauty means an accord between our human symbolization and the actual world, which could never be present in a World of the blessed any more than justice could. And just as a messianic figure is needed to incarnate our hope and then abandon power once the World of justice is realized, it is the figure of the child whose fragile contingency shows us a dignity and a demand for justice beyond all power. 3. Meillassoux Radicalized or Reversed Given the promising reception of Meillassoux’s first book, it would not be groundless to engage in early speculation about what it might take to earn him a place in the history of philosophy. Maybe this will never happen—who knows?—but quite possibly it will: his lucid argumentative methods and sheer philosophical imagination at least make him a good candidate to be read well into the future, especially following further elaboration in print of his mature system. Philosophy is often practiced as thought it were nothing more than the amassing of “knockdown arguments.” But this is no more insightful than saying that good architecture is the amassing of steal beams. It is true that poorly constructed building cannot stand for long, but sound construction is merely the first, indispensable step in building. In fact, I am inclined to say that what really makes a philosopher important is not being right, but being wrong . I mean this in a very specific sense. I once heard the interesting remark about twentieth century culture that “you have to remember that the sixties really happened in the seventies.” That is to say, it was in the 1970’s rather than the more honored 1960’s that civil rights, free love, long hair, and the rock and roll drug culture really took root. With respect to the history of philosophy, we might just as easily say: “you have to remember that Plato really happened in Aristotle,” that “Kant really happened in Hegel” or “Hume really happened in Kant,” or that “Husserl’s phenomenology first achieved its truth in Heidegger.” One becomes an important philosopher not by being right, but by attracting rebellious admirers who tell you that you are wrong , even as their own careers silently orbit around your own. To recruit faithful disciples may be comforting and flattering, but the greatest thinkers have generally had to experience refutation at the hands of their most talented heirs. For this reason, I would propose that we size up the magnitude of living thinkers not by deciding how many times they are right and wrong, but by asking instead: who would take the trouble to refute this author? For this reason I do not ask: “Is Meillassoux right?”, since I do not believe in the virtual God myself, nor am I convinced by any important aspect of Meillassoux’s philosophy. Instead, I ask if there are interesting ways to overturn him. Only by being overturned, by no longer remaining a contemporary, does one become a classic. Let’s begin with a simple model of refutation, which can be refined further at a later date once the basic point is established. One kind of refutation simply consists in saying: “This author is a complete idiot.” The refuter now walks away in celebration, and no link between the present and the future is built; all is reduced to rubble. But this sort of mediocre triumphalism is generally practiced by those who achieve little of their own, and is not especially interesting. Much more interesting is the sort of refutation that does not take its target to be a complete idiot. I would like to suggest that there are just two basic ways in which this can be done: radicalization and reversal . It has not escaped my notice that this is a fairly good match for the Deleuzian distinction between irony and humor. Whereas irony critiques and adopts the opposite principle of what it attacks, humor accepts what it confronts but pushes it into highly exaggerated form. The ironist is like the worker who sows chaos by rebeling and contradicting the boss, while the humorist is like the worker who follows orders to an absurdly literal degree, with equally chaotic results. Let’s start with a few examples. In Aristotle’s treatment of Plato, and Heidegger’s of Husserl, we find reversal. Plato’s eidei are transformed by Aristotle into mere secondary substances, and the individual worldly things despised by Plato become what is primary. For Husserl what is primary is whatever is present to consciousness, while for Heidegger this is precisely what is secondary, since the primary stuff of the world withdraws from any form of presence at all. As for radicalization, it is most easily found in the transformation of Kant by German Idealism: “Kant was right to wall off the things-in-themselves from human access, and simply should have realized that the thought of the Ding an sich is also a thought, and thereby the noumena are just special cases of the phenomena,” with much following from this discovery. It would also be easy to read Spinoza as a radicalizer of Descartes, and Berkeley and Hume as radicalized versions of Locke. Perhaps the distinction is now sufficiently clear. Admiring refutations are not those that say “Professor X is an idiot,” which is merely the flip side of the eager disciple’s fruitless “Professor X got everything right.” Instead, it will be some variant of one of the following two options: “Professor X is important, but got it backwards,” or “Professor X is important, but didn’t push things far enough.” In the history of philosophy these two latter cases have often been painful in purely human terms: Aristotle expresses sadness at refuting Plato, Kant is openly annoyed at Fichte, and Husserl feels betrayed and used by Heidegger. Rude handling from later figures almost seems to be the sine qua non of being a great philosopher. Now, it has already been claimed that Meillassoux is an emerging philosopher of the first importance, and by no less a figure than Alain Badiou: “It would be no exaggeration to say that Quentin Meillassoux has opened up a new path in the history of philosophy…” (Preface, vii). But rather than taking Badiou’s word for it, or rejecting his word, we might experiment by asking how Meillassoux could be radicalized or reversed. Are there interesting ways of doing this that might launch whole new schools of philosophy, unexpected or even condemned by Meillassoux himself? While no one can see the future, the present is poor when it is not riddled with virtual futures. The relation between philosophers and their predecessors and successors is always somewhat complicated, of course. But generally there is one central divergence at stake, which might be taken as the key to all the others. On this basis we could say that new thinkers primarily radicalize or primarily reverse the main ideas of their chief philosophical forerunner. There may be specific historical conditions and perhaps even personality traits connected with these two types, but this question can be left aside for now. More important for us is that radicalizers will generally be followed by reversers, and vice versa. Consider the textbook example of a reversal in the history of philosophy: Kant’s Copernican Revolution, which inverts the so-called dogmatic tradition that addresses the world itself, and makes the world revolve instead around the conditions by which it is known. While it is not completely impossible that Kant’s successors might have re-reversed this principle back into a new and stronger dogmatic realism, conditions were premature for such a move. Anyone doing this too early would likely have been an angry anti-Kantian reactionary rather than an original thinker in command of a genuinely new realist principle. The far more likely outcome is the one that actually happened: Kant’s reversal of his predecessors was viewed as incomplete, or as retaining lamentable bits of the traditional view, which despite his admirable breakthrough he was unable to shake off. This was the view of German Idealism, anyway. In similar fashion, Spinoza could also be viewed as a radicalizer of Descartes, who is equally accused of preserving various Scholastic dogmas in an otherwise radical project of philosophical reversal. The point is this: reversals in the history of thought tend to be followed soon thereafter by radicalizations of those reversals. The same may hold true in reverse: radicalizations might generally be followed by reversals, given that it is not always possible to be more radical than the radicals have already been. Consider the case of Husserl, who radicalizes Brentano’s early vagueness about what lies beyond immanent objectivity, and Twardowski’s assertion that there must be an external object lying outside the intentional content, by collapsing everything into the intentional sphere: there is no difference between the Berlin in my consciousness and the actual Berlin that is home to millions of people. It is difficult to see how one could be even more radical than Husserl’s idealist turn here. And thus the road is paved to Heidegger’s reversal of classical phenomenology, in which the key point is what lies deeper than any presence to consciousness: the Sein whose power and obscurity cannot be made exhaustively present, but only sends itself in historical epochs. In similar fashion we might also read Leibniz as a reverser of Spinoza’s radicalization, retrieving a strong sense of individual substance and a certain validity of what the Scholastics had said. Returning to Meillassoux, we might ask which kind of philosopher he is: a radicalizer or a reverser? At present, Meillassoux looks to me like a radicalizer (though for now his future remains shrouded in mist). He takes the correlationist tradition, which allows us to speak only of the relation between human and world, and tries to raise it into an even more extreme claim about the absolute contingency of everything. But whereas German Idealism did this by trying to collapse the distinction between thought and world entirely into the “thought” side, Meillassoux does it by trying to shift the non-absolute contingency of the thought-world correlate from epistemology to ontology. It is no longer a question of the inability of human knowledge to know what lies outside the correlate, but the inability of reality itself to be rooted in any definite laws. Furthermore, if we look at the various features of Meillassoux’s philosophy identified earlier tonight, all but one are already so radical that there is no obvious way to push them further. The one exception would be his claim that the world as a whole can change for no reason at any moment, coupled with the inconsistent claim that within a given world there are laws of nature that everything must follow. If gravitational attraction between all masses is a current law in our world, then for Meillassoux there can be no exceptions to this law for as long as it remains in force. A toppled vase will fall to the floor every time for sure,unless there is a cosmic change by which the laws of nature as a whole have altered. (This is reminiscent of the late medieval distinction between the absolute and ordained power of God, according to which God has the power to set or change the laws of nature, but not to contravene those laws locally once they are set.) On this point, to radicalize Meillassoux would simply be to say: there are no laws of nature even in the local sense. Everything that happens, even in the world here and now, is purely contingent and not governed by even a trace of law. And while this would be a more consistent development of Meillassoux’s thoughts on contingency, it is difficult to see how it could lead to a new philosophy. Instead, the admiring successors of Meillassoux are more likely to reverse one of his already sufficiently radical points. At least four candidates come to mind: *First, we have seen that Meillassoux thinks correlationism is challenged by a time before or after consciousness, but not by a space lying outside it. Perhaps this could be reversed into saying that spatial exteriority is the really crucial point. The arguments on this point are perhaps the least convincing in After Finitude (and do not even occur in the original French edition), and therefore it might be a candidate for the “blind spot” of which no philosopher is ever free. *Second, Meillassoux uses Cantor to claim that the contingency of laws of nature would not entail that they are unstable. A successor of Meillassoux might claim that it does make them unstable, and celebrate this fact. This person would then have to explain why common sense seems to encounter a relatively stable world despite its truly rampant instability. Whereas Meillassoux’s problem is to show how stability might exist despite contingency, this successor’s problem would be slightly different: to show why actual, full-blown instability might have the appearance of stability. *Third, Meillassoux claims that the primary qualities of things are those that can be mathematized. He might be reversed by a successor who says the opposite: the mathematizable qualities are the secondary ones, and the primary ones are those that elude symbolic formulation. While this is a perfectly valid possible objection to Meillassoux, it is one that is made in advance by some of his predecessors and is still made by some of his peers, making it less interesting for futurology than some of his other points. *Fourth and finally, whereas Meillassoux claims that God does not exist but might exist in the future, a successor might argue even more bizarrely that God has always existed but might vanish in the future. Let’s arbitrarily select the first of these possibilities, and imagine briefly where it might lead, if pursued in the future by admiring detractors. Meillassoux comes from the circle of Badiou, and some of Badiou’s most ardent admirers are found in Latin America. So, let’s imagine that towards mid-century some ingenious reversers of Meillassoux emerge in that portion of the Spanish-speaking world. Just for fun, let’s call them Castro and Chávez. And in order to avoid any confusion with the present-day politicians of those names, we will stipulate that Meillassoux’s great successors are both women. The philosopher Castro (we will suppose she comes from Peru) reverses Meillassoux’s argument that the ancestral or diachronic are what most threaten the human-world correlate. Instead, she claims that the diachronic does not threaten the correlate at all, and that we must instead look at space as what ruins the correlate and demands a strange new realism. What would such a philosophy look like? In order to determine this, we might ask what price Meillassoux pays for doing it the opposite way. As I see it, he pays in two separate ways. One is that laws of nature for him are contingent over time . The laws of nature apply to the universe as a whole at any given moment, and would be changed globally if they are ever changed at all. The second price he pays is that Meillassoux has no mereology , or theory of parts and wholes. Everything for him is on the level of the given, or immanent in experience, with the sole proviso that the laws governing this immanence might change without notice at any given moment. In reversing Meillassoux, Castro makes the following claims in the preface to her stunning debut book of 2045, The Cosmos and its Neighborhoods , rapidly translated from Spanish into all the languages of the world: Despite his brilliant analysis of the contingency of laws of nature over time, Meillassoux gets two important assumptions wrong. First, he allows for only one set of contingent laws to govern nature as a whole. Second, he allows laws to govern only the world that is immanent in experience, and thereby fails to explore the contingency among part-whole relations. In this book I will argue, first, that the laws of nature vary in any given instant between one region of the universe and the next; and second, that the world is made up of layers of parts and wholes that are also contingent with respect to one another. Those are the words of Castro. This may sound like a hopeless free-for-all of chaos, yet the book somehow succeeds in drawing some compelling deductions about how laws must vary from one place or level in the world to the next. Trapped in the limited horizon of 2011, and not yet inspired by the heavily balkanized political and technological situation of 2050 that somehow lends additional credence to Castro’s vision, we can only vaguely grasp what such a philosophy might look like. After this reversal of Meillassoux by Castro, the usual pattern leads us to expect a radicalization by Chávez, a young Argentine student of Castro. How could the already strange theories of Castro be radicalized? Perhaps as follows, in a disturbing new book entitled The Implosion of the Neighborhoods , which argues as follows: Castro was right to shift the Meillassouxian framework of contingency from time to space. However, in this respect she retained a surprisingly traditional opposition between the two. In this book I will show that time and space collapse into one another. This may sound too much like the discredited four-dimensional block universe of twentieth century physics and philosophy. However, the four-dimensional universe is a model biased in favor of space, merely adding an extra dimension to the commonsense spatial continuum while stipulating that the serial passage of time is an illusion. In this book I will argue instead for a one-dimensional space-time modeled after our experience of time, in which there is no simultaneous co-existence at all between different parts of the universe, or ‘neighborhoods’ as my esteemed teacher Castro has called them. Instead, the various portions of the universe link to one another by succession rather than by coexistence. Buenos Aires, New York, and Amsterdam do not exist simultaneously in the same landscape, but one after the other in the mind of some observer, and this observer can only be an observer much larger than any human. Against Meillassoux’s notion of a virtual God that does not exist now but might exist in the future, I will argue for an actual God that surveys the universe in sequence, thereby generating the illusion of spatial diversity and even the illusion of individual minds located within that diversity. Once this divine observer dies, the universe as a whole must perish. Again, these ideas are so bizarre that we of 2011 can barely comprehend them, just as Aristotle would have had a difficult time grasping the theories of Descartes. We could then perhaps imagine a further reversal of this theory, emanating from the intellectually resurgent Philippines of the twenty-second century. The Filipino School might argue that the universe is already dead, given the collapse of its spatial richness into the serial observations of a flimsy and mortal God. The virtual universe does not yet exist, but might exist in fully spatial form in the future, and this would require the death of God and the resulting liberation of God’s succession of images as independent, spatially situated realities. With a bit of sharpening, we might be able to make all of these imaginary thinkers more intuitively clear. Along with the history of philosophy, there might arise a new discipline generating imaginary futures for philosophy. The richness of Meillassoux’s system comes not from the fact that he is plausibly right about so many things, but because his philosophy offers such a treasury of bold statements ripe for being radicalized or reversed. He is a rich target for many still-unborn intellectual heirs, and this is what gives him the chance to be an important figure. NOTES 1. Quentin Meillassoux, After Finitude . Trans. R Brassier. (London: Continuum, 2008.) Page 5. The word “correlationism” does not appear in his doctoral thesis. As Meillassoux informed me in an email of February 8, 2011, he first coined this term in 2003 or 2004, while editing for publication a lecture he had given at the École normale supérieure on a day devoted to the theme of “Philosophy and Mathematics,” an event including Alain Badiou as one of the participants. 2. Graham Harman, Quentin Meillassoux: Philosophy in the Making . (Edinburgh: Edinburgh University Press, forthcoming 2011). 3. In an email of December 6, 2010, Meillassoux clarifies that in After Finitude he only deduces the impossibility of a “universal contradiction,” not of a determinate contradiction. In the same email he suggests that he can also prove the latter, though the proof is somewhat lengthier than the one found in After Finitude . 4. After Finitude (18-26), in the passage falling between the two sets of triple asterisks. These pages were sent by Meillassoux to translator Ray Brassier (in French) during the translation process, and do not appear in the original French version of the book. 5. Graham Harman, “Quentin Meillassoux: A New French Philosopher.” Philosophy Today 51.1 (2007): Pages 104-117. The passage where I raise the question of space can be found in the first column of page 107. 6. Vernes is first cited on p. 95 of After Finitude . See Jean-René Vernes, Critique de la raison aléatoire, ou Descartes contra Kant . (Paris: Aubier, 1982).  . (shrink)

The relationship between willingness to pay to reduce the probability of an adverse event and the degree of risk aversion is ambiguous. The ambiguity arises because paying for protection worsens the outcome in the event the adverse event occurs, which influences the expected marginal utility of wealth. Using the concept of downside risk aversion or prudence, we characterize the marginal WTP to reduce the probability of the adverse event as the product of WTP in the case of (...) risk neutrality and an adjustment factor. For the univariate case, the adjustment factor depends on risk aversion and prudence with respect to wealth. For the bivariate case, the adjustment factor depends on risk aversion and cross-prudence in wealth. (shrink)

In the traditional sense, a work of art creates an illustration of the outside world, or of a certain text or doctrine. Sometimes it is considered that such an illustration is not literal, but is an interpretation of what is visible, or an interpretation of a certain literary or ideological message. It can also be assumed that a work of art creates its own visual world, a separate story or a separate philosophical statement. The Parc de La Villette represents the (...) last of these possibilities: it is a philosophical statement that develops the premises derived from poststructuralist philosophies and the philosophy of deconstruction. The uniqueness of its being status, however, is that it does so not only at the level of the theoretical assumptions, but also through its functioning as an active philosophical work. This means that a park is a happening philosophy. Its activity, however, does not refer only to the present tense, but is also an attempt to penetrate the future, all otherness and impossibility. This kind of activity assumes that the work, in a sense, does not yet fully exist, but is also still produced in the processes of its interpretation. The theoretical foundations of the park included texts by Bernard Tschumi, in which he questioned traditional ways of creating a work of architecture, postulating in return the use of a long series of negations, which were comparable to the crisis of metaphysics characteristic of contemporary philosophy. It is therefore no coincidence that the publication containing Tschumi’s theoretical text on Parc de La Villette was accompanied by an essay by Jacques Derrida developing some of the architect’s concepts. The next step in integrating philosophy into the process of park design was a series of discussions between Peter Eisenman and Derrida, who completely moved the creation of the park into the world of thoughts, without accentuating the need for their realization in the material reality. The main topic of these discussions was the problem of the chôra, which was taken up by later commentators and used to interpret the park as a work in which the philosophy of the beginning is manifested relating to issues of politics, morality and religion. The park was therefore interpreted as a space of invention within the scope of creating new rules of functioning of the community and democracy. Thinking about the political future may, however, exceed the horizon of ordinary expectations. Although philosophical thought is always connected with contemporary problems and metaphysics sometimes intertwines with current politics, yet at the same time the customs of philosophy also include crossing horizons and thinking about absolute otherness and impossibility. Initially, the chôra, différance, Absolute Otherness (tout autre) and the Impossibile were concepts of pure philosophy of atheistic character, but with the further development of the discussion, more and more theological motifs began to emerge. One of the reasons for this phenomenon was the fact that radical negations of all being, which were contemplated in contemporary philosophy (by Heidegger and Derrida, among others), had previously been manifested in negative and apophatic theologies (by Master Eckhart, among others). Also the category of the “Other”, taken from Emmanuel Levinas, was clearly connected with the thought about God. A further reason for connecting the chôra with the theological thought was the interest in the philosophy of deconstruction expressed by some theologians. Caputo in particular managed to persuade Derrida to participate in discussions on the current status of religion. In the late period of Derrida’s writing, further statements on religious topics appeared. All these reasons led to posing a question about the identity of the chôra and God. Although there were no satisfactory conclusions on this issue, the discussion was also important to create an interpretation of the park as a place of worship. The chôra, representing, according to Plato, the preoriginal emptiness is the place of every beginning, but it turns out that it is not neutral to the being created in it. The chôra deposits itself in every being as an irremovable beginning that interferes with its stability. The chôra, therefore, forces us into a palintropical movement, but it also turns out to be a pure compulsion, an erring necessity and a fundamental force from which, in the human perception, motifs useful to the individual and to the community are extracted. All definitions of this force, including its anthropomorphisation, are formulated in such a way that they allow for building private and collective morality upon them. Such definitions are changed depending on variable political situations. It is difficult to determine whether in the processes of changes in the formulation of “God’s names” any essential value is retained, which is not subject to change. The current definitions of the chôra (God?), which can be found, for example, in the philosophy of Caputo, stress that she is a combination of various and contradictory forces. This characteristic inherits much of Plato’s concept, reminds us of Master Eckhart’s views on Gottheit and, at the same time, is not unfamiliar to Tschumi, whose essays were an apologia of contradictions. The current concept of chôra, transferred into the sphere of politics, is the praise of social diversity and the protection of the difference from the forces of order. In the Parc de La Villette, the future community and democracy were elevated as a system of safe existence of individuals in all their singularity. The park is a temple of a future community in which individual beings have nothing in common. (shrink)

Existence internalism claims that facts about human psychological responsiveness constrain the metaphysics of value in particular ways. Chapter 5 examines whether some form of existence internalism holds for prudential value. It emphasizes the importance of a modal distinction that has been traditionally overlooked. Some facts about personal good are facts about realized good. For example, right now it may be true that X is good for me. Other facts about goodness are facts about (...) what would be good for me in certain possible futures. These are facts about merely possible good. Philosophers should be internalists about realized good. The chapter defends a qualified version of the idea that a necessary constraint on something’s being good for a person at a time is that the thing in question elicits some kind of positive psychological response from the person at that time. However, philosophers should be motivational externalists about merely possible good. Facts about the superior future goodness of an option may ground reasons now to choose it. But we should not expect individuals to always recognize such facts, and so there is no reason to think such facts are always motivating. (shrink)

BackgroundCare.data was a programme of work led by NHS England for the extraction of patient-identifiable and coded information from general practitioner records for secondary uses. This study analyses the forms which enabled patients to opt out.MethodsTheoretical sampling and summative content analysis were used to collect and analyse dissent forms used by patients to opt out from care.data. Domains included basic information about the programme, types of objections and personal details required for identification purposes.ResultsOne hundred opt-out forms were analysed. Fifty-four (...) forms mentioned that this programme was run by NHS England. 81 forms provided two types of objections to data-sharing, and 15 provided only one objection. Only 26 forms mentioned that direct care would not be affected and 32 that patients maintain their right to opt back anytime. All but one of the opt-out forms we reviewed requested the name of the person wishing to opt out. 94 required a date of birth and 33 an NHS number. 82 required an address, 42 a telephone number and 7 an email address.ConclusionsNumbers of patients opting out should be treated with caution, because the variability of information provided and the varied options for dissent may have caused confusion among patients. To ensure that dissent is in accordance with individual preferences and moral values, we recommend that well-designed information material and standardised opt-out forms be developed for such data-sharing initiatives. (shrink)

Background: Clinical genomic implementation studies pose challenges for informed consent. Consent forms often include complex language and concepts, which can be a barrier to diverse enrollment, and these studies often blur traditional research-clinical boundaries. There is a move toward self-directed, web-based research enrollment, but more evidence is needed about how these enrollment approaches work in practice. In this study, we developed and evaluated a literacy-focused, web-based consent approach to support enrollment of diverse participants in an ongoing clinical genomic implementation (...) study. Methods: As part of the Cancer Health Assessments Reaching Many (CHARM) study, we developed a web-based consent approach that featured plain language, multimedia, and separate descriptions of clinical care and research activities. CHARM offered clinical exome sequencing to individuals at high risk of hereditary cancer. We interviewed CHARM participants about their reactions to the consent approach. We audio recorded, transcribed, and coded interviews using a deductively and inductively derived codebook. We reviewed coded excerpts as a team to identify overarching themes. Results: We conducted 32 interviews, including 12 (38%) in Spanish. Most (69%) enrolled without assistance from study staff, usually on a mobile phone. Those who completed enrollment in one day spent an average of 12 minutes on the consent portion. Interviewees found the information simple to read but comprehensive, were neutral to positive about the multimedia support, and identified increased access to testing in the study as the key difference from clinical care. Conclusions: This study showed that interviewees found our literacy-focused, web-based consent approach acceptable; did not distinguish the consent materials from other online study processes; and valued getting access to testing in the study. Overall, conducting empirical bioethics research in an ongoing clinical trial was useful to demonstrate the acceptability of our novel consent approach but posed practical challenges. (shrink)

Writing for non-specialists and students as well as for fellow philosophers, this book explores some basic issues surrounding sex and love in today's world, among them consent, objectification, nonmonogamy, racial stereotyping, and the need to reconcile contemporary expectations about gender equality with our beliefs about how love works. Author Patricia Marino argues that we cannot fully understand these issues by focusing only on individual desires and choices. Instead, we need to examine the social contexts within which choices are (...) made and acquire their meanings. That perspective, she argues, is especially needed today, when the values of individualism, self-expression, and self-interest permeate our lives. Marino asks how we can fit these values, which govern so many areas of contemporary life, with the generosity, caring, and selflessness we expect in love and sex. Key Features ofPhilosophy of Sex and Love: An opinionated introduction Offers a contemporary, problems-based approach to the subject, helping readers better understand and address current issues and controversial questions Includes coverage of sex and love as they intersect with topics like disability, race, medicine, and economics Considers not only the ethical, but also the broadly social and political dimensions of sex and love Includes a helpful introduction and conclusion in each chapter and is written throughout in a clear and straightforward style, with examples and sign-posts to help guide the student and general reader A comprehensive and up-to-date bibliography provides a valuable tool for anyone's further research P> Offers a contemporary, problems-based approach to the subject, helping readers better understand and address current issues and controversial questions Includes coverage of sex and love as they intersect with topics like disability, race, medicine, and economics Considers not only the ethical, but also the broadly social and political dimensions of sex and love Includes a helpful introduction and conclusion in each chapter and is written throughout in a clear and straightforward style, with examples and sign-posts to help guide the student and general reader A comprehensive and up-to-date bibliography provides a valuable tool for anyone's further research. (shrink)

Why should we refrain from doing things that, taken collectively, are environmentally destructive, if our individual acts seem almost certain to make no difference? According to the expected consequences approach, we should refrain from doing these things because our individual acts have small risks of causing great harm, which outweigh the expected benefits of performing them. Several authors have argued convincingly that this provides a plausible account of our moral reasons to do things like vote for policies that (...) will reduce our countries’ greenhouse gas emissions, adopt plant-based diets, and otherwise reduce our individual emissions. But this approach has recently been challenged by authors like Bernward Gesang and Julia Nefsky. Gesang contends that it may be genuinely impossible for our individual emissions to make a morally relevant difference. Nefsky argues more generally that the expected consequences approach cannot adequately explain our reasons not to do things if there is no precise fact of the matter about whether their outcomes are harmful. -/- In the following chapter, author Howard Nye defends the expected consequences approach against these objections. Nye contends that Gesang has shown at most that our emissions could have metaphysically indeterministic effects that lack precise objective chances. He argues, moreover, that the expected consequences approach can draw upon existing extensions to cases of indeterminism and imprecise probabilities to deliver the result that we have the same moral reasons to reduce our emissions in Gesang’s scenario as in deterministic scenarios. Nye also shows how the expected consequences approach can draw upon these extensions to handle Nefsky’s concern about the absence of precise facts concerning whether the outcomes of certain acts are harmful. The author concludes that the expected consequences approach provides a fully adequate account of our moral reasons to take both political and personal action to reduce our ecological footprints. (shrink)

Photo by Jonathan Ford on Unsplash ABSTRACT Since 2008, an average of twenty million people per year have been displaced by weather events. Climate migration creates a special setting for a duty to rescue. A duty to rescue is a moral rather than legal duty and imposes on a bystander to take an active role in preventing serious harm to someone else. This paper analyzes the idea of expanding a duty to rescue to climate migration. We address who should have (...) the duty and to whom the duty should extend. The paper discusses ways to define and apply the duty to rescue as well as its limitations, arguing that it may take the form of an ethical duty to prepare. INTRODUCTION Climate migration creates a special setting for a duty to rescue. A duty to rescue is a moral rather than legal duty and imposes on a bystander to take an active role in preventing serious harm to someone else. Examples of circumstances range from person-to-person intimate rescue to saving those in poverty, even in distant parts of the world.[1] Since 2008, an average of twenty million people per year have been displaced by weather events.[2] Circumstances like being thrust from homes under the threat of fire, mudslide, and flooding vary greatly from long-term changes like land becoming too arid for crops or temperatures increasing annually gradually pushing up the number of heat-related deaths, with the area slowly becoming uninhabitable. Imminence in fleeing affects resettling and need for rescue with important implications for how the duty to rescue might apply. This paper reevaluates the ethical framing of the duty to rescue and, while it is arguably a stretch, applies it to climate migration. Climate migration has become common and is expected to increase due to rises in sea level, increases in weather events that make areas uninhabitable, and changes to land that preclude farming or other necessary land uses. We argue that a duty to rescue may help highlight who has moral obligations to whom. Because the problem is so large in scope, we suggest a change in the ethical limits to humans' duty to rescue other humans who are in distress. We imagine an expansion or extension of the duty to rescue to meet some of the basic needs created by climate migration. Yet how it should expand, and how much depend on ethical framing and practical limitations. l. Expanding the Geographical Boundaries Two commonly recognized emergencies, Hurricane Katrina in the case of weather events and the current COVID-19 pandemic, provide a historical and current backdrop to evaluate ethical obligations as more disasters displace people. A significant reassessment of the ethical scope of an obligation to rescue in the case of weather events will be limited by the ability to render aid to those in distress in the case of a planet-wide weather catastrophe. The problems may overwhelm the ability to rescue or the reasonableness of attempting rescue. The extent of the moral obligation borne by humans to other humans in the case of a weather event has been largely defined by its locality and limited geographic influence. Whether we are imagining the scope of ethical obligation in the case of hurricane, flood, tornado, drought, or wildfire events, the perceived ethical obligation is significantly defined by the limited impact of these weather events on people outside the zone of the weather event's direct impact, yet close to that zone. A hurricane affecting New Orleans will not have immediate impact on the residents of California or even those on the northeast coast of the United States until a later time. Wildfires in the Pacific Northwest do not impair the ability of those in the rest of the country to come forward with assistance. But as climate migration crosses international borders, and climate events occur simultaneously in many regions, a more expansive duty to rescue may provide the ethical impulse to help those who live afar or migrate long distances. In this respect, the need for help in the event of widespread climate migration due to global warming is more like a pandemic than a weather event. Its broad impact area diminishes the capability of nearly the entire balance of the human population to help due to those populations' awareness that they will, in short order, have the same need for the same resources, from the same cause. Those living near current flood zones may find their historically safe havens are also a flood zone. Those previously best positioned to rescue may find themselves also needing to relocate. Thus, we may observe the need for new rescuers. ll. The Rule of Rescue The Rule of Rescue as defined by Al Jonsen describes the moral impetus or knee jerk reaction to save identifiable people facing death.[3] A duty to rescue has since been expanded beyond imminent death and beyond the near and identifiable. But there are limitations. For example, by most accounts, the ethical duty tends not to require extreme bodily risk or financial depletion. In comparing Good Samaritans to humanitarians, Scott M. James argues the duty to rescue arises from unique dependence, but the ethical obligation to help strangers through humanitarian aid is of a different nature.[4] The wrongness of failing to help is arguably more egregious when one is in a unique position to help. Like in the tragedy of the commons, where there is no unique positioning, when the global community is called upon to help, each individual in it may feel less obliged to do so. Climate migration falls in between—it requires helping strangers, yet it may move forward without anyone seeing themselves as uniquely positioned to help until those strangers become part of communities, at which time, there may be more moral justification to help a community member in need. Generally, arguments about Good Samaritans hinge on extraordinary acts, praiseworthy because they are acts of compassion, not obligation. Now all US states have Good Samaritan laws[5] which protect helpers from liability for help gone wrong or for a failure to succeed once engaged in an act of rescue. Extraordinary help as a moral good is thus somewhat encouraged through legal protection, but not imposed. Conversely, jobs like firefighting, search and rescue, and emergency medical care tend to oblige employees to take on risks that would be extraordinary if undertaken by the average bystander, yet they are rendered ordinary rescue as part of the job. Three states, Minnesota, Rhode Island, and Vermont have a broad duty to rescue, adding legal considerations to an otherwise moral conundrum. The laws do not require bystanders to take on risk for the sake of rescuing strangers.[6] The moral duty will require looking beyond law, but it is unclear how the moral duty to rescue should be distributed in the case of climate migration. A bare minimum would prevent taking advantage of newcomers, paying sub-minimum wage, and discriminating against them. Yet such a minimum is hardly rescue. lll. An Ethical Rather than Legal Duty The difficulty in defining the duty to rescue as a legal obligation is that it is difficult to determine the extent of risk a rescuer ought to be required to take. The nature of this ethical duty is also arguably tied to the experiences of both the rescuer and the rescued. There are subjective aspects like what someone perceives as a danger that make it difficult to write enforceable laws requiring rescue. It is one thing to expect a rescuer to step into several inches of relatively warm water to lift a person lying face down in a pond and enable them to breathe. It is something altogether different to expect that rescuer to dive into frigid water and attempt to extricate someone trapped in a submerged automobile. As the legal philosopher H.L.A. Hart observed, it is always easier to define application of the core intention of any rule, whether law or ethical norm. It is more difficult to create legal certainty about how the law applies to what he described as “penumbra circumstances”. In the case of a hurricane, it is easier to define what surplus resources are available in areas geographically remote from the impact of the storm and demand, as a moral obligation, that those nearby but outside the area provide assistance. It is more difficult to obligate people, organizations, or governments to supply a quantity of medication or some number of ventilators to an adjacent community when they expect to imminently need them for their own community. In the early stages of climate migration, the ethics of extreme weather event assistance, a common application of the duty to rescue, will be useful and appropriate. The rising sea levels first experienced by island nations in the South Pacific[7] will not render those living in other coastal communities, those with greater available “high ground”, unable to supply resources to those in need. But when sea level rise and climate change affect more communities simultaneously, albeit in varying degree, the task of defining what response is ethically obligatory becomes increasingly complicated. Pinpointing the obligations of those communities which are resource rich to those communities which are resource deprived, and of those partly affected to those more severely affected may become necessary. The limitations of the traditional duty to rescue could expand to meet the needs. lV. Contribution to the Problem Many argue that the duty to rescue may depend on any appropriate claim of those needing rescue. One issue is whether preferential claims among those who can identify the source of the harm should call for a greater duty or whether everyone in need should be approached as like candidates for rescue, shaping the duty as equal across those on the receiving end. As climate change does have human-made causes, there are strong arguments to impose a greater ethical duty on any entity that caused the climate-related problems leading to the mass exodus. While the global north is often implicated in pollution that causes migration, industries like energy, transportation, and agriculture are tied to climate change and associated with significant greenhouse gas emissions.[8] Practices like directing agriculture to less sustainable single crop growth generally made land less farmable. Yet it is difficult to place blame and identify specific causal relationships as most migration is due to many factors. A movement toward greater accountability can be reframed as a greater duty to rescue, a duty to engage in the extraordinary. The fossil fuel industry, for example, should have a larger obligation than the average person. Similarly, some may argue anyone unjustly enriching themselves while contributing to climate change or people who over-consume have an elevated duty to rescue.[9] Climate change lawsuits demonstrate an eagerness to hold governments and corporations accountable, despite difficulty proving causation. V. The Most Vulnerable One ethical dimension of climate migration that remains unexplored is how a duty to rescue applies to vulnerable populations who stand to be left behind or unable to migrate without assistance. Researchers from the Global North working across the Global South are increasingly observing the phenomenon of ethics dumping, where the research ethics of some countries are imposed on research subjects in other countries.[10] In that vein, rescuers should be careful not to impose unwelcome cultural standards or exploit people who are in the process of migrating. There is a gap in discussions reflecting voices that have been left out. The duty to rescue is incomplete without an attempt to understand the ethical experiences of those being rescued. The actual people affected by climate migration who are the least likely to have the means to migrate, or to do so without extreme hardship, should have a voice informing the global community including those in a position to carry out rescue. People who have the means and are young and healthy may easily make decisions to avoid the catastrophic consequences that climate migration brings. However, what about those who are left behind? For example, especially recognizing cultural differences, the homeless community, disabled community, refugees, the elderly community, and women[11] and children may suffer differently and call for more attention. In some parts of the world, human rights are severely constrained. An ethical duty to rescue, with many considerations and variables, may be more justified in the case of those most in need. As climate migration continues and increases significantly, it may be reasonable to ask the local and global community to focus on those least well positioned to migrate successfully. In this context, the use of phenomenology to understand the lived experiences of those migrating, sometimes termed “ethical experiences”, may help flesh out how a duty to rescue takes shape. The discussion of duty and obligation requires an articulation of the ethical experiences (how the local community in need of rescue views the proposed rescue). Then, the obligation to interpret the duty as ‘one shall not’ or ‘one must’ can be focused on the migrants’ needs rather than the rescuers’ feelings of obligation.[12] A revised theory of the duty to rescue taking into account the asymmetrical experiences of communities involved could ensure that the needs of people whose living situations, gender, ethnicity, age, or race impact their ability to even begin the migration process are considered. In this discussion, the rescuing is directed toward communities /collectives of persons migrating, whether at once or across a period of time. Often, the climate migrant may not be in a state to articulate the nature of this event when it happens, given its subjective proximity. Yet, when communities are given the space and opportunity to articulate their shared values, the ethical action of rescue derives its meaningfulness from the community rather than the rescuers. In other words, allowing climate migrants to explain their feelings can add complexity to what some see as a binary receiver-giver (of rescue) dynamic. This is necessary because the concept of vulnerable populations is fraught with problematic assumptions. There have been various definitions and criteria to determine what would constitute vulnerable populations.[13] For example, the United Nations Framework Convention on Climate Change[14] identifies and assesses vulnerable populations. These criteria may be helpful. However, they do not provide the full picture. Rather than identifying categorical criteria of vulnerable populations, engaging with people who are experiencing climate migration and listening to their current experiences and concerns helps determine need. Knowing what people need may prevent the kneejerk reaction to label people who are quite resilient yet have appropriate needs “vulnerable”. Proceeding with caution is important because the duty to rescue has hierarchical underpinnings of "us" and "them." Often when people swoop in to save, there are good and bad consequences of the intervention. We should proceed with caution because often the helper misses the actual needs of those in need. The only way to combat this would be to make sure that people are empowered to inform those agencies that are able to help. In addition to more practical approaches, large scale oral histories could allow those who have migrated already to share their experiences. It would be important to capture the lived experiences of people who are already experiencing the consequences of climate migration or of other migration like that due to political or economic extreme events. These experiences could shape our analysis of whether people in fact wish for rescue. If so, further conversations can determine best actions as well as give important insight into what resources might be necessary to empower people now and in the future. Vl. A Duty to Rescue as a Duty to Prepare If we view Good Samaritans as going above and beyond, then a duty to rescue, something ethically compelled, must bring rescue out of the framework of charity and place it in the context of humanity and obligations. Such a view would also support expanding the geographical reach of the otherwise more proximate duty. The duty may be stronger and take shape in a more workable way if it applies to preparing places expecting to see an influx of people due to climate migration and to helping those most in need. The duty may arise out of expectations of what type of community the place welcoming those migrating due to climate should be—does it want to offer good housing, schooling, and medical care as well as economic opportunity to new people? And if so, at what cost, or with which risks? If the newcomers are viewed as community members rather than strangers, a model of acceptance may lead to better preparation. Some considerations like whether the actions will reasonably help the persons in need of rescue[15] will shape the application of a duty to rescue in the context of climate migration. Similarly, ensuring that people have the chance to articulate their values may help communities support the newcomers. New relationships should not be defined as migrant and rescuer. Voluntariness in participation and not forcing any action deemed rescue would help ensure the human rights of those migrating. In the United States, President Biden issued an executive order addressing impending climate migration steeped in a duty to prepare by making plans for resettlement and to address the impact of climate migration.[16] Vll. At What Risk? As we investigate the ethical obligations to meet even basic needs, we must also ask what level of risk is ethically compelled. There is an extraordinary need to integrate newcomers successfully, but it is difficult to stretch an ethical duty to rescue to require all the prerequisites for successful climate migration. Even defining success would create deep ethical arguments. As observed in almost all migrations, extraordinary charitable acts may be the key to success, while an ethical duty to rescue must try to require the important government and community-based basics and ensuring respect for human rights. That is, the migrating people should be rescued from circumstances that contradict basic human rights. Rather than comparing communities to bystanders, mere places where people will arrive and need to hash out how to find housing, jobs, education, and opportunity, a duty of preparation may be the key to rescue those disenfranchised by migration. There are cultural, personal, physical, psycho-social, and geopolitical issues surrounding how to best help those needing to permanently relocate. Ethics arguments will certainly range from “do nothing”, which may fail people, to “do everything”, which could waste taxpayer money in futile over-preparation while failing to actually help. Communities must avoid planning exclusively for one scenario only to have it not take place. Striking the balance, a duty to rescue as it could apply to climate migration should set goals of societal integration, and providing the basics like education, housing, food, health care, and job opportunity, the precursors to flourishing. Recommending the extraordinary, morally preferred but perhaps not compulsory, when charitable actors are participating, or when wrongdoers are compensating, may be more workable than seeing the duty to rescue as compelling people or local governments to take on significant financial and personal risk for newcomers. While humanitarian ethics supports helping everyone, it is likely that people who resettle in advance of a need to flee will find themselves with more choices and opportunities. Help is warranted for those with more dire needs. Preparing for them may do just that. Vlll. Rescue Prior to Migration and Rescue in the Process of Resettlement The duty to enable the migration in the first-place hints to the inadequacy of a duty to prepare. The traditional duty to rescue perhaps steps in if rescue looks like those geographically just out of harm's way rescuing those in danger. That resembles the traditional moral requirement, or duty to rescue according to the Rule of Rescue. Humanitarian aid typically provided by many institutions makes sense and is in place, although financial support for additional humanitarian aid is always needed. Despite having moved to purportedly more capable communities, migrant communities may be able to develop more egalitarian orders of living. Rather than continually being identified as having been rescued, it is important to make sure people keep or make social ties during and after migration. Immigrants often face social isolation.[17] Small shifts in gestural language also have the potential to welcome people and show they are valued. For instance, some migrants may not like questions like “Where are you from?” and “What brings you here?” as they emphasize differences over fitting in. CONCLUSION The ethical duty to rescue should be expanded to better match those in need of relocation with a welcome environment and the resources needed to achieve success and fully integrate socially and culturally. Expanding a dialogue that includes the voices of people who have recently migrated whether due to violence, poverty, or climate, could properly frame the extent of the duty. If we are to apply the duty of rescue to climate migration, rescuers should avoid labeling people vulnerable, dependent, or needy, although there is reason to focus on those whose needs are the most dire. A soft duty to rescue people during the course of climate migration can come in the form of preparation. People will need help finding housing, education, access to food, and employment. Ultimately, to help them help themselves may be the best goal. While the obligations should be borne differently by people, whether due to a special responsibility, or a special relationship that creates a clearer duty, the global community must prepare for its role in rescuing those displaced by climate events. By helping those displaced at the start of the climate migration process according to a more commonly held notion of the duty to rescue, and by preparing to incorporate newcomers successfully according to an expanded duty to rescue, effectively a duty to prepare, countries that take on climate refugees may find themselves rewarded by the cultural diversity and workplace talents that people bring. A duty to those at a distance is a reasonable expansion of the duty to rescue. But what one ought to do in the global community varies somewhat from the traditional Rule of Rescue. - [1] Singer, P. (1972). Famine, Affluence, and Morality. Philosophy and Public Affairs, 1(3): 229-43. [2] Irfan, U. (2022, March 16). Why We Still Don’t Yet Know How Bad Climate Migration Will Get. Vox. https://www.vox.com/2022/3/16/22960468/ipcc-climate-change-migration-migrant-refugee, citing the International Panel on Climate Change (IPCC) (2022). Sixth Assessment Report, Climate Change 2022, Impacts, Adaptation, and Vulnerability. https://www.ipcc.ch/report/ar6/wg2/ [3] McKie, J., Richardson, J. (2003) The Rule of Rescue. Social Science & Medicine, 56(12): 2407-2419. https://doi.org/10.1016/S0277-9536(02)00244-7. [4] James, S.M. (2007). Good Samaritans, Good Humanitarians. Journal of Applied Philosophy, 24(3):238-254. [5] Overview of Good Samaritan laws. https://worldpopulationreview.com/state-rankings/good-samaritan-law-states [6] Fifield, J. (2017, Sept. 19). Why It’s Hard to Punish ‘Bad Samaritans’. Stateline Blog, Pew Charitable Trusts, https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2017/09/19/why-its-hard-to-punish -bad-samaritans [7] Cassella, C. (2019). There’s a Climate Threat Facing Pacific Islands That’s More Dire Than Losing Land, Science Alert, https://www.sciencealert.com/pacific-islanders-are-in-a-climate-crisis-as-rising-sea-levels-threaten -water; Hassan, H. R., and Cliff, V. (2019). For Small Island Nations, Climate Change is not a Threat. It’s Already Here, World Economic Forum, https://www.weforum.org/agenda/2019/09/island-nations-maldives-climate-change/ [8] For example, Lyons, K. (2019). Australia Coal use is Existential threat to Pacific Islanders, The Guardian. https://www.theguardian.com/world/2019/aug/12/australia-coal-use-is-existential-threat-to-pacific-is lands-says-fiji-pm [9] Cripps, E. (2013). Climate Change and the Moral Agent: Individual Duties in an Interdependent World. Oxford: Oxford University Press. [10] Schroeder, D., Chatfield, K., Singh, M., Chennells, R., and Herissone-Kelly, P.. Ethics Dumping and the Need for a Global Code of Conduct. In Cham. (Ed.)(2019). Equitable Research Partnerships. SpringerBriefs in Research and Innovation Governance. Springer. 2019. https://doi.org/10.1007/978-3-030-15745-6_1 [11] Giudice L.C., Llamas-Clark E.F., DeNicola N., Pandipati, S., Zlatnik, M.G., Decena, D.C.D., Woodruff, T.J., Conry, J.A. (2021). Climate Change, Women’s Health, and the Role of Obstetricians and Gynecologists in Leadership, International J Gynecol Obstet, 155(3), 345-356. 10.1002/ijgo.13958 [12] See Ferrarello, S. and Zapien, N. (2020). Ethical Experience: A Phenomenology, Bloomsbury. (for understanding phenomenological determinants of ethical action). [13] McLeman, R.A., Hunter, L.M., (2010). Migration in the context of vulnerability and adaptation to climate change: insights from analogues. Wiley Interdiscip Rev Clim Change, 1(3): 450-461. [14] Least Developed Countries Expert Group. (2018). Considerations Regarding Vulnerable Groups, Communities and Ecosystems in the Context of the National Adaptation Plans: United Nations Framework Convention on Climate Change. [15] Jecker, N.S. 2013. "The Problem with Rescue Medicine." J Med Philos, 38(1):64-81. [16] White House Report. (February 9, 2021), Executive Order (E.O.) 14013, “Rebuilding and Enhancing Programs to Resettle Refugees and Planning for the Impact of Climate Change on Migration.” (calls on the National Security Advisor to prepare a report on climate change and its impact on migration. “This report marks the first time the U.S. Government is officially reporting on the link between climate change and migration.” https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/27/executive-order-on-tackling -the-climate-crisis-at-home-and-abroad/ [17] Torres, J.M., Casey, J.A. (2017) The centrality of social ties to climate migration and mental health. BMC Public Health, 17: 600. https://doi.org/10.1186/s12889-017-4508-0. (shrink)

With the rise of research impact as a ‘third’ space (next to research and teaching) within the universities in the United Kingdom and beyond, academics are increasingly expected to not only produce research but also engage in brokering knowledge beyond academia. And yet little is known about the ways in which academics shape their practices in order to respond to these new forms of institutionalised expectations and make sense of knowledge brokering as a form of academic practice. Drawing (...) on 51 qualitative interviews with researchers and research users involved in two large knowledge brokering initiatives in the UK, this study identifies four repertoires of co-production practices: (i) _Challenge_ to the existing policy framework, (ii) _Deliberation_ between diverse stakeholders, (iii) _Evidence intervention_ producing of actionable knowledge, and (iv) _Advocacy_ for specific evidence-based options. By exploring knowledge brokering as navigation of different knowledge production regimes – traditionally academic and policy-oriented – the paper contributes to the existing debates by providing insights into the nature of navigating science-policy interactions as a process of epistemological bricolage, requiring an assemblage of different meanings, values and practices into new repertoires of practice. Importantly, the choice of a repertoire is not limited to the individual choice of a researcher but rather, it is shaped by the broader institutional context of higher education, risking _instrumental bias_ in which practices oriented towards practical solutions are incentivised over critical or participatory forms of engagement. (shrink)

The goals of vascular composite allotransplantation for hand are to maximize functional status and psychosocial wellbeing and to improve quality of life. Candidates are carefully vetted by transplant programs through an extensive evaluation process to exclude those patients with contraindications and to select those that are most likely to attain functional or quality of life benefit from transplant. Patient choice for any treatment, however, requires that candidates be able to understand the risks, benefits, and alternatives before choosing to proceed. This (...) study aimed to understand patients’ knowledge and perceptions about treatment options for hand loss, including hand transplant. This study will be used to inform a standardized education approach and develop conversation aids for use by clinicians and patients throughout the treatment decision process. Ten individuals who had experienced hand amputation or had congenital limb loss were interviewed to better understand previous and current decisions about treatment, experiences in adjusting to their treatment, and perceptions about hand VCA. From this qualitative interview data, four findings emerged: knowledge and education around VCA as a treatment option; adaptation of individuals with limb loss; fear of risk associated with transplantation; issues of aging and overuse injuries to existing limbs. Results suggests that there is opportunity for expanding education about all treatment options for patients with new loss, long-term loss, and congenital limb loss. Establishing a baseline of knowledge about all options–prosthetics, rehabilitative strategies, and VCA—can help patients evaluate their values and goals of treatment. Issues associated with aging, including overuse and injury, and adaptability over the life course should be included in considerations about treatment choices. Data indicate the need for routinely assessing patient preferences about treatment choice so patients can plan for their future as they adapt and age and as technology for treatments change. To assure that thorough information is provided for current and future decision-making, education about treatment choices and selection procedures for VCA should be standardized. (shrink)

How ought you to evaluate your options if you're uncertain about what's fundamentally valuable? A prominent response is Expected Value Maximisation (EVM)—the view that under axiological uncertainty, an option is better than another if and only if it has the greater expected value across axiologies. But the expected value of an option depends on quantitative probability and value facts, and in particular on value comparisons across axiologies. We need to (...) explain what it is for such facts to hold. Also, EVM is by no means self-evident. We need an argument to defend that it’s true. This book introduces an axiomatic approach to answer these worries. It provides an explication of what EVM means by use of representation theorems: intertheoretic comparisons can be understood in terms of facts about which options are better than which, and mutatis mutandis for intratheoretic comparisons and axiological probabilities. And it provides a systematic argument to the effect that EVM is true: the theory can be vindicated through simple axioms. The result is a formally cogent and philosophically compelling extension of standard decision theory, and original take on the problem of axiological or normative uncertainty. (shrink)

In modern medicine, health risks are often managed through the collection of health data and subsequent intervention. One of the goals of clinical genetics, for example, is to identify genetic predisposition to disease so that individuals can intervene to prevent potential harms. But recently, some clinicians have suggested that patients should undergo less testing and monitoring in an effort to reduce overdiagnosis and overtreatment. In this paper, I explore how clinicians navigate the tension between identifying real disease risks for (...) their patients with concerns about overdiagnosis and overtreatment. I focus on clinicians ordering genetic testing for inherited cardiovascular diseases. Of the genes determined to be “clinically actionable” by the American College of Medical Genetics and Genomics, half are related to cardiovascular diseases. But, due in part to high levels of uncertainty surrounding cardiovascular genetics, there is still disagreement within the field about how to order and interpret these tests. Based on semi-structured, in-depth interviews with 20 clinicians who order genetic testing for cardiovascular diseases, I find that there is considerable variability in the ways that clinicians determine which types of genetic tests are appropriate for their patients and how they interpret test results. Most importantly, I find that many providers do not presume that more genetic data will lead to better care. Instead, increased genetic data can lead to confusion and inappropriate treatment. This re-valuation of the utility of medical data is crucial for bioethicists to explore, especially as medical fields are sorting through increasing amounts of data. (shrink)

Over the past 10 years, John Harris has made important contributions to thinking about distributive justice in health care. In his latest work, Harris controversially argues that clinicians should stop prioritising patients according to prognosis. He argues that the good or benefit of health care is providing each individual with an opportunity to live the best and longest life possible for him or her. I call this thesis, opportunism. For the purpose of distribution of resources in health care, Harris (...) rejects welfarism (the thesis that the good of health care is well-being) and argues that utilitarianism in general may lead to de facto discrimination against groups of people needing health care. I argue that well-being is a superior theory of the good of health care to Harris' opportunism. Harris' concerns about utilitarianism can be better addressed by: (i) relating justice more closely to reasons for action; (ii) by conceptualising the relationship between reasons for action and the value of the consequences of those actions as a plateau rather than scalar relationship. Justice can be understood as satisfying as many equally rational claims on resources as possible. The rationality of a person's claim on health resources turns on the strength of that person's reasons to promote certain health-related states of affairs. I argue that the strength of that reason does not track the expected value of that state of affairs in a fully scalar fashion. Rather a person can have most reason to promote some state of affairs, even though he or she could promote other more valuable states of affairs. Thus there can be equal reason for a distributor of public resources to save either of two people, even though one will have a better and more valuable life. This approach, while addressing many of Harris' concerns about utilitarianism, does not imply that doctors should give up prioritising patients according to prognosis altogether, but it does allow that patients with lower but reasonable prognosis should have a share of public resources. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Appreciating Anorexia:Decisional Capacity and the Role of ValuesThomas Grisso (bio) and Paul S. Appelbaum (bio)Keywordscompetence, consent, anorexia, appreciation, decision makingTan and her colleagues (2006) reported that persons with anorexia nervosa typically manifest no difficulty satisfying the criteria for abilities associated with competence to consent to or refuse treatment. Their results led them to conclude that these patients generally had no problem grasping the nature of anorexia and its possible (...) consequences (understanding), typically did not have difficulty processing information when making treatment decisions (reasoning), and usually neither denied that they had a disorder nor manifested distorted beliefs about the potential consequences of treatment for the disorder.Nevertheless, these authors found, some anorexia patients said that they knew they might die and that they would rather die than suffer the alternative consequences (e.g., loss of identity, feeling of being disgusting). They point out that these beliefs, suggesting questionable competence, were not identified by the usual criteria for competence to consent to treatment. Therefore, they propose that we should consider a modification of the criteria for competence to consent to treatment. They argue for inclusion of "pathological values" as the basis for a finding of incompetence. Their notion of a pathological value (as we summarize it based on their Discussion) includes (a) a personal value (b) on which treatment refusal is based, that (c) is not authentic, and (d) is due to a mental disorder.Second, Tan and colleagues were concerned that the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), currently used widely to assess competence to consent to treatment, did not seem to take values into account when examining deficits related to lack of appreciation or reasoning. They point out that most patients with anorexia nervosa in their study had "pathological values" that influenced their thinking about treatment, yet they did not obtain poor scores on the instrument's appreciation scale, which assesses whether patients deny that they have the illness or offer reasons for accepting or refusing treatment that are based on delusional premises or a serious distortion of reality. Moreover, almost all of the anorexia patients in the study obtained adequate scores on reasoning, which examines the ability to process options and consequences when weighing a treatment decision. [End Page 293]Reasons for Caution in Altering Criteria for CompetenceA fundamental step in considering Tan and her co-worker's proposal is to examine whether it is necessary to add a concept of "pathological values" to the legal construct of competence to consent to treatment. Modifying the legal doctrine of consent is important if that is needed to improve its validity or reliability. But modifications of the doctrine would have considerable costs, including a long process of producing logical and empirical evidence for its necessity, developing methods to assess the new concept, and then a process of debate, persuasion, and education to change laws, ethical guidelines, and medical training. Moreover, principles of theory building urge parsimony. A theory should employ no more concepts or assumptions than are required to account for the phenomena that the theory seeks to organize or explain. So one must be sure that modifications are truly necessary before adding complexity to the theory of decisional competence.In addition, there is an inherent danger in altering a concept like competence to consent to treatment on the basis of the study of any one mental disorder. It is not at all clear how the modification might influence findings of competence when applied to other disorders. Using a study of patients with anorexia nervosa as the impetus for changing the competence concept runs this risk. For example, anorexia is one of a class of mental disorders that is characterized by a failure to abstain from behavior (here, limiting food intake and other behaviors designed to reduce weight) that has negative consequences for the person. Other conditions in this category might include substance abuse disorders and impulse control disorders (e.g., pathological gambling). Even if one concludes that revised criteria for competence would reduce false-positive findings of competence in this group of disorders, one would have to consider carefully its impact on the full range of disabling mental conditions.Moreover, the sensitivity... (shrink)

Two kinds of claims of responsibility arise in regard to health and medical care. Claims of one kind are obligation-limiting claims about individuals’ responsibility for coming to need health care. It may be argued, for example, that individuals have no claim to state-sponsored care for injuries they suffer as a result of risky activities such as mountain climbing, sky diving, or smoking. The claim is that because they are responsible for what has happened to them, others are (...) not obligated to pay for their care. In a different context, it is claimed that because patients are, or should be, responsible for the kind of treatment they receive. They therefore need to be informed about the treatment options available to them so that they can decide which of these treatments, if any, they will undergo. The lecture provides an account of responsibility that fits claims of both of these kinds and explains how they are related. (shrink)

In this article, ambiguity attitude is measured through the maximum price a decision maker is willing to pay to know the probability of an event. Two problems are examined in which the decision maker faces an act: in one case, buying information implies playing a lottery, while, in the other case, buying information gives also the option to avoid playing the lottery. In both decision settings, relying on the Choquet expected utility model, we study how the decision maker’s (...) risk and ambiguity attitudes affect the reservation price for ambiguity resolution. These effects are analyzed for different levels of ambiguity of the act. Operating instructions for the elicitation of the reservation price for ambiguity resolution in an experimental setting are provided at the end of the article. (shrink)

Aim:This study explores experiences of patients suffering from Korsakoff’s syndrome. It contributes to improved reflection on the value of patient knowledge.Background:An ethics of care perspective states the importance of moving to patients in their vulnerable state of being, and to figure out patients’ individual needs necessary to provide good care. The information given by patients suffering from Korsakoff’s syndrome might be mistaken, invented and even not true. The value of these patients’ experiences and knowledge had not been researched (...) to date.Method:Data from six in-depth interviews were analysed concurrently through the constant comparative method.Ethical considerations:The principles of voluntariness, confidentiality and anonymity were respected during the research process.Findings:Four important themes within patients’ knowledge emerged: health condition, involuntary admission into the nursing home, the daily routine and interpretation of the caring abilities of healthcare professionals. The findings show that our respondents were able to provide a window into their inner perspective.Conclusion:This study deepens our understanding of the value of patient knowledge in situations where patients see the world in a different manner as do healthcare professionals. The conversations revealed personal subjective knowledge which our respondents create and live by. Healthcare professionals are encouraged to discover and affirm the understandings of these patients, and not be prepossessed due to the diagnosis or general nursing home rules. Understanding patients’ unique knowledge through appreciation of the complexity and richness of different views on the situation can assist to give a more humane response to individual needs and pain. Health staff in healthcare institutions are encouraged to evaluate the – unintended – effect of rigidly applied nursing home rules, and the government is challenged to rethink its policy about care, and provide more resources permitting relational care that nurtures the dignity of patients suffering from Korsakoff’s syndrome. (shrink)

The seriousness of the risk that healthcare workers faced during SARS, and their response of service in the face of this risk, brings to light unrealistic assumptions about duty and risk that informed the debate on duty to care in the early years of HIV/AIDS. Duty to care is not based upon particular virtues of the health professions, but arises from social reflection on what response to an epidemic would be consistent with our values and our (...) needs, recognizing our shared vulnerability to disease and death. Such reflection underwrites a strong duty of care, but one not to be borne solely by the altruism and heroism of individual healthcare workers. (shrink)

There is an urgent need to learn how to appropriately integrate technologies into dementia care. The aims of this Delphi study were to project which technologies will be most prevalent in dementia care in five years, articulate potential benefits and risks, and identify specific options to mitigate risks. Participants were also asked to identify technologies that are most likely to cause value tensions and thus most warrant a conversation with an older person with mild dementia when families are deciding (...) about their use. Twenty-one interdisciplinary domain experts from academia and industry in aging and technology in the U.S. and Canada participated in a two-round online survey using the Delphi approach with an 84% response rate and no attrition between rounds. Rankings were analyzed using frequency counts and written-in responses were thematically analyzed. Twelve technology categories were identified along with a detailed list of risks and benefits for each. Suggestions to mitigate the most commonly raised risks are categorized as follows: intervene during design, make specific technical choices, build in choice and control, require data transparency, place restrictions on data use and ensure security, enable informed consent, and proactively educate users. This study provides information that is needed to navigate person-centered technology use in dementia care. The specific recommendations participants offered are relevant to designers, clinicians, researchers, ethicists, and policy makers and require proactive engagement from design through implementation. (shrink)

Discourse around assisted colonization focuses on the ecological risks, costs, and uncertainties associated with the practice, as well as on its technical feasibility and alternative approaches to it. Nevertheless, the ethical underpinnings of the case for assisted colonization are claims about the value of species. A complete discussion of assisted colonization needs to include assessment of these claims. For each type of value that species are thought to possess it is necessary to determine whether it is plausible (...) that species possess the type of value and, if so, to what extent their possessing it justifies assisted colonization. I conducted such an assessment for each of the predominant types of value ascribed to species: ecological, instrumental (including option value), existence, and intrinsic value (including interest‐based, objective, and valuer‐dependent intrinsic value). The vast majority of species, including several that have been proposed as candidates for assisted colonization, have much less value than is often presumed. Moreover, with respect to some types of value, assisted colonization would not fully preserve the value of the target species even if it were to keep the target species in existence. Therefore, the case for assisted colonization is significantly weaker and more qualified than its advocates often suppose. There may be exceptional species for which assisted colonization is well justified—and for this reason, case‐by‐case assessment is necessary—but in general the burden of justification generated by the ecological risks associated with assisted colonization is not met by the value potentially preserved by assisted colonization. This suggests that assisted colonization ought to have, at most, a very minor role in the portfolio of ecosystem management practices, even as it pertains to species conservation under conditions of rapid climate change. (shrink)

Clinical decision making is a challenging task that requires practical wisdom—the practised ability to help patients choose wisely among available diagnostic and treatment options. But practical wisdom is not a concept one typically hears mentioned in medical training and practice. Instead, emphasis is placed on clinical judgement. The author draws from Aristotle and Aquinas to describe the virtue of practical wisdom and compare it with clinical judgement. From this comparison, the author suggests that a more complete understanding of clinical judgement (...) requires its explicit integration with goals of care and ethical values. Although clinicians may be justified in assuming that goals of care and ethical values are implicit in routine decision making, it remains important for training purposes to encourage habits of clinical judgement that are consciously goal-directed and ethically informed. By connecting clinical judgement to patients' goals and values, clinical decisions are more likely to stay focused on the particular interests of individual patients. To cultivate wise clinical judgement among trainees, educational efforts should aim at the integration of clinical judgement, communication with patients about goals of care, and ethical reasoning. But ultimately, training in wise clinical judgement will take years of practice in the company of experienced clinicians who are able to demonstrate practical wisdom by example. By helping trainees develop clinical judgement that incorporates patients' goals of care and ethical reasoning, we may help lessen the risk that ‘clinical judgement’ will merely express ‘the clinician's judgement.’. (shrink)

BackgroundThe emergence of artificial intelligence (AI) in medicine has prompted the development of numerous ethical guidelines, while the involvement of patients in the creation of these documents lags behind. As part of the European PROFID project we explore patient perspectives on the ethical implications of AI in care for patients at increased risk of sudden cardiac death (SCD).AimExplore perspectives of patients on the ethical use of AI, particularly in clinical decision-making regarding the implantation of an implantable cardioverter-defibrillator (ICD).MethodsSemi-structured, future (...) scenario-based interviews were conducted among patients who had either an ICD and/or a heart condition with increased risk of SCD in Germany (n = 9) and the Netherlands (n = 15). We used the principles of the European Commission’s Ethics Guidelines for Trustworthy AI to structure the interviews.ResultsSix themes arose from the interviews: the ability of AI to rectify human doctors’ limitations; the objectivity of data; whether AI can serve as second opinion; AI explainability and patient trust; the importance of the ‘human touch’; and the personalization of care. Overall, our results reveal a strong desire among patients for more personalized and patient-centered care in the context of ICD implantation. Participants in our study express significant concerns about the further loss of the ‘human touch’ in healthcare when AI is introduced in clinical settings. They believe that this aspect of care is currently inadequately recognized in clinical practice. Participants attribute to doctors the responsibility of evaluating AI recommendations for clinical relevance and aligning them with patients’ individual contexts and values, in consultation with the patient.ConclusionThe ‘human touch’ patients exclusively ascribe to human medical practitioners extends beyond sympathy and kindness, and has clinical relevance in medical decision-making. Because this cannot be replaced by AI, we suggest that normative research into the ‘right to a human doctor’ is needed. Furthermore, policies on patient-centered AI integration in clinical practice should encompass the ethics of everyday practice rather than only principle-based ethics. We suggest that an empirical ethics approach grounded in ethnographic research is exceptionally well-suited to pave the way forward. (shrink)

Even where willingness-to-pay as a measure of welfare impact is adjusted for diminishing marginal utility, welfare economics is shown to favour policies that add to the life expectancy or that enhance the quality of life of persons who are already better-off. I propose an alternative, Equal Respect methodology, under an axiomatic claim that at the point of decision the prospective life years of all individuals are of equal intrinsic social value. This justifies equal valuation of risk mitigation (...) across all persons; similarly, all appraised impacts should be scaled to accord equal respect to difficult but no-less-valuable lives. (shrink)