RATIONALE, AIMS AND OBJECTIVES: This paper deals with the problem of surgical waiting lists and is aimed, in particular, at comparing two different prioritization approaches: (1) the clinical assessment of treatment urgency aimed at categorizing patients into urgency-related groups (URGs) with a given recommended maximum waiting time for treatment; and (2) the implementation of an original prioritization scoring algorithm aimed at determining the relative priority of each patient in the waiting list and the corresponding order of (...) admission. METHODS: A modelling exercise based on a cohort of 236 patients enrolled on the waiting list of a surgical department in an Italian public university hospital, from 1 January to 30 June 2004, is presented. The comparison is based on a measure called need-adjusted-waiting-days, which allows to take into proper account both urgency and priority. RESULTS: The results show that both methods should be implemented simultaneously for increasing the department's performance in terms of both efficiency--outcome gained from a given amount of resources--and equity--how patients are admitted according to their need. CONCLUSIONS: Waiting list prioritization should not be limited to classifying patients into URGs, but to using a scoring system as well, in order to schedule patient admissions in an explicit and transparent way. (shrink)

ABSTRACT In a Living Donor List Exchange program, the donor makes his kidney available for allocation to patients on the postmortal waiting‐list and receives in exchange a postmortal kidney, usually an O‐kidney, to be given to the recipient he favours. The program can be a solution for a candidate donor who is unable to donate directly or to participate in a paired kidney exchange because of blood group incompatibility or a positive cross‐match. Each donation within an LDLE program makes (...) an additional organ available for transplantation. But because most of the pairs making use of the program will be A/o incompatible, it will also tend to increase the waiting time for patients with blood group O, who already have the longest waiting time. It has therefore been objected that the program is materially unjust, because it further disadvantages the least advantaged. This objection appeals to John Rawls’ difference principle. However, the context for which Rawls proposed that difference principle, is significantly different from the present one. Applying the principle here amounts to a lop‐sided trade‐off between considerations of need and considerations of overall utility. Considerations of formal justice, however, may lead to a stronger objection to LDLE programs. Such a program means that one O‐patient on the waiting list is exempted from the application of the general criteria used in constructing the list because he has a special bargaining advantage. This objection is spelled out and weighed against the obvious attraction of LDLE in a situation of (extreme) organ scarcity. (shrink)

RATIONALE AND AIMS: Total hip and knee replacements, usually, have long waiting lists. There are several prioritization tools for these kind of patients. A new tool should undergo a standardized validation process. The aim of the present study was to validate a new prioritization tool for primary hip and knee replacements. METHODS: We carried out a prospective study. Consecutive patients placed on the waiting list were eligible for the study. Patients included were mailed a questionnaire which included, (...) among other questions, the seven items of the priority tool and the Western Ontario and McMasters Universities Arthritis Index (WOMAC) specific questionnaire. The priority tool gives a score from 0 to 100 points, and three categories (urgent, preferent and ordinary). We studied the content and construct validity. We used Student's t-test or one-way analysis of variance. Correlational analysis was used to evaluate convergent and discriminate validity. RESULTS: The sample consisted of 838 patients (62.3% were female), with mean age of 70.2 years (SD 8.4). A total of 55.5% patients underwent knee replacement. Given that the tool was elaborated by patients and orthopaedic surgeons, it shows a good content validity. The priority score was statistically different (P < 0.001) among the three urgency categories created. The scores of the three WOMAC dimensions showed differences (P < 0.001) by the three urgency categories created. The correlations between the priority score and WOMAC dimensions were 0.79 (function), 0.69 (pain) and 0.51 (stiffness). The correlations between WOMAC items and items from priority tool were greater (0.47-0.69) between items measuring similar constructs than those measuring different constructs (0.27-0.49). These data are similar in both joints. CONCLUSIONS: Results support the validity of the prioritization tool to be used with patients waiting for hip or knee replacement. (shrink)

It has often been proposed to restrict access to postmortal organs to registered donors, or at least to give them priority on the waiting list. Such proposals are motivated by considerations of fairness: everyone benefits from the existence of a pool of available organs and of an organised system of distributing them and it is unfair that people who are prepared to contribute to this public good are duped by people who are not. This paper spells out this rationale (...) and goes on to discuss the main principled objections that have been brought forward to such proposals. The most fundamental objection is that healthcare resources should be allocated in accordance with need, not with merit. The reply to this objection is that the principle of allocation according to need only holds in cases in which the provision of such resources and the fair distribution of the burdens of contribution are independently secured, as they are in an obligatory insurance system. (shrink)

Anna Chavlovski,1 Greg A Knoll,1–3 Timothy Ramsay,4 Swapnil Hiremath,1–3 Deborah L Zimmerman1–31University of Ottawa, 2Ottawa Hospital, 3Kidney Research Centre, Ottawa Hospital Research Institute, 4Ottawa Methods Centre, Ottawa, ON, CanadaBackground: In patients with end-stage renal disease, use of vitamin D and calcium-based phosphate binders have been associated with progression of vascular calcification that might have an impact on renal transplant candidacy. Our objective was to examine management of mineral metabolism in patients wait-listed for renal transplant and to determine the impact on (...) cardiac perfusion imaging.Methods: Data was collected retrospectively on patients wait-listed for a renal transplant, being either active and on hold. Demographic data, medications, serum concentrations of calcium, phosphate, parathyroid hormone, and cardiac perfusion imaging studies were collected from the electronic health record. Chi-square and Student’s t-tests were used to compare active and on-hold patients as appropriate. Logistic regression was used to examine variables associated with worsening cardiac imaging studies.Results: The wait-listed patients were of mean age 56 ± 14 years and had been on dialysis for 1329 ± 867 days. On-hold patients had received a significantly greater total dose of calcium and were more likely to have developed worsening cardiovascular imaging studies. Total doses of calcium and calcitriol were associated with worsening cardiovascular imaging studies.Conclusion: Patients on hold on the renal transplant waiting list received higher total doses of calcium. A higher total dose of calcium and calcitriol was also associated with worsening cardiovascular imaging. Time on dialysis before transplant has been associated with worse post-transplant outcomes, and it is possible that the total calcium and calcitriol dose received contributed to these inferior outcomes.Keywords: dialysis, calcium, cardiac, transplantation. (shrink)

Hospital waiting lists are a feature ofpublicly funded health services that resultswhen demand appears to exceed supply. Whilemuch has been written about hospital waitinglists, little is known about the dynamics ofdiagnostic waiting lists, or more generally whyhospital waiting lists behave in perverse andoften counter-intuitive ways. This paperattempts to address this gap by applying arecent development in critical systems thinkingcalled boundary critique to understand how aparticular ultrasound waiting list was managed.A new waiting list (...) metaphor based on waitinglists as ritual forms is proposed. (shrink)

The scarcity of livers available for transplants forces tough choices upon us. Lives for those not receiving a transplant are likely to be short. One large group of potential recipients needs a new liver because of alcohol consumption, while others suffer for reasons unrelated to their own behaviour. Should the former group receive lower priority when scarce livers are allocated? This discussion connects with one of the most pertinent issues in contemporary political philosophy; the role of personal responsibility in distributive (...) justice. One prominent theory of distributive justice, luck egalitarianism, assesses distributions as just if, and only if, people's relative positions reflect their exercises of responsibility. There is a principled luck egalitarian case for giving lower priority to those who are responsible for their need. Compared to the existing literature favouring such differentiation, luck egalitarianism provides a clearer rationale of fairness, acknowledges the need for individual assessments of responsibility, and requires initiatives both inside and outside of the allocation systems aimed at mitigating the influence from social circumstances. Furthermore, the concrete policies that luck egalitarians can recommend are neither too harsh on those who make imprudent choices nor excessively intrusive towards those whose exercises of responsibility are assessed. (shrink)

Organ transplantation has increased worldwide while the number of organ donors have not increased similarly. Consequently, the waiting period for transplant candidates is prolonged. Patient narratives have uncovered physical and psychosocial suffering in the transplantation process. However, relatively few studies have explored patients’ experiences in the actual waiting period. This qualitative study was conducted in Norway and aimed to describe patients’ experiences of being accepted as recipients of a new liver and their waiting following this decision. A (...) sample of 21 patients with end‐stage liver disease, placed on the ordinary waiting list for a liver transplant, were interviewed in the hospital before they went home to wait for a compatible liver. Uncertainty related to life and death was a major issue, both in the waiting period and as a response to being put on the waiting list. Another central issue was their overwhelming lack of energy. Patients inferred a linear relationship between lack of energy, physical limitations and mental distress. Despite major advances in medical treatment, little follow‐up was given during the waiting period and most of the patients seemed resigned to the inevitability of their suffering. This raises issues of health personnel responsibility and a need to heighten awareness about patient suffering during the waiting period. (shrink)

Recently, debate about the distribution of scarce organs for transplantation has focused on whether patients should have the right to place themselves on waiting lists at several transplant centers, thereby gaining an advantage over other potential recipients. This article explores the social and ethical issues raised by multiple listing, contrasting policies adopted at the national level with those implemented in New York State. It concludes by examining the implications of the debate for broader questions about entitlement and access (...) to health care. (shrink)

ABSTRACT In the 1960s, when Dr. Belding Scribner discovered how to accomplish the process of dialysis in a repeated way, he could not imagine that in solving such a problem others as or more difficult would appear. Given the technological progress and the impossibility of assisting all patients through the most modern methods, the medical doctor often finds himself faced with the moral dilemma of choosing which patient in the waiting list will receive the treatment. This same dilemma is (...) amplified in the case of organ transplants. Professionals, students, professors of the juridical and health fields, and the population in general, were interviewed as a means of documenting the moral concepts and opinions surrounding this problem. In the reality in which we find ourselves, it seems to us that deciding who lives, and the responsibility for all the events that culminate in such decisions, is still a subject left open to discussion. (shrink)

ABSTRACT In the 1960s, when Dr. Belding Scribner discovered how to accomplish the process of dialysis in a repeated way, he could not imagine that in solving such a problem others as or more difficult would appear. Given the technological progress and the impossibility of assisting all patients through the most modern methods, the medical doctor often finds himself faced with the moral dilemma of choosing which patient in the waiting list will receive the treatment. This same dilemma is (...) amplified in the case of organ transplants. Professionals, students, professors of the juridical and health fields, and the population in general, were interviewed as a means of documenting the moral concepts and opinions surrounding this problem. In the reality in which we find ourselves, it seems to us that deciding who lives, and the responsibility for all the events that culminate in such decisions, is still a subject left open to discussion. (shrink)

Debates continue to surround the system in the United States for allocating transplantable cadaveric organs, due in large part to the scarcity of such organs in relation to the number of individuals waiting to undergo transplantation. Candidates awaiting transplantation gain access to cadaveric organs by being placed by individual transplant programs on the national list of the Organ Procurement and Transplantation Network, overseen by the United Network for Organ Sharing. In recent years, the UNOS board has visited the issue (...) of multiple listing, that is, allowing one candidate to be registered on the waiting lists of two or more transplant programs, and has continued to permit multiple listing. (shrink)

Are companies, churches, and states genuine agents? Or are they just collections of individuals that give a misleading impression of unity? This question is important, since the answer dictates how we should explain the behaviour of these entities and whether we should treat them as responsible and accountable on the model of individual agents. Group Agency offers a new approach to that question and is relevant, therefore, to a range of fields from philosophy to law, politics, and the social sciences. (...) Christian List and Philip Pettit argue that there really are group or corporate agents, over and above the individual agents who compose them, and that a proper approach to the social sciences, law, morality, and politics must take account of this fact. Unlike some earlier defences of group agency, their account is entirely unmysterious in character and, despite not being technically difficult, is grounded in cutting-edge work in social choice theory, economics, and philosophy. (shrink)

It is often argued that higher-level special-science properties cannot be causally efficacious since the lower-level physical properties on which they supervene are doing all the causal work. This claim is usually derived from an exclusion principle stating that if a higher-level property F supervenes on a physical property F* that is causally sufficient for a property G, then F cannot cause G. We employ an account of causation as difference-making to show that the truth or falsity of this principle is (...) a contingent matter and derive necessary and sufficient conditions under which a version of it holds. We argue that one important instance of the principle, far from undermining non-reductive physicalism, actually supports the causal autonomy of certain higher-level properties. (shrink)

Just as different sciences deal with different facts—say, physics versus biology—so we may ask a similar question about normative theories. Is normative political theory concerned with the same normative facts as moral theory or different ones? By developing an analogy with the sciences, we argue that the normative facts of political theory belong to a higher— more coarse-grained—level than those of moral theory. The latter are multiply realizable by the former: competing facts at the moral level can underpin the same (...) facts at the political one. Consequently, some questions that moral theories answer are indeterminate at the political level. This proposal offers a novel interpretation of John Rawls’s idea that, in public reasoning, we should abstract away from comprehensive moral doctrines. We contrast our distinction between facts at different levels with the distinction between admissible and inadmissible evidence and discuss some implications for the practice of political theory. (shrink)

Philosophers have argued about the nature and the very existence of free will for centuries. Today, many scientists and scientifically minded commentators are skeptical that it exists, especially when it is understood to require the ability to choose between alternative possibilities. If the laws of physics govern everything that happens, they argue, then how can our choices be free? Believers in free will must be misled by habit, sentiment, or religious doctrine. Why Free Will Is Real defies scientific orthodoxy and (...) presents a bold new defense of free will in the same naturalistic terms that are usually deployed against it. -/- Unlike those who defend free will by giving up the idea that it requires alternative possibilities to choose from, Christian List retains this idea as central, resisting the tendency to defend free will by watering it down. He concedes that free will and its prerequisites—intentional agency, alternative possibilities, and causal control over our actions—cannot be found among the fundamental physical features of the natural world. But, he argues, that’s not where we should be looking. Free will is a “higher-level” phenomenon found at the level of psychology. It is like other phenomena that emerge from physical processes but are autonomous from them and not best understood in fundamental physical terms—like an ecosystem or the economy. When we discover it in its proper context, acknowledging that free will is real is not just scientifically respectable; it is indispensable for explaining our world. (shrink)

Suppose that the members of a group each hold a rational set of judgments on some interconnected questions, and imagine that the group itself has to form a collective, rational set of judgments on those questions. How should it go about dealing with this task? We argue that the question raised is subject to a difficulty that has recently been noticed in discussion of the doctrinal paradox in jurisprudence. And we show that there is a general impossibility theorem that that (...) difficulty illustrates. Our paper describes this impossibility result and provides an exploration of its significance. The result naturally invites comparison with Kenneth Arrow's famous theorem (Arrow, 1963 and 1984; Sen, 1970) and we elaborate that comparison in a companion paper (List and Pettit, 2002). The paper is in four sections. The first section documents the need for various groups to aggregate its members' judgments; the second presents the discursive paradox; the third gives an informal statement of the more general impossibility result; the formal proof is presented in an appendix. The fourth section, finally, discusses some escape routes from that impossibility. (shrink)

I argue that free will and determinism are compatible, even when we take free will to require the ability to do otherwise and even when we interpret that ability modally, as the possibility of doing otherwise, and not just conditionally or dispositionally. My argument draws on a distinction between physical and agential possibility. Although in a deterministic world only one future sequence of events is physically possible for each state of the world, the more coarsely defined state of an agent (...) and his or her environment can be consistent with more than one such sequence, and thus different actions can be “agentially possible”. The agential perspective is supported by our best theories of human behaviour, and so we should take it at face value when we refer to what an agent can and cannot do. On the picture I defend, free will is not a physical phenomenon, but a higher-level one on a par with other higher-level phenomena such as agency and intentionality. (shrink)

The aim of this exploratory paper is to review an under-appreciated parallel between group agency and artificial intelligence. As both phenomena involve non-human goal-directed agents that can make a difference to the social world, they raise some similar moral and regulatory challenges, which require us to rethink some of our anthropocentric moral assumptions. Are humans always responsible for those entities’ actions, or could the entities bear responsibility themselves? Could the entities engage in normative reasoning? Could they even have rights and (...) a moral status? I will tentatively defend the (increasingly widely held) view that, under certain conditions, artificial intelligent systems, like corporate entities, might qualify as responsible moral agents and as holders of limited rights and legal personhood. I will further suggest that regulators should permit the use of autonomous artificial systems in high-stakes settings only if they are engineered to function as moral (not just intentional) agents and/or there is some liability-transfer arrangement in place. I will finally raise the possibility that if artificial systems ever became phenomenally conscious, there might be a case for extending a stronger moral status to them, but argue that, as of now, this remains very hypothetical. (shrink)

Appearing between two historical touchstones—the alleged end of communism and the 100th anniversary of Nietzsche’s death—this book offers a provocative hypothesis about the philosopher’s afterlife and the fate of leftist thought and culture. At issue is the relation of the dead Nietzsche and his written work to subsequent living Nietzscheanism across the political spectrum, but primarily among a leftist _corps_ that has been programmed and manipulated by concealed dimensions of the philosopher’s thought. If anyone is responsible for what Geoff Waite (...) maintains is the illusory death of communism, it is Nietzsche, the man and concept. Waite advances his argument by bringing Marxist—especially Gramscian and Althusserian—theories to bear on the concept of Nietzsche/anism. But he also goes beyond ideological convictions to explore the vast Nietzschean influence that proliferates throughout the marketplace of contemporary philosophy, political and literary theory, and cultural and technocultural criticism. In light of a philological reconstruction of Nietzsche’s published and unpublished texts, _Nietzsche’s Corps/e_ shuttles between philosophy and everyday popular culture and shows them to be equally significant in their having been influenced by Nietzsche—in however distorted a form and in a way that compromises all of our best interests. Controversial in its “decelebration” of Nietzsche, this remarkable study asks whether the postcontemporary age already upon us will continue to be dominated and oriented by the haunting spectre of Nietzsche’s corps/e. Philosophers, intellectual historians, literary theorists, and those interested in western Marxism, popular culture, Friedrich Nietzsche, and the intersection of French and German thought will find this book both appealing and challenging. (shrink)

This paper provides an introductory review of the theory of judgment aggregation. It introduces the paradoxes of majority voting that originally motivated the field, explains several key results on the impossibility of propositionwise judgment aggregation, presents a pedagogical proof of one of those results, discusses escape routes from the impossibility and relates judgment aggregation to some other salient aggregation problems, such as preference aggregation, abstract aggregation and probability aggregation. The present illustrative rather than exhaustive review is intended to give readers (...) new to the field of judgment aggregation a sense of this rapidly growing research area. (shrink)

This paper provides an introductory review of the theory of judgment aggregation. It introduces the paradoxes of majority voting that originally motivated the field, explains several key results on the impossibility of propositionwise judgment aggregation, presents a pedagogical proof of one of those results, discusses escape routes from the impossibility and relates judgment aggregation to some other salient aggregation problems, such as preference aggregation, abstract aggregation and probability aggregation. The present illustrative rather than exhaustive review is intended to give readers (...) new to the field of judgment aggregation a sense of this rapidly growing research area. (shrink)

This paper generalises the classical Condorcet jury theorem from majority voting over two options to plurality voting over multiple options. The paper further discusses the debate between epistemic and procedural democracy and situates its formal results in that debate. The paper finally compares a number of different social choice procedures for many-option choices in terms of their epistemic merits. An appendix explores the implications of some of the present mathematical results for the question of how probable majority cycles (as in (...) Condorcet's paradox) are in large electorates. (shrink)

The existence of group agents is relatively widely accepted. Examples are corporations, courts, NGOs, and even entire states. But should we also accept that there is such a thing as group consciousness? I give an overview of some of the key issues in this debate and sketch a tentative argument for the view that group agents lack phenomenal consciousness. In developing my argument, I draw on integrated information theory, a much-discussed theory of consciousness. I conclude by pointing out an implication (...) of my argument for the normative status of group agents. (shrink)

Scientists and philosophers frequently speak about levels of description, levels of explanation, and ontological levels. In this paper, I propose a unified framework for modelling levels. I give a general definition of a system of levels and show that it can accommodate descriptive, explanatory, and ontological notions of levels. I further illustrate the usefulness of this framework by applying it to some salient philosophical questions: (1) Is there a linear hierarchy of levels, with a fundamental level at the bottom? And (...) what does the answer to this question imply for physicalism, the thesis that everything supervenes on the physical? (2) Are there emergent properties? (3) Are higher-level descriptions reducible to lower-level ones? (4) Can the relationship between normative and non-normative domains be viewed as one involving levels? Although I use the terminology of “levels”, the proposed framework can also represent “scales”, “domains”, or “subject matters”, where these are not linearly but only partially ordered by relations of supervenience or inclusion. (shrink)

This paper sketches a new and somewhat heterodox metaphysical theory of consciousness: the “many-worlds theory”. It drops the assumption that all conscious subjects’ experiences are features of one and the same world and instead associates different subjects with different “first-personally centred worlds”. We can think of these as distinct “first-personal realizers” of a shared “third-personal world”, where the latter is supervenient, in a sense to be explained. This is combined with a form of modal realism, according to which different subjects’ (...) first-personally centred worlds are all real, though only one of them is present for each subject. The theory offers a novel way of capturing the irreducibly subjective nature of conscious experience without lapsing into solipsism. The paper also looks at some scientific theories of consciousness, such as integrated information theory, through the proposed lens and reconsiders the hard problem of consciousness. (shrink)

In this discussion paper, I argue that no theory of consciousness can simultaneously respect four initially plausible metaphysical claims – namely, “first-person realism”, “non-solipsism”, “non-fragmentation”, and “one world” – but that any three of the four claims are mutually consistent. So, theories of consciousness face a “quadrilemma”. Since it will be hard to achieve a consensus on which of the four claims to retain and which to give up, we arrive at a landscape of competing theories, all of which have (...) pros and cons. I will briefly indicate which kinds of theories correspond to the four horns of the quadrilemma. (shrink)

Political science is divided between methodological individualists, who seek to explain political phenomena by reference to individuals and their interactions, and holists (or nonreductionists), who consider some higher-level social entities or properties such as states, institutions, or cultures ontologically or causally significant. We propose a reconciliation between these two perspectives, building on related work in philosophy. After laying out a taxonomy of different variants of each view, we observe that (i) although political phenomena result from underlying individual attitudes and behavior, (...) individual-level descriptions do not always capture all explanatorily salient properties, and (ii) nonreductionistic explanations are mandated when social regularities are robust to changes in their individual-level realization. We characterize the dividing line between phenomena requiring nonreductionistic explanation and phenomena permitting individualistic explanation and give examples from the study of ethnic conflicts, social-network theory, and international-relations theory. (shrink)

We offer a new argument for the claim that there can be non-degenerate objective chance (“true randomness”) in a deterministic world. Using a formal model of the relationship between different levels of description of a system, we show how objective chance at a higher level can coexist with its absence at a lower level. Unlike previous arguments for the level-specificity of chance, our argument shows, in a precise sense, that higher-level chance does not collapse into epistemic probability, despite higher-level properties (...) supervening on lower-level ones. We show that the distinction between objective chance and epistemic probability can be drawn, and operationalized, at every level of description. There is, therefore, not a single distinction between objective and epistemic probability, but a family of such distinctions. (shrink)