Diagnostic testing can be used for many purposes, including testing to facilitate the clinical care of individual patients, testing as an inclusion criterion for clinical trial participation, and both passive and active surveillance testing of the general population in order to facilitate public health outcomes, such as the containment or mitigation of an infectious disease. As such, diagnostic testing presents us with ethical questions that are, in part, already addressed in the literature on clinical care as well as clinical research (...) (such as the rights of patients to refuse testing or treatment in the clinical setting or the rights of participants in randomized controlled trials to withdraw from the trial at any time). However, diagnostic testing, for the purpose of disease surveillance also raises ethical issues that we do not encounter in these settings, and thus have not been much discussed. In this paper we will be concerned with the similarities and differences between the ethical considerations in these three domains: clinical care, clinical research, and public health, as they relate to diagnostic testing specifically. Via an examination of the COVID-19 case we will show how an appeal to the concept of diagnostic justice helps us to make sense of the (at times competing) ethical considerations in these three domains. (shrink)

Evidence‐based medicine (EBM) proponents have argued that mechanistic evidence concerning medical treatments should be considered secondary to evidence derived from randomized controlled trials (RCTs). One common criticism of RCTs is that they often do not yield results that are generalizable to clinical practice, and that for clinical practice application, mechanistic evidence is needed. However, proponents of EBM have argued that mechanistic reasoning is often unreliable and thus not very useful. Here we suggest an important role of mechanistic explanation that has (...) been left out of this discussion entirely, namely, its importance in a patient’s decision of whether or not to take certain drugs. We argue that in certain cases, knowing how a treatment works is just as important for the patient as knowing whether it does. In this paper, we explore how and why giving patients mechanistic information can be an important factor in obtaining informed consent for medical treatment, focusing on the example case of hormonal contraceptives. (shrink)

This paper critically examines Deleuze’s treatment of the Nietzschean problem of nihilism. Of all the major figures in contemporary continental thought, Deleuze is at once one of the most luminous, and practically a lone voice in suggesting that nihilism may successfully be overcome. Whether or not he is correct on this point is thus a commanding question in relation to our understanding of the issue. Many commentators on Nietzsche have argued that his project of overcoming nihilism is destined to (...) failure because of the affinity between the problem of nihilism and the logic of negation. While Nietzsche wants an absolute affirmation of life, Spinoza’s principle that “all determination is negation,” as well as Hegel’s dialectical conception of negation, suggest that affirmation free of negation is not possible. However, some commentators indicate that Deleuze successfully shows how overcoming nihilism is possible because his “logic of difference” allows for an affirmation which is not dialectically reappropriated by negation. This paper argues that beyond such logical considerations, there are metaphysical and existential reasons why Deleuze’s interpretation of nihilism fails to show that it can be overcome. For Deleuze, the overcoming of nihilism hinges not just on a logic of difference, but on a radical interpretation of Nietzsche’s doctrine of eternal return as “selective being.” Drawing on recent scholarship and on Nietzsche’s own writings I argue that this is not a tenable interpretation, and also, more importantly, that the metaphysical and existential implications of this understanding of eternal return reinstate nihilism at the very point where it is supposedly overcome. Moreover, I argue that there are attendant ethical and political dangers to Deleuze’s position on nihilism. (shrink)

This piece, included in the drift special issue of continent. , was created as one step in a thread of inquiry. While each of the contributions to drift stand on their own, the project was an attempt to follow a line of theoretical inquiry as it passed through time and the postal service(s) from October 2012 until May 2013. This issue hosts two threads: between space & place and between intention & attention . The editors recommend that to experience the (...) drifiting thought that attention be paid to the contributions as they entered into conversation one after another. This particular piece is from the BETWEEN SPACE & PLACE thread: April Vannini, Those Between the Common * Laura Dean & Jesse McClelland, Ballard: A Portrait of Placemaking * Amara Hark Weber, Crossroad * Isaac Linder & Berit Soli-Holt, The Call of the Wild: Terro(i)r Modulations * Ashley D. Hairston, Momma taught us to keep a clean house * Sean Smith, The Garage (Take One) * * * * Momma taught us to keep a clean house. Dust the wood furniture every two weeks. Clean the bathrooms once a week. Wipe down the baseboards once a season (Those damn baseboards. I still got bruises on my knees from scrubbing those things). Sweep away the cobwebs—and pray that those spiders are either dead or delirious (Livin in the country don’t mean you like bugs, especially the ones with too many legs ). Didn’t matter that the house was full of stuff: Great-Grandma’s heirloom dresser, that weird Mammy salt shaker and matching Uncle Tom pepper grinder (Where the hell did Momma get those P.O.S.’s?), the outdated drapes from Belks, Dad’s favorite wooden TV tray, and that uuuuugly love seat that some crazy uncle thought was a glorious find from the Salvation Army (Momma tried to make it pretty with some pillows, but no amount of love could help that seat). Spring Cleaning meant pullin all that furniture away from the walls and holdin your breath to see what time collected in the crevices. Then you gotta be careful not to breathe out too heavy cause the dust would go flying fore you got a chance to catch it. If you didn’t, you’d quickly find out if you’re allergic to dust. Quarter cup of lemon Lysol in a bucket of steaming water and an old wash rag. Maybe two. A dust towel and citrus-scent Pledge. Me and my brothers would fight over who cleaned what. Somehow the twins always got the easy stuff: vacuuming or moving dirt around with the feather-duster. Finishing in enough time to fly down the street on their bikes with the neighborhood kids. Older sister never got off that easy. Each of my stubby fingers morphed into plump, lemon-fresh golden raisins by the time that whole damn house was done. I would finish just in time to sit with Nadine on the porch, counting the seconds til the sun turned off and the fireflies fluttered on. The craziest thing: despite all that cleaning, the house still smelled like Momma’s cookin. That Old House. Might have been some of Grandma’s and Great-Grandma’s cookin mixed in there too. Pork chops. Ham hock soaked in collards. Pinto beans and mustard greens. Corn bread and my Auntie’s famous macaroni and cheese. Didn’t matter if the oven was cold and the valve of the gas stove had been shut for days. A stranger woulda thought someone’d been slavin away in that kitchen for a week straight. No Sweet Citrus & Zest Fabreze back then. Lysol would mask the odors for a little while. Not long enough to overpower the 50 years of goodness marinated in buttermilk, kneaded with lard, and fried in Crisco that’d been embedded in the wallpaper and window treatments. All that grime—dead skin, hair follicles, Carolina clay, carpet lint, yippee-little-dog fur—was evidence of life. We were a socially-awkward newly-minted teenager, two rowdy twin boys, a multi-tasking mother, and a road-warrior father. Eventually a strangely-feline Yorkie was added to the mix. And don’t forget about the stray distant relative stopping by unannounced. No corner of that damn house was unmarked. Hand-sewn pillows in the living room that we were forbidden to breathe on somehow had tiny burnt orange paw prints on them (sneaky little dog). It drove Momma crazy. And tore up my fingernails. They still won’t grow back right. Wipe all that shit off just for it to build up again. But that house was inherited and fully paid for. No reason to move. I did move. I was ready to move on. Move up. Move out. Over that small town. Into the big city. Here the streets take on the smells of Momma’s house. Plus piss, shit, and unbathed skin. A hot day means everything cooks and stews in its own juices, making the stench 10x more intense. The apartment is another story. 11 floors up. Big, east-facing windows. Great view of the skyline dotted with some green foliage. And the great lake. Immaculate. Odorless. Not even a trace of tobacco from the previous tenant’s bad habits. No lingering scent of lemon Lysol. No street stench seeping through the window panes. No stray cat hairs. Or dog fur. Not a speck of dust. Futon. Throw pillows. Photos. Knickknacks. Bowls of fresh citrus. Cursedly-assembled desk set from IKEA. Yet the void is too big to fill. Too clean. (shrink)

Sleep and mental health are important aspects of human health that work concurrently. However, sleep and mental health disorders are often overlooked and undiagnosed in sport due to the negative stigma associated with them. Evidence suggests that athletes are disproportionately affected by mental health issues and sleep problems. Internal and external pressures contribute to psychological distress. Variable competition times, travel and stress are detrimental to sleep quality. Retirement from sport can deteriorate sleep and psychological wellbeing, particularly for those who retired (...) involuntarily and identify strongly with their athletic role. When untreated, these issues can manifest into a range of clinical disorders. This is concerning, not only for compromised athletic performance, but for general health and wellbeing beyond sport. Previous research has focussed on sleep and health independently among currently competing, or former, athletes. To date, no research has comprehensively assessed and compared sleep complaints and mental health issues between these two cohorts. Moreover, research has failed to obtain data across a variety of different competition levels, sports, and genders, leaving the current scope of the literature narrow. Comorbid conditions, ex-college athletes, and mental health has been the focus of existing literature post-retirement. Future research would benefit from employing both quantitative and qualitative methodologies to comprehensively assess the prevalence and severity of sleep and mental health disorders across current and retired athletes. Research outcomes would inform education strategies, safeguarding athletes from these issues by reducing negative stigmas associated with help-seeking in sport and ultimately increase self-guided treatment. (shrink)

Forty years after Dax Cowart fought to have his voice heard regarding his medical treatment, patient autonomy and rights are at the heart of patient care today. Yet, despite its centrality in patient care, the tension between a severely burned patient’s right to stop treatment and the physician’s role in saving a life has not abated. As this case study explores, barriers remain to hearing and respecting a patient’s treatment decisions. Dismantling these barriers involves dispelling the myths (...) that burn patients must grin and bear intense pain to recover and that a patient’s choice to discontinue treatment equals physician failure. Moreover, in these situations, sustained, direct engagement between physician and patient can reduce the moral distress of all involved and enable physicians to hear and better accept when a patient is calling for the end of the day. (shrink)

Placebos are much discussed in both the medical and philosophy of medicine literatures. Once narrowly defined as inert “sugar pills,”, they now are now most often taken to be “treatments that appear similar to experimental treatments, but that lack their characteristic components”. In addition to their use in the control groups of many clinical trials, placebos are also now widely recognized by medical practitioners to be powerful therapies in themselves, often outperforming conventional drug therapies in these studies.Given this, I find (...) Haller’s book, which is divided into six chapters, “Evidence Based Medicine,” “Postmodernist Medicine,” “The Powerful Placebo,” “Politics of... (shrink)

:The theme of sacrifice appears in Jean-François Lyotard's writings on cinema not in terms of any representational content but in terms of the economy of the images from which a film is formally constructed. Sacrifice is here understood in a sense derived from Bataille, and related to his notions of general economy, and of sovereignty. Lyotard's writings on cinema have received some attention in English-language scholarship, but so far this attention has been focused almost exclusively on two essays which have (...) appeared in English translation: “Acinema” and “The Unconscious as Mise-en-Scène.” I offer an analysis which also incorporates his two other important essays on cinema, “Deux métamorphoses du séduisant au cinéma” [Two Metamorphoses of the Seductive in Cinema] and “Idée d'un film souverain” [The Idea of a Sovereign Film]. The interest of the former is that it makes most explicit the aesthetic politics – evident in many of Lyotard's writings on art – specific to cinema. In the latter, Lyotard gives his most extensive treatment of cinema, and frames it in terms of Bataille's notion of sovereignty. I offer an interpretation of Lyotard's philosophy of cinema which links these quite disparate essays, foregrounding the political dimension of the sacrificial economy of images he proposes: films of any variety, even commercial cinema, may include some sequences and images which are “sacrificial” in that they are “other” to the chronological narrative of the whole. These images liberate us from the seductive effects of the narrative, and the invitation to fantasise, which act as means of imposing and reproducing dominant social and cultural norms. (shrink)

This article surveys the notion of the event as it is treated in Lyotard’s works, and examines the implications of this treatment for his method, and for critical theory in general. While the event is of importance to many influential French philosophers, it is arguably Lyotard who has positioned his philosophy most central around the problem of accounting for events. For Lyotard, an event is an occurence which cannot be predicted in advance, and cannot be fully determined in retrospect. (...) An event is "nothing," in so far as it cannot be captured in theoretical representations, but it is of import to theory in so far as it disrupts representations and indicates their limits. Lyotard's work engages with the problem of the event both theoretically and performatively, not only discussing the nature of the event, but letting it govern his methodology. This chapter outlines the way in which Lyotard's engagement with the event demonstrates the implications of this notion across a wide variety of critical concerns, including metaphysics, epistemology, aesthetics, ethics, and politics. It also distinguishes Lyotard’s understanding of the event from that of other French philosophers, such as Derrida, Deleuze, and Badiou. While this chapter does not explicitly treat of the book’s main themes, its placement as the first chapter serves a general introductory function, outlining the main phases and concepts of Lyotard’s work which are frequent points of reference in the proceeding chapters. (shrink)

In Words Are Weapons, Philippe-Joseph Salazar has produced a work that's garnered international acclaim. Winning the Prix Bristol des Lumières in 2015 and earning rave reviews, the book is one of the first, perhaps only, robust treatments of ISIS's rhetoric with an eye toward its persuasive efforts. For these reasons, the book is vitally important as we approach turning the corner into a second decade of Western-led terror wars that created the conditions under which ISIS formed. Salazar deserves serious credit (...) for this contribution; it is undoubtedly a text that should appear in every library throughout the world.For these reasons, I struggle with this book. I find several areas in... (shrink)

Since its introduction just over two decades ago, evidence-based medicine (EBM) has come to dominate medical practice, teaching, and policy. There are a growing number of textbooks, journals, and websites dedicated to EBM research, teaching, and evidence dissemination. EBM was most recently defined as a method that integrates best research evidence with clinical expertise and patient values and circumstances in the treatment of patients. There have been debates throughout the early 21st century about what counts as good research evidence (...) between EBM proponents and philosophical critics and even within the EBM community itself. Similar controversy arises about the relative worth of patient values and clinical expertise (and how these can be integrated). EBM has also evolved in ways that have come under scrutiny. Specifically, policymakers have used EBM research methodology to increase the relative importance of clinical guidelines that some clinicians have argued are tyrannical. Philosophers have addressed all of these controversies, and with very few exceptions have been critical of EBM. In addition most philosophical attention has been on the epistemic role of Randomization and evidence hierarchies, with relatively little attention being paid to the role of Diagnosis, expertise, patient values, and Systematic Reviews within EBM. (shrink)

This clinical case report illustrates the potential dilemmas that can arise from knowledge gained through genetic analysis. These conflicts require careful ethical analysis of presumed duties to protect patient privacy and maintain confidentiality, the duty to warn a second party of a health risk, and the duty of veracity. While the questions raised by genetic testing of one individual for disease that reveals potentially important information about relatives, such as risk for Huntington chorea or breast cancer, have been discussed, the (...) continuing expansion in our capacity for sophisticated genetic analysis continues to present new and challenging situations. The resolution of this case and others like it requires close collaboration among the treatment team, geneticists, and clinical ethicists. (shrink)

Background: Transgender health care is a subject of much debate among clinicians, political commentators, and policy-makers. While the World Professional Association of Transgender Health (WPATH) Standards of Care (SOC) establish clinical standards, these standards contain implied ethics but lack explicit focused discussion of ethical considerations in providing care. An ethics chapter in the SOC would enhance clinical guidelines. Aims: We aim to provide a valuable guide for healthcare professionals, and anyone interested in the ethical aspects of clinical support for gender (...) diverse and transgender people of all ages. Recognizing that the WPATH is a global association, we address broad challenges. We offer a reflection on general ethical principles, providing conceptual tools for healthcare providers, patients, and families to navigate the specific challenges they might encounter in transgender health care, in line with WPATH’s worldwide mission and scope. Method: This article employs a descriptive analysis, and our framework of reference is the four principles of biomedical ethics: respect for autonomy, beneficence, nonmaleficence, and justice. Results: The article presents a discussion on the four ethical principles as applied to transgender health care. We address issues such as respect for patient autonomy in decision-making, the role of beneficence and nonmaleficence in clinical interventions, and the importance of justice in equitable treatment and access to care. Some of the ethical concerns we address in this article pertain to the current sociopolitical climate, where there has been increasing legal interference, internationally, for transgender and nonbinary people, particularly youth, seeking medical care. Discussion: We highlight the interplay between ethical principles and clinical practice, underscoring the need for ethical guidance in addressing the diverse challenges faced by healthcare providers and patients in transgender health care. We advocate for continuous refinement of ethical thinking to ensure that transgender health care is not only medically effective but also ethically sound. (shrink)

In this work we study, design, and evaluate computational methods to support interpretation of statutory terms. We propose a novel task of discovering sentences for argumentation about the meaning of statutory terms. The task models the analysis of past treatment of statutory terms, an exercise lawyers routinely perform using a combination of manual and computational approaches. We treat the discovery of sentences as a special case of ad hoc document retrieval. The specifics include retrieval of short texts, specialized document (...) types, and, above all, the unique definition of document relevance provided in detailed annotation guidelines. To support our experiments we assembled a data set comprising 42 queries which we plan to release to the public in the near future in order to support further research. Most importantly, we investigate the feasibility of developing a system that responds to a query with a list of sentences that mention the term in a way that is useful for understanding and elaborating its meaning. This is accomplished by a systematic assessment of different features that model the sentences’ usefulness for interpretation. We combine features into a compound measure that accounts for multiple aspects. The definition of the task, the assembly of the data set, and the detailed task analysis provide a solid foundation for employing a learning-to-rank approach. (shrink)

Out of 288 Hong Kong cancer patients, 92.3% include themselves in decision-making, 71% prefer joint decision-making: with family, with doctor, with doctor plus family, with family minus doctor, and with doctor minus family. <5% want decision-making by “doctor-alone” and <1% desire decision-making by “family-alone”. Harmony, communication and responsibility are reasons for family participation. Most patients prefer “specialist” for information, followed by “family”, “friends”, and “GP”. Trust in doctors and prospects for controlling/curing disease are important factors in decision-making. Patients want to (...) participate and be listened to rather than make decisions. Doctors should not disclose information to family without patients’ permission, nor withhold information from patient [End Page 109] on family’s request. Only 25% of patients have discussed post-competent treatment with others and 7% have heard of Advance Directive ; 24% refuse to discuss it. After AD has been explained to them, 66% remain reluctant to sign one, preferring to leave oral instructions or appoint family as proxy decision-makers. The family’s decision-making role increases when patients become incompetent. The top reason for signing AD is to receive preferred post-competent treatments, and for not signing it, difficulty with making a prospective decision. The implications of these findings will be discussed. (shrink)

Community volunteering is an under-utilized, at least under-researched, strategy to supplement existing treatment for affective disorders. We present findings from a feasibility study incorporating community volunteering into clinical treatment for depression and anxiety among adolescents and young adults. This exploratory pilot study had four aims: to investigate recruitment feasibility; to describe participants’ experiences with volunteering; to explore psychosocial assets by which volunteering might decrease depressive and anxiety symptoms; and to document preliminary changes in mental health outcomes before and (...) after the volunteering intervention. Interviews and surveys were employed with participants newly diagnosed with: mild to moderate depression, mild to moderate anxiety, or adjustment disorder. Recruitment was feasible overall, successes and challenges are discussed. Experiences with volunteering were very positive. Qualitative findings revealed perceived positive effects of volunteering on mood and well-being such as helping with social anxiety and being a positive distraction. Qualitative findings revealed several psychosocial assets that improved related to volunteering. On average, participants reported a 19% decrease in depressive symptoms from the pre-survey to the post-survey. Although more research is warranted, the implication of this study for practicing psychologists treating adolescents and young adults for mild to moderate depression and/or anxiety is that they may wish to consider incorporating community volunteer activities into treatment. Volunteering was a desirable activity for interested participants in treatment for affective disorders. (shrink)

The ‘Ashley treatment’ has raised much ethical controversy. This article starts from the observation that this debate suffers from a lack of careful philosophical analysis which is essential for an ethical assessment. I focus on two central arguments in the debate, namely an argument defending the treatment based on quality of life and an argument against the treatment based on dignity and rights. My analysis raises doubts as to whether these arguments, as they stand in the (...) debate, are philosophically robust. I reconstruct what form good arguments for and against the treatment should take and which assumptions are needed to defend the according positions. Concerning quality of life, I argue that to make a discussion about quality of life possible, it needs to be clear which particular conception of the good life is employed. This has not been sufficiently clear in the debate. I fill this lacuna. Regarding rights and dignity, I show that there is a remarkable absence of references to general philosophical theories of rights and dignity in the debate about the Ashley treatment. Consequently, this argument against the treatment is not sufficiently developed. I clarify how such an argument should proceed. Such a detailed analysis of arguments is necessary to clear up some confusions and ambiguities in the debate and to shed light on the dilemma that caretakers of severely disabled children face. (shrink)

This “current controversies” contribution describes the recent case of a severely disabled six year old girl who has been subjected to a range of medical interventions at the request of her parents and with the permission of a hospital clinical ethics committee. The interventions prescribed have become known as “the Ashley treatment” and involve the performance of invasive medical procedures (eg, hysterectomy) and oestrogen treatment. A central aim of the treatment is to restrict the growth of (...) the child and thus make it easier for her parents to care for her at home. The paper below discusses the main objections to the treatment. It concludes that the most serious concern raised by the case is that it may set a worrying precedent if the moral principle employed in justification of the treatment is applied again to endorse it in similar circumstances. Finally, it raises the possibility that that same moral principle may even be invoked to justify more radical interventions than those that were actually performed in the Ashley treatment. (shrink)

The story of Ashley, a nine-year-old from Seattle, has caused a good deal of controversy since it appeared in the Los Angeles Times on January 3, 2007.1 Ashley was born with a condition called static encephalopathy, a severe brain impairment that leaves her unable to walk, talk, eat, sit up, or roll over. According to her doctors, Ashley has reached, and will remain at, the developmental level of a three-month-old.

In 2006, a paper in the journal Archives of Pediatric and Adolescent Medicine described a novel case of growth attenuation therapy and other treatments carried out on Ashley, a severely cognitively, neurologically and physically disabled 6-year-old girl. Some of the moral arguments that have sprung up in respect of the so-called “Ashley treatment” are considered, and it is suggested that they all miss something—that the proper treatment of Ashley may have as much to do with (...) doctors’ duties to themselves as with their duties to her. It is suggested that the Ashley treatment may have been in violation of doctors’ self-regarding duties and that this possibility is worthy of further investigation. (shrink)

To submit a case that has been reviewed by an ethics committee or to submit papers on related topics in clinical ethics, readers are invited to contact Ruchika Mishra, editor of at: [email protected].

It is commonly thought that when a patient is unable to make a treatment decision for herself, patient autonomy should be respected by consulting the views of a patient surrogate, normally either the next-of-kin or a person previously designated by the patient. On one view, the task of this surrogate is to make the treatment decision that the patient would have made if competent. But this so-called ‘substituted judgment standard’ (SJS) has come in for has come in for (...) a good deal of criticism recently. For instance, some question whether surrogates are able to reliably predict what the patient would have chosen. Others wonder how respecting a patient's counter-factual, rather than actual, choices is supposed to respect her autonomy. Such concerns have lead some to reject the SJS and argue for alternative characterisations of the role of surrogate decision-makers. (shrink)

Abstract:What is in the best interests of a child, and could that ever include interventions that we might regard as prima facie detrimental to a child’s physical well-being? This question is raised a fortiori by growth attenuation treatments in children with severe neurological disorders causing extreme developmental delay. I argue that two principles that provide guidance in generating a conception of best interests for each individual child yield the right results in such cases. The principles are as follows: thepotentiality principle, (...) whereby every child should be able to develop its potential and is entitled to receive certain help in doing so, and theprinciple of psychosomatic harmony, whereby every human being is entitled to treatment that is appropriate to or enables a life in which mind and body are in tune with each other. These principles indicate a certain response to what we can call Ashley-type cases and admit certain caveats. (shrink)

The case of Ashley X involved a young girl with profound and permanent developmental disability who underwent growth attenuation using high-dose estrogen, a hysterectomy, and surgical removal of her breast buds. Many individuals and groups have been critical of the decisions made by Ashley's parents, physicians, and the hospital ethics committee that supported the decision. While some of the opposition has been grounded in distorted facts and misunderstandings, others have raised important concerns. The purpose of this paper is (...) to provide a brief review of the case and the issues it raised, then address 25 distinct substantive arguments that have been proposed as reasons that Ashley's treatment might be unethical. We conclude that while some important concerns have been raised, the weight of these concerns is not sufficient to consider the interventions used in Ashley's case to be contrary to her best interests, nor are they sufficient to preclude similar use of these interventions in the future for carefully selected patients who might also benefit from them. (shrink)

The controversy over the so-called Ashley Treatment (AT), a series of medical procedures that inhibited both growth and sexual development in the body of a profoundly intellectually impaired girl, usually centers either on Ashley’s rights, including a right to an intact, unaltered body, or on Ashley’s parents’ rights to make decisions for her. The claim made by her parents, that the procedure would improve their ability to care for her, is often dismissed as inappropriate or, at (...) best, irrelevant. We argue, however, that caregiving is a central issue in the controversy, as Ashley’s need for caregiving is a defining characteristic of her life. In this article, we analyze the ethics of the Ashley Treatment within the context of family caregiving. Through the physical and emotional work of caregiving, families participate in the formation and maintenance of personal identity, a process that Hilde Lindemann recently called “holding.” We argue that, in an intellectually disabled person such as Ashley, who depends on her family for every aspect of her care, the family’s contribution to identity is an essential source of personhood. We believe that the treatment can be justified if it is indeed an instance of appropriate family “holding” for Ashley. (shrink)

The case of Ashley X involved a young girl with profound and permanent developmental disability who underwent growth attenuation using high-dose estrogen, a hysterectomy, and surgical removal of her breast buds. Many individuals and groups have been critical of the decisions made by Ashley's parents, physicians, and the hospital ethics committee that supported the decision. While some of the opposition has been grounded in distorted facts and misunderstandings, others have raised important concerns. The purpose of this paper is (...) to provide a brief review of the case and the issues it raised, then address 25 distinct substantive arguments that have been proposed as reasons that Ashley's treatment might be unethical. We conclude that while some important concerns have been raised, the weight of these concerns is not sufficient to consider the interventions used in Ashley's case to be contrary to her best interests, nor are they sufficient to preclude similar use of these interventions in the future for carefully selected patients who might also benefit from them. (shrink)

This paper recounts the events surrounding the case of Ashley X, a severely disabled young girl whose parents opted for oestrogen therapy, a hysterectomy and breast removal – the so-called ‘Ashley treatment’ – in order to reduce her projected adult weight and improve her quality of life. Following a description of the events leading up to the procedure itself, and the worldwide debate which ensued, the main arguments in favour and against the procedures are presented. The paper (...) also critically engages with a recent defence of the treatments presented by one of those closely involved with the case – Dr D Diekema. Finally, the recommendations of a report which criticizes procedures at the hospital in which the treatments took place are described, and it is argued that the main recommendation regarding the constitution of the Hospital Ethics Committee (HEC) is ill-thought through and is unlikely to have made any difference to the decision taken by the HEC to approve the Ashley treatments. (shrink)

According to the powerful qualities view, properties are both powerful and qualitative. Indeed, on this view the powerfulness of a property is identical to its qualitativity. Proponents claim that this view provides an attractive alternative to both the view that properties are pure powers and the view that they are pure qualities. It remains unclear, however, whether the claimed identity between powerfulness and qualitativity can be made coherent in a way that allows the powerful qualities view to constitute this sort (...) of alternative. I argue here that this can be done, given a particular conception of both the qualitativity and powerfulness of properties. On this conception, a property is qualitative just in the sense that its essence is fixed independently of any distinct properties, and it is powerful just if its essence grounds its dispositional role. (shrink)

Programmatic secularism aims to secure public reason from rival rationalities, notably those from religious experience and education. The gathering of knowledge in clinical ethics into a concrete array of consensus claims and consensus-derived principles are thought by Janet Malek to secure such public reason—an essential tool for clinical ethics consultants to execute their professional role. The author compares this gathering of knowledge to an understanding of what technology is. Accordingly, the following interrogates Malek’s programmatic secularism, which is a moral technique (...) that not only homogenizes moral dialogue but also dehumanizes persons as it tyrannizes the creative freedom for moral conversation and genuine encounter. Thus, the reader is encouraged to dissent of such a vision for delimiting the role of clinical ethics consultants according to the rule and measure of technology, the ontology of our age. (shrink)

Discussions about the nature of essence and about the inference problem for non-Humean theories of nomic modality have largely proceeded independently of each other. In this article I argue that the right conclusions to draw about the inference problem actually depend significantly on how best to understand the nature of essence. In particular, I argue that this conclusion holds for the version of the inference problem developed and defended by Alexander Bird. I argue that Bird’s own argument that this problem (...) is fatal for David Armstrong’s influential theory of the laws of nature but not for dispositional essentialism is seriously flawed. In place of this argument, I develop an argument that whether Bird’s inference problem raises serious difficulties for Armstrong’s theory depends on the answers to substantial questions about how best to understand essence. The key consequence is that considerations about the nature of essence have significant, underappreciated implications for Armstrong’s theory. (shrink)

This paper explores the influence of transpersonal thinking, including the mythological perspective of Joseph Campbell and the holotropic perspective of Stanislav Grof, on actor training using the neutral mask. An outline of training in the neutral mask is given, focusing on the approach of David Latham, as experienced by the author in his own training. Points of correspondence with the vision of Campbell and Grof, and their influence, are discriminated and discussed. These correspondences open up two areas of inquiry: the (...) transformative effect of the mask work when conducted in a transpersonally-oriented set, and the use of the neutral mask as an approach to the study of myth and archetype. Both are discussed, and some preliminary conclusions drawn based on experiences reported by student-actors and the author’s observations during his own research and his practice as actor and teacher. (shrink)

It is often taken for granted that our desires can contribute to what it is rational for us to do. This paper examines an account of desire—the ‘guise of the good’— that promises an explanation of this datum. I argue that extant guise-of-the-good accounts fail to provide an adequate explanation of how a class of desires—basic desires—contributes to practical rationality. I develop an alternative guise-of-the-good account on which basic desires attune us to our reasons for action in virtue of their (...) biological function. This account emphasises the role of desire as part of our competence to recognise and respond to normative reasons. (shrink)

I defend a new account of constitutive essence on which an entity’s constitutively essential properties are its most fundamental, nontrivial necessary properties. I argue that this account accommodates the Finean counterexamples to classic modalism about essence, provides an independently plausible account of constitutive essence, and does not run into clear counterexamples. I conclude that this theory provides a promising way forward for attempts to produce an adequate nonprimitivist, modalist account of essence. As both triviality and fundamentality in the account are (...) understood in terms of grounding, the theory also potentially has important implications for the relation between essence and grounding. (shrink)

According to a well-known argument, originally due to David Armstrong, powers theory is objectionable, as it leads to a ‘Meinongian’ ontology on which some entities are real but do not actually exist. I argue here that the right conclusion to draw from this argument has thus far not been identified and that doing so has significant implications for powers theory. Specifically, I argue that the key consequence of the argument is that it provides substantial grounds for trope powers theorists, but (...) not other powers theorists, to accept one version of the view that properties are powerful qualities. In particular, they have grounds to favour the view that powerful properties are properties with exclusively qualitative natures that ground modal facts. (shrink)

Recent research indicates that interpersonal communication is noisy, and that people exhibit considerable insensitivity to problems in communication. Using a dyadic referential communication task, the goal of which is accurate information transfer, this study examined the extent to which interlocutors are sensitive to problems in communication and use other‐initiated repairs (OIRs) to address them. Participants were randomly assigned to dyads (N = 88 participants, or 44 dyads) and tried to communicate a series of recurring abstract geometric shapes to a partner (...) across a text–chat interface. Participants alternated between directing (describing shapes) and matching (interpreting shape descriptions) roles across 72 trials of the task. Replicating prior research, over repeated social interactions communication success improved and the shape descriptions became increasingly efficient. In addition, confidence in having successfully communicated the different shapes increased over trials. Importantly, matchers were less confident on trials in which communication was unsuccessful, communication success was lower on trials that contained an OIR compared to those that did not contain an OIR, and OIR trials were associated with lower Director Confidence. This pattern of results demonstrates that (a) interlocutors exhibit (a degree of) sensitivity to problems in communication, (b) they appropriately use OIRs to address problems in communication, and (c) OIRs signal problems in communication. (shrink)

A recent, seemingly appealing version of the powerful qualities view defines properties’ qualitativity via an essentialist claim and their powerfulness via a grounding claim. Roughly, this approach holds that properties are qualities because they have qualitative essences, while they are powerful because their instances or essences ground causal-modal facts. I argue that this theory should be replaced with one that defines the powerfulness of qualities in terms of both a grounding claim and a ‘meta-grounding’ claim. Specifically, I formulate and defend (...) a view on which qualities are powerful just if instances of those qualitiesat least partiallyground dispositionsin virtue of the essences of those qualities. (shrink)

Understanding everyday behavior relies heavily upon understanding our ability to improvise, how we are able to continuously anticipate and adapt in order to coordinate with our environment and others. Here we consider the ability of musicians to improvise, where they must spontaneously coordinate their actions with co-performers in order to produce novel musical expressions. Investigations of this behavior have traditionally focused on describing the organization of cognitive structures. The focus, here, however, is on the ability of the time-evolving patterns of (...) inter-musician movement coordination as revealed by the mathematical tools of complex dynamical systems to provide a new understanding of what potentiates the novelty of spontaneous musical action. We demonstrate this approach through the application of cross wavelet spectral analysis, which isolates the strength and patterning of the behavioral coordination that occurs between improvising musicians across a range of nested time-scales. Revealing the sophistication of the previously unexplored dynamics of movement coordination between improvising musicians is an important step towards understanding how creative musical expressions emerge from the spontaneous coordination of multiple musical bodies. (shrink)