Free choice permission, a crucial test case concerning the semantics/ pragmatics boundary, usually receives a pragmatic treatment. But its pragmatic features follow from its semantics. We observe that free choice inferences are defeasible, and defend a semantics of free choice permission as strong permission expressed in terms of a modal conditional in a nonmonotonic logic.

Stress induction reduces people's ability to modify their instrumental choices following changes in the value of outcomes, but the mechanisms underpinning this effect have not been specified because previous studies have lacked crucial control conditions. To address this, the current study had participants learn two instrumental responses for food and water, respectively, before water was devalued by specific satiety. Choice between these two responses was then measured in extinction, reacquisition and Pavlovian to instrumental transfer tests. Concurrently during these (...) tests, a negative emotional appraisal group evaluated aversive images, whereas a control group evaluated neutral images, at the same time as choosing between the two instrumental responses. Negative emotional appraisal abolished the impact of water devaluation on instrumental choice in the extinction test, but did not affect instrumental choice in the reacquisition or PIT tests. These findings suggest that negative emotional appraisal selectively impaired participants’ ability to retrieve the expected value of outcomes required to make goal-directed instrumental choices in the extinction test, and that this effect was not due to task disengagement, nullification of the devaluation treatment or impaired knowledge of response-outcome relationships. (shrink)

Different immunotherapeutic approaches are in the pipeline for the treatment of drug dependence. “Drug vaccines” aim to induce the immune system to produce antibodies that bind to drugs and prevent them from inducing rewarding effects in the brain. Drugs of abuse currently being tested using these new approaches are opioids, nicotine, cocaine, and methamphetamine. In human clinical trials, “cocaine and nicotine vaccines” have been shown to induce sufficient antibody levels while producing few side effects. Studies in humans, determining how (...) these vaccines interact in combination with their target drug, are underway. However, although vaccines can become a reasonable treatment option for drugs of abuse, there are several disadvantages that must be considered. These include i) great individual variability in the formation of antibodies, ii) the lack of protection against a structurally dissimilar drug that produces the same effects as the drug of choice, and iii) the lack of an effect on the drug desire that may predispose an addict to relapse. In addition, a comprehensive overview of several crucial ethical issues has not yet been widely discussed in order to have not only a biological approach to immunotherapy of addiction. Overall, immunotherapy offers a range of possible treatment options: the pharmacological treatment of addiction, the treatment of overdoses, the prevention of toxicity to the brain or the heart, and the protection of the fetus during pregnancy. So far, the results obtained from a small-scale experiment using vaccines against cocaine and nicotine suggest that a number of important technical challenges still need to be overcome before such vaccines can be approved for clinical use. (shrink)

It has been claimed that beneath the government rhetoric of patient choice, no real choice exists either in law or in National Health Service policy. Thus, choice is considered to be a fallacy in that patients are not able to demand specific treatment, but are only able to express preferences amongst the available options. This article argues that, rather than considering choice only in terms of patient autonomy or consumer rights, choice ought to be seen as serving other functions: (...) Choice serves as a mechanism of destabilisation, i.e., as a lever for change. This is apparent at the level of patient and doctor, and at the level of patient and health authority, but even more so, at the level of government. Patient choice, rather than benefiting the individual, can have effects on a wider scale. It encourages change and reform in healthcare practices and in the NHS institutions. (shrink)

: Our paper discusses the epistemic attitudes of particle physicists on the discovery of the Higgs boson at the Large Hadron Collider. It is based on questionnaires and interviews made shortly before and shortly after the discovery in 2012. We show, to begin with, that the discovery of a Standard Model Higgs boson was less expected than is sometimes assumed. Once the new particle was shown to have properties consistent with SM expectations – albeit with significant experimental uncertainties –, there (...) was a broad agreement that ‘a’ Higgs boson had been found. Physicists adopted a two-pronged strategy. On the one hand, they treated the particle as a SM Higgs boson and tried to establish its properties with higher precision; on the other hand, they searched for any hints of physics beyond the SM. This motivates our first philosophical thesis: the Higgs discovery, being of fundamental importance and establishing a new kind of particle, represented a crucial experiment if one interprets this notion in an appropriate sense. By embedding the LHC into the tradition of previous precision experiments and the experimental strategies thus established, underdetermination and confirmational holism are kept at bay. Second, our case study suggests that criteria of theory preference should be understood as epistemic and pragmatic values that have to be weighed in factual research practice. The Higgs discovery led to a shift from pragmatic to epistemic values as regards the mechanisms of electroweak symmetry breaking. Complex criteria, such as naturalness, combine epistemic and pragmatic different values, but are coherently applied by the community. (shrink)

I would say very simply that the function of the intellectual is this: to put at the disposal of others, to put in common, this greater set of critical analytical tools, to make those tools freely available, and this naturally demands being rooted in reality that is in movement, a reality in which the researcher herself puts certain choices into practice, in which she can deem some matters to be more crucial than others. And the hope is, depending (...) on the choices made by all of those who are today committed to transforming that which exists, that there effectively comes about the wide-ranging social transformation of which we are in need.Costa’s definition of the intellectual is both inspiring and radical. Her.. (shrink)

This paper traces the development of parental rights to accept or to refuse treatment for a defective newborn infant in the United Kingdom and in the United States of America; its main purpose is to explore the common trends from which an acceptable policy may be derived. It is probable that the British law on parental decision-making in respect of infants suffering from Down's syndrome is to be found in the civil case of In Re B rather than in (...) the criminal case of R v Arthur. United States court decisions are strongly influenced by constitutional law and reflect the right to personal privacy. The position on each side of the Atlantic seems very similar but this similarity includes a sense of uncertainty as to legal responsibility. There is a case for agreed guidelines and a suggested format is offered for consideration. (shrink)

It is a remarkable fact about the development of medical ethics from the 1960s until today that there has been a dramatic shift from a position where it was taken for granted that the physician knows best, to a position where much greater emphasis is put on the patient’s treatment preferences. This shift is evident with regard to physician attitudes towards disclosing a cancer diagnosis. For example, in 1961, a survey of cancer physicians showed that almost 90% of the (...) physicians reported that their usual policy was not to tell their patients that they had cancer . The survey was repeated in 1979, and it showed a complete reversal in attitudes over this 20-year period. 90% reported that their usual policy was to tell their patients that they had cancer .One common way of justifying the new approach is to claim that patients have a right to make their own treatment decisions, referring to the basic value of patient autonomy. However, it is immediately obvious that physicians should not respect all choices made by patients. Consider the following case: A thirty-eight-year-old man with mild upper respiratory infection suddenly developed severe headache, stiff neck, and high fever. He went to an emergency room for help. The diagnosis was pneumococcal meningitis, a bacterial meningitis almost always fatal if not treated. If treatment is delayed, permanent neurological damage is likely. A physician told the patient that urgent treatment was needed to save his life and forestall brain damage. The patient refused to consent to treatment saying he wanted to be allowed to die .Very few, if any, physicians would respect this person’s treatment choice. The reason is that this patient is not competent to make his own decisions. Respect for autonomy only requires that the choices of patients who are competent to make their own decisions are honoured. Judgements about which patients are competent to make their own decisions therefore become crucial. (shrink)

Crisis resolution and home treatment teams have been introduced into mental health care in the UK because, in general, patients do not want to be admitted to hospital, treatment at home is cheaper and in the only randomized controlled trial conducted so far there was no difference in symptomatic outcome. However, because of compulsory gate-keeping by CRHT teams, some patients no longer have the option of going to hospital if they want to. This aspect of the introduction of (...) CRHT teams has not been discussed so far, but it certainly warrants further examination. Intervention through CRHT teams may in fact increase compulsory admissions and serious and untoward incidents, although this is not certain. Sufferers from psychosis are the patient group most likely to be compulsorily admitted to hospital and they are generally considered less responsible for serious and untoward incidents. Therefore, a possible solution could be to offer a choice to some patients, namely those with a psychotic disorder, on whether they want to be admitted or not. At least one should investigate what the consequences of this policy would be, if it were to be adopted in a test region. This example shows that in developing policies for rationing health care, it can be important to look at subgroups and not just at average results when determining the best course of action. (shrink)

Cancer is a group of diseases that are complicated by various treatment choices available. Information exchange between a patient and physician is critical in helping people to understand what is happening to them and what options for therapy are recommended and available. When information is not exchanged, information control by one or both of the participants occurs. Information needs to be taken into account by both health care professional and patients in making decisions during the crucial phases (...) of care. The phases of care presented are a diagnosis, treatment, the decision, and a recurrence. Factors that influence effective information exchange among patient-provider systems are discussed. (shrink)

This article outlines the struggle between the power of the health care professional and the rights of the individual to choose freely a modality of treatment. Nurses are instrumental in assisting patients in making the best decision for a therapy they will have to assume for the rest of their lives. In guiding patients' decision, nurses must take into account these unavoidable contingencies: changes in lifestyle, nutritional restrictions, level of acceptance, compliance issues, ease of training and availability of support/facilities. (...) Ensuring that the patient makes an informed decision is therefore an ongoing challenge for nurses as they are taking part in a delicate balancing act between not directly influencing the patient's decision while making sure the patient is accurately informed. (shrink)

This article is about the information relevant to decision-making capacity in refusal of life-prolonging medical treatment cases. We examine the degree to which the phenomenology of the options available to the agent—what the relevant states of affairs will feel like for them—forms part of the capacity-relevant information in the law of England and Wales, and how this informational basis varies across adolescent and adult medical treatment cases. We identify an important doctrinal phenomenon. In the leading authorities, the courts (...) appear to count the first-personal phenomenology of the available options among the information that adolescents seeking to refuse life-prolonging treatment must understand and appreciate in order to possess capacity; adults are not held to this (higher) standard. We evaluate this differential treatment in light of philosophical work on transformative choice—decisions involving options whose sensory character, and effect on our values and preferences, are grasped only through experience itself. (shrink)

Rawls' Difference Principle asserts that a basic economic structure is just if it makes the worst off people as well off as is feasible. How well off someone is is to be measured by an ‘index’ of ‘primary social goods’. It is this index that gives content to the principle, and Rawls gives no adequate directions for constructing it. In this essay a version of the difference principle is proposed that fits much of what Rawls says, but that makes use (...) of no index. Instead of invoking an index of primary social goods, the principle formulated here invokes a partial ordering of prospects for opportunities. (shrink)

I call an experiment “crucial” when it makes possible a decisive choice between conflicting hypotheses. Joharmsen's selection for size and weight within pure lines of beans played a central role in the controversy over continuity or discontinuity in hereditary change, often known as the Biometrician-Mendelian controversy. The “crucial” effect of this experiment was not an instantaneous event, but an extended process of repeating similar experiments and discussing possible objections. It took years before Johannsen's claim about the genetic stability (...) of pure lines was accepted as conclusively demonstrated by the community of geneticists. The paper also argues that crucial experiments thus interpreted contradict certain ideas about the underdetermination of theories by facts and the theory-ladenness of facts which have been influential in recent history and sociology of science. The acceptance of stability in the pure lines did not rest on prior preference for continuity or discontinuity. And this fact permitted a final choice between the two theories. When such choice is characterized as “decisive” or “final”, this is not meant in an absolute philosophical sense. What we achive in these cases is highly reliable empirical knowledge. The philosophical possibility of drawing (almost) any conclusion in doubt should be distinguished from reasonable doubt in empirical science. (shrink)

Opioid treatment agreements are written agreements between physicians and patients enumerating the risks associated with opioid medications along with the requirements that patients must meet to receive these medications on an ongoing basis. The choice to use such agreements goes beyond the standard informed consent process, and has a distinctive symbolic significance. Specifically, it suggests that physicians regard it as important to hold their patients accountable for adhering to various protocols regarding the use of their opioid medications. After laying (...) out a taxonomy of accountability relationships between physicians and patients, I argue that opioid treatment agreements are only justifiable for physicians to use in their provision of care if they improve public health outcomes, which has yet to be demonstrated. (shrink)

There is robust scientific evidence from meta-analyses in psychotherapy research that common factors such as the alliance between patients and therapists, empathy, goal consensus/collaboration, positive regard/affirmation and genuineness have a much greater effect on the overall psychotherapy outcome than the so-called specific factors like particular treatment methods or ingredients of therapy.1 The current evidence base also suggests that the effects of telepsychiatric treatment are comparable with those of face-to-face treatment, not only regarding clinical outcome parameters but also (...) with respect to patient satisfaction, acceptance and adherence—all common factors of psychotherapy.2 According to a comprehensive review of the main ethical arguments for and against different forms of online psychotherapy, the online setting provides several weighty advantages: for example, increased access, availability, flexibility, convenience, satisfaction, acceptance and increased demand.3 Among the arguments against online psychotherapy, privacy, confidentiality and data security issues, emergency issues, as well as communication issues have been mentioned.3 Frittgen and Haltaufderheide 4 are concerned that telepsychiatry could ‘impact ethically relevant aspects of the therapeutic relationship’. They conclude that ‘there is evidence for ethically relevant changes of the therapeutic relationship in video-based telepsychiatric consultations’,4 particularly pertaining to ‘respect for autonomy, lucidity, fidelity, justice and humanity towards each other’.4 Indeed, video-based consultations as technically mediated communication ‘do not only transmit but transform what can be perceived, …. (shrink)

To speak of patients' choices is to obscure the distinction between request and refusal of treatment. The distinction is particularly crucial for questions of killing or letting die.

The American Journal of Bioethics, Volume 12, Issue 9, Page 6-7, September 2012.

Aristotle's treatment of the choice between the political and contemplative lives (in EN I 5 and X 7-8) can seem awkward. To offer one explanation of this, I argue that when he invokes self-sufficience (autarkeia) as a criterion for this choice, he appeals to two different and incompatible specifications of "lacking nothing." On one specification, suitable to a human being living as a political animal and thus seeking to realize his end as an engaged citizen of a polis, a (...) person lacks nothing by possessing a wide range of goods that directly require other people. On the other, more suitable to a god or a beast, a person lacks nothing by having no need of goods that directly require other people. The ambiguity of this criterion renders the choice between the political and contemplative lives difficult. (shrink)

_Covert treatment raises a number of ethical and practical issues in psychiatry. Viewpoints differ from the standpoint of psychiatrists, caregivers, ethicists, lawyers, neighbours, human rights activists and patients. There is little systematic research data on its use but it is quite certain that there is relatively widespread use. The veil of secrecy around the procedure is due to fear of professional censure. Whenever there is a veil of secrecy around anything, which is aided and abetted by vociferous opposition from (...) some sections of society, the result is one of two: 1) either the activity goes underground or 2) it is reluctantly discarded, although most of those who used it earlier knew it was needed. Covert treatment has the dubious distinction of suffering both such secrecy and disapproval. Covert treatment has a number of advantages and disadvantages in psychotic disorders. The advantages are that it helps solve practical clinical problems; prevents delays in starting treatment, which is associated with clinical risks and substantial costs; prevents risk of self-destructive behaviour and/or physical assault by patient; prevents relapse; and prevents demoralization of staff. The disadvantages are that it maybe used with malafide intent by caregivers with or without the complicity of psychiatrists; it may be used to force conformity in dissenters; and the clinician may land himself in legal tangles even with its legitimate use. In addition, it may prevent insight, encourage denial, promote unhealthy practices in the treating staff and prevent understanding of why noncompliance occurs in the first place. Some support its use in dementia and learning disorders but oppose it in schizophrenia. The main reason is that uncooperative patients of schizophrenia (and related psychoses) are considered to be those who refuse treatment but retain capacity; while in dementia and severe learning disorder, uncooperative patients are those who lack capacity. This paper disputes this contention by arguing that although uncooperative patients of schizophrenia (and related psychoses) apparently retain capacity, it is limited, in fact distorted, since they lack insight. It presents the concept of insight-unconsciousness in a patient of psychosis. Just as an unconscious patient has to be given covert medical/surgical treatment, similarly an insight-unconscious patient with one of the different psychoses (in the acute phase or otherwise) may also have to be given covert treatment till he regains at least partial insight. It helps control psychotic symptoms and assists the patient in regaining enough insight to realize he needs treatment. Another argument against covert treatment is that people with schizophrenia have the capacity to learn and therefore can learn that they are required to take medications, but if medications are given covertly it may well fuel their paranoia. However, it should be noted that the patient who has lack of insight cannot learn unless he regains that insight, and he may need covert treatment to facilitate this process. Covert treatment can fuel the paranoia, true, but it can also control the psychotic symptoms sufficiently so that regular treatment can be initiated. In a patient who refuses to accept that he is sick and when involuntary commitment is not an option to be considered, covert treatment is the only option, apart from physical restraint. Ultimately, a choice has to be made between a larger beneficence (control of symptoms and start of therapy) and a smaller malevolence (necessary therapy, but without the patient's knowledge and consent). A number of practical clinical scenarios are outlined wherein the psychiatrist should adopt covert treatment in the best interests of the patient. Ethical issues of autonomy, power, secrecy and malafide intent arise; each of these can be countered only by non-malfeasance (above all, do no harm) under the overarch of beneficence (even above that, dare to care). An advance directive with health care proxy that sanctions covert treatment is presented. Questions raised by the practical clinical scenarios are then answered. The conclusions are as follows: covert treatment, i.e, temporary treatment without knowledge and consent, is seldom needed or justified. But, where needed, it remains an essential weapon in the psychiatrist's armamentarium: to be used cautiously but without guilt or fear of censure. However, the psychiatrist must use it very judiciously, in the rarest of rare cases, provided: i) he is firmly convinced that it is needed for the welfare of the patient; ii) it is the only option available to tide over a crisis; iii) continuing efforts are made to try and get the patient into regular psychiatric care; iv) the psychiatrist makes it clear that its use is only as a stop-gap; v) he is always alert to the chances of malevolence inherent in such a process and keeps away from conniving or associating with anything even remotely suspicious; and vi) he takes due precautions to ensure that he does not land into legal tangles later. The need of the hour is to explore in greater detail the need and justification for covert treatment, to lay out clear and firm parameters for its legitimate use, follow it up with standard literature and, finally, to establish clinical practice guidelines by unconflicted authors. The term "covert treatment" is preferable to "surreptitious prescribing"; they should not be used synonymously, the latter term being reserved for those cases where there is malafide intent._. (shrink)

This book, written by four internationally renowned bioethicists and first published in 2000, was the first systematic treatment of the fundamental ethical issues underlying the application of genetic technologies to human beings. Probing the implications of the remarkable advances in genetics, the authors ask how should these affect our understanding of distributive justice, equality of opportunity, the rights and obligations as parents, the meaning of disability, and the role of the concept of human nature in ethical theory and practice. (...) The book offers a historical context to contemporary debate over the use of these technologies by examining the eugenics movement of the late nineteenth and early twentieth centuries. The questions raised in this book will be of interest to any reflective reader concerned about science and society and the rapid development of biotechnology, as well as to professionals in such areas as philosophy, bioethics, medical ethics, health management, law, and political science. (shrink)

In The Harm Principle, Personal Identity and Identity-Relative Paternalism,1 Wilkinson offers a thoughtful argument about medical decision-making and Derek Parfit’s reductionist account of personal identity. I agree that Parfit’s account can contribute to the ethical analysis of patients’ choices. My own work in this area emphasises challenges the reductionist account presents to conventional understanding of advance treatment directives, particularly in cases involving people with dementia.2 I have also urged people making directives to consider the harm their directives could (...) impose on future selves with dementia.3 But as Wilkinson points out, Parfit’s account has implications in other medical contexts as well. Wilkinson presents examples of people making medical decisions that could impose serious harm on their future selves. These examples consider decisions made before a health crisis. Another kind of case involves people in the midst of illness who face a series of ongoing care choices. As people in this situation adjust to their …. (shrink)

This book, written by four internationally renowned bioethicists and first published in 2000, was the first systematic treatment of the fundamental ethical issues underlying the application of genetic technologies to human beings. Probing the implications of the remarkable advances in genetics, the authors ask how should these affect our understanding of distributive justice, equality of opportunity, the rights and obligations as parents, the meaning of disability, and the role of the concept of human nature in ethical theory and practice. (...) The book offers a historical context to contemporary debate over the use of these technologies by examining the eugenics movement of the late nineteenth and early twentieth centuries. The questions raised in this book will be of interest to any reflective reader concerned about science and society and the rapid development of biotechnology, as well as to professionals in such areas as philosophy, bioethics, medical ethics, health management, law, and political science. (shrink)

Recent studies of scientific interaction based on agent-based models suggest that a crucial factor conducive to efficient inquiry is what Zollman has dubbed ‘transient diversity’. It signifies a process in which a community engages in parallel exploration of rivaling theories lasting sufficiently long for the community to identify the best theory and to converge on it. But what exactly generates transient diversity? And is transient diversity a decisive factor when it comes to the efficiency of inquiry? In this paper (...) we examine the impact of different conditions on the efficiency of inquiry, as well as the relation between diversity and efficiency. This includes certain diversity-generating mechanisms previously proposed in the literature, as well as some factors that have so far been neglected. This study is obtained via an argumentation-based ABM. Our results suggest that cautious decision-making does not always have a significant impact on the efficiency of inquiry while different evaluations underlying theory-choice and different social networks do. Moreover, we find a correlation between diversity and a successful performance of agents only under specific conditions, which indicates that transient diversity is sometimes not the primary factor responsible for efficiency. Altogether, when comparing our results to those obtained by structurally different ABMs based on Zollman’s work, the impact of specific factors on efficiency of inquiry, as well as the role of transient diversity in achieving efficiency, appear to be highly dependent on the underlying model. (shrink)

Professional control in the selection of treatment options for patients is changing. In light of social and legal developments emphasising patient choice and autonomy, and restricting medical paternalism and judicial deference, this article examines how far patients and families can demand NHS treatment in England and Wales. It considers situations where the patient is an adult with capacity, an adult lacking capacity and a child. In all three cases, there is judicial support for professional autonomy, but there are (...) also inconsistencies that have potential to elevate the importance of patient and family preferences. In combination, they may be perceived by healthcare professionals as an obligation to follow patient preferences, even where doing so conflicts with other professional obligations. It is argued that a more nuanced approach to shared decision-making could help clarify the boundaries of decision-making responsibility. (shrink)

This paper explores some issues about the choice of variables for causal representation and explanation. Depending on which variables a researcher employs, many causal inference procedures and many treatments of causation will reach different conclusions about which causal relationships are present in some system of interest. The assumption of this paper is that some choices of variables are superior to other choices for the purpose of causal analysis. A number of possible criteria for variable choice are described and (...) defended within a broadly interventionist approach to causation. (shrink)

Recent studies of scientific interaction based on agent-based models suggest that a crucial factor conducive to efficient inquiry is what Zollman has dubbed ‘transient diversity’. It signifies a process in which a community engages in parallel exploration of rivaling theories lasting sufficiently long for the community to identify the best theory and to converge on it. But what exactly generates transient diversity? And is transient diversity a decisive factor when it comes to the efficiency of inquiry? In this paper (...) we examine the impact of different conditions on the efficiency of inquiry, as well as the relation between diversity and efficiency. This includes certain diversity-generating mechanisms previously proposed in the literature, as well as some factors that have so far been neglected. This study is obtained via an argumentation-based ABM. Our results suggest that cautious decision-making does not always have a significant impact on the efficiency of inquiry while different evaluations underlying theory-choice and different social networks do. Moreover, we find a correlation between diversity and a successful performance of agents only under specific conditions, which indicates that transient diversity is sometimes not the primary factor responsible for efficiency. Altogether, when comparing our results to those obtained by structurally different ABMs based on Zollman’s work, the impact of specific factors on efficiency of inquiry, as well as the role of transient diversity in achieving efficiency, appear to be highly dependent on the underlying model. (shrink)

Next SectionThe principle of respect for autonomy has shaped much of the bioethics' discourse over the last 50 years, and is now most commonly used in the meaning of respecting autonomous choice. This is probably related to the influential concept of informed consent, which originated in research ethics and was soon also applied to the field of clinical medicine. But while available choices in medical research are well defined, this is rarely the case in healthcare. Consideration of ordinary medical (...) practice reveals that the focus on patient choice does not properly grasp the moral aspects involved in healthcare. Medical decisions are often portrayed as if doctors and patients in confidence confront specific decisions about examinations or treatment, yet the reality often involves many different participants, with decisions being made over time and space. Indeed, most of the decisions are never even presented to patients, as it would be unethical to suggest something that is not medically justifiable. The options patients do confront are somewhat arbitrarily constructed within the narrow framework of both what is deemed to be medically appropriate and how the healthcare system is organised practically. While the autonomy discourse has proven valuable, a failure to distinguish between the fields of medical research and clinical medicine has generated a focus on patient choice that does not reflect what is really at stake in healthcare settings. This is alarming, because the current discourse misrepresents medical practice in a way that actually contributes to bioethical self-delusion. (shrink)

While issues of efficacy and specificity are crucial for the future of neurofeedback training, there may be alternative designs and control analyses to circumvent the methodological and ethical problems associated with double-blind placebo studies. Surprisingly, most NF studies do not report the most immediate result of their NF training, i.e. whether or not children with ADHD gain control over their brain activity during the training sessions. For the investigation of specificity, however, it seems essential to analyze the learning and (...) adaptation processes that take place in the course of the training and to relate improvements in self-regulated brain activity across training sessions to behavioral, neuropsychological and electrophysiological outcomes. To this aim, a review of studies on neurofeedback training with ADHD patients, which include the analysis of learning across training sessions or relate training performance to outcome, is presented. Methods on how to evaluate and quantify learning of EEG regulation over time are discussed. “Non-learning” has been reported in a small number of ADHD-studies, but has not been a focus of general methodological discussion so far. For this reason, selected results from the brain-computer interface (BCI) research on the so-called “brain-computer illiteracy”, the inability to gain control over one’s brain activity, are also included. It is concluded that in the discussion on specificity, more attention should be devoted to the analysis of EEG regulation performance in the course of the training and its impact on clinical outcome. It is necessary to improve the knowledge on characteristic cross-session and within-session learning trajectories in ADHD and to provide the best conditions for learning. (shrink)

Background: Patients in different countries have different attitudes toward self‐determination and medical information. Little is known how much respect Japanese patients feel should be given for their wishes about medical care and for medical information, and what choices they would make in the face of disagreement. Methods: Ambulatory patients in six clinics of internal medicine at a university hospital were surveyed using a self‐administered questionnaire. Results: A total of 307 patients participated in our survey. Of the respondents, 47% would (...) accept recommendations made by physicians, even if such recommendations were against their wishes; 25% would try to persuade their physician to change their recommendations; and 14% would leave their physician to find a new one. Seventy‐six percent of the respondents thought that physicians should routinely ask patients if they would want to know about a diagnosis of cancer, while 5% disagreed; 59% responded that physicians should inform them of the actual diagnosis, even against the request of their family not to do so, while 24% would want their physician to abide by their family's request and 14% could not decide. One‐third of the respondents who initially said they would want to know the truth would yield to the desires of the family in a case of disagreement. Interpretations: In the face of disagreement regarding medical care and disclosure, Japanese patients tend to respond in a diverse and unpredictable manner. Medical professionals should thus be prudent and ask their patients explicitly what they want regarding medical care and information. (shrink)

The Choice Principle presents an evangelical Christian argument for a legal framework that tolerates most sinful choices by individuals, forbidding only those acts that directly victimize others. Many vocal evangelicals have assumed that Christians who take the Bible seriously and hew to moral absolutes should support laws forbidding sin. Most, however, are unwilling to outlaw all sins. Which sins should be legally tolerated and which outlawed? Are the reasons biblical or merely pragmatic? The Choice Principle confronts these crucial (...) questions head-on, proposing an alternative interpretation of Scripture that views government as God's instrument to punish victimizers and expand human autonomy. Grounded in legal theory, moral philosophy, and excerpts from the Bible and Christian theological texts, this timely work concludes that Christianity, particularly an evangelical commitment to the authority of Scripture, need not logically entail government endorsement of religious truths or legislation of any particular view of what constitutes a virtuous life. (shrink)

In this response article, we challenge a core assumption that lies at the centre of a round table discussion regarding the Pharmacogenetics to Avoid Loss of Hearing trial. The round table regards a genetic test for a variant that increases the risk of deafness if a carrier is given the antibiotic gentamicin. The idea is that rapid testing can identify neonates at risk, providing an opportunity to prevent giving an antibiotic that might cause deafness. We challenge the assumption that a (...) positive test unequivocally guides antibiotic choice because, aside from the risk of deafness, all antibiotics for neonatal sepsis are equivalent. We argue that this assumption is faulty and has particularly troubling moral consequences. We claim that giving an alternative to gentamicin is potentially providing inferior treatment and thereby may increase the risk of death. Parents and doctors are faced with a terrible choice as a result of positive point-of-care testing : give gold-standard treatment and risk deafness or give second line care and risk death. While we do not indicate an answer to this choice, what we do argue is that such a deep and difficult choice is one that may make parents wish genetic testing was never undertaken, and therefore, contra some authors in the round table, provides a reason to gain specific consent for POCT. (shrink)

Free choice of provider is heralded as a right of autonomy, but the goals of autonomy are better served in today's health care environment when there is informed choice of the care delivery system. The principle of liberty is distinguished from respect for auton omy. Free choice of provider would be demanded only by liberty, except that allocation of health care resources does not meet criteria for the application of liberty. Patients attempting to choose the best practitioner do not have (...) data to support the decision. If data were available, access to these superior practitioners would become an allocation problem. A mythology of the wise practitioner fosters the concept of provider choice as a personal judgement about clinical knowledge. The emerging trends of collaborative care, standardization of practice guidelines and diversity of delivery systems among reimbursers create a situation where a patient's autonomy to choose goals for treatment is respected through the choice of delivery sys tem. (shrink)

The article discusses some of the fundamental conceptual and theoretical aspects of rational choice and moral order. A distinction is drawn between constitutional interests and compliance interests, and it is argued that a viable moral order requires that the two interests somehow be brought into congruence. It is shown that with regard to the prospects for a spontaneous emergence of such congruence, a distinction between two kinds of moral rules which we call trust-rules and solidarity-rules is of crucial importance.

In this article I reflect on the question of whether we can have reason to make transformative choices. In attempting to answer it, I do three things. First, I bring forward an internalist account of practical reasons which entails the idea that agents should deliberate to the best of their ability. Second, I discuss L.A. Paul’s views on transformative choice, arguing that, although they present a real problem, the problem is not as profound as she believes it is. Third, (...) I argue that, given the situation in which we face transformative choices, trust is an appropriate response to transformative choices, and that when one’s trust that one’s current desires will be fulfilled in making a transformative choice is reasonable, one has a reason to make it. Thus, trust turns out to be a crucial response to a profound problem each of us will face during our lives. (shrink)

This article elaborates on foundational issues in the social sciences and their impact on the contemporary theory of belief revision. Recent work in the foundations of economics has focused on the role external social norms play in choice. Amartya Sen has argued in [Sen93] that the traditional rationalizability approach used in the theory of rational choice has serious problems accommodating the role of social norms. Sen's more recent work [Sen96, Sen97] proposes how one might represent social norms in the theory (...) of choice, and in a very recent article [BS07] Walter Bossert and Kotaro Suzumura develop Sen's proposal, offering an extension of the classical theory of choice that is capable of dealing with social norms. The first part of this article offers an alternative functional characterization of the extended notion of rationality employed by Bossert and Suzumura in [BS07]. This characterization, unlike the one offered in [BS07], represents a norm-sensitive notion of rationality in terms of a pure functional constraint unmediated by a notion of revealed preference (something that is crucial for the application developed in the second part of this article). This functional characterization is formulated for general domains (as is Bossert and Suzumura's characterization) and is therefore empirically more applicable than usual characterizations of rationality. Interestingly, the functional constraint we propose is a variant of a condition first entertained in [AGM85] by Carlos Alchourrón, Peter Gärdenfors and David Makinson in the area of belief change. The second part of this article applies the theory developed in the first part to the realm of belief change. We first point out that social norms can be invoked to concoct counterexamples against some postulates of belief change (like postulate (*7)) that are necessary for belief change to be relational. These examples constitute the epistemological counterpart of Sen's counterexamples against condition α in rational choice (as a matter of fact, Rott has showed in [Rot01] that condition and postulate (*7) are mutually mappable). These examples are variants of examples Rott has recently presented in [Rot04]. One of our main goals in this article consists in applying the theory developed in the first part to develop a theory of norm-inclusive belief change that circumvents the counterexamples. We offer a new axiomatization for belief change and we furnish correspondence results relating constraints of rational choice to postulates of belief change. (shrink)

A hard choice is a situation in which an agent is unable to make a justifiable choice from a given menu of alternatives. Our objective is to present a systematic treatment of the axiomatic structure of such situations. To do so, we draw on and contribute to the study of choice functions that can be indecisive, i.e., that may fail to select a non-empty set for some menus. In this more general framework, we present new characterizations of two well-known (...) choice rules, the maximally dominant choice rule and the top-cycle choice rule. Together with existing results, this yields an understanding of the circumstances in which hard choices arise. (shrink)

In this paper, I make three arguments regarding Crisis Standards of Care developed during the COVID-19 pandemic. First, I argue against the consideration of third person quality of life judgments that deprioritize disabled or chronically ill people on a basis other than their survival, even if protocols use the language of health to justify maintaining the supposedly higher well-being of non-disabled people. Second, while it may be unavoidable that some disabled people are deprioritized by triage protocols that must consider the (...) likelihood that someone will survive intensive treatment, Crisis Standards of Care should not consider the amount or duration of treatment someone may need to survive. Finally, I argue that, rather than parsing who should be denied treatment to maximize lives saved, professional bioethicists should have put our energy into reducing the need for such choices at all by resisting the systemic injustices that drive the need for triage. (shrink)

Mentalizing - the ability to understand oneself and others by inferring the mental states that lie behind overt behavior - develops during childhood within the context of a secure attachment relationship. It is crucial to self-regulation and constructive, intimate relationships. Failure to retain mentalizing, particularly in the midst of emotional interactions, is a core problem in borderline personality disorder and results in severe emotional fluctuations, impulsivity, and vulnerability to interpersonal and social interactions. Mentalization-based treatment for borderline personality disorder (...) is a 'How to Do It' book outlining a clinically proven treatment for Borderline Personality Disorder. Containing illustrative clinical examples, it details precisely how to develop and implement treatment and is a companion to the highly successful book Psychotherapy for Borderline Personality Disorder - mentalization based treatment. This practical guide explains how to treat borderline patients by helping them develop a more robust mentalizing capacity within the context of an attachment relationship. It provides the practitioner with everything they need to know about how to practise mentalizing treatment in day patient and out-patient settings. Enough theory is provided to orientate the clinician and there is step-by-step practical advice on the assessment of mentalizing and interpersonal relationships, how to structure treatment, the use of basic mentalizing interventions and how to apply them, as well as information on what not to do. In addition, it includes a check list to be used in the assessment of mentalizing and a self-rating exercise for practitioners to evaluate their adherence to mentalizing. (shrink)

ABSTRACT In this paper, I support the claim that placing certain restrictions on public access to possible new treatments is morally problematic under some exceptional circumstances. Very ill patients may find that all available standard treatments are unacceptable, either because they are ineffective or have serious adverse effects, and these patients may understandably be desperate to try something new even if this means stepping into the unknown. Faced with certain death, it is rational to want to try something new and (...) to chance a dire outcome. Restricting possible new treatments to research trials may put these treatments scientifically, geographically or economically out of reach of these patients. For those who can get access, research restrictions could weaken, though not necessarily eliminate, the value of consent participants of such trials are able to give. Some participants may therefore be exploited for scientific purposes in the name of public interest. There are nonetheless compelling reasons for keeping some restrictive regulation in this area. (shrink)

Our lives are filled with aesthetic choices, that is, choices of objects for aesthetic experience. Choice is crucial to having a fulfilling aesthetic life. Our immediate satisfaction and long term flourishing require the ability to generate rewarding aesthetic opportunities. A good aesthetic life is one of good aesthetic choices. Given the centrality of choice to a good aesthetic life, aesthetic theory is in need of an account of choice. However, aesthetic choice has gone unexamined. This paper (...) considers how choice helps to make us who we are as aesthetic persons. I situate aesthetic choice within debates in contemporary choice theory. The paper also examines whether the recommenders on websites like Amazon or Netflix pose a risk to our aesthetic flourishing. Aesthetic choice is mostly constructive and conditional, in other words, ad hoc and easily influenced. Aesthetic choices tend to be small choices, with low stakes and relaxed deliberation. The effect of our choices is cumulative, and the import of individual choices is best judged by seeing them in the context of other choices, especially the plans to which they belong. (shrink)