In lieu of an abstract, here is a brief excerpt of the content:Hume, Shaftesbury, and the Peirce-James Controversy EDMUND G. HOWELLS I. ACCORDING TO HUME, the "religious hypothesis" is "a particular method of accounting for the visible phenomena of the universe''1 that is "mere conjecture and hypothesis," (Enquiry, 145) and "both uncertain and useless" (Enquiry, 142). But there was one version of this hypothesis that seemed to pose particular difficulties for him in making these claims convincing. This was (...) Shaftesbury 's view of the world as the object of "divine passion." Besides Shaftesbury's massive influence at the time, Hume was wrestling with the peculiar disadvantage of having agreed with him on so many points, particularly in the attempt to solve the problem of personal identity. He attempted to discredit Shaftesbury's "particular method" on several levels: viz., it cannot be rationally justified, deductively or inductively ; it is not really a belief, so afortiori it is not a natural belief; to the extent it is confused with a genuine belief, its effects are very rare and transitory unless it degenerates into superstition or enthusiasm, which are demonstrably pernicious. 2 These attacks were frequently reinforced with arguments ad hominem. Shaftesbury's theism is extremely ambiguous. In the Essay Concerning Virtue or Merit he pronounced, "to believe therefore that everything is governed, ordered, or regulated for the best, by a designing principle or mind, necessarily good or permanent, is to be a perfect theist" (CH I:240). This is merely the least common denominator of what all eighteenth-century natural theologians agreed could be inferred a posteriori from some form of design argument. Shaftesbury used several analogies to support this view, each based upon a comparison of a part of the universe to the whole:(l) an artifact, for example, a watch (CH I: 190), a ship (CH i Enquiry Concerning Human Understanding, ed. L. A. Selby-Bigge,2nd ed. (Oxford: Clarendon Press, 1902),p. 139;hereafter cited as Enquiry. The quotes in my opening statement are technically not from Hume himself but from his "sceptical friend who lovesparadoxes." But the closest Hume comes to a single refutation of all forms of the "religious hypothesis," comparable to Cleanthes' "entirely decisive" refutation of Demea's version of the ontological argument (Dialogues, 189),is stated by Hume in his own person in the final paragraph of this section (Enquiry, XI). Other abbreviations used in this paper are: Treatisefor.4 Treatiseof Human Nature, ed. L. A. SelbyBigge {Oxford: Clarendon Press, 1949);Abstract for An Abstract of a Treatiseof Human Nature, 1740, ed. J. M. Keynesand P. Sraffa (Cambridge: Cambridge University Press, 1938);G&G for David Hume: The Philosophical Works, ed. T. H. Green and T. H. Grose, 4 vols. (London, 1886); Dialogues for Dialogues ConcerningNatural Religion, ed. Norman Kemp Smith, 2nd ed. (Indianapolis: Bobbs-Merrill, 1947); Letters for The Letters of David Hume, ed. J. Y. T. Grieg, 2 vols. (Oxford: Clarendon Press, 1932); CH for Characteristics of Men, Manners, Opinions, Times, ed. J. M. Robertson, 2 vols. (Indianapolis : Bobbs-Merrill, 1964). A roman numeral followed by a colon denotes volume; other roman numerals denote parts or sections; arabic numbers denote pages. 2For a striking exampleof one of their many points of agreement cf. Hume's essay(G&G 111: 144-150) with CH 11: 178-180. [4491 450 HISTORY OF PHILOSOPHY II:66), "a pile of regular architecture" (CH II:66-67), is to the artisan as the universe is to God. (2) A work of art, for example, a symphony (CH II :66), is to the artist as the universe is to God. (3) An organ is to the organism as the organism or species is to the teleologically structured and intelligent whole (CH I:243ff.) 3 (4) Microcosm (man) to Macrocosm (God), that is, man's mind is the governing principle over the other parts of his nature as God's mind is to the universe: though "all else may be only dream and shadow. All which even sense suggests may be deceitful.... Reason subsists." We are "in a manner conscious" that our reason is part of the pervasive world soul which inhabits our own, and "all nature's wonders serve to excite and perfect this idea of their author" (CH II : 112). In keeping with... (shrink)

I suggest that we may want to strive, over time, to change our present professional-cultural view, from one that sees an expression of moral distress as a threat, to a professional-cultural view that welcomes these challenges. Such an effort to better medicine would not only include dissenting clinicians, but patients (and their loved ones) as well.

Shared decision making (SDM) is the state of the art for clinicians’ communication with patients and surrogate decision makers. SDM involves give and take, in which all parties interact to maximize the autonomy of patients. In this article I summarize the core steps of SDM and explore ways to use it to benefit patients to the greatest extent. I review three articles included in this issue of The Journal of Clinical Ethics that highlight additional approaches we can use to help (...) patients and parents to see what may be in their own or their child’s best interest. I describe how these approaches can be used in most other medical fields. I explore ways to share information with patients that are outside the usual scope of SDM. Finally, I discuss how we might look, together with patients, at what all parties are feeling before we begin the process of SDM. (shrink)

Ethics consultants’ grasp of ethical principles is ever improving. Yet, what still remains and will remain lacking is their ability to access factors that lie outside their conscious awareness and thus still effect suboptimal outcomes. This article will explore several ways in which these poor outcomes may occur. This discussion will include clinicians’ implicit biases, well-intentioned but nonetheless intrusive violations of patients’ privacy, and clinicians’ unwittingly connoting to patients and families that clinicians regard their moral values and conclusions as superior. (...) I shall suggest several ways in which clinicians may seek to reduce these sources of bad outcomes or at least to do better when they occur. (shrink)

How might clinicians best try to retain the trust of patients and family members after clinicians oppose giving a treatment? If clinicians can maintain the trust of patients and families in these situations, this may soften what may be the greatest possible loss—the death of a loved one.I discuss what clinicians seeking to retain trust should not do—namely impose their values and reason wrongly—and introduce strategies that clinicians may use to reduce both. I present five principles that clinicians can follow (...) to try to retain trust, with examples that illustrate each. I suggest specific interventions that clinicians can make, especially when they anticipate that a patient and/or family may, in time, want a treatment that is futile. (shrink)

In this article I will discuss how clinicians might best treat adolescents who may die. I initially discuss these patients’ cognition, emotional tendencies, and sensitivity to interpersonal cues. I next discuss their parents’ feelings of loss and guilt and their clinicians’ risk of imposing their own moral views without knowing this. I then address the practical concerns of helping these patients gain or regain resilience and to identify strengths they have had in the past. I finally explore who, among staff, (...) might be best able to do this. I highlight as the main goal that patients, their parents, and ideally also their clinicians are able to come to agree on the best course the patients should take. (shrink)

In this piece I discuss two ways in which providers may become able to treat patients better. The first is for them to encourage all medical parties, including medical students, to always speak up. The second is to take initiatives to learn of pain that patients feel but neither show nor spontaneously report. They may refer to this pain as invisible pain, often bitterly, in that others not seeing their pain judge them wrongly and harshly. Providers, once seeing this pain, (...) are encouraged to then take additional measures to try to alleviate it. Clinical examples provided to illustrate the range of treatments providers may add are post-traumatic stress disorders, problems involving substance use, and hoarding disorders. Similar concerns regarding people who are deaf and hard of hearing are also addressed. (shrink)

In this introduction to this issue of The Journal of Clinical Ethics (JCE), I will discuss the legacy of our recently departed friend and colleague, Edmund D. Pellegrino, MD. In this light, I will discuss three articles in this issue of the journal that provide insight into the cultures of China, Mexico, and the U.S., and propose alternative approaches for careproviders in the U.S. to include in their practice as they work with patients and family members at the end (...) of life. (shrink)

Attention to the ethical concerns of healthcare aides can provide important information about patients’ needs to careproviders, improve the ethical environment of an institution, and benefit aides who suffer from bearing ethical concerns alone. All persons benefit from sharing their ethical concerns with others. Among other benefits, ethics consultation offers careproviders, caregivers, healthcare aides, patients, and patients’ loved ones an opportunity to have their concerns heard.John Fletcher tried to follow every ethics consultation with a debriefing for all participants, including patients (...) and family members, to increase the possibility for continued healing after the conclusion of the consultation, and there are good reasons to follow this practice. (shrink)

The author describes an alternative approach that careproviders may want to consider when caring for patients who request interventions that careproviders see as futile. This approach is based, in part, on findings of recent neuroimaging research. The author also provides several examples of seemingly justifiable “paternalistic omissions,” taken from articles in this issue of The Journal of Clinical Ethics (JCE). The author suggests that while careproviders should always give patients and their loved ones all potentially relevant information regarding “futile” decisions, (...) careproviders may wish to consider, paradoxically, not giving advice in these situations, when the advice is based mostly or wholly on their own moral views, based on this same, ethical rationale. (shrink)

This article discusses a case in this issue of The Journal of Clinical Ethics by McCrary and colleagues, “Elective Delivery Before 39 Weeks’ Gestation Reconciling Maternal, Fetal, and Family Circumstances,” in which parents asked the medical team to deliver their fetus “early.” The author discusses (1) the importance that parents have to a child when they are able to love the child, and how important it is for decision makers to consider this; (2) exceptional approaches that may enable parents to (...) “change their minds”; and (3) substantive and procedural innovations that may help to prevent clinicians’ views from playing too big a role and/or being arbitrary. The author concludes by describing how he felt when reading the case and uses this to illustrate how clinicians may benefit by assessing their feelings. (shrink)

Should people with exceptionally profound disabilities be given an equal chance of surviving a pandemic, even when their care might require a greater use of limited medical resources? How might an ethics of care be used to shape a policy regarding these patients?

One of the most important and difficult tasks in medicine is to determine when patients have the capacity to make decisions for themselves. This determination may determine a patient’s life or death. This article presents criteria and approaches now used to make this assessment and discusses how these approaches are presently applied in five common disorders that can serve as paradigms for approaches in other disorders. I propose that since there are new diagnoses and treatments, reconsidering our current practices is (...) warranted. The possibilities that clinicians can nudge patients to make better choices for themselves and, above all, that clinicians can maintain and maximize positive patient/careprovider relationships during and after these assessments, are emphasized. (shrink)

The primary task of ethics consultants is to work with patients—and sometimes also their families—to discern and then meet patients’ and families’ needs and wants to the extent possible. That is primarily a cognitive endeavor. Yet the feelings of patients and ethics consultants may determine what they can work together to accomplish. This article considers their feelings. It looks at sources of distrust and their hopedfor resolution, specific means to enhance patients’ decision making in their relationship with ethics consultants, and (...) a new, highly different approach that may enhance their relationships more than most commonly used ways of relating. (shrink)

After COVID-19 first began to spread in the United States, dentists developed new guidelines that limited whom they could treat under these emergency conditions. Patients who faced greater limits to accessing treatment included children. Using a case of a child who was not able to access treatment, I discuss how careproviders might best seek to maintain their emotional bonding with patients and their loved ones, even if they must turn them down for an intervention.I also address whether and when to (...) give patients and their loved ones warning that access to treatment could be limited, using illness caused by COVID-19 as an example of how careproviders may better anticipate patients’ needs at all times.Finally, I discuss careproviders’ needs. I suggest that medical professionals’ culture should make it as easy as possible for them to acknowledge their feelings of vulnerability, so that they may better determine, in times of disaster, whether they should treat or triage patients. Careproviders who triage may choose to share with patients and loved ones that they also feel pain when they deny patients an intervention. (shrink)

This introductory article presents some subtle and, perhaps, controversial aspects of providing care to adolescents who identify as transgender. I will describe (1) how praise from careproviders can benefit parents who have difficulty accepting the gender identity of their child that was not assigned at birth; (2) how adolescents who identify as transgender may follow the internet advice of peers on how to “con” careproviders; (3) how it may be difficult for careproviders to decide whether to further patients’ felt needs (...) and to protect them, paternalistically, from making an irreversible decision they may later regret; and (4) how careproviders can benefit adolescents by taking the initiative to discuss sex and how to say “no.” I emphasize how careproviders who see these patients, even when they have no special expertise in this area, may be able to enhance patients’ equality in every respect, even when they otherwise might not choose to do so. (shrink)