Terry Pratchett's writing celebrates the possibilities opened up by inventiveness and imagination. It constructs an ethical stance that values informed and self-aware choices, knowledge of the world in which one makes those choices, the importance of play and humor in crafting a compassionate worldview, and acts of continuous self-examination and creation. This collection of essays uses inventiveness and creation as a thematic core to combine normally disparate themes, such as science fiction studies, the effect of collaborative writing and shared authorship, (...) steampunk aesthetics, productive modes of "ownership," intertextuality, neomedievalism and colonialism, adaptations into other media, linguistics and rhetorics, and coming of age as an act of free will. In all Pratchett's constructed worlds and narratives-from Discworld, to the science-fictional flat planet of Strata, from a parody of Conan the Barbarian's Cimmeria to the comedically apocalyptic Good Omens-questions of identity, community, and the relations between self and other are constantly examined, debated, and reshaped. Pratchett's worlds thus become ethical worlds: fantasies in which language always matters, stories resonate with the past and the future, and choices emphasize the importance of compassion and creation. (shrink)

The idea of basic action is a fixed point in the contemporary investigation of the nature of action. And while there are arguments aimed at putting the idea in place, it is meant to be closer to a gift of common sense than to a hard-won achievement of philosophical reflection. It first appears at the stage of innocuous description and before the announcement of philosophical positions. And yet, as any decent magician knows, the real work so often gets done in (...) the set-up. I argue that the seemingly innocent idea of basic action is, in fact, bound up with a wide-spread conception of the nature of bodily or physical action (section 3). Its legitimacy is vital to the intelligibility of the causal theory of action, according to which physical action consists of a mere event and a condition of mind joined (in the right way) by the bond of causality. Left unchecked, means-end reason threatens to permeate physical action, and thus threatens the sovereignty of the sphere of material events at the center of the causal theory: such events, including the movements of one’s body when one intentionally moves it, are thought to be constitutively independent of the subject’s rational capacities. Basic action is a necessary countermeasure, a sort of metaphysical containment wall needed to preserve the separate jurisdictions of the mind of the acting subject and what merely happens. I argue that so long as action theory proceeds under the assumption that there must be basic action, it must regard our relation to the progress of our own deeds as not different in principle from Marx’s understanding of the relation of the non-worker (Nichtarbeiter) to the material processes that realize his own ideas, namely the work done on the factory floor. Each is alienated from the progress, or getting done, of his deeds. In each the process of doing something intentionally turns out to be a case of delegating tasks to another power. How the process comes to completion is not willed, and at best watched: the causal work is not the agent’s work, his knowledge not self-knowledge (section 5). We should find this unacceptable. And if this is right, it should be a pressing question whether there must be basic action. I argue that we have no good reason to think so: basic action is not forced on us by argument (sections 2 and 4). It is open to us to consider an alternative, one on which action is not, in the fundamental case, barren of means- end structure, but instead permeated by it: we register as a force in nature not at the limit of the means-end order but precisely in its constitution. [from article introduction]. (shrink)

A measure of good and bad is internal to something falling under it when that thing falls under the measure in virtue of what it is. The concept of an internal standard has broad application. Compare the external breed standards arbitrarily imposed at a dog show with the internal standards of health at work in the veterinarian's office. This paper is about practical standards, measures of acting well and badly, and so measures deployed in deliberation and choice. More specifically, it (...) is about the attempt to explain the unconditional validity of certain norms (say, of justice and prudence) by showing them to be internal to our agency and the causality it involves. This is constitutivism. Its most prominent incarnations share a set of assumptions about the nature of agency and our knowledge of it: conceptualism, formalism and absolutism. This essay investigates the merits and viability of rejecting all of them while still seeking the ground of practical normativity in what we are, in our fundamental activity. (shrink)

Other wills: the second-person in ethics. . ???aop.label???. doi: 10.1080/13869795.2014.941907.

There is little agreement about Aristotle’s philosophy of geometry, partly due to the textual evidence and partly part to disagreement over what constitutes a plausible view. I keep separate the questions ‘What is Aristotle’s philosophy of geometry?’ and ‘Is Aristotle right?’, and consider the textual evidence in the context of Greek geometrical practice, and show that, for Aristotle, plane geometry is about properties of certain sensible objects—specifically, dimensional continuity—and certain properties possessed by actual and potential compass-and-straightedge drawings qua quantitative and (...) continuous. For their part, the objects of stereometry are potential sensible three-dimensional figures qua quantitative and continuous. (shrink)

“On the Problem of Action” contrasts two conceptions of the task of action theory: the dominant conception, which I call the decompositional approach, and an alternative, non-decompositional approach that is implicit in the tradition of action theory descending from Aristotle. Decompositionalists seek to characterize intentional action as a composite of something inward and something outward, bound together by some generic kind of causal relation. I show that this approach is committed to characterizing action in terms that treat the agent’s own (...) standpoint on her action as a separable factor, not integral to the worldly happening that constitutes her action proper, and I argue that this commitment leads decompositionalists to focus their theorizing not on actions-in-progress, but on cases of completed action. I then show how the neo-Aristotelian approach to understanding action contrasts with the decompositional approach in each of these respects: it seeks, not to explain what intentional action is by decomposing action into several not-intrinsically-agential factors, but rather to characterize the understanding of what it is to act implicit in the agent’s knowledge of her own action-in-progress. The main aim of this paper is simply to show that there is an alternative to the decompositional project, one that resists the demand for an explanation of action in non-agential terms, while not simply treating the notion of intentional agency as an unexplained primitive. To see the possibility of this sort of understanding of action is, I argue, to see how action could turn out to be, not a worldly event with certain psychological causes, but a distinctive form of material process, one that is not simply caused by an exercise of reason but is itself a exercise of reason, it is itself the exercise of a power of practical cognition. (shrink)

Given a rich environment, how do we decide on what information to use? A view of a single entity (e.g., a group of birds) affords many distinct interpretations, including their number, average size, and spatial extent. An enduring challenge for cognition, therefore, is to focus resources on the most relevant evidence for any particular decision. In the present study, subjects completed three tasks—number discrimination, surface area discrimination, and convex hull discrimination—with the same stimulus set, where these three features were orthogonalized. (...) Therefore, only the relevant feature provided consistent evidence for decisions in each task. This allowed us to determine how well humans discriminate each feature dimension and what evidence they relied on to do so. We introduce a novel computational approach that fits both feature precision and feature use. We found that the most relevant feature for each decision is extracted and relied on, with minor contributions from competing features. These results suggest that multiple feature dimensions are separately represented for each attended ensemble of many items and that cognition is efficient at selecting the appropriate evidence for a decision. (shrink)

ABSTRACT There has been extensive debate among various disciplines about the nature and value of play. From these discussions it seems clear that play is a phenomenon with more than just one dimension: as a specific type of activity, as a form or structure, as an ontologically distinctive phenomenon, as a type of experience, or as a stance or an attitude towards a particular activity. This article focuses on the importance of the playful attitude in sport. It begins by attempting (...) to describe the underpinning features of a playful attitude, and its relation to Suits’ lusory attitude and the concept of gamification. Finally, it considers and critically evaluates the relationship between play and sport and the importance of the playful attitude in sporting activities. The purpose of this paper is a far deeper analysis of the playful attitude and its relationship to sport than has been previously provided, and a more precise definition as to what the playful attitude is. This will ultimately help to answer questions about the value of sport and how sport ought to be played. (shrink)

Research on the specific features of daydreaming compared with mind-wandering and night dreaming is a neglected topic in the philosophy of mind and the cognitive neuroscience of spontaneous thought. The extant research either conflates daydreaming with mind-wandering (whether understood as task-unrelated thought, unguided attention, or disunified thought), characterizes daydreaming as opposed to mind-wandering (Dorsch, 2015), or takes daydreaming to encompass any and all “imagined events” (Newby-Clark & Thavendran, 2018). These dueling definitions obstruct future research on spontaneous thought, and are insufficiently (...) precise to guide empirical studies. They also fail to illuminate the phenomenal core of daydreaming, namely, its dreamlike qualities. Although daydreaming is related to both mind-wandering and narrative imagination, it is not reducible to either. We argue that daydreams are experiences of spontaneous, immersive imagination in the waking state. The main task of our investigation is to distinguish daydreaming, conceptually and phenomenologically, from mind-wandering, on the one hand, and night dreaming, on the other. Although daydream experiences can vary widely, we distinguish prototypical experiences of daydreaming from adjacent imaginative activity, including fleeting imagery and “focused daydreaming,” or crafted visualization. We consider our phenomenological analysis as preparatory work for conceptually distinguishing different spontaneous and imaginative states so that they can be investigated accordingly with questionnaires and qualitative methods. We argue that precision about the phenomenal character of daydreaming can guide neurophenomenological investigations, help delimit studies on individual variance in daydreaming features, and identify differences among daydreaming, mind-wandering, and night dreaming conceptually and phenomenologically, and possibly eventually in terms of neural correlates. (shrink)

A decade after the ‘‘Sokal Hoax,’’ Alan Sokal and Paul Boghossian still claim that postmodern arguments are incoherent attacks on reason and truth. However, both also continue to mischaracterize ‘‘constructivist’’ epistemology, to engage in highly problematic logical gymnastics to defend their own views, and to ignore changes in philosophy of science and science studies since 1996. I offer a brief description of my own, rather different understanding of postmodern science criticism in order to contextualize my dissatisfaction with Sokal and Boghossian’s (...) arguments, and to highlight the value of cross-subfield anthropological collaboration based on the constructivist perspective articulated by Barbara Herrnstein Smith. Downloaded by [New York University] at 03:33 19 July 2011.. (shrink)

Medical ethics assumes a clear boundary between clinical research and clinical medicine: one produces knowledge for the benefit of future patients, while the other provides optimal care to individuals right now. It also assumes that the two cannot be integrated without sacrificing the needs of the current patient to those of future patients. But integration could allow us to provide better care to everyone, now and in the future.

Abstract:Vulnerability is an important criterion to assess the ethical justification of the inclusion of participants in research trials. Currently, vulnerability is often understood as an attribute inherent to a participant by nature of a diagnosed condition. Accordingly, a common ethical concern relates to the participant’s decisionmaking capacity and ability to provide free and informed consent. We propose an expanded view of vulnerability that moves beyond a focus on consent and the intrinsic attributes of participants. We offer specific suggestions for how (...) relational aspects and the dynamic features of vulnerability could be more fully captured in current discussions and research practices. (shrink)

Ontological separation plays a key role in Aristotle’s metaphysical project: substances alone are ontologically χωριστόν. The standard view identifies Aristotelian ontological separation with ontological independence, so that ontological separation is a non-symmetric relation. I argue that there is strong textual evidence that Aristotle employs an asymmetric notion of separation in the Metaphysics—one that involves the dependence of other entities on the independent entity. I argue that this notion allows Aristotle to prevent the proliferation of substance-kinds and thus to secure the (...) unity of his metaphysical system. (shrink)

Abstract:Vulnerability is an important criterion to assess the ethical justification of the inclusion of participants in research trials. Currently, vulnerability is often understood as an attribute inherent to a participant by nature of a diagnosed condition. Accordingly, a common ethical concern relates to the participant’s decisionmaking capacity and ability to provide free and informed consent. We propose an expanded view of vulnerability that moves beyond a focus on consent and the intrinsic attributes of participants. We offer specific suggestions for how (...) relational aspects and the dynamic features of vulnerability could be more fully captured in current discussions and research practices. (shrink)

The paper considers and rejects two arguments against the performance of sexual reassignment surgery. First, it is argued that the operation is not mutilating, but functionally enabling. Second, it is argued that the operation is not objectionably deceptive, since, if there is such a thing as our 'real sex', we do not know (ordinarily) what it is. The paper is also intended to shed light on what our sexual identity is and on what matters in sexual relations.

Jean-Marc Vallée’s HBO miniseries, Sharp Objects (2018), follows Camille Preaker (Amy Adams) as she returns to her childhood home in Wind Gap, Missouri, to investigate the murders of two young girls. This article explores a specific type of object related to the systems of violence that reveal themselves over the course of the miniseries: ivory tiles. Here, the ivory tiles affixed to the floor of Camille’s mother’s, Adora Crellin’s (Patricia Clarkson), master bedroom both reveal and influence sinister behaviours of the (...) household’s women. In employing concepts inspired from Thing Theory and Object-Oriented Ontology, as well as critical theory, this article examines how the ivory tiles possess multilayered excesses that constitute an object’s thingness. The foremost excess that informs the ivory tiles’ thingness, I contend, is its relationship to white supremacy. It is not only the tiles’ material history that informs its relationship to white supremacy, but how, through outlining the forms of agency things possess under Thing Theory, the tiles are able to reveal the forms of violence that are structured within the domestic sphere of the Crellin home. A product of violence, the ivory tiles as things speak back to the design of white supremacy. (shrink)

Payment to recruit research subjects is a common practice but raises ethical concerns relating to the potential for coercion or undue influence. We conducted the first national study of IRB members and human subjects protection professionals to explore attitudes as to whether and why payment of research participants constitutes coercion or undue influence. Upon critical evaluation of the cogency of ethical concerns regarding payment, as reflected in our survey results, we found expansive or inconsistent views about coercion and undue influence (...) that may interfere with valuable research. In particular, respondents appear to believe that coercion and undue influence lie on a continuum; by contrast, we argue that they are wholly distinct: whereas undue influence is a cognitive distortion relating to assessment of risks and benefits, coercion is a threat of harm. Because payment is an offer, rather than a threat, payment is never coercive. (shrink)

Despite frequent calls by players, managers and fans, FIFA's resistance to the implementation of goal-line technology (GLT) has been well documented in national print and online media as well as FIFA's own website. In 2010, FIFA president Sepp Blatter outlined eight reasons why GLT should not be used in football. The reasons given by FIFA can be broadly separated into three categories; those dealing with the nature and value of the game of football, those related to issues of justice, and (...) those concerned with the practical implementation of GLT. This paper intends to evaluate these eight reasons in order to assess whether there are, indeed, any good arguments against GLT in football. (shrink)

_Philosophers consider race and racism from the perspective of lived, bodily experience._.

With the normative demand to attend to social difference and an absence of universal evaluative terms with which to do so, recent theory has increasingly turned to the study of the affective rather than epistemological conditions of ethical encounter. This I call a “dispositional ethics” that construes responsibility as responsiveness. Recent articulations of such an ethics, notably in the most current work of Judith Butler, James Tully, Jade Larissa Schiff, and Ella Myers, highlight its connection to situated practices of concrete (...) bodies-in-relation, but often stop short of developing an account of what such embodied practices might be. Based on interviews with thirteen experts who take the body as their primary vocational and intellectual field and characterize their practice as an art of listening, I distinguish three dimensions of a dispositional ethics in practice and some of the specific strategies available to cultivate the conditions for responsiveness in political life. (shrink)

Frege argues that number is so unlike the things we accept as properties of external objects that it cannot be such a property. In particular, (1) number is arbitrary in a way that qualities are not, and (2) number is not predicated of its subjects in the way that qualities are. Most Aristotle scholars suppose either that Frege has refuted Aristotle's number theory or that Aristotle avoids Frege's objections by not making numbers properties of external objects. This has led some (...) to conclude that Aristotle's accounts of arithmetical and geometrical objects differ substantially. I close this supposed gap by showing that Aristotle's arithmetical objects, like geometrical objects, are just certain sensible things qua certain properties they in fact possess. Specifically, numbers are pluralities qua quantitative or relational properties like ten units or ten. I show that this view is resistant to the Fregean concerns about arbitrariness and numerical predication. (shrink)

In this article we report relevant data that shed light on the topic of hope and patients’ expectations in the use of DBS, for standard, approved, and established indications, based on a broader qualitative study on the ethical and social challenges that healthcare providers face in the field of DBS.

Elder abuse presents difficult ethical considerations that the field of psychology has yet to sufficiently address. As demographics and sociocultural factors shift in the coming decade, this deficit in ethical competence may become an increasingly serious problem. Although legal definitions of elder abuse lack uniformity and clarity, there is much room for improvement in the field of psychology. Ethical considerations most relevant to professionals in psychology draw heavily on the principles of beneficence and nonmaleficence and respect for people's rights and (...) dignity. Professional standards of competence, discrimination, informed consent, privacy and confidentiality, and cooperation with other professionals are also critical in these considerations. A number of recommendations are made, centering around the needs for more education, frank discussion, and empirical examination of the complexities of elder abuse. (shrink)

Some individuals facing dementia contemplate hastening their own death: weighing the possibility of living longer with dementia against the alternative of dying sooner but avoiding the later stages of cognitive and functional impairment. This weighing resonates with an ethical and legal consensus in the United States that individuals can voluntarily choose to forgo life‐sustaining interventions and also that medical professionals can support these choices even when they will result in an earlier death. For these reasons, whether and how a terminally (...) ill individual can choose to control the timing of their death is a topic that cannot be avoided when considering the dementia trajectory. With a focus on the U.S. context, this landscape review considers the status of provisions that would legally permit people facing dementia to hasten death with appropriate support from medical professionals. This review can be used to plan and guide clinical and legal practitioner discussion and policy development concerning evolving questions not fully covered by existing medical decision‐making provisions. (shrink)

Listening appears as elusive as it is crucial to democratic life, particularly in conditions of structural injustice. Dominant groups benefit from histories and habits of inattention and, when enlisted, common responses of denial, defensiveness, and resentment. What lies behind this pervasive and persistent failure to listen to claims of structural injustice by more advantaged groups, and what does this mean for democratic engagement? This paper addresses this question via three interventions: first, it develops a novel account of listening that reveals (...) why listening to claims of structural injustice often proves difficult. Second, it examines how inhabiting positions of relative advantage shapes whether and how people listen to such claims. Finally, it explores the implications these challenges have for the design of democratic processes that seek to engage advantaged groups regarding structural injustice. To develop this account, I draw together current scholarship regarding listening and structural injustice with original fieldwork of recent and current efforts to engage more advantaged communities regarding a specific form of structural injustice: specifically, interviews and observation of the ten organizations across Aotearoa New Zealand most active in efforts to engage communities regarding socio-economic inequality in the country. (shrink)

Decolonization requires critical attention to settler logics that reinforce settler-colonialism, yet settler communities, as a rule, operate without a collective sense of identity and history. This article, provoked by Māori protocols of encounter, explores the necessity of developing a sense of collective identity as precursor to meeting in settler-Indigenous politics. It argues that the ability, desire, and experience of being unmarked as a social group—apparent in paradigmatic approaches to engaging social difference in settler communities—is at the heart of the particularity (...) of settler group identity and also stands at the heart of countless failures to meet in settler-Indigenous politics. This essay thus seeks to mark the particular ground of this unmarkedness of settler identity in Western philosophies that set being unmarked as both ontology and ideal; the dominance of settler communities in places of settlement; and the willful forgetting of the colonial histories brought about by such dominance. (shrink)

Drawing on qualitative interviews with parents of preschool children, the author addresses parental responses to children’s gender nonconformity. The author’s analyses indicate that parents welcome what they perceive as gender nonconformity among their young daughters, while their responses in relation to sons are more complex. Many parents across racial and class backgrounds accept or encourage some tendencies they consider atypical for boys. But this acceptance is balanced by efforts to approximate hegemonic ideals of masculinity. The author considers these patterns in (...) the context of gender as an interactional accomplishment, demonstrating that parents are often consciously aware of their own role in accomplishing gender with and for their sons. Heterosexual fathers are especially likely to be motivated in that accomplishment work by their own personal endorsement of hegemonic masculinity, while heterosexual mothers and gay parents are more likely to be motivated by accountability to others in relation to those ideals. (shrink)

The opening argument in the Metaphysics M.2 series targeting separate mathematical objects has been dismissed as flawed and half-hearted. Yet it makes a strong case for a point that is central to Aristotle’s broader critique of Platonist views: if we posit distinct substances to explain the properties of sensible objects, we become committed to an embarrassingly prodigious ontology. There is also something to be learned from the argument about Aristotle’s own criteria for a theory of mathematical objects. I hope to (...) persuade readers of Metaphysics M.2 that Aristotle is a more thoughtful critic than he is often taken to be. (shrink)

Long histories and entrenched habits of inattention among advantaged groups mean that even minor challenge and concession can provoke subjective perceptions of victimization. How, in such conditions, might claims of structural injustice break through? Drawing on field work with practitioners across conflict mediation, therapy, education, and performance – four sectors that facilitate listening in fraught contexts yet are undertheorized in politics – this article makes the case that among the most overlooked and powerful resources for cultivating receptivity and responsiveness among (...) advantaged groups are the arts of listening. Practices of engagement across these sectors establish listening as potent rather than passive, given the extent to which it constitutes the field of encounter and shapes what emerges within it, both in terms of expression and, more significantly in this context, receptivity of those to whom one listens. Yet this also means that how one listens is a pivotal consideration – particularly when listening might serve to reinforce and normalize unjustly dominant positions. In contrast to progressive politics’ emphasis on finding more forceful forms of voice and conventional reliance on direct communicative practices, this article explores how specific comedic, theatrical, and embodied tactics can generate ‘oblique forms of listening’ potentially useful to social justice struggles. (shrink)

In the article “Nudging and Informed Consent”, Cohen argues that the use of “nudging” by physicians in the clinical encounter may be ethically warranted because it results in an informed consent where obligations for beneficence and respect for autonomy are both met. However, the author's overenthusiastic support for nudging and his quick dismissal of shared decision-making leads him to assume that “soft” manipulation is un-problematic and that “wisdom” on the side of medical professionals will suffice to guard against abuse. Opposing (...) this view, we propose that: 1) patient preferences and values should not be boiled down to rational or irrational decisions based on cognitive reasoning alone, 2) potential threats to the physician-patient must be mitigated and could be minimized by employing alternative strategies that acknowledge the impact of cognitive heuristics in shaping decision-making but maintain transparency and trust, and 3) patient preferences and values can be legitimately influenced only under specific circumstances. The latter include: (1) exhaustion of other means; (2) evidence that nudging is effective in a specific context; (3) evidence of clear and active public misinformation (e.g., industry promoting smoking); (4) explicit pubic dialogue between various stakeholders including medical professional societies about nudging; (5) upholding shared decision-making as a preferred approach; and (6) a rich understanding of clinical reality beyond the simple dichotomy of beneficence-autonomy. (shrink)

Stigma can influence the prevention and identification of fetal alcohol spectrum disorder, a leading cause of developmental delay in North America. Understanding the effects of public health practices and policies on stigma is imperative. We reviewed social science and biomedical literatures to understand the nature of stigma in FASD and its relevance from an ethics standpoint in matters of health practices and policies. We propose a descriptive model of stigma in FASD and note current knowledge gaps; discuss the ethical implications (...) of stigma based on two distinct criteria ; and describe two cases and the concerns associated with inadvertent stigmatization by public health initiatives for FASD. We recommend further empirical and ethical analyses to examine whether public health policies and practices inadvertently stigmatize and impact the success of public health initiatives and programs for FASD. (shrink)

Exploring the intimate tie between body movement and space and time, Lee begins with the position that body movement generates space and time and explores the ethical implications of this responsibility for the situations one’s body movements generate. Whiteness theory has come to recognize the ethical responsibility for situations not of one’s own making and hence accountability for the results of more than one’s immediate personal conscious decisions. Because of our specific history, whites have developed a particular embodiment and body (...) movement that generates places that can only be characterized as more comfortable and more enabling to whites. (shrink)

To ensure that the information resulting from research is relevant to patients, the Patient‐Centered Outcomes Research Institute eschews the “traditional health research” paradigm, in which investigators drive all aspects of research, in favor of one in which patients assume the role of research partner. If we accept the premise that patient engagement can offer fresh perspectives that shape research in valuable ways, then at least two important sets of questions present themselves. First, how are patients being engaged—and how should they (...) be engaged? Second, which patients are being engaged—and which patients should be? This set has received relatively less attention, and the neglect is surprising, given that the “who” question is conceptually prior to the question of “how.”This article focuses attention on the “who” of patient engagement in research. First, we provide background on the rationale for patient engagement, underscoring the importance of ensuring the representativeness of engaged patients. Second, we present what little is known about patients engaged in PCORI‐funded research. Third, we identify and discuss the ethical implications of ways in which current practices of patient identification and recruitment may lead to a lack of representativeness. These practices include reliance on the well‐connected and well‐informed, reliance on patients who are not well trained or well‐informed, and reliance on patient advocacy organizations. Finally, we consider several strategies for addressing these pitfalls in order to maximize the positive goals of patient engagement. Patient engagement is intended to address the inability of researchers, funders, and others to fully represent patient views and priorities, but without sufficient attention, the patients selected for this role may still leave important gaps. (shrink)

The rule of rescue describes the moral impulse to save identifiable lives in immediate danger at any expense. Think of the extremes taken to rescue a small child who has fallen down a well, a woman pinned beneath the rubble of an earthquake, or a submarine crew trapped on the ocean floor. No effort is deemed too great. Yet should this same moral instinct to rescue, regardless of cost, be applied in the emergency room, the hospital, or the community clinic? (...) -/- In health care, the desire to save lives at any cost must be reconciled with the reality of resource scarcity. As one example, the estimated cost for prophylactic Factor VIII to treat one patient with hemophilia for one year is $300,000. Costs of this magnitude have been accepted by public and private insurers in the developed world, even though, in principle, these sums could provide greater overall health benefit if allocated to pay for the unmet health care needs of many other patients. Looking forward, however, broad application of the rule of rescue will be increasingly untenable. But the moral instinct will remain: the desire to help those weakest among us, especially when their small numbers allow us to see them as unique individuals. What, then, is the ethical framework that can guide coverage and reimbursement decisions for orphan drugs into the future? (shrink)