: The "difference position" holds that clinical research and therapeutic medical practice are sufficiently distinct activities to require different ethical rules and principles. The "similarity position" holds instead that clinical investigators ought to be bound by the same fundamental principles that govern therapeutic medicine—specifically, a duty to provide the optimal therapeutic benefit to each patient or subject. Some defenders of the similarity position defend it because of the overlap between the role of attending physician and the role of investigator in (...) a research trial. This overlap is maximal when the same physician occupies both roles with respect to a particular patient-subject. We address the ethical tensions inherent in that role conflict and argue that the tensions are real but manageable. The difference position provides a sound ethical framework within which to manage those tensions, while the similarity position is unsatisfactory because it seeks to deny the existence of the tensions. (shrink)

Some ethical issues facing contemporary medicine cannot be fully understood without addressing medicine's internal morality. Medicine as a profession is characterized by certain moral goals and morally acceptable means for achieving those goals. The list of appropriate goals and means allows some medical actions to be classified as clear violations of the internal morality, and others as borderline or controversial cases. Replies are available for common objections, including the superfluity of internal morality for ethical analysis, the argument that internal morality (...) is merely an apology for medicine's traditional power and authority, and the claim that there is no single, "core" internal morality. The value of addressing the internal morality of medicine may be illustrated by a detailed investigation of ethical issues posed by managed care. Managed care poses some fundamental challenges for medicine's internal morality, but also calls for thoughtful reflection and reconsideration of some traditionally held moral views on patient fidelity in particular. (shrink)

A special report of The Hastings Center and the Association of American Medical Colleges addressed the ethical oversight of learning health systems, which seek to combine high‐quality patient care with routine data collection aimed at improving patient outcomes. The report contained two position papers, authored by a number of distinguished bioethicists, and several commentaries. The position papers urged two changes. First, they urged a rethinking of our approach to the regulation of human subjects research, so as to make it easier (...) in the future for learning health systems to function well. Second, they argued that the rethinking required dispensing with a strict distinction between research and therapy, which has been a major tenet of bioethics since the Belmont Report, which explicated basic ethical principles governing human subjects research. We fully support the objectives of the authors, and we agree that the learning health system is an important advance that serves patients well. Unnecessary regulatory burden ought not impede this progress. We disagree, however, that the best way to bring about these needed changes in the regulatory environment is to reject the basic distinction between research and treatment. Unfortunately, we find the arguments in favor of that strategy to be, in places, reminiscent of what we take to be basic conceptual errors that hampered the ethical understanding of human subjects research prior to adoption of the Belmont Report. To see why one need not reject the research‐treatment distinction in order to promote learning health systems, we first investigate in some detail the arguments offered for eliminating the distinction. We next turn to an issue not addressed by those authors, namely, the relationship between the physician or investigator and the patient or subject, to illustrate why the distinction is important and what is lost if it is jettisoned. (shrink)

Cosmetic surgery is a fast-growing medical practice. In 1997 surgeons in the United States performed the four most common cosmetic procedures443,728 times, an increase of 150% over the comparable total for 1992. Estimated total expenditures for cosmetic surgery range from $1 to $2 billion. As managed care cuts into physicians' income and autonomy, cosmetic surgery, which is not covered by health insurance, offers a financially attractive medical specialty.

A predominant ethical view holds that physician‐investigators should conduct their research with therapeutic intent. And since a physician offering a therapy wouldn't prescribe second‐rate treatments, the experimental intervention and the best proven therapy should appear equally effective. "Clinical equipoise" is necessary. But this perspective is flawed. The ethics of research and of therapy are fundamentally different, and clinical equipoise should be abandoned.

The doctrine of clinical equipoise is appealing because it appears to permit physicians to maintain their therapeutic obligation to offer optimal medical care to patients while conducting randomized controlled trials (RCTs). The appearance, however, is deceptive. In this article we argue that clinical equipoise is defective and incoherent in multiple ways. First, it conflates the sound methodological principle that RCTs should begin with an honest null hypothesis with the questionable ethical norm that participants in these trials should never be randomized (...) to an intervention known to be inferior to standard treatment. Second, the claim that RCTs preserve the therapeutic obligation of physicians misrepresents the patient-centered orientation of medical care. Third, the appeal to clinical equipoise as a basic principle of risk-benefit assessment for RCTs is incoherent. Finally, the difficulties with clinical equipoise cannot be resolved by viewing it as a presumptive principle subject to exceptions. In the final sections of the article, we elaborate on the non-exploitation framework for the ethics clinical research and indicate issues that warrant further inquiry. (shrink)

The leading ethical position on placebo-controlled clinical trials is that whenever proven effective treatment exists for a given condition, it is unethical to test a new treatment for that condition against placebo. Invoking the principle of clinical equipoise, opponents of placebo-controlled trials in the face of proven effective treatment argue that they (1) violate the therapeutic obligation of physicians to offer optimal medical care and (2) lack both scientific and clinical merit. We contend that both of these arguments are mistaken. (...) Clinical equipoise provides erroneous ethical guidance in the case of placebo-controlled trials, because it ignores the ethically relevant distinction between clinical trials and treatment in the context of clinical medicine and the methodological limitations of active-controlled trials. Placebo controls are ethically justifiable when they are supported by sound methodological considerations and their use does not expose research participants to excessive risks of harm. (shrink)

With breathtalung speed, traditional criminal prohibitions against assisted suicide have been declared unconstitutional in twelve states, including California and New York. This poses great promise and great peril. The promise is that competent terminally ill patients, as a compassionate measure of last resort, will have the option of putting an end to their suffering by physician-assisted suicide. More sigmficant, legally permitting this controversial option may be a catalyst for doctors, health care institutions, and society to improve the care of the (...) dying. PAS should be limited only to those relatively few competent patients who continue to suffer intolerably despite unrestrained efforts to palliate and who face a continued existence that they regard as worse than death. When dying patients know they will not be abandoned to miserable and pointless suffering if palliative care fails, they will be fortified to cope better with the process of dying.The immediate peril is that PAS will become a quick fix, available on demand to any patient diagnosed as terminally ill, thus bypassing palliative care and producing premature deaths. (shrink)

A basic question of medical ethics is whether the norms governing medical practice should be understood as the application of principles and rules of the common morality to medicine or whether some of these norms are internal or proper to medicine. In this article we describe and defend an evolutionary perspective on the internal morality of medicine that is defined in terms of the goals of clinical medicine and a set of duties that constrain medical practice in pursuit of these (...) goals. This perspective is developed by means of a critical examination of the essentialist conception of the internal morality of medicine advocated by Edmund Pellegrino and the critique of internal morality approaches by Robert Veatch and Tom Beauchamp. (shrink)

The practice of voluntary physician‐assisted death as a last resort is compatible with doctors' duties to practice competently, to avoid harming patients unduly, to refrain from medical fraud, and to preserve patients' trust. It therefore does not violate physicians' professional integrity.

*The opinions expressed are the views of the author and do not necessarily reflect the policy of the National Institutes of Health, the Public Health Service, or the U.S. Department of Health and Human Services.

Realism in international relations theory is frequently understood to entail the abandonment or cynical manipulation of moral rules and principles. But realism has always been more than an amoral or immoral doctrine. More interesting versions of realism offer moral justifications for limiting the role of morality. We argue for a version of realism that flows from the function of the liberal democratic state as an indispensable condition of value. After setting out its central characteristics, we also argue that this liberal (...) democratic realism can adequately address four severe criticisms typically raised against realism in general. (shrink)

"Unlike most photographs of Eads Bridge, which are taken from a distance, Quinta Scott's intimate photographic essay shows the subtleties of form and texture that give this structure its remarkable aesthetic impact. Howard Miller's text complements the photos, explaining the place of James Eads's unorthodox design in the history of American architecture and aesthetics. Miller also explains the bridge's place in local and national economic history, describes its innovative engineering, and brings to life its unique creator."--Jacket.

We are drowning in information, while starving for wisdom.Are the smartest people also the wisest? Not necessarily. While traditional intellectual reasoning and procedural knowledge have helped build the communities we live in, there is a growing scientific understanding that we need emotionally balanced and better-fitting prosocial frameworks for coping with the uncertainties and complexities of life and addressing new challenges of the modern world. We are now poised on the edge of a new science of wisdom.The concept of wisdom, long (...) considered the “pinnacle of insight into the human condition”, has been that of an intangible, subjective, culturally specific entity—an unscientific... (shrink)

CHAPTER I POLITICAL FAITH AND UTOPIAN THOUGHT In the three and a half centuries since Bacon and the miller prayed for peace among the willows, countless men ...

A letter to the editor from Howard Brody, David Buchanan, and Franklin G. Miller in response to the recent article by Erik Malmqvist Understanding Exploitation," March-April 2011).

In The Healer's Power, Howard Brody placed the concept of power at the heart of medicine's moral discourse. Struck by the absence of “power” in the prevailing vocabulary of medical ethics, yet aware of peripheral allusions to power in the writings of some medical ethicists, he intuited the importance of power from the silence surrounding it. He formulated the problem of the healer's power and its responsible use as “the central ethical problem in medicine.” Through the prism of power (...) he refracted a wide range of ethical problems, from informed consent to truth-telling, from confidentiality to futility, from the physician's fantasies to the physician's virtues. At times this prism shed new light on old problems, enabling us to see from an unexpected angle the elements of which the problem was composed. At other times it exposed issues of ethical significance that had been neglected in the bioethics literature. (shrink)

Like Henry Harris, I began doing intensive research on Hegel's Phenomenology of Spirit in the mid-sixties. I recall going through all the chapters as a graduate student during one academic year, and looking around for commentaries. The only English-language commentary available was Loewenberg's Hegel's Phenomenology: Dialogues in the Life of Mind, which was suggestive of the dialectic taking place in the book, but not much help in getting over the “rough spots”. This gave me an incentive to work through Jean (...) Hyppolite's commentary, not yet translated into English, with my basic reading-knowledge of French. My 1976 Hegel's Phenomenology, Part I: Analysis and Commentary was one of the first in a long line of Anglophone commentaries. Harris in his introduction to Vol. I. mentions this effort at “analysis”, along with Findlay's “analysis” accompanying the 1977 Miller translation of the Phenomenology, as incentives for the inclusion of his own improved running analysis in the present commentary. I have included discussions of numerous partial or complete commentaries on Hegel's Phenomenology in review articles published in 1971 in the American Philosophical Quarterly and Teorema, in 1979 in the American Philosophical Quarterly, and in 1981 in Hegel-Studien. Harris has the advantage of producing the most recent of all these commentaries, and in a way offers us a compendium of everything that has been done on the Phenomenology. His analysis and commentary includes a survey of the literature, in which almost all previous laborers in the field can find themselves commended or criticized in the endnotes. Thus I find comments like “Kainz has completely misunderstood the argument here”, “This is a point which Kainz has grasped more definitely than most commentators”, “[Kainz] does not deserve the brickbat Flay hurls at him”, and so forth. Other commentators, living and dead – Flay, Pöggeler, Navickas, Kenneth and Merold Westphal, Heidegger, Lauer, Werner Becker, Kojève, Wahl, Hyppolite, Labarrière, Bonsiepen, Forster, Shklar, Solomon, Werner Marx, and Robert Williams — are similarly discussed and critiqued. For some of us Anglophone commentators, such remarks may seem like red marks on essays from a patient professor. But certainly no one will mind, since Harris has spent more time and energy on this very specialized project than any of us. In fact, some former commentators almost have a “conflict of interest” in reviewing Harris' work, since so many of us have benefited at various points in our research from Harris' personal support and criticism. But in academics, as in life, mentors cannot always be assured of loyalty. (shrink)

Like Henry Harris, I began doing intensive research on Hegel's Phenomenology of Spirit in the mid-sixties. I recall going through all the chapters as a graduate student during one academic year, and looking around for commentaries. The only English-language commentary available was Loewenberg's Hegel's Phenomenology: Dialogues in the Life of Mind, which was suggestive of the dialectic taking place in the book, but not much help in getting over the “rough spots”. This gave me an incentive to work through Jean (...) Hyppolite's commentary, not yet translated into English, with my basic reading-knowledge of French. My 1976 Hegel's Phenomenology, Part I: Analysis and Commentary was one of the first in a long line of Anglophone commentaries. Harris in his introduction to Vol. I. mentions this effort at “analysis”, along with Findlay's “analysis” accompanying the 1977 Miller translation of the Phenomenology, as incentives for the inclusion of his own improved running analysis in the present commentary. I have included discussions of numerous partial or complete commentaries on Hegel's Phenomenology in review articles published in 1971 in the American Philosophical Quarterly and Teorema, in 1979 in the American Philosophical Quarterly, and in 1981 in Hegel-Studien. Harris has the advantage of producing the most recent of all these commentaries, and in a way offers us a compendium of everything that has been done on the Phenomenology. His analysis and commentary includes a survey of the literature, in which almost all previous laborers in the field can find themselves commended or criticized in the endnotes. Thus I find comments like “Kainz has completely misunderstood the argument here”, “This is a point which Kainz has grasped more definitely than most commentators”, “[Kainz] does not deserve the brickbat Flay hurls at him”, and so forth. Other commentators, living and dead – Flay, Pöggeler, Navickas, Kenneth and Merold Westphal, Heidegger, Lauer, Werner Becker, Kojève, Wahl, Hyppolite, Labarrière, Bonsiepen, Forster, Shklar, Solomon, Werner Marx, and Robert Williams — are similarly discussed and critiqued. For some of us Anglophone commentators, such remarks may seem like red marks on essays from a patient professor. But certainly no one will mind, since Harris has spent more time and energy on this very specialized project than any of us. In fact, some former commentators almost have a “conflict of interest” in reviewing Harris' work, since so many of us have benefited at various points in our research from Harris' personal support and criticism. But in academics, as in life, mentors cannot always be assured of loyalty. (shrink)

After critiquing some earlier attempts (including those of Marcus Singer and Frances Howard–Snyder) to ground objections to actual–consequence act utilitarianism (ACAU) on human cognitive limitations, I present two new objections with this same foundation. Both start with the observation that, because human cognitive abilities are not up to the task of reliably recognizing utility–maximizing actions, any agents who are recognizably human – including the best possible humans, morally speaking – are certain to perform many actions every day that ACAU (...) says are immoral, and to perform some actions over the course of their lives that it says are highly immoral. The first objection is that, if Mill's analysis of what it means to call an action wrong is accurate, then ACAU entails a conclusion that no one will accept, viz., that the morally–best humans possible ought to undergo constant punishment. The second objection is that ACAU entails that even the morally–best humans possible are bad moral agents in some respect. This conclusion, while unpalatable, is not so obviously unacceptable as the first. However, I do briefly consider some ways in which it might be possible to demonstrate that it is false and thereby complete a reductio of ACAU. (shrink)

This Introduction introduces readers to the concepts of political philosophy: authority, democracy, freedom and its limits, justice, feminism, multiculturalism, and nationality. Accessibly written and assuming no previous knowledge of the subject, it encourages the reader to think clearly and critically about the leading political questions of our time. THe book first investigates how politcial philosophy tackles basic ethical questions such as 'how should we live together in society?' It furthermore looks at political authority, discusses the reasons society needs politics in (...) the first place, explores the limitations of politics, and asks if there are areas of life that shouldn't be governed by politics. Moreover, the book explores the connections between political authority and justice, a constant theme in political philosophy, and the ways in which social justice can be used to regulate rather than destroy a market economy. In his travels through this realm, Miller covers why nations ar the natural units of government and wonders if the rise of multiculturalism and transnational co-operation will change all this, and asks in the end if we will ever see the formation of a world government. (shrink)

At Sophist 253d-e the Eleatic Visitor offers a notoriously obscure description of the fields of one-and-many that the dialectician “adequately discerns.” Against the readings of Stenzel, Cornford, Sayre, and Gomez-Lobo, I propose an interpretation of that passage that takes into account the trilogy of Theaetetus-Sophist-Statesman as its context. The key steps are to respond to the irony of Socrates’ refutations at the end of the Theaetetus by reinterpreting the last two senses of logos as directed to forms and to recognize (...) their correlation with the two different modes of diairesis practiced by the Eleatic Visitor. These steps position us to recognize in the Visitor’s remarks at Sophist 253d-e a schematic description of the two kinds of eidetic field that the two modes of diairesis trace. (shrink)

People increasingly form beliefs based on information gained from automatically filtered Internet ‎sources such as search engines. However, the workings of such sources are often opaque, preventing ‎subjects from knowing whether the information provided is biased or incomplete. Users’ reliance on ‎Internet technologies whose modes of operation are concealed from them raises serious concerns about ‎the justificatory status of the beliefs they end up forming. Yet it is unclear how to address these concerns ‎within standard theories of knowledge and justification. (...) To shed light on the problem, we introduce a ‎novel conceptual framework that clarifies the relations between justified belief, epistemic responsibility, ‎action, and the technological resources available to a subject. We argue that justified belief is subject to ‎certain epistemic responsibilities that accompany the subject’s particular decision-taking circumstances, ‎and that one typical responsibility is to ascertain, so far as one can, whether the information upon which ‎the judgment will rest is biased or incomplete. What this responsibility comprises is partly determined by ‎the inquiry-enabling technologies available to the subject. We argue that a subject’s beliefs that are ‎formed based on Internet-filtered information are less justified than they would be if she either knew how ‎filtering worked or relied on additional sources, and that the subject may have the epistemic ‎responsibility to take measures to enhance the justificatory status of such beliefs.‎. (shrink)

Infallibilism is the view that a belief cannot be at once warranted and false. In this essay we assess three nonpartisan arguments for infallibilism, arguments that do not depend on a prior commitment to some substantive theory of warrant. Three premises, one from each argument, are most significant: if a belief can be at once warranted and false, then the Gettier Problem cannot be solved; if a belief can be at once warranted and false, then its warrant can be transferred (...) to an accidentally true belief; if a belief can be at once warranted and false, then it can be warranted and accidentally true. We argue that each of these is either false or no more plausible than its denial. Along the way, we offer a solution to the Gettier Problem that is compatible with fallibilism. (shrink)

[This book offers] compilation of examples from TV, newspapers, magazines, advertisements, and our nation's political dialogue.

This chapter outlines the main ideas of my book National responsibility and global justice. It begins with two widely held but conflicting intuitions about what global justice might mean on the one hand, and what it means to be a member of a national community on the other. The first intuition tells us that global inequalities of the magnitude that currently exist are radically unjust, while the second intuition tells us that inequalities are both unavoidable and fair once national responsibility (...) is allowed to operate. This conflict might be resolved either by adopting a cosmopolitan theory of justice (which leaves no room for national responsibility) or by adopting a ?political? theory of justice (which denies that questions of distributive justice can arise beyond the walls of the sovereign state). Since neither resolution is satisfactory, the chapter defends the idea of national responsibility and proposes a new theory of global justice, whose main elements are the protection of basic human rights worldwide, and fair terms of interaction between independent political communities. (shrink)

Platonists and nominalists disagree about whether mathematical objects exist. But they almost uniformly agree about one thing: whatever the status of the existence of mathematical objects, that status is modally necessary. Two notable dissenters from this orthodoxy are Hartry Field, who defends contingent nominalism, and Mark Colyvan, who defends contingent Platonism. The source of their dissent is their view that the indispensability argument provides our justification for believing in the existence, or not, of mathematical objects. This paper considers whether commitment (...) to the indispensability argument gives one grounds to be a contingentist about mathematical objects. (shrink)

There is considerable evidence that the hippocampal system contributes both to (1) the temporary maintenance of memories and to (2) the processing of a particular type of memory representation. The findings on amnesia suggest that these two distinguishing features of hippocampal memory processing are orthogonal. Together with anatomical and physiological data, the neuropsychological findings support a model of cortico-hippocampal interactions in which the temporal and representational properties of hippocampal memory processing are mediated separately. We propose that neocortical association areas maintain (...) shortterm memories for specific items and events prior to hippocampal processing as well as providing the final repositories of long-term memory. The parahippocampal region supports intermediate-term storage of individual items, and the hippocampal formation itself mediates an organization of memories according to relevant relationships among items. Hippocampal-cortical interactions produce (i) strong and persistent memories for events, including their constituent elements and the relationships among them, and (ii) a capacity to express memories flexibly across a wide range of circumstances. (shrink)

The paper presents a realist account of the epistemic objectivity of science. Epistemic objectivity is distinguished from ontological objectivity and the objectivity of truth. As background, T.S. Kuhn’s idea that scientific theory-choice is based on shared scientific values with a role for both objective and subjective factors is discussed. Kuhn’s values are epistemologically ungrounded, hence provide a minimal sense of objectivity. A robust account of epistemic objectivity on which methodological norms are reliable means of arriving at the truth is presented. (...) The problem remains that deliberative judgement is required to determine the relevance and relative significance of a range of methodological norms. A role is sketched for cognitive virtues which may be exercised in the course of the deliberative judgement. (shrink)

Published in 1982 by CUP (pb. 2009) it discusses the forms of materialism then current, including Davidson, early Rorty, but concentrating on Smart and Armstrong, and arguing that central state materialism fails to give a better 'occurrent' account of conscious states than does behaviourism/functionalism, as Armstrong claims. The book starts with a version of the 'knowledge argument' and ends with a chapter claiming that our conception of matter/the physical is more problematic than our conception of mind.

Scientific consensus is widely deferred to in public debates as a social indicator of the existence of knowledge. However, it is far from clear that such deference to consensus is always justified. The existence of agreement in a community of researchers is a contingent fact, and researchers may reach a consensus for all kinds of reasons, such as fighting a common foe or sharing a common bias. Scientific consensus, by itself, does not necessarily indicate the existence of shared knowledge among (...) the members of the consensus community. I address the question of under what conditions it is likely that a consensus is in fact knowledge based. I argue that a consensus is likely to be knowledge based when knowledge is the best explanation of the consensus, and I identify three conditions—social calibration, apparent consilience of evidence, and social diversity, for knowledge being the best explanation of a consensus. (shrink)

In a recent paper, Barry Loewer attempts to defend Humeanism about laws of nature from a charge that Humean laws are not adequately explanatory. Central to his defense is a distinction between metaphysical and scientific explanations: even if Humeans cannot offer further metaphysical explanations of particular features of their “mosaic,” that does not preclude them from offering scientific explanations of these features. According to Marc Lange, however, Loewer’s distinction is of no avail. Defending a transitivity principle linking scientific explanantia to (...) their metaphysical grounds, Lange argues that a charge of explanatory inadequacy resurfaces once this intuitive principle is in place. This paper surveys, on behalf of the Humean, three strategies for responding to Lange’s criticism. The ready availability of these strategies suggests that Lange’s argument may not bolster anti-Humean convictions, since the argument rests on premises that those not antecedently sharing these convictions may well reject. The three strategies also correspond to three interesting ways of thinking about relations of grounding linking Humean laws and their instances, all of which are consistent with theses of Humean supervenience, and some of which have been heretofore overlooked. (shrink)

Philosophers have recently argued, against a prevailing orthodoxy, that standards of knowledge partly depend on a subject’s interests; the more is at stake for the subject, the less she is in a position to know. This view, which is dubbed “Pragmatic Encroachment” has historical and conceptual connections to arguments in philosophy of science against the received model of science as value free. I bring the two debates together. I argue that Pragmatic Encroachment and the model of value-laden science reinforce each (...) other. Drawing on Douglas’ argument about the indispensability of value judgments in science, and psychological evidence about people’s inability to objectively reason about what they care about, I introduce a novel argument for Pragmatic Encroachment. (shrink)

In this chapter I defend a methodological view about how we should conduct substantive ethical inquiries in the fields of normative and practical ethics. I maintain that the direct plausibility and implausibility of general ethical principles – once fully clarified and understood – should be foundational in our substantive ethical reasoning. I argue that, in order to expose our ethical intuitions about particular cases to maximal critical scrutiny, we must determine whether they can be justified by directly plausible principles. To (...) expose apparently plausible principles to maximal critical scrutiny, we must determine whether their direct plausibility can survive careful clarification of what they are really saying. This means that intuitions about cases are useful only in (a) suggesting principles that must stand on their own two feet, and (b) illustrating or otherwise helping us clarify what a principle is really saying. We should not reject principles that seem most directly plausible after we have fully clarified their content simply because they conflict with our intuitions about cases, because to do so is to side with uncritical prejudices over the teachings of critical scrutiny. (shrink)

Since 1962 Kuhn's concept of incommensurability has undergone a process of transformation. His current account of incommensurability has little in common with his original account of it. Originally, incommensurability was a relation of methodological, observational and conceptual disparity between paradigms. Later Kuhn restricted the notion to the semantical sphere and assimilated it to the indeterminacy of translation. Recently he has developed an account of it as localized translation failure between subsets of terms employed by theories.