Rawls famously argues that the parties in the original position would agree upon the two principles of justice. Among other things, these principles guarantee equal political liberty—that is, democracy—as a requirement of justice. We argue on the contrary that the parties have reason to reject this requirement. As we show, by Rawls’ own lights, the parties would be greatly concerned to mitigate existential risk. But it is doubtful whether democracy always minimizes such risk. Indeed, no one currently knows which political (...) systems would. Consequently, the parties—and we ourselves—have reason to reject democracy as a requirement of justice in favor of political experimentalism, a general approach to political justice which rules in at least some non-democratic political systems which might minimize existential risk. (shrink)

The controversy over the equivalence of continuous sedation until death (CSD) and physician-assisted suicide/euthanasia (PAS/E) provides an opportunity to focus on a significant extended use of CSD. This extension, suggested by the equivalence of PAS/E and CSD, is designed to promote additional patient autonomy at the end-of-life. Samuel LiPuma, in his article, “Continuous Sedation Until Death as Physician-Assisted Suicide/Euthanasia: A Conceptual Analysis” claims equivalence between CSD and death; his paper is seminal in the equivalency debate. Critics contend that sedation follows (...) proportionality protocols for which LiPuma’s thesis does not adequately account. Furthermore, sedation may not eliminate consciousness, and as such LiPuma’s contention that CSD is equivalent to neocortical death is suspect. We not only defend the equivalence thesis, but also expand it to include additional moral considerations. First, we explain the equivalence thesis. This is followed by a defense of the thesis against five criticisms. The third section critiques the current use of CSD. Finally, we offer two proposals that, if adopted, would broaden the use of PAS/E and CSD and thereby expand options at the end-of-life. (shrink)

This revised edition of The Idea of Private Law makes one of the major works of modern legal theory accessible to a new generation of lawyers and students. It includes a new introduction by the author, looking back at the work, its origins, and its aspirations.

Benardete paradoxes involve infinite collections of Grim Reapers, assassins, demons, deafening peals, or even sentences. These paradoxes have recently been used in arguments for finitist metaphysical theses such as temporal finitism, causal finitism, and discrete views of time. Here we develop a new finite Benardete-like paradox. We then use this paradox to defend a companions in guilt argument that challenges recent applications of patchwork principles on behalf of the aforementioned finitist arguments. Finally, we develop another problem for those applications by (...) examining the notion of exact duplication. (shrink)

Growing concern has been expressed that we have entered a “post-truth” era in which each of us willfully believes whatever we choose, aided and abetted by alternative and social media that spin alternative realities for boutique consumption. A prime example of the belief in alternative realities is said to be acceptance of “conspiracy theories”—a term that is often used as a pejorative to indict claims of conspiracy that are so obviously absurd that only the unhinged could believe them. The epistemological (...) standard often involved in this indictment, however—the standard of “obvious” falsity—invites subjectivity in its application, because what is obviously false to one person can be common sense to another. This is not just a truism; considerable research suggests that people’s political beliefs, in general, and their acceptance or rejection of conspiracy theories in particular, tends in large part to be determined by partisan, ideological, and other priors. (shrink)

As human beings age, they become weak, fragile, and feeble. It is a slowly progressing yet complex syndrome in which old age or some disabilities are not prerequisites; neither does loss of human parts lead to frailty among the physically fit older persons. This paper aims to describe the influences of transhumanist perspectives on human‐technology enhancements and replacements in the transcendence of human frailties, including those of older persons, in which technology is projected to deliver solutions toward transcending these frailties. (...) Through technologies including genetic screening and other technological manipulations, intelligent machines and augmented humans improve, maintain, and remedy human‐linked susceptibilities. Furthermore, other technologies replace parts fabricated through inorganic‐mechanical processes such as 3D‐printing. Advancing technologies are reaching the summit of technological sophistication contributing to the transhumanist views of being human in a technological world. Technologies enhance the transcendence of human frailties as essential expressions of the symbiosis between human beings and technology in a transcendental world. (shrink)

This book turns to virtue language as an important resource for understanding moral injury, a form of subjectivity where one feels they can no longer strive to be good as a result of wartime experience. Drawing specifically on Iris Murdoch’s moral philosophy, and examining the experiences of civilians during the Bosnian War, Joseph Wiinikka-Lydon argues that current research into war and current understandings of subjectivity need new ways to articulate the moral dimension of being a subject if we are (...) to understand how violence affects one’s moral being and development. He develops an understanding of the human person as a tensile moral subject, one that forefronts the moral challenges and vulnerability inherent in lives affected by war. With these resources, Wiinikka-Lydon argues for a moral vocabulary and images of the human as a moral being that can better articulate the experience of violence and moral injury. (shrink)

Sport poses a number of important and no less significant questions, which, on the face of it, may not necessarily seem very important or significant to begin with – a peculiarity that we believe to be integral to sport itself. This article introduces, explores and outlines the psychoanalytic significance of this peculiarity. It explores how the emotions stirred by sport are intertwined with a realm of fiction and fantasy. Despite its lack of practical utility, sport carries an undeniable gravity, encapsulating (...) the aspirations of communities, nations and continents. As a result, psychoanalysis can be used to critically reflect on the purpose and meaning of sport: that is, why do we need sport, and why, for large sections of the world’s population, do we rely on it? Ultimately, while psychoanalysis maintains a unique relation to a variety of unexpected fields of study – including art, culture and neuroscience – we seek to add to this expanding list of inquiry by including sport in this critical domain. By utilising sport as a platform to elucidate psychoanalytic concepts, it is recognised that sport can also prompt questions for psychoanalysis. In so doing, theoretical discussions on the social, cultural and political dimensions of sport through psychoanalytic theory are introduced and applied. (shrink)

Background The ethical governance of Artificial Intelligence (AI) in health care and public health continues to be an urgent issue for attention in policy, research, and practice. In this paper we report on central themes related to challenges and strategies for promoting ethics in research involving AI in global health, arising from the Global Forum on Bioethics in Research (GFBR), held in Cape Town, South Africa in November 2022. Methods The GFBR is an annual meeting organized by the World Health (...) Organization and supported by the Wellcome Trust, the US National Institutes of Health, the UK Medical Research Council (MRC) and the South African MRC. The forum aims to bring together ethicists, researchers, policymakers, research ethics committee members and other actors to engage with challenges and opportunities specifically related to research ethics. In 2022 the focus of the GFBR was “Ethics of AI in Global Health Research”. The forum consisted of 6 case study presentations, 16 governance presentations, and a series of small group and large group discussions. A total of 87 participants attended the forum from 31 countries around the world, representing disciplines of bioethics, AI, health policy, health professional practice, research funding, and bioinformatics. In this paper, we highlight central insights arising from GFBR 2022. Results We describe the significance of four thematic insights arising from the forum: (1) Appropriateness of building AI, (2) Transferability of AI systems, (3) Accountability for AI decision-making and outcomes, and (4) Individual consent. We then describe eight recommendations for governance leaders to enhance the ethical governance of AI in global health research, addressing issues such as AI impact assessments, environmental values, and fair partnerships. Conclusions The 2022 Global Forum on Bioethics in Research illustrated several innovations in ethical governance of AI for global health research, as well as several areas in need of urgent attention internationally. This summary is intended to inform international and domestic efforts to strengthen research ethics and support the evolution of governance leadership to meet the demands of AI in global health research. (shrink)

Integrating large language models (LLMs) like GPT-4 into medical ethics is a novel concept, and understanding the effectiveness of these models in aiding ethicists with decision-making can have significant implications for the healthcare sector. Thus, the objective of this study was to evaluate the performance of GPT-4 in responding to complex medical ethical vignettes and to gauge its utility and limitations for aiding medical ethicists. Using a mixed-methods, cross-sectional survey approach, a panel of six ethicists assessed LLM-generated responses to eight (...) ethical vignettes.The main outcomes measured were relevance, reasoning, depth, technical and non-technical clarity, as well as acceptability of GPT-4’s responses. The readability of the responses was also assessed. Of the six metrics evaluating the effectiveness of GPT-4’s responses, the overall mean score was 4.1/5. GPT-4 was rated highest in providing technical (4.7/5) and non-technical clarity (4.4/5), whereas the lowest rated metrics were depth (3.8/5) and acceptability (3.8/5). There was poor-to-moderate inter-rater reliability characterised by an intraclass coefficient of 0.54 (95% CI: 0.30 to 0.71). Based on panellist feedback, GPT-4 was able to identify and articulate key ethical issues but struggled to appreciate the nuanced aspects of ethical dilemmas and misapplied certain moral principles.This study reveals limitations in the ability of GPT-4 to appreciate the depth and nuanced acceptability of real-world ethical dilemmas, particularly those that require a thorough understanding of relational complexities and context-specific values. Ongoing evaluation of LLM capabilities within medical ethics remains paramount, and further refinement is needed before it can be used effectively in clinical settings. (shrink)

When intense public controversy erupted around agricultural biotechnology in the late 1990s, critics found opportunities to challenge risk assessment criteria and test methods for genetically modified products. In relation to GM food, they criticized the concept of substantial equivalence, which European Union and United States regulators had adopted as the basis for a harmonized, science-based approach to risk assessment. Competing policy agendas framed scientific uncertainty in different ways. Substantial equivalence was contested and eventually recast to accommodate some criticisms. To explain (...) how the concept changed, this article links two analytical perspectives. Regulatory-science perspectives illuminate how the scientification of politics and politicization of science led to shifts in the boundary between science and policy. Governance perspectives illuminate how the collective problem for policy was redefined to provide a new common ground for some stakeholders. Overall, substantial equivalence was recast to govern the social conflict and address legitimacy problems of regulatory procedures. (shrink)

Ang pagpapalaganap ng wikang Filipino ay hindi payak na romantisasyon ng nasyonalismo. Sa halip, ito ay instrumento tungo sa higit na demokratisasyon ng wikang Filipino, at samakatuwid ay may malalim na implikasyon sa usapin ng katarungang panlipunan. Sa kontekstong ito mabibigyang-diin ang dulot na suliranin ng Dambuhalang Pagkakahating Pangkalinangan, na dahilan kung bakit mas namomonopolisa ng elit ang mga daluyan ng kapangyarihan tulad ng edukasyon, komersyo at pulitika. Tungo sa paghahanap ng lunas sa suliraning ito, makatutulong ang pagsasa-Filipino ng agham (...) panlipunan bilang esensyal na bahagi ng sistemang pang-edukasyon. -/- Bilang ambag sa adhikaing ito ng pagsasa-Filipino ng agham panlipunan, naglunsad ang pag-aaral na ito ng isang payak na bahaginan ng best practices para sa pagsasa-Filipino ng pagtuturo at pananaliksik sa antas ng silid-aralan at Departamento/Kolehiyo. Hinalaw ang best practices na ito mula sa iba’t ibang guro, mananaliksik, at institusyon, para makabuo ng isang munting imbentaryo ng mga “armas-panturo.” Binubuo ang imbentaryong ito ng 17 gawi/aktibidad/programa para sa antas ng silid-aralan, at 6 gawi/aktibidad/programa para sa antas ng Departamento/Kolehiyo. Nilalayon na maging munting batis ang imbentaryong ito para sa pagpapainam ng pedagohiya ng mga guro at polisiya ng mga institusyon tungo sa higit na pagsasa-Filipino ng pagtuturo at pananaliksik sa agham panlipunan. (shrink)

It is commonly thought that disability is a harm or “bad difference” because having a disability restricts valuable options in life. In his recent essay “Disability, Options and Well-Being,” Thomas Crawley offers a novel defense of this style of reasoning and argues that we and like-minded critics of this brand of argument are guilty of an inconsistency. Our aim in this article is to explain why our view avoids inconsistency, to challenge Crawley's positive defense of the Options Argument, and to (...) suggest that this general line of reasoning employs a double standard. (shrink)

UK Higher Education is characterised by structural and institutional forms of whiteness. As scholars and activists are increasingly speaking out to testify, whiteness has wide-ranging implications that affect curricula, pedagogy, knowledge production, university policies, campus climate, and the experiences of students and faculty of colour. Unsurprisingly then, calls to decolonize the university abound. In this article, we draw upon the Critical Race Theory method of counter-storytelling. By introducing composite characters, we speak back to assumptions that universities are race-neutral, meritocratic institutions. (...) We illustrate some of the key themes that shape the experiences of faculty of colour in UK Higher Education: institutional racism, racial microaggressions, racial battle fatigue, and steadfast fugitive resistance. We argue that, despite the paradox of working under (what purports to be) a ‘decolonial’ agenda, widespread calls to decolonize our universities have further embedded rather than dismantled whiteness, thus continuing to characterise the careers, wellbeing, and daily lives of faculty of colour. (shrink)

What does it mean to give a "gift"? In this timely collection, distinguished anthropologists--Maurice Godelier, George Marcus, Stephen Tyler--and philosophers--Mark C. Taylor, John D. Caputo, Jean-Joseph Goux and Adriaan Peperzak, explore an enigma that has disturbed contemporary philosophers from Marcel Mauss to Jacques Derrida.The essays included in the volume: Some Things You Give, Some Things You Sell, But Some Things You Must Keep for Yourselves: What Mauss Did Not Say about Sacred Objects by Maurice Godelie.The Gift and Globalization: A (...) Prolegomenon to the Anthropological Study of Contemporary Finance Capital and Its Mentalities by George MarcusCapitalizing (on) Gifting by Mark C. Taylor"Even Steven" or "No Strings Attached" by Stephen TylerMothering, Co-muni-cation and the Gifts of Language by Genevieve VaughanThe Time of Giving, the Time of Forgiving by John D. CaputoSeneca against Derrida: Gift and Alterity by Jean-Joseph Goux Giving by Adriaan Peperzak. (shrink)

Recent global events demonstrate that analytical frameworks to aid professionals in healthcare ethics must consider the pervasive role of social structures in the emergence of bioethical issues. To address this, the authors propose a new sociologically informed approach to healthcare ethics that they term “social bioethics.” Their approach is animated by the interpretive social sciences to highlight how social structures operate vis-à-vis the everyday practices and moral reasoning of individuals, a phenomenon known as social discourse. As an exemplar, the authors (...) use social bioethics to reframe common ethical issues in psychiatric services and discuss potential implications. Lastly, the authors discuss how social bioethics illuminates the ways healthcare ethics consultants in both policy and clinical decision-making participate in and shape broader social, political, and economic systems, which then cyclically informs the design and delivery of healthcare. (shrink)

The number of clinical trials for experimental brain implants continues to grow, and with this growth comes an increased reliance upon patients with treatment-refractory conditions to volunteer as...

Virtues can be considered to play a causal role in the production of behaviour and so too can our self-narratives. We identify a point of connection between the two cases and draw a parallel between them. But, those folk psychological notions, virtues and self-narratives, fail to reduce smoothly to the underlying human physiology. As a first step towards handling that failure to connect with the scientific framework that is the familiar grounding for our understanding of causation, we consider the causal (...) theory of action, a leading theory of action, which shows how reasons, understood as an appropriate pair of beliefs and desires, can be treated as causes of action. Davidson’s picture is based on cause as a relation between events, which can have both a description in scientific terms and in folk psychological terms. The character of both virtues and self-narratives is not that of events, even extended ones, so we need to refer to examples of scientific explanation that incorporate structural properties of objects. While we retain the spirit of the causal theory, we wish to guard against any unwarranted optimism that an explicitly scientific explanation for human action lies in our future, drawing on Chomsky’s view that a causal explanation of human actions is likely to remain beyond human science forming capacities. We take a mild-realist view of virtues and self-narratives, in the style of Dennett. We argue that, in spite of that limited form of realism, underlined by Chomsky’s mysterian position in this domain, we still need to frame our explanations of behaviour based on virtues and self-narratives in causal terms. (shrink)

Evolving practice requires peer review of clinical ethics (CE) consultation for quality assessment and improvement. Many institutions have identified the chart note as the basis for this process, but to our knowledge, electronic health record (EHR) systems are not necessarily designed to easily include CE consultation notes. This article provides a framework for the inclusion of CE consultation notes into the formal EHR, describing a developed system in the Epic EHR that allows for the elaborated electronic notation of the CE (...) chart note. The implementation of the “meaningful use” criteria for EHR, mandated by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, requires that health professionals meet certain standards for quality, efficiency, and safety, all of which overlap with the goals of standardization, peer review, and quality improvement within CE consultation. (shrink)

In two studies, we tested how the expression of civic hope in narratives and the perceived authenticity of civic/political actions relate to civic/political engagement. In a cross-sectional study of undergraduates (N = 230), the expression of civic hope predicted the perceived authenticity of civic actions (e.g., voting), which in turn predicted the motivation to engage in them. In a longitudinal on-line study that began 8 weeks prior to the 2020 U.S. Presidential election (N = 308 MTurk workers), overall expressions of (...) civic hope positively predicted the perceived authenticity of voting and the motivation to vote. In addition, expressions of civic hope positively predicted the perceived authenticity of voting, which in turn positively predicted the likelihood of reporting that one did vote. These findings indicate that a sense of civic hope and the experience of authenticity in political contexts may be important for democratic engagement. (shrink)

What does Wittgenstein say about the learning child? In the Philosophical Investigations, he writes, ‘An important part … will consist in the teacher’s pointing to the objects, directing the child’s attention to them, and at the same time uttering a word.’ Here Wittgenstein is describing what is called ‘joint attention’ which is agreed to be a rich resource for learning in children. In this essay, I explore the developmental significance of this passage particularly with regards the learning that occurs in (...) the pre-linguistic child during joint attention. I refer to critical remarks elsewhere in the PI which can help further convey what Wittgenstein means when he talks about attentional capacities and how they develop, including the relevant ability for responsiveness required for the learning to proceed. These considerations should motivate a defence of the social initiation model of learning contra Luntley’s mentalist-individualist account, this despite conceding that certain prior capacities do play a role, though not a central one since these do not pick out the relevant ability (responsiveness) required for learning to take place in the child. (shrink)

In the last century, science fiction has become an incredibly powerful tool in depicting alternative social imaginaries, particularly those of the future. Extending beyond their fictious nature is a commentary on the stark realities of modern society. The ‘cyberpunk’ subgenre, for example, offers a dystopian critique on the dangers of technological dependence and hypercapitalism. In studying science fiction, future imaginaries can be developed as utopian goals for governance systems to strive for. In contrast to cyberpunk, the subgenre of ‘solarpunk’ depicts (...) a utopian society where humanity lives locally, sustainably, and in harmony with nature. This paper deconstructs solarpunk media to describe three guiding principles of solarpunk: anarchism, ecology, and justice. As an anarchist community, solarpunk strives for a post-scarcity, post-capitalist society devoid of hierarchy and domination. As an ecological community, solarpunk strives for local, self-sufficient, and sustainable living where both the human and non-human flourish. Finally, as a just community, solarpunk strives to rid society of marginalization and celebrate authenticity. These three principles can be used to guide humanity towards a utopian, solarpunk future. (shrink)

This paper develops some modal metatheory for quantified modal logic. In such a theory, the logic of a first-order modal object-language is made sensitive to the modal facts, stated in the metalanguage. This is radically different from possible worlds semantics, which reduces questions of validity to questions of nonmodal set theory. We consider theories which characterize a notion of truth under a second-order interpretation, where an operator for metaphysical necessity is treated homophonically. The form they take is crucially influenced by (...) whether the Barcan formulas are part of the metalogic. The main result is that, with the Barcan formulas, formulating a modal metatheory is easy; principles of classical semantics transfer over smoothly with natural adaptations to the modal setting. Without the Barcan formulas, it seems to be much harder. Several options are considered, but each involves commitments plausibly in tension with the underlying philosophical motivations for rejecting them. (shrink)

Since ChatGPT’s debut in 2022, questions abound what ethical implications artificial intelligence (AI) platforms enabled by large language models (LLMs) have for medicine (Cohen 2023). In the area...

This Is A New Release Of The Original 1899 Edition.

This work has been selected by scholars as being culturally important, and is part of the knowledge base of civilization as we know it. This work was reproduced from the original artifact, and remains as true to the original work as possible. Therefore, you will see the original copyright references, library stamps (as most of these works have been housed in our most important libraries around the world), and other notations in the work. This work is in the public domain (...) in the United States of America, and possibly other nations. Within the United States, you may freely copy and distribute this work, as no entity (individual or corporate) has a copyright on the body of the work. As a reproduction of a historical artifact, this work may contain missing or blurred pages, poor pictures, errant marks, etc. Scholars believe, and we concur, that this work is important enough to be preserved, reproduced, and made generally available to the public. We appreciate your support of the preservation process, and thank you for being an important part of keeping this knowledge alive and relevant. (shrink)

In The Ethics of War and the Force of Law, Uwe Steinhoff argues “[t]he legitimate authority criterion should be abandoned.” (33) His position explicitly rejects the views of those defending legitimate authority as both indispensable and prior to the other criteria of the just war theory. In a subtle rejoined to these views, Steinhoff contends these accounts misrepresent the tradition and can provide no effective justification for retaining the criterion. Indeed, the criterion proves redundant. Much of Steinhoff’s analysis is compelling. (...) I shall argue, however, that despite correctly representing the tradition as more “pluralist” regarding possible authorization of war beyond the state, Steinhoff’s rejection of legitimate authority fails to account for its primary justification, namely, as identifying the proper agent through which to gauge the moral action involved in this particular use of force. My essay will advance this view by vindicating Steinhoff’s insight about the plurality of possible actors for whom “war” is appropriate necessitates the criterion of legitimate authority rather than making it redundant. (shrink)

Both a Popper biography and an autobiography, Agassi's "A Philosopher's Apprentice" tells the riveting story of his intellectual formation in 1950s London, a young brilliant philosopher struggling with an intellectual giant - father, mentor, and rival, all at the same time. His subsequent rebellion and declaration of independence leads to a painful break, never to be completely healed. No other writer has Agassi's psychological insight into Popper, and no other book captures like this one the intellectual excitement around the Popper (...) circle in the 1950s and the struggles of the 1960s and 1970s - personal, academic, political, all important philosophically. Agassi's Popper - whether one agrees with it or not - is an enormous contribution to scholarship. This second revised edition includes also Popper's and Agassi's last correspondence and, in a postscript it shows Agassi leafing through Popper's archives, reaching a sort of reconciliation, an appropriate ending to the drama. A must read. Malachi Hacohen, Duke University. (shrink)

For many years before his composition of the Prince, Niccolò Machiavelli produced a vast body of writings in a range of genres, which are seldom studied. The Rope and the Chains examines these texts in order to locate the intellectual origins of the Machiavelli with whom people are widely familiar.

This chapter contains sections titled: What is a Father? Fatherly Mercy as Attitude Mercy Enables Connection with Children Mercy Strengthens Relationships What Does Fatherly Mercy Look Like? Notes.

In “Informed Consent: What Must be Disclosed and What Must be Understood?”, we reject a dogma at the heart of research ethics. We demonstrate that the constitutive claim...

El cuidado de sí es cuidado de lo más humano de cada uno de nosotros. La convicción nuclear que lo rige es siempre la misma: que lo humano puede intensificarse y crecer. Y que el peligro reside siempre en la degeneración. Intensificar lo humano es ir hacia lo “más humano”. En absoluto se busca la “superación” o el “más allá” de lo humano. Este artículo es un intento de relacionar la lectura que hace Foucault del tema del cuidado de sí (...) con la urgente necesidad de repensar hoy el lugar de lo educativo como lugar propio para ese cuidado. Para tal fin, se propone el concepto de altertopía educativa, como lugar, no solo de resistencia al dominio de la banalidad contextual, sino de gestación de la fuerza revolucionaria. (shrink)

PHOTO ID 121339257© Designer491| Dreamstime.com ABSTRACT When physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be apparent conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters future physicians’ commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. We use an ethical dilemma that was presented to a group of third-year medical students to examine how ethics education might be causing (...) them to give undue deference to autonomy, thereby undermining their commitment to beneficence. INTRODUCTION The right of patients to choose which treatments they prefer is rooted in today’s social mores and taught as a principle of medical ethics as respect for autonomy. Yet, when physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be a conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters a commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. I. An Ethical Dilemma The impetus for this paper arose when students who were completing their third clinical year discussed a real-life ethical dilemma. A middle-aged man developed a pulmonary hemorrhage while on blood thinners for a recently placed coronary stent. The bleeding was felt to be reversible, but the patient needed immediate intubation or he would die. The cardiologist was told that the patient previously expressed to other physicians that he never wanted to be intubated. However, the cardiologist made the decision to intubate the patient anyway, and the patient eventually recovered.[1] Students were asked if they believed that the cardiologist had acted ethically. Their overwhelming response was, “No, the patient should have been allowed to die.” We looked into how students applied ethical reasoning to conclude that this outcome was ethically preferred. To explore how the third-year clinical experience might have formed the students’ judgment, we presented the same case to students who were just beginning their third year. Their responses were essentially uniform in recommending intubation. While there is likely more than one reasonable view in this case, we agree with the physician and the younger medical students that intubation was the ethically appropriate decision and will present an argument for it. But first, we explain the reasoning behind the more advanced medical students’ decision to choose patient autonomy at the expense of beneficence. II. Medical Ethics Education and the Priority of Autonomy Beauchamp and Childress’s Principles of Biomedical Ethics, first published in 1979 and now in its 8th edition, is a significant part of the formal ethics education in medical school.[2] Students learn an ethical decision-making approach based on respect for four ethical principles: autonomy, beneficence, nonmaleficence, and justice. While Beauchamp and Childress officially afford no prima facie superiority to any principle, the importance of respect for patient autonomy has increased through the editions of their book. For example, early editions of their book opposed the legalization of physician-assisted death compared to recent editions that defended it.[3] As another example, Beauchamp and Childress make paternalism harder to justify by adding an autonomy-protecting condition to the list of conditions for acceptable paternalism.[4] Authority, they contend, need not conflict with autonomy—provided the authority is autonomously chosen.[5] “The main requirement,” they write, “is to respect a particular patient’s or subject’s autonomous choices, whatever they may be.[6] In the principlism of Beauchamp and Childress, autonomy now seems to have a kind of default priority.[7] However, the bioethics discourse has strong counternarratives, noting some movement to elevate the role of beneficence and to respect the input of stakeholders, including the family and the healthcare team. Ethics education achieves particular relevance in the third clinical year when students become embedded in the care of patients and learn from what has been called the informal curriculum. They observe how attending physicians approach day-to-day ethical problems at the patient’s bedside. In this context, students observe the importance of informed consent for serious treatments or invasive procedures, a practice that highlights the principle of patient autonomy. In both the formal and informal curriculum, medical students observe how, in the words of Paul Wolpe, “patient autonomy has become the central and most powerful principle in ethical decision-making in American medicine.”[8] In short, students appear to learn a deference for patient autonomy. This curricular shift in favor of autonomy coincides with legal developments that protect patients’ rights and decision-making with respect to their healthcare choices. The priority of autonomy in medicine benefits patients by reflecting their choices and, in some cases, their fundamental liberty. III. The Practice of Medicine and the Commitment to Beneficence There are many critiques of the dominant place that autonomy has in biomedical ethics,[9] especially considering that autonomy seems to be biased toward individualistic, Western, and somewhat American culture-driven values.[10] In addition, many bioethical dilemmas are cast as a conflict between autonomy and beneficence. Our point is that medical students bring to their study of medicine a commitment to beneficence that seems to be suppressed by practical ethics education. We think this commitment is rationally defensible and should be nurtured. It is striking that young medical students have a pre-reflective commitment to beneficence at all. For, as we mentioned, it is not just medicine but Western culture generally that prioritizes autonomy in settling ethical dilemmas. In wanting to act for the good of others (rather than simply agreeing to what others want), physicians are already swimming somewhat against the cultural tide.[11] However, doing so makes sense, given the nature of medicine and the profession of healing. When prospective medical students are asked why they wish to become physicians, the usual answer is some variation on caring for the sick and preventing disease. It is unlikely that a reason to become a physician is to respect a patient’s autonomy. It would be easy to dismiss medical students’ commitment to beneficence as a mere intuition and contrary to a more reasoned and deliberative approach. Beauchamp and Childress seem to minimize the value of physician intuition, stating that justifications for certain procedures are “…supported by good reasons. They need not rest merely in intuition or feeling.”[12] Henry Richardson writes that “situational or perceptive intuition…leaves the reasons for decision unarticulated.”[13] We think this is a crude and rather thin way of understanding intuition. Some bioethicists have defended intuition as essential to the practice of medicine and not something opposed to reason.[14] In the case we describe, we believe the ethical justifications s for the patient’s intubation are fundamentally sound: the patient did not have a “do not intubate” order written in the chart, the emergency intubation had not been foreseen, so the patient did not have the opportunity to consent to or reject intubation; the patient had consented to the treatment for his cardiac disease so his consent for intubation could have been assumed;[15] and the consequences of respecting his autonomy did not justify allowing him to die.[16] While it is possible to have more than one reasonable view on this case, we think the case for beneficence is strong and certainly should not be dismissed out of hand. We do not deny that if a patient makes a clearly documented, well-informed decision to forgo intubation that this decision ought to be respected by the physician (even if the physician disagrees with the patient’s decision). But, in this situation, as in many others in the practice of medicine, the patient’s real wishes and preferences are not well-articulated in advance. There are many cases where a physician acts based on what she believes the patient, or the surrogate, would want, sometimes in situations that do not allow much time for reflection. An example might be resuscitation of a newborn at the borderline of viability. In their ethics education, beneficence would mean acting first to save a life. If the patient or surrogate makes an informed decision to the contrary, a beneficent physician respects that autonomous decision. In the case presented, the patient expressed gratitude to the cardiologist when extubated. But what if he had expressed anger at the physician for violating his autonomy? There are those who could argue that not only was intubation ethically wrong but that the cardiologist put himself in legal jeopardy by his actions (especially if there had been a written refusal applicable to the specific situation). In the example we use, we point out that the cardiologist may not have escaped a lawsuit if the patient had died without intubation. His family, when hearing the circumstances, may have sued for failure to act and dereliction of the cardiologist’s duty to save him. Beyond a potential legal challenge for either action or inaction, there is an overriding ethical question the cardiologist had to address: what course would be most satisfying to his conscience? Would he rather allow a patient to die for fear of recrimination, or act to save his life, regardless of the personal consequences? In the absence of real knowledge about the patient’s considered wishes, it is most reasonable to err on the side of promoting patient well-being. A physician’s commitment to beneficence is not necessarily a way of undermining a patient’s autonomy. In acting for the patient's good, physicians are also acting on what it is reasonable to believe a patient (or most patients, perhaps) would want, which is obviously connected to what a patient does want. Pellegrino and Thomasma argue that beneficence includes respect for a patient’s autonomy since “the best interests of the patient are intimately linked with their preferences.”[17] Instead of conceptualizing ethical dilemmas in medicine as conflicts between autonomy and beneficence, it is possible that medical schools could teach students that truly practicing beneficence is a way of valuing patient autonomy, especially when the patient’s wishes are not specific to the situation and are not clearly expressed. CONCLUSION It is important for students and practicing physicians to understand the principle of respect for patient autonomy in a pluralistic society that demands personal self-determination. However, the role of the physician as a beneficent healer should not be diminished by this respect for autonomy. Respecting a patient’s autonomy is grounded in and manifested by physician beneficence.[18] That is, seeking what is good for the patient can only be good if it respects their personhood and dignity. We propose that a commitment to beneficence, incipient in young medical students, should be developed over time with their other clinical reasoning skills. Such a commitment need not be sacrificed on the altar of patient autonomy. Beneficence needs greater relative moral weight with students as they proceed in their ethics education. - [1] S. Jauhar, “When Doctors Need to Lie,” New York Times, February 22, 2014, https://www.nytimes.com/2014/02/23/opinion/sunday/when-doctors-need-to-lie.html. [2] T. L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019). [3] Louise A. Mitchell, “Major Changes in Principles of Biomedical Ethics,” The National Catholic Bioethics Quarterly 14, no. 3 (2014): 459–75, https://doi.org/10.5840/ncbq20141438. [4] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019), 238. [5] Beauchamp and Childress, 103. [6] Beauchamp and Childress, p. 108. [7] For other accounts that prioritize autonomy, see e.g. Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of Surrogate Decision Making (Cambridge University Press, 1989), 38–39; R Gillon, “Ethics Needs Principles—Four Can Encompass the Rest—and Respect for Autonomy Should Be ‘First among Equals,’” Journal of Medical Ethics 29, no. 5 (October 2003): 307–12, https://doi.org/10.1136/jme.29.5.307. For examples of critiques of these accounts, see footnote 9. [8] P. R. Wolpe, “The Triumph of Autonomy in American Bioethics: A Sociological View,” in Bioethics and Society: Constructing the Ethical Enterprise, p. 43. [9] V. A. Entwistle et al., “Supporting Patient Autonomy: The Importance of Clinician-Patient Relationships,” Journal of General Internal Medicine 25, no. 7 (July 2010): 741–45; C. Foster, Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law, 1st ed. (Oxford ; Hart Publishing, 2009); O. O’Neill, Autonomy and Trust in Bioethics, The Gifford Lectures, University of Edinburgh 2001 (Cambridge, UK: Cambridge University Press, 2002). [10] P. Marshall and B. Koenig, “Accounting for Culture in a Globalized Bioethics,” The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics 32, no. 2 (2004): 252–66; R. Fan, “Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy,” Bioethics 11, no. 3–4 (1997): 309–22. [11] Arguments stressing the importance of beneficence, as ours does here, certainly approach paternalistic arguments. We set aside the complex issue of paternalism for purposes of this paper and simply note that the principle of beneficence as such does not say anything specifically about acting against the patient’s will. In the case study that focuses this paper, we do not believe the patient’s will or wishes were clearly indicated. [12] Beauchamp and Childress, Principles of Biomedical Ethics, p. 20, see note 2 above. [13] H. S. Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 25, no. 3 (January 1, 2000): 285–307, p. 287. [14] H. D. Braude, Intuition in Medicine a Philosophical Defense of Clinical Reasoning (Chicago ; University of Chicago Press, 2012). [15] R. Kukla, “Conscientious Autonomy: Displacing Decisions in Health Care,” The Hastings Center Report 35, no. 2 (2005): 34–44. [16] M. Schermer, The Different Faces of Autonomy: Patient Autonomy in Ethical Theory and Hospital Practice, vol. 13, Library of Ethics and Applied Philosophy (Dordrecht: Springer Netherlands, 2002). [17] E. D. Pellegrino and D. C. Thomasma, For the Patient’s Good - the Restoration of Beneficence in Health Care (New York, NY: Oxford University Press, 1988), p. 29. [18] Pellegrino and Thomasma, For the Patient’s Good. 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In the longstanding foundational debate whether to require that probability is countably additive, in addition to being finitely additive, those who resist the added condition raise two concerns that we take up in this paper. (1) _Existence_: Settings where no countably additive probability exists though finitely additive probabilities do. (2) _Complete Additivity_: Where reasons for countable additivity don’t stop there. Those reasons entail complete additivity—the (measurable) union of probability 0 sets has probability 0, regardless the cardinality of that union. Then (...) probability distributions are discrete, not continuous. We use Easwaran’s (Easwaran, Thought 2:53–61, 2013) advocacy of the _Comparative_ principle to illustrate these two concerns. Easwaran supports countable additivity, both for numerical probabilities and for finer, qualitative probabilities, by defending a condition he calls the _Comparative_ principle [ \({\mathcal{C}}\) ]. For numerical probabilities, principle \({\mathcal{C}}\) contrasts pairs, P 1 and P 2, defined over a common partition \(\prod\) = {a _i_ : _i_ ∈ I} of measurable events. \({\mathcal{C}}\) requires that no P 1 may be pointwise dominated, i.e., no (finitely additive) probability P 2 exists such that for each _i_ ∈ I, P 2 (a _i_ ) > P 1 (a _i_ ). By design, the cardinality of \(\prod\) is not limited in \({\mathcal{C}}\), which Easwaran asserts is important when arguing that the principle does not require more, or less, than that probability is countably additive. We agree that a numerical probability P satisfies principle \({\mathcal{C}}\) in all partitions just in case P is countably additive. However, we show that for numerical probabilities, by considering the size of the algebra of events to which probability is applied, principle \({\mathcal{C}}\) is subject to each of the above concerns, (1) and (2). Also, Easwaran considers principle \({\mathcal{C}}\) with non-numerical, qualitative probabilities, where a qualitative probability may be finer than an almost agreeing numerical probability P. A qualitative probability is regular if possible events are strictly more likely than impossible events. Easwaran motivates and illustrates regular qualitative probabilities using a continuous, almost agreeing quantitative probability that is uniform on the unit interval. We make explicit the conditions for applying principle \({\mathcal{C}}\) with qualitative probabilities and show that \({\mathcal{C}}\) restricts regular qualitative probabilities to those whose almost agreeing quantitative probabilities are completely additive. For instance, Easwaran’s motivating example of a regular qualitative probability is precluded by principle \({\mathcal{C}}\). (shrink)

ABSTRACTEvidence suggests that older adults experience greater emotional well-being compared to younger adults. Appraisal theories of emotion posit that differences in emotional experience are the...