In his essay on paternalism and personal identity, Wilkinson draws on Derek Parfit’s Reasons and Persons (1984) to call for a reappraisal of the role of paternalism in healthcare decision-making in situations in which patients with capacity make decisions which are likely to have harmful consequences for themselves.1 The imperative to respect autonomy, coupled with JS Mill’s insistence that the state is justified in interfering with an individual’s liberty only in situations in which she harms or threatens to harm (...) another person, leaves clinicians with little room to constrain decisions in which a patient’s choice may seriously harm her. Parfit reduces personal identity to the continuity of psychological and physical traits across the lifecourse, and suggests that, since these sets of characteristics change significantly over time, it may make more sense to view a person at different time points as different ‘selves’, rather than as the same person. Parfit’s defence of paternalism involves arguing that, given this inevitable lack of continuity, causing harm to one’s future self is analogous to harming another person and that intervening to prevent this may be justifiable in accordance with the Harm Principle.2 The issue of personal identity has received considerable attention in the philosophical literature and it remains a vexed question. Parfit’s argument, along with the thought experiments on …. (shrink)

Is it ethical for doctors or courts to prevent patients from making choices that will cause significant harm to themselves in the future? According to an important liberal principle the only justification for infringing the liberty of an individual is to prevent harm to others; harm to the self does not suffice.In this paper, I explore Derek Parfit’s arguments that blur the sharp line between harm to self and others. I analyse cases of treatment refusal by capacitous patients and describe (...) different forms of paternalism arising from a reductionist view of personal identity. I outline an Identity Relative Paternalistic Intervention Principle for determining when we should disallow refusal of treatment where the harm will be accrued by a future self, and consider objections including vagueness and non-identity.Identity relative paternalism does not always justify intervention to prevent harm to future selves. However, there is a stronger ethical case for doing so than is often recognised. (shrink)

Mitochondrial replacement techniques have the potential to allow prospective parents who are at risk of passing on debilitating or even life-threatening mitochondrial disorders to have healthy children to whom they are genetically related. Ethical concerns have however been raised about these techniques. This article focuses on one aspect of the ethical debate, the question of whether there is any moral difference between the two types of MRT proposed: Pronuclear Transfer and Maternal Spindle Transfer. It examines how questions of identity impact (...) on the ethical evaluation of each technique and argues that there is an important difference between the two. PNT, it is argued, is a form of therapy based on embryo modification while MST is, instead, an instance of selective reproduction. The article's main ethical conclusion is that, in some circumstances, there is a stronger obligation to use PNT than MST. (shrink)

There are not enough solid organs available to meet the needs of patients with organ failure. Thousands of patients every year die on the waiting lists for transplantation. Yet there is one currently available, underutilized, potential source of organs. Many patients die in intensive care following withdrawal of life-sustaining treatment whose organs could be used to save the lives of others. At present the majority of these organs go to waste.In this paper we consider and evaluate a range of ways (...) to improve the number and quality of organs available from this group of patients. Changes to consent arrangements (for example conscription of organs after death) or changes to organ donation practice could dramatically increase the numbers of organs available, though they would conflict with currently accepted norms governing transplantation.We argue that one alternative, Organ Donation Euthanasia, would be a rational improvement over current practice regarding withdrawal of life support. It would give individuals the greatest chance of being able to help others with their organs after death. It would increase patient autonomy. It would reduce the chance of suffering during the dying process. We argue that patients should be given the choice of whether and how they would like to donate their organs in the event of withdrawal of life support in intensive care.Continuing current transplantation practice comes at the cost of death and prolonged organ failure. We should seriously consider all of the alternatives. (shrink)

Since 2000, 11 human uterine transplantation procedures (UTx) have been performed across Europe and Asia. Five of these have, to date, resulted in pregnancy and four live births have now been recorded. The most significant obstacles to the availability of UTx are presently scientific and technical, relating to the safety and efficacy of the procedure itself. However, if and when such obstacles are overcome, the most likely barriers to its availability will be social and financial in nature, relating in particular (...) to the ability and willingness of patients, insurers or the state to pay. Thus, publicly funded healthcare systems such as the UK9s National Health Service (NHS) will eventually have to decide whether UTx should be funded. With this in mind, we seek to provide an answer to the question of whether there exist any compelling reasons for the state not to fund UTx. The paper proceeds as follows. It assumes, at least for the sake of argument, that UTx will become sufficiently safe and cost-effective to be a candidate for funding and then asks, given that, what objections to funding there might be. Three main arguments are considered and ultimately rejected as providing insufficient reason to withhold funding for UTx. The first two are broad in their scope and offer an opportunity to reflect on wider issues about funding for infertility treatment in general. The third is narrower in scope and could, in certain forms, apply to UTx but not other assisted reproductive technologies (ARTs). The first argument suggests that UTx should not be publicly funded because doing so would be inconsistent with governments’ obligations to prevent climate change and environmental pollution. The second claims that UTx does not treat a disorder and is not medically necessary. Finally, the third asserts that funding for UTx should be denied because of the availability of alternatives such as adoption and surrogacy. (shrink)

It is argued that there are good reasons for believing that commercial surrogacy is often exploitative. However, even if we accept this, the exploitation argument for prohibiting (or otherwise legislatively discouraging) commercial surrogacy remains quite weak. One reason for this is that prohibition may well 'backfire' and lead to potential surrogates having to do other things that are more exploitative and/or more harmful than paid surrogacy. It is concluded, therefore, that those who oppose exploitation should concentrate on: (a) improving the (...) conditions under which paid surrogates 'work'; and (b) changing the background conditions (in particular, the unequal distribution of power and wealth) which generate exploitative relationships. (edited). (shrink)

Ethical discussions about medical treatment for seriously ill babies or children often focus on the ‘value of life’ or on ‘quality of life’ and what that might mean. In this paper, I look at the other side of the coin—on the value of death, and on the quality of dying. In particular, I examine whether there is such a thing as a good way to die, for an infant or an adult, and what that means for medical care. To do (...) that, I call on philosophy and on personal experience. However, I will also make reference to art, poetry and music. That is partly because the topic of mortality has long been reflected on by artists as well as philosophers and ethicists. It is also because, as we will see, there may be some useful parallels to draw. (shrink)

Care of the critically ill newborn includes support for the birth mother/parents with regular updates around the clinical condition of the baby, and involvement in discussions around complex decision-making issues. Discussions around continuation or discontinuation of life-sustaining are challenging even in the most straightforward of cases, but what happens when the birth mother is critically unwell? Such cases can lead to uncertainty around who should assume the parental role for these difficult discussions. In this round table discussion, we explore the (...) ethical, moral and legal uncertainties raised by coincident severe maternal and neonatal illness in the context of surrogacy. (shrink)

Imagine that we are considering whether our healthcare system (or insurer) should fund treatment or procedure X. One factor that may be cited is that of so-called ‘medical necessity’. The claim would be that treatment X should be eligible for funding if it is medically necessary, but ineligible if this does not apply. Similarly, (and relevant to the debates in this special issue), if considering whether a particular treatment should be ethically and/or legally permitted, we may wish to distinguish between (...) cases where the treatment is medically necessary, and those were it is not. But what do we mean by this concept? Here I will propose and briefly defend one plausible and practical definition. (shrink)

Why do people in more unequal societies have worse health and shorter lives than those in less unequal ones? Why do more unequal societies tend to have more violence and weaker community life? This paper discusses the research evidence on the psychosocial pathways which suggest how and why we are affected by inequality.How big income differences are in any society seems to serve as an indicator of the scale of social differentiation and social distances within it. The evidence shows that (...) more hierarchical societies incur a wide range of social costs reflecting the corrosive effects of inequality. But why are we so sensitive to inequality? Epidemiological research on health inequalities and the social determinants of health has demonstrated that the quality of the social environment has powerful effects on health. Particularly important are social status, friendship and early childhood experience. The indications are that poor health may share causal pathways with many other social problems associated with relative deprivation - including violence.Summarizing my recent book, The Impact of Inequality , this paper provides an account of how inequality gets under the skin to affect both health and wellbeing. Rather than making comparisons with some impractical state of complete equality, all the evidence presented shows the importance of the differences in inequality between different states of the USA or between different developed market democracies: it shows that even small increases in equality matter. (shrink)

Predictions of poor prognosis for critically ill patients may become self-fulfilling if life-sustaining treatment or resuscitation is subsequently withheld on the basis of that prediction. This paper outlines the epistemic and normative problems raised by self-fulfilling prophecies (SFPs) in intensive care. Where predictions affect outcome, it can be extremely difficult to ascertain the mortality rate for patients if all treatment were provided. SFPs may lead to an increase in mortality for cohorts of patients predicted to have poor prognosis, they may (...) lead doctors to feel causally responsible for the deaths of their patients, and they may compromise honest communication with patients and families about prognosis. However, I argue that the self-fulfilling prophecy is inevitable when life-sustaining treatment is withheld or withdrawn in the face of uncertainty. SFPs do not necessarily make treatment limitation decisions problematic. To minimize the effects of SFPs, it is essential to carefully collect and appraise evidence about prognosis. Doctors need to be honest with themselves and with patients and their families about uncertainty and the limits of knowledge. (shrink)

In this paper, we explore three separate questions that are relevant to assessing the prudential value of life in infants with severe life-limiting illness. First, what is the value or disvalue of a short life? Is it in the interests of a child to save her life if she will nevertheless die in infancy or very early childhood? Second, how does profound cognitive impairment affect the balance of positives and negatives in a child’s future life? Third, if the life of (...) a child with life-limiting illness is prolonged, how much suffering will she experience and can any of it be alleviated? Is there a risk that negative experiences for such a child will remain despite the provision of palliative care? We argue that both the subjective and objective components of well-being for children could be greatly reduced if they are anticipated to have a short life that is affected by profound cognitive impairment. This does not mean that their overall well-being will be negative, but rather that there may be a higher risk of negative overall well-being if they are expected to experience pain, discomfort, or distress. Furthermore, we point to some of the practical limitations of therapies aimed at relieving suffering, such that there is a risk that suffering will go partially or completely unrelieved. Taken together, these considerations imply that some life-prolonging treatments are not in the best interests of infants with severe life-limiting illness. (shrink)

This paper is about even in downward entailing contexts. Karttunen and Peters (1979) have shown that there are two different sets of implicatures of even in such contexts. They argue that the two sets of implicatures are derived by allowing even to take scope either higher or lower than a negative polarity licenser. Rooth (1985) argues that even is lexically ambiguous, that is, there is a negative polarity even. I argue against Rooth's ambiguity theory and show that within Rooth's theory (...) of focus, a scope theory of even has better empirical coverage. I also answer objections to the scope theory raised by Rooth (1985) and Karttunen and Karttunen (1977). (shrink)

In the case that triggered this round-table discussion there are three separate factors that contribute to moral uncertainty.1 First, the infant, baby T, is extremely premature with suspected brain injury and potentially poor prognosis. Second, the gestational mother is critically unwell herself and her outlook is guarded. Third, as linked commentaries make clear, the legal status of the intended parents is complex and ambiguous.2 3 Any of these factors on their own would be enough to generate ethical complexity and distress (...) in the neonatal intensive care unit. The combination of the three is likely to be highly stressful for all concerned.4 Commentaries on the case emphasise the complex legal questions and the potential need to involve the court. One resource that is not mentioned is the potential value of clinical ethics input in such a case. This is complementary to the need for legal advice. Its aim would be to help think through the specifically ethical, rather than legal questions. There are several things that I would aim to clarify if chairing a clinical ethics discussion on the case. First, it may be useful to draw on the concept of the …. (shrink)

Once the preserve of philosophy and theology, what Weber called `the problem of theodicy' - the problem of reconciling normative ideals with the reality in which we live - recurs in the social sciences in the secular form of `sociodicy'. Within a functionalist framework, sociodicies have offered legitimizing rationalizations of social adversities, inequalities and injustice, but seldom address the existential meaning and ethical implications of human affliction and suffering in social life. We suggest that an apparent indifference to these questions (...) in social theory reflects a deeper tension between modernity's millennial expectations of moral progress and the escalating history of violence, exploitation and suffering in the modern world. The task of sociodicy, we argue, should be reconstructed as a critique of the decivilizing implications of this tension, not just to document the consequences of suffering on people's lives, but in order to reassess the experience of modernity at the end of one of the most disturbed and violent centuries the world has known. (shrink)

If the discovery of life elsewhere in the universe is just around the corner, what would be the consequences for religion? Would it represent another major conflict between science and religion, even leading to the death of faith? Some would suggest that the discovery of any suggestion of extraterrestrial life would have a greater impact than even the Copernican and Darwinian revolutions. It is now over 50 years since the first modern scientific papers were published on the search for extraterrestrial (...) intelligence. Yet the religious implications of this search and possible discovery have never been systematically addressed in the scientific or theological arena. SETI is now entering its most important era of scientific development. New observation techniques are leading to the discovery of extra-solar planets daily, and the Kepler mission has already collected over 1000 planetary candidates. This deluge of data is transforming the scientific and popular view of the existence of extraterrestrial intelligence. Earth-like planets outside of our solar system can now be identified and searched for signs of life. Now is a crucial time to assess the scientific and theological questions behind this search. This book sets out the scientific arguments undergirding SETI, with particular attention to the uncertainties in arguments and the strength of the data already assembled. It assesses not only the discovery of planets but other areas such as the Fermi paradox, the origin and evolution of intelligent life, and current SETI strategies. In all of this it reflects on how these questions are shaped by history and pop culture and their relationship with religion, especially Christian theology. It is argued that theologians need to take seriously SETI and to examine some central doctrines such as creation, incarnation, revelation, and salvation in the light of the possibility of extraterrestrial life. (shrink)

Paternalist policies in public health often aim to improve people’s well-being by reducing their options, regulating smoking offering a prime example. The well-being challenge is to show that people really are better off for having their options reduced. The distribution challenge is to show how the policies are justified since they produce losers as well as winners. If we start from these challenges, we can understand the importance of the empirical evidence that a very high proportion of smokers regret smoking. (...) In short, it is important that they regret it and important that the proportion is so high. This paper explains how, philosophically, regret can relate to well-being and it considers some of the strengths and weakness in the empirical research that the explanation brings out. The regret case for regulating smoking is indeed strong, although not as strong as the empirical researchers think. It is much weaker for paternalistic intervention in other public health problems, such as obesity and binge drinking. (shrink)

The Theory Theory (TT) versus Simulation Theory (ST) debate is primarily concerned with how we understand others’ mental states. Theory theorists claim we do this using rules that are akin to theoretical laws, whereas simulation theorists claim we use our own minds to imagine ourselves in another’s position. Theorists from both camps suggest a consideration of individuals with autism spectrum disorders (ASD) can help resolve the TT/ST debate (e.g., Baron-Cohen 1995; Carruthers 1996a; Goldman 2006). We present a three-part argument that (...) such research has so far been inconclusive and that the prospects for studies of ASD to resolve the debate in the near future remain uncertain. First, we discuss evidence indicating that some individuals with ASD can perform effectively on tests of mental state understanding, which questions what ASD can tell us regarding theorising or simulation. Second, we claim that there is compelling evidence that domain-general mechanisms are implicated in mental state reasoning, which undermines how ASD might inform the TT/ST debate given that both theories appeal to domain-specific mindreading mechanisms. Third, we suggest that neuroscientific evidence for an assumed role of the mirror neuron system in autism also fails to arbitrate between TT and ST. We suggest that while the study of ASD may eventually provide a resolution to the TT/ST debate, it is also vital for researchers to examine the issues through other avenues, for example, by examining people’s everyday counterfactual reasoning with mental state scenarios. (shrink)

The experiences described in the VIP transcripts are incredibly varied and yet frequently explicitly labelled by participants as "voices." How can we make sense of this? If we reflect carefully on uses of the word "voice", we see that it can express at least two entirely different concepts, which pick out categorically different phenomena. One concept picks out a speech sound (e.g. "This synthesizer has a "voice" setting"). Another concept picks out a specific agent (e.g. "I hear two voices: one (...) is a ten year-old boy…"). This chapter explores how these two concepts are related to one another in the context of voice-hearing. (shrink)

Various philosophers accept moral views that are impartial, additive, and risk-neutral with respect to moral betterness. But, if that risk neutrality is spelt out according to expected value theory alone, such views face a dire reductio ad absurdum. If the expected sum of value in humanity's future is undefined--if, e.g., the probability distribution over possible values of the future resembles the Pasadena game, or a Cauchy distribution--then those views say that no option is ever better than any other. And, as (...) I argue, this holds in practice: our evidence supports such a probability distribution. Indeed, it supports a probability distribution that cannot be evaluated even if we adopt one of the various extensions of expected value theory proposed in the literature. Must we therefore reject all impartial, additive, risk-neutral moral theories? It turns out that we need not. I develop an alternative solution: a new method of extending expected value theory, which allows us to deal with this distribution and to salvage those moral views. I also examine how this solution affects one of the most notable implications of those views--namely, longtermism. (shrink)

This article is about the potential justification for deploying some form of affirmative action (AA) in the context of healthcare, and in particular in relation to the pandemic. We call this Affirmative Action in healthcare Resource Allocation (AARA). Specifically, we aim to investigate whether the rationale and justifications for using prioritization policies based on race in education and employment apply in a healthcare setting, and in particular to the COVID-19 pandemic. We concentrate in this article on vaccines and ventilators because (...) these are both highly scarce resources in the pandemic, and there has been a need to develop policies for allocating them. However, as will become clear, the ethical considerations relating to them may diverge. We first set out two rationales for AAs and what they might entail in a healthcare setting. We then consider some disanalogies between AA and AARA, as well as the different implications of AARA for allocating ventilators as opposed to vaccines. Finally, we consider some of the practical ways in which AARA could be implemented, and conclude by responding to some key objections. (shrink)

Radical feminism has critiqued heterosexuality both as a primary means through which people are constituted as women and as men, and as inherently oppressive for women. Two recent developments challenge this critique: the concept of “virgin” heterosexuality, a form of heterosexuality in which the performance of heterosexual sex, with or without sexual intercourse, is voluntarily chosen, and “queer” heterosexuality, a concept derived from postmodernist and queer theory, which does not only reinscribe, but also actively subverts and disrupts, oppressive categories of (...) gender and sexual orientation. This article analyzes the attempts made in “virgin” and “queer” theory to rehabilitate heterosexuality, and finds both fundamentally flawed from a radical feminist perspective. It ends by considering why such rehabilitatory attempts are currently being made, and what they reveal about heterosexuality. (shrink)

Covering both practical and theoretical aspects of strategic management, this three-volume work brings the complex topic down to earth and enables readers to gain competitive business advantages in their marketplace. This clear, insightful, and interesting work covers all aspects of strategic management, including chapters that discuss SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis, the Resource-Based View, transaction cost economics, and real options theory. Unlike other books, this three-volume work examines strategic management from different perspectives, effectively interweaving seemingly disparate subdisciplines, such (...) as entrepreneurship and international business, with specialized foci, such as creativity, innovation, and trust. Incorporating information from contributors as varied as a proprietor of a worldwide motorcycle business to one of the most published scholars in the field of international strategic management, the practical and theoretical perspectives presented in Strategic Management in the 21st Century will benefit business strategists, professors of strategic management, and graduate students in the field. (shrink)

> この道や行く人なしに秋の暮れ Matsuo Basho 16941 The surface is asymmetrical, the pigment flecked and uneven. Looking close, what seems at a distance to be smooth is actually covered in tiny gentle indentations and irregularities. On one edge, there are a series of fine lines—evidence of past damage, and repair. It is obviously old. But its age is part of its specialness. It is simple, one of a kind, beautiful. The above is a description of a Japanese stoneware tea bowl, like the (...) one in figure 1, embodying an aesthetic dating back to at least the 16th century called wabi-sabi (侘び寂び). Figure 1 Wabi-sabi tea bowl. ottmarliebert.com from Santa Fe, Turtle Island, CC BY-SA 2.0 via Wikimedia Commons. Wabi-sabi is famously difficult to translate, but derives from the words wabi 侘– indicating austerity, simplicity, the quiet life and sabi 寂—indicating maturity, solitude, naturalness. Wabi-sabi refers to the aesthetic appreciation of natural imperfection and impermanence.2 It is embodied in a tradition of handmade pottery, sometimes including repair of past breaks with gold inlay (kintsugi). But it is also reflected in stone gardens, in bonsai, in haiku, and some forms of the Japanese tea ceremony. What, you might ask, does this have to do with medicine? Pottery and aesthetics seem a long way from pathology and medical ethics. First, some …. (shrink)

This article critically investigates the presumption that we are living in a qualitatively new `age of anxiety'. It suggests that most sociologists who address this topic have so far failed to recognize the analytical complexity of the condition of anxiety itself. By examining the possibility of establishing sociological indicators of the prevalence and character of anxiety in contemporary societies, the author argues that the `sociological imagination' has yet to provide a sufficient account of the interrelationship between representations of social problems (...) in the public sphere and the variety of anxieties which individuals may encounter in their `personal troubles of milieu'. (shrink)

Bioethics, Volume 36, Issue 7, Page 809-811, September 2022.

BioDwelling is an arts-led research project that brings ethical concerns of culture, gender and multispecies relationality from the feminist technosciences into direct conversation with the emerging field of biotechnological architecture (bio-architecture). Working within a multi-disciplinary bio-architecture research group, we develop a practice-led methodology to facilitate the exploration of questions that arise when we begin to engineer more-than-human dwelling spaces. In this article we give a brief overview of the work of the Hub for Biotechnology in the Built Environment (HBBE) and (...) the Responsible Interactions research theme, which outlines the project context. We go on to describe the BioDwelling methodology and introduce three arts-led interventions that draw on feminist science and cultural theory to invite reflections on the ethical implications of working with living materials to build (or grow?) spaces in which humans intend to live. We conclude with a summary of the project to date, reflections on methods and possible next steps. (shrink)

Doctors’ strikes are legally permissible in the UK, with the situation differing in other countries. But are they morally permissible? Doug McConnell and Darren Mann have systematically attempted to dismiss the arguments for the moral impermissibility of doctors’ strikes and creatively attempted to provide further moral justification for them. Unfortunately for striking doctors, they fail to achieve this. Meanwhile, junior doctors’ strikes have continued in the UK through 2023 and have now extended into 2024. In this response, which focuses on (...) the UK situation and specifically junior doctors’ strikes in the National Health Service (NHS) in England, I will demonstrate a central problem with their arguments—namely that they underplay the harms caused by prolonged doctors’ strikes by ignoring the harms to patients with cancer. This weakens their conclusion that strikes are morally permissible in terms of the conditions and thresholds they set. I then provide a psychological critique of their justification for strikes in terms of the interests of the public. It follows that invoking the controversial concept of supererogatory action is ungrounded but also absurd when you consider time-critical cancer care. If those representing striking doctors wish to maintain a modicum of moral respectability, they should mitigate for patients with cancer and negotiate reasonably and with urgency. (shrink)