Physicians generally recommend that patients resuscitated with naloxone after opioid overdose stay in the emergency department for a period of observation in order to prevent harm from delayed sequelae of opioid toxicity. Patients frequently refuse this period of observation despiteenefit to risk. Healthcare providers are thus confronted with the challenge of how best to protect the patient’s interests while also respecting autonomy, including assessing whether the patient is making an autonomous choice to refuse care. Previous studies have shown that physicians (...) have widely divergent approaches to navigating these conflicts. This paper reviews what is known about the effects of opioid use disorder on decision-making, and argues that some subset of these refusals are non-autonomous choices, even when patients appear to have decision making capacity. This conclusion has several implications for how physicians assess and respond to patients refusing medical recommendations after naloxone resuscitation. (shrink)

It is argued that Nuyen's objectivist perspective on the method of the natural sciences is misleading, failing to capture its primary feature: maintaining a separation between two levels--a level takes as observations and data and a level taken as conceptually integrated theory--and at the same time working between these two levels in a manner that draws them together. Appropriately articulated this feature gives a perspective that (i) sees in the natural sciences an essential relation between knower and known similar to (...) that attributed by Nuyen to the human sciences; and (ii) specifies the function of generalization in the natural sciences in a manner that specifies crucial questions challenging Nuyen's contrast of the natural and human sciences. (shrink)

Causal models have proven extremely useful in offering formal representations of causal relationships between a set of variables. Yet in many situations, there are non-causal relationships among variables. For example, we may want variables LDL, HDL, and TOT that represent the level of low-density lipoprotein cholesterol, the level of lipoprotein high-density lipoprotein cholesterol, and total cholesterol level, with the relation LDL+HDL=TOT. This cannot be done in standard causal models, because we can intervene simultaneously on all three variables. The goal of (...) this paper is to extend standard causal models to allow for constraints on settings of variables. Although the extension is relatively straightforward, to make it useful we have to define a new intervention operation that disconnects a variable from a causal equation. We give examples showing the usefulness of this extension, and provide a sound and complete axiomatization for causal models with constraints. (shrink)

Scientific models describe natural phenomena at different levels of abstraction. Abstract descriptions can provide the basis for interventions on the system and explanation of observed phenomena at a level of granularity that is coarser than the most fundamental account of the system. Beckers and Halpern (2019), building on work of Rubenstein et al. (2017), developed an account of abstraction for causal models that is exact. Here we extend this account to the more realistic case where an abstract causal model offers (...) only an approximation of the underlying system. We show how the resulting account handles the discrepancy that can arise between low- and high-level causal models of the same system, and in the process provide an account of how one causal model approximates another, a topic of independent interest. Finally, we extend the account of approximate abstractions to probabilistic causal models, indicating how and where uncertainty can enter into an approximate abstraction. (shrink)

As autonomous systems rapidly become ubiquitous, there is a growing need for a legal and regulatory framework to address when and how such a system harms someone. There have been several attempts within the philosophy literature to define harm, but none of them has proven capable of dealing with with the many examples that have been presented, leading some to suggest that the notion of harm should be abandoned and "replaced by more well-behaved notions". As harm is generally something that (...) is caused, most of these definitions have involved causality at some level. Yet surprisingly, none of them makes use of causal models and the definitions of actual causality that they can express. In this paper we formally define a qualitative notion of harm that uses causal models and is based on a well-known definition of actual causality (Halpern, 2016). The key novelty of our definition is that it is based on contrastive causation and uses a default utility to which the utility of actual outcomes is compared. We show that our definition is able to handle the examples from the literature, and illustrate its importance for reasoning about situations involving autonomous systems. (shrink)

We consider a sequence of successively more restrictive definitions of abstraction for causal models, starting with a notion introduced by Rubenstein et al. (2017) called exact transformation that applies to probabilistic causal models, moving to a notion of uniform transformation that applies to deterministic causal models and does not allow differences to be hidden by the "right" choice of distribution, and then to abstraction, where the interventions of interest are determined by the map from low-level states to high-level states, and (...) strong abstraction, which takes more seriously all potential interventions in a model, not just the allowed interventions. We show that procedures for combining micro-variables into macro-variables are instances of our notion of strong abstraction, as are all the examples considered by Rubenstein et al. (shrink)

Book Review. . ???aop.label???. doi: 10.1080/00048402.2014.929720.

Anti-luck epistemology is an approach to analyzing knowledge that takes as a starting point the widely-held assumption that knowledge must exclude luck. Call this the anti-luck platitude. As Duncan Pritchard (2005) has suggested, there are three stages constituent of anti-luck epistemology, each which specifies a different philosophical requirement: these stages call for us to first give an account of luck; second, specify the sense in which knowledge is incompatible with luck; and finally, show what conditions must be satisfied in order (...) to block the kind of luck with which knowledge was argued to be incompatible. What I’ll show here is that the modal account of luck offers a plausible story at the first stage and leads naturally to equally plausible lines to take at the second and third stages, at which a safety condition on knowledge is squarely motivated. There are, however, recent challenges—advanced by Jonathan Kvanvig (Philosophy and Phenomenological Research 77: 272–281, 2008); Kelly Becker (2007); and Jennifer Lackey (Australasian Journal of Philosophy 86(2):255–267, 2008), among others—to the plausibility of the safety-based anti-luck project I’ve sketched here at each of its three stages of development. Once I’ve made precise the challenges, I’ll show why none implies that we abandon the commitments of the safety-based anti-luck project at any of its stages. What we should conclude, then, is that a safety-condition on knowledge is motivated by independently defensible accounts of (1) what luck is; and (2) just how knowledge should be thought incompatible with it. (shrink)

I propose to analyze the concept of basing beliefs on reasons. The concept is an important one in understanamg the so-called "inferential" or "indirect" knowledge. After briefly stating the causal analyses of this concept given by D.M. Armstrong and Marshall Swain I will present two cases which show these analyses to be too strong and too weak. Finally, I will propose an analysis which avoids these twin difficulties.

I propose to analyze the concept of basing beliefs on reasons. The concept is an important one in understanamg the so-called "inferential" or "indirect" knowledge. After briefly stating the causal analyses of this concept given by D.M. Armstrong and Marshall Swain I will present two cases which show these analyses to be too strong and too weak. Finally, I will propose an analysis which avoids these twin difficulties.

Biomedical engineering technologies such as brain–machine interfaces and neuroprosthetics are advancements which assist human beings in varied ways. There are exciting yet speculative visions of how the neurosciences and bioengineering may influence human nature. However, these could be preparing a possible pathway towards an enhanced and even posthuman future. This article seeks to investigate several ethical themes and wider questions of enhancement, transhumanism and posthumanism. Four themes of interest are: autonomy, identity, futures, and community. Three larger questions can be asked: (...) will everyone be enhanced? Will we be “human” if we are not, one day, transhuman? Should we be enhanced or not? The article proceeds by concentrating on a widespread and sometimes controversial application: the cochlear implant, an auditory prosthesis implanted into Deaf patients. Cochlear implantation and its reception in both the deaf and hearing communities have a distinctive moral discourse, which can offer surprising insights. The paper begins with several points about the enhancement of human beings, transhumanism’s reach beyond the human, and posthuman aspirations. Next it focuses on cochlear implants on two sides. Firstly, a shorter consideration of what technologies may do to humans in a transhumanist world. Secondly, a deeper analysis of cochlear implantation’s unique socio-political movement, its ethical explanations and cultural experiences linked with pediatric cochlear implantation—and how those wary of being thrust towards posthumanism could marshal such ideas by analogy. As transhumanism approaches, the issues and questions merit continuing intense analysis. (shrink)

This book covers the issue of tyranny and freedom. Included are selections from Hobbes, Rousseau, Jefferson, Machiavelli, Sophocles, Aristotle, Locke, Montesquieu, Madison, Calhoun, Plato, Milton, Mill, Tocqueville, Douglass, Chief Joseph, Thoreau, King, Arendt, and Holocaust documents. Co-published with Lynchburg College.

Van Leeuwen’s Religion as Make-Believe, A Theory of Belief, Imagination, and Group Identity argues that religious and political beliefs are fundamentally different from mundane, factual beliefs and represent a cognitive attitude more akin to imagining. To ground this difference, Van Leeuwen proposes four principles defining factual beliefs: ‘involuntariness’ mandates that people cannot choose what they believe; ‘no compartmentalization’ says that factual – but not religious – beliefs guide behavior in all domains; ‘cognitive governance’ requires that inferences be readily drawn from (...) factual beliefs; ‘evidential vulnerability' entails that beliefs are revised given contradictory evidence. While factual beliefs are supposed to meet these standards, Van Leeuwen marshals evidence that religious and tribal beliefs – or “credences” – fail to obey these four principles. In this commentary, I argue that beliefs – both factual and religious – are often much more complicated than Van Leeuwen assumes. This complexity makes perfect conformity to the four principles unlikely, even for factual beliefs. I review Van Leeuwen’s evidence for credences and suggest that this evidence is compatible with the null hypothesis: that religious beliefs are simply beliefs. (shrink)

The root of any system of economic theory is the theory of price. But while modern Austrian economists have put a great deal of effort and ingenuity into building up the superstructure of their discipline since the mid-1970s, they have paid scant attention to ensuring that the price theory supporting the edifice is a sound and settled doctrine. The result is that, for many current Austrians, price theory is a “dynamic” version of neoclassical price theory. More precisely, it is Chicago (...) price theory with a theory of entrepreneurship and of competition as a rivalrous process grafted onto it. This ad hoc approach to Austrian price theory thus relies heavily on the analytical tools and techniques developed by Alfred Marshall, Frank Knight, and Jacob Viner. George Stigler later elaborated these individual contributions into a systematic price theory.The prevailing approach almost completely ignores the fact that there exists an alternative “causal-realist” tradition of price theory that was founded by Carl Menger and developed by his followers both in Austria and abroad. These include especially Böhm-Bawerk, J.B. Clark, Frank Fetter, Herbert Davenport, Philip Wicksteed, and Ludwig von Mises. The causal-realist tradition, which is explicitly anti-Marshallian and anti-Stiglerian, maintained a shadowy presence in Austrian economics for most of the postwar period. It is only in recent years that some Austrian economists, seeking a sound price theory to sure up the foundations of their discipline, have explicitly recognized and embraced it.Israel M. Kirzner’s neglected book, Market Theory and the Price System, which was first published in 1963 and reprinted in a new edition this year, was the first and only systematic attempt to marry Stiglerian price theory with elements of the causal-realist tradition. Murray N. Rothbard, who had already reformulated and significantly advanced the causal-realist tradition in his own treatise Man, Economy, and State, wrote a comprehensive and quite critical referee report on Kirzner’s book manuscript for the publisher in 1961. His comments have never been published before.This article contains two parts. The first part is a response to certain claims and omissions made by Peter J. Boettke and Frédéric Sautet, the editors of the new edition of Kirzner’s book. The second part contains Rothbard’s report on the book as a supporting document for the arguments of the first part. By proceeding in this way the goal is to clarify the important issues at stake for Austrian price theory. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Ill HUME ON THE MORALITY OF PRINCES "There is a maxim very current in the world," says Hume (Treatise III, ii, sec. 11) "that there is a system of morals calculated for princes, much more free than that which ought to govern private persons. " He interprets the maxim to mean that "the morality of princes... has not the same force as that of private persons, and may lawfully (...) be transgress 'd from a more trivial motive." And he gives as an example: "we must necessarily give a greater indulgence to a prince or minister, who deceives another; than to a private gentleman, who breaks his word of honour" (T 569). This passage, cryptic though it is, makes Hume sound bad. He seems to be a cynic, or a skeptic, or an immoralist, with respect to the morality of nations. Does he think that princes have a special right to act immorally? Even worse is the reason he gives: international relations just don't matter very much, he says. And the chapter in question is not just a self-contained essay more or less tacked on to the Treatise. Hume tries to connect it integrally with his theory of justice. The point of the chapter is not to put forward a view about the morality of international relations (a view Hume himself admits may be found shocking), but to demonstrate the power of the theory of justice by showing how the "maxim current in the world" can be defended upon the theory's principles. The passage has not won approval from recent commentators. One, Marshall Cohen, labels Hume a "moderate skeptic" with regard to international morality and argues vehemently that Hume's position 2 should be condemned as immoral. Cohen, who thinks that there is only one system of morality and that it 112 applies "with equal force to princes and private persons," evidently thinks any system weakening ordinary standards is immoral by definition. He traces Hume's allegedly morally flawed views to what he regards as a deep flaw in Hume's moral theory, namely, his conventionalism. J. L. Mackie and Jonathan Harrison are both considerably more sympathetic to Hume's general position, but nevertheless are critical of the chapter in question. They agree with Hume's observation that international morality is weaker than private. (Harrison points out that people tend to regard breaches of private morality as more serious than breaches of international morality: "A minister may be dismissed for sexual misconduct, although he breaks solemn treaties with other nations with impunity." But, contrary to Hume, they find this weakness deplorable, Harrison arguing that, given the relative amount of harm princes do, the indulgence allowed them is irrational. Harrison in fact at first agrees with Hume: "He is right, too, in suggesting that the obligations of nations to be just in their dealings with one another is [sic] of less force than the obligations of private persons." But after ten pages he has evidently changed his mind: "[with respect to] what Hume says about the comparative force of the morality of princes and the morality of private persons, though it is clear that there is nothing in principle wrong with Hume's view that the former has less force than the latter... it is doubtful whether he is right in saying that the former do in fact have less force than the latter." Like Cohen, who holds that "Injustice among nations should be regarded as being as reprehensible as injustice among individuals," Harrison concludes (more tentatively than Cohen) "my 113 own feeling... is that though Hume is right in thinking that the morality of princes is commonly regarded as being of less force than private morality, he is wrong... in thinking that... they [sic] are of less force." So none of our commentators agree with Hume that international morality not only is, but is properly, weaker than domestic. How did Hume go wrong? Hume argues that international morality is weaker because the interests at stake are less. Where the interests at stake do not matter very much, Hume thinks, it is not so important what people do, and thus the moral obligations involved are weaker. (Hume thinks this idea... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Ill HUME ON THE MORALITY OF PRINCES "There is a maxim very current in the world," says Hume (Treatise III, ii, sec. 11) "that there is a system of morals calculated for princes, much more free than that which ought to govern private persons. " He interprets the maxim to mean that "the morality of princes... has not the same force as that of private persons, and may lawfully (...) be transgress 'd from a more trivial motive." And he gives as an example: "we must necessarily give a greater indulgence to a prince or minister, who deceives another; than to a private gentleman, who breaks his word of honour" (T 569). This passage, cryptic though it is, makes Hume sound bad. He seems to be a cynic, or a skeptic, or an immoralist, with respect to the morality of nations. Does he think that princes have a special right to act immorally? Even worse is the reason he gives: international relations just don't matter very much, he says. And the chapter in question is not just a self-contained essay more or less tacked on to the Treatise. Hume tries to connect it integrally with his theory of justice. The point of the chapter is not to put forward a view about the morality of international relations (a view Hume himself admits may be found shocking), but to demonstrate the power of the theory of justice by showing how the "maxim current in the world" can be defended upon the theory's principles. The passage has not won approval from recent commentators. One, Marshall Cohen, labels Hume a "moderate skeptic" with regard to international morality and argues vehemently that Hume's position 2 should be condemned as immoral. Cohen, who thinks that there is only one system of morality and that it 112 applies "with equal force to princes and private persons," evidently thinks any system weakening ordinary standards is immoral by definition. He traces Hume's allegedly morally flawed views to what he regards as a deep flaw in Hume's moral theory, namely, his conventionalism. J. L. Mackie and Jonathan Harrison are both considerably more sympathetic to Hume's general position, but nevertheless are critical of the chapter in question. They agree with Hume's observation that international morality is weaker than private. (Harrison points out that people tend to regard breaches of private morality as more serious than breaches of international morality: "A minister may be dismissed for sexual misconduct, although he breaks solemn treaties with other nations with impunity." But, contrary to Hume, they find this weakness deplorable, Harrison arguing that, given the relative amount of harm princes do, the indulgence allowed them is irrational. Harrison in fact at first agrees with Hume: "He is right, too, in suggesting that the obligations of nations to be just in their dealings with one another is [sic] of less force than the obligations of private persons." But after ten pages he has evidently changed his mind: "[with respect to] what Hume says about the comparative force of the morality of princes and the morality of private persons, though it is clear that there is nothing in principle wrong with Hume's view that the former has less force than the latter... it is doubtful whether he is right in saying that the former do in fact have less force than the latter." Like Cohen, who holds that "Injustice among nations should be regarded as being as reprehensible as injustice among individuals," Harrison concludes (more tentatively than Cohen) "my 113 own feeling... is that though Hume is right in thinking that the morality of princes is commonly regarded as being of less force than private morality, he is wrong... in thinking that... they [sic] are of less force." So none of our commentators agree with Hume that international morality not only is, but is properly, weaker than domestic. How did Hume go wrong? Hume argues that international morality is weaker because the interests at stake are less. Where the interests at stake do not matter very much, Hume thinks, it is not so important what people do, and thus the moral obligations involved are weaker. (Hume thinks this idea... (shrink)

(No abstract is available for this citation).

In Smith’s view, the dédoublement that structures any act of sympathy is internalized and doubled within the self. In endeavoring to “pass sentence” upon one’s own conduct, Smith writes, “I divide myself, as it were, into two persons; and … I, the examiner and judge, represent a different character from that other I, the person whose conduct is examined into and judged of” . Earlier in his book, Smith claims that in imagining someone else’s sentiments, we “imagine ourselves acting the (...) part” of that person ; here he pictures us trying to play ourselves by representing ourselves as two different characters. “The first,” writes Smith, “is the spectator, whose sentiments with regard to my own conduct I endeavour to enter into, by placing myself in his situation.” The second character, according to Smith, is “the agent, the person whom I properly call myself, and of whose conduct, under the character of a spectator, I was endeavouring to form some opinion” . In the version of this chapter that appeared in the first edition, Smith made these roles explicitly by stating that “we must imagine ourselves not the actors, but the spectators of our own character and conduct” . In his final exposition, he makes it clear that we are both actors and spectators of our characters. We are actors not just because we appear before spectators played by ourselves but also because, as Smith describes, we personate ourselves in different parts, persons, and characters. The self is theatrical in its relation to others and in its self-conscious relation to itself; but it also enters the theater because “the person whom I properly call myself” must be the actor who can dramatize or represent to himself the spectacle of self-division in which the self personates two different persons who try to play each other’s part, change positions, and identify with each others. Ironically, after founding his Theory of Moral Sentiments on a supposedly universal principle of sympathy, and then structuring the act of sympathy around the epistemological void that prevents people from sharing each other’s feelings, Smith seems to separate the self from the one self if could reasonably claim to know: itself. In order to sympathize with ourselves, we must imagine ourselves as an other who looks upon us as an other and tries to imagine us. Indeed, calling the spectator within the self the person judged of, Smith writes, “but that the judge should, in every respect, be the same with the person judged of, is as impossible, as that the cause should in every respect, be the same with the effect” . Thus the actor and spectator into which one divides oneself can never completely identify with each other or be made identical. Identity is itself undermined by the theatrical model which pictures the self as an actor who stands beside himself and represents the characters of both spectator and spectacle.14 14. Smith’s depiction of the impartial spectator and the relations it creates within the self suggest that he has been reading Shaftesbury. The characterization of the impartial spectator as the “man within the breast” recalls Joseph Butler’s discussion of “the witness of conscience” in his sermons “Upon the Natural Supremacy of Conscience” . Hume discusses the moral value of considering how we appear in the eyes of those who regard us: “By our continual and earnest pursuit of a character, a reputation in the world, we bring our own deportment and conduct frequently in review, and consider how they appear in the eyes of those who approach and regard us. This constant habit of surveying ourselves, as it were, in reflection, keeps alive al the sentiments of right and wrong” . It is Shaftesbury, however, who expounds a “doctrine of two persons in one individual self” as he presents his “dramatic method” …. The terms and figures of theater are clearly inscribed within Smith’s characterizations of sympathy and the impartial spectator but they are clearly informed by Shaftesbury’s meditation on the dramatic character of the self and the problem of theatricality that threatens the self as it appears before the eyes of the world. This interpretation of Shaftesbury is developed at length in my The Figure of Theater. David Marshall, assistant professor of English and comparative literature at Yale University, has written on Rilke and Shakespeare. The present essay is adapted from a chapter of his forthcoming book, The Figure of Theater: Shaftesbury, Defoe, Adam Smith, and George Eliot. (shrink)

William Sidney Allen, 1918B2004 George Wishart Anderson, 1913B2002 Albinia Catherine de la Mare, 1932B2001 John Stanton Flemming, 1941B2003 Patrick Gardiner James William Harris, 1940B2004 John Gilbert Hurst, 1927B2003 Casimir Lewy, 1919B1991 George Donald Alastair MacDougall, 1912B2004 Henry Colin Gray Matthew, 1941B1999 Edward Miller, 1915B2000 Michio Morishima, 1923B2004 William Brian Reddaway, 1913B2002 Marjorie Ethel Reeves, 1905B2003 Charles Martin Robertson, 1911B2004 Conrad Sebastian Robert Russell, 1937B2004 Arnold Joseph Taylor, 1911B2002 Kathleen Mary Tillotson, 1906B2001 Glanmor Williams, 1920-2005.

Stephen Nickell: Practical Issues in UK Monetary Policy, 2000-2005 Alan C Dessen: Staging Matters: Shakespeare, the Director, and the Theatre Historian Lord Bingham of Cornhill: The Judges: Active or Passive? Marilyn Strathern: Useful Knowledge Jane Stabler: Byron, Conversation and Discord Keith Wrightson: Mutualities and Obligations: Changing Social Relationships in Early Modern England Carlo Ginzburg: Dante's Epistle to Cangrande and its Two Authors Colin Renfrew: Becoming Human: the Archaeological Challenge Lothar von Falkenhausen: The Inscribed Bronzes from Yangjiacun: New Evidence on Social (...) Structure and Historical Consciousness in Late Western Zhou China Joseph Koerner: Everyman in Motion: from Bosch to Bruegels and Notes on Lectures. (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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The importance of legal epidemiology in public health law research has undoubtedly grown over the last five years. Scholars and practitioners together have developed guidance on best practices for the field, including: placing emphasis on transdisciplinary collaborations; creating valid, reliable, and repeatable research; and publishing timely products for use in decision-making and change. Despite the energy and expertise researchers have brought to this important work, they name significant challenges in marshalling the diverse skill sets, quality controls, and funding to implement (...) legal epidemiology activities. The Centers for Disease Control and Prevention has worked to develop cross-cutting research and translation on issues of national priority in legal epidemiology, and has explored ways to overcome some of these challenges. As such, this article describes a case study of the use of law to characterize states' prior authorization policies regarding medication used to treat attention-deficit/hyperactivity disorder, a central component of a broader effort to improve behavior therapy options for young children with ADHD. This article highlights the types of legal epidemiology work we have undertaken, the application of this work to an emerging public health problem, and the lessons learned in creating impactful research for the field. (shrink)

Theories of discourse bring to realism new ideas about how knowledge develops and how representations of reality are influenced. We gain an understanding of the conceptual aspect of social life and the processes by which meaning is produced. This collection reflects the growing interest realist critics have shown towards forms of discourse theory and deconstruction. The diverse range of contributions address such issues as the work of Derrida and deconstruction, discourse theory, Eurocentrism and poststructuralism. What unites all of the contributions (...) is a sense that it is essential to provide a realist alternative to the hitherto dominance of social constructionism, hermeneutics and postmodernism, over many of the issues discussed. By developing a realist perspective the different authors attempt to embed discourse within the structured nature of the reality of the world. Realism can situate language, discourse and ideology within context specific, or 'causally efficacious' circumstances. Realism can help to uncover issues of power, representation, and subjectivity and how discursive and other social practices produce real effects. This can help us understand the manner in which social structures are reproduced through various forms of ideology and discourse. And by knowing this, we can start to address questions concerning human emancipation and how the world is to be transformed. (shrink)

Topics covered in Discrete Mathematics have become essential tools in many areas of studies in recent years. This is primarily due to the revolution in technology, communications, and cyber security. The book treats major themes in a typical introductory modern Discrete Mathematics course: Propositional and predicate logic, proof techniques, set theory (including Boolean algebra, functions and relations), introduction to number theory, combinatorics and graph theory. An accessible, precise, and comprehensive approach is adopted in the treatment of each topic. The ability (...) of abstract thinking and the art of writing valid arguments are emphasized through detailed proof of (almost) every result. Developing the ability to think abstractly and roguishly is key in any areas of science, information technology and engineering. Every result presented in the book is followed by examples and applications to consolidate its comprehension. The hope is that the reader ends up developing both the abstract reasoning as well as acquiring practical skills. All efforts are made to write the book at a level accessible to first-year students and to present each topic in a way that facilitates self-directed learning. Each chapter starts with basic concepts of the subject at hand and progresses gradually to cover more ground on the subject. Chapters are divided into sections and subsections to facilitate readings. Each section ends with its own carefully chosen set of practice exercises to reenforce comprehension and to challenge and stimulate readers. As an introduction to Discrete Mathematics, the book is written with the smallest set of prerequisites possible. Familiarity with basic mathematical concepts (usually acquired in high school) is sufficient for most chapters. However, some mathematical maturity comes in handy to grasp some harder concepts presented in the book. (shrink)

What a person is doing often depends on that person’s thought about what they are doing, or about the wider circumstances of their action. For example, whether my killing is murder or manslaughter depends, in part, on whether I understand that what I am doing is killing you, and on whether I understand that my killing is unjustified. Similarly, if I know that the backpack I am taking is yours, then my taking it may be an act of theft; but (...) it is not theft if I simply mistook your backpack for my own. And if I don’t know that in signing a document I’m promising to do some thing, then in signing it I’m not promising to do this at all. -/- According to Elizabeth Anscombe, a central task of philosophical psychology is to articulate this dependency of action on thought. And in a range of papers published during the 1960s, Anscombe sought to elucidate various aspects of this dependency. In this paper we give a systematic overview of how Anscombe understands this dependency, and in the process reveal the conceptual framework underlying Anscombe’s thinking about perception, desire, intention, voluntariness, responsibility, guilt, and sin. (shrink)

Dan Marshall and Josh Parsons note, correctly. that the property of being either a cube or accompanied by a cube is incorrectly classified as intrinsic under the definition we have given unless it turns out to be disjunctive. Whether it is disjunctive, under the definition we gave, turns on certain judgements of the relative naturalness of properties. They doubt the judgements of relative naturalness that would classify their property as disjunctive. We disagree. They also suggest that the whole idea (...) of judging relative naturalness is a dubious business. We reply that, like them or not, such judgements cannot easily be avoided. (shrink)

In a recent study, Becker and Elliott [Becker, C., & Elliott, M. A. . Flicker induced color and form: Interdependencies and relation to stimulation frequency and phase. Consciousness & Cognition, 15, 175–196] described the appearance of subjective experiences of color and form induced by stimulation with intermittent light. While there have been electroencephalographic studies of similar hallucinatory forms, brain activity accompanying the appearance of hallucinatory colors was never measured. Using a priming procedure where observers were required to indicate (...) the presence of one of eight target colors we compared electrophysiological correlates of hallucinatory color with brain states associated with other visual phenomena. Different target colors were accompanied by different patterns of EEG activation. However, in general, we found that the appearance of hallucinatory colors is preceded by a power decrease in the lower alpha band alongside an increase in gamma band frequencies. We argue that decreasing activity in the lower alpha band acts as a gating mechanism, inducing a switch in perception between different colors. The increasing gamma activation may correlate with the formation of a coherent conscious percept. (shrink)

I describe a realist, ontologically objective interpretation of probability, "far-flung frequency (FFF) mechanistic probability". FFF mechanistic probability is defined in terms of facts about the causal structure of devices and certain sets of frequencies in the actual world. Though defined partly in terms of frequencies, FFF mechanistic probability avoids many drawbacks of well-known frequency theories and helps causally explain stable frequencies, which will usually be close to the values of mechanistic probabilities. I also argue that it's a virtue rather than (...) a failing of FFF mechanistic probability that it does not define single-case chances, and compare some aspects of my interpretation to a recent interpretation proposed by Strevens. (shrink)

Organisms' environments are thought to play a fundamental role in determining their fitness and hence in natural selection. Existing intuitive conceptions of environment are sufficient for biological practice. I argue, however, that attempts to produce a general characterization of fitness and natural selection are incomplete without the help of general conceptions of what conditions are included in the environment. Thus there is a "problem of the reference environment"—more particularly, problems of specifying principles which pick out those environmental conditions which determine (...) fitness. I distinguish various reference environment problems and propose solutions to some of them. While there has been a limited amount of work on problems concerning what I call "subenvironments", there appears to be no earlier work on problems of what I call the "whole environment". The first solution I propose for a whole environment problem specifies the overall environment for natural selection on a set of biological types present in a population over a specified period of time. The second specifies an environment relevant to extinction of types in a population; this kind of environment is especially relevant to certain kinds of long-term evolution. (shrink)

One controversy about the existence of so called evolutionary forces such as natural selection and random genetic drift concerns the sense in which such “forces” can be said to interact. In this paper I explain how natural selection and random drift can interact. In particular, I show how population-level probabilities can be derived from individual-level probabilities, and explain the sense in which natural selection and drift are embodied in these population-level probabilities. I argue that whatever causal character the individual-level probabilities (...) have is then shared by the population-level probabilities, and that natural selection and random drift then have that same causal character. Moreover, natural selection and drift can then be viewed as two aspects of probability distributions over frequencies in populations of organisms. My characterization of population-level probabilities is largely neutral about what interpretation of probability is required, allowing my approach to support various positions on biological probabilities, including those which give biological probabilities one or another sort of causal character. ‡This paper has benefited from feedback on and discussions of this and earlier work. I want to thank André Ariew, Matt Barker, Lindley Darden, Patrick Forber, Nancy Hall, Mohan Matthen, Samir Okasha, Jeremy Pober, Robert Richardson, Alex Rosenberg, Eric Seidel, Denis Walsh, and Bill Wimsatt. †To contact the author, please write to: Department of Philosophy, University of Alabama at Birmingham, HB 414A, 900 13th Street South, Birmingham, AL 35294-1260; e-mail: [email protected]. (shrink)

It has been argued that biological fitness cannot be defined as expected number of offspring in all contexts. Some authors argue that fitness therefore merely satisfies a common schema or that no unified mathematical characterization of fitness is possible. I argue that comparative fitness must be relativized to an evolutionary effect; thus relativized, fitness can be given a unitary mathematical characterization in terms of probabilities of producing offspring and other effects. Such fitnesses will sometimes be defined in terms of probabilities (...) of effects occurring over the long term, but these probabilities nevertheless concern effects occurring over the short term. †To contact the author, please write to: Department of Philosophy, University of Alabama at Birmingham, HB 414A, 900 13th Street South, Birmingham, AL 35294‐1260; e‐mail: [email protected]. (shrink)

Citing a lifelong engagement with Marxism, critic and writer Marshall Berman reveals the movement's positive points and suggests a new beginning for Marxism may be on the horizon with its recent 150th anniversary attention.