Liver transplantation is the treatment of choice for many forms of liver disease. Unfortunately, the scarcity of cadaveric donor livers limits the availability of this technique. To improve the availability of liver transplantation, surgeons have developed the capability of removing a portion of liver from a live donor and transplanting it into a recipient. A few liver transplants using living donors have been performed worldwide.Our purpose was to analyze the ethics of liver transplants using living donors and to propose guidelines (...) for the procedure before it was introduced in the United States. We used a process of research ethics consultation that involves a collaboration between clinical investigators and clinical ethicists. We concluded that it was ethically appropriate to perform liver transplantation using living donors in a small series of patients on a trial basis, and we published our ethical guidelines in a medical journal before the procedure was introduced. We recommend this prospective, public approach for the introduction of other innovative therapies in medicine and surgery. (shrink)

There are some paradoxes in the way doctors and patients make medical decisions today. Today's patients are more empowered than were patients in the past. They have the right to see their medical records. The law requires doctors to obtain their informed consent for treatment. Patients are told about the options for treatment and the risks and benefits of each option. Their values and preferences are elucidated in order to guide the treatments that are provided.

As I write this, in November 1971, people are dying in East Bengal from lack of food, shelter, and medical caxc. The suffering and death that are occurring there now axe not inevitable, 1101; unavoidable in any fatalistic sense of the term. Constant poverty, a cyclone, and a civil war have turned at least nine million people into destitute refugees; nevertheless, it is not beyond Lhe capacity of the richer nations to give enough assistance to reduce any further suffering to (...) very small proportions. The decisions arid actions of human beings can prevent this kind of suffering. Unfortunately, human beings have not made the necessary decisions. At the individual level, people have, with very few exceptions, not responded to the situation in any signihczmt way. Generally speaking, people have not given large sums to relief funds; they have not written t0 their parliamentaxy representatives demanding increased government assistance; they have not demonstrated in the streets, held symbolic fasts, or done anything else directed toward providing thc refugees with the means to satisfy their essential needs. At thc government level, no govcrmmcnt has given the sort of massive aid that would enable the refugees to survive fm: more than a few days. Britain, for instance, has given rather more than most countries. It has, to date, given £14,750,000. For comparative purposes, B1~itain’s share of thc nonreccverabla development costs of the Anglo-French Concorde project is already in excess of £275,000,000, and on present estimates will reach £440,000,¤00. The implication is that the British government values a supersonic transport more than thirty times as.. (shrink)

Spceial Care explores the moral and legal issues in neonatal intensive care. It is an urgently needed entry in the current discussions of treatment for badly damaged babies.

In current American medical practice, autonomy is assumed to be more valuable than human life: if a patient autonomously refuses lifesaving treatment, the doctors are supposed to let him die. In this paper we discuss two values that might be at stake in such clinical contexts. Usually, we hear only of autonomy and best interests. However, here, autonomy is ambiguous between two concepts—concepts that are tied to different values and to different philosophical traditions. In some cases, the two values (that (...) of agency and that of authenticity) entail different outcomes. We argue that the comparative value of these values needs to be assessed. (shrink)

I am currently caring for a child named Priscilla who is ventilator-dependent and whose care confronted me with questions of justice. Priscilla was born at the County Hospital after a normal pregnancy to a 17-year-old single mother. At birth, she was noted to have some dysmorphic features: widely spaced eyes, low-set ears, and a cleft palate. Her chest X-ray showed hypoplastic ribs and scapulae. Her chromosome studies were normal. Eventually, a diagnosis of a rare dwarfing syndrome campomelic dysplasia – was (...) made. (shrink)

There is an inconsistency in the ways that doctors make clinical decisions regarding the treatment of babies born extremely prematurely. Many experts now recommend that clinical decisions about the treatment of such babies be individualized and consider many different factors. Nevertheless, many policies and practices throughout Europe and North America still appear to base decisions on gestational age alone or on gestational age as the primary factor that determines whether doctors recommend or even offer life-sustaining neonatal intensive care treatment. These (...) policies are well intentioned. They aim to guide doctors and parents to make decisions that are best for the baby. That is an ethically appropriate goal. But in relying so heavily on gestational age, such policies may actually do the babies a disservice by denying some babies treatment that might be beneficial and lead to intact survival. In this paper, we argue that such policies are unjust to premature babies and ought to be abolished. In their place, we propose individualized treatment decisions for premature babies. This would treat premature babies as we treat all other patients, with clinical decisions based on an individualized estimation of likelihood that treatment would be beneficial. (shrink)

This paper argues that a set of questioning attitudes are among the foundations of human and animal minds. While both verbal questioning and states of curiosity are generally explained in terms of metacognitive desires for knowledge or true belief, I argue that each is better explained by a prelinguistic sui generis type of mental attitude of questioning. I review a range of considerations in support of such a proposal and improve on previous characterizations of the nature of these attitudes. I (...) then broaden their explanatory scope to include a number of forms of exploratory search. The paper has three main goals: to characterize the nature of the questioning attitudes, outlining their causal role and type of content; to argue that they are fundamental components of the mind, being widespread among animals and not constructed during ontogeny out of other attitudes; and to suggest that they explain a great deal more behavior than one might think. (shrink)

Since its original publication in 1975, this groundbreaking work has awakened millions of people to the existence of "speciesism"—our systematic disregard of nonhuman animals—inspiring a worldwide movement to transform our attitudes to animals and eliminate the cruelty we inflict on them. In Animal Liberation, author Peter Singer exposes the chilling realities of today’s "factory farms" and product-testing procedures—destroying the spurious justifications behind them, and offering alternatives to what has become a profound environmental and social as well as moral issue. (...) An important and persuasive appeal to conscience, fairness, decency, and justice, it is essential reading for the supporter and the skeptic alike. (shrink)

We propose a solution to the problem of logical omniscience in what we take to be its fundamental version: as concerning arbitrary agents and the knowledge attitude per se. Our logic of knowledge is a spin-off from a general theory of thick content, whereby the content of a sentence has two components: an intension, taking care of truth conditions; and a topic, taking care of subject matter. We present a list of plausible logical validities and invalidities for the logic of (...) knowledge per se for arbitrary agents, and isolate three explanatory factors for them: the topic-sensitivity of content; the fragmentation of knowledge states; the defeasibility of knowledge acquisition. We then present a novel dynamic epistemic logic that yields precisely the desired validities and invalidities, for which we provide expressivity and completeness results. We contrast this with related systems and address possible objections. (shrink)

Many states prohibit patients from appointing their physicians as health care proxies, fearing paternalism and conflict of interest. But the potential for conflict is not unique to physicians, and patients may have compelling reasons to prefer that their doctor make decisions on their behalf. Managing potential conflicts serves patients better than denying them the right to choose who will make health care decisions for them when they are no longer competent.

The growth of managed care was accompanied by concern about the impact that changes in health care organization would have on the doctor-patient relationship. We now are in a “post-managed care era,” where some of these changes in health care delivery have come to pass while others have not. A re-examination of the DPR in this setting suggests some surprising results. Rather than posing a new and unprecedented threat, managed care was simply the most recent of numerous strains on the (...) DPR that have occurred throughout the century. These strains are a constant, inevitable consequence of the varying needs and concerns of patient and physicians as they seek to balance their desires for a certain type of DPR with their simultaneous desire for other aspects of care such as lower costs, greater technological sophistication, and improved outcomes. (shrink)

Single-premise epistemic closure is the principle that: if one is in an evidential position to know that P where P entails Q, then one is in an evidential position to know that Q. In this paper, I defend the viability of opposition to closure. A key task for such an opponent is to precisely formulate a restricted closure principle that remains true to the motivations for abandoning unrestricted closure but does not endorse particularly egregious instances of closure violation. I focus (...) on two brands of epistemic theory that naturally incorporate closure restrictions. The first type holds that the truth value of a knowledge ascription is relative to a relevant question. The second holds that the truth value of a knowledge ascription is relative to a relevant topic. For each approach, I offer a formalization of a leading theory from the literature and use this formalization to evaluate the theory’s adequacy in terms of a precise set of desiderata. I conclude that neither theory succeeds in meeting these desiderata, casting doubt on the viability of the underlying approaches. Finally, I offer a novel variant of the topic-sensitive approach that fares better. (shrink)

Collection of essays on the connection between medicine and literature and how novelists and physicians are both, in a sense, diagnosticians; the book focuses, in particular, on Walker Percy, a writer who had trained as a pathologist.

Introduction These essays have been written over a period of about ten years and have already been published separately in various places. ...

Equipoise is an essential condition to justify a clinical trial. The term, describes a state of uncertainty: the data suggest but do not prove a drug's safety and efficacy The only way to resolve this uncertainty is further study In many cases, a clinical trial seems to be the most efficient way to prove safety and efficacy Equipoise is therefore not an esoteric philosophic construct applied to research ethics. Rather, since it is vital for the justification of clinical trials, it (...) is part of how society regulates medical progress. Where there is equipoise, drug design and development proceeds according to Food and Drug Administration and Health and Human Services regulations. When that equipoise ends, a drug is either not approved or becomes standard care. (shrink)

I lay out the framework for my theory of sensory imagination in “Imagining as a guide to possibility.” Sensory imagining involves mental imagery , and crucially, in describing the content of imagining, I distinguish between qualitative content and assigned content. Qualitative content derives from the mental image itself; for visual imaginings, it is what is “pictured.” For example, visually imagine the Philadelphia Eagles defeating the Pittsburgh Steelers to win their first Super Bowl. You picture the greenness of the field and (...) the football’s brown oblong shape. Some of what you imagine isn’t explicitly pictured, however. That it is Sunday, that it is the Super Bowl: these facts are assigned. (shrink)

Political decisions have the potential to greatly impact our lives. Think of decisions in relation to abortion or climate change, for example. This makes political legitimacy an important normative concern. But what makes political decisions legitimate? Are they legitimate in virtue of having support from the citizens? Democratic conceptions of political legitimacy answer in the affirmative. Such conceptions righly highlight that legitimate political decision-making must be sensitive to disagreements among the citizens. But what if democratic decisions fail to track what (...) there is most reason to do? What if a democratically elected government fails to take measures necessary to protect its population from threats related to climate change? Peter argues that the legitimacy of political decisions doesn't just depend on respect for the citizens' will; and defends a novel hybrid conception of political legitimacy, called the Epistemic Accountability conception. According to this conception, political legitimacy also depends on how political decision-making responds to evidence for what there is most reason to do. Grounds for Political Legitmacy starts with an overview of the main ways in which philosophers have thought about political legitimacy, and identifies the epistemic accountability conception as an overlooked alternative. It then develops the epistemic accountability conception of political legitimacy and discusses its implications for legitimate political decision-making. Considering the norms that should govern political debate, it examines the role of experts in politics, and probes the responsibilities of democratically elected political leaders and as well as of citizens. (shrink)

Most bioethicists and professional medical societies condemn the practice of ?slow codes.? The American College of Physicians ethics manual states, ?Because it is deceptive, physicians or nurses should not perform half-hearted resuscitation efforts (?slow codes?).? A leading textbook calls slow codes ?dishonest, crass dissimulation, and unethical.? A medical sociologist describes them as ?deplorable, dishonest and inconsistent with established ethical principles.? Nevertheless, we believe that slow codes may be appropriate and ethically defensible in situations in which cardiopulmonary resuscitation (CPR) is likely (...) to be ineffective, the family decision makers understand and accept that death is inevitable, and those family members cannot bring themselves to consent or even assent to a do-not-resuscitate (DNR) order. In such cases, we argue, physicians may best serve both the patient and the family by having a carefully ambiguous discussion about end-of-life options and then providing resuscitation efforts that are less vigorous or prolonged than usual. (shrink)

Many scientists and doctors hope that affordable genome sequencing will lead to more personalized medical care and improve public health in ways that will benefit children, families, and society more broadly. One hope in particular is that all newborns could be sequenced at birth, thereby setting the stage for a lifetime of medical care and self‐directed preventive actions tailored to each child's genome. Indeed, commentators often suggest that universal genome sequencing is inevitable. Such optimism can come with the presumption that (...) discussing the potential limits, cost, and downsides of widespread application of genomic technologies is pointless, excessively pessimistic, or overly cautious. We disagree. Given the pragmatic challenges associated with determining what sequencing data mean for the health of individuals, the economic costs associated with interpreting and acting on such data, and the psychosocial costs of predicting one's own or one's child's future life plans based on uncertain testing results, we think this hope and optimism deserve to be tempered.In the analysis that follows, we distinguish between two reasons for using sequencing: to diagnose individual infants who have been identified as sick and to screen populations of infants who appear to be healthy. We also distinguish among three contexts in which sequencing for either diagnosis or screening could be deployed: in clinical medicine, in public health programs, and as a direct‐to‐consumer service. Each of these contexts comes with different professional norms, policy considerations, and public expectations. Finally, we distinguish between two main types of genome sequencing: targeted sequencing, where only specific genes are sequenced or analyzed, and whole‐exome or whole‐genome sequencing, where all the DNA or all the coding segments of all genes are sequenced and analyzed.In a symptomatic newborn, targeted or genome‐wide sequencing can help guide other tests for diagnosis or for specific treatment that is urgently needed. Clinicians use the infant's symptoms (or phenotype) to interrogate the sequencing data. These same complexities and uncertainties, however, limit the usefulness of genome‐wide sequencing as a population screening tool. While we recognize considerable benefit in using targeted sequencing to screen for or detect specific conditions that meet the criteria for inclusion in newborn screening panels, use of genome‐wide sequencing as a sole screening tool for newborns is at best premature. We conclude that sequencing technology can be beneficially used in newborns when that use is nuanced and attentive to context. (shrink)

Many babies with trisomy 13 and 18 die in the first year of life. Survivors all have severe cognitive impairment. There has been a debate among both professionals and parents about whether it is appropriate to provide life-sustaining interventions to babies with these serious conditions. On one side of the debate are those who argue that there is no point in providing invasive, painful, and expensive procedures when the only outcomes are either early death or survival with severe cognitive impairment. (...) Others suggest that, although mortality is high and cognitive impairment universal, babies with these conditions have an acceptable quality of life. In this paper, we will discuss both points of view. We will review the ways in which these conditions are portrayed in pediatrics textbooks and on social media sites that offer support to parents. We will then suggest an appropriate way to deal with clinical decisions for babies with these trisomies. (shrink)

In at least some cases of justified perceptual belief, our perceptual experience itself, as opposed to beliefs about it, evidences and thereby justifies our belief. While the phenomenon is common, it is also mysterious. There are good reasons to think that perceptions cannot justify beliefs directly, and there is a significant challenge in explaining how they do. After explaining just how direct perceptual justification is mysterious, I considerMichael Huemers (Skepticism and the Veil of Perception, 2001) and Bill Brewers (Perception and (...) Reason, 1999) recent, but radically different, attempts to eliminate it. I argue that both are unsuccessful, though a consideration of their mistakes deepens our appreciation of the mystery. (shrink)

This book offers a reassessment of the political philosophy of the British Idealists, a group of once influential and now neglected nineteenth-century Hegelian philosophers, whose work has been much misunderstood. Peter Nicholson focuses on F. H. Bradley's idea of morality and moral philosophy; T. H. Green's theory of the Common Good, of the social nature of rights, of freedom, and of state interference; and Bernard Bosanquet's notorious theory of the General Will. By examining the arguments offered by the Idealists (...) and by their critics the author is able to penetrate the deep layers of hostile comment laid down by several generations of later writers and to show that these ideas, once properly understood, are not only defensible but interesting and important. (shrink)

In the Western world it is usually taken as given that we all want happiness, and our educational arrangements tacitly acknowledge this. Happiness, Hope, and Despair argues, however, that education has an important role to play in deepening our understanding of suffering and despair as well as happiness and joy. Education can be uncomfortable, unpredictable, and unsettling; it can lead to greater uncertainty and unhappiness. Drawing on the work of Søren Kierkegaard, Miguel de Unamuno, Fyodor Dostoevsky, Simone Weil, Paulo Freire, (...) and others, Peter Roberts shows why these features of educational life need not be feared; to the contrary, they can be seen as a source of hope and human fulfilment. After years of negotiating an education system dominated by the language of competition, performance, and economic advancement, students and teachers often long for something different; they seek not just measurable success but also opportunities to ask searching questions of themselves and the world they encounter. Happiness, Hope, and Despair makes an important contribution toward meeting this need. It fosters a rethinking of the nature, purpose, and value of education, and opens up possibilities for further scholarly and professional inquiry. (shrink)

Dominic Wilkinson suggests that one of Schubert’s songs has relevance for neonatologists today. In the song, Schubert suggests that death sometimes comes as a friend. Wilkinson ponders whether the song has a message for doctors and parents, who sometimes struggle to figure out whether death is an enemy or a friend to a dying baby. Wilkinson reflects on the case of baby ‘Hal’, who was born with serious cardiomyopathy. Hal’s parents and doctors disagree about whether to withdraw life-support. Through his (...) recreations of their discussions, Wilkinson shows how hard it is to confront—and maybe even welcome—death for a child. While adults often frame their own decision to forego life-sustaining treatment with thoughts that they have lived a good life, death in childhood can seem unfair because it robs the child of their opportunity to live a good or completed life. Much as we try, we cannot really imagine what a critically ill neonate experiences or desires. We have very little insight into Hal’s interests or subjective experience. Without direct access to the child’s experience, it is impossible to know whether, like an adult, a child would choose to allow death to occur. We cannot verify the claim that the child’s death was good in the sense that it was good for them. Wilkinson proposes that a prolonged dying process …. (shrink)

What is ethics? Where do moral standards come from? Are they based on emotions, reason, or some innate sense of right and wrong? For many scientists, the key lies entirely in biology---especially in Darwinian theories of evolution and self-preservation. But if evolution is a struggle for survival, why are we still capable of altruism? In his classic study The Expanding Circle, Peter Singer argues that altruism began as a genetically based drive to protect one's kin and community members but (...) has developed into a consciously chosen ethic with an expanding circle of moral concern. Drawing on philosophy and evolutionary psychology, he demonstrates that human ethics cannot be explained by biology alone. Rather, it is our capacity for reasoning that makes moral progress possible. In a new afterword, Singer takes stock of his argument in light or recent research on the evolution of morality.--Publisher's description. (shrink)

Our topic is the theory of topics. My goal is to clarify and evaluate three competing traditions: what I call the way-based approach, the atom-based approach, and the subject-predicate approach. I develop criteria for adequacy using robust linguistic intuitions that feature prominently in the literature. Then I evaluate the extent to which various existing theories satisfy these constraints. I conclude that recent theories due to Parry, Perry, Lewis, and Yablo do not meet the constraints in total. I then introduce the (...) issue-based theory—a novel and natural entry in the atom-based tradition that meets our constraints. In a coda, I categorize a recent theory from Fine as atom-based, and contrast it to the issue-based theory, concluding that they are evenly matched, relative to our main criteria of adequacy. I offer tentative reasons to nevertheless favour the issue-based theory. (shrink)

This book presents and evaluates the late philosophy (Spätphilosophie) of F. W. J. Schelling (1775-1854) across a wide range of issues, ranging from relation between pure thinking and being, to the philosophy of mythology and religion, to the philosophy of history, to questions concerning the philosophy of nature and freedom. Simultaneously, it discusses Hegel's treatment of similar issues, and systematically compares the two thinkers. This is the first time, in an English-language publication, that these two major German Idealists have been (...) compared in such detail along such a broad front. The book begins with three chapters exploring the development of Schelling's thinking concerning transcendental philosophy, nature and teleology, human freedom, and the theory of history, from his earliest publications up to his middle years. Against this background, the book then presents Schelling's distinction between "positive" and "negative" philosophy, the defining mark of his late philosophy. It explores his theory of pure a priori thinking (negative philosophy), and his account of the transition from negative to positive philosophy. The major components of Schelling's positive philosophy, including his conception of "un-pre-thinkable being", and his theories of mythology and revelation, are then discussed. Throughout, a comparative assessment of Hegel's approach similar issues is sustained. Schelling emerges as a philosopher who traced his own highly distinctive path through the thicket of problems bequeathed by Kant, and whose systematic responses to these problems still merit serious consideration as alternatives to those of Hegel. (shrink)

This is the first volume of a projected three-volume set on the subject of innateness. The extent to which the mind is innate is one of the central questions in the human sciences, with important implications for many surrounding debates. By bringing together the top nativist scholars in philosophy, psychology, and allied disciplines these volumes provide a comprehensive assessment of nativist thought and a definitive reference point for future nativist inquiry. The Innate Mind: Structure and Content, concerns the fundamental architecture (...) of the mind, addressing such question as: What capacities, processes, representations, biases, and connections are innate? How do these innate elements feed into a story about the development of our mature cognitive capacities, and which of them are shared with other members of the animal kingdom? The editors have provided an introduction giving some of the background to debates about innateness and introducing each of the subsequent essays, as well as a consolidated bibliography that will be a valuable reference resource for all those interested in this area. The volume will be of great importance to all researchers and students interested in the fundamental nature and powers of the human mind. Together, the three volumes in the series will provide the most intensive and richly cross-disciplinary investigation of nativism ever undertaken. They point the way toward a synthesis of nativist work that promises to provide a new understanding of our minds and their place in the natural order. (shrink)

The Surfactant, Positive Pressure, and Oxygenation Randomized Trial (SUPPORT) has been the focal point of many different criticisms regarding the ethics of the study ever since publication of the trial's findings in 2010 and 2012. In this article, we focus on a concern that the technical design and implementation details of the study were ethically flawed. While the federal Office Human Research Protections focused on the consent form, rather than on the study design and implementation, OHRP's critiques of the consent (...) form reveal views about the study design and implementation that we believe are fundamentally flawed. These criticisms about the design and implementation of SUPPORT, if generalized, become relevant concerns about these aspects of many comparative effectiveness research studies.Our analytical approach will be to use SUPPORT as a prime example of comparative effectiveness research and show why it challenges some prevailing assumptions about the riskiness of research. We will address five aspects of the study design and implementation: 1) randomization, 2) treatment by protocol, 3) choice of endpoints, 4) lack of a “standard care” control group, and 5) the use of altered oximeters. Examining these aspects will allow us to answer two specific central questions. The first is a methodological question with ethical implications: was the study designed in such a way as to answer the primary study question? The second question is whether the study design added or decreased risk to the babies enrolled in the study compared to babies who were not in the study. (shrink)

Epistemic defeat is standardly understood in either evidentialist or responsibilist terms. The seminal treatment of defeat is an evidentialist one, due to John Pollock, who famously distinguishes between undercutting and rebutting defeaters. More recently, an orthogonal distinction due to Jennifer Lackey has become widely endorsed, between so-called doxastic (or psychological) and normative defeaters. We think that neither doxastic nor normative defeaters, as Lackey understands them, exist. Both of Lackey’s categories of defeat derive from implausible assumptions about epistemic responsibility. Although Pollock’s (...) evidentialist view is superior, the evidentialism per se can be purged from it, leaving a general structure of defeat that can be incorporated in a reliabilist theory that is neither evidentialist nor responsibilist in any way. (shrink)

Equipoise is an essential condition to justify a clinical trial. The term, describes a state of uncertainty: the data suggest but do not prove a drug's safety and efficacy The only way to resolve this uncertainty is further study In many cases, a clinical trial seems to be the most efficient way to prove safety and efficacy Equipoise is therefore not an esoteric philosophic construct applied to research ethics. Rather, since it is vital for the justification of clinical trials, it (...) is part of how society regulates medical progress. Where there is equipoise, drug design and development proceeds according to Food and Drug Administration and Health and Human Services regulations. When that equipoise ends, a drug is either not approved or becomes standard care. (shrink)

In the mid-seventeenth century a movement of self-styled experimental philosophers emerged in Britain. Originating in the discipline of natural philosophy amongst Fellows of the fledgling Royal Society of London, it soon spread to medicine and by the eighteenth century had impacted moral and political philosophy and even aesthetics. Early modern experimental philosophers gave epistemic priority to observation and experiment over theorising and speculation. They decried the use of hypotheses and system-building without recourse to experiment and, in some quarters, developed a (...) philosophy of experiment. The movement spread to the Netherlands and France in the early eighteenth century and later impacted Germany. Its important role in early modern philosophy was subsequently eclipsed by the widespread adoption of the Kantian historiography of modern philosophy, which emphasised the distinction between rationalism and empiricism and had no place for the historical phenomenon of early modern experimental philosophy. The re-emergence of interest in early modern experimental philosophy roughly coincided with the development of contemporary x-phi and there are some important similarities between the two. (shrink)

Explores how to identify future-proof science. Peter Vickers takes a transdisciplinary approach in his analysis of 'scientific fact' in order to defend science against potentially dangerous scepticism.