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)

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)

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)

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)

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)

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)

Although interpretivists are right to give inner speech a central role in generating self-knowledge, they mischaracterize the precise nature of this role. Inner speech is fundamentally an action, a form of speech, and provides us with self-knowledge not by being something that we perceive (or “quasi-perceive”) and interpret, but by being something that we knowingly do. Once this is appreciated, interpretivism is undermined.

The four thoughtful commentaries on our feature article draw out interesting empirical and normative questions. The aim of our study was to examine the views of a sample of the general public about a set of cases of disputed treatment for severely impaired infants.1 We compared those views with legal determinations that treatment was or was not in the infants’ best interests, and with some published ethical frameworks for decisions. We deliberately did not draw explicit ethical conclusions from our survey (...) findings, both because of the acknowledged limitations of survey methodology, and because survey conclusions cannot, in themselves, yield answers about what the right threshold should be for providing or withholding treatment.2 In this brief response, we are going to address head-on the important ethical question raised within our survey – when life is worth living for an infant. We follow-up on the suggestion of two commentators that the presence or absence of “relational potential” might be ethically important to report in studies of the outcome of severely impaired infants,3 and to whether parental requests for treatment should be supported.4 The notion of “relational potential” was introduced by John Arras in a 1984 commentary.5 Arras was responding to the Baby Doe Regulations and a …. (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)

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 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)

Cladistic analyses are based on the distinction between primitive and derived character states (hypotheses of the polarity of evolutionary transformations) and a complete reliance on only derived character state distributions as bona fide evidence of holophyletic assemblages of taxa. The cladistic premise that only derived character state distributions provide evidence of holophyly is reconsidered and shown to be both unjustified and inconsistent with the desire or methodological prescription of using all the available evidence. Cladistic techniques are here viewed primarily as (...) methods for the ordering of character states so that they may be differentially weighted. The problem of assigning realistic differential weight to primitive and derived character state distributions is briefly discussed. One possible use of primitive character state distributions as evidence of holophyly that is largely free of the problem of weight is proposed. This application is illustrated with an example from the caecilian amphibians (Amphibia: Gymnophiona). (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)

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)

Mill's On Liberty is centrally concerned with avoiding social tyranny. But Mill's Principle of Liberty defines interfering, in the context of social pressure, as intentionally punishing and it seems to allow speech and actions that critics have thought would conflict with liberty in self-regarding matters. To critics, Mill draws distinctions among social influences where no genuine difference is to be found and he permits more social pressure than can be accepted by someone who values liberty highly. In this article, I (...) explain where and why Mill draws the line he does between permitted and forbidden influences and show the line is coherent and tracks a genuine difference. I also show that although the Principle leaves residual social pressure, Mill has resources besides the Principle that can prevent social influences that threaten individuality while retaining beneficial social influences. (shrink)

An attempt is made in this paper to analyze the purely formal nature of information-theoretic concepts. The suggestion follows that such concepts, used to supplement the logical and mathematical structure of the language of science, represent an addition to this language of such a sort as to allow the use of a unitary language for the description of phenomena. (The alternative to this approach must be certain multi-linguistic and mutually untranslatable descriptions of related phenomena, as with the various versions of (...) Complementarity). This conception is tested for the specific case of Heisenberg's Uncertainty Principle, in order to show that, with the assumption of a suitable and intuitively satisfactory definition of the quantity of information contained in a measurement, the Heisenberg Principle becomes an informational restriction arising from the formal properties of the symbols of a given language rather than as a "law" of nature. (shrink)

La concepción de Marcus sobre las creencias se aplica al debate centrado en la cuestión: "¿Son creencias los delirios?" Dos consecuencias que se siguen de ello son: i) que la cuestión "¿Son creencias los delirios?" necesita reformularse, y ii) que la respuesta es: "No, algunos pacientes que sufren delirios no creen lo que, "prima facie", parecen creer".

In his valuable contribution to the Fondation Hardt Entretiens of 1960 on Hesiod Professor La Penna dealt with the famous ‘theodicy of labour’ in Virgil, Georgics I. 118–59. He recalled that, whereas Hesiod made Prometheus' trickery the reason for Zeus' hiding fire and the other goods and so rendering labour necessary, Virgil omits mention of Prometheus or of any element of guilt.

> 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)

Just Health, by the well-known American philosopher Norman Daniels, has the ambitious goal of presenting 'an integrated theory of justice and population health, to address a set of theoretical and real-world challenges to that theory, and to demonstrate that the theory can guide our practice with regard to health both here and abroad.' Daniels's fundamental question is what we owe each other in the way of the protection and promotion of health. He thinks this is fruitfully dealt with by breaking (...) it down and answering three separate questions: (i) what is the moral importance of health? (ii) when are differences in health unjust? and (iii) how should we meet health needs fairly when we cannot meet them all? (shrink)

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

Robert Rupert argues against the view that human cognitive processes comprise elements beyond the boundary of the organism, developing a systems-based conception in place of this extended view. He also argues for a conciliatory understanding of the relation between the computational approach to cognition and the embedded and embodied views.

Transplantation is a medically successful and cost-effective way to treat people whose organs have failed--but not enough organs are available to meet demand. T. M. Wilkinson explores the major ethical problems raised by policies for acquiring organs. Key topics include the rights of the dead, the role of the family, and the sale of organs.

_Bodies for Sale: Ethics and Exploitation in the Human Body Trade _explores the philosophical and practical issues raised by activities such as surrogacy and organ trafficking. Stephen Wilkinson asks what is it that makes some commercial uses of the body controversial, whether the arguments against commercial exploitation stand up, and whether legislation outlawing such practices is really justified. In Part One Wilkinson explains and analyses some of the notoriously slippery concepts used in the body commodification debate, including exploitation, (...) harm and consent. In Part Two he focuses on three controversial issues outlining contemporary regulation and investigating both the moral issues and the arguments for legal prohibition. (shrink)