A single Sanskrit commentary exists for the Caṇḍamahāroṣaṇatantra—the Padmāvatī of Mahāsukhavajra—the only palm-leaf witness of which is preserved in a late thirteenth-century manuscript in Kathmandu. The tantra is relatively late, unmentioned outside Nepal, and the only in-depth study to date examines only the first eight of its twenty five chapters. No study or edition of the Padmāvatī exists. Here we present the first edition and translation of a complete chapter, the sixth paṭala, a section dealing mainly with transgressive sexual practices. (...) Some of the ideas and pragmatic details presented by the author, Mahāsukhavajra, are unique in Vajrayāna literature. (shrink)

In this paper, I will argue that there is a version of possibilism—inspired by the modal analogue of Kit Fine’s fragmentalism—that can be combined with a weakening of actualism. The reasons for analysing this view, which I call Modal Fragmentalism, are twofold. Firstly, it can enrich our understanding of the actualism/possibilism divide, by showing that, at least in principle, the adoption of possibilia does not correspond to an outright rejection of the actualist intuitions. Secondly, and more specifically, it can enrich (...) our understanding of concretism, by proving that, at least in principle, the idea that objects have properties in an absolute manner is compatible with transworld identity. (shrink)

In this essay, we suggest practical ways to shift the framing of crisis standards of care toward disability justice. We elaborate on the vision statement provided in the 2010 Institute of Medicine (National Academy of Medicine) “Summary of Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations,” which emphasizes fairness; equitable processes; community and provider engagement, education, and communication; and the rule of law. We argue that interpreting these elements through disability justice entails a commitment to both (...) distributive and recognitive justice. The disability rights movement's demand “Nothing about us, without us” requires substantive inclusion of disabled people in decision‐making related to their interests, including in crisis planning before, during, and after a pandemic like Covid‐19. (shrink)

Gils-Schmidt and Salloch recognise that human and climate health are inextricably linked, and that mitigating healthcare-associated climate harms is essential for protecting human health.1 They argue that physicians have a duty to consider how their own practices contribute to climate change, including during their interactions with patients. Acknowledging the potential for conflicts between this duty and the provision of individual patient care, they propose the application of Korsgaard’s neo-Kantian account of practical identities to help navigate such scenarios. In this commentary, (...) we argue that by focusing attention on this physician–patient level, the authors overlook the complexity of climate change, both within the healthcare sector and beyond. We recognise the importance of individual agency in tackling this issue, and we also recognise that the authors do briefly acknowledge the importance of considering these broader complexities; however, we emphasise the need for climate and health discussions/action to be situated in a wider framework of systemic change. Our concern is that overemphasis on patient-level interactions risks normalising the prioritisation of individual-level approaches to addressing climate change, detracting from such a broader approach. Physician training emphasises the need for trust, confidentiality and shared decision-making in the doctor–patient relationship. …. (shrink)

The COVID-19 (Coronavirus disease of 2019) pandemic has led to intense conversations about ventilator allocation and reallocation during a crisis standard of care. Multiple voices in the media and multiple state guidelines mention reallocation as a possibility. Drawing upon a range of neuroscientific, phenomenological, ethical, and sociopolitical considerations, the authors argue that taking away someone’s personal ventilator is a direct assault on their bodily and social integrity. They conclude that personal ventilators should not be part of reallocation pools and that (...) triage protocols should be immediately clarified to explicitly state that personal ventilators will be protected in all cases. (shrink)

On the life and philosophy of Ramana Maharshi and his views on Advaita and epistemology.

This article challenges the association between realist methodology and ideals of legitimacy. Many who seek a more “realistic” or “political” approach to political theory replace the familiar orientation towards a state of justice with a structurally similar orientation towards a state of legitimacy. As a result, they fail to provide more reliable practical guidance, and wrongly displace radical demands. Rather than orienting action towards any state of affairs, I suggest that a more practically useful approach to political theory would directly (...) address judgments, by comparing the concrete possibilities for action faced by real political actors. (shrink)

Ableist attitudes and structures regarding disability are increasingly recognized across all sectors of healthcare delivery. After Dobbs, novel questions arose in the USA concerning how to protect reproductive autonomy while avoiding discrimination against and devaluation of disabled persons. As a case study, we examine the Louisiana’s Department of Public Health August 1st Emergency Declaration, “List of Conditions that shall deem an Unborn Child ‘Medically Futile.’” We raise a number of medical, ethical, and public health concerns that lead us to argue (...) the declaration should be rescinded. The ethically objectionable declaration provides valuable lessons concerning how to uphold both reproductive and disability justice in a post-Dobbs landscape. (shrink)

The question of whether a patient has insight is among the first to be considered in psychiatric contexts. There are several competing conceptions of clinical insight, which broadly refers to a patient’s awareness of their mental illness. When a patient is described as lacking insight, there are significant implications for patient care and to what extent the patient is trusted as a knower. Insight is currently viewed as a multidimensional and continuous construct, but competing conceptions of insight still lack consensus (...) on the specifics. Studies also give contradictory evidence regarding the frequency and consequences of poor insight. A number of crucial questions remain unanswered. After outlining some of the key theoretical disagreements about what insight means, I highlight ethical issues that have not received much attention in the literature. Given the conceptual ambiguities and the absence of standardised bedside tools, there are significant ethical concerns about insight assessments. I highlight two main ethical concerns, specifically that these assessments risk: marginalising patients by setting unattainable ideals for self-knowledge and minimising the patient’s own perspective on their mental health. I close with recommendations for documenting and responding to concerns about poor insight, so patients who are vulnerable to losing epistemic trust are better supported in their therapeutic relationships. (shrink)

Robert Veatch’s The Foundations of Justice: Why the Retarded and the Rest of Us Have Claims to Equality delves into deep questions of justice through the case of a child with disabilities. I describe what is basically right about this vision, as well as what is problematic from the standpoint of contemporary disability bioethics. From there, I dive into the notion of vulnerability that is at play in his work. He describes disability as necessarily a condition of weakness, lesser-than existence, (...) and neediness. When disability is viewed in this way as an inherently vulnerable state of being, the essential sociopolitical dimensions of disability receive inadequate attention, which, in turn, makes it impossible to identify injustices correctly. I connect these points to concrete challenges faced by disability communities during the COVID-19 pandemic, which have raised profound questions about the just use of scarce critical care resources. Any case drawn from the pandemic is a very different kind of case than that of the child in Veatch’s book, but a commonality is the question of who should get what limited resources when needs and urgency vary. (shrink)

According to Aristotle, the medical art aims at health, which is a virtue of the body, and does so in an unlimited way. Consequently, medicine does not determine the extent to which health should be pursued, and “mental health” falls under medicine only via pros hen predication. Because medicine is inherently oriented to its end, it produces health in accordance with its nature and disease contrary to its nature—even when disease is good for the patient. Aristotle’s politician understands that this (...) inherent orientation can be systematically distorted, and so would see the need for something like the Hippocratic Oath. (shrink)

In response to Anne L. Dalle Ave and David M. Shaw, we agree with their general argument but emphasize a moral risk of HIV disclosure in deceased donation cases: the risk of relational rupture. Because of the importance that close relationships have to our sense of self and our life plans, this kind of rupture can have long-ranging implications for surviving loved ones. Moreover, the now-deceased individual cannot participate in any relational mending. Our analysis reveals the hefty moral costs that (...) disclosure can bring, which should influence what information is given to wouldbe donors and how organ procurement coordinators approach these conversations. (shrink)

The covert administration of medication occurs with incapacitated patients without their knowledge, involving some form of deliberate deception in disguising or hiding the medication. Covert medication in food is a relatively common practice globally, including in institutional and homecare contexts. Until recently, it has received little attention in the bioethics literature, and there are few laws or rules governing the practice. In this paper, we discuss significant, but often overlooked, ethical issues related to covert medication in food. We emphasise the (...) variety of ways in which eating has ethical importance, highlighting what is at risk if covert administration of medication in food is discovered. For example, losing trust in feeders and food due to covert medication may risk important opportunities for identity maintenance in contexts where identity is already unstable. Since therapeutic relationships may be jeopardised by a patient’s discovery that caregivers had secretly put medications in their food, this practice can result in an ongoing deception loop. While there may be circumstances in which covert medication is ethically justified, given a lack of suitable alternatives, we argue that in any particular case this practice should be continually re-evaluated in light of the building moral costs to the relational agent over time. (shrink)

How can social institutions complicate and worsen vulnerabilities of particular individuals or groups? We begin by explicating how certain diagnoses within mental health and medicine operate as interactive kinds of labels and how such labels can create institutional barriers that hinder one's capacity to achieve wellbeing. Interactive-kind modeling is a conceptual tool that elucidates the ways in which labeling can signal to others how the labeled person ought to be treated, how such labeling comes about and is perceived, and how (...) it compounds vulnerabilities. We argue that this shift in standpoint helps us recognize and mitigate compounded vulnerabilities. (shrink)

In this issue of the Hastings Center Report, Jason Wasserman and Mark Navin argue that patients without decisional capacity can still have relatively stable wishes or inclinations toward one treatment option over another and that these preferences are “not devoid of moral weight and might therefore guide or at least influence treatment decisions when they cannot be defeated by other considerations.” This position is not controversial among most bioethicists. The hard work comes in sussing out the details of this position. (...) How much moral weight do these preferences have? When should preferences be defeated by other considerations? How should we identify actual preferences, and how should preferences be differentiated and weighed against one another? (shrink)

Baby A1 was born prematurely with severe encephalopathy, injured brainstem, and a potentially injured spinal cord. He had no response to pain or other external stimuli. The neonatal team unanimousl...

Most democratic theorists agree that concentrations of wealth and power tend to distort the functioning of democracy and ought to be countered wherever possible. Deliberative democrats are no exception: though not its only potential value, the capacity of deliberation to ‘neutralise power’ is often regarded as ‘fundamental’ to deliberative theory. Power may be neutralised, according to many deliberative democrats, if citizens can be induced to commit more fully to the deliberative resolution of common problems. If they do, they will be (...) unable to get away with inconsistencies and bad or private reasons, thereby mitigating the illegitimate influence of power. I argue, however, that the means by which power inflects political disagreement is far more subtle than this model suggests and cannot be countered so simply. As a wealth of recent research in political psychology demonstrates, human beings persistently exhibit ‘motivated reasoning’, meaning that even when we are sincerely committed to the deliberative resolution of common problems, and even when we are exposed to the same reasons and evidence, we still disagree strongly about what ‘fair cooperation’ entails. Motivated reasoning can be counteracted, but only under exceptional circumstances such as those that enable modern science, which cannot be reliably replicated in our society at large. My analysis suggests that in democratic politics – which rules out the kind of anti-democratic practices available to scientists – we should not expect deliberation to reliably neutralise power. (shrink)

Variabilism is the view that proper names (like pronouns) are semantically represented as variables. Referential names, like referential pronouns, are assigned their referents by a contextual variable assignment (Kaplan 1989). The reference parameter (like the world of evaluation) may also be shifted by operators in the representation language. Indeed verbs that create hyperintensional contexts, like ‘think’, are treated as operators that simultaneously shift the world and assignment parameters. By contrast, metaphysical modal operators shift the world of assessment only. Names, being (...) variables, refer rigidly in the latter merely intensional contexts, but may vary their reference in hyperintensional contexts. This conforms to the intuition that the content of attitude ascriptions encapsulates referential uncertainty. Furthermore, names in hyperintensional contexts are ambiguous between de re* and de dicto* interpretations. This fact is used to account for asymmetric mistaken identity attributions (for example, Biron thinks Katherine is Rosaline, but he doesn’t think Rosaline is Katherine). -/- The variable theory compares favourably with its alternatives, including Millianism and descriptivism. Millians cannot account for the behaviour of names in hyperintensional contexts, while descriptivists cannot generate a necessary contrast between intensional and hyperintensional contexts. No other theory can capture the facts pertaining to the existentially bound use of names. (shrink)

Cognitive science has recently made some startling discoveries about temporal experience, and these discoveries have been drafted into philosophical service. We survey recent appeals to cognitive science in the philosophical debate over whether time objectively passes. Since this research is currently in its infancy, we identify some directions for future research.

Although research into the biosemiotic mechanisms underlying the purposeful behavior of brainless living systems is extensive, researchers have not adequately described biosemiosis among neurons. As the conscious use of signs is well-covered by the various fields of semiotics, we focus on subconscious sign action. Subconscious semiotic habits, both functional and dysfunctional, may be created and reinforced in the brain not necessarily in a logical manner and not necessarily through repeated reinforcement. We review literature that suggests hypnosis may be effective in (...) changing subconscious dysfunctional habits, and we offer a biosemiotic framework for understanding these results. If it has been difficult to evaluate any psychological approach, including hypnosis, this may be because contemporary neuroscience lacks a theory of the sign. We argue that understanding the fluid nature of representation in biological organisms is prerequisite to understanding the nature of the subconscious and may lead to more effective of treatments for dysfunctional habits developed through personal experience or culture. (shrink)

Much current debate in the metaphysics of time is between A-theorists and B-theorists. Central to this debate is the assumption that time exists and that the task of metaphysics is to catalogue time’s features. Relatively little consideration has been given to an error theory about time. Since there is very little extant work on temporal error theory the goal of this paper is simply to lay the groundwork to allow future discussion of the relative merits of such a view. The (...) paper thus develops a conceptual framework from within which to evaluate claims about the actual existence, or not, of temporality as that notion appears in folk discourses about time, and from there to examine claims about the counterfactual existence, or not, of temporality so conceived. We subsequently apply this framework to three extant positions drawn from physics and metaphysics that deny the existence of time. We show that only one of these positions is a folk temporal error theory; that is, a view that denies the existence of time as that notion is operative in our everyday thought and talk. (shrink)

This paper examines the interplay of semantics and pragmatics within the domain of film. Films are made up of individual shots strung together in sequences over time. Though each shot is disconnected from the next, combinations of shots still convey coherent stories that take place in continuous space and time. How is this possible? The semantic view of film holds that film coherence is achieved in part through a kind of film language, a set of conventions which govern the relationships (...) between shots. In this paper, we develop and defend a new version of the semantic view. We articulate it for a pair of conventions that govern spatial relations between viewpoints. One such rule is already well-known; sometimes called the "180° Rule," we term it the X-Constraint; to this we add a previously unrecorded rule, the T-Constraint. As we show, both have the effect, in different ways, of limiting the way that viewpoint can shift through space from shot to shot over the course of a film sequence. Such constraints, we contend, are analogous to relations of discourse coherence that are widely recognized in the linguistic domain. If film is to have a language, it is a language made up of rules like these. (shrink)

This collection addresses whether ethicists, like authorities in other fields, can speak as experts in their subject matter. Though ethics consultation is a growing practice in medical contexts, there remain difficult questions about the role of ethicists in professional decision-making. Contributors examine the nature and plausibility of moral expertise, the relationship between character and expertise, the nature and limits of moral authority, how one might become a moral expert, and the trustworthiness of moral testimony. This volume engages with the growing (...) literature in these debates and offers new perspectives from both academics and practitioners. The readings will be of particular interest to bioethicists, clinicians, ethics committees, and students of social epistemology. These new essays promise to advance discussions in the professionalization and accreditation of ethics consultation. (shrink)

Contemporary critics of the administrative state are right to highlight the dangers of vesting too much power in a centralized bureaucracy removed from popular oversight and accountability. Too often neglected in this literature, however, are the dangers of vesting too little power in a centralized state, which enables dominant groups to further expand their social and economic advantages through decentralized means. This article seeks to synthesize these concerns, understanding them as reflecting the same underlying danger of state capture. It then (...) articulates a set of heuristics for the design of public and administrative institutions, which aim at minimizing the risks of capture from both public and private sources. By following these heuristics, it claims, we can successfully employ the administrative state as a weapon against concentrated private power, rather than allowing it to serve as a tool of dominant groups. (shrink)

What if "liberal democracy" were a contradiction in terms? This book distinguishes liberalism from democracy to defend a Rancirean vision of impure politics. Disclosing Rancire's refusal of ontology as political, The Lessons of Rancire enacts a critical theory beyond unmasking and a democratic politics beyond liberalism.

Scientists, clinicians, and bioethicists are worried about how so‐called personhood measures would limit access to certain types of contraception, research involving stem cells, and access to fertility treatments. While these measures have been struck down in Colorado, South Dakota, California, and Mississippi, the bill signed into law in Oklahoma in February deserves critical scrutiny, particularly into the ways these legal measures influence eligibility for clinical research. Oklahoma's bill states that the laws of the state “shall be interpreted and construed to (...) acknowledge on behalf of the unborn child at every stage of development all the rights, privileges, and immunities available to other persons, citizens, and residents of this state.”. (shrink)

Clinical and ethical reasoning often follows the grooves, the forks, the paths of decision trees. Health-care professionals and clinical ethicists can come to rely on them, especially in intricate cases with complex problems that need to be broken down into analyzable steps. Despite their usefulness, decision trees can lead everyone astray if they are rooted in outdated medicine. In his 2015 book, Rights Come to Mind: Brain Injury, Ethics, and the Struggle for Consciousness, Joseph Fins illuminates the errors of common (...) medical and ethical understandings of disorders of consciousness, especially vegetative states and minimally conscious states.1 Fins weaves together over 50 in-depth interviews with patients... (shrink)

Ask any clinical ethics consultant, and they can tell you about their transformative cases. Some stick with us because all roads led nowhere. Cassandra Lee had a history of pulling out lines and tubes and a distaste of warming blankets. Her admission marked her thirtieth over the past year. Many of the challenges facing the hospital caring for her were not unique: significant psychiatric issues, prolonged nonadherence to medical advice, and end‐of‐life decision‐making combined to create an ethically dense and vexing (...) situation. Ms. Lee, like so many patients, was suffering because of system failures. (shrink)

ABSTRACT:Robert Veatch argues that physician oaths should not be valued as substantive moral commitments, transformational rituals, or symbolic acts. Further, he insists that oath recitation in medical schools is immoral. I respond to Veatch's criticisms and argue that, with alterations to their content and practice, oaths can have value for articulating moral commitments and building a sense of moral community within the profession. I break down Veatch's multitude of objections to oaths over his career, and I suggest how medical schools (...) can avoid the pitfalls identified by Veatch. A promising and innovative path forward is to integrate a commitment to diversity, equity, and inclusion—though with an understanding that a few lines in an oath are far from sufficient for institutional culture, faculty accountability, or students' education. (shrink)

The MedStar Washington Hospital Center clinical ethics team became involved in a case when the family requested the posthumous removal of a patient’s ovaries for future reproductive use. This case presents a novel question for clinical ethicists, since the technology for posthumous female reproduction is still in development. In the bioethics literature, the standard position is to refuse to comply with such a request, unless there is explicit consent or evidence of explicit conversations that demonstrate the deceased would have wanted (...) this option pursued. Ms D’s case, we suggest, offers an exception to this default position; complying with the family’s request could have been ethically permissible in this case, had it been medically feasible. (shrink)

The leading reductive approaches to shared agency model that phenomenon in terms of complexes of individual intentions, understood as plan-laden commitments. Yet not all agents have such intentions, and non-planning agents such as small children and some non-human animals are clearly capable of sophisticated social interactions. But just how robust are their social capacities? Are non-planning agents capable of shared agency? Existing theories of shared agency have little to say about these important questions. I address this lacuna by developing a (...) reductive account of the social capacities of non-planning agents, which I argue supports the conclusion that they can enjoy shared agency. The resulting discussion offers a fine-grained account of the psychological capacities that can underlie shared agency, and produces a recipe for generating novel hypotheses concerning why some agents do not engage in shared agency. (shrink)

This work presents the basic arguments and fundamental themes of the political and moral thought of the seventeenth-century philosopher, Samuel Pufendorf--one of the most widely read natural lawyers of the pre-Kantian era. Selections from the texts of Pufendorf's two major works, Elements of Universal Jurisprudence and The Law of Nature and of Nations, have been brought together to make Pufendorf's moral and political thought more accessible. The selections included have received a new English translation, the first for both works (...) in roughly sixty years. The editor, a political scientist, and the translator, a philosopher, have developed a volume that is comprehensive and representative of Pufendorf's thought without being repetitive, fragmented, or obscure. (shrink)

Over the past decade, Jacques Rancière’s writings have increasingly provoked and inspired political theorists who wish to avoid both the abstraction of so-called normative theories and the philosophical platitudes of so-called postmodernism. Rancière offers a new and unique definition of politics, la politique, as that which opposes, thwarts and interrupts what Rancière calls the police order, la police — a term that encapsulates most of what we normally think of as politics (the actions of bureaucracies, parliaments, and courts). Interpreters have (...) been tempted to read Rancière as proffering a formally pure conception of politics, wherein politics is ultimately separate from and in utter opposition to all police orders. Here I provide a different account of Rancière’s thinking of politics: for Rancière politics goes on within police orders and for this reason he strongly rejects the very idea of a pure politics. Politics is precisely that which could never be pure; politics is an act of impurity, a process that resists purification. In carefully delineating the politique—police relation I show that the terms of Rancière’s political writings are multiple and multiplied. Rancière consistently undermines any effort to render politics pure, and therein lies his potential contribution to contemporary political theory. (shrink)

In recent years, some have claimed that a Darwinian perspective will revolutionize the study of human society and culture. This project is viewed with disdain and suspicion, on the other hand, by many practicing social scientists. This article seeks to clear the air in this heated debate by dissociating two claims that are too often assumed to be inseparable. The first is the ‘ontological’ claim that Darwinian principles apply, at some level of abstraction, to human society and culture. The second (...) is the more ‘pragmatic’ claim that this observation necessitates substantial changes in the practices of social scientists. Even if some version of the first claim is true, I argue – which I believe is quite likely – the second does not follow. This observation ought to chasten the most overzealous advocates of Darwinian social science, as well as softening the instinctive resistance of many social scientists and historians to the genuine insights enabled by a Darwinian approach. The conclusion discusses these insights, the most important of which is a methodological prescription for normative theory. (shrink)

Kraut and other neo-Aristotelians have argued that there is no such thing as absolute goodness. They admit only good in a kind, e.g. a good sculptor, and good for something, e.g. good for fish. What is the view of Aristotle? Mostly limiting myself to the Nicomachean Ethics, I argue that Aristotle is committed to things being absolutely good and also to a metaphysics of absolute goodness where there is a maximally best good that is the cause of the goodness of (...) all other things in virtue of being their end. I begin by suggesting that the notion of good as an end, which is present in the first lines of the NE, is not obviously accounted for by good in a kind or good for something. I then give evidence that good in a kind and good for something can explain neither certain distinctions drawn between virtues nor the determinacy ascribed to what is good “in itself.” I argue contra Gotthelf that because several important arguments in the Nicomachean Ethics rely on comparative judgments of absolute value—e.g. “Man is the best of all animals”—Aristotle is committed to the existence of both absolute goodness and an absolutely best being. I focus on one passage, Aristotle’s division of goods in NE I 12, which presupposes this metaphysical picture. (shrink)

End-of-life decision making is fraught with ethical challenges. Withholding or withdrawing life support therapy is widely considered ethical in patients with high treatment burden, poor premorbid status, or significant projected disability even when such treatment is not “futile.” Whether such withdrawal of therapy in the aftermath of attempted suicide is ethical is not well established in the literature. We provide a clinical vignette and propose criteria under which such withdrawal would be ethical. We suggest that it is appropriate to withdraw (...) life support, regardless of the cause of the critical illness or disability, when the following criteria are met: Surrogates request withdrawal of care and the adequacy of surrogates is confirmed, an external reasonability standard is met, passage of time, perhaps 72 hours, to allow certainty regarding the patient's wishes, and psychiatric morbidity should be considered as grounds for withdrawal only in truly treatment-refractory cases. Fundamentally, we believe the question to ask is, “If this were not an attempted suicide, would a request to withdraw care be reasonable?” We believe that under these circumstances, such withdrawal of life support, even in an individual who has attempted suicide, does not constitute physician assistance with suicide and is distinct from physician aid-in-dying in several important respects. (shrink)

According to the Reasoning View about normative reasons, facts about normative reasons for action can be understood in terms of facts about the norms of practical reasoning. I argue that this view is subject to an overlooked class of counterexamples, familiar from debates about Subjectivist theories of normative reasons. Strikingly, the standard strategy Subjectivists have used to respond to this problem cannot be adapted to the Reasoning View. I think there is a solution to this problem, however. I argue that (...) the norms of practical reasoning, like the norms of theoretical reasoning, are characteristically defeasible, in a sense I make precise. Recognizing this property of those norms makes space for a solution to the problem. The resulting view is in a way analogous to the familiar defeasibility theory of knowledge, but it avoids a standard objection to that theory. (shrink)

Frege's picture of attitude states and attitude reports requires a notion of content that is shareable between agents, yet more fine-grained than reference. Kripke challenged this picture by giving a case on which the expressions that resist substitution in an attitude report share a candidate notion of fine-grained content. A consensus view developed which accepted Kripke's general moral and replaced the Fregean picture with an account of attitude reporting on which states are distinguished in conversation by their (private) representational properties. (...) I begin in support of the consensus by showing how a sort of de facto coordination on mental symbols is possible, even for unsophisticated agents. But I go on to argue that whenever conditions are ripe for de facto coordination on symbols, there is an inter-subjective relation that supports a fine-grained notion of content resistant to Kripke's challenge. The consensus view corresponds to a Kripke-resistant strain of the Fregean picture. (shrink)

End-of-life decision making is fraught with ethical challenges. Withholding or withdrawing life support therapy is widely considered ethical in patients with high treatment burden, poor premorbid status, or significant projected disability even when such treatment is not ?futile.? Whether such withdrawal of therapy in the aftermath of attempted suicide is ethical is not well established in the literature. We provide a clinical vignette and propose criteria under which such withdrawal would be ethical. We suggest that it is appropriate to withdraw (...) life support, regardless of the cause of the critical illness or disability, when the following criteria are met: (1) Surrogates request withdrawal of care and the adequacy of surrogates is confirmed, (2) an external reasonability standard is met, (3) passage of time, perhaps 72 hours, to allow certainty regarding the patient's wishes, and (4) psychiatric morbidity should be considered as grounds for withdrawal only in truly treatment-refractory cases. Fundamentally, we believe the question to ask is, ?If this were not an attempted suicide, would a request to withdraw care be reasonable?? We believe that under these circumstances, such withdrawal of life support, even in an individual who has attempted suicide, does not constitute physician assistance with suicide and is distinct from physician aid-in-dying in several important respects. (shrink)

I describe and motivate Rational Internalism, a principle concerning the relationship between motivating reasons (which explain actions) and normative reasons (which justify actions). I use this principle to construct a novel argument against Objectivist theories of normative reasons, which hold that facts about normative reasons can be analyzed in terms of an independently specified class of normative or evaluative facts. I then argue for an alternative theory of normative reasons, the Reasoning View, which is consistent with both Rational Internalism and (...) one standard motivation for Objectivism. (shrink)