Decision making for incompetent patients is a much-discussed topic in bioethics. According to one influential decision making standard, the substituted judgment standard, a surrogate decision maker ought to make the decision that the incompetent patient would have made, had he or she been competent. Empirical research has been conducted in order to find out whether surrogate decision makers are sufficiently good at doing their job, as this is defined by the substituted judgment standard. This research investigates to what (...) extent surrogates are able to predict what the patient would have preferred in the relevant circumstances. In this paper we address a methodological shortcoming evident in a significant number of studies. The mistake consists in categorizing responses that only express uncertainty as predictions that the patient would be positive to treatment, on the grounds that the clinical default is to provide treatment unless it is refused. We argue that this practice is based on confusion and that it risks damaging the research on surrogate accuracy. (shrink)

The American Journal of Bioethics, Volume 12, Issue 10, Page 41-43, October 2012.

To what extent are people able to make predictions about other people’s preferences and values? We report two experiments that present a novel method assessing some of the basic processes in surrogate decision-making, namely surrogate-utility estimation. In each experiment participants formed dyads who were asked to assign utilities to health related items and commodity items, and to predict their partner’s utility judgments for the same items. In experiment one we showed that older adults in long-term relationships were able (...) to accurately predict their partner’s wishes. In experiment two we showed that younger adults who were relatively unfamiliar with one another were also able to predict other people’s wishes. Crucially we demonstrated that these judgments were accurate even after partialling out each participant’s own preferences indicating that in order to make surrogate utility estimations people engage in perspective-taking rather than simple anchoring and adjustment, suggesting that utility estimation is not the cause of inaccuracy in surrogate decision-making. The data and implications are discussed with respect to theories of surrogate decision-making. (shrink)

The authority of surrogates—often close family members—to make treatment decisions for previously capacitated patients is said to come from their knowledge of the patient, which they are to draw on as they exercise substituted judgment on the patient’s behalf. However, proxy accuracy studies call this authority into question, hence the Patient Preference Predictor (PPP). We identify two problems with contemporary understandings of the surrogate’s role. The first is with the assumption that knowledge of the patient entails knowledge of (...) what the patient’s choice of treatment would be. The second is with the assumption that a good decision reproduces the content of that choice. If we are right, then the PPP, helpful though it might be in guiding surrogates’ decisions, nevertheless would hold them to the wrong standards and in that way could add to, rather than relieve, the stress they experience as they try to do their job. (shrink)

The increasing accuracy of algorithms to predict values and preferences raises the possibility that artificial intelligence technology will be able to serve as a surrogate decision-maker for incapacitated patients. Following Camillo Lamanna and Lauren Byrne, we call this technology the autonomy algorithm. Such an algorithm would mine medical research, health records, and social media data to predict patient treatment preferences. The possibility of developing the AA raises the ethical question of whether the AA or a relative ought to (...) serve as surrogate decision-maker in cases where the patient has not issued a medical power of attorney. We argue that in such cases, and against the standard practice of vesting familial surrogates with decision making authority, the AA should have sole decision-making authority. This is because the AA will likely be better at predicting what treatment option the patient would have chosen. It would also be better at avoiding bias and, therefore, choosing in a more patient-centered manner. Furthermore, we argue that these considerations override any moral weight of the patient’s special relationship with their relatives. (shrink)

Part of the standard protection of decisionally incapacitated research subjects is a prohibition against enrolling them unless surrogate decision makers authorize it. A common view is that surrogates primarily ought to make their decisions based on what the decisionally incapacitated subject would have wanted regarding research participation. However, empirical studies indicate that surrogate predictions about such preferences are not very accurate. The focus of this article is the significance of surrogate accuracy in the context of research (...) that is not expected to benefit the research subject. We identify three morally relevant asymmetries between being enrolled and not being enrolled in such non-beneficial research, and conclude that when there is a non-negligible probability that surrogates’ predictions are wrong, it will generally be better to err on the side of not authorizing enrollment. (shrink)

As medical technology continues to improve, more people will live longer lives with multiple chronic illnesses with increasing cumulative debilitation, including cognitive dysfunction. Combined with the aging of society in most developed countries, an ever-growing number of patients will require surrogate decision-makers. While advance care planning by patients still capable of expressing their preferences about medical interventions and end-of-life care can improve the quality and accuracy of surrogate decisions, this is often not the case, not infrequently leading (...) to demands for ineffective, inappropriate and prolonged interventions. In 1980 LaFollette called for the licensing of prospective parents, basing his argument on the harm they can do to vulnerable people. In this paper, I apply his arguments to surrogate decision-makers for cognitively incapacitated patients, rhetorically suggesting that we require potential surrogates to qualify for this position by demonstrating their ability to make reasonable and rational decisions for others. I employ this theoretical approach to argue that the loose criteria by which we authorize surrogates’ generally unchallenged power should be reconsidered. (shrink)

Incompetent patients need to have someone else make decisions on their behalf. According to the Substituted Judgment Standard the surrogate decision maker ought to make the decision that the patient would have made, had he or she been competent. Objections have been raised against this traditional construal of the standard on the grounds that it involves flawed counterfactual reasoning, and amendments have been suggested within the framework of possible worlds semantics. The paper shows that while this approach may circumvent (...) the alleged problem, the way it has so far been elaborated reflects insufficient understanding of the moral underpinnings of the idea of substituted judgment. Proper recognition of these moral underpinnings has potentially far-reaching implications for our normative assumptions about accuracy and objectivity in surrogate decision making. (shrink)

Substituted judgment assumes adequate knowledge of patient’s mind-set. However, surrogates’ prediction of individual healthcare decisions is often inadequate and may be based on shared background rather than patient-specific knowledge. It is not known whether surrogate’s prediction of patient’s integrative life-story narrative is better. Respondents in 90 family pairs rank-ordered 47 end-of-life statements as life-story narrative measure and completed instruments on decision-control preference and healthcare-outcomes acceptability as control measures, from respondent’s view and predicted pair’s view. They also scored their confidence (...) in surrogate’s decision-making and familiarity with pair’s healthcare-preferences. Life-story narratives’ prediction was examined by calculating correlation of statements’ ranking scores between respondent-personal and respondent-surrogate Q-sorts and between respondent-surrogate and pair-personal Q-sorts before and after controlling for correlation with respondent-personal scores, and by comparing percentages of respondent-surrogate Q-sorts co-loading with pair-personal vs. respondent-personal Q-sorts. Accuracy in predicting decision-control preference and healthcare-outcomes acceptability was determined by percent concordance. Results were compared among subgroups defined by intra-pair relationship, surrogate’s decision-making confidence, and healthcare-preferences familiarity. Mean age was 35.4 years, 69% were females, and 73 and 80% reported ≥ very good health and life-quality, respectively. Mean surrogate’s decision-making confidence score was 3.35 and 75% were ≥ familiar with pair’s healthcare-preferences. Mean projection, simulation, and adjusted-simulation correlations were 0.68, 0.42, and 0.26, respectively. Out of 180 respondent-surrogate Q-sorts, 24, 9, and 32% co-loaded with respondent-personal, pair-personal, or both Q-sorts, respectively. Accuracy in predicting decision-control preference and healthcare-outcomes acceptability was 47 and 52%, respectively. Surrogate’s decision-making confidence score correlated with adjusted-simulation’s correlation score. There were significant differences among the husband-wife, parent-child, and sibling-sibling subgroups in percentage of respondent-surrogate Q-sorts co-loading with pair-personal Q-sorts and percent agreement on healthcare-outcomes acceptability. Despite high self-reported surrogate’s decision-making confidence and healthcare-preferences familiarity, family surrogates are variably inadequate in simulating life-story narratives. Simulation accuracy may not follow the next-of-kin concept and is 38% based on shared background. (shrink)

BackgroundHealthcare providers have to make ethically complex clinical decisions which may be a source of stress. Researchers have recently introduced Artificial Intelligence (AI)-based applications to assist in clinical ethical decision-making. However, the use of such tools is controversial. This review aims to provide a comprehensive overview of the reasons given in the academic literature for and against their use.MethodsPubMed, Web of Science, Philpapers.org and Google Scholar were searched for all relevant publications. The resulting set of publications was title and abstract (...) screened according to defined inclusion and exclusion criteria, resulting in 44 papers whose full texts were analysed using the Kuckartz method of qualitative text analysis.ResultsArtificial Intelligence might increase patient autonomy by improving the accuracy of predictions and allowing patients to receive their preferred treatment. It is thought to increase beneficence by providing reliable information, thereby, supporting surrogate decision-making. Some authors fear that reducing ethical decision-making to statistical correlations may limit autonomy. Others argue that AI may not be able to replicate the process of ethical deliberation because it lacks human characteristics. Concerns have been raised about issues of justice, as AI may replicate existing biases in the decision-making process.ConclusionsThe prospective benefits of using AI in clinical ethical decision-making are manifold, but its development and use should be undertaken carefully to avoid ethical pitfalls. Several issues that are central to the discussion of Clinical Decision Support Systems, such as justice, explicability or human–machine interaction, have been neglected in the debate on AI for clinical ethics so far.Trial registrationThis review is registered at Open Science Framework (https://osf.io/wvcs9). (shrink)

When a patient lacks sufficient capacity to make a certain treatment decision, whether because of deficits in their ability to make a judgement that reflects their values or to make a decision that reflects their judgement or both, the decision must be made by a surrogate. Often the best way to respect the patient’s autonomy, in such cases, is for the surrogate to make a ‘substituted’ judgement on behalf of the patient, which is the decision that best reflects (...) the patient’s values and identity-infused beliefs as they were when the patient last possessed capacity. It is by now well-known that there is troubling evidence that surrogates do only slightly better than chance at making accurate substituted judgements. The use of a patient preference predictor, an algorithm that predicts patient preferences based on characteristics like the patient’s age, gender, socioeconomic status and education level, could help. Rid and Wendler have done important work making a moral case for using the PPP.1 If it were shown to enhance accuracy, it is not at all obvious what objections there could be to its use. Yet several subtle criticisms of the PPP have emerged in the literature. In their feature article, Jardas, Wasserman and Wendler select six of the most prominent objections to the PPP in the literature and defend the PPP against them.2 Along the way they make significant contributions to broader issues concerning the proper uses of statistical evidence and limits on the kinds of preferences there can be reasons of autonomy to respect. Since I found the authors’ answers to the final two objections—that the PPP relies on naked statistical evidence and that it uses non-endorsed reasons—to be especially interesting and provocative, I will examine those answers and raise a few questions about …. (shrink)

The Patient Preference Predictor (PPP) proposal places a high priority on the accuracy of predicting patients’ preferences and finds the performance of surrogates inadequate. However, the quest to develop a highly accurate, individualized statistical model has significant obstacles. First, it will be impossible to validate the PPP beyond the limit imposed by 60%–80% reliability of people’s preferences for future medical decisions—a figure no better than the known average accuracy of surrogates. Second, evidence supports the view that a sizable (...) minority of persons may not even have preferences to predict. Third, many, perhaps most, people express their autonomy just as much by entrusting their loved ones to exercise their judgment than by desiring to specifically control future decisions. Surrogate decision making faces none of these issues and, in fact, it may be more efficient, accurate, and authoritative than is commonly assumed. (shrink)

This paper is divided in two parts. In part I, I argue against two attempts to naturalise the notion of scientific representation, by reducing it to isomorphism and similarity. I distinguish between the means and the constituents of representation, and I argue that isomorphism and similarity are common means of representation; but that they are not constituents of scientific representation. I look at the prospects for weakened versions of these theories, and I argue that only those that abandon the aim (...) to naturalise scientific representation are likely to be successful. In part II of the paper, I present a deflationary conception of scientific representation, which minimally characterises it by means of two necessary conditions: representation is essentially intentional and it has the capacity to allow surrogate reasoning and inference. I then defend this conception by showing that it successfully meets the objections and difficulties that make its competitors, such as isomorphism and similarity, untenable. In addition the inferential conception explains the success of various means of representation in their appropriate domains, and it sheds light on the truth and accuracy of scientific representations. (shrink)

Research involving adults who lack capacity to consent relies on proxy (or surrogate) decision making. Proxy decisions about participation are ethically complex, with a disparity between normative accounts and empirical evidence. Concerns about the accuracy of proxies’ decisions arise, in part, from the lack of an ethical framework which takes account of the complex and morally pluralistic world in which proxy decisions are situated. This qualitative study explored the experiences of family members who have acted as a research (...) proxy in order to develop an understanding of the ethical concepts involved, and the interactions between those concepts. Proxies described a complex process of respecting the wishes and preferences of the person they represented, whist integrating preferences with what they viewed as being in the interests of the person. They aimed to make a decision that was ‘best’ for the person and protected them from harm; they also aimed to make the ‘right’ decision, viewed as being authentic to the person’s values and life. Decisions were underpinned by the relationship between the person and their proxy, in which both trust and trustworthiness were key. Proxies’ decisions, based both on respect for the person and the need to protect their interests, arose out of their dual role as both proxy and carer. The findings raise questions about accounts which rely on existing normative assumptions with a focus on accuracy and discrepancy, and which fail to take account of the requirement for proxies to make authentic decisions that arise out of their caring obligations. (shrink)

Background: Research involving adults lacking mental capacity relies on the involvement of a proxy or surrogate, although this raises a number of ethical concerns. Empirical studies have examined attitudes towards proxy decision-making, proxies’ authority as decision-makers, decision accuracy, and other relevant factors. However, a comprehensive evidence-based account of proxy decision-making is lacking. This systematic review provides a synthesis of the empirical data reporting the ethical issues surrounding decisions made by research proxies, and the development of a conceptual framework (...) of proxy decision-making for research. Methods: A systematic review was conducted according to PRISMA guidelines. Databases including MEDLINE, EMBASE, and CINAHL were searched using a combination of search terms, and empirical data from eligible studies were retrieved. The review followed the framework synthesis approach to refine and develop a conceptual framework. Results: Thirty-four studies were included in the review. Two dimensions of proxy decision-making emerged. The ethical framing criteria of decision-making used by proxies: use of a substituted judgement, use of a best interests approach, combination of substituted judgement and best interests, and ‘something else’, and the active elements of proxy decision-making: ‘knowing the person’, patient-proxy relationship, accuracy of the decision, and balancing risks, benefits and burdens, and attitudes towards proxy decision-making. Interactions between the framing criteria and the elements of decision-making are complex and contextually-situated. Conclusions: The findings from this systematic review challenge the accepted reductionist account of proxy decision-making. Decision-making by research proxies is highly contextualized and multifactorial in nature. The choice of proxy and the relational features of decision-making play a fundamental role: both in providing the proxy’s authority as decision-maker, and guiding the decision-making process. The conceptual framework describes the relationship between the framing criteria used by the proxy, and the active elements of decision-making. Further work to develop, and empirically test the proposed framework is needed. (shrink)

This paper is divided in two parts. In part I, I argue against two attempts to naturalise the notion of scientific representation, by reducing it to isomorphism and similarity. I distinguish between the means and the constituents of representation, and I argue that isomorphism and similarity are common (although not universal) means of representation; but that they are not constituents of scientific representation. I look at the prospects for weakened versions of these theories, and I argue that only those that (...) abandon the aim to naturalise scientific representation are likely to be successful. In part II of the paper, I present a deflationary conception of scientific representation, which minimally characterises it by means of two necessary conditions: representation is essentially intentional and it has the capacity to allow surrogate reasoning and inference. I then defend this conception by showing that it successfully meets the objections and difficulties that make its competitors, such as isomorphism and similarity, untenable. In addition the inferential conception explains the success of various means of representation in their appropriate domains, and it sheds light on the truth and accuracy of scientific representations. (shrink)

BackgroundSevere brain injury is a leading cause of death and disability. Diagnosis and prognostication are difficult, and errors occur often. Novel neuroimaging methods can improve diagnostic and prognostic accuracy, especially in patients with prolonged disorders of consciousness (PDoC). Yet it is currently unknown how family caregivers understand this information, raising ethical concerns that disclosure of neuroimaging results could result in therapeutic misconception or false hope.MethodsTo examine these ethical concerns, we conducted semi-structured interviews with caregivers of patients with PDoC who (...) were enrolled in a concurrent neuroimaging research program designed to detect covert consciousness following severe brain injury. Caregivers held surrogate decision-making status for a patient. Interviews were conducted at two time points for each caregiver. The first interview occurred before the disclosure of neuroimaging results. The second occurred after disclosure. Descriptive analysis was applied to the data of four interview topics: (1) expectations for neuroimaging; (2) reactions to evidence of preserved cognition; (3) reactions to null results; and (4) understanding of the results and study.ResultsTwelve caregivers participated in the study; two caregivers shared surrogate decision-making status for one patient with PDoC. Twenty-one interviews were completed; one caregiver declined to participate in the post-disclosure interview. Three patients with PDoC associated with the study displayed evidence of covert consciousness. Overall, caregivers understood the neuroimaging research and results. Caregivers who received results of covert consciousness were generally pleased. However, there was some variation in expectations and reactions to these data and null results.ConclusionThis study, for the first time, reveals caregiver expectations for and reactions to neuroimaging evidence of covert consciousness in patients with PDoC. Caregivers understood the neuroimaging research and results, casting doubt on speculative ethical concerns regarding therapeutic misconception and false hope. However, disclosure of neuroimaging result could be improved. Pre-disclosure consultations might assist professionals in shaping caregiver expectations. Standardization of disclosure might also improve comprehension of the results. (shrink)

Classic conceptions of model simplicity for machine learning are mainly based on the analysis of the structure of the model. Bayesian, Frequentist, information theoretic and expressive power concepts are the best known of them, which are reviewed in this work, along with their underlying assumptions and weaknesses. These approaches were developed before the advent of the Big Data deluge, which has overturned the importance of structural simplicity. The computational simplicity concept is presented, and it is argued that it is more (...) encompassing and closer to actual machine learning practices than the classic ones. In order to process the huge datasets which are commonplace nowadays, the computational complexity of the learning algorithm is the decisive factor to assess the viability of a machine learning strategy, while the classic accounts of simplicity play a surrogate role. Some of the desirable features of computational simplicity derive from its reliance on the learning system concept, which integrates key aspects of machine learning that are ignored by the classic concepts. Moreover, computational simplicity is directly associated with energy efficiency. In particular, the question of whether the maximum possibly achievable predictive accuracy should be attained, no matter the economic cost of the associated energy consumption pattern, is considered. (shrink)

This paper is divided in two parts. In part I, I argue against two attempts to naturalise the notion of scientific representation, by reducing it to isomorphism and similarity. I distinguish between the means and the constituents of representation, and I argue that isomorphism and similarity are common means of representation; but that they are not constituents of scientific representation. I look at the prospects for weakened versions of these theories, and I argue that only those that abandon the aim (...) to naturalise scientific representation are likely to be successful. In part II of the paper, I present a deflationary conception of scientific representation, which minimally characterises it by means of two necessary conditions: representation is essentially intentional and it has the capacity to allow surrogate reasoning and inference. I then defend this conception by showing that it successfully meets the objections and difficulties that make its competitors, such as isomorphism and similarity, untenable. In addition the inferential conception explains the success of various means of representation in their appropriate domains, and it sheds light on the truth and accuracy of scientific representations. (shrink)

Advance care planning allows patients to articulate preferences for their medical treatment, lifestyle, and surrogate decision-makers in order to anticipate and mitigate their potential loss of decision-making capacity. Written advance directives are often emphasized in this regard. While these directives contain important information, there are several barriers to consider: veracity and accuracy of surrogate decision-makers in making choices consistent with the substituted judgement standard, state-to-state variability in regulations, literacy issues, lack of access to legal resources, lack of (...) understanding of medical options, and cultural disparities. Given these issues, it is vital to increase the use of patient and healthcare provider conversations as an advance care planning tool and to increase integration of such discourse into advance care planning policy as adjuncts and complements to written advance directives. This paper reviews current legislation about written advance directives and dissects how documentation of spoken interactions might be integrated and considered. We discuss specific institutional policy changes required to facilitate implementation. Finally, we explore the ethical issues surrounding the increased usage and recognition of clinician–patient conversations in advance care planning. (shrink)

In the philosophy of perception, representationalism is the view that all phenomenological differences among mental states are representational differences, in other words, differences in content. In this paper I defend an alternative view which I call external sortalism, inspired by traditional adverbialism, and according to which experiences are not essentially representational. The central idea is that the external world serves as a model for sorting, conceptualizing, and reasoning surrogatively about perceptual experience. On external sortalism, contents are construed as a kind (...) of gloss on experiences themselves. We can retain what is attractive about representationalism, namely, that perceptual experiences can be evaluated for accuracy, without problematic commitment to the idea that they bear a substantive, representational relation to external objects and properties and that this relation determines the phenomenal character of experience. (shrink)

ObjectiveTo determine whether gait and accelerometric features can predict disorientation events in young and older adults.MethodsCognitively healthy younger and older participants navigated on a treadmill through a virtual representation of the city of Rostock featured within the Gait Real-Time Analysis Interactive Lab system. We conducted Bayesian Poisson regression to determine the association of navigation performance with domain-specific cognitive functions. We determined associations of gait and accelerometric features with disorientation events in real-time data using Bayesian generalized mixed effect models. The (...) class='Hi'>accuracy of gait and accelerometric features to predict disorientation events was determined using cross-validated support vector machines and Hidden Markov models.ResultsBayesian analysis revealed strong evidence for the effect of gait and accelerometric features on disorientation. The evidence supported a relationship between executive functions but not visuospatial abilities and perspective taking with navigation performance. Despite these effects, the cross-validated percentage of correctly assigned instances of disorientation was only 72% in the SVM and 63% in the HMM analysis using gait and accelerometric features as predictors.ConclusionDisorientation is reflected in spatiotemporal gait features and the accelerometric signal as a potentially more easily accessible surrogate for gait features. At the same time, such measurements probably need to be enriched with other parameters to be sufficiently accurate for individual prediction of disorientation events. (shrink)

PurposeThe information technology related ethical issues will only increase in frequency and complexity with the increasing diffusion of IT in economies and societies. The purpose of this paper is to explore Egyptian students' attitudes towards the information ethics issues of privacy, access, property, and accuracy, and it evaluates the possible impact of a number of personal characteristics on such attitudes.Design/methodology/approachThis research utilized a cross‐sectional sample and data set to test five hypotheses. It adopted an instrument to collect the respondents' (...) background information and assess their attitudes towards the information ethics issues of privacy, property, accuracy, and access. Egyptian business students at Alexandria University were asked to participate in the survey. A total of 305 responses were collected and analyzed.FindingsThe analysis revealed that students are sensitive to the ethicality of information privacy, information accuracy, and information access. However, students are insensitive to the ethicality of property right. In addition, years of education have a main effect on students' attitudes towards property, and gender and age have an interaction effect on students' attitudes towards access.Research limitations/implicationsThe findings of this research are based on a cross‐sectional data set collected from a sample of business students at a public university. Students, however, may make poor surrogates for business or IT professionals. Future similar research designs that employ large samples from Egyptian working professionals and students in other private and public universities are needed to verify the findings of this research.Practical implicationsThe findings suggest that the investigated university as well as the other similar Egyptian universities should consider integrating ethics education into their curricula. Teaching information ethics, especially from an Islamic perspective, is expected to positively influence students' information ethical attitudes. The enforcement of the existing property right protection laws should also curb software piracy in the Egyptian market.Originality/valueIt is vital to expand the ethical research currently being performed in IT in order to help bridge the gap between behavior and IT. The findings of this research extend the understanding of students' attitudes towards the information ethics issues in Egyptian culture and contribute to the growing body of knowledge on global information ethics. (shrink)

Clinicians are often called upon to assess the capacity of a patient to appoint a healthcare agent. Although a consensus has emerged that the standard for such assessment should differ from that for capacity to render specific healthcare decisions, exactly what standard should be employed remains unsettled and differs by jurisdiction. The current models in use draw heavily upon analogous methods used in clinical assessment, such as the “four skills” approach. This essay proposes an alternative model that relies upon categorization (...) and sliding scale risk assessment that can be used to determine to how much scrutiny the proxy appointment should be subjected and how much certainty of accuracy should be required in order to maximize the patient’s autonomy and ensure that her underlying wishes are met. (shrink)

We argue that subjective Bayesians face a dilemma: they must offend against the spirit of their permissivism about rational credence or reject the principle that one should avoid accuracy dominance.

Background: Current practice frequently fails to provide care consistent with the preferences of decisionally-incapacitated patients. It also imposes significant emotional burden on their surrogates. Algorithmic-based patient preference predictors (PPPs) have been proposed as a possible way to address these two concerns. While previous research found that patients strongly support the use of PPPs, the views of surrogates are unknown. The present study thus assessed the views of experienced surrogates regarding the possible use of PPPs as a means to help make (...) treatment decisions for decisionally-incapacitated patients. -/- Methods: This qualitative study used semi-structured interviews to determine the views of experienced surrogates [n=26] who were identified from two academic medical centers and two community hospitals. The primary outcomes were respondents’ overall level of support for the idea of using PPPs and the themes related to their views on how a PPP should be used, if at all, in practice. -/- Results: Overall, 21 participants supported the idea of using PPPs. The remaining five indicated that they would not use a PPP because they made decisions based on the patient’s best interests, not based on substituted judgment. Major themes which emerged were that surrogates, not the patient’s preferences, should determine how treatment decisions are made, and concern that PPPs might be used to deny expensive care or be biased against minority groups. -/- Conclusions: Surrogates, like patients, strongly support the idea of using PPPs to help make treatment decisions for decisionally-incapacitated patients. These findings provide support for developing a PPP and assessing it in practice. At the same time, patients and surrogates disagree over whose preferences should determine how treatment decisions are made, including whether to use a PPP. These findings reveal a fundamental disagreement regarding the guiding principles for surrogate decision-making. Future research is needed to assess this disagreement and consider ways to address it. (shrink)

Structural requirements of rationality prohibit various things, like having inconsistent combinations of attitudes, having means-end incoherent combinations of attitudes, and so on. But what is the distinctive feature of structural requirements of rationality? And do we fall under an obligation to be structurally rational? These issues have been at the heart of significant debates over the past fifteen years. Some philosophers have recently argued that we can unify the structural requirements of rationality by analyzing what is constitutive of our attitudes (...) (Lee, 2020; Worsnip, 2018a). It has also been suggested that, in the course of good first-personal deliberation, agents should treat structurally irrational combinations of attitudes as off-limits (Worsnip, 2021). In this paper, I raise a worry for these two theses concerning structural rationality. Roughly, I argue that some imperfect epistemic agents (like us) can be disposed to have structurally irrational combinations of attitudes. Also, when these imperfect agents deliberate, they should not treat structurally irrational combinations of attitudes as off-limits. Given our imperfections, being structurally irrational can very well be the best option we have. More generally, these observations reveal that structural rationality should not always be theorized independently from more “substantive” norms, like responsiveness to reasons or expected value optimization. (shrink)

Richard Pettigrew offers an extended investigation into a particular way of justifying the rational principles that govern our credences. The main principles that he justifies are the central tenets of Bayesian epistemology, though many other related principles are discussed along the way. Pettigrew looks to decision theory in order to ground his argument. He treats an agent's credences as if they were a choice she makes between different options, gives an account of the purely epistemic utility enjoyed by different sets (...) of credences, and then appeals to the principles of decision theory to show that, when epistemic utility is measured in this way, the credences that violate the principles listed above are ruled out as irrational. The account of epistemic utility set out here is the veritist's: the sole fundamental source of epistemic utility for credences is their accuracy. Thus, Pettigrew conducts an investigation in the version of epistemic utility theory known as accuracy-first epistemology. (shrink)

This comprehensive book covers the research, theory, policy and practice context of unusual reproduction using third parties. Olga Van den Akker details the psychological adaptation required to continuing changes in public opinion, advances in technologies and new legislations in surrogate motherhood and discusses their impact at an individual, societal and global level. She describes the competing interests and interactions between legal, organisational, personal, social, psychological and cultural issues in relation to biological and genetic surrogate and commissioning parenthood. This (...) book is intended for professionals, practitioners, academics and students interested in the complexities of unusual reproduction using multidisciplinary perspectives. (shrink)

In Accuracy and the Laws of Credence Richard Pettigrew assumes a particular view of belief, which states that people don't have any other doxastic states besides credences. This is in tension with the popular position that people have both credences and outright beliefs. Pettigrew claims that such a dual view of belief is incompatible with the accuracy-first approach. I argue in this paper that it is not. This is good news for Pettigrew, since it broadens the appeal of (...) his framework. (shrink)

In Bayesian epistemology, the problem of the priors is this: How should we set our credences (or degrees of belief) in the absence of evidence? That is, how should we set our prior or initial credences, the credences with which we begin our credal life? David Lewis liked to call an agent at the beginning of her credal journey a superbaby. The problem of the priors asks for the norms that govern these superbabies. -/- The Principle of Indifference gives a (...) very restrictive answer. It demands that such an agent divide her credences equally over all possibilities. That is, according to the Principle of Indifference, only one initial credence function is permissible, namely, the uniform distribution. In this paper, we offer a novel argument for the Principle of Indifference. I call it the Argument from Accuracy. (shrink)

Accuracy arguments for the core tenets of Bayesian epistemology differ mainly in the conditions they place on the legitimate ways of measuring the inaccuracy of our credences. The best existing arguments rely on three conditions: Continuity, Additivity, and Strict Propriety. In this paper, I show how to strengthen the arguments based on these conditions by showing that the central mathematical theorem on which each depends goes through without assuming Additivity.

Two different programmes are in the business of explicating accuracy—the truthlikeness programme and the epistemic utility programme. Both assume that truth is the goal of inquiry, and that among inquiries that fall short of realizing the goal some get closer to it than others. Truthlikeness theorists have been searching for an account of the accuracy of propositions. Epistemic utility theorists have been searching for an account of the accuracy of credal states. Both assume we can make cognitive (...) progress in an inquiry even while falling short of the target. I show that the prospects for combining these two programmes are bleak. A core accuracy principle, proximity, that is universally embraced within the truthlikeness programme turns out to be incompatible with a central principle within the epistemic utility programme, namely propriety. 1Truthlikeness and Epistemic Utility 2Inquiries 3Accuracy for Propositions 4Proximity 5Accuracy for Credal States 6Propriety 7Proximity for Credal States 8Extensionality 9Admissible Weightings 10Propriety Violates Proximity 11Possible Responses 11.1Retreat to convexity 11.2Reject boundedness 11.3Reject additivity 12The Upshot. (shrink)

Epistemic decision theorists aim to justify Bayesian norms by arguing that these norms further the goal of epistemic accuracy—having beliefs that are as close as possible to the truth. The standard defense of Probabilism appeals to accuracy dominance: for every belief state that violates the probability calculus, there is some probabilistic belief state that is more accurate, come what may. The standard defense of Conditionalization, on the other hand, appeals to expected accuracy: before the evidence is in, (...) one should expect to do better by conditionalizing than by following any other rule. We present a new argument for Conditionalization that appeals to accuracy‐dominance, rather than expected accuracy. Our argument suggests that Conditionalization is a rule of coherence: plans that conflict with Conditionalization don't just prescribe bad responses to the evidence; they also give rise to inconsistent attitudes. (shrink)

Credences, unlike full beliefs, can’t be true or false. So what makes credences more or less accurate? This chapter offers a new answer to this question: credences are accurate insofar as they license true educated guesses, and less accurate insofar as they license false educated guesses. This account is compatible with immodesty; : a rational agent will regard her own credences to be best for the purposes of making true educated guesses. The guessing account can also be used to justify (...) certain coherence constraints on rational credence, such as probabilism. The chapter concludes by discussing some advantages of the guessing account over rival accounts of accuracy. (shrink)

Some of the most interesting recent work in formal epistemology has focused on developing accuracy-based approaches to justifying Bayesian norms. These approaches are interesting not only because they offer new ways to justify these norms, but because they potentially offer a way to justify all of these norms by appeal to a single, attractive epistemic goal: having accurate beliefs. Recently, Easwaran & Fitelson (2012) have raised worries regarding whether such “all-accuracy” or “purely alethic” approaches can accommodate and justify (...) evidential Bayesian norms. In response, proponents of purely alethic approaches, such as Pettigrew (2013b) and Joyce (2016), have argued that scoring rule arguments provide us with compatible and purely alethic justifications for the traditional Bayesian norms, including evidential norms. In this paper I raise several challenges to this claim. First, I argue that many of the justifications these scoring rule arguments provide are not compatible. Second, I raise worries for the claim that these scoring rule arguments provide purely alethic justifications. Third, I turn to assess the more general question of whether purely alethic justifications for evidential norms are even possible, and argue that, without making some contentious assumptions, they are not. Fourth, I raise some further worries for the possibility of providing purely alethic justifications for content-sensitive evidential norms, like the Principal Principle. (shrink)

Accuracy‐first epistemology is an approach to formal epistemology which takes accuracy to be a measure of epistemic utility and attempts to vindicate norms of epistemic rationality by showing how conformity with them is beneficial. If accuracy‐first epistemology can actually vindicate any epistemic norms, it must adopt a plausible account of epistemic value. Any such account must avoid the epistemic version of Derek Parfit's “repugnant conclusion.” I argue that the only plausible way of doing so is to say (...) that accurate credences in certain propositions have no, or almost no, epistemic value. I prove that this is incompatible with standard accuracy‐first arguments for probabilism, and argue that there is no way for accuracy‐first epistemology to show that all credences of all agents should be coherent. (shrink)

It is usually taken for granted, in discussions about fiction, that real things or events can occur as referents of fictional names . In this paper, I take issue with this view, and provide several arguments to the effect that it is better to take the names in fiction to refer to fictional surrogates of real objects. Doing so allows us to solve a series of problems that arise on the reference-continuity view. I also show that the arguments philosophers usually (...) rely on in order to ban surrogates are not as serious as they have been taken to be. In the first part of the paper, I describe the two conflicting views. In the second part, I discuss several specific arguments in favor of surrogates. In the third part I take up the kind of reasons ordinarily offered against them. (shrink)

This paper accomplishes two tasks. First, I examine in detail Edmund Husserl’s earliest philosophy of surrogates, as it is found in his 1890 “On the Logic of Signs ”. I analyze his psychological and logical investigations of surrogates, where the former is concerned with explaining how these signs function and the latter with how they do so reliably. His differentiation of surrogates on the basis of their genetic origins and degrees of necessity is discussed. Second, the historical importance of this (...) text is disclosed by showing how Semiotic serves as both the inspiration for, and the foil to, Husserl’s 1901 First Logical Investigation. Husserl not only adopts the idea that linguistic signs can function via association, but also maintains that such signs can motivate me to execute one of two experiences. The key difference between the texts is that Husserl abandons his theory of surrogates in 1901, instead holding that I can experience absent objects by means of empty intentions. The reasons why Husserl found it necessary to transform this tenet of his philosophy are discussed at length. (shrink)

How shall we decide for others who cannot decide for themselves? And who—or what, in the case of artificial intelligence — should make the decision? The present issue of the journal tackles several interrelated topics, many of them having to do with surrogate decision making. For example, the feature article by Jardas et al 1 explores the potential use of artificial intelligence to predict incapacitated patients’ likely treatment preferences based on their sociodemographic characteristics, raising questions about the means by (...) which we come to decide for others. And a clinical ethics round table led by Wilkinson and Pillay2 examines the case of a premature baby on life support whose primary surrogate is herself incapacitated. Together, these examples force us to think more deeply about the meaning and significance of taken-for-granted concepts: respect for autonomy, substituted judgement, best interests. We’ll consider the baby first and then turn to AI. “Baby T” is a critically ill newborn delivered prematurely by emergency caesarean section. The mother had entered into a surrogacy arrangement with a same-sex male couple, the intended parents, who were to take over the baby’s care after birth—just as soon as a formal parental order could be obtained through the court. Until then, the birth mother, who had used her own eggs to conceive Baby T along with sperm from an unidentified donor, would have legal and ethical responsibility to decide about the baby’s care. Unfortunately, she too was in critical condition, having fallen unconscious prior to delivery due to a sudden brain haemorrhage. She remained unconscious, and thus incapacitated, during a crucial period in which time-sensitive decisions about Baby T’s care needed to be made, including whether to continue life support. Given the mother’s incapacity, who should …. (shrink)

There is a well-known equivalence between avoiding accuracy dominance and having probabilistically coherent credences (see, e.g., de Finetti 1974, Joyce 2009, Predd et al. 2009, Pettigrew 2016). However, this equivalence has been established only when the set of propositions on which credence functions are defined is finite. In this paper, I establish connections between accuracy dominance and coherence when credence functions are defined on an infinite set of propositions. In particular, I establish the necessary results to extend the (...) classic accuracy argument for probabilism to certain classes of infinite sets of propositions including countably infinite partitions. (shrink)

Recently, several epistemologists have defended an attractive principle of epistemic rationality, which we shall call Ur-Prior Conditionalization. In this essay, I ask whether we can justify this principle by appealing to the epistemic goal of accuracy. I argue that any such accuracy-based argument will be in tension with Evidence Externalism, i.e., the view that agent's evidence may entail non-trivial propositions about the external world. This is because any such argument will crucially require the assumption that, independently of all (...) empirical evidence, it is rational for an agent to be certain that her evidence will always include truths, and that she will always have perfect introspective access to her own evidence. This assumption is in tension with Evidence Externalism. I go on to suggest that even if we don't accept Evidence Externalism, the prospects for any accuracy-based justification for Ur-Prior Conditionalization are bleak. (shrink)

A diagnosis of fetal abnormality presents parents with a difficult – even tragic – moral dilemma. Where this diagnosis is made in the context of surrogate motherhood there is an added difficulty, namely that it is not obvious who should be involved in making decisions about abortion, for the person who would normally have the right to decide – the pregnant woman – does not intend to raise the child. This raises the question: To what extent, if at all, (...) should the intended parents be involved in decision-making? In commercial surrogacy it is thought that as part of the contractual agreement the intended parents acquire the right to make this decision. By contrast, in altruistic surrogacy the pregnant woman retains the right to make these decisions, but the intended parents are free to decide not to adopt the child. We argue that both these strategies are morally unsound, and that the problems encountered serve to highlight more fundamental defects within the commercial and altruistic models, as well as in the legal and institutional frameworks that support them. We argue in favour of the professional model, which acknowledges the rights and responsibilities of both parties and provides a legal and institutional framework that supports good decision-making. In particular, the professional model acknowledges the surrogate's right to decide whether to undergo an abortion, and the intended parents' obligation to accept legal custody of the child. While not solving all the problems that arise in surrogacy, the model provides a framework that supports good decision-making. (shrink)

Epistemic decision theory produces arguments with both normative and mathematical premises. I begin by arguing that philosophers should care about whether the mathematical premises (1) are true, (2) are strong, and (3) admit simple proofs. I then discuss a theorem that Briggs and Pettigrew (2020) use as a premise in a novel accuracy-dominance argument for conditionalization. I argue that the theorem and its proof can be improved in a number of ways. First, I present a counterexample that shows that (...) one of the theorem’s claims is false. As a result of this, Briggs and Pettigrew’s argument for conditionalization is unsound. I go on to explore how a sound accuracy-dominance argument for conditionalization might be recovered. In the course of doing this, I prove two new theorems that correct and strengthen the result reported by Briggs and Pettigrew. I show how my results can be combined with various normative premises to produce sound arguments for conditionalization. I also show that my results can be used to support normative conclusions that are stronger than the one that Briggs and Pettigrew’s argument supports. Finally, I show that Briggs and Pettigrew’s proofs can be simplified considerably. (shrink)

Many have claimed that epistemic rationality sometimes requires us to have imprecise credal states (i.e. credal states representable only by sets of credence functions) rather than precise ones (i.e. credal states representable by single credence functions). Some writers have recently argued that this claim conflicts with accuracy-centered epistemology, i.e., the project of justifying epistemic norms by appealing solely to the overall accuracy of the doxastic states they recommend. But these arguments are far from decisive. In this essay, we (...) prove some new results, which show that there is little hope for reconciling the rationality of credal imprecision with accuracy-centered epistemology. (shrink)