In lieu of an abstract, here is a brief excerpt of the content:Comme Elle Respire:Memory of Breath, Breath of MemoryFrédérique Berthet (bio)Translated by David F. Bell (bio)La poésie est un système de respiration, c'est fait pour mieux respirer.[Poetry is a respiration system, it's made for breathing better.]—Erri De Luca- Stop!- What?- I can hear you breathing!...- Stop!- Breathing?- Yes!—Paul Thomas AndersonLittle paper-fish cutouts have been placed on the ground, on the carpet.We're in the reassuring '70s stylishness of a doctor's office. (...) The carpet is soft and glistens like in interior decoration magazines, it's with it, in. We couldn't care less about what Dyson vacuum cleaners and "purifiers" boast they can eliminate several decades later: acarids, those microscopic domestic arthropods, human parasites (notably), and airborne vectors of infectious disease (colds, coughs, respiratory distress). No, in the spring of 1975, innocently and self-satisfyingly, the urbane doctor flaunts the opulent carpet with curly pile in his luxury apartment with its state-of-the-art waiting room.In this grand interior of a medical office, a man in a white coat plies his important trade. For example, that day a little girl is re-learning how to breathe. One might think that exhaling and inhaling is learned for life—je t'aime comme je respire, elle parle comme elle respire, il ment comme il respire1—from the very first cry at birth. But in fact, sometimes in life breathing gets stuck between the nasal cavity and the bronchial tubes, between the respiratory tract and the lungs. Progressively, imperceptibly, the organism is short of air, a malicious infection spreads and impairs [End Page 92] alveolar diffusion to the point of respiratory exhaustion: Is it serious, doctor? We must act quickly, very quickly. How to liquify what stopped up the system one day to the point of blocking it—the doctors know what to do.This doctor undertook long, arduous and learned studies. He knows functionally how a living being breathes, how a child lives organically. He can also re-teach the little girl what she no longer knows how to do: inhale, exhale using the full volume of the thoracic cage, regulating the ventilatory flow, solidifying the invisible membranes. In the child's family, everyone knows (and knows how to do) important things, but no one undertook extensive studies, much less studies of the aerial exchanges in the human body. This special knowledge possessed by the doctor (unless special means something else unspoken that would explain why this specific doctor was chosen rather than any other) surrounds him with a padding of respect that creates (and the little girl feels this) a sort of protective continuum between him and the walls within which he sees her, where he practices his kind of calm and slow urbane medicine. It's far from the formidable hospital she has just left, with its spherical apparatus next to the bed aspirating the red and yellow pleural liquid, the "treatment room" where the surgeon, the "butcher" as the nurses call him among themselves, manipulated the drain without anesthesia, with no regard for the child's suffering. The doctor, and his place in the elevated tower, even though they are not to be confused, make for a cozy reception space in which one is comfortable, even in passing.This doctor—who is, in truth, a massage-physiotherapist—is located in a designer high-rise building with a façade decorated by white, pointed features that manifest a will toward an architectural act. On the ground floor, the entrance hall is finished in dark-veined, clear brown marble, and the entry threshold between the exterior and interior is marked by large transparent glass panes that must be manipulated with care. The entrance hall has an intimidating sonority and a useless cold nudity from which one escapes in an elevator where one is surrounded by mirrors and gold buttons and in which one speeds upward silently toward floors, clouds.The designer high-rise is located at the outskirts, the outskirts of a city of recent Olympic stature, where several years earlier Olympic athletes were welcomed and trained to increase their respiratory capacity and... (shrink)

In response to the COVID‐19 pandemic philosophers and governments have proposed scarce resource allocation guidelines. Their purpose is to advise healthcare professionals on how to ethically allocate scarce medical resources. One challenging feature of the pandemic has been the large numbers of patients needing mechanical ventilatory support. Guidelines have paradigmatically focused on the question of what doctors should do if they have fewer ventilators than patients who need respiratory support: which patient should get the ventilator? There is, however, an (...) important higher level allocation problem. Namely, how are we to ethically distribute newly obtained ventilators across hospitals: which hospital should get the ventilator(s)? In this paper, we identify a set of principles for allocating newly obtained ventilators across hospitals. We focus particularly on low and middle income countries, who frequently have limited pre‐existing intensive care capacity, and have needed to source additional ventilators. We first provide some background. Second, we argue that the main population healthcare aim during the COVID‐19 pandemic should be to save the most lives. Next, we assess a series of potential heuristics or principles that could be used to guide allocation: allocation to the most densely populated cities, random allocation, allocation based on the ratio of patients to ICU personnel, prioritisation in terms of intrahospital mortality, prioritisation of younger populations, and prioritisation in terms of population mortality. We conclude by providing a plausible ranking of the principles, while noting a number of epistemological challenges, in terms of how they best further the aim of increasing the probability of saving the most lives. (shrink)

Misunderstanding of the dynamical behavior of the ventilatory system, especially under assisted ventilation, may explain the problems encountered in ventilatory support monitoring. Proportional assist ventilation (PAV) that theoretically gives a breath by breath assistance presents instability with high levels of assistance. We have constructed a mathematical model of interactions between three objects: the central respiratory pattern generator modelled by a modified Van der Pol oscillator, the mechanical respiratory system which is the passive part of the system and a (...) controlled ventilator that follows its own law. The dynamical study of our model shows the existence of two crucial behaviors, i.e. oscillations and damping, depending on only two parameters, namely the time constant of the mechanical respiratory system and a cumulative interaction index. The same result is observed in simulations of spontaneous breathing as well as of PAV. In this last case, increasing assistance leads first to an increase of the tidal volume (VT), a further increase in assistance inducing a decrease in VT, ending in damping of the whole system to an attractive fixed point. We conclude that instabilities observed in PAV may be explained by the different possible dynamical behaviors of the system rather than changes in mechanical characteristics of the respiratory system. (shrink)

We ordinarily suppose that there is a difference between having and failing to exercise a rational capacity on the one hand, and lacking a rational capacity altogether on the other. This is crucial for our allocations of responsibility. Someone who has but fails to exercise a capacity is responsible for their failure to exercise their capacity, whereas someone who lacks a capacity altogether is not. However, as Gary Watson pointed out in his seminal essay ’Skepticism (...) about Weakness of Will’, the idea of an unexercised capacity is much more difficult to make sense of than it initially appears. The aim of ’Rational Capacities’ is to provide the needed explication of this idea. (shrink)

To systematically compare welfare across species, it is first necessary to explore whether welfare subjects of different species have the same or rather a different capacity for welfare. According to what seems to be the dominant philosophical view, welfare subjects with higher cognitive capacities have a greater capacity for welfare and are generally much better off than those with lower cognitive capacities. Višak carefully explores and rejects this view and argues instead that welfare subjects of different species have (...) the same capacity for welfare despite different cognitive capacities. This book prepares the philosophical ground for comparisons of welfare across species. It will inform and inspire ethicists and animal welfare scientists alike, as well as a broader readership interested in wellbeing, animals, and ethics. (shrink)

Working memory limits are best defined in terms of the complexity of the relations that can be processed in parallel. Complexity is defined as the number of related dimensions or sources of variation. A unary relation has one argument and one source of variation; its argument can be instantiated in only one way at a time. A binary relation has two arguments, two sources of variation, and two instantiations, and so on. Dimensionality is related to the number of chunks, because (...) both attributes on dimensions and chunks are independent units of information of arbitrary size. Studies of working memory limits suggest that there is a soft limit corresponding to the parallel processing of one quaternary relation. More complex concepts are processed by or In segmentation, tasks are broken into components that do not exceed processing capacity and can be processed serially. In conceptual chunking, representations are to reduce their dimensionality and hence their processing load, but at the cost of making some relational information inaccessible. Neural net models of relational representations show that relations with more arguments have a higher computational cost that coincides with experimental findings on higher processing loads in humans. Relational complexity is related to processing load in reasoning and sentence comprehension and can distinguish between the capacities of higher species. The complexity of relations processed by children increases with age. Implications for neural net models and theories of cognition and cognitive development are discussed. (shrink)

In this paper we present an account of practical rationality and weakness of will in terms of rational capacities. We show how our account rectifies various shortcomings in Michael Smith's related theory. In particular, our account is capable of accommodating cases of weak-willed behaviour that are not `akratic', or otherwise contrary to the agent's better judgement. Our account differs from Smith's primarily by incorporating resolve: a third rational capacity for resolute maintenance of one's intentions. We discuss further two ways (...) to explain the importance of resolve to practical rationality: one based on Richard Holton's recent work, and an alternative, non-consequentialist account. (shrink)

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

Marshall et al. (2024) raise questions regarding patient refusals of care. In this commentary we address refusals of care from the lens of patient autonomy and provide suggestions for patient cente...

Capacity evaluation has become a widely used assessment device in clinical practice to determine whether patients have the cognitive ability to render their own medical decisions. Such evaluations, which might be better thought of as “capacity challenges,” are generally thought of as benign tools used to facilitate care. This paper proposes that such challenges should be reconceptualized as significant medical interventions with their own set of risks, side effects, and potentially deleterious consequences. As a result, a cost–benefit analysis (...) should be implemented prior to imposing such capacity challenges, and efforts should be made to minimize such challenges in situations where they are unlikely to alter the course of treatment. (shrink)

In paradigm exercises of agency, individuals guide their activities toward some goal. A central challenge for action theory is to explain how individuals guide. This challenge is an instance of the more general problem of how to accommodate individuals and their actions in the natural world, as explained by natural science. Two dominant traditions–primitivism and the causal theory–fail to address the challenge in a satisfying way. Causal theorists appeal to causation by an intention, through a feedback mechanism, in explaining guidance. (...) Primitivists postulate primitive agential capacities in their explanations. The latter neglect to explain how primitive capacities integrate with findings from natural science. The former do not explain why some feedback mechanism’s activity amounts to the agent’s guidance. In this paper I argue that both traditions should acknowledge a capacity to guide, as actually constituted by the executive system. I argue that appeals to this empirically discovered psychological system explain how individuals guide in a way that integrates with explanations from cognitive science. Individuals’ capacity to guide is embedded in the natural world through the activity of its constituent (mechanistic) components. (shrink)

IntroductionRights-ethicists intensely debate what properties of an individual are necessary and sufficient in order for that individual to have moral rights. At the heart of this important debate is the issue of whether individuals such as human foetuses, infants, and unconscious adults have moral rights, and if so, what these rights are. This paper focuses on the moral status of unconscious adults, as well as human foetuses, which are potential agents in the sense that they follow a “normal” path of (...) development towards agency. Using Michael Tooley’s (Tooley 1983) and Jeff McMahan’s (McMahan 2002) influential discussions on this topic as a point of departure, this paper defends two claims. (1) Possession of the capacity for autonomous agency that is temporarily “blocked” by sleep or coma is sufficient in order for an individual to have intrinsic worth and thus, moral rights. (2) If possession of the blocked capacity for autonomous agency is sufficient in order for an individual to hav. (shrink)

Addiction of the variety discussed in this chapter, is a condition that by its very nature compromises decision-making capacity across the decisional spectrum. The impairment is present not only at moments of withdrawal and intoxication, but at all stages of the active addictive cycle, as long as the pathological dispositions to overvalue addictive drugs remain entrenched and operative. In light of this entrenched and pervasive reorientation in pathological values, it seems reasonable to question the unilateral presumption of capacity (...) for cases of this sort. The reason is that there is an important, but restricted, sense in which the addicted individuals in question are not ‘responsible’ for their decisions regarding drug use. The high likelihood of relapse means that, as a clinical matter of fact, they are usually not accountable. At the same time, clinical experience also suggests that we should treat addicted individuals as if they are responsible because that empowerment is crucial to their recovery. In the end, there is probably only one safe course of action to take when faced with such a difficult situation. This is to suspend the unilateral global presumption of capacity and instead assess decision-making capacity on a case-by-case basis, with careful monitoring and encouragement. (shrink)

Despite their importance in the history of philosophy and in particular in the work of Aristotle and Kant, mental capacities have been neglected in recent philosophical work. By contrast, the notion of a capacity is deeply entrenched in psychology and the brain sciences. Driven by the idea that a cognitive system has the capacity it does in virtue of its internal components and their organization, it is standard to appeal to capacities in cognitive psychology. The main benefit of (...) invoking capacities in an account of the mind is that it allows for an elegant counterfactual analysis of mental states: it allows us to analyze mental states on three distinct yet interrelated levels. A first level of analysis pertains to the function of mental capacities. A second level of analysis pertains to the mental capacities employed, irrespective of the context in which they are employed. A third level of analysis pertains to the mental capacities employed, taking into account the context in which they are employed. This paper develops an account of perceptual capacities. This account involves an analysis of their function, their individuation and possession conditions, the relation between perceptual capacities and their employment, as well as their informational and neural base conditions. (shrink)

The situationist experiments demonstrate that most people's behaviour is influenced by environmental factors much more than we expect, and that ordinary people can be led to behave very immorally. A number of philosophers have investigated whether these experiments demonstrate that subjects' responsibility-relevant capacities are impeded. This paper considers how, in practice, we can assess when agents have a reduced capacity to avoid wrongdoing. It critiques some previously offered strategies including appeals to the reasonable person standard, appeals to counterfactuals and (...) understandability of behaviour, and appeals to base rates of wrongdoing. It then proposes we should think a certain factor impeded capacities when this is the best explanation of a change in patterns of responses. With this approach in hand, I then argue that subjects in many of the situationist experiments are (mostly) excused for their actions. (shrink)

Many debates about the moral status of things—for example, debates about the natural rights of human fetuses or nonhuman animals—eventually migrate towards a discussion of the capacities of the things in question—for example, their capacities to feel pain, think, or love. Yet the move towards capacities is often controversial: if a human’s capacities are the basis of its moral status, how could a human having lesser capacities than you and I have the same "serious" moral status as you and I? (...) This book answers this question by arguing that if something is human, it has a set of typical human capacities; that if something has a set of typical human capacities, it has serious moral status; and thus all human beings have the same sort of serious moral status as you and I. Beginning from what our common intuitions tell us about situations involving "temporary incapacitation"—where a human organism has, then loses, then regains a certain capacity—this book argues for substantive conclusions regarding human fetuses and embryos, humans in a permanent vegetative state, humans suffering from brain diseases, and humans born with genetic disorders. Since these conclusions must have some impact on our ongoing moral and political debates about the proper treatment of such humans, this book will be useful to professionals and students in philosophy, bioethics, law, medicine, and public policy. (shrink)

This article presents an overview for clinician investigators on the concepts of decision-making capacity and vulnerability as related to human subjects research. Tools for capacity assessment and unacknowledged sources of vulnerability are discussed, and the practical gaps in current informed consent requirements related to impaired capacity and potential vulnerability are described. Options are suggested for research discussions when full regulatory consent is not possible and an exception from informed consent does not apply.

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)

The model for capacity assessment in the United States and much of the Western world relies upon the demonstration of four skills including the ability to communicate a clear, consistent choice. Yet such assessments often occur at only one moment in time, which may result in the patient expressing a choice to the evaluator that is highly inconsistent with the patient’s underlying values and goals, especially if a short-term factor (such as frustration with the hospital staff) distorts the patient’s (...) preferences momentarily. These challenges are particularly concerning in cases, which arise frequently in hospital settings, in which patients demand immediate self-discharge, often during off-hours, while faced with life-threatening risks. This paper examines the distinctive elements that shape such cases and explores their ethical implications, ultimately offering a model for such situations that can be operationalized. (shrink)

Gilbert Ryle's distinction between knowledge-how and knowledge-that faces a significant challenge: accounting for the unity of knowledge. Jason Stanley, an ‘intellectualist’ opponent of Ryle's, brings out this problem by arguing that Ryleans must treat ‘know’ as an ambiguous word and must distinguish knowledge proper from knowledge-how, which is ‘knowledge’ only so-called. I develop the challenge and show that underlying Ryle's distinction is a unified vision of knowledge as ‘a capacity to get things right’, covering both knowledge-how and knowledge-that. I (...) show how Ryle specifies the general notion into knowledge-how and knowledge-that and discuss the mutual interdependence exhibited by the two forms of knowledge. Ryle's positive view of knowledge, properly understood, emerges as an important, neglected, alternative which should be brought back into the ongoing conversation about practical and theoretical knowledge. (shrink)

Decision-Making Capacity First published Tue Jan 15, 2008; substantive revision Fri Aug 14, 2020 In many Western jurisdictions the law presumes that adult persons, and sometimes children that meet certain criteria, are capable of making their own medical decisions; for example, consenting to a particular medical treatment, or consenting to participate in a research trial. But what exactly does it mean to say that a subject has or lacks the requisite capacity to decide? This question has to do (...) with what is commonly called “decisional capacity”, a central concept in health care law and ethics, and increasingly an independent topic of philosophical inquiry. -/- Decisional capacity can be defined as the ability of subjects to make their own medical decisions. Somewhat similar questions of capacity arise in other contexts, such as capacity to stand trial in a court of law and the ability to make decisions that relate to personal care and finances. However, the history behind the more general legal notions of capacity to stand trial and capacity to manage one’s life is different and operates somewhat differently in law (Roth, Meisel, & Litz 1977; Zapf & Roesch 2005). For the purposes of this discussion the notion of decisional capacity will be limited to medical contexts only; most notably, those where decisions to consent or to refuse treatment or participation in clinical research are concerned. (shrink)

Gilbert Ryle's distinction between knowledge-how and knowledge-that faces a significant challenge: accounting for the unity of knowledge. Jason Stanley, an ‘intellectualist’ opponent of Ryle's, brings out this problem by arguing that Ryleans must treat ‘know’ as an ambiguous word and must distinguish knowledge proper from knowledge-how, which is ‘knowledge’ only so-called. I develop the challenge and show that underlying Ryle's distinction is a unified vision of knowledge as ‘a capacity to get things right’, covering both knowledge-how and knowledge-that. I (...) show how Ryle specifies the general notion into knowledge-how and knowledge-that and discuss the mutual interdependence exhibited by the two forms of knowledge. Ryle's positive view of knowledge, properly understood, emerges as an important, neglected, alternative which should be brought back into the ongoing conversation about practical and theoretical knowledge. (shrink)

The capacity to designate a surrogate is not simply another kind of medical decision-making capacity. A patient with DMC can express a preference, understand information relevant to that choice, appreciate the significance of that information for their clinical condition, and reason about their choice in light of their goals and values. In contrast, a patient can possess the CDS even if they cannot appreciate their condition or reason about the relative risks and benefits of their options. Patients who (...) lack DMC for many or most kinds of medical choices may nonetheless possess the CDS, particularly since the complex means-ends reasoning required by DMC is one of the first capacities to be lost in progressive cognitive diseases. That is, patients with significant cognitive decline or mental illness may still understand what a surrogate does, express a preference about a potential surrogate, and be able to provide some kind of justification for that selection. Moreover, there are many legitimate and relevant rationales for surrogate selection that are inconsistent with the reasoning criterion of DMC. Unfortunately, many patients are prevented from designating a surrogate if they are judged to lack DMC. When such patients possess the CDS, this practice is ethically wrong, legally dubious and imposes avoidable burdens on healthcare institutions. (shrink)

The notion of a capacity in the sense of a power to bring about or undergo change plays a key role in Aristotle’s theories about the natural world. However, in Metaphysics Θ Aristotle also extends ‘ capacity ’, and the corresponding concept of ‘activity’, to cases where we want to say that something is in capacity, or in activity, such and such but not, or not directly, in virtue of being capable of initiating or undergoing change. This (...) paper seeks to clarify and confirm a certain view of how Aristotle wishes us to see the relationship between the two uses of ‘ capacity ’ and ‘activity’. To that end, I consider also Aristotle’s employment of the terms in the De Anima, which sheds light on the key examples which direct the discussion in Metaph. Θ. (shrink)

When a patient lacks decision-making capacity, then according to standard clinical ethics practice in the United States, the health care team should seek guidance from a surrogate decision-maker, either previously selected by the patient or appointed by the courts. If there are no surrogates willing or able to exercise substituted judgment, then the team is to choose interventions that promote a patient’s best interests. We argue that, even when there is input from a surrogate, patient preferences should be an (...) additional source of guidance for decisions about patients who lack decision-making capacity. (shrink)

_ Source: _Volume 60, Issue 1, pp 88 - 126 The dominant interpretation of Metaphysics Θ.8 commits Aristotle to the claim that the heavenly bodies’ eternal movements are not the exercises of capacities. Against this, I argue that these movements are the result of necessarily exercised capacities. I clarify what it is for a heavenly body to possess a nature and argue that a body’s nature cannot be a final cause unless the natural body possesses capacities that are exercised for (...) the sake of its nature qua form. This discussion yields a better understanding of what capacities are, what explanatory work capacities do, and what it is to possess a nature. (shrink)

This paper argues that research on the business case for corporate social responsibility (CSR) must account for the path dependent nature of firm-stakeholderrelations, and develops the construct of stakeholder influence capacity (SIC) to fill this void. SIC helps to explain why the effects of CSR on corporate financial performance (CFP) vary across firms and across time, therein providing a missing link in the study of the business case. This paper distinguishes CSR from related and confounded corporate resource allocations and (...) from corporate social performance (CSP), then incorporates SIC into a model that explains how acts of CSR are transformed into CFP through stakeholder relationships. This paper also develops a set of propositions to aid future research on the contingencies that produce variable financial returns to investments in CSR. (shrink)

In this paper I criticize Cartwright's analysis of capacities and offer an alternative analysis. I argue that Cartwright's attempt to connect capacities to her condition CC fails because individuals can exercise capacities only in certain contexts. My own analysis emphasizes three features of capacities: 1) Capacities belong to individuals; 2) Capacities are typically not metaphysically fundamental properties of individuals, but can be explained by referring to structural properties of individuals; and 3) Laws are best understood as ascriptions of capacities.

In “Conscientious of the Conscious: Interactive Capacity as a Threshold Marker for Consciousness” (2013), Fischer and Truog argue that recent studies showing that some patients diagnosed as being in a vegetative state are in fact in a minimally conscious state raise various ethical questions for clinicians and family members. I argue that these findings raise a further ethical dilemma about how and whether to seek the involvement of the minimally conscious person herself in decisions about her care. There may (...) be a conflict between doing what is believed to accord with the patient’s prior stated wishes and/or her best interests, on the one hand, and respecting her own potential decision-making capacity and epistemic authority, on the other. (shrink)

This paper investigates the nature of dispositional properties in the context of artificial intelligence systems. We start by examining the distinctive features of natural dispositions according to criteria introduced by McGeer (2018) for distinguishing between object-centered dispositions (i.e., properties like ‘fragility’) and agent-based abilities, including both ‘habits’ and ‘skills’ (a.k.a. ‘intelligent capacities’, Ryle 1949). We then explore to what extent the distinction applies to artificial dispositions in the context of two very different kinds of artificial systems, one based on rule-based (...) classical logic and the other on reinforcement learning. Here we defend three substantive claims. First, we argue that artificial systems are not equal in the kinds of dispositional properties they instantiate. In particular, we show that logical systems instantiate merely object-centered dispositions whereas reinforcement learning systems allow for the instantiation of agent-based abilities. Second, we explore the similarities and differences between the agent-centered abilities of artificial systems and those of humans, especially as relates to the important distinction made in the human case between habits and skills/intelligent capacities. The upshot is that the agent-centered abilities of truly intelligent artificial systems are distinctive enough to constitute a third type of agent-based ability — blended agent-based ability — raising substantial questions as to how we understand the nature of their agency. Third, we explore one aspect of this problem, focussing on whether systems of this type are properly considered ‘responsible agents’, at least in some contexts and for some purposes. The ramifications of our analysis will turn out to be directly relevant to various ethical concerns of artificial intelligence. (shrink)

In "Rational Capacities" Michael Smith outlines the sense of capacity he believes to be required before blame is appropriate. I question whether this sense of capacity is required. In so doing, I consider different ways in which blame might be conditioned.

Background Bioethics and law distinguish between the practices of "physician-assisted death" and "allowing the patient to die." Discussion Advances in biotechnology have allowed medical devices to be used as destination therapy that are designed for the permanent support of cardiac function and/or respiration after irreversible loss of these spontaneous vital functions. For permanent support of cardiac function, single ventricle or biventricular mechanical assist devices and total artificial hearts are implanted in the body. Mechanical ventilators extrinsic to the body are used (...) for permanent support of respiration. Clinical studies have shown that destination therapy with ventricular assist devices improves patient survival compared to medical management, but at the cost of a substantial alteration in end-of-life trajectories. The moral and legal assessment of the appropriateness and permissibility of complying with a patient's request to electively discontinue destination therapy in a life-terminating act in non-futile situations has generated controversy. Some argue that complying with this request is ethically justified because patients have the right to request withdrawal of unwanted treatment and be allowed to die of preexisting disease. Other commentators reject the argument that acceding to an elective request for death by discontinuing destination therapy is 'allowing a patient to die' because of serious flaws in interpreting the intention, causation, and moral responsibility of the ensuing death. Summary Destination therapy with cardiac and/or ventilatory medical devices replaces native physiological functions and successfully treats a preexisting disease. We posit that discontinuing cardiac and/or ventilatory support at the request of a patient or surrogate can be viewed as allowing the patient to die if--and only if--concurrent lethal pathophysiological conditions are present that are unrelated to those functions already supported by medical devices in destination therapy. In all other cases, compliance with a patient's request constitutes physician-assisted death because of the pathophysiology induced by the turning off of these medical devices, as well as the intention, causation, and moral responsibility of the ensuing death. The distinction between allowing the patient to die and physician-assisted death is pivotal to the moral and legal status of elective requests for death by discontinuing destination cardiac and/or ventilatory medical devices in patients who are not imminently dying. This distinction also represents essential information that must be disclosed to patients and surrogates in advance of consent to this type of therapy. (shrink)

With the waves of reform occurring in mental health legislation in England and other jurisdictions, mental capacity is set to become a key medico-legal concept. The concept is central to the law of informed consent and is closely aligned to the philosophical concept of autonomy. It is also closely related to mental disorder. This paper explores the interdisciplinary terrain where mental capacity is located. Our aim is to identify core dilemmas and to suggest pathways for future interdisciplinary research. (...) The terrain can be separated into three types of discussion: philosophical, legal and psychiatric. Each discussion approaches mental capacity and judgmental autonomy from a different perspective yet each discussion struggles over two key dilemmas: whether mental capacity and autonomy is/should be a moral or a psychological notion and whether rationality is the key constitutive factor. We suggest that further theoretical work will have to be interdisciplinary and that this work offers an opportunity for the law to enrich its interpretation of mental capacity, for psychiatry to clarify the normative elements latent in its concepts and for philosophy to advance understanding of autonomy through the study of decisional dysfunction. The new pressures on medical and legal practice to be more explicit about mental capacity make this work a priority. (shrink)

Objectives: To investigate whether different methods of obtaining informed consent affected recruitment to a study of delirium in older, medically ill hospital inpatients.Design: Open randomised study.Setting: Acute medical service for older people in an inner city teaching hospital.Participants: Patients 70 years or older admitted to the unit within three days of hospital admission randomised into two groups.Intervention: Attempted recruitment of subjects to a study of the natural history of delirium. This was done by either a formal test of capacity, (...) followed by either a request for consent or an attempt at obtaining assent from a proxy, or a combined informal capacity/consent process.Main outcome measures: Prevalence and severity of delirium, and, as case mix measures, length of hospital stay and destination on discharge.Results: Recruitment of subjects through establishing formal capacity and then informed consent was less successful and, compared with those recruited through the usual combined capacity/consent approach, yielded a sample with less cognitive impairment, lower severity of delirium, lower probability of case note diagnosis of delirium and lower rate of entering a care home.Conclusions: Methods of obtaining informed consent may significantly influence the case mix of subjects recruited to a study of delirium. Stringent testing of capacity may exclude patients with delirium from studies, thus rendering findings less generalisable. A different method is necessary to achieve an ethical balance between respecting autonomy through obtaining adequate informed consent and avoiding sample bias. (shrink)

This paper argues for a sufficient evidence condition on knowledge and I argue that there is no belief condition on knowledge.

This article investigates whether or not theories of justice from political philosophy, first, support the position that health research should contribute to justice in global health, and second, provide guidance about what is owed by international clinical research (ICR) actors to parties in low- and middle-income countries. Four theories—John Rawls's theory of justice, the rights-based cosmopolitan theories of Thomas Pogge and Henry Shue, and Jennifer Ruger's health capability paradigm—are evaluated. The article shows that three of the four theories require the (...) conduct of health research for justice in global health. The theories help identify the ends of justice to which ICR is to contribute, but they cannot tell us how to organize ICR to promote these ends. Aside from Ruger's health capability paradigm, the theories also lack an allocative principle for assigning specific duties to specific actors. This creates difficulties for establishing obligations for certain types of ICR actors. (shrink)

Recent legal developments challenge how valid the concept of mental capacity is in determining whether individuals with impairments can make decisions about their care and treatment. Kong defends a concept of mental capacity but argues that such assessments must consider how relationships and dialogue can enable or disable the decision-making abilities of these individuals. This is thoroughly investigated using an interdisciplinary approach that combines philosophy and legal analysis of the law in England and Wales, the European Court of (...) Human Rights, and the United Nations Convention on the Rights of Persons with Disabilities. By exploring key concepts underlying mental capacity, the investigation concludes that both primary relationships and capacity assessments themselves must display key competencies to ensure that autonomy skills are promoted and encouraged. This ultimately provides scope for justifiable interventions into disabling relationships and articulates the dialogical practices that help better situate, interpret, and understand the choices and actions of individuals with impairments. (shrink)