We read with interest Lanphier and Anani’s manuscript on trauma-informed ethics consultation. Their model rightly integrates trauma-informed principles within the ethics c...

Not all hospital inpatients need the level of care uniquely available in the acute-care setting. In the United States, these longer-term, nonacute inpatients tend to be some combination of chronically ill, poor, homeless, undocumented, uninsured, and disabled—all groups who have struggled for health equity, political recognition, and voice. Even so, these “permanent patients” continue to receive care in one of the most expensive settings. This phenomenon is the result of federal legislation that creates an affirmative duty to care for all (...) able to access our emergency departments without also making safe housing available to all. A handful of federal laws and policies as well as a potpourri of state laws and policies are involved. (shrink)

In their target article, Doernberg and Truog (2023) correctly recognize that the doctor-patient relationship is considered a “fiduciary” relationship (i.e., other-regarding rather than self-interes...

Under what circumstances should the federal government pay for outpatient prescription drugs? Should the government (and by extension, taxpayers) pay for all of the drugs prescribed by health care providers, regardless of price or use—adhering to a medical standard? Or should taxpayers only pay for prescriptions supported by scientific evidence of effectiveness—a scientific standard?

Lawyers are most often portrayed and understood to be zealous advocates for individual clients in adversarial litigation or zero-sum transactions. Law schools provide excellent preparation for this type of lawyer role, but lawyers' unique understanding of the law is also needed for systemic advocacy, policymaking, and legal education to solve the most difficult societal problems. An interdisciplinary public health law class is one way for law schools to provide students an opportunity to explore and develop these other professional identities.

Hospital-dependent patients are individuals who are repeatedly readmitted to the hospital because their acute medical needs cannot be met elsewhere. Unlike the chronically critically ill, these patients do not have a continuous need for life-sustaining equipment and can experience periods of relative stability where they have a good quality of life. However, some end up spending months or even years in the hospital receiving resource-intensive care because they are unable to be safely discharged, despite an initial optimistic prognosis. It is (...) hard to reliably identify these patients on admission and more research is needed to better understand the unique medical needs of this population. But the inability to safely discharge these patients to their home or to a skilled nursing facility without rapid readmissions also creates ethical implications for the physicians who care for them. The aim of this paper is to clarify some of the ethical considerations involved in caring for hospital-dependent patients. Among physicians, the care of hospital-dependent patients is likely to disproportionately affect hospitalists and intensivists, whose care is often evaluated in terms of reducing patient length of stay and readmissions. Because hospital-dependent patients’ medical needs thwart the traditional goal of safe discharge, both clinical ethics and physicians’ professional obligations are implicated by their care. The inability to reliably identify these patients early can complicate discussions about treatment goals and informed consent. Similarly, the tremendous dedication of limited resources to these patients without safe discharge back to the community may raise concerns about the just allocation of healthcare resources. Our current acute care hospitals are not designed to provide long-term care for hospital-dependent patients. Unfortunately, safe discharge options remain elusive for these patients. Further research and support of this population is needed to more reliably identify hospital-dependent patients on admission, better inform the discussions of short- and long-term treatment goals, and more wisely allocate resources both within our acute care hospitals and larger healthcare system. (shrink)

Background Hospital-dependent patients are individuals who are repeatedly readmitted to the hospital because their acute medical needs cannot be met elsewhere. Unlike the chronically critically ill, these patients do not have a continuous need for life-sustaining equipment and can experience periods of relative stability where they have a good quality of life. However, some end up spending months or even years in the hospital receiving resource-intensive care because they are unable to be safely discharged, despite an initial optimistic prognosis. It (...) is hard to reliably identify these patients on admission and more research is needed to better understand the unique medical needs of this population. But the inability to safely discharge these patients to their home or to a skilled nursing facility without rapid readmissions also creates ethical implications for the physicians who care for them. The aim of this paper is to clarify some of the ethical considerations involved in caring for hospital-dependent patients. Main body Among physicians, the care of hospital-dependent patients is likely to disproportionately affect hospitalists and intensivists, whose care is often evaluated in terms of reducing patient length of stay and readmissions. Because hospital-dependent patients’ medical needs thwart the traditional goal of safe discharge, both clinical ethics and physicians’ professional obligations are implicated by their care. The inability to reliably identify these patients early can complicate discussions about treatment goals and informed consent. Similarly, the tremendous dedication of limited resources to these patients without safe discharge back to the community may raise concerns about the just allocation of healthcare resources. Conclusion Our current acute care hospitals are not designed to provide long-term care for hospital-dependent patients. Unfortunately, safe discharge options remain elusive for these patients. Further research and support of this population is needed to more reliably identify hospital-dependent patients on admission, better inform the discussions of short- and long-term treatment goals, and more wisely allocate resources both within our acute care hospitals and larger healthcare system. (shrink)

Melanie presented at twenty weeks of gestation to an obstetrics clinic in a critical access hospital in rural Vermont. She was excited to undergo routine fetal ultrasonography, but her obstetrician gave her grave news: the ultrasound revealed hypoplastic left heart syndrome, a devastating congenital heart defect. Initially, Melanie agreed in general to pursue surgical care for her fetus—a three‐stage process that has somewhat uncertain results and could only be done in tertiary care facilities far from her home in Vermont. A (...) week later, while the maternal fetal medicine and pediatric cardiology units made arrangements with colleagues in Boston, Melanie began having second thoughts. An ethics meeting was called to discuss conflicting clinician reactions to Melanie's dilemma. Most of the clinicians were stunned that the patient would change her mind. What advice should the ethics consultant offer the team about caring for Melanie? (shrink)

Multidrug resistant organisms are a public health threat that have reduced the effectiveness of many available antibiotics. Antimicrobial stewardship programs have been tasked with reducing antibiotic use and therefore the emergence of MDROs. While fecal microbiota transplant has been proposed as therapy to reduce patient colonization of MDROs, this will require additional evidence to support an expansion of the current clinical indication for FMT. This article discusses the evidence and ethics of the expanded utilization of FMT by ASPs for reasons (...) other than severe recurrent or refractory Clostridioides difficile infection. (shrink)

The coronavirus disease-2019 (COVID-19) has caused shortages of life-sustaining medical resources, and future waves of the virus may cause further scarcity. The Yale New Haven Health System developed a triage protocol to allocate scarce medical resources during the COVID-19 pandemic, with the primary goal of saving the most lives possible, and a secondary goal of making triage assessments and decisions consistent, transparent, and fair. We outline the process of developing the protocol, summarize the protocol, and discuss the major ethical challenges (...) encountered, along with our answers to the challenges. These challenges include (1) the role of age and chronic comorbidities; (2) evaluating children and pregnant patients; (3) racial, ethnic, and socioeconomic disparities in health; (4) prioritization of healthcare workers; and (5) balancing clinical judgment versus protocolized assessments.We conclude with a review of the limitations of our protocol and the lessons learned. We hope that a robust public discussion of such protocols and the ethical challenges they raise will result in the fairest possible processes, less need for triage, and more lives saved during future waves of the pandemic and similar public health emergencies. (shrink)

The increasing use of pharmacotherapy raises specific ethical concerns for psychologists working with vulnerable populations. Due to a shortage of trained specialists, professionals without training in mental health, such as primary care providers, are increasingly prescribing and monitoring psychotropic medications. Vulnerable populations face additional barriers to mental health treatment and are at heightened risk when these factors intersect. Hence, these patients experience unique barriers to receiving optimal psychopharmacological care and are differentially vulnerable to deleterious outcomes associated with misdiagnosis and overmedication. (...) Taken together, these factors fuel inequities in the access, quality, and utilization of mental health care. Psychologists working with these patients are ethically mandated to protect patients from harm and ensure equitable care across patient populations. Specifically, psychologists must respond to the dilemma of how to effectively treat patients within these vulnerable populations who have been misdiagnosed or poorly medicated while remaining within the bounds of their competence. This article recommends pathways to address these dilemmas through education, training, research, and advocacy. (shrink)

Among philosophical questions about human agency, one can distinguish in a rough and ready way between those that arise in philosophy of mind and those that arise in ethics. In philosophy of mind, one central aim has been to account for the place of agents in a world whose operations are supposedly ‘physical’. In ethics, one central aim has been to account for the connexion between ethical species of normativity and the distinctive deliberative and practical capacities of human beings. Ethics (...) then is involved with questions of moral psychology whose answers admit a kind of richness in the life of human beings from which the philosophy of mind may ordinarily prescind. Philosophy of mind, insofar as it treats the phenomenon of agency as one facet of the phenomenon of mentality, has been more concerned with how there can be ‘mental causation’ than with any details of a story of human motivation or of the place of evaluative commitments within such a story. (shrink)

Introduction -- Elucidating complexity theories -- Complexity in the natural sciences -- Complexity in social theory -- Towards transdisciplinarity -- Complexity in philosophy: complexification and the limits to knowledge -- Complexity in ethics -- Earth in the anthropocene -- Complexity and climate change -- American dreams, ecological nightmares and new visions -- Complexity and sustainability: wicked problems, gordian knots and synergistic solutions -- Conclusion.

ABSTRACT:The primacy of shareholder demands in the traditional theory of the firm has typically excluded marginalised stakeholder voices. However, shareholders involved in social shareholder engagement (SSE) purport to bring these voices into corporate decision-making. In response to ethical concerns about the legitimacy of SSE, we use the lens of discourse ethics to provide a normative analysis at both action and constitutional levels. By specifying three normative questions, we extend the analysis of SSE to identify a political role for shareholders in (...) pursuit of the common good. We demonstrate the desirability for SSE to promote regulatory/institutional change to guarantee marginalised stakeholders a voice in corporate decisions that affect them. The theory of SSE we propose thus calls into question the stark separation of the political and economic spheres and reveals an underlying tension, often overlooked, within the responsible investment literature. (shrink)

When and why does it matter whether we can give an explicit justification for what we believe? This paper examines these questions in the light of recent empirical work on the social functions served by our capacity to reason, in particular, Mercier and Sperber’s argumentative theory of reasoning.

Testimony is an invaluable source of knowledge. We rely on the reports of those around us for everything from the ingredients in our food and medicine to the identity of our family members. Recent years have seen an explosion of interest in the epistemology of testimony. Despite the multitude of views offered, a single thesis is nearly universally accepted: testimonial knowledge is acquired through the process of transmission from speaker to hearer. In this book, Jennifer Lackey shows that this (...) thesis is false and, hence, that the literature on testimony has been shaped at its core by a view that is fundamentally misguided. She then defends a detailed alternative to this conception of testimony: whereas the views currently dominant focus on the epistemic status of what speakers believe, Lackey advances a theory that instead centers on what speakers say. The upshot is that, strictly speaking, we do not learn from one another's beliefs - we learn from one another's words. Once this shift in focus is in place, Lackey goes on to argue that, though positive reasons are necessary for testimonial knowledge, testimony itself is an irreducible epistemic source. This leads to the development of a theory that gives proper credence to testimony's epistemologically dual nature: both the speaker and the hearer must make a positive epistemic contribution to testimonial knowledge. The resulting view not only reveals that testimony has the capacity to generate knowledge, but it also gives appropriate weight to our nature as both socially indebted and individually rational creatures. The approach found in this book will, then, represent a radical departure from the views currently dominating the epistemology of testimony, and thus is intended to reshape our understanding of the deep and ubiquitous reliance we have on the testimony of those around us. (shrink)

Background:The public domain of midwifery practice, represented by the educational and hospital institutions could be blamed for a subconscious ethical dilemma for midwifery practitioners. The result of such tension can be seen in complaints from maternity service users of dehumanised care. When expectations are not met, women report dehumanising experiences that carry long term consequences to both them and their child.Objectives:To revisit the ethical foundation of midwifery practice to reflect the feminist Ethic of Care and reframe what is valuable to (...) women and midwives during the childbirth experience.Research Design:A comprehensive literature review is presented from the midwifery and feminist ethics discourse.Ethical Considerations:Nil to report.Findings:Women are vulnerable during childbirth as they need care, yet they prioritise elements of relationship in their experience. The Ethic of Care approach equalises the relationship between the midwife and the woman, providing the space for relationship building and allowing midwives to meet the expectations of their accepted responsibility.Discussion:Some midwives manage to balance the demands of the institution with the needs of the woman. This is described as both an emotional and professionally challenging balancing act.Conclusion:Until there is a formal acknowledgement of the different ethical approach to midwifery practice from within the profession and the Institution, midwifery identity and practice will continue to be compromised. (shrink)

Dispositionality is a modal notion of a certain sort. When an object is said to have a disposition, we typically understand this to mean that under certain circumstances, the object would behave in a certain way. For instance, a fragile object is disposed to break when dropped onto a concrete surface. It need not actually break - its being fragile has implications that, so to speak, point beyond the actual world. According to dispositionalism, all modal features of the world may (...) be accounted for in terms of its dispositional features. My aim in this paper is to assess the prospects for dispositionalism by examining the most promising theories. Sections 1 and 2 clarify the assumptions and desiderata of a successful dispositionalist theory of modality. Section 3 introduces the principles governing the dispositionalist theories that apparently meet the desiderata. Sections 4 through 6 show that dispositionalism nonetheless faces three problems: while dispositions help account for modal features of the world that are local, diachronic, or gradable, they cannot account for certain modal features of the world that are global, synchronic, or absolute. I end by discussing the costs of preserving dispositionalism. (shrink)

1. Lying -- 2. The problem of what is said -- 3. What is said -- 4. Is lying worse than merely misleading? -- 5. Some interesting cases.

Ethical codes have been hailed as an explicit vehicle for achieving more sustainable and defensible organizational practice. Nonetheless, when legal compliance and corporate governance codes are conflated, codes can be used to define organizational interests ostentatiously by stipulating norms for employee ethics. Such codes have a largely cosmetic and insurance function, acting subtly and strategically to control organizational risk management and protection. In this paper, we conduct a genealogical discourse analysis of a representative code of ethics from an international corporation (...) to understand how management frames expectations of compliance. Our contribution is to articulate the problems inherent in codes of ethics, and we make some recommendations to address these to benefit both an organization and its employees. In this way, we show how a code of ethics can provide a foundation for ethical sustainability, while addressing management intentions and employees’ ethical satisfaction. (shrink)

There is a puzzle concerning the essences of fundamental entities that arises from considerations about essence, on one hand, and fundamentality, on the other. The Essence-Dependence Link (EDL) says that if x figures in the essence of y, then y is dependent upon x. EDL is prima facie plausible in many cases, especially those involving derivative entities. But consider the property negative charge. A negatively charged object exhibits certain behaviors that a positively charged object does not: it moves away from (...) other negatively charged objects, towards positively charged objects, etc. It is commonly thought that negative charge disposes its bearer to move away from other negatively charged objects, towards positively charged objects, etc. But if negative charge is fundamental, then no other entities—including the property positive charge—can figure in its essence. We thus have a prima facie puzzle: How can we say anything interesting about the essences of fundamental entities without running afoul of EDL? In this paper, I present and discuss the consequences of EDL for the debate between causal essentialists and quidditists about properties, and propose solutions to the puzzle. (shrink)

Properties seem to play an important role in causal relations. But philosophers disagree over whether or not properties play their causal or nomic roles essentially. Causal essentialists say that they do, while quidditists deny it. This article surveys these two views, as well as views that try to find a middle ground.

Jennifer Lackey presents a ground-breaking exploration of the epistemology of groups, and its implications for group agency and responsibility. She argues that group belief and knowledge depend on what individual group members do or are capable of doing, while being subject to group-level normative requirements.

This essay explores the speech act of dogwhistling (sometimes referred to as ‘using coded language’). Dogwhistles may be overt or covert, and within each of these categories may be intentional or unintentional. Dogwhistles are a powerful form of political speech, allowing people to be manipulated in ways they would resist if the manipulation was carried outmore openly—often drawing on racist attitudes that are consciously rejected. If philosophers focus only on content expressed or otherwise consciously conveyed they may miss what is (...) most powerful and pernicious in the speech of political culture. This essay is a call to start paying attention to these more covert speech acts, and a first attempt at beginning to theorize them. It argues that dogwhistles present a complex and interesting case for the philosopher of language, and explores their implications for democratic politics. (shrink)

There is a widely accepted family of views in the epistemology of testimony centering around the claim that belief is the central item involved in a testimonial exchange. For instance, in describing the process of learning via testimony, Elizabeth Fricker provides the following: “one language-user has a belief, which gives rise to an utterance by him; as a result of observing this utterance another user of the same language, his audience, comes to share that belief.” In a similar spirit, Alvin (...) Plantinga says that “…a belief on the part of the testifiee has warrant only if that belief has warrant for the testifier.” In both of these passages, we find strands of what I shall call the Belief View of Testimony. (shrink)

A view of knowledge—what I call the "Deserving Credit View of Knowledge" —found in much of the recent epistemological literature, particularly among so-called virtue epistemologists, centres around the thesis that knowledge is something for which a subject deserves credit. Indeed, this is said to be the central difference between those true beliefs that qualify as knowledge and those that are true merely by luck—the former, unlike the latter, are achievements of the subject and are thereby creditable to her. Moreover, it (...) is often further noted that deserving credit is what explains the additional value that knowledge has over merely lucky true belief. In this paper, I argue that the general conception of knowledge found in the DCVK is fundamentally incorrect. In particular, I show that deserving credit cannot be what distinguishes knowledge from merely lucky true belief since knowledge is not something for which a subject always deserves credit. (shrink)

Philosophers of language have long recognized that in opaque contexts, such as those involving propositional attitude reports, substitution of co-referring names may not preserve truth value. For example, the name ‘Clark Kent’ cannot be substituted for ‘Superman’ in a context like:1. Lois believes that Superman can flywithout a change in truth value. In an earlier paper, Jennifer Saul demonstrated that substitution failure could also occur in ‘simple sentences’ where none of the ordinary opacity-producing conditions existed, such as:2. Superman leaps (...) more tall buildings than Clark Kent does.Accounts focusing on opacity were unable to explain our ‘anti-substitution intuitions’ in such cases.In Simple Sentences, Substitution, and Intuitions, Saul extends her earlier work. She provides a comprehensive presentation and criticism of recent accounts of simple sentence substitution failure, and proposes a new approach drawing on psychological evidence about cognitive processing. Saul's purpose is not merely to solve the substitution puzzle cases, but to make …. (shrink)

Hurley’s is a difficult book to work through—partly because of its length and the complexity of its arguments, but also because each of the ten essays of which it is composed has a rather different starting point and focus, and because few of her arguments achieve real closure. Essay 2 discusses competing interpretations of Kant, essay 4 articulates nonconceptual forms of self-consciousness, essay 5 offers fresh interpretations of commissurotomy patients’ behavior, essay 6 develops an objection to Wittgenstein on rule following, (...) essay 8 attacks an alleged assumption of externalism, and chapter 10 explores the possibility of combining a “motor theory” and a “control theory” of perception. This is a very rich brew, and at least half the challenge this book presents consists in discerning its central argument and conclusion with enough precision to bring criticism to bear. (shrink)

Testimony is a crucial source of knowledge: we are to a large extent reliant upon what others tell us. It has been the subject of much recent interest in epistemology, and this volume collects twelve original essays on the topic by some of the world's leading philosophers. It will be the starting point for future research in this fertile field. Contributors include Robert Audi, C. A. J. Coady, Elizabeth Fricker, Richard Fumerton, Sanford C. Goldberg, Peter Graham, Jennifer Lackey, Keith (...) Lehrer, Richard Moran, Frederick F. Schmitt, Ernest Sosa, and James Van Cleve. (shrink)

This essay raises new objections to the two dominant approaches to understanding the justification of group beliefs—_inflationary_ views, where groups are treated as entities that can float freely from the epistemic status of their members’ beliefs, and _deflationary_ views, where justified group belief is understood as nothing more than the aggregation of the justified beliefs of the group's members. If this essay is right, we need to look in an altogether different place for an adequate account of justified group belief. (...) From these objections emerges the skeleton of the positive view that this essay goes on to develop and defend, called the _group epistemic agent account_: groups are epistemic agents in their own right, with justified beliefs that respond to both evidence and normative requirements that arise only at the group level but that are nonetheless importantly constrained by the epistemic status of the beliefs of their individual members. (shrink)

Actualist counterpart theory replaces David Lewis’s concrete possible worlds and individuals with ersatz worlds and individuals, but retains counterpart theory about de re modality. While intuitively attractive, this view has been rejected for two main reasons: the problem of indiscernibles and the Humphrey objection. I argue that in insisting that ersatz individuals play the same role as Lewisian individuals, actualists commit the particularist fallacy. The actualist should not require stand-ins for every Lewisian individual. Ersatz individuals should instead be construed as (...) representations of actually existing qualitative ways for individuals to be, or qualitative properties individuals can instantiate. This necessitates changes elsewhere. Non-instrumental uses of Kripke semantics and standard counterpart semantics also require stand-ins for particular non-actual individuals. I argue that the actualist should instead adopt a non-standard counterpart semantics that more clearly illuminates the role that actual properties and relations play in explaining de re possibilities and necessities. The result is an intuitive and forceful reply to both the problem of indiscernibles and the Humphrey objection. (shrink)

The rationality of concern for oneself has been taken for granted by the authors of western moral and political thought in a way in which the rationality of concern for others has not. While various authors have differed about the morality of self-concern, and about the extent to which such concern is rationally required, few have doubted that we have at least some special reasons to care for our selves, reasons that differ either in degree or in kind from those (...) we have to care for others. The rationality of prudence as traditionally conceived was thus taken to be threatened by Lockean accounts of personal identity. For taking a person’s identity through time to consist in psychological continuity is often thought to result in the numerical distinctness of his present and future selves, thus leaving his present self in the unsavoury position of having to ask, “Why care specially about my future self, if he won’t really be me?”. (shrink)

A dramatic shift in British and French ideas about empire unfolded in the sixty years straddling the turn of the nineteenth century. As Jennifer Pitts shows in A Turn to Empire, Adam Smith, Edmund Burke, and Jeremy Bentham were among many at the start of this period to criticize European empires as unjust as well as politically and economically disastrous for the conquering nations. By the mid-nineteenth century, however, the most prominent British and French liberal thinkers, including John Stuart (...) Mill and Alexis de Tocqueville, vigorously supported the conquest of non-European peoples. Pitts explains that this reflected a rise in civilizational self-confidence, as theories of human progress became more triumphalist, less nuanced, and less tolerant of cultural difference. At the same time, imperial expansion abroad came to be seen as a political project that might assist the emergence of stable liberal democracies within Europe. Pitts shows that liberal thinkers usually celebrated for respecting not only human equality and liberty but also pluralism supported an inegalitarian and decidedly nonhumanitarian international politics. Yet such moments represent not a necessary feature of liberal thought but a striking departure from views shared by precisely those late-eighteenth-century thinkers whom Mill and Tocqueville saw as their forebears. Fluently written, A Turn to Empire offers a novel assessment of modern political thought and international justice, and an illuminating perspective on continuing debates over empire, intervention, and liberal political commitments. (shrink)

Saul_Jennifer, Scepticism and Implicit Bias.

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)