Since the nineteenth century the theory and practice of mainstream Western medicine has been grounded in the biomedical model. In the later years of the twentieth century, however, it has faced a range of serious problems, which when viewed collectively, remain unresolved despite a variety of responses. The question we now face is whether these problems can be dealt with by modifying and extending the principles underlying the biomedical model, or whether a more radical solution is required. Recent critiques of (...) Western medicine have focused mainly on the biopsychosocial model in relation to the former approach, but it will be contended that this cannot deal adequately with the challenges that medicine currently faces, because although it addresses both the scientific and humanistic aspects of medicine it fails to harmonise them. I shall therefore argue for the necessity of a more radical approach, and suggest that what is required to accomplish this is the development of a new medical cosmology, rooted in an older and more global framework. Such a fundamental change would inevitably involve a long term process which it is not yet possible to fully comprehend let alone specify in detail. Some of the necessary features of such a new medical cosmology can, however, already be distinguished and the outline of these is described. (shrink)

Attention has been given to cross-cultural differences in adolescent growth, but far less is known about developmental variability during juvenility (ages 3–10). Previous research among the Pumé, a group of South American foragers, found that girls achieve a greater proportion of their adult stature during juvenility compared with normative growth expectations. To explain rapid juvenile growth, in this paper we consider girls’ activity levels and energy expended in subsistence effort. Results show that Pumé girls spend far less time in subsistence (...) tasks in proportion to their body size compared with adults, and they have lower physical activity levels compared with many juveniles cross-culturally. Low activity levels help to explain where the extra energy comes from to support rapid growth in a challenging environment. We suggest that activity levels are important to account for the variation of resource and labor transfers in mediating energy availability. (shrink)

Dispersal of individuals from their natal communities at sexual maturity is an important determinant of kin association. In this paper we compare postmarital residence patterns among Pumé foragers of Venezuela to investigate the prevalence of sex-biased vs. bilateral residence. This study complements cross-cultural overviews by examining postmarital kin association in relation to individual, longitudinal data on residence within a forager society. Based on cultural norms, the Pumé have been characterized as matrilocal. Analysis of Pumé marriages over a 25-year period finds (...) a predominant pattern of natalocal residence. We emphasize that natalocality, bilocality, and multilocality accomplish similar ends in maximizing bilateral kin affiliations in contrast to sex-biased residential patterns. Bilateral kin association may be especially important in foraging economies where subsistence activities change throughout the year and large kin networks permit greater potential flexibility in residential mobility. (shrink)

The failure of Western medicine to deal with many of the problems it is currently facing has led to an awareness of the need for a fundamental reappraisal. The way in which medical concepts derived from the nineteenth century have brought technical medical advances in this century and the alliances that medicine has made with statistics and more recently the social sciences, have prevented a questioning of medicine's underlying assumptions. Thus, despite a number of critical initiatives from both within and (...) outside medicine, there has been no coherent development to seriously confront the question 'what is medicine?'. It is suggested that the basis for such a development depends on the return to a philosophical questioning of our conceptual understanding of disease, a subject which has largely been ignored during the past hundred years. (shrink)

Section 47 of the National Assistance Act is controversial in that it makes provision for the compulsory removal and care of mentally competent adults in certain limited circumstances. A case is described in which it is argued that compulsory management could be justified. This is because the diversity and potentially conflicting nature of the relevant considerations involved in this and a restricted range of other cases, defies their being captured in any wholly rational moral scheme. It follows that if the (...) law is to be both sensitive and just it cannot always provide definitive guidance as to how the community doctor, as the designated decision-maker, should act. The acceptance of his or her judgement is therefore necessary and depends for its proper working on trust, which can only be gained through compassion and respect for the patients concerned. (shrink)

During the past thirty years a high proportion of all long stay hospital beds have been closed. The responsibility for those who would have occupied those beds previously has to a large extent been transferred from health to social services departments, or to family, voluntary and private care. The overall effect has been to prioritize acute medical care, and to expose the public provision and funding of long term residential care, whether medical or social, to the direct determination of political (...) and economic forces. These policy changes have been introduced under the banner of community care, but are dependent on complex concepts which are morally contentious and often obscure. The purpose of this paper is to analyse these processes as a prerequisite to devising better policies in future. (shrink)

A postgraduate Diploma in Medical Ethics and Law was started in October 1984 by the Centre of Medical Law and Ethics at King's College. It is a part-time one year course designed so as to enable students to continue with full-time employment if they wish. It is multidiscipinary and is open to all who have a first degree in a relevant discipline, for example law, philosophy, theology, medicine and nursing studies. It is unique in combining medical law and medical ethics (...) and has attracted students of high calibre from a variety of backgrounds during its first three years. Building on the experience of the diploma the course is being upgraded to an MA in 1987-88. It will be available either full-time for one year or part-time for two years. (shrink)

Following the first enactment of living will legislation in California in 1976 the majority of the states of the USA have now passed similar laws. However, flaws have been identified in the way they work in practice and many states are considering reviewing their legislation. In Britain there is no legislation but the subject is currently commanding considerable interest. This paper assesses the future prospects for living wills in both the USA and Britain, analysing the different options available and comparing (...) the two countries. If patients who become permanently incompetent are to have their previous autonomous decision-making respected, there is general agreement that advance directives for health care must be introduced. The difficulty is in deciding how to implement them, and especially whether this should be by statutory or non-statutory means, the traditions in the two countries being very different in this respect. It is concluded that whichever route is taken, promoting respect for patient autonomy is as much a matter for education and persuasion of doctors as of the adoption of particular instruments. Doctors should therefore be trained in what constitutes good medical practice in this area and, to ensure that it can be carried out properly, the general level of medical facilities for these patients must also be protected and promoted. (shrink)

Nick Bostrom and others have suggested treating decision-making under moral uncertainty as analogous to parliamentary decision-making. The core suggestion of this “parliamentary approach” is that the competing moral theories function like delegates to the parliament, and that these delegates then make decisions by some combination of bargaining and voting. There seems some reason to hope that such an approach might avoid standard objections to existing approaches (for example, the “maximise expected choiceworthiness” (MEC) and “my favourite theory” approaches). However, the parliamentary (...) approach is so far extremely underspecified, making it largely indeterminate how such a model will in fact behave in the respects that those concerned with moral uncertainty care about. This paper explores one way of making it precise. We treat predicaments of moral uncertainty as analogous to bargaining situations alone (setting aside voting), and apply a version of the Nash solution that is standard in bargaining theory. The resulting model does indeed perform in many of the hoped-for ways. However, so also does a version of MEC that employs a structural approach to intertheoretic comparisons. It seems to us an open question which, regarding this version of MEC and the bargaining-theoretic approach, is superior to the other. We identify the key points on which the two differ. (shrink)

ABSTRACT The assumptions underlying the traditional biomedical model of health and illness and criticisms of it are described. An examination of the historical development of ideas concerning cot (crib) deaths shows how early explanations, which were congruent with this model, came to be discredited. Because subsequent explanations have also been considered unsatisfactory, cot deaths have come to be regarded as medically problematic. The relationship of models of health and illness to cot deaths has therefore been exposed to an unusual degree (...) of scrutiny. Two possible contending models, social epidemiological and socio‐economic are identified, and their status vis‐à‐vis the biomedical model is considered. The choice as to which of these models is applied to cot deaths is shown to be not only of theoretical interest but also to have ethical implications for health care policy and medical practice. (shrink)

Armstrong describes the rise of a new mode of medical practice that he calls in the following terms: Surveillance medicine gives rise to a novel and underexplored aspect of the long-standing tension between the different goals of clinical medicine and public health.

Richard Feynman has claimed that anti-particles are nothing but particles `propagating backwards in time'; that time reversing a particle state always turns it into the corresponding anti-particle state. According to standard quantum field theory textbooks this is not so: time reversal does not turn particles into anti-particles. Feynman's view is interesting because, in particular, it suggests a nonstandard, and possibly illuminating, interpretation of the CPT theorem. In this paper, we explore a classical analog of Feynman's view, in the context of (...) the recent debate between David Albert and David Malament over time reversal in classical electromagnetism. (shrink)

According to Bayesian epistemology, the epistemically rational agent updates her beliefs by conditionalization: that is, her posterior subjective probability after taking account of evidence X, pnew, is to be set equal to her prior conditional probability pold(·|X). Bayesians can be challenged to provide a justification for their claim that conditionalization is recommended by rationality—whence the normative force of the injunction to conditionalize? There are several existing justifications for conditionalization, but none directly addresses the idea that conditionalization will be epistemically rational (...) if and only if it can reasonably be expected to lead to epistemically good outcomes. We apply the approach of cognitive decision theory to provide a justification for conditionalization using precisely that idea. We assign epistemic utility functions to epistemically rational agents; an agent’s epistemic utility is to depend both upon the actual state of the world and on the agent’s credence distribution over possible states. We prove that, under independently motivated conditions, conditionalization is the unique updating rule that maximizes expected epistemic utility. (shrink)

Population axiology is the study of the conditions under which one state of affairs is better than another, when the states of affairs in ques- tion may differ over the numbers and the identities of the persons who ever live. Extant theories include totalism, averagism, variable value theories, critical level theories, and “person-affecting” theories. Each of these the- ories is open to objections that are at least prima facie serious. A series of impossibility theorems shows that this is no coincidence: (...) it can be proved, for various sets of prima facie intuitively compelling desiderata, that no axiology can simultaneously satisfy all the desiderata on the list. One’s choice of population axiology appears to be a choice of which intuition one is least unwilling to give up. (shrink)

I explore the prospects for modelling epistemic rationality (in the probabilist setting) via an epistemic decision theory, in a consequentialist spirit. Previous work has focused on cases in which the truth-values of the propositions in which the agent is selecting credences do not depend, either causally or merely evidentially, on the agent’s choice of credences. Relaxing that restriction leads to a proliferation of puzzle cases and theories to deal with them, including epistemic analogues of evidential and causal decision theory, and (...) of the Newcomb Problem and ‘Psychopath Button’ Problem. A variant of causal epistemic decision theory deals well with most cases. However, there is a recalcitrant class of problem cases for which no epistemic decision theory seems able to match our intuitive judgements of epistemic rationality. This lends both precision and credence to the view that there is a fundamental mismatch between epistemic consequentialism and the intuitive notion of epistemic rationality; the implications for understanding the latter are briefly discussed. (shrink)

Decisions, whether moral or prudential, should be guided at least in part by considerations of the consequences that would result from the various available actions. For any given action, however, the majority of its consequences are unpredictable at the time of decision. Many have worried that this leaves us, in some important sense, clueless. In this paper, I distinguish between ‘simple’ and ‘complex’ possible sources of cluelessness. In terms of this taxonomy, the majority of the existing literature on cluelessness focusses (...) on the simple sources. I argue, contra James Lenman in particular, that these would-be sources of cluelessness are unproblematic, on the grounds that indifference-based reasoning is far less problematic than Lenman (along with many others) supposes. However, there does seem to be a genuine phenomenon of cluelessness associated with the ‘complex’ sources; here, indifference-based reasoning is inapplicable by anyone’s lights. This ‘complex problem of cluelessness’ is vivid and pressing, in particular, in the context of Effective Altruism. This motivates a more thorough examination of the precise nature of cluelessness, and the precise source of the associated phenomenology of discomfort in forced-choice situations. The latter parts of the paper make some initial explorations in those directions. (shrink)

True benevolence is, most fundamentally, a desire that the world be better. It is natural and common, however, to frame thinking about benevolence indirectly, in terms of a desire to make a difference to how good the world is. This would be an innocuous shift if desires to make a difference were extensionally equivalent to desires that the world be better. This paper shows that at least on some common ways of making a “desire to make a difference” precise, this (...) extensional equivalence fails. Where it fails, “difference-making preferences” run counter to the ideals of benevolence. In particular, in the context of decision making under uncertainty, coupling a “difference-making” framing in a natural way with risk aversion leads to preferences that violate stochastic dominance, and that lead to a strong form of collective defeat, from the point of view of betterness. Difference-making framings and true benevolence are not strictly mutually inconsistent, but agents seeking to implement true benevolence must take care to avoid the various pitfalls that we outline. GPI Working Paper No. 16-2022. (shrink)

This article is a critical survey of the debate over the value of the social discount rate, with a particular focus on climate change. The ma- jority of the material surveyed is from the economics rather than from the philosophy literature, but the emphasis of the survey itself is on founda- tions in ethical and other normative theory rather than highly technical details. I begin by locating the standard approach to discounting within the overall landscape of ethical theory, and explaining (...) the assumptions and simplifications that are needed in order to arrive at the model that is standard in the discounting literature. The article then covers the general theory of the Ramsey equation and its relationship to observed interest rates, arguments for and against a positive rate of pure time preference, the consumption elasticity of utility, and the effect of various sorts of uncertainty on the discount rate. Finally, it turns specifically to the ap- plication of this debate to the case of climate change, focussing on the recent controversy over the low discount rate used in the Stern Review of the Economics of Climate Change. (shrink)

In this important study D. M. Armstrong offers a comprehensive system of analytical metaphysics that synthesises but also develops his thinking over the last twenty years. Armstrong's analysis, which acknowledges the 'logical atomism' of Russell and Wittgenstein, makes facts the fundamental constituents of the world, examining properties, relations, numbers, classes, possibility and necessity, dispositions, causes and laws. All these, it is argued, find their place and can be understood inside a scheme of states of affairs. This is a comprehensive and (...) rigorously this-worldly account of the most general features of reality, argued from a distinctive philosophical perspective, and it will appeal to a wide readership in analytical philosophy. (shrink)

Difficulties over probability have often been considered fatal to the Everett interpretation of quantum mechanics. Here I argue that the Everettian can have everything she needs from `probability' without recourse to indeterminism, ignorance, primitive identity over time or subjective uncertainty: all she needs is a particular *rationality principle*. The decision-theoretic approach recently developed by Deutsch and Wallace claims to provide just such a principle. But, according to Wallace, decision theory is itself applicable only if the correct attitude to a future (...) Everettian measurement outcome is subjective uncertainty. I argue that subjective uncertainty is not to be had, but I offer an alternative interpretation that enables the Everettian to live without uncertainty: we can justify Everettian decision theory on the basis that an Everettian should *care about* all her future branches. The probabilities appearing in the decision-theoretic representation theorem can then be interpreted as the degrees to which the rational agent cares about each future branch. This reinterpretation, however, reduces the intuitive plausibility of one of the Deutsch -Wallace axioms. (shrink)

The Everett (many-worlds) interpretation of quantum mechanics faces a prima facie problem concerning quantum probabilities. Research in this area has been fast-paced over the last few years, following a controversial suggestion by David Deutsch that decision theory can solve the problem. This article provides a non-technical introduction to the decision-theoretic program, and a sketch of the current state of the debate.

Given the deep disagreement surrounding population axiology, one should remain uncertain about which theory is best. However, this uncertainty need not leave one neutral about which acts are better or worse. We show that, as the number of lives at stake grows, the Expected Moral Value approach to axiological uncertainty systematically pushes one toward choosing the option preferred by the Total View and critical-level views, even if one’s credence in those theories is low.

Much of the evidence for quantum mechanics is statistical in nature. The Everett interpretation, if it is to be a candidate for serious consideration, must be capable of doing justice to reasoning on which statistical evidence in which observed relative frequencies that closely match calculated probabilities counts as evidence in favour of a theory from which the probabilities are calculated. Since, on the Everett interpretation, all outcomes with nonzero amplitude are actualized on different branches, it is not obvious that sense (...) can be made of ascribing probabilities to outcomes of experiments, and this poses a prima facie problem for statistical inference. It is incumbent on the Everettian either to make sense of ascribing probabilities to outcomes of experiments in the Everett interpretation, or to find a substitute on which the usual statistical analysis of experimental results continues to count as evidence for quantum mechanics, and, since it is the very evidence for quantum mechanics that is at stake, this must be done in a way that does not presuppose the correctness of Everettian quantum mechanics. This requires an account of theory confirmation that applies to branching-universe theories but does not presuppose the correctness of any such theory. In this paper, we supply and defend such an account. The account has the consequence that statistical evidence can confirm a branching-universe theory such as Everettian quantum mechanics in the same way in which it can confirm a probabilistic theory. (shrink)

Prioritarianism is supposed to be a theory of the overall good that captures the common intuition of . But it is difficult to give precise content to the prioritarian claim. Over the past few decades, prioritarians have increasingly responded to this by formulating prioritarianism not in terms of an alleged primitive notion of quantity of well-being, but instead in terms of von NeumannPrimitivistTechnicalpriority to the worse offMorgenstern utility is a retrograde step.

Harsanyi claimed that his Aggregation and Impartial Observer Theorems provide a justification for utilitarianism. This claim has been strongly resisted, notably by Sen and Weymark, who argue that while Harsanyi has perhaps shown that overall good is a linear sum of individuals’ von Neumann-Morgenstern utilities, he has done nothing to establish any con- nection between the notion of von Neumann-Morgenstern utility and that of well-being, and hence that utilitarianism does not follow. The present article defends Harsanyi against the Sen-Weymark cri- (...) tique. I argue that, far from being a term with precise and independent quantitative content whose relationship to von Neumann-Morgenstern utility is then a substantive question, terms such as ‘well-being’ suffer (or suffered) from indeterminacy regarding precisely which quantity they refer to. If so, then (on the issue that this article focuses on) Harsanyi has gone as far towards defending ‘utilitarianism in the original sense’ as could coherently be asked. (shrink)

An important objection to preference-satisfaction theories of well-being is that these theories cannot make sense of interpersonal comparisons of well-being. A tradition dating back to Harsanyi () attempts to respond to this objection by appeal to so-called extended preferences: very roughly, preferences over situations whose description includes agents’ preferences. This paper examines the prospects for defending the preference-satisfaction theory via this extended preferences program. We argue that making conceptual sense of extended preferences is less problematic than others have supposed, but (...) that even so extended preferences do not provide a promising way for the preference satisfaction theorist to make interpersonal well-being comparisons. Our main objection takes the form of a trilemma: depending on how the theory based on extended preferences is developed, either the result will be inconsistent with ordinary preference-satisfaction theory, or it will fail to recover sufficiently rich interpersonal well-being comparisons, or it will take on a number of other arguably odd and undesirable commitments. (shrink)

Recent work in the Everett interpretation has suggested that the problem of probability can be solved by understanding probability in terms of rationality. However, there are *two* problems relating to probability in Everett --- one practical, the other epistemic --- and the rationality-based program *directly* addresses only the practical problem. One might therefore worry that the problem of probability is only `half solved' by this approach. This paper aims to dispel that worry: a solution to the epistemic problem follows from (...) the rationality-based solution to the practical problem. (shrink)

Recent work in the Everett interpretation has suggested that the problem of probability can be solved by understanding probability in terms of rationality. However, there are *two* problems relating to probability in Everett --- one practical, the other epistemic --- and the rationality-based program *directly* addresses only the practical problem. One might therefore worry that the problem of probability is only `half solved' by this approach. This paper aims to dispel that worry: a solution to the epistemic problem follows from (...) the rationality-based solution to the practical problem. (shrink)