The Harvard University Program in Ethics and Health, 651 Huntington Avenue, 6th floor c/o HSPH, François Xavier Bagnoud Building Boston, MA 02115, USA. Email: Nir_Eyal{at}hms.harvard.edu ' + u + '@' + d + ' '//--> Abstract Access to medicines, vaccination and care in resource-poor settings is threatened by the emigration of physicians and other health workers. In entire regions of the developing world, low physician density exacerbates child and maternal mortality and hinders treatment of HIV/AIDS. This article invites philosophers to (...) help identify ethical and effective responses to medical brain drain. It reviews existing proposals and their limitations. It makes a case that, in resource-poor countries, ‘locally relevant medical training’—teaching primarily locally endemic diseases and practice in scarcity conditions, training in rural communities and admitting rural students preferentially—could help improve retention. Locally relevant training would arguably diminish medical brain drain in five ways. It would (i) make graduates less attractive for Western employers, (ii) align graduates’ expectations with actual practice, diminishing ‘burn-out’, (iii) enhance the professional prestige of local practice, (iv) hold rotations in, and recruit applicants from, rural areas, which is known to improve retention there, and (v) create local career development options that attract practitioners to stay. Such educational reform may raise worries about poor-quality care, breach of the freedom of education and occupation, breach of the freedom of movement, unequal distribution of opportunities among students, hypocrisy and resistance from influential actors. We address these worries. CiteULike Connotea Del.icio.us What's this? (shrink)
The article begins by reconstructing the just distribution of the social bases of self-respect, a principle of justice that is covert in Rawls’s writing. I argue that, for Rawls, justice mandates that each social basis for self-respect be equalized (and, as a second priority, maximized). Curiously, for Rawls, that principle ranks higher than Rawls’s two more famous principles of justice - equal liberty and the difference principle. I then recall Rawls’s well-known confusion between self-respect and another form of self-appraisal, namely, (...) confidence in one’s determinate plans and capacities. Correcting that confusion forces Rawls to accept objectionable and illiberal politics. Surprisingly, a consistent Rawls must endorse absolute economic equality, deny liberty any priority whatsoever, or sponsor still other illiberal political views - evidence of a flaw in the ethical basis of Rawls’s politics. -/- Key Words: self-respect • self-esteem • distributive justice • Rawls • maximin • primary goods • liberty • equality • lexicographical order. (shrink)
This article argues that, in its standard formulation, luck-egalitarianism is false. In particular, I show that disadvantages that result from perfectly free choice can constitute egalitarian injustice. I also propose a modified formulation of luck-egalitarianism that would withstand my criticism. One merit of the modification is that it helps us to reconcile widespread intuitions about distributive justice with equally widespread intuitions about punitive justice.
Commentators on the ethics of translational research find it morally problematic. Types of translational research are said to involve questionable benefits, special risks, additional barriers to informed consent, and severe conflicts of interest. Translational research conducted on the global poor is thought to exploit them and increase international disparities. Some commentators support especially stringent ethical review. However, such concerns are grounded only in pre-approval translational research (now called T1 ). Whether or not T1 has these features, translational research beyond approval (...) ( T2 : phase IV, health services, and implementation research) is unlikely to and, when conducted on the global poor, may support development. Therefore, insofar as T1 is morally problematic, and no independent objections to T2 exist, the ethics of translational research is diverse: while some translational research is problematic, some is not. Funding and oversight should reflect this diversity, and T2 should be encouraged, particularly when conducted among the global poor. (shrink)
The majority of deaths due to tobacco in the twenty-first century will occur in the developing world, where over 80% of current tobacco users live. In November 2010 guidelines were adopted for implementing Article 14 of the World Health Organization’s Framework Convention on Tobacco Control (FCTC). The guidelines call on all countries to promote tobacco treatment programs. Nevertheless, some experts argue for a strict focus, at least in developing countries, on population-based measures such as taxes and indoor air laws, which (...) they consider more cost-effective than individual treatment. In this article we defend tobacco dependence treatment in developing countries. First, these experts understate the comparative cost-effectiveness of individual treatment programs. Second, they overlook numerous ethical considerations beyond cost-effectiveness that support individual tobacco treatment in developing countries. We conclude that the strict population-based focus in developing country tobacco control advocated by some experts is misplaced. In general, developing nations should combine population-based measures and individual tobacco treatment programs. (shrink)
We analyse three moral dilemmas involving resource allocation in care for HIV-positive patients. Ole Norheim and Kjell Arne Johansson have argued that these cases reveal a tension between egalitarian concerns and concerns for better population health. We argue, by contrast, that these cases reveal a tension between, on the one hand, a concern for equal *chances*, and, on the other hand, both a concern for better health and an egalitarian concern for equal *outcomes*. We conclude that, in these cases, there (...) is much less tension than Norheim and Johansson claim between egalitarian concerns and concerns for better population health. (shrink)
Patients’ medical conditions can result from their own avoidable risk taking. Some lung diseases result from avoidable smoking and some traffic accidents result from victims’ reckless driving. Although in many nonmedical areas we hold people responsible for taking risks they could avoid, it is normally harsh and inappropriate to deny patients care because they risked needing it. Why? A popular account is that protecting everyone’s "decent minimum," their basic needs, matters more than the benefits of holding people accountable. This account (...) is deficient. Protecting the decent minimum is not always served by offering noncompliant patients either nonbasic or basic care. Nor is protecting that minimum always served by unconditional medical care better than by nonmedical interventions. To interpret the decent minimum in democratic terms is a futile response to these challenges. Ideas for new accounts are suggested. (shrink)
In many countries worldwide, especially in Sub-Saharan Africa, a shortage of physicians limits the provision of lifesaving interventions. One existing strategy to increase the number of physicians in areas of critical shortage is conditioning medical school scholarships on a precommitment to work in medically underserved areas later. Current practice is usually to demand only one year of service for each year of funded studies. We show the effectiveness of scholarships conditional on such precommitment for increasing physician supplies in underserved areas. (...) Then we defend these scholarships against ethical worries that they constitute slavery contracts; rely on involuntary, biased, or unauthorized early consent by a young signatory; put excessive strains on signed commitments; give rise to domination; and raise suspicion of slavery contracts. Importantly, we find that scholarships involving far longer commitment than current practice allows would also withstand these worries. Policymakers should consider introducing conditional scholarships, including long-term versions, as a means to increasing the supply of physicians to medically underserved areas. (shrink)
Bitton and Eyal's lengthy critique of our article on unassisted cessation was premised on several straw-man arguments. These are corrected in our reply. It also confused the key concepts of efficacy and effectiveness in assessing the impact of cessation interventions and policies in real-world settings; ignored any consideration of reach (cost, consumer acceptability and accessibility) and failed to consider that clinical cessation interventions which fail more than they succeed also may ‘harm’ smokers by reducing agency. Our article addresses each (...) of these problems, concluding that any consideration of the ethics of promoting smoking cessation in low-income nations should begin and end with the question of whether the strategies to be adopted have any prospect of influencing significant numbers of smokers to quit. (shrink)
Law, Economics, and Morality examines the possibility of combining economic methodology and deontological morality through explicit and direct incorporation of moral constraints into economic models. Economic analysis of law is a powerful analytical methodology. However, as a purely consequentialist approach, which determines the desirability of acts and rules solely by assessing the goodness of their outcomes, standard cost-benefit analysis (CBA) is normatively objectionable. Moderate deontology prioritizes such values as autonomy, basic liberties, truth-telling, and promise-keeping over the promotion of good outcomes. (...) It holds that there are constraints on promoting the good. Such constraints may be overridden only if enough good (or bad) is at stake. While moderate deontology conforms to prevailing moral intuitions and legal doctrines, it is arguably lacking in methodological rigor and precision. -/- Eyal Zamir and Barak Medina argue that the normative flaws of economic analysis can be rectified without relinquishing its methodological advantages and that moral constraints can be formalized so as to make their analysis more rigorous. They discuss various substantive and methodological choices involved in modeling deontological constraints. Zamir and Medina propose to determine the permissibility of any act or rule infringing a deontological constraint by means of mathematical threshold functions. Law, Economics, and Morality presents the general structure of threshold functions, analyzes their elements and addresses possible objections to this proposal. It then illustrates the implementation of constrained CBA in several legal fields, including contract law, freedom of speech, antidiscrimination law, the fight against terrorism, and legal paternalism. (shrink)
The paper explores the role played by concepts of temporality in shaping the self's identity and its moral responsibility. This theme is examined in both Kant and Benjamin, two theorists who view the modern self as an essentially historical being. For Kant, teleological and uniform time shoulders the heightening of the self's universal attributes and the constant expansion of a moral community. The desired end is the establishment of an integrated and homogeneous human space, a cosmopolitan stage wherein history is (...) finally redeemed. This progressive notion of time is seen as dangerous by Benjamin, since it generates forgetfulness and inner impoverishment of the self. Instead, Benjamin advances a fragmented conception of time, one allowing conversation between distant moments and grounding identity in concrete images. While the poetic recovery of memory leads to the distinct and exclusive, Benjamin follows Kant in demanding universal moral responsibility of the self. However, Benjamin's strategy, so to speak, is the integration of our temporal - not spatial - experience. Key Words: Benjamin • history • Kant • nation-state • space • time. (shrink)
Reingold and MerikleÕs (1988, 1990) critique of the classic dissociation paradigm identified several issues as inherent problems that severely undermine the utility of this paradigm. Erdelyi (2004) extending his prior analysis (Erdelyi, 1985, 1986) points out several additional factors that may complicate the interpretation of empirically obtained dissociations. The goal of the present manuscript is to further discuss some of these commonly neglected interpretive difficulties. Ó 2003 Elsevier Inc. All rights reserved.
In a recent paper, Graf and Komatsu (1994) argued that the process dissociation procedure (Jacoby, 1991) is limited in its ability to separate and measure conscious and unconscious forms of memory and so should be "handIed with caution". Given that the study of unconscious influences has always posed a difficult problem for memory researchers, we agree with the general emphasis on caution. In this paper, we too advocate caution, especially as it applies to the use of indirect tests, assessing Graf (...) and Komatsu’s critique, and using the process dissociation procedure. We address the substantive issues raised by Graf and Komatsu and also point out the errors, both factual and logical, in their paper. Any method proposing to provide separate measures of conscious and unconscious influences requires judicious use and a careful examination of its underlying assumptions. The assumptions underlying the process dissociation framework are supported by a large number of experiments spanning a diverse range of.. (shrink)
The present paradigm involved manipulating the congruency of the perceptual processing during the study and test phases of a recognition memory task. During each trial, a gaze-contingent window was used to limit the stimulus display to a region either inside or outside a 108 square centred on the participant’s point of gaze, constituting the Central and Peripheral viewing modes respectively. The window position changed in real time in concert with changes in gaze position. Four experiments documented better task performance when (...) viewing modes at encoding and retrieval matched than when they mismatched (i.e., perceptual specificity effects). Viewing mode congruency effects were demonstrated with both verbal and non-verbal stimuli. The present research is motivated and discussed in terms of theoretical views proposed in the 1970s including the levels-of-processing framework and the proceduralist viewpoint. In addition, implications for current processing and multiple systems views of memory are outlined. (shrink)
How might revolutions and other processes of institutional disintegration inform political processes preceding them? By mapping paths of agency through processes of institutional disintegration, the trajectory improvisation model of institutional breakdown overcomes "action-structure" binaries by framing political revolutions as possible outcomes of such disintegrative processes. The trajectory improvisation approach expands the trajectory adjustment model of social change developed by Gil Eyal, Iván Szelényi, and Eleanor Townsley. An overview of political revolution in Soviet Russia between 1989 and 1991 illustrates trajectory (...) improvisation. The recent American invasion and occupation of Iraq shows alternative routes to institutional disintegration, indicating the independence of models of institutional breakdown from those of social movements. These cases illustrate both the diversity of situations the trajectory improvisation model speaks to, and the limitation of models of trajectory adjustment, improvisation, social movements, and invasions, illustrating why such models at best enable what are called "explanatory narratives" of actual historical processes. (shrink)
There are hundreds of indications leading us to conclude that at every moment there is in us an infinity of perceptions, unaccompanied by awareness or reflection; that is, of alterations in the soul itself, of which we are unaware because the impressions are either too minute or too numerous, or else too unvarying, so that they are not sufficiently distinctive on their own. But when they are combined with others they do nevertheless have their effect and make themselves felt, at (...) least confusedly, within the whole. (Leibniz, 1704/1981, p. 53). (shrink)
We evaluate the consistency of different constructs affecting risk attitude in individuals’ decisions across different levels of risk. Specifically, we contrast views suggesting that risk attitude is a single primitive construct with those suggesting it consists of multiple latent components. Additionally, we evaluate such constructs as sensitivity to losses, diminishing sensitivity to increases in payoff, sensitivity to variance, and risk acceptance (the willingness to accept probable outcomes over certainty). In search of trait-like constructs, the paper reviews experimental results focusing on (...) the consistency of these constructs in different tasks as well as their temporal consistency. Overall, the findings show that the most consistent factor is risk acceptance, and they also demonstrate its potential boundaries. These results are modeled with a simple quantitative index of subjective risk. A survey of decisions under risk further reveals that participants exhibit almost no consistency across different tasks in this setting, highlighting the advantage of experiential tasks for studying individual differences. (shrink)
Several gaze contingent studies that used a fixed delay between physical eye movements and a display change documented a dip in the fixation duration distributions (e.g., Blanchard et al. 1984; McConkie et al. 1985; van Diepen et al. 1995). In a study by van Diepen et al. (1995), a moving mask paradigm was employed in which subjects searched line drawings of everyday scenes for non-objects. The appearance of the mask was delayed relative to the end of a saccade (beginning of (...) fixation) by 17, 46, 76 or 121 msec. All fixation duration distributions in the masking conditions exhibited a dip with longer masking delays resulting in the dip occurring at longer fixation durations. In contrast, a no-mask condition did not produce a dip. Similar effects in reading were reported by Blanchard et al. (1984), and McConkie et al. (1985). In both these studies the text was.. (shrink)
Detecting that two images are different is faster for highly dissimilar images than for highly similar images. Paradoxically, we showed that the reverse occurs when people are asked to describe how two images differ—that is, to state a difference between two images. Following structure-mapping theory, we propose that this disassociation arises from the multistage nature of the comparison process. Detecting that two images are different can be done in the initial (local-matching) stage, but only for pairs with low overlap; thus, (...) “different” responses are faster for low-similarity than for high-similarity pairs. In contrast, identifying a specific difference generally requires a full structural alignment of the two images, and this alignment process is faster for high-similarity pairs. We described four experiments that demonstrate this dissociation and show that the results can be simulated using the Structure-Mapping Engine. These results pose a significant challenge for nonstructural accounts of similarity comparison and suggest that structural alignment processes play a significant role in visual comparison. (shrink)
This paper intends to evaluate two competing models of multicultural integration in stratified societies: the "multiple publics" model of Nancy Fraser and the "fragmented public sphere" model of Jeffrey Alexander. Fraser and Alexander disagree on whether or not claims to a general "common good" or "common humanity" are democratically legitimate in light of systemic inequality. Fraser rejects the idea that cultural integration can be democratic in conditions of social inequality, while Alexander accepts it and tries to explain how it may (...) be realized. In order to address this debate, I analyze the cultural foundations of the female-led, maternally themed social movements of nineteenth-century America. The language of these movements supports Alexander's position over Fraser's, though it also suggests that Alexander is mistaken in the specifics of his cultural theory of a general and democratic "common good." While Alexander's model of integration is structured uniquely by what he and Philip Smith have called "the discourse of civil society," the evidence suggests a distinctly alternative, equally democratic code at play in this case, which I have labeled a discourse of affection and compassion. (shrink)
Whenever knowledge of the possible interpretation or conceptualization of some- thing helps in perceiving that thing, we say the processing is conceptually driven. That is, the process starts with conceptualization of what might be present and then looks for confirming evidence, biasing the processing mechanisms to give the expected result... Conceptually driven processing and data-driven processing almost always occur together, with each direction of processing contributing something to the total analysis. (Lindsay and Norman 1977, p. 13).
Many voting rules and, in particular, the plurality rule and Condorcet-consistent voting rules satisfy the simple-majority decisiveness property. The problem implied by such decisiveness, namely, the universal disregard of the preferences of the minority, can be ameliorated by applying unbiased scoring rules such as the classical Borda rule, but such amelioration has a price; it implies erosion in the implementation of the widely accepted majority principle . Furthermore, the problems of majority decisiveness and of the erosion in the majority principle (...) are not necessarily severe when one takes into account the likelihood of their occurrence. This paper focuses on the evaluation of the severity of the two problems, comparing simple-majoritarian voting rules that allow the decisiveness of the smallest majority larger than 1/2 and the classical Borda method of counts. Our analysis culminates in the derivation of the conditions that determine, in terms of the number of alternatives k, the number of voters n, and the relative (subjective) weight assigned to the severity of the two problems, which of these rules is superior in light of the dual majoritarian approach. (shrink)
It is argued here that a critical prediction of the E-Z Reader model is that experimental manipulations that disrupt early encoding of visual and orthographic features of the fixated word without affecting subsequent lexical processing should influence the processing difficulty of the fixated word without producing any processing effect on the next word. This prediction is explained and illustrated.
In three experiments, participants' visual span was measured in a comparative visual search task in which they had to detect a local match or mismatch between two displays presented side by side. Experiment 1 manipulated the dif®culty of the comparative visual search task by contrasting a mismatch detection task with a substantially more dif®cult match detection task. In Experiment 2, participants were tested in a single-task condition involving only the visual task and a dual-task condition in which they concurrently performed (...) an auditory task. Finally, in Experiment 3, participants performed two dual-task conditions, which differed in the dif®culty of the concurrent auditory task. Both the comparative search task dif®culty (Experiment 1) and the divided attention manipulation (Experiments 2 and 3) produced strong effects on visual span size. q 2001 Elsevier Science B.V. All rights reserved. (shrink)
Salience of Peripheral 2 Abstract The three experiments reported document a slowing of peripheral target acquisition associated with the presence of a gaze-contingent window. This window effect was shown for displays using either moving video or still images. The window effect was similar across a resolutiondefined window condition and a luminance-defined window condition suggesting that peripheral image degradation is not a prerequisite of this effect. The window effect was also unaffected by the type of window boundary used (sharp or blended). (...) These results are interpreted in terms of an attentional bias resulting in a reduced saliency of peripheral targets due to increased competition from items within the window. We discuss the implications of the window effect for investigating the perceptual processes involved in natural scenes and for gaze-contingent multiresolutional displays (GCMRDs) that have been proposed to solve the processing and bandwidth bottleneck in many single-user displays, by dynamically placing high-resolution in a window at the center of gaze, with lower resolution everywhere else. (shrink)
& The present study investigated saccadic inhibition in both voluntary and stimulus-elicited saccades. Two experiments examined saccadic inhibition caused by an irrelevant flash occurring subsequent to target onset. In each trial, participants were required to perform a single saccade following the presentation of a black target on a gray background, 48 to the left or to the right of screen center. In some trials (flash trials), after a variable delay, a 33-msec flash was displayed at the top and bottom third (...) of the monitor (these regions turned white). In all experimental conditions, histograms of flash-to-saccade latencies documented a decrease in saccadic frequency, forming a dip, time-locked to the flash and occurring as early as 60–70 msec following its onset. The fast latency of this effect strongly suggests a low-level, reflex-like, oculomotor effect, which was referred to as saccadic inhibition. A novel procedure was developed to allow comparisons of saccadic inhibition even across conditions, which in the absence of a flash (no-. (shrink)
Two experiments demonstrated letter-context effects that cannot easily be accounted for by postperceptual theories based on structural redundancy, iigural goodness, or memory advantage. In Experiment 1, subjects identified the color of a letter fragment more accurately in letter than in nonletter contexts. In Experiment 2, subjects identified the feature presented in a precued color more accurately in letters than in nonletters. We argue that these effects result from topdown perceptual processing.
A critical prediction of the E-Z Reader model is that experimental manipulations that disrupt early encoding of visual and orthographic features of the fixated word without affecting subsequent lexical processing should influence the processing difficulty of the fixated word without affecting the processing of the next word. We tested this prediction by monitoring participants’ eye movements while they read sentences in which a target word was presented either normally or altered. In the critical condition, the contrast between the target word (...) and the background was substantially reduced. Such a reduction in stimulus quality is typically assumed to have an impact that is largely confined to a very early stage of word recognition. Results were consistent with the E-Z Reader model: This faint presentation had a robust influence on the duration of fixations on the target word without substantially altering the processing of the next word. (shrink)
We treat a class of multi-person bargaining mechanisms based on games in coalitional form. For this class of games we identify properties of non-cooperative solution concepts, which are necessary and sufficient for the equilibrium outcomes to coincide with the core of the underlying coalitional form game. We view this result as a non-cooperative axiomatization of the core. In contrast to most of the literature on multi-person bargaining we avoid a precise specification of the rules of the game. Alternatively, we impose (...) properties of such games, which give rise to a large class of mechanisms, all of which are relevant for our axiomatization. (shrink)
In 5 experiments, participants read text that was briefly replaced by a transient image for 33 ms at random intervals. A decrease in saccadic frequency, referred to as saccadic inhibition, occurred as early as 60 –70 ms following the onset of abrupt changes in visual input. It was demonstrated that the saccadic inhibition was influenced by the saliency of the visual event (Experiment 3) and was not produced in response to abrupt but irrelevant auditory stimuli (Experiment 1). Display changes restricted (...) to an area either inside or outside the perceptual span required for normal reading produced strong saccadic inhibition (Experiment 2). Finally, Experiments 4 and 5 demonstrated higher level cognitive or attentional modulation of the saccadic inhibition effect. (shrink)
