ABSTRACT A discussion of some issues from Grant Gillett's book Reasonable Care. At the metaethical level, Gillett's views about the origin, scope and bindingness of morality are outlined and criticised. Against him it is argued that moral capacity does not follow from linguistic ability, things can matter to non‐concept‐users and universalisability arguments fail to show that immorality is irrational. At the first order level, Gillett's arguments against surrogacy and euthanasia are answered.

ABSTRACT A discussion of some issues from Grant Gillett's book Reasonable Care. At the metaethical level, Gillett's views about the origin, scope and bindingness of morality are outlined and criticised. Against him it is argued that (a) moral capacity does not follow from linguistic ability, (b) things can matter to non‐concept‐users and (c) universalisability arguments fail to show that immorality is irrational. At the first order level, Gillett's arguments against surrogacy and euthanasia are answered.

The most compelling defense of the standard of reasonable care in negligence law casts itself in terms of equality. This commitment to equality may paradoxically turn out to be flatly inegalitarian. This is because it discriminates against the less capable through ignoring their deficient capabilities (and so against their chances of meeting the standard of reasonable care successfully). A promising, though still unfamiliar, way to revive the egalitarian aspirations of reasonable care would be to (...) show that imposing the standard of reasonable care even on the less competent expresses, rather than inhibits, a true devotion to equality. I seek to make this showing, and thus to reclaim for this standard of care its egalitarian foundations more adequately than has so far been proposed. (shrink)

This book offers a philosophically-based, yet clinically-oriented perspective on current medical reasoning aiming at 1) identifying important forms of uncertainty permeating current clinical reasoning and practice 2) promoting the application of an abductive methodology in the health context in order to deal with those clinical uncertainties 3) bridging the gap between biomedical knowledge, clinical practice, and research and values in both clinical and philosophical literature. With a clear philosophical emphasis, the book investigates themes lying at the border between several disciplines, (...) such as medicine, nursing, logic, epistemology, and philosophy of science; but also ethics, epidemiology, and statistics. At the same time, it critically discusses and compares several professional approaches to clinical practice such as the one of medical doctors, nurses and other clinical practitioners, showing the need for developing a unified framework of reasoning, which merges methods and resources from many different clinical but also non-clinical disciplines. In particular, this book shows how to leverage nursing knowledge and practice, which has been considerably neglected so far, to further shape the interdisciplinary nature of clinical reasoning. Furthermore, a thorough philosophical investigation on the values involved in health care is provided, based on both the clinical and philosophical literature. The book concludes by proposing an integrative approach to health and disease going beyond the so-called “classical biomedical model of care”. (shrink)

Are non-natural properties worth caring about? I consider two objections to metaethical non-naturalism. According to the intelligibility objection, it would be positively unintelligible to care about non-natural properties that float free from the causal fabric of the cosmos. According to the ethical idlers objection, there is no compelling motivation to posit non-natural normative properties because the natural properties suffice to provide us with reasons. In both cases, I argue, the objection stems from misunderstanding the role that non-natural properties play (...) in the non-naturalist's understanding of normativity. The role of non-natural properties is not to be responded to, but to "mark" which natural properties it is correct for us to respond to in certain ways. (shrink)

In bioethics, the predominant categorization of various types of influence has been a tripartite classification of rational persuasion (meaning influence by reason and argument), coercion (meaning influence by irresistible threats—or on a few accounts, offers), and manipulation (meaning everything in between). The standard ethical analysis in bioethics has been that rational persuasion is always permissible, and coercion is almost always impermissible save a few cases such as imminent threat to self or others. However, many forms of influence fall into the (...) broad middle terrain—and this terrain is in desperate need of conceptual refining and ethical analysis in light of recent interest in using principles from behavioral science to influence health decisions and behaviors. This paper aims to address the neglected space between rational persuasion and coercion in bioethics. First, I argue for conceptual revisions that include removing the “manipulation” label and relabeling this space “nonargumentative]influence,” with two subtypes: “reason-bypassing” and “reason-countering.” Second, I argue that bioethicists have made the mistake of relying heavily on the conceptual categories themselves for normative work and instead should assess the ethical permissibility of a particular instance of influence by asking several key ethical questions, which I elucidate, that relate to (1) the impact of the form of influence on autonomy and (2) the relationship between the influencer and the influenced. Finally, I apply my analysis to two examples of nonargumentative influence in health care and health policy: (1) governmental agencies such as the Food and Drug Administration (FDA) trying to influence the public to be healthier using nonargumentative measures such as vivid images on cigarette packages to make more salient the negative effects of smoking, and (2) a physician framing a surgery in terms of survival rates instead of mortality rates to influence her patient to consent to the surgery. (shrink)

Current mainstream approaches to conscientious objection either uphold the standards of public health care by preventing objections or protect the consciences of health‐care professionals by accommodating objections. Public justification approaches are a compromise position that accommodate conscientious objections only when objectors can publicly justify the grounds of their objections. Public justification approaches require objectors and assessors to speak a common normative language and to this end it has been suggested that objectors should be required to cast their objection (...) in terms of public reason. We provide critical support for such a public reason condition and argue that it would be neither too demanding nor too permissive. We also respond to objections that it unfairly favours secular over religious objectors and that public reasons cannot be held with the kind of sincerity thought to characterize conscientious objections. (shrink)

<b>Objectives:</b> To gather empirical data on how gender and educational level influence bioethical reasoning among medical students by analyzing their use of care versus justice arguments for reconciling a bioethical dilemma. <b>Setting:</b> University Departments of Medical Ethics, Social and Communication Psychology in Germany. Participants: First and fifth year medical students. Design and method: Multidisciplinary, empirical, 2-segment study of ethics in action: In intrapersonal Segment 1, the students were presented with a bioethical dilemma and then administered a 13-item questionnaire to (...) survey their individual preferences for care versus justice arguments in resolving the conflict. The survey questioned 6 justice, 6 care-related items and 1 socially critical item. Data were analysed by gender and year of medical school. In interpersonal Segment 2, the bioethical dilemma from Segment 1 was discussed in gender-mixed and gender-homogeneous groups. Coded transcripts were evaluated to identify prevalences in care versus justice reasoning. <b>Results:</b> Data on 462 medical students were evaluable (n=338 in Segment 1, n=168 in Segment 2, n=44 overlap). Gender and level of education had no effect on moral reasoning in intrapersonal Segment 1, but significantly affected reasoning in interpersonal Segment 2, where women significantly tended to use more care-orientated arguments. Justice arguments predominated the group discussions. <b>Conclusion:</b> Interpersonal contexts affect moral reasoning in medical students, probably by amplifying the socialisation relating to gender and educational level. Care orientation is associated with the female gender. Professional socialisation tends to reduce the diversity and richness of moral reasoning towards a more justice-weighted orientation. Medical ethics should teach both justice and care reasoning modes in order to broaden physicians' ability to reconcile bioethical dilemmas. (shrink)

Interpretation of Aristotle’s theory of action in the last few decades has tended toward an intellectualist position, according to which reason is in charge of setting the goals of action. This position has recently been criticized by the revival of anti-intellectualism (particularly from J. Moss’ work), according to which character, and not reason, sets the goals of action. In this essay I argue that neither view can sufficiently account for the complexities of Aristotle’s theory, and propose an intermediate account, which (...) I call indirect intellectualism, that preserves the merits of both traditional interpretations and is able to dispel the problems that trouble each. There is very strong textual evidence for the claim that goal-setting is the task not of reason but of character (and in this anti-intellectualists are right); but reason is able to set goals indirectly by carefully shaping the processes of habituation that constitute a person’s character (and in this intellectualists are right). I argue for this position through a study of the division of labour between character and reason, and through a reconstruction of Aristotle’s conception of habituation. (shrink)

abstractPosthumanism can be understood as a position that de-prioritizes or rescinds the privilege of the human in some way – frequently by attempting to think humanity as one element of a wider ecology of interdependent forces. This paper argues that one can be on the side of the human without neglecting the assemblages of which we are all a part – by conceiving of humanity as a site of nascent potential for sapience + care – an alienated understanding of (...) a complex world combined with the will to engage in the reparative processes of tending to it. (shrink)

Health systems that provide for universal patient access through a scheme of prepayments—whether through taxes, social insurance, or a combination of the two—need to make decisions on the scope of coverage that they secure. Such decisions are inherently controversial, implying, as they do, that some patients will receive less than comprehensive health care, or less than complete protection from the financial consequences of ill-heath, even when there is a clinically effective therapy to which they might have access.Controversial decisions of (...) this sort call for a public justification for covering or not covering a given treatment. Priority-setting agencies play a key role in providing such a justification. A recent... (shrink)

Recently, debate over whether health care providers should have a protected right to conscientiously refuse to offer legal health care services—such as abortion, elective sterilization, aid in dying, or treatments for transgender patients—has grown exponentially. I advance a modified compromise view that bases respect for claims of conscientious refusal to provide specific health care services on a publicly defensible rationale. This view requires health care providers who refuse such services to disclose their availability by other providers, (...) as well as to arrange for referrals or facilitate transfers of care. This requirement raises the question of whether providers are being forced to be complicit in the provision of services they deem to be morally objectionable. I conclude by showing how this modified compromise view answers the most significant objections mounted by critics of the right to conscientious refusal and safeguards providers from having to offer services that most directly threaten their moral integrity. (shrink)

There are studies on the normative ethical frameworks used by long-term care staff and studies proposing how staff should reason, but few studies explore how staff actually reason. This study reports on the ethical reasoning process and experiences of moral distress of long-term care staff in the provision of social care. Seven interdisciplinary focus groups were conducted with twenty front-line staff. Staff typically did not have difficulty determining the ethical decision and/or action; however, they frequently experience moral (...) distress. To manage these experiences of moral distress in making ethical decisions, staff 1) comply with being told what to do out of fear of consequences, 2) defer decisions to family, 3) “have a meeting,” 4) socialization into and acceptance of workplace culture. Findings suggest that to better understand how and why staff make ethical decisions and improve quality and ethical care, we must explore the interaction between front-line practice and organizational and public policy. (shrink)

We have compelling extra-philosophical reasons for caring about identity, parthood, and location. For example, we desire ceteris paribus that nothing every part of which is very near to our location be very near to the location of something dangerous, evil, or otherwise unpleasant. This essay argues that such considerations are relevant to certain first-order metaphysical debates, namely, the debates over immanent universals and tropes and endurantism and perdurantism, respectively. As a consequence, even the non-specialist has a reason to care (...) about the metaphysics of properties and persistence. (shrink)

The Sleeping Beauty Problem attracts so much attention because it connects to a wide variety of unresolved issues in formal epistemology, decision theory, and the philosophy of science. The problem raises unanswered questions concerning relative frequencies, objective chances, the relation between self-locating and non-self-locating information, the relation between self-location and updating, Dutch Books, accuracy arguments, memory loss, indifference principles, the existence of multiple universes, and many-worlds interpretations of quantum mechanics. After stating the problem, this article surveys its connections to all (...) of these areas. (shrink)

To achieve its goals of managing andrestricting access to psychiatric care, managedcare organizations rely on an instrument, theoutpatient treatment report, that carriessignificant implications about how they viewpsychiatric patients and psychiatric care. Inaddition to involving ethical transgressionssuch as violation of patient confidentiality,denial of access to care, spurious use ofconcepts like quality of care, and harassmentof practitioners, the managed care approachalso depends on an overly technical,instrumental interpretation of human beings andpsychiatric treatment. It is this grounding ofmanaged (...) class='Hi'>care in technical reason that I willexplore in this study. I begin with a reviewof a typical outpatient treatment report andshow how, with its dependence on the DSM-IV,on behavioral symptoms and patient`functioning'', on the biomedical model ofpsychiatric illness, and on gross quantitativemeasures, the report results in a crude,skeletonized view of the human being as acongeries of behavioral symptoms and functions. I then develop the managed care construal ofhuman existence further by showing itsgrounding in technical reason, exploring thelatter in its modern embodiment and deriving itand its opposite, practical reason, fromAristotle''s distinction between technical andpractical reason, techne and phronesis. Inthis analysis of the role of technical reasonin managed care, I point out that managed caredid not have to develop its rationale de novobut could rather lift its arguments, e.g. thebiomedical model, from contemporary psychiatryand simply apply them in a restrictive manner. Finally, I conclude this study by arguing forpsychiatry''s status as a discipline ofpractical knowledge. (shrink)

The importance of developing cultural competence among healthcare professionals is well recognized. However, the widespread reports of insensitivity and deficiencies in care for culturally diverse patients illuminate the need to review how cultural competence development is taught, learnt and applied in practice. Unless we can alter the ‘hearts and minds’ of practising nurses to provide the care that they know they should, culturally insensitive care will continue operating in subtle ways. This paper explores the ideas behind nurses’ (...) actions and omissions when caring for culturally diverse patients and proposes the need to examine cultural competence development through a moral reasoning lens. Examining cultural competence development through a moral reasoning lens can help empower nurses, whilst nurturing commitment and courage to providing quality care that meets the needs of culturally diverse patients. The model of morality provides a framework that explores how moral motivation and behaviour occur and can provide a vehicle for critically examining the knowledge, skills and attitudes required to provide culturally responsive care. (shrink)

Journal Name: Apeiron Issue: Ahead of print.

Despite its title, this is an extremely useful book: the first four of its five chapters expound the standard range of theories of practical reasoning more clearly and accurately than one might have thought possible. A measure of Schaubroeck’s authoritative handling of her material is her ability to navigate the peaks, troughs and crevasses of the myriad variations of ‘internalism’ and ‘externalism’ without inducing either vertigo or fury. Thus she patiently guides the reader through the stupefying obstacles along the route (...) of post-Bernard Williams usages of the terminology as well, it seems to me, as anyone could possibly do. Her specific focus, furthermore, on what she terms—albeit in my view somewhat misleadingly—Humean , Kantian and Platonic variations on a theme enables the reader to see very clearly just what is at stake in the tangled literature on practical reasoning and why it matters. As a guide for the perplexed, then, or for t .. (shrink)

Shared decision making has become the standard of care, yet there remains no consensus about how it should be conducted. Most accounts are concerned with threats to patient autonomy, and they address the dangers of a power imbalance by foregrounding the patient as a person whose complex preferences it is the practitioner's task to support. Other corrective models fear that this level of mutuality risks abdicating the practitioner's responsibilities as an expert, and they address that concern by recovering a (...) nuanced but genuinely directive clinical role. Cribb and Entwistle helpfully categorize models of shared decision making as ‘narrower’ and ‘broader’ and praise the latter's ‘open‐ended and fully dialogical ways of relating’. However, they stop short of providing a philosophical account of how that dialogue works. In this paper, a nurse–midwife and a philosopher collaborate to argue that the Socratic model of dialogue offers a solution to the practitioner–patient dilemma. In the Theaetetus, Socrates compares dialogical reasoning to ‘midwifery with all its standard features’. By means of a three‐way analogy, elements of midwifery practice are used to illuminate features of Socrates' claim that his dialogue is like midwifery; those features are then translated into an approach to shared decision making as the ‘midwifery of good thinking’ which both midwives and physicians would do well to adopt. A key concept that emerges is the need for practitioners to make a risk‐confidence assessment of the particular content of any decision to appropriately modulate their role in the practice of shared decision making. (shrink)

There has been much discussion about how to obtain legitimacy at macro-level priority setting in health care by use of fair procedures, but how should we consider priority setting by individual clinicians or health workers at the micro-level? Despite the fact that just health care totally hinges upon their decisions, surprisingly little attention seems being paid to the legitimacy of these decisions. This paper addresses the following question: what are the conditions that have to be met in order (...) to ensure that individual claims on health care are well aligned with an overall concept of just health care? Drawing upon a distinction between individual and aggregated needs, I argue that even though we assume the legitimacy of macro-level guidelines, this legitimacy is not directly transferable to decisions at micro-level simply by adherence to the guidelines’ recommendation. Further, I argue that individual claims are subject to the formal principle of equality and the demands of vertical and horizontal equity in a way that gives context- and patient-related equity concerns precedence over equity concerns captured at the macro-level. I conclude that if we aim to achieve just health care, we need to develop a complementary framework for legitimising individual judgment of patients’ claims on health care resources. Moreover, I suggest the basic structure of such a framework. (shrink)

The paper "Care Ethics and Impartial Reasons" was given at the United Kingdom SWIP (Society for Women in Philosophy) meeting in Stirling, Scotland, on April 21, 2007, and while in her lifetime she would surely have reworked this piece thoroughly before allowing it to appear in print, we publish it here as an expression of sorrow and affection.

The aim of this study was to investigate relationships between care and justice reasoning, dispositional empathy variables and meta‐ethical thinking among 128 students from a university of applied sciences. The measures were Skoe’s Ethic of Care Interview, the Defining Issues Test, Davis’s Interpersonal Reactivity Index and Meta‐Ethical Questionnaire. The results showed that levels of care reasoning were positively related to the post‐conventional schema and negatively related to the personal interest schema in justice reasoning. Age, meta‐ethical thinking, the (...) post‐conventional schema and perspective taking predicted care reasoning. Sympathy was positively related to both modes of moral reasoning among men and predicted their care reasoning. The results point out common elements for care and justice reasoning, underscore the importance of perspective taking for moral reasoning and indicate that the relationship between affective‐based empathy and moral reasoning is gender‐specific and far more complex than previous theories suggest. (shrink)

Human beings working in fields involving life, death, and morality are going to have fundamental and occasionally irreconcilable differences of opinion regarding goals, values, and actions. This has been true from the beginning of civilization. Along the way, civilized peoples have created laws that accommodate these differences so that a diverse population can coexist peaceably in one pluralistic society. As such, the Law is the practical, inchoate expression of that society's combined morals.For more than a decade, scholarly articles about conscientious (...) objection in medical care have tended to involve one group of people telling other groups what they must value and how they must behave in order to be good... (shrink)

Conscientious objection in the health care field—that is, refusal on the part of a medical professional to perform or cooperate in a procedure when it violates his or her conscience—is a growing concern for international legislators and a source of contentious debates among ethicists and the general public. Recognizing a general right to conscientious objection based on individual liberty, and thus a subjective right, could have negative consequences. Conscientious objection in health care settings should be fully protected, however, (...) when the objection is based on principles that are fundamental to the medical profession and the legal system. Examples from Italy and other nations show how protections there safeguard conscientious objection when a health professional objects to taking a human life. National Catholic Bioethics Quarterly 12.4 (Winter 2012): 611–620. (shrink)

In recent literature, there has been much debate about whether and how luck egalitarianism, given its focus on personal responsibility, can justify universal health care. In this paper we argue that, whether or not this is so, and in fact whether or not egalitarianism should be sensitive to responsibility at all, the question of personal responsibilization for health is not settled. This is the case because whether or not individuals are responsible for their own health condition is not all (...) that is relevant when considering whether we should somehow hold them responsible for their own health condition, e.g. cost-wise. There may also be efficiency-based reasons to hold them responsible, and there may even be egalitarian reasons. Defining universal health care as an insurance system where everyone’s deductible and premium is 0, we will argue that efficiency-based reasons for cost-responsibilization are not convincing, but that there are egalitarian reasons for cost-responsibilization. Luck egalitarianism, therefore, cannot, at least not on its own term, justify universal health care. (shrink)

Background:The debate over the ethical implications of care robots has raised a range of concerns, including the possibility that such technologies could disrupt caregiving as a core human moral activity. At the same time, academics in information ethics have argued that we should extend our ideas of moral agency and rights to include intelligent machines.Research objectives:This article explores issues of the moral status and limitations of machines in the context of care.Design:A conceptual argument is developed, through a four-part (...) scheme derived from the work of Alasdair MacIntyre. No empirical data are used.Ethical consideration:No primary data were gathered for this study. Secondary sources and authorship have been acknowledged throughout.Findings / discussion:Certain kinds of social experience, including the narrative unity of a life, and the giving and receiving of care, are essential for moral development. Machines, no matter how advanced, cannot participate in such experiences in key respects, and thus cannot develop as practical reasoners.Conclusion:It follows that they cannot be moral agents and that they cannot care. There are, it seems, no such things as care robots. In view of the institutional power of tech companies and commissioning bodies, care practitioners need to take more of a lead in developing new assistive technologies which are appropriate to their practice. (shrink)

This thesis discusses how societies should allocate clinical care resources. The first aim of the thesis is to defend the idea that clinical care resource allocation is a matter for deliberative democratic procedures. I argue that deliberative democracy is justified because of its ability to implement equal respect and autonomy. Furthermore, I address several in-principle objections to the project of applying deliberative democracy to clinical care resource allocation. Most notably, I respond to the narrow view of the (...) scope of deliberative democracy and the critiques of explicit rationing. -/- The second aim of the thesis is to determine what is required by deliberative democracy in clinical care resource allocation. I identify the general requirements that resource allocation agencies should meet, namely public reason, public involvement, transparency, accuracy and revisability. I then examine what is required by deliberative democracy with regard to two particularly salient specific topics, namely the substantive values that should govern resource allocation and the involvement of scientific experts in decision-making. -/- I demonstrate that public reason imposes severe constraints on the substantive values that should be employed. Most of these constraints are rooted in the idea that, under a regime of scarcity, public reason requires that resources be allocated so as to minimise the strongest complaint anyone may have. Out of the variety of values that are commonly proposed as relevant, only priority to the worst-off, ability to benefit, specialness of clinical care and cost are consistent with public reason. Turning to expert involvement, I argue that deliberative democracy can overcome several formidable threats, such as the opacity of expert opinions to laypersons and the tendency to hide uncertainty and disagreement from the public. I also discuss how my proposals on substantive values and expert involvement could be implemented, in order to add to the plausibility of my theory. (shrink)

Much of the literature supports the moral development theory as a justification for teachers to care, where teachers should care for their students because it contributes to their moral education as caring persons. If no causal relationship can be established, the question remains whether we would want teachers to care, preferably one that does not merely import its external normative significance into teaching. I argue that an understanding of teaching, and moreover, of good teaching already has embedded (...) within it conceptions of care. Understanding that teaching involves care would then challenge virtue/character-based conceptions of the good teacher. While these clarifications are modest in scope, taking caring seriously in teaching has implications on how we conceptualize the good teacher, which in turn affects how both teacher education and professional ethics might be understood. (shrink)

The standard argument for longtermism assumes that we should care as much about far future people as about our contemporaries. I challenge this assumption. I first consider existing interpretations of ‘temporal discounting’, and argue that such discounting seems either unwarranted or insufficient to block the argument. I then offer two alternative reasons to care less about far future people: caring as much about them as about our contemporaries would make our lives less authentic and less meaningful. If I’m (...) right, this undermines at least the strongest versions of longtermism. Plausibly, we should do much more for the far future than we’re currently doing. Still, we often ought to act for contemporaries’ sakes, even if longtermist actions would expectably do more good. (shrink)

Robert Card’s “Reasonability View” is a significant contribution to the debate over the place of conscientious objection in health care. In his view, conscientious objections can only be accommodated if the grounds for the objection meet a reasonability standard. I identify inconsistencies in Card’s description of the reasonability standard and argue that each version he specifies is unsatisfactory. The criteria for reasonability that Card sets out most frequently have no clear underpinning principle and are too permissive of immoral objections. (...) Card has also claimed that petitioners must justify their positions with Rawlsian public reason. I argue that, although the resulting reasonability standard is principled, it is overly restrictive. I also show that a reasonability standard built on Rawls’ more lenient conception of reasonableness would be overly permissive of objections at odds with professional healthcare standards. Finally, I argue for my favored solution, which bases the reasonability standard on minimal professional standards. (shrink)

This paper argues that, in a community of rights, the prima facie responsibilities of researchers to attend to the ancillary-care needs of their participants would be determined by a four-stage test . This test, it is suggested, sets a standard for common law courts that are invited to recognize the ancillary-care responsibilities of researchers, whether as a matter of contract or tort law.

Vaccine refusal forces us to confront tensions between many values, including scientific expertise, parental rights, children’s best interests, social responsibility, public trust, and community health. Recent outbreaks of vaccine-preventable and emerging infectious diseases have amplified these issues. The prospect of a coronavirus disease 2019 vaccine signals even more friction on the horizon. In this contentious sociopolitical landscape, it is therefore more important than ever for clinicians to identify ethically justified responses to vaccine refusal.

It is axiomatic that the first responsibility of researchers, whether they are working in the developed or the developing world, is to do no harm to those who participate in their studies or trials. However, on neither side of the Atlantic is there any such settled view with regard to the responsibility of researchers to attend to the ancillary-care needs of their participants – that is, a responsibility to advise or assist participants who have medical condition X in circumstances (...) where the research concerns medical condition Y, and the research did not contribute to the presence of condition X in participants, nor did the having of condition X contribute to the research. Consider, for example, the following hypothetical posed by Leah Belsky and Henry Richardson:Researchers testing a new treatment for tuberculosis in a developing country discover some patients have HIV infection. Do they have a responsibility to provide antiretroviral drugs? (shrink)