The diagnostic category of borderline personality disorder (BPD) has come under increasing criticism in recent years. In this paper, we analyze the role and impact of epistemic injustice, specifically testimonial injustice, in relation to the diagnosis of BPD. We first offer a critical sociological and historical account, detailing and expanding a range of arguments that BPD is problematic nosologically. We then turn to explore the epistemic injustices that can result from a BPD diagnosis, showing how they can lead to experiences (...) of testimonial injustice which impede patient engagement in meaning-making activities, thereby undermining standard therapeutic goals. We conclude by showing how our arguments bolster ongoing efforts to replace the diagnostic category of BPD with alternatives such as complex post-traumatic stress disorder. (shrink)

The ongoing debate within neuroethics concerning the degree to which neuromodulation such as deep brain stimulation (DBS) changes the personality, identity, and agency (PIA) of patients has paid relatively little attention to the perspectives of prospective patients. Even less attention has been given to pediatric populations. To understand patients’ views about identity changes due to DBS in obsessive-compulsive disorder (OCD), the authors conducted and analyzed semistructured interviews with adolescent patients with OCD and their parents/caregivers. Patients were asked about projected impacts (...) to PIA generally due to DBS. All patient respondents and half of caregivers reported that DBS would impact patient self-identity in significant ways. For example, many patients expressed how DBS could positively impact identity by allowing them to explore their identities free from OCD. Others voiced concerns that DBS-related resolution of OCD might negatively impact patient agency and authenticity. Half of patients expressed that DBS may positively facilitate social access through relieving symptoms, while half indicated that DBS could increase social stigma. These views give insights into how to approach decision-making and informed consent if DBS for OCD becomes available for adolescents. They also offer insights into adolescent experiences of disability identity and “normalcy” in the context of OCD. (shrink)

BackgroundDeep brain stimulation is approved for treating refractory obsessive-compulsive disorder in adults under the US Food and Drug Administration Humanitarian Device Exemption, and studies hav...

Questions about when to limit unhelpful treatments are often raised in general medicine but are less commonly considered in psychiatry. Here we describe a survey of U.S. psychiatrists intended to characterize their attitudes about the management of suicidal ideation in patients with severely treatment-refractory illness. Respondents (n = 212) received one of two cases describing a patient with suicidal ideation due to either borderline personality disorder or major depressive disorder. Both patients were described as receiving all guideline-based and plausible emerging (...) treatments. Respondents rated the expected helpfulness and likelihood of recommending each of four types of intervention: hospitalization, additional medication changes, additional neurostimulation, and additional psychotherapy. Across both cases, most respondents said they were likely to provide each intervention, except for additional neurostimulation in borderline personality disorder, while fewer thought each intervention would be helpful. Substantial minorities of respondents indicated that they would provide an intervention they did not think was likely to be helpful. Our results suggest that while most psychiatrists recognize the possibility that some patients are unlikely to be helped by available treatments, many would continue to offer such treatments. (shrink)

Do we need a right to mental privacy? In an era of increasing sophistication in recording, interpreting, and directly intervening on our neural activity – not to mention efforts at combining neural...

IntroductionDeep brain stimulation (DBS) is utilized to treat pediatric refractory dystonia and its use in pediatric patients is expected to grow. One important question concerns the impact of hope and unrealistic optimism on decision-making, especially in “last resort” intervention scenarios such as DBS for refractory conditions.ObjectiveThis study examined stakeholder experiences and perspectives on hope and unrealistic optimism in the context of decision-making about DBS for childhood dystonia and provides insights for clinicians seeking to implement effective communication strategies.Materials and MethodsSemi-structured interviews (...) with clinicians (n = 29) and caregivers (n = 44) were conducted, transcribed, and coded.ResultsUsing thematic content analysis, four major themes from clinician interviews and five major themes from caregiver interviews related to hopes and expectations were identified. Clinicians expressed concerns about caregiver false hopes (86%, 25/29) and desperation (68.9%, 20/29) in light of DBS being a last resort. As a result, 68.9% of clinicians (20/29) expressed that they intentionally tried to lower caregiver expectations about DBS outcomes. Clinicians also expressed concern that, on the flip side, unrealistic pessimism drives away some patients who might otherwise benefit from DBS (34.5%, 10/29). Caregivers viewed DBS as the last option that they had to try (61.3%, 27/44), and 73% of caregivers (32/44) viewed themselves as having high hopes but reasonable expectations. Fewer than half (43%, 19/44) expressed that they struggled setting outcome expectations due to the uncertainty of DBS, and 50% of post-DBS caregivers (14/28) expressed some negative feelings post treatment due to unmet expectations. 43% of caregivers (19/44) had experiences with clinicians who tried to set low expectations about the potential benefits of DBS.ConclusionThoughtful clinician-stakeholder discussion is needed to ensure realistic outcome expectations. (shrink)

The application of machine learning in health care holds great promise for improving care. Indeed, our own team is collaborating with experts in machine learning and statistical modeling to bu...

ABSTRACT:Bioethicists today are taking a greater role in the design and implementation of emerging technologies by "embedding" within the development teams and providing their direct guidance and recommendations. Ideally, these collaborations allow ethical considerations to be addressed in an active, iterative, and ongoing process through regular exchanges between ethicists and members of the technological development team. This article discusses a challenge to this embedded ethics approach—namely, that bioethical guidance, even if embraced by the development team in theory, is not easily (...) actionable in situ. Many of the ethical problems at issue in emerging technologies are associated with preexisting structural, socioeconomic, and political factors, making compliance with ethical recommendations sometimes less a matter of choice and more a matter of feasibility. Moreover, incentive structures within these systemic factors maintain them against reform efforts. The authors recommend that embedded bioethicists utilize principles from behavioral science (such as behavioral economics) to better understand and account for these incentive structures so as to encourage the ethically responsible uptake of technological innovations. (shrink)

Drawing on recent findings in the cognitive and neurosciences, this article discusses how people manage to predict each other’s actions, which is fundamental for joint action. We explore how a common coding of perceived and performed actions may allow actors to predict the what, when, and where of others’ actions. The “what” aspect refers to predictions about the kind of action the other will perform and to the intention that drives the action. The “when” aspect is critical for all joint (...) actions requiring close temporal coordination. The “where” aspect is important for the online coordination of actions because actors need to effectively distribute a common space. We argue that although common coding of perceived and performed actions alone is not sufficient to enable one to engage in joint action, it provides a representational platform for integrating the actions of self and other. The final part of the paper considers links between lower‐level processes like action simulation and higher‐level processes like verbal communication and mental state attribution that have previously been at the focus of joint action research. (shrink)

Background:Moral distress is a complex phenomenon frequently experienced by critical care nurses. Ethical conflicts in this practice area are related to technological advancement, high intensity work environments, and end-of-life decisions.Objectives:An exploration of contemporary moral distress literature was undertaken to determine measurement, contributing factors, impact, and interventions.Review Methods:This state of the science review focused on moral distress research in critical care nursing from 2009 to 2015, and included 12 qualitative, 24 quantitative, and 6 mixed methods studies.Results:Synthesis of the scientific literature revealed (...) inconsistencies in measurement, conflicting findings of moral distress and nurse demographics, problems with the professional practice environment, difficulties with communication during end-of-life decisions, compromised nursing care as a consequence of moral distress, and few effective interventions.Conclusion:Providing compassionate care is a professional nursing value and an inability to meet this goal due to moral distress may have devastating effects on care quality. Further study of patient and family outcomes related to nurse moral distress is recommended. (shrink)

Although there is now a substantial body of literature exploring the effects of language diversity in international management contexts, little attention has been paid to the ethical dimensions of language diversity at work. This conceptual paper draws on the concept of epistemic injustice in order to explore how language, and in particular corporate language policies, may act as a source of epistemic injustice within the workplace. It demonstrates how language competence affects credibility judgements about a speaker, and also considers how (...) corporate language policies can create situations of hermeneutic injustice, in which marginalised groups are denied the vocabularies to understand their own experiences. Finally, ways in which such epistemic harms can be reduced are discussed, and the possibilities for management education to create epistemically responsible managers are highlighted. (shrink)

Game theory is central to modern understandings of how people deal with problems of coordination and cooperation. Yet, ironically, it cannot give a straightforward explanation of some of the simplest forms of human coordination and cooperation--most famously, that people can use the apparently arbitrary features of "focal points" to solve coordination problems, and that people sometimes cooperate in "prisoner's dilemmas." Addressing a wide readership of economists, sociologists, psychologists, and philosophers, Michael Bacharach here proposes a revision of game theory that resolves (...) these long-standing problems. In the classical tradition of game theory, Bacharach models human beings as rational actors, but he revises the standard definition of rationality to incorporate two major new ideas. He enlarges the model of a game so that it includes the ways agents describe to themselves their decision problems. And he allows the possibility that people reason as members of groups, each taking herself to have reason to perform her component of the combination of actions that best achieves the group's common goal. Bacharach shows that certain tendencies for individuals to engage in team reasoning are consistent with recent findings in social psychology and evolutionary biology. As the culmination of Bacharach's long-standing program of pathbreaking work on the foundations of game theory, this book has been eagerly awaited. Following Bacharach's premature death, Natalie Gold and Robert Sugden edited the unfinished work and added two substantial chapters that allow the book to be read as a coherent whole. (shrink)

Feminist epistemologies hold that differences in the social locations of inquirers make for epistemic differences, for instance, in the sorts of things that inquirers are justified in believing. In this paper we situate this core idea in feminist epistemologies with respect to debates about social constructivism. We address three questions. First, are feminist epistemologies committed to a form of social constructivism about knowledge? Second, to what extent are they incompatible with traditional epistemological thinking? Third, do the answers to these questions (...) raise serious problems for feminist epistemologies? We argue that some versions of two of the main strands in feminist epistemology – feminist standpoint theory and feminist empiricism – are committed to a form of social constructivism, which requires certain departures from traditional epistemological thinking. But we argue that these departures are less problematic than one might think. Thus, (some) feminist epistemologies provide a plausible way of understanding how (some) knowledge might be socially constructed. (shrink)

In this paper I make the case for a feminist hinge epistemology in three steps. My first step is to explain hinge epistemologies as contemporary epistemologies that take Wittgenstein’s work in On Certainty as their starting point. My second step is to make three criticisms of this literature as it currently stands. My third step is to introduce feminist epistemologies, which argue that social factors like race and gender affect what different people and groups justifiably believe, and argue that developing (...) a feminist hinge epistemology is both plausible and desirable. (shrink)

Standard game theory cannot explain the selection of payoff-dominant outcomes that are best for all players in common-interest games. Theories of team reasoning can explain why such mutualistic cooperation is rational. They propose that teams can be agents and that individuals in teams can adopt a distinctive mode of reasoning that enables them to do their part in achieving Pareto-dominant outcomes. We show that it can be rational to play payoff-dominant outcomes, given that an agent group identifies. We compare team (...) reasoning to other theories that have been proposed to explain how people can achieve payoff-dominant outcomes, especially with respect to rationality. Some authors have hoped that it would be possible to develop an argument that it is rational to group identify. We identify some large—probably insuperable—problems with this project and sketch some more promising approaches, whereby the normativity of group identification rests on morality. (shrink)

This paper proposes a refocusing of consent for clinical genetic testing, moving away from an emphasis on autonomy and information provision, towards an emphasis on the virtues of healthcare professionals seeking consent, and the relationships they construct with their patients. We draw on focus groups with UK healthcare professionals working in the field of clinical genetics, as well as in-depth interviews with patients who have sought genetic testing in the UK’s National Health Service. We explore two aspects of consent: first, (...) how healthcare professionals consider the act of ‘consenting’ patients; and second how these professional accounts, along with the accounts of patients, deepen our understanding of the consent process. Our findings suggest that while healthcare professionals working in genetic medicine put much effort into ensuring patients’ understanding about their impending genetic test, they acknowledge, and we show, that patients can still leave genetic consultations relatively uninformed. Moreover, we show how placing emphasis on the informational aspect of genetic testing is not always reflective of, or valuable to, patients’ decision-making. Rather, decision-making is socially contextualised – also based on factors outside of information provision. A more collaborative on-going consent process, grounded in virtue ethics and values of honesty, openness and trustworthiness, is proposed. (shrink)

In this paper I explore the relationship between social epistemology and relativism in the context of feminist epistemology. I do this by focusing on one particular branch of feminist epistemology - a branch known as standpoint theory - and investigating the connection between this view and epistemic relativism. I begin by defining both epistemic relativism and standpoint theory, and by briefly recounting the standard way that the connection between these two views is understood. The literature at the moment focuses on (...) an aspect of standpoint theory called the epistemic advantage thesis, and on an aspect of relativism which has been called equality. I then show that the connection between relativism and standpoint theory actually turns on a different aspect of standpoint theory, known as the standpoint thesis, and on an aspect of relativism which has been called non-neutrality. I argue that shifting our attention to these other aspects reveals that standpoint theory is clearly and unavoidably relativist, but that this isn’t a problem - standpoint theory can capture everything that it set out to, even on a relativist understanding of the view. (shrink)

Based on Pacherie’s dynamic theory of intentions, this study investigated how the way an intention is formed and sustained affects action performance and the experience of control during acting. In Experiment 1, task-irrelevant verbal commands were given while participants responded to stimuli in a two-choice reaction time task. The commands referred to an action goal congruent or incongruent with the actor’s current intention, or ordered the initiation or abortion of the action. In Experiment 2, the same commands were given as (...) participants freely chose between two actions. The distractors affected performance in the reactive task only. In both experiments, feelings of control were based on movement parameters as well as perceived matches between distractors and intended actions. These findings suggest that the way an intention is implemented affects how well it can be shielded against external perturbations and how much one feels in control. (shrink)

Following important work by Pizarro, Uhlmann and Salovey (2003) on moral judgments of uncontrolled/impulsive versus controlled/ deliberate action, we focus on the related issue of the moral evaluation of emotion-motivated versus principle-driven behavior. We examine: (a) the potential lesser blameworthiness of antisocial acts perceived as driven by emotion as opposed to principle; (b) how factors governing the moral evaluation of antisocial acts might extend to the evaluation of prosocial acts; and (c) how overriding a moral emotion in favor of a (...) moral principle affects moral attributions. (shrink)

In 2004, Natalie Lloyd and Jane Mulcock initiated the Australian Animals & Society Study Group, a network of social science, humanities and arts scholars that quickly grew to include more than 100 participants. In July 2005, about 50 participants attended the group's 4-day inaugural conference at the University of Western Australia, Perth. Papers in this issue emerged from the conference. They exemplify the Australian academy's work in the fields of History, Population Health, Sociology, Geography, and English and address strong (...) themes: human-equine relationships; management of native and introduced animals; and relationships with other domestic, nonhuman animals—from cats and dogs to cattle. Human-Animal Studies is an expanding field in Australia. However, many scholars, due to funding and teaching concerns, focus their primary research in different domains. All authors in this issue—excepting one—are new scholars in their respective fields. The papers represent the diversity and innovation of recent Australian research on human-animal interactions. The authors look at both past and present, then anticipate future challenges in building an effective network to expand this field of study in Australia. (shrink)

Background: Limited knowledge of the experiences of conflicts of conscience found in nursing literature. Objectives: To explore the individual experiences of a conflict of conscience for neonatal nurses in Alberta. Research design: Interpretive description was selected to help situate the findings in a meaningful clinical context. Participants and research context: Five interviews with neonatal nurses working in Neonatal Intensive Care Units throughout Alberta. Ethical consideration: Ethics approval from the Health Research Ethics Board at the University of Alberta. Findings: Three common (...) themes emerged from the interviews: the unforgettable conflict with pain and suffering, finding the nurse’s voice, and the unique proximity of nurses. Discussion and conclusion: The nurses described a conflict of conscience when the neonate in their care experienced undermanaged pain and unnecessary suffering. During these experiences, they felt guilty, sad, hopeless, and powerless when they were unable to follow their conscience. Informal ways to follow their conscience were employed before declaration of conscientious objection was considered. This study highlights the vital importance of respecting a conflict of conscience to maintain the moral integrity of neonatal nurses and exposes the complexities of conscientious objection. (shrink)

In the literature of collective intentions, the ‘we-intentions’ that lie behind cooperative actions are analysed in terms of individual mental states. The core forms of these analyses imply that all Nash equilibrium behaviour is the result of collective intentions, even though not all Nash equilibria are cooperative actions. Unsatisfactorily, the latter cases have to be excluded either by stipulation or by the addition of further, problematic conditions. We contend that the cooperative aspect of collective intentions is not a property of (...) the intentions themselves, but of the mode of reasoning by which they are formed. We analyse collective intentions as the outcome of team reasoning, a mode of practical reasoning used by individuals as members of groups. We describe this mode of reasoning in terms of formal schemata, discuss a range of possible accounts of group agency, and show how existing theories of collective intentions fit into this framework. (shrink)

Universities and other research institutions are increasingly providing additional training in research integrity to improve the quality and reliability of research. Various training courses have been developed, with diverse learning goals and content. Despite the importance of training that focuses on moral character and professional virtues, there remains a lack of training that adopts a virtue ethics approach. To address this, we, a European Commission-funded consortium, have designed a train-the-trainer programme for research integrity. The programme is based on (1) virtue (...) ethics, (2) the ethos of science, (3) learning by doing and (4) learner-centred teaching. The blended learning programme combines e-learning modules with participatory group sessions. Trainers are taught how to guide researchers through a series of structured exercises for fostering reflection on scientific virtues, and how to promote understanding and application of the European Code of Conduct for Research Integrity. Trainers are provided with adaptable tools and resources that can be used and combined in different ways. The programme implementation began in Spring 2020 and 470 trainers have participated to date. When trainers were asked to grade – between 0 (very bad) and 10 (excellent) – the e-learning modules and the participatory exercises, 60% scored a grade 8 or higher (median = 8, IQR = 2) for the e-learning modules, whereas 80% scored a grade 8 or higher (median = 9, IQR = 1) for the participatory exercises. A majority felt that the training helped them as a trainer to learn about ways to organise and teach a research integrity course (82%) and would recommend the interactive exercises to others (92%). Trainers have educated over 3300 researchers in Europe using our virtue-based approach. The VIRT2UE train-the-trainer programme fosters research integrity by providing trainers with exercises and tools which enable them to stimulate the development of good researchers across Europe. (shrink)

Joseph Raz’s The Morality of Freedom is well known for defending both a perfectionist form of liberalism and an ‘externalist’ conception of autonomy. John Christman proposes that there is a logical connection between the two theses and argues that externalist accounts of autonomy should be rejected on the basis that they are perfectionist. Christman’s perfectionism argument contains two premises: externalist theories of autonomy entail political perfectionism and political perfectionism is not defensible. I argue that neither premise is true. Externalist theories (...) of autonomy do not entail political perfectionism. Further, even assuming for the sake of argument that premise is true, premise is false. The strongest challenge to political perfectionism is that it is incompatible with the value of respect. I argue that those defending political perfectionism misconstrue what is required for respect. Once we see that respect is secured through features inherent in processes, the value of respect can be reconciled with political perfectionism. Political perfectionism is a defensible thesis and premise is false. (shrink)

Recent research suggests that individuals with relatively weak global precedence (i.e., a smaller propensity to view visual stimuli in a configural manner) show a reduced face inversion effect (FIE). Coupled with such findings, a number of recent studies have demonstrated links between an advantage for feature-based processing and the presentation of traits associated with autism among the general population. The present study sought to bridge these findings by investigating whether a relationship exists between the possession of autism-associated traits (i.e., as (...) indicated by individuals’“autism quotient” [(AQ) and the size of the FIE. Participants completed an on-line study in which the AQ was measured prior to a standard face recognition task where half of the faces were inverted at test. The results confirmed that higher AQ levels were predictive of smaller FIEs. Implications for a common underlying factor relating to processing orientation are discussed. (shrink)

The debate about what constitutes the discipline of ethics and who qualifies as an ethics consultant is linked unavoidably to a debate that is potentiated by the reality of a rapidly changing and high-stakes health care consultation marketplace. Who we are and what we can offer to the moral gesture that is medicine is shaped by our fundamental understanding of the place of expert knowledge in the transformation of social reality. The struggle for self-definition is particularly freighted since clinical ethics (...) consultation aspires to be more than academic contemplation. Two recent books (Ethics Consultation by John La Puma and David Schiedermayer and The Health Care Ethics Consultant: A Practical Guide, edited by Francoise Baylis) exemplify the two most popular but most widely divergent positions on these issues. We argue that while useful, neither book addresses fully the particular and distinct role of the professional ethicist. (shrink)

I connect commodification arguments to an empirical literature, present a mechanism by which commodification may occur, and show how this may restrict the range of goods and services that are subject to commodification, therefore having implications for the use of commodification arguments in political theory. Commodification arguments assert that some people’s trading a good or service can debase it for third parties. They consist of a normative premise, a theory of value, and an empirical premise, a mechanism whereby some people’s (...) market exchange affects how goods can be valued by others. Hence, their soundness depends on the existence of a suitable candidate mechanism for the empirical premise. The ‘motivation crowding effect’ has been cited as the empirical base of commodification. I show why the main explanations of motivation crowding – signaling and over-justification – do not provide mechanisms that could underpin the empirical premise. In doing this, I reveal some requirements on any candidate me... (shrink)

ABSTRACTThis article develops a theory of just contractual relationships for a liberal society. As a liberal theory, our account is premised on liberalism's canonical commitments to self-determination and substantive equality. As a theory of contract law, it focuses on the parties’ interpersonal interactions rather than on the justice of the social order as a whole.Normatively, the article claims that the rules governing cases where one party experiences harsh circumstances or vulnerability during the bargaining process or operates under significant informational disadvantage (...) must be guided by the commitment to relational justice, that is, to reciprocal respect for self-determination and substantive equality. Jurisprudentially, the article studies the systemic difficulties hindering the translation of these normative prescriptions into legal language and analyzes how they affect the form assumed by the law of precontractual justice and its institutional pedigree. (shrink)

The debate about what constitutes the discipline of ethics and who qualifies as an ethics consultant is linked unavoidably to a debate that is potentiated by the reality of a rapidly changing and high-stakes health care consultation marketplace. Who we are and what we can offer to the moral gesture that is medicine is shaped by our fundamental understanding of the place of expert knowledge in the transformation of social reality. The struggle for self-definition is particularly freighted since clinical ethics (...) consultation aspires to be more than academic contemplation. Two recent books (Ethics Consultation by John La Puma and David Schiedermayer and The Health Care Ethics Consultant: A Practical Guide, edited by Francoise Baylis) exemplify the two most popular but most widely divergent positions on these issues. We argue that while useful, neither book addresses fully the particular and distinct role of the professional ethicist. (shrink)

According to Duncan Pritchard, there are two kinds of radical sceptical problem; the closure-based problem, and the underdetermination-based problem. He argues that distinguishing these two problems leads to a set of desiderata for an anti-sceptical response, and that the way to meet all of these desiderata is by supplementing a form of Wittgensteinian contextualism with disjunctivist views about factivity. I agree that an adequate response should meet most of the initial desiderata Pritchard puts forward, and that some version of Wittgensteinian (...) contextualism shows the most promise as a starting point for this, but I argue, contra Pritchard, that the addition of disjunctivism is unnecessary and potentially counter-productive. If we draw on lessons from Michael Williams's inferential contextualism then it is both possible, and preferable, to meet the most important of Pritchard's desiderata, undercutting both closure-based and underdetermination-based sceptical problems in a unified way, without the need to resort to disjunctivism. (shrink)

This book presents a radical and intuitive argument against the notion that intentional action, agency and autonomy are features belonging only to humans. Using evidence from research into the minds of non-human animals, it explores the ways in which animals can be understood as individuals who are aware of themselves, and the consequent basis of our moral obligations towards them. The first part of this book argues for a conception of agency in animals that admits to degrees among individuals and (...) across species. It explores self-awareness and its various levels of complexity which depend on an animals’ other mental capacities. The author offers an overview of some established theories in animal ethics including those of Peter Singer, Tom Regan, Bernard Rollin and Lori Gruen, and the ways these theories serve to extend moral consideration towards animals based on various capacities that both animals and humans have in common. The book concludes by challenging traditional Kantian notions of rationality and what it means to be an autonomous individual, and discussing the problems that still remain in the study of animal ethics. (shrink)