When people are making certain medical decisions – especially potentially transformative ones – the specter of regret may color their choices. In this paper, I ask: can predicting that we will regret a decision in the future serve any justificatory role in our present decision-making? And if so, what role? While there are many pitfalls to such reasoning, I ultimately conclude that considering future retrospective emotions like regret in our decisionmaking can be both rational and authentic. Rather than indicating that (...) one is about to make a mistake or that there is some underlying value that one already cares about but is overlooking, the prediction that one will regret a decision in the future makes one confront how her present values and priorities may change as a result of her choice in ways she cannot presently anticipate. (shrink)

Background: Current practice frequently fails to provide care consistent with the preferences of decisionally-incapacitated patients. It also imposes significant emotional burden on their surrogates. Algorithmic-based patient preference predictors (PPPs) have been proposed as a possible way to address these two concerns. While previous research found that patients strongly support the use of PPPs, the views of surrogates are unknown. The present study thus assessed the views of experienced surrogates regarding the possible use of PPPs as a means to help make (...) treatment decisions for decisionally-incapacitated patients. -/- Methods: This qualitative study used semi-structured interviews to determine the views of experienced surrogates [n=26] who were identified from two academic medical centers and two community hospitals. The primary outcomes were respondents’ overall level of support for the idea of using PPPs and the themes related to their views on how a PPP should be used, if at all, in practice. -/- Results: Overall, 21 participants supported the idea of using PPPs. The remaining five indicated that they would not use a PPP because they made decisions based on the patient’s best interests, not based on substituted judgment. Major themes which emerged were that surrogates, not the patient’s preferences, should determine how treatment decisions are made, and concern that PPPs might be used to deny expensive care or be biased against minority groups. -/- Conclusions: Surrogates, like patients, strongly support the idea of using PPPs to help make treatment decisions for decisionally-incapacitated patients. These findings provide support for developing a PPP and assessing it in practice. At the same time, patients and surrogates disagree over whose preferences should determine how treatment decisions are made, including whether to use a PPP. These findings reveal a fundamental disagreement regarding the guiding principles for surrogate decision-making. Future research is needed to assess this disagreement and consider ways to address it. (shrink)

In The Minority Body, Elizabeth Barnes rejects prevailing social constructionist accounts of disability for two reasons. First, because they understand disability in terms of oppressive social responses to bodily impairment, they cannot make sense of disability pride. Second, they maintain a problematic distinction between impairment and disability. In response to these challenges, this paper defends a version of the social model of disability, which we call the Social Exclusion Model. On our account, to be disabled is to be in a (...) bodily or psychological state that is represented as an impairment in the prevailing ideology of one’s society, and to be excluded from valuable activities on the basis of this representation. While this model refers to a distinction between disability and impairment, it makes no presuppositions about which bodies function ‘normally’ and which do not. It is the ideology of impairment rather than impairment itself that does any work to determine whether a person is disabled. We argue that this model answers some of the important objections that Barnes raises against prevailing social constructionist accounts of disability, and that it’s focus on the oppressive social positioning of disabled people gives it explanatory power that Barnes’s own account lacks. (shrink)

John Rawls, among others, has argued that one of aims political philosophy is that it provides reasonable hope in the possibility of justice in the future. But what makes hope reasonable? What sorts of theories of justice are best suited to foster reasonable hope in us? To answer these questions, this paper investigates Rawls’s conception of reasonable hope and the kinds of unreasonableness Rawls sought to guard against with his account of a realistic utopia. Rawls's idea of reasonable hope goes (...) beyond the weaker kind of “reconciliation” put forward by Rousseau’s account of a conjectural history that sketches a picture of how we could have developed into the kind of people and the kind of society where justice is possible. It is one thing to believe, with Rousseau, that our deep natures are not incompatible with the possibility of a just society. It is something further to harbor any hope for this in the future. I argue that this temporal aspect, which is built into what Kant and Rawls mean by reasonable hope, is useful approach to the practice of political philosophy. An approach that takes the need for reasonable hope seriously is one that moves political theorizing from a more passive framework of theoretical imagination toward a more active one that entails political anticipation. (shrink)

We often find ourselves in situations where it is up to us to make decisions on behalf of others. How can we determine whether such decisions are morally justified, especially if those decisions may change who it is these others end up becoming? In this paper, I will evaluate one plausible kind of justification that may tempt us: we may want to justify our decision by appealing to the likelihood that the other person will be glad we made that specific (...) choice down the line. Although it is tempting, I ultimately argue that we should reject this sort of appeal as a plausible justification for the moral permissibility of our vicarious decisions. This is because the decisions that we make on behalf of another may affect the interests and values that that person will hold in the future. As I will show, this complicates the justificatory relationship between present decisions and future attitudes, since the latter can depend on the former. This is not to say that the predicted future attitudes of others can play no significant role in justifying our decisions on others’ behalf. Rather, appealing to the future attitudes in our moral justifications may play an important role in our practical thinking but only when we consider the future attitudes of all relevant possible futures. (shrink)

Those arguing that conscientious objection in medicine should be declared unethical by professional societies face the following challenge: conscientious objection can function as an important reforming mechanism when it involves health care workers refusing to participate in certain medical interventions deemed standard of care and legally sanctioned but which undermine patients’ rights. In such cases, the argument goes, far from being unethical, conscientious objection may actually be a professional duty. I examine this sort of challenge and ultimately argue that these (...) acts of conscience done in the interest of reforming professional norms or medical regulations are best understood as episodes of civil disobedience rather than episodes of conscientious objection. In contrast to the private, exempting nature of conscientious objection, civil disobedience is a public breach of a norm or law undertaken with the aim of bringing about a change in governmental policies or professional standards. Consequently, clinicians may have a duty to engage in civil disobedience even while professional societies are right to declare limitations on the ethical appropriateness of conscientious objection. (shrink)

Alex John London’s new book, For the Common Good: Philosophical Foundations of Research Ethics highlights the fact that establishing just social arrangements is not only a matter of incentivizing popular will to act for the common good; it also requires filling in informational gaps about which policies, arrangements, and interventions will advance the basic interests of members in an equitable, effective and efficient manner. Promoting justice requires, in part, acquiring the knowledge for how to do so. In developing this point, (...) London carefully traces these missteps in the main philosophical debates and then resuscitates the importance of questions of justice at the heart of research ethics. In doing so, it provides a transformative corrective for the field. This review critically examines one of the central pillars of London’s egalitarian research imperative approach: the way in which the social value of research is closely linked with minimizing uncertainty among reasonable experts. (shrink)

Within bioethics, two prevailing approaches structure how we think about the role of medical surrogates and the decisions that they must make on behalf of incompetent patients. One approach views the surrogate primarily as the patient's agent, obediently enacting the patient's predetermined will. The second approach views the surrogate as the patient's custodian, judging for herself how to best safeguard the patient's interests. This paper argues that both of these approaches idealize away some of the ethically relevant features of advance (...) care planning that make patient preferences so inscrutable and surrogate decision-making so burdensome. It proposes a new approach to surrogate decision-making, the Fiduciary Agency Approach. On this novel approach, the surrogate has authority to not only act on the patient's behalf as the patient's agent but also to decide on the patient's behalf as the patient's fiduciary. One upshot of this new approach is that surrogates must sometimes go against the expressed dictates of the patients' advance directives not necessarily because doing so would be in the patient's best interest but rather because doing so would best represent the patients' will. (shrink)

This paper considers the responsibilities of the FDA with regard to disseminating information about the benefits and harms of e-cigarettes. Tobacco harm reduction advocates claim that the FDA has been overcautious and has violated ethical obligations by failing to clearly communicate to the public that e-cigarettes are far less harmful than cigarettes. We argue, by contrast, that the FDA’s obligations in this arena are more complex than they may appear at first blush. Though the FDA is accountable for informing the (...) public about the health risks and benefits of products it regulates, it also has other roles that inform when and how it should disseminate information. In addition to being a knowledge purveyor, it is also a knowledge producer, an advisor to the public, and a practical agent shaping the material conditions in which people make health-related choices. In our view, those other roles call for caution in the way the FDA interprets and communicates the available evidence. (shrink)

Recently, bioethicists and the UNCRPD have advocated for supported medical decision-making on behalf of patients with intellectual disabilities. But what does supported decision-making really entail? One compelling framework is Anita Silvers and Leslie Francis’ mental prosthesis account, which envisions supported decision-making as a process in which trustees act as mere appendages for the patient’s will; the trustee provides the cognitive tools the patient requires to realize her conception of her own good. We argue that supported decision-making would be better understood (...) as a collaborative process, giving patients with intellectual disabilities the opportunity to make decisions in a respectful relationship with trusted others. We offer an alternative account of supported decision-making where the primary constraint is to protect the patient from domination by the trustee. This is advantageous in its preservation of the prospects for genuine collaboration, for the mental prosthesis approach ultimately reinforces a problematic ideal of isolated patient self-determination. (shrink)

As the age of genomic medicine has advanced rapidly, many questions pertaining to the reportability of both clinical and research findings have emerged. For example, the integration of genomic test...

Many people view disabilities as misfortunes, call this the standard view. In this paper, I examine one criticism that has been launched against the Standard View. Rather than determine in advance whether having a disability is good or bad for a person, some critics argue that the Standard View is reflective of and brings about inappropriate emotional responses toward people with disabilities and their circumstances. For instance, philosophers have recently argued that in holding the standard view, we become prone to (...) a destructive kind of unwarranted pity or that the view leads us to hold certain untenable or inappropriate hopes for our children and for our society. I think this sort of challenge to the Standard View has a lot of appeal, but I worry that if it is not properly articulated, the approach is vulnerable to what has been known as “The Wrong Kind of Reason” problem. The paper highlights and addresses this worry. (shrink)

This chapter explores whether it is possible to treat incompetent persons paternalistically. What is often seen to be wrong about acting paternalistically towards others is that one is treating these others as if they cannot make their own decisions about their own good. So how should one think about situations where one must make decisions on behalf of people who indeed cannot make their own decisions about their own good – especially if these people are still to some extent capable (...) of expressing their desires and concerns about what happens to them? This is often the case in the medical setting, when a patient has lost decisional capacity or has not developed such a capacity in the first place. Focusing on the medical setting, this chapter argues that insofar as someone has the component elements of agency, they can be the target of unjustified paternalism. The chapter first explores the ways in which patients may lack decisional capacity and whether such patients nevertheless retain a sense of agency that can be disrespected. It then examines whether, on some plausible accounts of paternalism, what constitutes disrespect towards the competent constitutes a similar disrespect to the agential capacities of the incompetent. (shrink)

The WHO recently made news by apparently advising couples in Zika affected areas to delay pregnancy. On closer inspection, however, it is not so clear what advice was actually being offered in their interim guidance regarding the prevention of the sexual transmission of Zika. In this paper, we lay out a framework for considering the ethical issues that arise in the context of advising and use it to evaluate the WHO guidance. We argue that advising is not merely an informative (...) act. The choices that agencies make in how and whom they advise are ethical choices with practical implications; these choices change not only how people ought to think about their options but also how they indeed ought to act. While we focus on these interim guidance updates from the WHO, the framework we provide can shed light more generally on the ethical issues surrounding advising in other public health contexts. (shrink)

Context Opioid treatment agreements (OTAs) are documents that clinicians present to patients when prescribing opioids that describe the risks of opioids and specify requirements that patients must meet to receive their medication. Notwithstanding a lack of evidence that OTAs effectively mitigate opioids’ risks, professional organizations recommend that they be implemented, and jurisdictions increasingly require them. We sought to identify the jurisdictions that require OTAs, how OTAs might affect the outcomes of lawsuits that arise when things go wrong, and instances in (...) which the law permits flexibility for clinicians and health care institutions to adopt best practices. -/- Methods We surveyed the laws and regulations of all 50 states and the District of Columbia to identify which jurisdictions require the use of OTAs, the circumstances in which OTA use is mandatory, and the terms OTAs must include (if any). We also surveyed criminal and civil judicial decisions in which OTAs were discussed as evidence on which a court relied to make its decision to determine how OTA use influences litigation outcomes. -/- Findings Results show that a slight majority (27) of jurisdictions now require OTAs. With one exception, the jurisdictions’ requirements for OTA use are triggered at least in part by long-term prescribing. There is otherwise substantial variation and flexibility within OTA requirements. Results also show that even in jurisdictions where OTA use is not required by statute or regulation, OTA use can inform courts’ reasoning in lawsuits involving patients or clinicians. Sometimes, but not always, OTA use legally protects clinicians from liability. -/- Conclusions -/- Our results show that OTA use is entwined with legal obligations in various ways. Clinicians and health care institutions should identify ways for OTAs to enhance clinician–patient relationships and patient care within the bounds of relevant legal requirements and risks. (shrink)

We appreciate that all our commentators accepted the central framework we argued for, namely that the FDA has multiple roles and attendant responsibilities, and we are excited to see this framework...

Danielle Spencer's book, "Metagnosis: Revelatory Narratives of Health and Identity," does many things. It is a work of autotheory, putting Spencer's own embodied narrative in constant conversation with the testimony of others along with a remarkably diverse set of critical and theoretical approaches. In the book, Spencer coins a new term, "metagnosis", which occurs when one is newly diagnosed in adulthood with a lifelong condition. The book explores Spencer's own metagnostic experience involving her eyesight along with chronicling the experiences of (...) others to highlight the ways in which newfound knowledge of a diagnosis can in itself transform us.Born with strabismus—"misaligned eyes," Spencer is practiced at... (shrink)

The increasing use of opioid treatment agreements has prompted debate within the medical community about ethical challenges with respect to their implementation. The focus of debate is usually on the efficacy of OTAs at reducing opioid misuse, how OTAs may undermine trust between physicians and patients and the potential coercive nature of requiring patients to sign such agreements as a condition for receiving pain care. An important consideration missing from these conversations is the potential for racial bias in the current (...) way that OTAs are incorporated into clinical practice and in the amount of physician discretion that current opioid guidelines support. While the use of OTAs has become mandatory in some states for certain classes of patients, physicians are still afforded great leeway in how these OTAs are implemented in clinical practice and how their terms should be enforced. This paper uses the guidelines provided for OTA implementation by the states of Indiana and Pennsylvania as case studies in order to argue that giving physicians certain kinds of discretion may exacerbate racial health disparities. This problem cannot simply be addressed by minimising physician discretion in general, but rather by providing mechanisms to hold physicians accountable for how they treat patients on long-term opioid therapy to ensure that such treatment is equitable. There are no data in this work. (shrink)

BACKGROUND Patients with chronic pain face significant barriers in finding clinicians to manage long-term opioid therapy (LTOT). For patients on LTOT, it is increasingly common to have them sign opioid treatment agreements (OTAs). OTAs enumerate the risks of opioids, as informed consent documents would, but also the requirements that patients must meet to receive LTOT. While there has been an ongoing scholarly discussion about the practical and ethical implications of OTA use in the abstract, little is known about how clinicians (...) use them and if OTAs themselves modify clinician prescribing practices. OBJECTIVE To determine how clinicians use OTAs and the potential impacts of OTAs on opioid prescribing. DESIGN We conducted qualitative analysis of four focus groups of clinicians from a large Midwestern academic medical center. Groups were organized according to self-identified prescribing patterns: two groups for clinicians who identified as prescribers of LTOT, and two who did not. PARTICIPANTS 17 clinicians from General Internal Medicine, Family Medicine, and Palliative Care were recruited using purposive, convenience sampling. APPROACH Discussions were recorded, transcribed, and analyzed for themes using reflexive thematic analysis by a multidisciplinary team. KEY RESULTS Our analysis identified three main themes: (1) OTAs did not influence clinicians’ decisions whether to use LTOT generally but did shape clinical decision-making for individual patients; (2) clinicians feel OTAs intensify the power they have over patients, though this was not uniformly judged as harmful; (3) there is a potential misalignment between the intended purposes of OTAs and their implementation. CONCLUSION This study reveals a complicated relationship between OTAs and access to pain management. While OTAs seem not to impact the clinicians’ decisions about whether to use LTOT generally, they do sometimes influence prescribing decisions for individual patients. Clinicians shared complex views about OTAs’ purposes, which shows the need for more clarity about how OTAs could be used to promote shared decision-making, joint accountability, informed consent, and patient education. (shrink)

AbstrctSean Aas, Dana Howard, and Leslie Francis raise compelling and interesting objections to the definition of disability I defend in The Minority Body. In this paper, I reply to these objections and elaborate on my criticisms of the disability/impairment distinction.

One challenge in providing an adequate definition of physical disability is unifying the heterogeneous bodily conditions that count as disabilities. We examine recent proposals by Elizabeth Barnes (2016), and Dana Howard and Sean Aas (2018), and show how this debate has reached an impasse. Barnes’ account struggles to deliver principled unification of the category of disability, whilst Howard and Aas’ account risks inappropriately sidelining the body. We argue that this impasse can be broken using a novel concept: (...) marginalised functioning. Marginalised functioning concerns the relationship between a person’s bodily capacities and their social world: specifically, their ability to function in line with the default norms about how people can typically physically function that influence the structuring of social space. We argue that attending to marginalised functioning allows us to develop, not one, but three different models of disability, all of which—whilst having different strengths and weaknesses—unify the category of disability without sidelining the body. (shrink)

This book shows how the traditional concerns of political theory push it increasingly into the study of international relations. This is done, first, by demonstrating how many of the issues usually dealt with by political theory, such as democracy and justice, arise within an increasingly global context and, secondly, by considering how international issues, such as colonialism and war, are best illuminated by building on the work of political theorists. The book suggests that political theory and international relations theory can (...) now both be successfully engaged in as a joint enterprise only. (shrink)

The paper takes off from the suggestion of Jouni-Matti Kuukkanen that Kuhn’s account of science may be understood in coherentist terms. There are coherentist themes in Kuhn’s philosophy of science. But one crucial element is lacking. Kuhn does not deny the existence of basic beliefs which have a non-doxastic source of justification. Nor does he assert that epistemic justification only derives from inferential relationships between non-basic beliefs. Despite this, the coherentist interpretation is promising and I develop it further in this (...) paper. I raise the question of whether Kuhn’s account of science can deal with the input objection to coherentism. I argue that the role played by problems in Kuhn’s theory of science ensures that there is input from the external world into scientists’ belief-systems. I follow Hoyningen-Huene in pointing to the causal role played by the external world in determining perceptual states. I next turn to the question of whether Kuhn’s rejection of foundationalism implies coherentism. I argue that Kuhn’s rejection of the one-to-one relation between object and experience is compatible with a foundationalist account of justification. Nor does Kuhn’s rejection of the given entail the same coherentist implications as Sellars’ critique of the myth of the given. (shrink)

Modes-of-being figure centrally in Heidegger's masterwork Being and Time. Testimony to this is Heidegger's characterisation of two of his most celebrated enquiries—the Existential analytic and the Zeug analysis—as investigations into the respective modes-of-being of the entities concerned. Yet despite the importance of this concept, commentators disagree widely about what a mode-of-being is. In this paper, I systematically outline and defend a novel and exegetically grounded interpretation of this concept. Strongly opposed to Kantian readings, such as those advocated by Taylor Carman (...) and Cristina Lafont, I interpret a mode-of-being as a universal that defines a district —that is, a natural class of entities that ought to be conceptualised in a special way. As such, every mode-of-being plays an important metaphysical and epistemic role: serving both to unify a natural class of a high degree of generality and as the interpretandum of an act yielding the basic-concepts pertaining to the entities therein. In explicating and arguing for this interpretation, I attribute a characteristically Aristotelian philosophical position to the early Heidegger, encompassing both metaphysical and epistemological realism and a conceptualist theory of universals. (shrink)

This reader has been assembled in response to increasing dissatisfaction among a growing number of international relations scholars with the currently dominant theory of realism as well as in recognition of the large number of newly independent states which are having to write new constitutions and develop foreign relations. The book includes excerpts and essays from political theory and international relations which provide a starting point for further study of these subjects. It draws together writings representing two distinct traditions and (...) demonstrates their interconnections. In political theory, excerpts are drawn from classical texts which have an important bearing on problems of international relations. In international relations, the collection includes essays which have had a seminal influence on the development of this discipline. (shrink)

In the summer of 1644, a physician and former imperial official by the name of Cyprian Kinner moved to Elbing (Elbląg) to collaborate with the leading pedagogical theorist of his day, Jan Amos Come...

This paper describes the position of scientific realism and presents the basic lines of argument for the position. Simply put, scientific realism is the view that the aim of science is knowledge of the truth about observable and unobservable aspects of a mind-independent, objective reality. Scientific realism is supported by several distinct lines of argument. It derives from a non-anthropocentric conception of our place in the natural world, and it is grounded in the epistemology and metaphysics of common sense. Further, (...) the success of science entitles us to infer both the approximate truth of mature scientific theories and the truth-conduciveness of the methods of science. (shrink)

Written by one of America's leading philosophers, _Race and Social Justice_ provides a powerful analysis of the enduring problems of race and social justice in American life.

A case study provides the basis for consideration of the purpose of business ethics teaching, the importance of reflection and the evaluation of ethics teaching. The way in which personal reflection and an increased capacity for ethical action can be encouraged and openly identified as aims of the course is discussed. The paper considers changes in the design and delivery of the international management ethics and values course taught at the University of South Australia as part of the undergraduate management (...) degree in Australia, Singapore and Hong Kong. As a result of student and teaching staff responses, and course evaluations, the course design, teaching and assessment has moved steadily toward an aim which explicitly refers to behaviour, without losing the significant conceptual base. Ways in which opportunities can be provided to enhance the development of a reflective capability are considered, including narrative, role models, ethical reflection, journal‐keeping and practice. The changes required a change in assessment practice. The difficulties of assessing intention and commitment to ethical action, whether in an individual course or across the curriculum, are discussed. (shrink)

Journal Name: Apeiron Issue: Ahead of print.

Uncivil behavior by leaders may be viewed as an effective way to motivate employees. However, supervisor incivility, as a form of unethical supervision, may be undercutting employees’ ability to do their jobs. We investigate linkages between workplace incivility and perceived work ability, a variable that captures employees’ appraisals of their ability to continue working in their jobs. We draw upon the appraisal theory of stress and social identity theory to examine incivility from supervisors as an antecedent to PWA, and to (...) investigate job involvement and grit as joint moderators of this association. Results from data collected in two samples of working adults provided evidence for three-way interactions in relation to PWA. Among employees with high levels of grit, there was no significant relation between supervisor incivility and PWA, regardless of employee job involvement. However, we found some evidence that for those low in grit, having high job involvement was associated with a stronger relationship between supervisor incivility and PWA. Findings attest to the importance of unethical supervisor behavior, showing the potential for supervisor incivility to erode PWA, as well as the importance of grit as a potential buffer. (shrink)

In his own lifetime Confucius never attained real power and he died feeling that his life had been a failure; yet his teaching came to dominate the political and ritual life of China for thousands of years and to inspire many thinkers in the outside world. Howard Smith describes China in the sixth century B.C. and shows how its history of internal conflict, together with the cult of ancestor worship, gave rise to Confucius' central doctrines of order and 'piety'. (...) He relates how a few disciples kept this teaching alive after Confucius' death and how it came finally to be accepted throughout the huge Chinese empire as the basis for political, educational and ceremonial life. He describes also how Confucianism was slowly changed by the rival philosophies and religions with which it had to compete. This book is therefore not only a history of one of the world's greatest systems of belief but also a study of how such a system both creates and is created by the society in which it exists. -- From publisher's description. (shrink)

I argue for a type of relativism that allows different people to have conflicting accurate representations of the world. This is contrary to the view of most Anglo-American philosophers, who would, with Paul Boghossian in Fear of Knowledge, deny that “there are many radically different, yet ‘equally valid’ ways of knowing the world.” My argument is not a metaphysical argument about the ultimate nature of the outside world, but a psychological argument about the mental processes of representation. The argument starts (...) from a few principles of naïve (or folk) psychology, but is later extended to apply to mechanisms that do not have a “psychology.” Finally, I briefly discuss the anti-relativist impulse in philosophy, with particular reference to Boghossian’s example of non-scientific beliefs regarding Lakota origins. I argue that both we and the Lakotas have good reason to reject such beliefs while still remaining relativists. Being a relativist does not mean that you get to believe whatever you like. (shrink)