A commentary on “What's Not Being Shared in Shared Decision‐Making?” from the July‐August 2013 issue.

Medical decision making when a patient cannot participate is complicated by the question of whose voice should be heard. The most common answer to this question is that “autonomy” is paramount, and therefore it is the voice of the unwell person that should be given priority. Advance care planning processes and practices seek to capture this sentiment and to allow treatment preferences to be documented and decision makers to be nominated. Despite good intentions, advance care planning is often deficient because (...) it is unable to facilitate a relational approach to decision making in cases when the patient’s competence is reduced. In this article we present findings from a study of the ways in which older people and their significant others understand decision making in such circumstances. Critical to the participants’ understanding was the emergent concept of “relational knowing,” a concept that is poorly articulated in the advance care planning literature. Our findings suggest that the dominant understanding of decision making in conditions of impaired competence is incomplete and obscures much of what matters to people. We conclude that, having recognized a broader set of ethical concerns, it is necessary to develop a relational and narrative based approach that applies in appropriate settings. (shrink)

"The doctrine of materialism is one of the perennial and most controversial ideas in the arts and sciences. Throughout history it has aroused strong passions, and in the Sixteenth and Twentieth centuries was a doctrine over which people were persecuted and killed. Yet it has been equally aligned with empirical, enlightened and tolerant thinking. This book explores the fascinating and important philosophy of materialism in an engaging and thought-provoking way. Opening with an overview of the ideas of some of the (...) most important materialists, including Lucretius, Epicurus, Hobbes and Hume up to Darwin and Marx, Brown and Ladyman show how materialism's origins were twofold: it was an early form of scientific explanation but also an intellectual outlook, or belief-system, about the world in general. They then explain how materialism's beginnings as imaginative vision of the true nature of things faced a major challenge from modern physics, in the form of quantum theory and the general theory of relativity. This posed major questions for materialism: how could it be reconciled with unobservable entities and new discoveries about the nature of space and time? As the authors show, out of this challenge materialism did not die but re-emerged - as the new doctrine of physicalism. Drawing on colourful examples throughout - from modern physics, the nature of the mind, and atheism - the authors argue that whilst materialism may not have all the answers, its humanism and staunch belief in observation, evidence and experiment remains our best hope in a fragmented and hyper-specialised world"--. (shrink)

We provide a formulation of physicalism, and show that this is to be favoured over alternative formulations. Much of the literature on physicalism assumes without argument that there is a fundamental level to reality, and we show that a consideration of the levels problem and its implications for physicalism tells in favour of the form of physicalism proposed here. Its hey elements are, fast, that the empirical and substantive part of physicalism amounts to a prediction that physics will not posit (...) new entities solely for the purpose of accounting for mental phenomena, nor new entities with essentially mental characteristics such as propositioned attitudes or intentions; secondly, that physicalism can safely make do with no more than a weak global formulation of supervenience. (shrink)

The doctrine of materialism is one of the most controversial in the history of ideas. For much of its history it has been aligned with toleration and englightened thinking, but it has also aroused strong, often violent, passions among both its opponents and proponents. This book explores the deelopment of materialism in an engaging and thought-provoking way and defends the form it takes in the twenty-first century.

With reference to the intergenerational theorizing of trauma, this article considersthe role of transcendence in the substance of our theoretical ideas about psycho-sis. Arguing against an emphasis on notions of developmental de fi cit, the author considers the recent work of Davoine and Gaudilliere as a means of questioningsome of the paradigmatic assumptions of clinical psychology. It is suggested that the relationship between psychosis and spirituality has often been conceived insuch a way as to depreciate both, and that a shift (...) in mainstream theorizingrequires that a more fundamental place be made for the question of transcen-dence in the theorizing of madness. (shrink)

The shortage of organs for transplantation by its nature prompts ethical dilemmas. For example, although there is an imperative to save human life and reduce suffering by maximising the supply of vital organs, there is an equally important obligation to ensure that the process by which we increase the supply respects the rights of all stakeholders. In a relatively unexamined practice in the USA, organs are procured from unrepresented decedents without their express consent. Unrepresented decedents have no known healthcare wishes (...) or advance care planning document; they also lack a surrogate. The Revised Uniform Anatomical Gift Act of 2006 sends a mixed message about the procurement of organs from this patient population and there are hospitals that authorise donation. In addition, in adopting the RUAGA, some states included provisions that clearly allow organ procurement from unrepresented decedents. An important unanswered question is whether this practice meets the canons of ethical permissibility. The current Brief Report presents two principled approaches to the topic as a way of highlighting some of the complexities involved. Concluding remarks offer suggestions for future research and discussion. (shrink)

_Psychoanalysis Beyond the End of Metaphysics_ offers a new paradigm approach which advocates reengaging the importance of metaphysics in psychoanalytic theorizing. The emergence of the relational trend has witnessed a revitalizing influx of new ideas, reflecting a fundamental commitment to the principle of dialogue. However, the transition towards a more pluralistic discourse remains a work in progress, and those schools of thought not directly associated with the relational shift continue to play only a marginal role. In this book, Robin (...) S. Brown argues that for contemporary psychoanalysis to more adequately reflect a clinical ethos of pluralism, the field must examine the extent to which a theoretical commitment to the notion of relationship can grow restrictive. Suggesting that in the very effort to negotiate theoretical biases, psychoanalytic practice may occlude a more adequate recognition of its own evolving assumptions, Brown proposes that the profession’s advance requires a return to first principles. Arguing for the fundamental role played by faith in supporting the emergence of consciousness, this work situates itself at the crossroads of relational, Jungian, and transpersonal approaches to the psyche. Psychoanalysis Beyond the End of Metaphysics will be of significant interest to all psychodynamically oriented clinicians, alongside scholars of depth psychology and the philosophy of mind. It will also be helpful to advanced and postgraduate students of psychoanalysis seeking to orient themselves in the field at present. (shrink)

This paper reviews the literature concerning the neural correlates of the self, the relationship between self and memory and the profile of memory impairments in Alzheimer’s disease and explores the relationship between the preservation of the self and anosognosia in this condition. It concludes that a potential explanation for anosognosia in AD is a lack of updating of personal information due to the memory impairments characteristic of this disease. We put forward the hypothesis that anosognosia is due in part to (...) the “petrified self.”. (shrink)

In seeking to move beyond causal-reductivism, this book explores a variety of perspectives on the question of finding inherent meaning in madness and extreme states.

The introductory section discusses supervenience and the role it plays in formulating contemporary physicalism. The section concludes with the definition of local supervenience used by Kim in the causal-exclusion argument. The second section outlines an abstract model for the analysis of supervenience, associating total mental states with total states of the nervous system. It is argued that Kim’s formulation confuses two orders of necessity: a metaphysical necessity attaching to the supervenience of the total mental state, and a nomological necessity attaching (...) to the correlation of particular elements of the concurrent physical and mental states. A central idea is the degree of resolution of the description of the state of the nervous system. This serves as a metaphor for the idea of multiplelevels of physical description, and in the third section it is argued that any formulation of supervenience that was attached to a particular level of description would risk error if changes at a more fundamental level of the subvening base proved to be significant for supervenience. In the fourth section it is argued that the problem of levels of properties and description cannot be avoided by a retreat from local to global supervenience. Loewer’s notion of a duplicate world may help, but an alternative weaker formulation is proposed that does avoid the difficulty. (shrink)

Alternative education often seeks to promote creativity. In so far as this tendency might come to suggest something ideological, then the intent thus indicated is liable to become self-defeating. This article considers C.G. Jung's conservative ideas about education, and explores how these notions might relate to his wider psychology. Contrasting Jung's position with Alfonso Montuori's notion of Creative Inquiry, the author argues for the importance of a more conscious relationship to the role of conflict in the development of a relationally (...) focused pedagogy. (shrink)

From a secular perspective, emphasizing the theme of spirituality can seem antithetical to the needs of a pluralistically nuanced clinical attitude. This article suggests that, on the contrary, the reticence of the clinical mainstream to more directly embrace spiritual concerns betrays an underlying dogmatism. The theme of spirituality is thus argued to have paradigmatic importance in demonstrating the pluralistic failings of Western psychology. Drawing on recent developments in American psychoanalysis, consideration is given to the theoretical challenges associated with maintaining a (...) pluralistic sensibility in clinical practice. Contemporary psychoanalysis is argued to offer spiritually oriented clinicians an important basis in which to ground practice, yet it is also argued that contemporary psychoanalysis can only hope to more adequately reflect its ostensible commitment to inclusivity by revising its implicit reliance on a secular worldview. Such an undertaking might be achieved by drawing from the recent “participatory turn” in transpersonal psychology to offer a reading of Jung’s work demonstrating the enduring importance of an archetypal approach. (shrink)

Emerging parallel to long-standing, academic and policy inquiries on personal responsibility for health is the empirical assessment of lay persons’ views. Yet, previous studies rarely explored personal responsibility for health among lay persons as dynamic societal values. We sought to explore lay persons’ views on personal responsibility for health using the Fairness Dialogues, a method for lay persons to deliberate equity issues in health and health care through a small group dialogue using a hypothetical scenario. We conducted two 2-h Fairness (...) Dialogues sessions (n = 15 in total) in Nova Scotia, Canada. We analyzed data using thematic analysis. Our analysis showed that personal choice played an important role in participants’ thinking about health. Underlying the concept of personal choice was considerations of freedom and societal debt. In participants’ minds, personal and social responsibilities co-existed and they were unwilling to determine health care priority based on personal responsibility. The Fairness Dialogues is a promising deliberative method to explore lay persons’ views as dynamic values to be developed through group dialogues as opposed to static, already-formed values waiting to be elicited. (shrink)

I. EXECUTIVE SUMMARY The MRCT Center Post-trial Responsibilities: Continued Access to an Investigational Medicine Framework outlines a case-based, principled, stakeholder approach to evaluate and guide ethical responsibilities to provide continued access to an investigational medicine at the conclusion of a patient’s participation in a clinical trial. The Post-trial Responsibilities (PTR) Framework includes this Guidance Document as well as the accompanying Toolkit. A 41-member international multi-stakeholder Workgroup convened by the Multi-Regional Clinical Trials Center of Brigham and Women’s Hospital and Harvard University (...) (MRCT Center) developed this Guidance and Toolkit. Project Motivation A number of international organizations have discussed the responsibilities stakeholders have to provide continued access to investigational medicines. The World Medical Association, for example, addressed post-trial access to medicines in Paragraph 34 of the Declaration of Helsinki (WMA, 2013): “In advance of a clinical trial, sponsors, researchers and host country governments should make provisions for post-trial access for all participants who still need an intervention identified as beneficial in the trial. This information must also be disclosed to participants during the informed consent process.” This paragraph and other international guidance documents converge on several consensus points: • Post-trial access (hereafter referred to as “continued access” in this Framework [for terminology clarification – see definitions]) is the responsibility of sponsors, researchers, and host country governments; • The plan for continued access should be determined before the trial begins, and before any individual gives their informed consent; • The protocol should delineate continued access plans; and • The plan should be transparent to potential participants and explained during the informed consent process. -/- However, there is no guidance on how to fulfill these responsibilities (i.e., linking specific responsibilities with specific stakeholders, conditions, and duration). To fill this gap, the MRCT Center convened a working group in September of 2014 to develop a framework to guide stakeholders with identified responsibilities. This resultant Framework sets forth applicable principles, approaches, recommendations and ethical rationales for PTR regarding continued access to investigational medicines for research participants. (shrink)

The powerful combination of genetic, developmental and molecular approaches possible with the fruit fly, Drosophila melanogaster, has led to a profound understanding of the genetic control of early developmental events. However, Drosophila is a highly specialized long germ insect, and the mechanisms controlling its early development may not be typical of insects or Arthropods in general. The beetle, Tribolium castaneum, offers a similar opportunity to integrate high resolution genetic analysis with the developmental/molecular approaches currently used in other organisms. Early results (...) document significant differences between insect orders in the functions of genes responsible for establishing developmental commitments. (shrink)

1. En este ensayo voy a explorar un aspecto del consecuencialismo que no debería ser ignorado completamente por las teorías rivales de la ética normativa, a saber, la extensión del ámbito de los individuos afectados por nuestras acciones presentes, y la importancia de tener en cuenta a los mismos. Incluso aquellas teorías rivales que descuentan algunos intereses necesitan una clara comprensión de la naturaleza de los intereses que están dispuestos a desechar. 2. Los intereses afectados incluyen los intereses futuros de (...) personas actuales y de fetos humanos, además de aquellos relativos a criaturas actuales no humanas, y también los de personas futuras y otras criaturas que no pueden ser reconocidos todavía. Las acciones humanas jugarán un importante rol a la hora de determinar no sólo qué humanos existirán, sino incluso qué no-humanos; podemos incluso influir considerablemente en la calidad de vida de todos ellos, y asumir así responsabilidades en relación a los impactos previsibles resultantes de nuestras acciones. 3. En la medida que establezcamos diferencias comparativas y constatables respecto a la calidad de vida de la gente, conviene advertir que no somos menos responsables de los individuos del futuro que del presente. Es más, si aceptamos que los costes previsibles para dentro de un millón de años importan tanto como los costes del mismo tipo en el presente, entonces la escala de nuestras responsabilidades actuales se hace más vasta. 4. Donald Brown ha mostrado cómo hay un fuerte debate entre los diversos intereses humanos a la hora de establecer cuáles han de ser las concentraciones de gas invernadero en la atmósfera; dicho debate ha sido reanima" do aún más por consideraciones biocéntricas y/o ecocéntricas. Pace Brown, una aproximación biocéntrica puede contra" pesar intereses humanos con intereses no humanos, y no tendría por qué prohibir todas las extinciones de especies; pero de hecho esta aproximación no podría justificar de ningún modo el incremento de las concentraciones de gases invernadero. Las emisiones requeridas para el desarrollo del Tercer Mundo necesitan ser contrapesadas con la reducción de emisiones en los países desarrollados. El consecuencialismo biocéntrico genera así políticas defendibles. También, como Brown subraya, los países desarrollados tienen obligación de apoyar un estricto acuerdo internacional sobre el cambio climático, con cuotas nacionales basadas en habilitaciones a una igual cantidad de emisiones per capita para todo planeta. (shrink)

Augustine is the person from the ancient world about whom we know most. He is the author of an intimate masterpiece, the Confessions, which continues to delight its many admirers. In it he writes about his infancy and his schooling in the classics in late Roman North Africa, his remarkable mother, his sexual sins ('Give me chastity, but not yet,' he famously prayed), his time in an outlawed heretical sect, his worldly career and friendships and his gradual return to God. (...) His account of his own eventual conversion is a classic study of anguish, hesitation and what he believes to be God's intervention. It has inspired philosophers, Christian thinkers and monastic followers, but it still leaves readers wondering why exactly Augustine chose to compose a work like none before it. Robin Lane Fox follows Augustine on a brilliantly described journey, combining the latest scholarship with recently found letters and sermons by Augustine himself to give a portrait of his subject which is subtly different from older biographies. Augustine's heretical years as a Manichaean, his relation to non-Christian philosophy, his mystical aspirations and the nature of his conversion are among the aspects of his life which stand out in a sharper light. For the first time Lane Fox compares him with two contemporaries, an older pagan and a younger Christian, each of whom also wrote about themselves and who illumine Augustine's life and writings by their different choices. More than a decade passed between Augustine's conversion and his beginning the Confessions. Lane Fox argues that the Confessions and their thinking were the results of a long gestation over these years, not a sudden change of perspective, but that they were then written as a single swift composition and that its final books are a coherent consummation of its scriptural meditation and personal biography. This exceptional study reminds us why we are so excited and so moved by Augustine's story. Praise for Pagans and Christians 'This open-hearted and learned book is one that any scholar of the ancient world and of early Christianity would be proud to have written... Lane Fox has opened his pages to let in an entirely new world.' Peter Brown, New York Review of Books 'A work of generous humanity and recondite erudition... of consuming interest to all of us who want to know and understand the consequences of the ancient world.' Henry Chadwick, Financial Times Praise for The Unauthorised Version 'I don't know where one would turn for an account of the Bible so clear, so lively and, in many respects, so just.' Frank Kermode, Guardian 'Magnificent... delivered with authority and verve. Learned but never pedantic, he is an unfailingly incisive, thought-provoking, humane, courteous, and often entertaining guide.' Economist. (shrink)

Recent work in judgment and decision-making has shown that a good’s price can have irrational effects on people’s preferences. People tend to prefer goods that cost more money and assume that such expensive goods will be more effective, even in cases where the price of the good is itself arbitrary. Although much work has documented the existence of these pricing effects, unfortunately little work has addressed where these price effects come from in the first place. Here we use a comparative (...) approach to distinguish between different accounts of this bias and to explore the origins of these effects. Specifically, we test whether brown capuchin monkeys (Cebus apella) are also susceptible to pricing effects within the context of an experimentally trained token economy. Using a capuchin population previously trained in a token market, we explored whether monkeys used price as an indicator of value across four experiments. Although monkeys demonstrated an understanding of which goods had which prices (consistently shifting preferences to cheaper goods when prices were increased), we observed no evidence that such price information affected their valuation of different kinds of goods. These results suggest that human price effects may involve more sophisticated human-unique cognitive capacities, such as an understanding of market forces and signaling. (shrink)

Gender classifications often are controversial. These controversies typically focus on whether gender classifications align with facts about gender kind membership: Could someone really be nonbinary? Is Chris Mosier really a man? I think this is a bad approach. Consider the possibility of ontological oppression, which arises when social kinds operating in a context unjustly constrain the behaviors, concepts, or affect of certain groups. Gender kinds operating in dominant contexts, I argue, oppress trans and nonbinary persons in this way: they marginalize (...) trans men and women, and exclude nonbinary persons. As a result, facts about membership in dominant gender kinds should not settle gender classification practices. (shrink)

Alex Byrne’s article, “Are Women Adult Human Females?”, asks a question that Byrne treats as nearly rhetorical. Byrne’s answer is, ‘clearly, yes’. Moreover, Byrne claims, 'woman' is a biological category that does not admit of any interpretation as (also) a social category. It is important to respond to Byrne’s argument, but mostly because it is paradigmatic of a wider phenomenon. The slogan “women are adult human females” is a political slogan championed by anti-trans activists, appearing on billboards, pamphlets, and anti-trans (...) online forums. In this paper, I respond to Byrne’s argument, revealing significant problems with its background assumptions, content, and methodology. (shrink)

What responsibility do individuals bear for structural injustice? Iris Marion Young has offered the most fully developed account to date, the Social Connections Model. She argues that we all bear responsibility because we each causally contribute to structural processes that produce injustice. My aim in this article is to motivate and defend an alternative account that improves on Young’s model by addressing five fundamental challenges faced by any such theory. The core idea of what I call the “Role-Ideal Model” is (...) that we are each responsible for structural injustice through and in virtue of our social roles, i.e. our roles as parents, colleagues, employers, citizens, etc., because roles are the site where structure meets agency. In short, the Role-Ideal Model explains how individual action contributes to structural change, justifies demands for action from each particular agent, specifies what kinds of acts should be undertaken, moderates between demanding too much and too little of individual agents, and provides an account of the critical responses appropriate for holding individuals accountable for structural injustice. (shrink)

Moral agency is limited, imperfect, and structurally constrained. This is evident in the many ways we all unwittingly participate in widespread injustice through our everyday actions, which I call ‘structural wrongs’. To do justice to these facts, I argue that we should distinguish between summative and formative moral criticism. While summative criticism functions to conclusively assess an agent's performance relative to some benchmark, formative criticism aims only to improve performance in an ongoing way. I show that the negative sanctions associated (...) with summative responses are only justifiably imposed under certain conditions when persons exercise their agency wrongly — conditions that do not always hold for structural wrongs. Yet even in such cases we can still use formative responses, which are warranted whenever agents fall short of moral ideals. Expanding our repertoire of moral criticism to include both summative and formative responses enables us to better appreciate both the powers and limitations of our agency, and the complexity of moral life. (shrink)

The goal of this article is to show that mainstream liberal accounts of civil disobedience fail to fully capture the latter’s specific characteristics as a genuinely political and democratic practice of contestation that is not reducible to an ethical or legal understanding either in terms of individual conscience or of fidelity to the rule of law. In developing this account in more detail, I first define civil disobedience with an aim of spelling out why the standard liberal model, while providing (...) a useful starting point, ultimately leads to an overly constrained, domesticated and sanitized understanding of this complex political practice. Second, I place the political practice of civil disobedience between two opposing poles: symbolic politics and real confrontation. I argue that the irreducible tension between these poles precisely accounts for its politicizing and democratizing potential. Finally, I briefly examine the role of civil disobedience in representative democracies, addressing a series of recent challenges made in response to this radically democratic understanding of disobedience. (shrink)

Sally Haslanger has recently argued that philosophical focus on implicit bias is overly individualist, since social inequalities are best explained in terms of social structures rather than the actions and attitudes of individuals. I argue that questions of individual responsibility and implicit bias, properly understood, do constitute an important part of addressing structural injustice, and I propose an alternative conception of social structure according to which implicit biases are themselves best understood as a special type of structure.

The recent philosophy of Quantum Bayesianism, or QBism, represents an attempt to solve the traditional puzzles in the foundations of quantum theory by denying the objective reality of the quantum state. Einstein had hoped to remove the spectre of nonlocality in the theory by also assigning an epistemic status to the quantum state, but his version of this doctrine was recently proved to be inconsistent with the predictions of quantum mechanics. In this essay, I present plausibility arguments, old and new, (...) for the reality of the quantum state, and expose what I think are weaknesses in QBism as a philosophy of science. (shrink)

In this paper, we defend two main claims. The first is a moderate claim: we have a negative duty to not use binary gender-specific pronouns he or she to refer to genderqueer individuals. We defend this with an argument by analogy. It was gravely wrong for Mark Latham to refer to Catherine McGregor, a transgender woman, using the pronoun he; we argue that such cases of misgendering are morally analogous to referring to Angel Haze, who identifies as genderqueer, as he (...) or she. The second is a radical claim: we have a negative duty to not use any gender-specific pronouns to refer to anyone, regardless of their gender identity. We offer three arguments in favor of this claim (which appeal to concerns about inegalitarianism and risk, invasions of privacy, and reinforcing essentialist ideologies). We also show why the radical claim is compatible with the moderate claim. Before concluding, we examine common concerns about incorporating either they or a neologism such as ze as a third-person singular gender-neutral pronoun. These concerns, we argue, do not provide sufficient reason to reject either the moderate or radical claim. (shrink)

In the Nicomachean Ethics Aristotle examines the nature of happiness, which he defines as a specially good kind of life. He considers the nature of practical reasoning, friendship, and the role and importance of the moral virtues in the best life. This new edition features a revised translation and valuable new introduction and notes.

This paper investigates whether gender affects ethically sensitive decisions of a personal or business nature. Data from 51 practicing accountants from both public accounting and private industry suggest that while differences exist between female and male accountants in responses to specific situations, overall responses are quite similar. Statistically significant differences were found for only five of the sixteen ethically sensitive situations. Further, when personal and business situations of a similar nature were paired together, two of the eight differences between personal (...) and business responses were significantly different between females and males. Taken as a whole, the results refute the suggestion that the ethical decision making of organizations may be enhanced as more women enter the business field. (shrink)