The significance of big data for driving health research and improvements in patient care is well recognised. Along with these potential benefits, however, come significant challenges, including those concerning the sharing and linkage of health and social care records. Recently, there has been a shift in attention towards a paradigm of data sharing centred on the ‘trusted research environment’ (TRE). TREs are being widely adopted by the UK’s health data initiatives including Health Data Research UK (HDR UK),1 Our Future Health2 (...) and Genomics England.3 A recent review commissioned by the UK’s Department of Health and Social Care (hereafter referred to as the ‘Goldacre Review’) places TREs at the heart of its recommendations around the future of National Health Service (NHS) health data sharing for research, describing them as the ‘clear path forward’ to a health data system in which trust is ‘earned’ through ‘provable, credible steps to protect patient privacy, and by being transparent with everyone about everything that is done with their deepest medical secrets’.4 We argue that rather than building public trust, the TRE model actually reduces the need for trust in the use and sharing of patient health data. This is because trust is importantly connected to vulnerability and uncertainty; an essential part of trusting someone is accepting that one’s trust could be disappointed or betrayed. In attempting to provide assurances or guarantees of data privacy and security, TREs strive to remove this vulnerability, and so remove the need for trust. We do not see this as a problem and are broadly supportive of this kind of data sharing model because of the increased security and oversight it provides. However, having argued that TREs are not actually concerned with trust, we consider the importance of being precise about the words that we use …. (shrink)

Powered by ‘big health data’ and enormous gains in computing power, artificial intelligence and related technologies are already changing the healthcare landscape. Harnessing the potential of these technologies will necessitate partnerships between health institutions and commercial companies, particularly as it relates to sharing health data. The need for commercial companies to be trustworthy users of data has been argued to be critical to the success of this endeavour. I argue that this approach is mistaken. Our interactions with commercial companies need (...) not, and should not, be based on trust. Rather, they should be based on confidence. I begin by elucidating the differences between trust, reliability, and confidence, and argue that trust is not the appropriate attitude to adopt when it comes to sharing data with commercial companies. I argue that what we really should want is confidence in a system of data sharing. I then provide an outline of what a confidence-worthy system of data sharing with commercial companies might look like, and conclude with some remarks about the role of trust within this system. (shrink)

Patients in the vegetative state are wholly unaware of themselves, or their surroundings. However, a minority of patients diagnosed as vegetative are actually aware. What is the well-being of these patients? How are their lives going, for them? It has been argued that on a reasonable conception of well-being, these patients are faring so poorly that it may be in their best interests not to continue existing. I argue against this claim. Standard conceptions of well-being do not clearly support the (...) conclusion that these patients would be better off having life-sustaining treatment withdrawn, and in fact, it may be possible for these patients to retain a passable level of well-being. I suggest that further research into the subjective experiences of these patients will allow us to better promote their well-being. (shrink)

Unresponsive wakefulness syndrome is a disorder of consciousness wherein a patient is awake, but completely non-responsive at the bedside. However, research has shown that a minority of these patients remain aware, and can demonstrate their awareness via functional neuroimaging; these patients are referred to as having ‘cognitive motor dissociation’. Unfortunately, we have little insight into the subjective experiences of these patients, making it difficult to determine how best to promote their well-being. In this paper, I argue that the capacity to (...) experience pain or pleasure is a key component of well-being for these patients. While patients with unresponsive wakefulness syndrome are believed to be incapable of experiencing pain or pleasure, I argue that there is evidence to support the notion that CMD patients likely can experience pain and pleasure. I analyze current neuroscientific research into the mechanisms of pain experience in patients with disorders of consciousness, and provide an explanation for why CMD patients likely can experience physical pain. I then do the same for physical pleasure. I conclude that providing these patients with pleasurable experiences, and avoiding subjecting them to pain, are viable means of promoting their well-being. (shrink)

Patients with disorders of consciousness after severe brain injury need surrogate decision makers to guide treatment decisions on their behalf. Formal guidelines for surrogate decisionmaking generally instruct decision makers to first appeal to a patient’s written advance directive, followed by making a substituted judgment of what the patient would have chosen, and lastly, to make decisions according to what seems to be in the patient’s best medical interests. Substituted judgment is preferable because it is taken to preserve patient autonomy, by (...) using a patient’s past wishes and values to reconstruct what they would have chosen for themselves. In this paper, the author argues that for a certain population of patients, the standard interpretation of substituted judgment cannot ensure the preservation of patient autonomy. Patients with “covert awareness” may continue to have values and an authentic sense of self, which may differ from their past values and wishes. Accordingly, surrogate decision makers should make decisions based on how the patient is likely to experience their condition in the present, rather than their past wishes and values. (shrink)

Neuroimaging research regularly yields “incidental findings”: observations of potential clinical significance in healthy volunteers or patients, but which are unrelated to the purpose or variables of the study.

Patients with severe disorders of consciousness are thought to be unaware of themselves or their environment. However, research suggests that a minority of patients diagnosed as having a disorder of consciousness remain aware. These patients, designated as having “cognitive motor dissociation”, can demonstrate awareness by imagining specific tasks, which generates brain activity detectable via functional neuroimaging. The discovery of consciousness in these patients raises difficult questions about their well-being, and it has been argued that it would be better for these (...) patients if they were allowed to die. Conversely, I argue that CMD patients may have a much higher level of well-being than is generally acknowledged. It is far from clear that their lives are not worth living, because there are still significant gaps in our understanding of how these patients experience the world. I attempt to fill these gaps, by analyzing the neuroscientific research that has taken place with these patients to date. Having generated as comprehensive a picture as possible of the capacities of CMD patients, I examine this picture through the lens of traditional philosophical theories of well-being. I conclude that the presumption that CMD patients do not have lives worth living is not adequately supported. (shrink)

Functional MRI shows promise as a candidate prognostication method in acutely comatose patients following severe brain injury. However, further research is needed before this technique becomes appropriate for clinical practice. Drawing on a clinical case, we investigate the process of obtaining informed consent for this kind of research and identify four ethical issues. After describing each issue, we propose potential solutions which would make a patient’s participation in research compatible with her rights and interests. First, we defend the need for (...) traditional proxy consent against two alternative approaches. Second, we examine the impact of the intensive care unit environment on the informed consent process. Third, we discuss the therapeutic misconception and its potential influence on informed consent. Finally, we deal with issues of timing in recruiting participants and related factors which may affect the risks of participation. (shrink)

Prognosis after severe brain injury is highly uncertain, and decisions to withhold or withdraw life‐sustaining treatment are often made prematurely. These decisions are often driven by a desire to avoid a situation where the patient becomes ‘trapped’ in a condition they would find unacceptable. However, this means that a proportion of patients who would have gone on to make a good recovery, are allowed to die. I propose a shift in practice towards the routine provision of aggressive care, even in (...) cases where the probability of survival and acceptable recovery is thought to be low. In conjunction with this shift, I argue in favour of a presumption towards withdrawing life‐sustaining treatment, including artificial nutrition and hydration, when it becomes clear that a patient will not recover to a level that would be acceptable to them. I then respond to three potential objections to this proposal. (shrink)

:Long-term patient outcomes after severe brain injury are highly variable, and reliable prognostic indicators are urgently needed to guide treatment decisions. Functional neuroimaging is a highly sensitive method of uncovering covert cognition and awareness in patients with prolonged disorders of consciousness, and there has been increased interest in using it as a research tool in acutely brain injured patients. When covert awareness is detected in a research context, this may impact surrogate decisionmaking—including decisions about life-sustaining treatment—even though the prognostic value (...) of covert consciousness is currently unknown. This paper provides guidance to clinicians and families in incorporating individual research results of unknown prognostic value into surrogate decisionmaking, focusing on three potential issues: Surrogate decisionmakers may misinterpret results; Results may create false hope about the prospects of recovery; There may be disagreement about the meaningfulness or relevance of results, and appropriateness of continued care. (shrink)

Disorders of consciousness continue to profoundly challenge both families and medical professionals. Once a brain-injured patient has been stabilized, questions turn to the prospect of recovery. However, what “recovery” means in the context of patients with prolonged DOC is not always clear. Failure to recognize potential differences of interpretation—and the assumptions about the relationship between health and well-being that underlie these differences—can inhibit communication between surrogate decisionmakers and a patient’s clinical team, and make it difficult to establish the goals of (...) care. The authors examine the relationship between health and well-being as it pertains to patients with prolonged DOC. They argue that changes in awareness or other function should not be equated to changes in well-being, in the absence of a clear understanding of the constituents of well-being for that particular patient. The authors further maintain that a comprehensive conception of recovery for patients with prolonged DOC should incorporate aspects of both experienced well-being and evaluative well-being. (shrink)

The modern biological definition of a chimera is a single organism composed of cells with multiple distinct genotypes. Chimeras combining human and nonhuman cells are invaluable for various kinds of research, providing a platform for the study of human cell development while avoiding the ethical issues involved in conducting this research on human subjects. There is also the possibility that human/nonhuman chimeras could one day be used to produce human organs for transplant. Yet human/nonhuman chimeras raise a number of unique (...) ethical challenges as well. Critics worry that they are ‘unnatural’, or will cause a kind of ‘moral confusion’, or pose a threat to human dignity. There are also concerns about the kinds of treatment we might owe to human/nonhuman chimeras. For example, introducing human pluripotent stem cells into a gorilla blastocyst could result in the animal developing a ‘humanlike’ brain, or developing human behaviours or characteristics. Would we need to treat such a being as we do our fellow humans? This chapter examines various arguments concerning research involving human/nonhuman chimeras, and the implications of these arguments for research policy. I conclude that research involving human/nonhuman chimeras is not intrinsically morally wrong, though it may be morally impermissible in some cases. However, I criticize the standard approach to evaluating the treatment of nonhumans in research, arguing that the moral treatment of nonhuman animals, including human/nonhuman chimeras, depends on contextual factors, rather than their moral status. (shrink)

The UK government has recently committed to adopting a new policy—dubbed ‘Martha’s Rule’—which has been characterised as providing patients the right to rapidly access a second clinical opinion in urgent or contested cases. Support for the rule emerged following the death of Martha Mills in 2021, after doctors failed to admit her to intensive care despite concerns raised by her parents. We argue that framing this issue in terms of patient rights is not productive, and should be avoided. Insofar as (...) the ultimate goal of Martha’s Rule is the provision of a clinical service that protects patient safety, an approach that focuses on the obligations of the health system—rather than the individual rights of patients—will better serve this goal. We outline an alternative approach that situates rapid clinical review as part of a suite of services aimed at enhancing and protecting patient care. This approach would make greater progress towards addressing the difficult systemic issues that Martha’s Rule does not, while also better engaging with the constraints of clinical practice. (shrink)

A general obligation to make aggregate research results available to participants has been widely supported in the bioethics literature. However, dementia research presents several challenges to this perspective, particularly because of the fear associated with developing dementia. The authors argue that considerations of respect for persons, beneficence, and justice fail to justify an obligation to make aggregate research results available to participants in dementia research. Nevertheless, there are positive reasons in favor of making aggregate research results available; when the decision (...) is made to do so, it is critical that a clear strategy for communicating results is developed, including what support will be provided to participants receiving aggregate research results. (shrink)

In our recent paper ‘Trust and the Goldacre Review: Why TREs are not about trust’1 we argue that trusted research environments (TREs) reduce the need for trust in the use and sharing of health data, and that referring to these data storage systems as ‘trusted’ raises a number of concerns. Recent replies to our paper have raised several objections to this argument. In this reply, we seek to build on the arguments presented in our original paper, address some of the (...) misunderstanding of our position expressed in these replies, and sketch out where further research is needed. One of the central arguments of our original paper was that the language we use to describe data-sharing initiatives matters, because the way things like TREs are presented and framed makes a difference to what people can, and should, expect from them. However, there is a more basic and obvious problem with referring to these institutions as ‘trusted’: it begs the question about whether these institutions are, in fact, trusted. We cannot know in advance of these initiatives being implemented, established, and appropriate assessments completed, whether they are actually trusted. Further questions abound: whom might TREs eventually be trusted by? If some people end up trusting them, but not others, is it appropriate to call them ‘trusted’? At best, this is simply a case of wishful thinking (and a more accurate name would be ‘hopefully-TREs’). More problematically, this may be an instance of ‘trustworthiness-signalling’: an attempt to convince others to trust, without meeting the requirements for genuine trustworthiness. By calling TREs ‘trusted’, the implication seems to be that placing our trust in them is perfectly fine: they are the kinds of things that are trusted by others and can safely be trusted by us. But not only does simply calling something ‘trusted’ …. (shrink)

A rapidly growing proportion of health research uses ‘secondary data’: data used for purposes other than those for which it was originally collected. Do researchers using secondary data have an obligation to disclose individual research findings to participants? While the importance of this question has been duly recognised in the context of primary research, it remains largely unexamined in the context of research using secondary data. In this paper, we critically examine the arguments for a moral obligation to disclose individual (...) research findings in the context of primary research, to determine if they can be applied to secondary research. We conclude that they cannot. We then propose that the nature of the relationship between researchers and participants is what gives rise to particular moral obligations, including the obligation to disclose individual results. We argue that the relationship between researchers and participants in secondary research does not generate an obligation to disclose. However, we also argue that the biobanks or data archives which collect and provide access to secondary data may have such an obligation, depending on the nature of the relationship they establish with participants. (shrink)

Volume 19, Issue 9, September 2019, Page 48-50.

A growing number of studies show that a significant proportion of patients, who meet the clinical criteria for the diagnosis of the vegetative state, demonstrate evidence of covert awareness through successful performance of neuroimaging tasks. Despite these important advances, the day-to-day life experiences of any such patient remain unknown. This presents a major challenge for optimizing the patient’s standard of care and quality of life. We describe a patient who, following emergence from a state of complete behavioral unresponsiveness and a (...) clinical diagnosis of VS, reported rich memories of his experience during this time. This case demonstrates the potential for a sophisticated mental life enabled by preserved memory in a proportion of patients who, similarly, are thought to be unconscious. Therefore, it presents an important opportunity to examine the implications for patient QoL and standard of care, both during the period of presumed unconsciousness and after recovery. (shrink)

We address two main issues: the distinction between time-constrained and spatially constrained tasks, and the separable A and W effects on movement time (MT) in spatially-constrained tasks. We consider MT and 3-D kinematic data from human adults pointing to targets in human-computer interaction. These are better fit by Welford's (1968) two-part model, than Fitts' (1954; Fitts & Peterson 1964) ID model. We identify theoretical and practical implications.

Many are calling for concrete mechanisms of oversight for health research involving artificial intelligence (AI). In response, institutional review boards (IRBs) are being turned to as a familiar model of governance. Here, we examine the IRB model as a form of ethics oversight for health research that uses AI. We consider the model's origins, analyze the challenges IRBs are facing in the contexts of both industry and academia, and offer concrete recommendations for how these committees might be adapted in order (...) to provide an effective mechanism of oversight for health‐related AI research. (shrink)

Patient outcome after serious brain injury is highly variable. Following a period of coma, some patients recover while others progress into a vegetative state (unresponsive wakefulness syndrome) or minimally conscious state. In both cases, assessment is difficult and misdiagnosis may be as high as 43%. Recent advances in neuroimaging suggest a solution. Both functional magnetic resonance imaging and electroencephalography have been used to detect residual cognitive function in vegetative and minimally conscious patients. Neuroimaging may improve diagnosis and prognostication. These techniques (...) are beginning to be applied to comatose patients soon after injury. Evidence of preserved cognitive function may predict recovery, and this information would help families and health providers. Complex ethical issues arise due to the vulnerability of patients and families, difficulties interpreting negative results, restriction of communication to “yes” or “no” answers, and cost. We seek to investigate ethical issues in the use of neuroimaging in behaviorally nonresponsive patients who have suffered serious brain injury. The objectives of this research are to: (1) create an approach to capacity assessment using neuroimaging; (2) develop an ethics of welfare framework to guide considerations of quality of life; (3) explore the impact of neuroimaging on families; and, (4) analyze the ethics of the use of neuroimaging in comatose patients. (shrink)

The norm of assertion, to be in force, is a social norm. What is the content of our social norm of assertion? Various linguistic arguments purport to show that to assert is to represent oneself as knowing. But to represent oneself as knowing does not entail that assertion is governed by a knowledge norm. At best these linguistic arguments provide indirect support for a knowledge norm. Furthermore, there are alternative, non-normative explanations for the linguistic data (as in recent work from (...) Van Elswyk). Direct arguments would rely on normative judgments about the permissibility or impermissibility of assertions with and without the speaker knowing the content asserted. John Turri's work experimental results purport to show that our norm of assertion is factive, and probably knowledge. But as a number of recent experimentalists (Kneer, Reuter and Broessel, Marsili and Wiegmann) have shown, Turri's results rely on the problemmatic use of 'should' as in 'Maria should assert that she owns a 1990 watch.' Correcting for this, these experimentalists provide strong evidence that our norm of assertion is not factive. The standard reply to evidence like this from the assertion of unlucky falsehoods is the excuse maneuver. But Marsili and Wiegmann, following Turri's protocol for testing for excuse validation, show that participants who judge that assertions unlucky falsehoods are permissible are not guilty of excuse validation. Given our current understanding of the experimental evidence, knowledge is not our norm of assertion. (shrink)

We often feel survivor guilt when the very circumstances that harm others leave us unscathed. Although survivor guilt is both commonplace and intelligible, it raises a puzzle for the standard philosophical account of guilt, according to which people feel guilt only when they take themselves to be morally blameworthy. The standard account implies that survivor guilt is uniformly unfitting, as people are not blameworthy simply for having fared better than others. In this paper, we offer a rival account of guilt, (...) the relational account of guilt, which makes sense of survivor guilt and other forms of guilt without self-blame while preserving the intelligibility of guilt about culpable wrongdoing. According to this account, guilt involves the feeling of being unable to justify ourselves to others, and we lack self-justification when we (however blamelessly) stand on the positive side of an undesirable asymmetry with them. When someone survives something that those around her do not, the disparity in outcome constitutes an asymmetry that is often undesirable, because it arises from luck or violates a requirement of solidarity. Thus, survivor guilt is often fitting. (shrink)

This book is a unique contribution to the philosophy of religion. It offers a comprehensive discussion of one of the most famous arguments for the existence of God: the ontological argument. The author provides and analyses a critical taxonomy of those versions of the argument that have been advanced in recent philosophical literature, as well as of those historically important versions found in the work of St Anselm, Descartes, Leibniz, Hegel and others. A central thesis of the book is that (...) ontological arguments have no value in the debate between theists and atheists. There is a detailed review of the literature on the topic (separated from the main body of the text) and a very substantial bibliography, making this volume an indispensable resource for philosophers of religion and others interested in religious studies. (shrink)

What is the biological function of perception? I hold perception, especially visual perception in humans, has the biological function of accurately representing the environment. Tyler Burge argues this cannot be so in Origins of Objectivity (Oxford, 2010), for accuracy is a semantical relationship and not, as such, a practical matter. Burge also provides a supporting example. I rebut the argument and the example. Accuracy is sometimes also a practical matter if accuracy partly explains how perception contributes to survival and reproduction.

Descartes with his sharp separation of the mental and the physical set the stage for the philosophy of mind for the next 350 years. Philosopher Patrick T. Mackenzie finds in the later writings of Wittgenstein the suggestion that Descartes got off on the wrong foot. Following Wittgenstein's lead, Mackenzie argues that instead of analyzing our human nature as a composite of mind and body, we should view ourselves as whole persons. One of the dividends of this approach to (...) the mind-body problem is that it provides us with a resolution to the problem of human freedom—i.e., how can a human being be free if his or her body (including the brain) belongs to a deterministic world? Mackenzie here argues that the person is largely free even though the movements of the body are determined by neurophysiological events. He takes the same approach to the philosophy of mind as that taken by M.R.Bennett and P.M.S.Hacker in their recent and controversial book, The Philosophical Foundations of Neuroscience. Mackenzie's approach is, however, much more accessible. Students of philosophy and philosophers interested in the problem of human freedom will welcome Mackenzie's fresh approach, especially those disenchanted by the present list of mind-body "isms.". (shrink)

In The Bodhisattva’s Brain: Buddhism Naturalized, Owen Flanagan undertakes a project of what he calls ‘cosmopolitan philosophy’, with an aim to develop and interrogate a naturalized Buddhism. A project of naturalization requires a conception of naturalism that can serve as a hermeneutic and philosophical standard against which certain things may be judged naturalistically acceptable or unacceptable. On Flanagan’s account, Buddhism ‘naturalized’ is primarily a Buddhism, “without the mind-numbing and wishful hocus-pocus.” Instead, he sets out to sketch a version of Buddhism (...) (or a new view inspired by it) that is consistent with neo-Darwinian evolutionary theory and scientific materialism, including ‘neurophysicalism’ or the view that “mental events are brain events.” However, classical Buddhist philosophers rejected materialism on philosophical, not merely dogmatic, grounds. In contemporary terms, Buddhist philosophers saw that phenomenal consciousness, intentionality, and mental causation present serious problems for materialism. So, rather than dismissing Buddhist anti-materialist accounts of mind as simply ‘hocus-pocus’, in this chapter takes up the question of whether and how these views might inform a naturalistic Buddhist philosophy. The question, then, is whether a naturalistic Buddhism requires some form of neurophysicalism. It is argued that it does not, by way of examining two distinct versions of naturalistic, but non-physicalist accounts of consciousness reconstructed from the Indian Buddhist tradition. The first, drawing on the work of Dharmakīrti, is a form of trope dualism. The second, drawing on the work of Śāntarakṣita, is a form of pragmatic pluralism that gives a central place to consciousness. And while these two accounts are distinct, and in some important respects incompatible, what they have in common is the idea that consciousness is both non-physical and fully natural. (shrink)

In this book, Graham Oppy examines arguments for and against the existence of God. He shows that none of these arguments is powerful enough to change the minds of reasonable participants in debates on the question of the existence of God. His conclusion is supported by detailed analyses of the arguments as well as by the development of a theory about the purpose of arguments and the criteria that should be used in judging whether or not arguments are successful. (...) Oppy discusses the work of a wide array of philosophers, including Anselm, Aquinas, Descartes, Locke, Leibniz, Kant, Hume and, more recently, Plantinga, Dembski, White, Dawkins, Bergman, Gale and Pruss. (shrink)

Genocide in Rwanda, multiple murder at Denver or Dunblane, the gruesome activities of serial killers - what makes these great evils, and why do they occur? In addressing such questions this book, unusually, interconnects contemporary moral philosophy with recent work in New Testament scholarship. The conclusions to emerge are surprising. Gordon Graham argues that the inability of modernist thought to account satisfactorily for evil and its occurrence should not lead us to embrace an eclectic postmodernism, but to take seriously (...) some unfashionable pre-modern conceptions - Satan, demonic possession, spiritual powers, cosmic battles. Precisely because it strives to observe the high standards of clarity and rigour that are the hallmarks of philosophy in the analytical tradition, the book makes a powerful case for the rejection of humanism and naturalism, and for explaining the moral obligation to struggle against evil by reference to the New Testament's cosmic narrative. (shrink)

This revised and considerably expanded 2nd edition brings together a wide range of topics, including modal, tense, conditional, intuitionist, many-valued, paraconsistent, relevant, and fuzzy logics. Part 1, on propositional logic, is the old Introduction, but contains much new material. Part 2 is entirely new, and covers quantification and identity for all the logics in Part 1. The material is unified by the underlying theme of world semantics. All of the topics are explained clearly using devices such as tableau proofs, and (...) their relation to current philosophical issues and debates are discussed. Students with a basic understanding of classical logic will find this book an invaluable introduction to an area that has become of central importance in both logic and philosophy. It will also interest people working in mathematics and computer science who wish to know about the area. (shrink)

This book is an exploration of philosophical questions about infinity. Graham Oppy examines how the infinite lurks everywhere, both in science and in our ordinary thoughts about the world. He also analyses the many puzzles and paradoxes that follow in the train of the infinite. Even simple notions, such as counting, adding and maximising present serious difficulties. Other topics examined include the nature of space and time, infinities in physical science, infinities in theories of probability and decision, the nature (...) of part/whole relations, mathematical theories of the infinite, and infinite regression and principles of sufficient reason. (shrink)

Based on Michel Foucault's 1978 and 1979 lectures at the Collège de France on governmental rationalities and his 1977 interview regarding his work on imprisonment, this volume is the long-awaited sequel to Power/Knowledge.