Guidelines around the world require children to provide assent for their participation in most research studies. Yet, little further guidance is provided on how review committees should implement this requirement, including which children are capable of providing assent and when the requirement for assent may be waived on the grounds that the research offers participating children the potential for important clinical benefit. The present paper argues that the assent requirement is supported by the importance of allowing children who are capable (...) to make their own decisions. This suggests children are capable of assent when they become able to understand the research in question. While development varies across individual children, existing data suggest most children develop this ability by approximately age 14. Until instruments are developed to assess the assent capacity of individual children, this age should be used as the threshold for assent. In addition, the importance of protecting children from harm suggests that the sustained dissent of all children, including those who are unable to provide assent, should be respected. While the assent requirement may be waived when research participation offers the potential for important medical benefit that is unavailable outside the research context, analysis suggests that children’s sustained dissent should be respected in all cases. (shrink)

The principle that physicians should always act in the best interests of the present patient is widely endorsed. At the same time, and often within the same document, it is recognised that there are appropriate exceptions to this principle. Unfortunately, little, if any, guidance is provided regarding which exceptions are appropriate and how they should be handled. These circumstances might be tenable if the appropriate exceptions were rare. Yet, evaluation of the literature reveals that there are numerous exceptions, several of (...) which pervade clinical medicine. This situation leaves physicians without adequate guidance on when to allow exceptions and how to address them, increasing the chances for unfairness in practice. The present article considers the range of exceptions, illustrates how the lack of guidance poses ethical concern and describes an alternative account of physician obligations to address this concern. (shrink)

When making substituted judgments for incapacitated patients, surrogates often struggle to guess what the patient would want if they had capacity. Surrogates may also agonize over having the (sole) responsibility of making such a determination. To address such concerns, a Patient Preference Predictor (PPP) has been proposed that would use an algorithm to infer the treatment preferences of individual patients from population-level data about the known preferences of people with similar demographic characteristics. However, critics have suggested that even if such (...) a PPP were more accurate, on average, than human surrogates in identifying patient preferences, the proposed algorithm would nevertheless fail to respect the patient’s (former) autonomy since it draws on the ‘wrong’ kind of data: namely, data that are not specific to the individual patient and which therefore may not reflect their actual values, or their reasons for having the preferences they do. Taking such criticisms on board, we here propose a new approach: the Personalized Patient Preference Predictor (P4). The P4 is based on recent advances in machine learning, which allow technologies including large language models to be more cheaply and efficiently ‘fine-tuned’ on person-specific data. The P4, unlike the PPP, would be able to infer an individual patient’s preferences from material (e.g., prior treatment decisions) that is in fact specific to them. Thus, we argue, in addition to being potentially more accurate at the individual level than the previously proposed PPP, the predictions of a P4 would also more directly reflect each patient’s own reasons and values. In this article, we review recent discoveries in artificial intelligence research that suggest a P4 is technically feasible, and argue that, if it is developed and appropriately deployed, it should assuage some of the main autonomy-based concerns of critics of the original PPP. We then consider various objections to our proposal and offer some tentative replies. (shrink)

The standard approach to treatment decision making for incapacitated patients often fails to provide treatment consistent with the patient’s preferences and values and places significant stress on surrogate decision makers. These shortcomings provide compelling reason to search for methods to improve current practice. Shared decision making between surrogates and clinicians has important advantages, but it does not provide a way to determine patients’ treatment preferences. Hence, shared decision making leaves families with the stressful challenge of identifying the patient’s preferred treatment (...) option. To address this concern, the present paper proposes to incorporate the use of a “Patient Preference Predictor” (PPP) into the shared decision-making process between surrogates and clinicians. A PPP would predict which treatment option a given incapacitated patient would most likely prefer, based on the individual’s characteristics and information on what treatment preferences are correlated with these characteristics. Use of a PPP is likely to increase the chances that incapacitated patients are treated consistent with their preferences and values and might reduce the stress and burden on their surrogates. Including a PPP in the shared decision-making process therefore has the potential to realize important ethical goals for making treatment decisions for incapacitated patients. The present paper justifies this approach on conceptual and normative grounds. (shrink)

There are substantial data establishing that surrogates are often mistaken in predicting what treatments incompetent patients would have wanted and that supplements such as advance directives have not resulted in significant improvements. Rid and Wendler’s Patient Preference Predictor (PPP) proposal will attempt to gather data about what similar patients would prefer in a variety of treatment choices. It accepts the usual goal of patient autonomy and the Substituted Judgment principle for surrogate decisions. I provide reasons for questioning sole reliance (...) on autonomy when surrogates, not patients, are deciding and for giving some independent weight to patient well-being. Moreover, that family members, typical surrogates, will know best what the patient if incompetent would have wanted is not the only reason why they are chosen. The more pressing problem is that the PPP would fail to remove the more serious mistakes that empirical psychology over the last few decades has shown to infect such decision making. (shrink)

This is an introduction to, and survey of, the constructive approaches to pure mathematics. The authors emphasise the viewpoint of Errett Bishop's school, but intuitionism. Russian constructivism and recursive analysis are also treated, with comparisons between the various approaches included where appropriate. Constructive mathematics is now enjoying a revival, with interest from not only logicans but also category theorists, recursive function theorists and theoretical computer scientists. This account for non-specialists in these and other disciplines.

Originally published in 1986. Both moral philosophers and philosophical psychologists need to answer the question ‘what is a virtue?’ and the best answer so far give is that of Aristotle. This book is a rigorous exposition of that answer. The elements of Aristotle’s doctrine of virtue are scattered throughout his writings; this book reconstructs his complex and comprehensive doctrine in one place. It also covers Aristotle’s views about choice, character, emotions and the role of pleasure and pain in virtue. The (...) celebrated function is considered carefully as well as the doctrine of virtue being related to Aristotle’s metaphysics and categories. (shrink)

Different types of consent are used to obtain human biospecimens for future research. This variation has resulted in confusion regarding what research is permitted, inadvertent constraints on future research, and research proceeding without consent. The National Institutes of Health Clinical Center's Department of Bioethics held a workshop to consider the ethical acceptability of addressing these concerns by using broad consent for future research on stored biospecimens. Multiple bioethics scholars, who have written on these issues, discussed the reasons for consent, the (...) range of consent strategies, and gaps in our understanding, and concluded with a proposal for broad initial consent coupled with oversight and, when feasible, ongoing provision of information to donors. This article describes areas of agreement and areas that need more research and dialogue. Given recent proposed changes to the Common Rule, and new guidance regarding storing and sharing data and samples, this is an important and tim.. (shrink)

Background: Demand for organisational ethics capacity is growing in health organisations, particularly among managers. The role of clinical ethicists in, and perspective on, organisational ethics has not been well described or documented in the literature. Objective: To describe clinical ethicists’ perspectives on organisational ethics issues in their hospitals, their institutional role in relation to organisational ethics, and their perceived effectiveness in helping to address organisational ethics issues. Design and Setting: Qualitative case study involving semi-structured interviews with 18 clinical ethicists across (...) 13 health organisations in Toronto, Canada. Results: From the clinical ethicists’ perspective, the most pressing organisational ethics issues in their organisations are: resource allocation, staff moral distress linked to the organisation’s moral climate, conflicts of interest, and clinical issues with a significant organisational dimension. Clinical ethicists were consulted in particular on issues related to staff moral distress and clinical issues with an organisational dimension. Some ethicists described being increasingly consulted on resource allocation, conflicts of interest, and other corporate decisions. Many clinical ethicists felt they lacked sufficient knowledge and understanding of organisational decision-making processes, training in organisational ethics, and access to organisational ethics tools to deal effectively with the increasing demand for organisational ethics support. Conclusion: Growing demand for organisational ethics expertise in healthcare institutions is reshaping the role of clinical ethicists. Effectiveness in organisational ethics entails a re-evaluation of clinical ethics training to include capacity building in organisational ethics and organisational decision-making processes as a complement to traditional clinical ethics education. (shrink)

In this bold, challenging book, D. S. Clarke outlines reasons for accepting panpsychism and defends the doctrine against its critics.

An anthology of readings in panpsychism, spanning two millennia.

Preimplantation genetic diagnosis (PID) is often seen as an improvement upon prenatal testing. I argue that PID may exacerbate the eugenic features of prenatal testing and make possible an expanded form of free-market eugenics. The current practice of prenatal testing is eugenic in that its aim is to reduce the numbers of people with genetic disorders. Due to social pressures and eugenic attitudes held by clinical geneticists in most countries, it results in eugenic outcomes even though no state coercion is (...) involved. I argue that technological advances may soon make PID widely accessible. Because abortion is not involved, and multiple embryos are available, PID is radically more effective as a tool of genetic selection. It will also make possible selection on the basis of non-pathological characteristics, leading, potentially, to a full-blown free-market eugenics. For these reasons, I argue that PID should be strictly regulated. (shrink)

Introduction What is the point of studying Aristotle's theory of moral virtue? In the first place, many interesting questions are raised, in metaphysics, ...

Nicholas Shackel (2011) has proposed a number of arguments to save the Dipert–Bird model of physical reality from the sorts of unpalatable consequence I identified in Oderberg 2011. Some consequences, he thinks, are only apparent; others are real but palatable. In neither case does he seem to me to have deflected the concerns I raised, leaving graph structuralism on Dipert–Bird lines as problematic as ever.

Within the increasingly complex picture which has emerged in recent years of the manuscript tradition of Ovid's Amores the relationship of the two earliest MSS appears to remain firm: cod. P or Puteaneus of the 9th or early 10th century, which begins at Am. 1.2.51, was copied, probably directly, from the second half of the 9th-century cod. R or Regius , whose first half now ends at Am. 1.2.50. This view, which originates in S. Tafel's dissertation of 1910 and lies (...) behind the stemma constructed by E. J. Kenney for his OCT edition of 1961 , has come to be taken by Ovidian scholars to be the truth. My purpose in this first section is to show that this idea is unlikely to be the truth and, in the form in which it has most strongly been put forward, cannot be the truth. In the second section consequences for the manuscript tradition as a whole are explored. First we shall need some details. P, the slightly later manuscript, consists in all of 99 folia, of which 1–54 contain most, but not all, of the Heroides — not all, because they are in a lacunose state, a point to which we shall return in greater detail later. Foll. 55–6 are blank sheets of paper, not parchment, clearly inserted at a much later date during rebinding. (shrink)

Within the increasingly complex picture which has emerged in recent years of the manuscript tradition of Ovid's Amores the relationship of the two earliest MSS appears to remain firm: cod. P or Puteaneus of the 9th or early 10th century, which begins at Am. 1.2.51, was copied, probably directly, from the second half of the 9th-century cod. R or Regius, whose first half now ends at Am. 1.2.50. This view, which originates in S. Tafel's dissertation of 1910 and lies behind (...) the stemma constructed by E. J. Kenney for his OCT edition of 1961, has come to be taken by Ovidian scholars to be the truth. My purpose in this first section is to show that this idea is unlikely to be the truth and, in the form in which it has most strongly been put forward, cannot be the truth. In the second section consequences for the manuscript tradition as a whole are explored. First we shall need some details. P, the slightly later manuscript, consists in all of 99 folia, of which 1–54 contain most, but not all, of the Heroides — not all, because they are in a lacunose state, a point to which we shall return in greater detail later. Foll. 55–6 are blank sheets of paper, not parchment, clearly inserted at a much later date during rebinding. (shrink)

This article asserts that traditionally dominant models of health promotion in the US are fairly characterized by methodological individualism. This schema produces a focus on the individual as the node of intervention. Such emphasis results in a number of scientific and ethical problems. I identify three principal ethical deficiencies: first, the health promotions used are generally ineffective, which violates canons of distributive justice because scarce health resources are expended on interventions that are unlikely to produce health benefits. Second, the health (...) promotions used tend to expand health inequalities between the affluent and the least well-off. Third, the health promotions used are likely to intensify stigma against the least well-off, a deficiency that itself may exacerbate the ‘densely-woven patterns of disadvantage’ that characterize life on the tail of the social gradient. Because Powers and Faden’s health sufficiency model of social justice argues that the amelioration of such clusters of disadvantage should be the primary ethical goal of public health policy, methodologically individualist models of health promotion are ethically deficient and should not stand as primary approaches for health promotion in a just social order. (shrink)

Powers and Faden argue that social justice ‘is concerned with securing and maintaining the social conditions necessary for a sufficient level of well-being in all of its essential dimensions for everyone’ (2006: 50). Moreover, social justice is concerned with the ‘achievement of well-being, not the freedom or capability to achieve well-being’ (p. 40). Although Powers and Faden note that an agent alone cannot achieve well-being without the necessary social conditions of life (e.g. equal civil liberties and basic material resources, such (...) as food and shelter), it seems that achievement requires that an agent actually pursue the six dimensions of well-being. In this article, I question the extent to which an individual has an obligation to achieve well-being, even if he or she would choose to do otherwise. For example, can an agent choose to forgo being healthy even if all the social conditions are met in her life, thereby choosing to not achieve well-being? It remains unclear how the dimension of self-determination coheres with the remaining five dimensions of well-being and the extent of society’s obligations toward an individual’s achievement of well-being, even in those instances when society’s actions may go against an individual’s right to self-determination. (shrink)

The Intergovernmental Platform on Biodiversity and Ecosystem Services have recently launched themselves as the UN-sanctioned instrument for conserving nature. They seek to establish themselves as the authority in this field alongside the well-known Intergovernmental Panel on Climate Change in climate science. Quickly following or even before recent publication of their conceptual framework in two biology journals, they were already underway building upon it. This headlong push, we believe, is ill advised. We show how the framework is unsound as a foundation (...) for further work—in a number of ways and perhaps even by its authors’ own lights. It is therefore urgent that the IPBES thoroughly and thoughtfully reconsider their framework before too much effort is wasted. (shrink)

abstractBackground: Evidence shows both a tendency for research participants to conflate research and clinical care and a limited public understanding of research. Conflation of research and care by participants is often referred to as the therapeutic misconception. Despite this evidence, few studies have explicitly asked participants, and especially minors, to explain what they think research is and how they think it differs from regular medical care. Methods: As part of a longer semistructured interview evaluating assent and parental permission for research, (...) adolescent research participants (n = 177), including adolescents with illnesses and healthy volunteers, and their parents (n = 177) were asked to describe medical research in their own words and say whether and how they thought being in medical research was different from seeing a regular doctor. Qualitative responses were coded and themes were identified through an iterative process. Results: When asked to describe medical research, the majority described research in terms of its goals of helping to advance science, develop treatments and medicines, and help others; fewer described research as having the goal of helping particular research participants, and fewer still in terms of the methods used in research. The majority of teen and parent respondents said being in research is different than seeing a regular doctor and explained this by describing different goals, different or more procedures, differences in the engagement of the doctors/researchers, and differences in logistics. Conclusions: Adolescents participating in clinical research and their parents generally describe medical research in terms of its goals of advancing science and finding new medicines and treatments, sometimes in combination with helping the enrolled individuals. The majority perceive a difference between research and regular medical care and described these differences in various ways. Further exploration is warranted about how such perceived differences matter to participants and how this understanding could be used to enhance informed consent and the overall research experience. (shrink)

Marking the 50th anniversary of one among this philosopher's most distinguished pieces, Blumenberg's Rhetoric proffers a decidedly dialogic and diversified interaction with the essay polyvalently entitled 'Anthropological Approach to the Actuality and Topicality (or Currency, Relevance) of Rhetoric' (Anthropologische Annäherung an die Aktualität der Rhetorik), first published in 1971. Following Blumenberg's lead, the contributors consider and tackle their topics rhetorically, 'in utramque partem vel in plures'--treating (inter alia) the variegated discourses of Phenomenology, the History of Philosophy, Anthropology, and the téchne (...) itself from a plurality of viewpoints. Quasi in actu--as a mise en abyme of this rhetorical method par excellence--said accent on approaching any matter polyperspectivally is reflected in the proceedings of the live(ly) discussions having taken place in preparation for the present volume. Along with the diachronically extensive, disciplinarily diverse essays, this publication of the actual academic interplay--notably in the current lingua franca--will facilitate, and is to conduce to, further scholarship with respect to Blumenberg and the art of rhetoric. (shrink)