Drawing on a landscape analysis of existing data-sharing initiatives, in-depth interviews with expert stakeholders, and public deliberations with community advisory panels across the U.S., we describe features of the evolving medical information commons. We identify participant-centricity and trustworthiness as the most important features of an MIC and discuss the implications for those seeking to create a sustainable, useful, and widely available collection of linked resources for research and other purposes.

Hayek argued that the central question of economics is the coordination problem: How does the spontaneous interaction of many purposeful individuals, each having dispersed bits of subjective knowledge, generate an order in which the actors' subjective data are coordinated in a way that enables them to dovetail their plans and activities successfully? In attempting to solve this problem, Hayek outlined an approach to economic theorizing that takes seriously the limited, subjective nature of human knowledge. Despite purporting to have appropriated Hayek's (...) thought by acknowledging the information-transmitting role of prices, mainstream economists have missed Hayek's point. The predominant tool of formal economics—equilibrium analysis—begins by assuming the data held by actors to have been pre-reconciled, and so evades the problem to be solved. Even the more advanced tools for modeling knowledge in economic analysis, such as the economics of information, assume away either the subjectivism of knowledge and expectations (rendering the coordination of beliefs and plans a trivial matter) or the frictions and “imperfections” of reality (rendering the coordination problem indeterminate). (shrink)

As contribution to a recent debate (James, 1998; Murphy etal., 1997, 1998) the proportion of twins following ovulation induction (OI) or assisted conception (AC) in 1994 in Oxfordshire and West Berkshire was estimated, and by extrapolation the natural twinning rate in England and Wales was judged to have maintained a plateau phase since the 1970s. Similar figures for 1995 and 1996 from the same study, and hence a more stable local estimate, are now provided. The proportions, as before, were estimated (...) from women's responses to a questionnaire within a case[hyphen]control study, with ascertainment from general practitioners' records or hospital case[hyphen]notes for non[hyphen]responders or for those excluded from the study originally. In 1994, 1995 and 1996 the proportion of twins following OI/AC was overall 27% (24%, 30% and 27% respectively). Restriction to the 87% locally resident made no difference. The national crude twinning rate for those years was overall 13·3 per 1000 maternities (12·8, 13·6 and 13·4 respectively). (shrink)

Most philosophical explorations of responsibility discuss the topic solely in terms of metaphysics and the "free will" problem. By contrast, these essays by leading philosophers view responsibility from a variety of perspectives -- metaphysics, ethics, action theory, and the philosophy of law. After a broad, framing introduction by the volume's editors, the contributors consider such subjects as responsibility as it relates to the "free will" problem; the relation between responsibility and knowledge or ignorance; the relation between causal and moral responsibility; (...) the difference, if any, between responsibility for actions and responsibility for omissions; the metaphysical requirements for making sense of "collective" responsibility; and the relation between moral and legal responsibility. The contributors include such distinguished authors as Alfred R. Mele, John Martin Fischer, George Sher, and Frances Kamm, as well as important rising scholars. Taken together, the essays in _Action, Ethics, and Responsibility_ offer a breadth of perspectives that is unmatched by other treatments of the topic. Contributors: Joseph Keim Campbell, David Chan, Randolph Clarke, E.J. Coffman, John Martin Fischer, Helen Frowe, Todd Jones, Frances Kamm, Antti Kauppinen, Alfred R. Mele, Michael O'Rourke, Paul Russell, Robert F. Schopp, George Sher, Harry S. Silverstein, Saul Smilansky, Donald Smith, Charles T. Wolfe The hardcover edition does not include a dust jacket. (shrink)

Contemplating Suicide: The Language and Ethnics of Self Harm By Gavin J. Fairbairn Routledge, 1995. Pp. xxx. ISBN 415?10606. £12.95(pbk). Religious Transformation in Western Society. The End of Happiness By Harvie Ferguson, Routledge, 1992. Pp. xvi + 269. ISBN 0?415?02574?5. £XX.xx. Feminism and the Self: The Web of Identity By Morwenna Griffiths Routledge, 1995. Pp. 191. ISBN 0?415?09821?1. £12.99 (pbk). Faith, Scepticism and Personal Identity. A Festschrift for Terence Penelhum Edited by J.J. Macintosh and H. A. Meynell University of Calgary (...) Press, 1994. Pp. vii + 304. CAN$27.95. The Shape of Space (second edition) By Graham Nerlich Cambridge University Press, 1994. ISBN 0?521?45645?2. Logical Learning Theory: A Human Teleology and its Empirical Support By Joseph F. Rychlak University of Nebraska Press, 1994. Pp. 387. ISBN 0?8032?3904?1. £32.95 Philosophical Idealism and Christian Belief By Alan P.F. Sell University of Wales Press, 1995. Pp. x + 338. (shrink)

Hegel introduced the Phenomenology of Mind as a work on the problem of knowledge. In the first chapter, entitled “Sense Certainty, or the This and Meaning,” he concluded that knowledge cannot consist of an immediate awareness of particulars ). The tradition discusses sense certainty in terms of this failure of immediate knowledge without, however, specifically addressing the problem of reference. Yet reference is distinct from knowledge in the sense that while there can be no knowledge of objects without reference, there (...) may be reference without knowledge. If that is the case, then the failure of immediate knowledge does not entitle us to conclude anything about the success or failure of reference. It is not surprising, then, that a few scholars have begun to examine sense certainty primarily as a thesis about reference. (shrink)

Is helping those whose subsistence needs are not meet a matter of charity or an obligation? What role should ordinary citizens of developed nations play? In a globalized world, the causes, connections, and responsibilities become complicated. Agriculture subsidies that keep food prices low for many in relatively rich countries may, for example, negatively impact poor farmers in developing countries. Students in Ethics/Philosophy 352 report on their project examining whether, and to what extent, a true obligation to aid exists.

Peter Abelard (1079–1142 ce) was the most wide‐ranging philosopher of the twelfth century. He quickly established himself as a leading teacher of logic in and near Paris shortly after 1100. After his affair with Heloise, and his subsequent castration, Abelard became a monk, but he returned to teaching in the Paris schools until 1140, when his work was condemned by a Church Council at Sens. His logical writings were based around discussion of the “Old Logic”: Porphyry's Isagoge, aristotle'S Categories and (...) On Interpretation and boethius'S textbook on topical inference. They comprise a freestanding Dialectica (“Logic”; probably c.1116), a set of commentaries (known as the Logica [Ingredientibus], c. 1119) and a later (c. 1125) commentary on the Isagoge (Logica Nostrorum Petititoni Sociorum or Glossulae). In a work Abelard called his Theologia, issued in three main versions (between 1120 and c.1134), he attempted a logical analysis of trinitarian relations and explored the philosophical problems surrounding God's claims to omnipotence and omniscience. The Collationes (“Debates,” also known as “Dialogue between a Christian, a Philosopher and a Jew”; probably c.1130) present a rational investigation into the nature of the highest good, in which the Christian and the Philosopher (who seems to be modeled on a philosopher of pagan antiquity) are remarkably in agreement. The unfinished Scito teipsum (“Know thyself,” also known as the “Ethics”; c.1138) analyses moral action. (shrink)

This is a collection of thirteen original essays, of uniformly high quality, on various aspects of Hegel’s political thought. The contributors include younger as well as established Hegel authorities. The opening and concluding pieces are by Z. Pelczynski, who also invited and selected the contributions and served as general editor. The other contributors are John Plamenatz, J.-F. Suter, Judith Shklar, D.-H. Ilting, G. Heiman, Manfred Riedel, D. Cooper, D. P. Verene, W. H. Walsh, R. N. Berki, and Eugène Fleischmann. Their (...) collective effort contributes much to clarifying the wealth of historical, sociological, psychological and philosophical matter that is packed into Hegel’s often obscure theoretical texts on society and polity. Attention is also paid to his less theoretical writings such as The German Constitution and ‘The English Reform Bill’, which helps to clarify the relationship between these and the major theoretical treatises, part III of the Encyclopedia and, especially, the Philosophy of Right. (shrink)

Contemporary developments in American epistemology, by R. M. Chisholm.--Contemporary metaphysics in the United States, by D. F. Gustafson.--Philosophy of physics, by H. Putnam--The influence of continental philosophy on the contemporary American scene: a summons to autonomy, by G. A. Scharader, Jr.--The influence of the later Wittgenstein on American philosophy, by J. O. Nelson.--Philosophy of mind, by F. H. Donnell, Jr.--Some remarks on the philosophy of language, by J. A. Fodor.--Ethics in the United States today, by D. Kading.--Social philosophy; philosophy of (...) social science, by P. Diesing. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:248 HISTORY OF PHILOSOPHY be taken from a philosophical point of view. Since it is not certain whether the author of the Prolegomena was or was not a Christian (p. xlix), "god" should not be capitalized, and the translation of T&~ia 5~l~ttovo'f~l~taTa as "God's creation" at IV. 15. 6 is actually misleading. Moreover, for no apparent reason, 0~oX07tz6gis translated as "metaphysical" in the first four chapters, but as "theological" (...) thereafter. Inaccuracies are very few indeed. "Ungrateful" is peculiar for o~5~5t• at I. 2. 25, and so is "adapted state" for ~to~tTe[a~ ~no~ae0g at I. 5.35; X. 26. 38, 40, and 44; at II. 10. 11, there is no need to translate o~Te&0t~6)g bu~yovxctL as "they do not aim at accurate expression," and on p. 32, line 1, "as yet" is not in the Greek of the Prolegomena, although it should have been, if the Anonymous had quoted correctly from Plato, Phaedrus 229 E. But this is trifling criticism of a work which leaves nothing to be desired in any other respect, and which displays the same high qualities of scholarship which we have come to expect of the author on the basis of his earlier achievements. MARTIN OSTWALI) Swarthmore College The Fountain of Life (Fons Vitae). By Solomon ibn Gabirol (Avicebron). Specially abridged edition, translated from the Latin by Harry E. Wedeck, with an Introduction by Theodore E. James. (New York: Philosophical Library, 1962. Unpaged introduction, 133 pp. $4.75.) The romance of the nineteenth-century discovery, by Salomon Munk, that "Avicebron's" Fons Vitae, a major source of neoplatonic thought in the thirteenth and fourteenth centuries, was actually the work of the eleventhcentury Hispano-Jewish poet, Solomon ibn Gabirol, and has often been retold. It is, indeed, a remarkable story. Perhaps its most noteworthy feature is that it reveals how closely alike Muslim, Jewish, and Christian philosophers were; by implication, then, it indicates that theological considerations were of less importance in medieval philosophy than is suggested by most historical accounts. Although the story of The Fountain of Lqe has now become an oft-told tale, the work itself has never been available in English dress. The present edition remedies this situation in part. It presents Tract III of the original text, a section dealing with the existence of simple spiritual substances. Harry Wedeck's translation is lucid and readable. Theodore E. James's introduction is useful for the beginning student but too elementary to be of much use to a more advanced reader. It is good that there is now this much to recommend to our students; we may hope that the day will come when BOOK REVIEWS 249 larger sections of the work will be translated-preferably not from the Latin, but from the Arabic original. JOSEPHL. B~u Columbia University Commentary on the Metaphysics of Aristotle. By St. Thomas Aquinas. Trans. by John P. Rowan. (Chicago, Illinois: Henry Regnery Company, 1961. Pp. xxiii + 955.2 vols., boxed, $25.00.) Generally speaking, the two Summae of St. Thomas, long available in English translation, contain all that is most personal and most profound in his philosophical thought. Nonetheless, it is quite impossible to get a fully adequate conception of St. Thomas' place in the history of western thought from a consideration of his theological writings alone. Hence, by translating St. Thomas' Commentary on the Metaphysics of Aristotle into English, Professor J. P. Rowan has provided the non-Latin reading student of the history of philosophy an invaluable service. For it is in his r61e as Aristotelian commentator that we see St. Thomas creating for the Schoolmen a version of Aristotle which served to render the Stagirite's thought into terms which became fundamental to the philosophical defense of Christianity. Further, by keeping in mind the fully-developed notions of St. Thomas on the existence of God and the nature of being as these are given us to understand in the Summae, the reader becomes better enabled, by a critical reading of Thomas' Commentary, to grasp the sense in which the Saint's theological writings are said by his enthusiasts to represent a "completing" and "perfecting" of... (shrink)

Self- Deception in General "A Liberal Decalogue" suggests (Russell, 1967, pp. 60-61) not to envy people who live in a fool's paradise: It is a place only for fools. This saying invites detailed commentary. A fool's paradise is not a place, but a state o f mind; it is a system of opinions, of assessments of situations, that calms one down, that reassures one into the opinion that all is well, even when all is far from well. Fools may be (...) ignorant of the severity of their situations, perhaps because being well informed tends to get them into a panic. This happens regularly, and there is little that can be done about it, except that the wise would still prefer to be well informed so as to try to cope with the panic more constructively. They would not easily fa ll for the reassuring hypothesis, preferring to examine any reasonable alternative hypothesis about any risk that might invite action - - so that if the hypothesis is corroborated they can try to mobilize some appropriate action. (shrink)

We study reals with infinitely many incompressible prefixes. Call $A \in 2^{\omega}$ Kolmogorot random if $(\exists^{\infty}n) C(A \upharpoonright n) \textgreater n - \mathcal{O}(1)$ , where C denotes plain Kolmogorov complexity. This property was suggested by Loveland and studied by $Martin-L\ddot{0}f$ , Schnorr and Solovay. We prove that 2-random reals are Kolmogorov random. Together with the converse-proved by Nies. Stephan and Terwijn [11]-this provides a natural characterization of 2-randomness in terms of plain complexity. We finish with a related characterization of 2-randomness.

La cuestión de si los lenguajes intensionalesson más expresivos que los lenguajes nointensionalessurge en el marco de unaperspect i va semánt i ca de l as t eorí as.Desde esta perspectiva, la cuestión esesta. ¿Hay clases modelo que se puedencaracterizar mediante teorías que usanconceptos intensionales que no se puedencaracterizar mediante teorías que no usanconceptos intensionales? Se sugiere unaformulación precisa de esta cuestión, perono se ofrece una respuesta.Para aproxi marse a est a cuest i ón, seresume la teoría de modelos de (...) primerorden [II] y se revisa el enfoque semánticode las teorías que emplea incrementost eóri cos, no i nt ensi onal es, de pri merorden [III].Los i nc r e me nt os t e ór i c os de pr i me rorden se bosquejan pero no se definenr i g u r o s a me n t e [ I V] . E s t e l e n g u a j ei n t e n s i o n a l pr o po r c i o n a e l a p a r a t op a r a a t r i b u i r u s o d e l l e n g u a j e yact i t udes i nt ens i onal es a i ndi vi duoscuyo comportami ento es el obj eto deinvestigación. También proporciona elaparato para habl ar sobre traducci óndel lenguaj e atribuido al lenguaj e delinvestigador.La cuestión inicial se convierte entoncesen si hay clases modelo que se puedanc a r a c t e r i z a r me d i a n t e i n c r e me n t o sintencionales de lógica de primer ordenq ue n o pue de n s e r c a pt ur a do s po rincrementos teóricos no-intensionales [V].The ques t i on of whet her i nt ens i onallanguages are more expressive than nonintensional languages is raised within the framework of a semantic view of theories. Fromthis perspective, the question isthis. Are there model classes that can becharacterized by theories using intensionalconcepts that cannot be characterizedby theories that do not use intensionalconcepts? A precise formulation of thisquestion is suggested, but no answer isgiven.To approach this question, model theory offirst order theories is summarized [II] andthe semantic approach to theories usingnon-intensional, theoretical augmentationsof first order theories is reviewed [III].I n t e n s i o n a l a u g me n t a t i o n s o f f i r s torder theories are sketched [IV] but notr i gor ous l y de f i ne d. Thi s i nt e ns i onall anguage provi des t he apparat us f orattributing language use and intensionalattitudes to individuals whose behavioris the object investigation. It also providesapparatus for talking about translationf r om t he at t r i but e d l anguage t o t heinvestigator’s language.T h e i n i t i a l q u e s t i o n t h e n b e c o me swhet her t here are model cl asses t hatc a n be c ha r a c t e r i z e d by i nt e ns i ona laugmentations of first order logic thatcannot be captured by non-intensionaltheoretical augmentations [V]. (shrink)

We show that the Turing degrees are not sufficient to measure the complexity of continuous functions on [0, 1]. Computability of continuous real functions is a standard notion from computable analysis. However, no satisfactory theory of degrees of continuous functions exists. We introduce the continuous degrees and prove that they are a proper extension of the Turing degrees and a proper substructure of the enumeration degrees. Call continuous degrees which are not Turing degrees non-total. Several fundamental results are proved: a (...) continuous function with non-total degree has no least degree representation, settling a question asked by Pour-El and Lempp; every non-computable f $\epsilon \mathcal{C}[0, 1]$ computes a non-computable subset of $\mathbb{N}$ ; there is a non-total degree between Turing degrees $a _\eqslantless_{\tau}$ b iff b is a PA degree relative to a; $\mathcal{S} \subseteq 2^{\mathbb{N}}$ is a Scott set iff it is the collection of f-computable subsets of $\mathbb{N}$ for some f $\epsilon \mathcal{C}[O, 1]$ of non-total degree; and there are computably incomparable f, g $\epsilon \mathcal{C}[0, 1]$ which compute exactly the same subsets of $\mathbb{N}$ . Proofs draw from classical analysis and constructive analysis as well as from computability theory. (shrink)

Spiritualist ethics: The problem of evil, by L. Lavelle. On conscience, or On the pain of having-done-it, by V. Jankélévitch. Value and immortality; and, Dangerous situation of ethical values, by G. Marcel. The concept of fallibility, by P. Ricoeur.--Axiological ethics: Ethics and metaphysics, by R. Le Senne. Good and evil, by H. Reiner. Values and truths, by R. Polin. Values as principles of action, by G. Gusdorf.--Three contemporary conceptions of humanism: Jean-Paul Sartre: Sartre on humanism, by J. J. Kockelmans. Moral (...) perspectives in Sartre's thought, by F. Jeanson. Ambiguity, by S. de Beauvoir. Albert Camus: Albert Camus and the ethic of absurdity, by H. Hochberg. On humanism, by M. Heidegger. Existentialism's basic ethical position, by O. Bollnow.--Situation ethics: Systematic essentialist ethics and existential situation ethics, by T. Steinbüchel. The question of the Single One, by M. Buber. What is a Christian ethic? By D. Bonhoeffer. Meaning and analysis of the borderline situation, by H. Thielicke. (shrink)

Self, Language, and World: Problems from Kant, Sellars, and Rosenberg Edited by James R. O'Shea and Eric M. Rubenstein Introduction KANT Willem deVries, Kant, Rosenberg, and the Mirror of Philosophy David Landy, The Premise That Even Hume Must Accept LANGUAGE AND MIND William G. Lycan, Rosenberg On Proper Names Douglas Long, Why Life is Necessary for Mind: The Significance of Animate Behavior Dorit Bar-On and Mitchell Green, Lionspeak: Communication, Expression, and Meaning David Rosenthal, The Mind and Its Expression MIND AND (...) KNOWLEDGE Jeffrey Sicha, The Manifest Image: the Sensory and the Mental Bruce Aune, Rosenberg on Knowing Joseph C. Pitt, Sellarsian Antifoundationalism and Scientific Realism Matthew Chrisman, The Aim of Belief and the Goal of Truth: Reflections on Rosenberg James O’Shea, Conceptual Thinking and Nonconceptual Content: A Sellarsian Divide ONTOLOGY Anton Koch, Persons as Mirroring the World Eric M. Rubenstein, Form and Content, Substance and Stuff Ralf Stoecker, On Being a Realist About Death William G. Lycan, Biographical Remarks on Jay F. Rosenberg Scholarly Publications of Jay F. Rosenberg. (shrink)

In 1886, Nietzsche wrote: ‘I am still waiting for a philosophical doctor in the extraordinary sense of the term’: a doctor who pursues not truth, but an exceptional kind of health. Nietzsche's will to health, his theory of drive organisation, and his insistence that the philosopher put himself at risk, all work together in his overall project, which consists of taking up the very role of the highly revalued physician for whom he is waiting. Deleuze and Guattari engage this same (...) task of a revalued doctoring in the Capitalisme et Schizophrénie books, attacking the disease of oedipality and providing instructions for the deorganisation of the organism as self-cure. Offering tips on this radical treatment, they employ the figure of the hypochondriac to show how it can fail. Both Nietzsche and Deleuze and Guattari perform a revaluation of health as a condition of chronic critique, a condition that wraps itself around illness to keep itself critical. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:248 HISTORY OF PHILOSOPHY be taken from a philosophical point of view. Since it is not certain whether the author of the Prolegomena was or was not a Christian (p. xlix), "god" should not be capitalized, and the translation of T&~ia 5~l~ttovo'f~l~taTa as "God's creation" at IV. 15. 6 is actually misleading. Moreover, for no apparent reason, 0~oX07tz6gis translated as "metaphysical" in the first four chapters, but as "theological" (...) thereafter. Inaccuracies are very few indeed. "Ungrateful" is peculiar for o~5~5t• at I. 2. 25, and so is "adapted state" for ~to~tTe[a~ ~no~ae0g at I. 5.35; X. 26. 38, 40, and 44; at II. 10. 11, there is no need to translate o~Te&0t~6)g bu~yovxctL as "they do not aim at accurate expression," and on p. 32, line 1, "as yet" is not in the Greek of the Prolegomena, although it should have been, if the Anonymous had quoted correctly from Plato, Phaedrus 229 E. But this is trifling criticism of a work which leaves nothing to be desired in any other respect, and which displays the same high qualities of scholarship which we have come to expect of the author on the basis of his earlier achievements. MARTIN OSTWALI) Swarthmore College The Fountain of Life (Fons Vitae). By Solomon ibn Gabirol (Avicebron). Specially abridged edition, translated from the Latin by Harry E. Wedeck, with an Introduction by Theodore E. James. (New York: Philosophical Library, 1962. Unpaged introduction, 133 pp. $4.75.) The romance of the nineteenth-century discovery, by Salomon Munk, that "Avicebron's" Fons Vitae, a major source of neoplatonic thought in the thirteenth and fourteenth centuries, was actually the work of the eleventhcentury Hispano-Jewish poet, Solomon ibn Gabirol, and has often been retold. It is, indeed, a remarkable story. Perhaps its most noteworthy feature is that it reveals how closely alike Muslim, Jewish, and Christian philosophers were; by implication, then, it indicates that theological considerations were of less importance in medieval philosophy than is suggested by most historical accounts. Although the story of The Fountain of Lqe has now become an oft-told tale, the work itself has never been available in English dress. The present edition remedies this situation in part. It presents Tract III of the original text, a section dealing with the existence of simple spiritual substances. Harry Wedeck's translation is lucid and readable. Theodore E. James's introduction is useful for the beginning student but too elementary to be of much use to a more advanced reader. It is good that there is now this much to recommend to our students; we may hope that the day will come when BOOK REVIEWS 249 larger sections of the work will be translated-preferably not from the Latin, but from the Arabic original. JOSEPHL. B~u Columbia University Commentary on the Metaphysics of Aristotle. By St. Thomas Aquinas. Trans. by John P. Rowan. (Chicago, Illinois: Henry Regnery Company, 1961. Pp. xxiii + 955.2 vols., boxed, $25.00.) Generally speaking, the two Summae of St. Thomas, long available in English translation, contain all that is most personal and most profound in his philosophical thought. Nonetheless, it is quite impossible to get a fully adequate conception of St. Thomas' place in the history of western thought from a consideration of his theological writings alone. Hence, by translating St. Thomas' Commentary on the Metaphysics of Aristotle into English, Professor J. P. Rowan has provided the non-Latin reading student of the history of philosophy an invaluable service. For it is in his r61e as Aristotelian commentator that we see St. Thomas creating for the Schoolmen a version of Aristotle which served to render the Stagirite's thought into terms which became fundamental to the philosophical defense of Christianity. Further, by keeping in mind the fully-developed notions of St. Thomas on the existence of God and the nature of being as these are given us to understand in the Summae, the reader becomes better enabled, by a critical reading of Thomas' Commentary, to grasp the sense in which the Saint's theological writings are said by his enthusiasts to represent a "completing" and "perfecting" of... (shrink)

It is widely believed that philosophical pessimism is committed to fatalism about the sufferings that characterize the human condition, and that it encourages resignation and withdrawal from the political realm in response. This paper offers an explanation for and argument against this perception by distinguishing two functions that pessimism can serve. Pessimism’s skeptical mode suggests that fundamental cross-cultural constraints on the human condition bar us from the good life (however defined). These constraints are often represented as immune to political amelioration, (...) leading to the perception that pessimism is intrinsically fatalistic and resigned. Yet pessimism’s critical function emphasizes the political, economic, and cultural contingency of many sources of suffering and crisis while exhorting us to reject and reimagine the social forces that actively harm our capacity to flourish. It also offers an internal critique of skeptical pessimism’s tendency to naturalize and depoliticize the sources of our sufferings. These sometimes contradictory skeptical and critical tendencies should both be grouped under the pessimist banner, and we should see pessimism’s critical mode as especially valuable to political critique. -/- . (shrink)

Memory sometimes yields knowledge and sometimes does not. It is, however, natural to suppose that i f a man remembers that p, then he knows that p and formerly knew that p. Remembering something is plausibly construed as a f o rm of knowing something which one has not forgotten and which one knew previously. We argue, to the contrary, that this thesis is false. We present four counterexamples to the thesis that support a different analysis of remembering. We propose (...) that a person remembers that p (at t) if and only if the thought or conviction that p comes from memory (at t) when, in fact, it is true that p. (shrink)

PHOTO ID 121339257© Designer491| Dreamstime.com ABSTRACT When physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be apparent conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters future physicians’ commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. We use an ethical dilemma that was presented to a group of third-year medical students to examine how ethics education might be causing (...) them to give undue deference to autonomy, thereby undermining their commitment to beneficence. INTRODUCTION The right of patients to choose which treatments they prefer is rooted in today’s social mores and taught as a principle of medical ethics as respect for autonomy. Yet, when physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be a conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters a commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. I. An Ethical Dilemma The impetus for this paper arose when students who were completing their third clinical year discussed a real-life ethical dilemma. A middle-aged man developed a pulmonary hemorrhage while on blood thinners for a recently placed coronary stent. The bleeding was felt to be reversible, but the patient needed immediate intubation or he would die. The cardiologist was told that the patient previously expressed to other physicians that he never wanted to be intubated. However, the cardiologist made the decision to intubate the patient anyway, and the patient eventually recovered.[1] Students were asked if they believed that the cardiologist had acted ethically. Their overwhelming response was, “No, the patient should have been allowed to die.” We looked into how students applied ethical reasoning to conclude that this outcome was ethically preferred. To explore how the third-year clinical experience might have formed the students’ judgment, we presented the same case to students who were just beginning their third year. Their responses were essentially uniform in recommending intubation. While there is likely more than one reasonable view in this case, we agree with the physician and the younger medical students that intubation was the ethically appropriate decision and will present an argument for it. But first, we explain the reasoning behind the more advanced medical students’ decision to choose patient autonomy at the expense of beneficence. II. Medical Ethics Education and the Priority of Autonomy Beauchamp and Childress’s Principles of Biomedical Ethics, first published in 1979 and now in its 8th edition, is a significant part of the formal ethics education in medical school.[2] Students learn an ethical decision-making approach based on respect for four ethical principles: autonomy, beneficence, nonmaleficence, and justice. While Beauchamp and Childress officially afford no prima facie superiority to any principle, the importance of respect for patient autonomy has increased through the editions of their book. For example, early editions of their book opposed the legalization of physician-assisted death compared to recent editions that defended it.[3] As another example, Beauchamp and Childress make paternalism harder to justify by adding an autonomy-protecting condition to the list of conditions for acceptable paternalism.[4] Authority, they contend, need not conflict with autonomy—provided the authority is autonomously chosen.[5] “The main requirement,” they write, “is to respect a particular patient’s or subject’s autonomous choices, whatever they may be.[6] In the principlism of Beauchamp and Childress, autonomy now seems to have a kind of default priority.[7] However, the bioethics discourse has strong counternarratives, noting some movement to elevate the role of beneficence and to respect the input of stakeholders, including the family and the healthcare team. Ethics education achieves particular relevance in the third clinical year when students become embedded in the care of patients and learn from what has been called the informal curriculum. They observe how attending physicians approach day-to-day ethical problems at the patient’s bedside. In this context, students observe the importance of informed consent for serious treatments or invasive procedures, a practice that highlights the principle of patient autonomy. In both the formal and informal curriculum, medical students observe how, in the words of Paul Wolpe, “patient autonomy has become the central and most powerful principle in ethical decision-making in American medicine.”[8] In short, students appear to learn a deference for patient autonomy. This curricular shift in favor of autonomy coincides with legal developments that protect patients’ rights and decision-making with respect to their healthcare choices. The priority of autonomy in medicine benefits patients by reflecting their choices and, in some cases, their fundamental liberty. III. The Practice of Medicine and the Commitment to Beneficence There are many critiques of the dominant place that autonomy has in biomedical ethics,[9] especially considering that autonomy seems to be biased toward individualistic, Western, and somewhat American culture-driven values.[10] In addition, many bioethical dilemmas are cast as a conflict between autonomy and beneficence. Our point is that medical students bring to their study of medicine a commitment to beneficence that seems to be suppressed by practical ethics education. We think this commitment is rationally defensible and should be nurtured. It is striking that young medical students have a pre-reflective commitment to beneficence at all. For, as we mentioned, it is not just medicine but Western culture generally that prioritizes autonomy in settling ethical dilemmas. In wanting to act for the good of others (rather than simply agreeing to what others want), physicians are already swimming somewhat against the cultural tide.[11] However, doing so makes sense, given the nature of medicine and the profession of healing. When prospective medical students are asked why they wish to become physicians, the usual answer is some variation on caring for the sick and preventing disease. It is unlikely that a reason to become a physician is to respect a patient’s autonomy. It would be easy to dismiss medical students’ commitment to beneficence as a mere intuition and contrary to a more reasoned and deliberative approach. Beauchamp and Childress seem to minimize the value of physician intuition, stating that justifications for certain procedures are “…supported by good reasons. They need not rest merely in intuition or feeling.”[12] Henry Richardson writes that “situational or perceptive intuition…leaves the reasons for decision unarticulated.”[13] We think this is a crude and rather thin way of understanding intuition. Some bioethicists have defended intuition as essential to the practice of medicine and not something opposed to reason.[14] In the case we describe, we believe the ethical justifications s for the patient’s intubation are fundamentally sound: the patient did not have a “do not intubate” order written in the chart, the emergency intubation had not been foreseen, so the patient did not have the opportunity to consent to or reject intubation; the patient had consented to the treatment for his cardiac disease so his consent for intubation could have been assumed;[15] and the consequences of respecting his autonomy did not justify allowing him to die.[16] While it is possible to have more than one reasonable view on this case, we think the case for beneficence is strong and certainly should not be dismissed out of hand. We do not deny that if a patient makes a clearly documented, well-informed decision to forgo intubation that this decision ought to be respected by the physician (even if the physician disagrees with the patient’s decision). But, in this situation, as in many others in the practice of medicine, the patient’s real wishes and preferences are not well-articulated in advance. There are many cases where a physician acts based on what she believes the patient, or the surrogate, would want, sometimes in situations that do not allow much time for reflection. An example might be resuscitation of a newborn at the borderline of viability. In their ethics education, beneficence would mean acting first to save a life. If the patient or surrogate makes an informed decision to the contrary, a beneficent physician respects that autonomous decision. In the case presented, the patient expressed gratitude to the cardiologist when extubated. But what if he had expressed anger at the physician for violating his autonomy? There are those who could argue that not only was intubation ethically wrong but that the cardiologist put himself in legal jeopardy by his actions (especially if there had been a written refusal applicable to the specific situation). In the example we use, we point out that the cardiologist may not have escaped a lawsuit if the patient had died without intubation. His family, when hearing the circumstances, may have sued for failure to act and dereliction of the cardiologist’s duty to save him. Beyond a potential legal challenge for either action or inaction, there is an overriding ethical question the cardiologist had to address: what course would be most satisfying to his conscience? Would he rather allow a patient to die for fear of recrimination, or act to save his life, regardless of the personal consequences? In the absence of real knowledge about the patient’s considered wishes, it is most reasonable to err on the side of promoting patient well-being. A physician’s commitment to beneficence is not necessarily a way of undermining a patient’s autonomy. In acting for the patient's good, physicians are also acting on what it is reasonable to believe a patient (or most patients, perhaps) would want, which is obviously connected to what a patient does want. Pellegrino and Thomasma argue that beneficence includes respect for a patient’s autonomy since “the best interests of the patient are intimately linked with their preferences.”[17] Instead of conceptualizing ethical dilemmas in medicine as conflicts between autonomy and beneficence, it is possible that medical schools could teach students that truly practicing beneficence is a way of valuing patient autonomy, especially when the patient’s wishes are not specific to the situation and are not clearly expressed. CONCLUSION It is important for students and practicing physicians to understand the principle of respect for patient autonomy in a pluralistic society that demands personal self-determination. However, the role of the physician as a beneficent healer should not be diminished by this respect for autonomy. Respecting a patient’s autonomy is grounded in and manifested by physician beneficence.[18] That is, seeking what is good for the patient can only be good if it respects their personhood and dignity. We propose that a commitment to beneficence, incipient in young medical students, should be developed over time with their other clinical reasoning skills. Such a commitment need not be sacrificed on the altar of patient autonomy. Beneficence needs greater relative moral weight with students as they proceed in their ethics education. - [1] S. Jauhar, “When Doctors Need to Lie,” New York Times, February 22, 2014, https://www.nytimes.com/2014/02/23/opinion/sunday/when-doctors-need-to-lie.html. [2] T. L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019). [3] Louise A. Mitchell, “Major Changes in Principles of Biomedical Ethics,” The National Catholic Bioethics Quarterly 14, no. 3 (2014): 459–75, https://doi.org/10.5840/ncbq20141438. [4] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019), 238. [5] Beauchamp and Childress, 103. [6] Beauchamp and Childress, p. 108. [7] For other accounts that prioritize autonomy, see e.g. Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of Surrogate Decision Making (Cambridge University Press, 1989), 38–39; R Gillon, “Ethics Needs Principles—Four Can Encompass the Rest—and Respect for Autonomy Should Be ‘First among Equals,’” Journal of Medical Ethics 29, no. 5 (October 2003): 307–12, https://doi.org/10.1136/jme.29.5.307. For examples of critiques of these accounts, see footnote 9. [8] P. R. Wolpe, “The Triumph of Autonomy in American Bioethics: A Sociological View,” in Bioethics and Society: Constructing the Ethical Enterprise, p. 43. [9] V. A. Entwistle et al., “Supporting Patient Autonomy: The Importance of Clinician-Patient Relationships,” Journal of General Internal Medicine 25, no. 7 (July 2010): 741–45; C. Foster, Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law, 1st ed. (Oxford ; Hart Publishing, 2009); O. O’Neill, Autonomy and Trust in Bioethics, The Gifford Lectures, University of Edinburgh 2001 (Cambridge, UK: Cambridge University Press, 2002). [10] P. Marshall and B. Koenig, “Accounting for Culture in a Globalized Bioethics,” The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics 32, no. 2 (2004): 252–66; R. Fan, “Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy,” Bioethics 11, no. 3–4 (1997): 309–22. [11] Arguments stressing the importance of beneficence, as ours does here, certainly approach paternalistic arguments. We set aside the complex issue of paternalism for purposes of this paper and simply note that the principle of beneficence as such does not say anything specifically about acting against the patient’s will. In the case study that focuses this paper, we do not believe the patient’s will or wishes were clearly indicated. [12] Beauchamp and Childress, Principles of Biomedical Ethics, p. 20, see note 2 above. [13] H. S. Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 25, no. 3 (January 1, 2000): 285–307, p. 287. [14] H. D. Braude, Intuition in Medicine a Philosophical Defense of Clinical Reasoning (Chicago ; University of Chicago Press, 2012). [15] R. Kukla, “Conscientious Autonomy: Displacing Decisions in Health Care,” The Hastings Center Report 35, no. 2 (2005): 34–44. [16] M. Schermer, The Different Faces of Autonomy: Patient Autonomy in Ethical Theory and Hospital Practice, vol. 13, Library of Ethics and Applied Philosophy (Dordrecht: Springer Netherlands, 2002). [17] E. D. Pellegrino and D. C. Thomasma, For the Patient’s Good - the Restoration of Beneficence in Health Care (New York, NY: Oxford University Press, 1988), p. 29. [18] Pellegrino and Thomasma, For the Patient’s Good. 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Evidence that an animal is capable of some degree of symbolic, human language processing supports the argument that the animal's consciousness is to some degree human-like. In this paper, we reinterpret the findings of Savage- Rumbaugh et al. using the twin tools of Deacon's referential hierarchy and Systemic Functional Linguistics, with a view to providing further corroborative evidence for a Bonobo ape's symbolic processing abilities, and as a result to open a window into the consciousness of at least one non-human (...) primate. (shrink)

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Memory sometimes yields knowledge and sometimes does not. It is, however, natural to suppose that i f a man remembers that p, then he knows that p and formerly knew that p. Remembering something is plausibly construed as a f o rm of knowing something which one has not forgotten and which one knew previously. We argue, to the contrary, that this thesis is false. We present four counterexamples to the thesis that support a different analysis of remembering. We propose (...) that a person remembers that p (at t) if and only if the thought or conviction that p comes from memory (at t) when, in fact, it is true that p. (shrink)

This is a new edition of Joseph Fletcher's 1966 work that ignited a firestorm of controversy at the time of its publication.