Physicians generally recommend that patients resuscitated with naloxone after opioid overdose stay in the emergency department for a period of observation in order to prevent harm from delayed sequelae of opioid toxicity. Patients frequently refuse this period of observation despiteenefit to risk. Healthcare providers are thus confronted with the challenge of how best to protect the patient’s interests while also respecting autonomy, including assessing whether the patient is making an autonomous choice to refuse care. Previous studies have shown that physicians (...) have widely divergent approaches to navigating these conflicts. This paper reviews what is known about the effects of opioid use disorder on decision-making, and argues that some subset of these refusals are non-autonomous choices, even when patients appear to have decision making capacity. This conclusion has several implications for how physicians assess and respond to patients refusing medical recommendations after naloxone resuscitation. (shrink)

The COVID-19 pandemic that struck New York City in the spring of 2020 was a natural experiment for the clinical ethics services of NewYork-Presbyterian (NYP). Two distinct teams at NYP’s flagship academic medical centers—at NYP/ Columbia University Medical Center (Columbia) and NYP/ Weill Cornell Medical Center (Weill Cornell)—were faced with the same pandemic and operated under the same institutional rules. Each campus used time as an heuristic to analyze our collective response. The Columbia team compares consults during the pandemic with (...) the same period during the year prior. The Weill Cornell service describes the phases of the pandemic to depict its temporal evolution and subsequent ethical challenges. Both sites report that the predominant ethical challenges centered around end-of-life decision making, setting goals of care, and medical futility, all complicated by resource allocation questions and the ambiguity of state law under crisis standards of care. The Columbia campus saw a statistically significant increase in ethics consultations provided to Hispanic patients, perhaps reflective of the disproportionate burden of COVID-19 suffered by this demographic. While Weill Cornell and Columbia saw a surge in clinical ethics consultations, the two services assumed a more expansive role than one normally played in institutional life. Serving as intermediaries between frontline clinicians and senior hospital administrators, consultants provided critical intelligence to hospital leadership about the evolution of the pandemic, disseminated information to clinicians, and attended to the moral distress of colleagues who were asked to provide care under truly extraordinary circumstances. The COVID-19 surge in New York City revealed latent capabilities in ethics consultation that may prove useful to the broader clinical ethics community as it responds to the current pandemic and reconceptualizes its potential for future service. (shrink)

From mid-March through May 2020, New York City was the world’s epicenter of the COVID-19 pandemic, and its hospitals faced an unparalleled surge of patients who were critically ill with the virus. In addition to putting an enormous strain on medical resources, the pandemic presented many ethical issues to emotionally and physically stressed clinicians and hospital administrators. Analyses of the challenges faced by the ethics consultation services of the two campuses of New York Presbyterian Hospital, and how they assisted their (...) clinician and administrative colleagues, is the subject of the following four articles. (shrink)

Behavior, language, development, identity, and science—all of these phenomena are commonly characterized as 'social' in nature. But what does it mean to be 'social'? Is there any intrinsic 'mark' of the social shared by these phenomena? In the first book to shed light on this foundational question, twelve distinguished philosophers and social scientists from several disciplines debate the mark of the social. Their varied answers will be of interest to sociologists, anthropologists, philosophers, psychologists, and anyone interested in the theoretical foundations (...) of the social sciences. (shrink)

Responding to volatile criticisms frequently leveled at Leo Strauss and those he influenced, the prominent contributors to this volume demonstrate the profound influence that Strauss and his students have exerted on American liberal democracy and contemporary political thought. By stressing the enduring vitality of classic books and by articulating the theoretical and practical flaws of relativism and historicism, the contributors argue that Strauss and the Straussians have identified fundamental crises of modernity and liberal democracy.

In response to national trends calling for increasing accountability and an emerging dialogue within bioethics, we describe an effort to credential clinical ethicists at a major academic medical center. This effort is placed within the historical context of prior calls for credentialing and certification and efforts currently underway within organized bioethics to engage this issue. The specific details, and conceptual rationale, behind the New York-Presbyterian Hospital’s graduated credentialing plan are shared as is their evolution and ratification within the context of (...) institutional policy. While other programs will design their credentialing schema consistent with their local context and demographics, the description of one such effort is offered to be instructive to others who want to bring additional standardization to the assessment of the readiness and credentials of those who will engage in the practice of clinical ethics case consultation. (shrink)

Some properties are discussed of regular polygons that may result from angular homeostatic processes in stable orbit. To characterize these homeostatic polygons we need to discuss the winding number, the sidedness (integer, fractional and irrational), multiplicity, envelopes, and density. A regular (i.e., equilateral, equiangular) polygon may be closed in one revolution about its unique center, in multiple revolutions, or not at all. A homeostatic polygon can be generated only if all vertices are included in a single polygon, which occurs if (...) and only if the number of vertices and the number of revolutions required to complete the polygon are relatively prime. For the homeostatic polygon to have a finite number of sides (without repeating itself) the angle subtended by any two successive vertices at the center must be a rational multiple of 2. Biological implications of these properties are illustrated. (shrink)

This collection of essays, offered in honor of the distinguished career of prominent political philosophy professor Clifford Orwin, brings together internationally renowned scholars to provide a wide context and discuss various aspects of the virtue of “humanity” through the history of political philosophy.

This collection of essays, offered in honor of the distinguished career of prominent political philosophy professor Clifford Orwin, brings together internationally renowned scholars to provide a wide context and discuss various aspects of the virtue of “humanity” through the history of political philosophy.

Moral leadership matters. As world politics enters a new and dangerous era, judgment, constancy, moral purpose, and a willingness to overcome partisan politicking are essential for America's leaders. Tempered Strength finds the alternative standard of leadership that Americans are seeking in the classical philosophy of prudence. Ethan Fishman's new work brings together leading American political scientists—including Ronald Beiner, Kenneth L. Deutsch, and George Anastaplo—to discuss the evolution of a standard of prudential leadership both reasonable in nature and practical in (...) scope. Section One studies the meaning of prudence and its evolution in the history of political science from Aristotelian phronesis to Xenophon, Thomas Aquinas, Edmund Burke, and Michael Oakeshott. Section Two demonstrates how the theory of prudential leadership can be applied to practical political issues. (shrink)

In ‘(Really) Defending Exclusionary Reasons’, Monti seeks to defend Raz’ notion of exclusionary reasons from the attack made by Daniel Whiting. Monti agrees with Whiting that exclusionary reasons cannot motivate and so suggests that they operate by guiding rather than motivating. However, Monti’s account of guiding omits the key feature that they can guide even when one’s action is the opposite to what the exclusionary reason seems to recommend. An amended account of what it is to be guided by exclusionary (...) reasons is needed to give the Razian account the explanatory power it is due. (shrink)

If medical complicity is understood as compliance with a directive to act against the professional's best medical judgment, the question arises whether it can ever be justified. This paper will trace the contours of what would legitimate a directive to act against a professional's best medical judgment (and in possible contravention of her oath) using Joseph Raz's service conception of authority. The service conception is useful for basing the legitimacy of authoritative directives on the ability of the putative authority (...) to enable subjects to comply better with reasons that already apply to them. Hence, the service conception bases the legitimacy of practical authority on a certain kind of greater knowledge or expertise. This helps to focus the conundrum regarding complicity on the clash of expertise between the medical expert and the governing body tasked with coordinating behaviour and otherwise devising rules for the social good. The ethical dilemma presented by a hypothetically legitimate directive to act against a professional's best medical judgment also serves to highlight the moral dimension of one's duty to obey a legitimate authority. (shrink)

I examine the impact of the presence of anarchists among key legal officials upon the legal positivist theories of H.L.A. Hart and Joseph Raz. For purposes of this paper, an anarchist is one who believes that the law cannot successfully obligate or create reasons for action beyond prudential reasons, such as avoiding sanction. I show that both versions of positivism require key legal officials to endorse the law in some way, and that if a legal system can continue to (...) exist and function when its key officials reject the reason-giving character of law, then we have a reason to re-examine and amend legal positivism. (shrink)

Joseph Raz argues that legal authority includes a claim by the law to replace subjects’ contrary reasons. I reply that this cannot be squared with the existence of choice-of-evils defenses to criminal prosecutions, nor with the view that the law has gaps (which Raz shares). If the function of authority is to get individuals to comply better with reason than they would do if left to their own devices, it would not make sense for law to claim both to (...) pre-empt our contrary reasons and to leave open spaces or catch-all exceptions which we must use our own devices to fill. (shrink)

In an earlier Dissecting Bioethics contribution, Debra J. H. Mathews, Joseph J. Fins, and Eric Racine challenge standard ways of thinking about the therapeutic misconception in the context of consent for research participation. They propose that instead of demanding “rational congruence” between how researchers and participants conceive of a given protocol, we should accept a less stringent standard of “reasonable coherence.” While Mathews, Fins, and Racine (MFR) provide some important insights, their proposal needs refinement. There is room for a (...) wide but not unlimited range of participant hopes and motivations. However, their model of reasonable coherence is too weak a standard for whether participants have adequate understanding of the scientific goals of a protocol. By the time participants are recruited for medical research, the goals of the protocol, having been set and agreed to through accepted scientific processes, are no longer open for alternate interpretations. This paper discusses this and other objections to MFR’s proposal. It then suggests that a concept of “deal breakers” might be useful in this context. (shrink)

This paper guides the reader through the use of functions in contemporary legal philosophy: in developing those philosophies and through methodological debates over their proper role. This paper is broken into two sections. In the first I canvass the role of functions in the legal philosophies of several mid to late twentieth century Anglo-American general jurisprudents whose theories are still common topics of discussion: Ronald Dworkin, H.L.A. Hart, Lon L. Fuller, John Finnis, and Joseph Raz. In the second, I (...) examine contemporary arguments over the role of functions in the methodology of legal philosophy. (shrink)

Joseph Raz's famous theory of authority is grounded in three claims about the nature and justification of authority. According to the Preemption Thesis, authoritative directives purport to replace the subject's judgments about what she should do. According to the Dependence Thesis, authoritative directives should be based on reasons that actually apply to the subjects of the directive. According to the Normal Justification Thesis (NJT), authority is justified to the extent that subjects are more likely to comply with right reason (...) by following the authority's directives than by following their own judgments about what right reason requires.1In this article, I consider a number of ways in which NJT might be construed as a justification for authority. First, I evaluate NJT construed as a principle that would provide a practical justification for an individual to accept or recognize a particular person or persons as a preemptive authority. Second, I evaluate NJT construed as a principle that describes the conditions under which a state or legal system is morally legitimate. I argue that NJT is true under none of these interpretations.2. (shrink)