A predominant ethical view holds that physician‐investigators should conduct their research with therapeutic intent. And since a physician offering a therapy wouldn't prescribe second‐rate treatments, the experimental intervention and the best proven therapy should appear equally effective. "Clinical equipoise" is necessary. But this perspective is flawed. The ethics of research and of therapy are fundamentally different, and clinical equipoise should be abandoned.

The doctrine of clinical equipoise is appealing because it appears to permit physicians to maintain their therapeutic obligation to offer optimal medical care to patients while conducting randomized controlled trials (RCTs). The appearance, however, is deceptive. In this article we argue that clinical equipoise is defective and incoherent in multiple ways. First, it conflates the sound methodological principle that RCTs should begin with an honest null hypothesis with the questionable ethical norm that participants in these trials should never be randomized (...) to an intervention known to be inferior to standard treatment. Second, the claim that RCTs preserve the therapeutic obligation of physicians misrepresents the patient-centered orientation of medical care. Third, the appeal to clinical equipoise as a basic principle of risk-benefit assessment for RCTs is incoherent. Finally, the difficulties with clinical equipoise cannot be resolved by viewing it as a presumptive principle subject to exceptions. In the final sections of the article, we elaborate on the non-exploitation framework for the ethics clinical research and indicate issues that warrant further inquiry. (shrink)

To the French critics who originally labelled certain films noir it seemed that a class of Hollywood products had gone darker during the war years – as though a dark filter had been placed over the lens. Films were not designed or marketed as noir, and retrospectively noir's status as a genre is still unsettled. Yet there is widespread interest today in experiencing diverse films as noir, and even in using a Noir Filter in Instagram and video games. Pursuing the (...) filter clue, the noir experience can be thought of as subjection to a dark filtering of narrative. Image filtering styles can help to resolve not only the puzzle of noir's quasi-genre status but also an issue of general interest in aesthetic experience. The use of image filters makes a distinctively powerful contribution to the experience of a work or genre, or to the cultural dominance of an aesthetic regime, due to the unobtrusive formative role it plays in the economy of experience. (shrink)

Rooting, defined as a spectator’s demonstrative encouragement of a contestant’s effort, ideally has the morally positive aspects of benevolent concern and helpfulness but in practice strains against reasonable standards of conduct by being rude, excessively biased, exploitative, fanatical, and superstitious. Rooting may activate an atavistic, morally cogent sense of fighting for one’s group that is at odds with the universalism of civilized morality. The ‘merely play’ excuse can cut both ways, deflecting moral objections but also removing moral credit from rooting. (...) Although rooting is often not humane, humane rooting can occur and is supported by humane commentary by sports participants, broadcasters, and journalists. Humane rooting supports the premise of benevolence theories (Mengzi, Hutcheson) that morally ideal benevolence has a foothold in an innate general benevolence – seen in this area especially in benevolence toward efforts. Being partisan, excited, and demonstrative, rooters cannot perfectly embody ‘universal calm benevolence’, but they can consciously minimize the inhumane aspects of rooting and achieve a more fully prosocial satisfaction. (shrink)

The leading ethical position on placebo-controlled clinical trials is that whenever proven effective treatment exists for a given condition, it is unethical to test a new treatment for that condition against placebo. Invoking the principle of clinical equipoise, opponents of placebo-controlled trials in the face of proven effective treatment argue that they (1) violate the therapeutic obligation of physicians to offer optimal medical care and (2) lack both scientific and clinical merit. We contend that both of these arguments are mistaken. (...) Clinical equipoise provides erroneous ethical guidance in the case of placebo-controlled trials, because it ignores the ethically relevant distinction between clinical trials and treatment in the context of clinical medicine and the methodological limitations of active-controlled trials. Placebo controls are ethically justifiable when they are supported by sound methodological considerations and their use does not expose research participants to excessive risks of harm. (shrink)

In ancient times, when persuasion played the role of public force, eloquence was necessary. Of what use would it be today, when public force has replaced persuasion. One needs neither art nor metaphor to say such is my pleasure. Jean Jacques Rousseau.

The practice of voluntary physician‐assisted death as a last resort is compatible with doctors' duties to practice competently, to avoid harming patients unduly, to refrain from medical fraud, and to preserve patients' trust. It therefore does not violate physicians' professional integrity.

A basic question of medical ethics is whether the norms governing medical practice should be understood as the application of principles and rules of the common morality to medicine or whether some of these norms are internal or proper to medicine. In this article we describe and defend an evolutionary perspective on the internal morality of medicine that is defined in terms of the goals of clinical medicine and a set of duties that constrain medical practice in pursuit of these (...) goals. This perspective is developed by means of a critical examination of the essentialist conception of the internal morality of medicine advocated by Edmund Pellegrino and the critique of internal morality approaches by Robert Veatch and Tom Beauchamp. (shrink)

With breathtalung speed, traditional criminal prohibitions against assisted suicide have been declared unconstitutional in twelve states, including California and New York. This poses great promise and great peril. The promise is that competent terminally ill patients, as a compassionate measure of last resort, will have the option of putting an end to their suffering by physician-assisted suicide. More sigmficant, legally permitting this controversial option may be a catalyst for doctors, health care institutions, and society to improve the care of the (...) dying. PAS should be limited only to those relatively few competent patients who continue to suffer intolerably despite unrestrained efforts to palliate and who face a continued existence that they regard as worse than death. When dying patients know they will not be abandoned to miserable and pointless suffering if palliative care fails, they will be fortified to cope better with the process of dying.The immediate peril is that PAS will become a quick fix, available on demand to any patient diagnosed as terminally ill, thus bypassing palliative care and producing premature deaths. (shrink)

Despite strong growth in scientific investigation of the placebo effect, understanding of this phenomenon remains deeply confused. We investigate critically seven common conceptual distinctions that impede clear understanding of the placebo effect: (1) verum/placebo, (2) active/inactive, (3) signal/noise, (4) specific/nonspecific, (5) objective/subjective, (6) disease/illness, and (7) intervention/context. We argue that some of these should be eliminated entirely, whereas others must be used with caution to avoid bias. Clearing away the conceptual underbrush is needed to lay down a path to understanding (...) and harnessing placebo effects in clinical medicine. (shrink)

Kant’s central notion of a “causality of freedom” seems inconsistent with his theoretical analysis of causation. Because of its detachment from any reference to time, it is also seriously in tension with ordinary moral ideals of individuality, efficacy, responsiveness, and personal growth in the exercise of freedom. I suggest a way of conceiving moral freedom that avoids the absurdity of practical timelessness while preserving the main strengths of Kant’s theories of theoretical and practical meaning, including his refusal to specify the (...) content of human fulfillment. Much as Kant’s ideal of the highest good combines the supreme good of moral virtue with its necessarily desired complement of worthy happiness, a Kantian ideal of the fullest freedom can combine the transcendental freedom of the moral disposition with individual exercises of freedom in the dramatic interaction of actual moral community. (shrink)

Although Emmanuel Levinas later expressed regret that he sided with Martin Heidegger rather than the more “ideal”-minded Ernst Cassirer in their 1929 Davos encounter, Cassirer’s philosophy of culture would never have been an apt framework for Levinas’s own project, which was always directed more to fundamental orientation than to formative activities or achievements. In “Meaning and Sense” (1964), Levinas conceived a totalizing cultural “meaning” as a foil to transcendent ethical “sense.” In a 1983 paper, however, he proposed an ethical conception (...) of culture. He could have developed this further using another element from “Meaning and Sense,” an ethical conception of work as service of the Other. The work-in-progress of culture combines pure ethics and implemented morality, pure command and consistent style, infinite vulnerability and actual power. (shrink)

A historically responsible agent is willing to be somehow in practical solidarity with all other actors with whom action is shared over time. The responsible idea of a most-inclusive history encompasses future occurrence together with all that has happened already. Despite our lack of control over future developments, we assess possible future ages as bright or dark and position ourselves as contributors to multigenerational endeavors that we hope will be long-term successes in themselves and part of a larger historical optimality. (...) Informed by the evolutionary sciences, a plausible modern envisioning of the future must include evolutionary innovations and surprises on a very long time scale. The historically responsible agent will therefore take seriously efforts like Olaf Stapledon’s Last and First Men to imagine the new powers and goals of our distantly posthuman future sharers in history. (shrink)

Modern law and economics received much of its impetus from Ronald Coase's analysis in ‘The Problem of Social Cost,’ and a goodly amount of that comes from the Coase theorem, which states that, absent transaction costs, externalities will be efficiently resolved through bargaining. The fact that the analysis that came to be codified in the Coase theorem was an exercise in pure fiction on Coase's part did not deter the erection of a substantial edifice of positive and normative analysis on (...) this foundation, nor, for that matter, has subsequent elaboration of Coase's intent done anything to abate the interest in the theorem and its implications. (shrink)

Once upon a time, I attempted to create a web-based one-stop-shop for global poverty relief called the Maximin Project. Drawing on aspects of that experience, I show that although some existing ways of rating and recommending charities are significantly better than others, there remain certain challenges that need to be overcome. Specifically, I argue that the emerging Effective Altruism movement, with its emphasis on measurable effectiveness, runs the risk of neglecting a whole range of projects that are necessary for a (...) well-rounded approach to human development. I briefly model an alternative virtue-based approach that calls on the personal insight of individual researchers and practitioners in addition to the more directly experimental approach of organizations like GiveWell. (shrink)

If the mental is subject to indeterminacy, does this rule out the possibility of psychophysical laws? One might think so. However, Jaegwon Kim has argued for the existence of a kind of psychophysical law that is not obviously susceptible to problems posed by indeterminacy. I begin by introducing a weak and relatively uncontroversial indeterminacy thesis. Then, by appealing to constraints on theories of strong supervenience and to general considerations about the nature of indeterminacy, I argue that even Kim’s laws cannot (...) accommodate indeterminacy. The result is an argument against the possibility of Kim‐Style psychophysical laws. (shrink)

An original metaphysical proposal building on classical and contemporary sources. In Centering and Extending, Steven G. Smith retrieves and refashions some of the best ideas of classical and early modern metaphysics to support insight into the natures of mental and material beings and their relations. Avoiding what he critiques as distortive paths of idealism, materialism, repressive monism, and overly permissive pluralism, Smith builds his framework on centering and extending as universal principles of formation. Identifying the basic consistency of being (...) with these principles in symmetrical partnership enables a naturalist process view that, unlike Whitehead’s, does not overbalance toward the subjective and teleological and, unlike Deleuze and Guattari’s, does not overbalance toward the material and chaotic. This view supports useful conceptions of mind and matter, form and energy, reason and cause, and a layered world order without relying on a blind concept of supervenience or emergence. It also respects and reinforces a division of roles between metaphysical sense-making and spiritual determinations of meaningfulness. Steven G. Smith is Jennie Carlisle Golding Professor of Philosophy at Millsaps College. He is the author of several books, including Worth Doing, also published by SUNY Press. (shrink)

Past research has found that skin colouration, particularly facial redness, influences the perceived health and emotional state of target individuals. In the current work, we explore several extensions of this past research. In Experiment 1, we manipulated facial redness incrementally on neutral and angry faces and had participants rate each face for anger and health. Different red effects emerged, as perceived anger increased in a linear manner as facial redness increased. Health ratings instead showed a curvilinear trend, as both extreme (...) paleness and redness were rated as less healthy than moderate levels of red. Experiment 2 replicated and extended these findings by manipulating the masculinity of both angry and neutral faces that varied in redness. The results found the effect of red on perceived anger and health was moderated by masculine face structure. Collectively, these results show that facial redness has context dependent effects that vary based on facial expression, appearance, and differentially impact ratings of emotional states and health. (shrink)

A concept of merit is used for spiritual accounting in many religious traditions, seemingly a substantial point of connection between religion and ordinary morality. Teachings of “merit transfer” (as in Buddhism and Roman Catholicism) might make us doubt this connection since they violate the principle that merit must be earned. If we examine the structure of ordinary schemes of desert, however, we find that personal worth is posited for a variety of reasons; the basic requirement in this realm is not (...) earning by individuals but rather a community’s program for cultivating desirable collaboration among its members. There are strong enough parallels between religiously envisioned merit transfer and socially normal conferrals and sharings of worth that we can conclude that the religious posits of transferred merit are indeed comprehensible as merit, whatever other problems of comprehensibility they pose. (shrink)

If the mental is subject to indeterminacy, does this rule out the possibility of psychophysical laws? One might think so. However, Jaegwon Kim has argued for the existence of a kind of psychophysical law that is not obviously susceptible to problems posed by indeterminacy. I begin by introducing a weak and relatively uncontroversial indeterminacy thesis. Then, by appealing to constraints on theories of strong supervenience and to general considerations about the nature of indeterminacy, I argue that even Kim’s laws cannot (...) accommodate indeterminacy. The result is an argument against the possibility of Kim‐Style psychophysical laws. (shrink)

If, as many historians and theorists now believe, narrative is the form proper to historical explanation, this raises the problem of the terms in which such narratives are to be evaluated. Without a clear account of evaluation, the status of historical knowledge remains obscure. Beginning with the view, found in Hayden White and others, that historical narrative constitutes a meaning not reducible to the factual content it engages, this essay argues that such meaning can arise only through a synthesis of (...) cognitive and normative discourses. Narrative combines "heterogeneous" language games in such a way that neither appeal to "truth content" nor to "justice" suffices to decide the question of which of two competing historical explanations is, as a whole, superior. Examining in critical detail the opposed positions on this issue articulated by two recent theorists-Frank Ankersmit and David Carr -the paper concludes that the debate between those who hold that historical narratives should be judged in essentially cognitive terms and those who hold that they should be judged in essentially political terms cannot be resolved and that a philosophical view of historical narrative that is neither realist nor idealist needs to be developed. (shrink)

This book develops the idea that meaningfulness is specified as a relation between an acknowledged appeal and an adopted attitude. In the Axial Age classics and again in modern refoundings of philosophy and theology, ideals of a fully commanding supreme appeal and a fully adequate orientation to the world in cognizance of that appeal--a sovereign attitude--are intellectually and spiritually central. Some of the most fundamental challenges of pluralism stem from differences in appeal and attitude ideals.

Explores the basic forms of responsibility that we willingly assume and the collaborative fulfillment that we find in each.

Influential moral theories keyed to benevolence (including Mengzi’s and Hutcheson’s) claim a footing for ideal moral benevolence in natural human benevolence. The meaning of this claim depends on how natural and ideal benevolence are conceived and how the two are supposed to be related—as Mengzi suggests, for example, that there is an innate “sprout” of compassionate aversion to suffering that tends to grow into moral humaneness. In any case it is plausible that some sort of spontaneous and consistent human friendliness (...) supports a moral standard of unselfish concern for the well-being of others. The premise of benevolence theory is strengthened when we take account of a largely overlooked form of general good will: benevolent interest in the efforts of others. Here too a form of moral benevolence may grow from a base in natural good will, a point anticipated in Aristotle’s observation that our friendly interest in others is stimulated by the contestants in sports events. The sports spectator act of “pulling for” contestants, though conflicted by competition and exploited for various nonmoral satisfactions, is a vivid specimen of a general pulling for all innocent efforts in an inclusive moral fellowship of triers. (shrink)

Emotion expressions convey valuable information about others’ internal states and likely behaviours. Accurately identifying expressions is critical for social interactions, but so is perceiver confidence when decoding expressions. Even if a perceiver correctly labels an expression, uncertainty may impair appropriate behavioural responses and create uncomfortable interactions. Past research has found that perceivers report greater confidence when identifying emotions displayed by cultural ingroup members, an effect attributed to greater perceptual skill and familiarity with own-culture than other-culture faces. However, the current research (...) presents novel evidence for an ingroup advantage in emotion decoding confidence across arbitrary group boundaries that hold culture constant. In two experiments using different stimulus sets participants not only labeled minimal ingroup expressions more accurately, but did so with greater confidence. These results offer novel evidence that ingroup advantages in emotion decoding confidence stem partly from social-cognitive processes. (shrink)

I argue that Gold & Stoljar's “trivial neuron doctrine” is not in fact trivial. Many familiar positions in the philosophy of mind run afoul of it, and it is unclear that even those whom Gold & Stoljar identify as adherents of the trivial neuron doctrine can be comfortably described as such.

This book illuminates the aesthetically underrated meaningfulness of particular elements in works of art and aesthetic experiences generally. Beginning from the idea of "hooks" in popular song, the book identifies experiences of special liveliness that are of enduring interest, supporting contemplation and probing discussion. When hooks are placed in the foreground of aesthetic experience, so is an enthusiastic “grabbing back” by the experiencer who forms a quasi-personal bond with the beloved singular moment and is probably inclined to share this still-evolving (...) realization of value with others. This book presents numerous models of enthusiastic “grabbing back” that are art-critically motivated to explain how hooks achieve their effects and philosophically motivated to discover how hooks and hook appreciation contribute to a more ideally desirable life. Framing hook appreciation with a defensible general model of aesthetic experience, this book gives an unprecedented demonstration of the substantial aesthetic and philosophical interest of hook-centered inquiry. (shrink)