A hypothetical scenario is presented in which a female patient is admitted to a private hospital to undergo a mastectomy and breast reconstruction. The surgeons and anaesthetists conducting the different procedures charge three times the medical aid rates. When the patient asks what the co-payments are likely to be, she is informed by the doctors’ accounts section that they can only provide this information after each procedure. The patient’s medical scheme also advises her that it cannot determine the (...) likely co-payments unless she completes the assessment form sent to her. The form requires her to include the costs reflected against the relevant ICD10 codes. The patient cannot complete the form because the doctors’ accounts sections have not informed her about the proposed procedures and the likely costs of each. This article builds on a previous article discussing doctors’ overarching responsibility to disclose medical treatment costs in advance. The present article outlines the legal requirements in the South African Constitution, the National Health Act and the Health Professions Act, and refers to the Promotion of Access to Information Act and Consumer Protection Act. Similar to the earlier article, this article addresses the ethical requirements of the Health Professions Council of South Africa and the internationally recognised biomedical ethical principles. Furthermore, it also refers to the National Patients Charter, the government’s policy document on health care services. (shrink)

Many people who have reached the age of majority still qualify as financial dependents of their parents, and may be registered as dependents on their parents’ medical schemes. This poses a practical conundrum, because major persons enjoy complete autonomy over their bodies to choose healthcare services as they please, including informational determination. However, their sensitive health information may end up being disclosed in the accounts rendered to their parents, as main members of medical schemes, thereby breaching (...) their informational privacy, medical confidentiality and possibly also damaging personal relationships. On the other hand, medical schemes must ensure that they strictly manage the business of their hospitalisation to ensure that they can adhere to their contractual and legal medical insurance obligations. Both major but financially dependent patients and medical schemes have good legal grounds to defend their respective positions. In this article, we will analyse and clarify the applicable legal and ethical grounds by considering medical confidentiality, the Protection of Personal Information Act, the Consumer Protection Act and the Medical Schemes Act and rules. We shall conclude with recommendations to accommodate the interests of both parties. (shrink)

A background assumption of this paper is that the repertoire of inference schemes available to humanity is not fixed, but subject to change as new schemes are invented or refined and as old ones are obsolesced or abandoned. This is particularly visible in areas like health and environmental sciences, where enormous societal investment has been made in finding ways to reach more dependable conclusions. Computational modeling of argumentation, at least for the discourse in expert fields, will require the (...) possibility of modeling change in a stock of schemes that may be applied to generate conclusions from data. We examine Randomized Clinical Trial, an inference scheme established within medical science in the mid-20th Century, and show that its successful defense by means of practical reasoning allowed for its black-boxing as an inference scheme that generates (and warrants belief in) conclusions about the effects of medical treatments. Modeling the use of a scheme is well-understood; here we focus on modeling how the scheme comes to be established so that it is available for use. (shrink)

If I am injured in the course of medical investigation or treatment, I may be eligible to receive compensation for some of the adverse consequences of my injury—at least, if I live in a developed country. In most such countries, there exists some form of state-administered compensation scheme for medical injuries. However, even within the developed world, there is considerable variation in the eligibility criteria for compensation. Different countries would, for example, respond very differently to the following pair (...) of cases... (shrink)

International research is an essential means of reducing health disparities between and within countries and should do so as a matter of global justice. Research funders from high-income countries have an obligation of justice to support health research in low and middle-income countries that furthers such objectives. This paper investigates how their current funding schemes are designed to incentivise health systems research in LMICs that promotes health equity. Semi-structured in-depth interviews were performed with 16 grants officers working for 11 (...) funders and organisations that support health systems research: the Alliance for Health Policy and Systems Research, Comic Relief, Doris Duke Foundation, European Commission, International Development Research Centre, Norwegian Agency for Development Cooperation, Research Council of Norway, Rockefeller Foundation, UK Department of International Development, UK Medical Research Council, and Wellcome Trust. Thematic analysis of the data demonstrates their funding schemes promote health systems research with five key features that advance health equity: being conducted with worst-off populations, focusing on research topics that advance equitable health systems, having LMIC ownership of the research agenda, strengthening LMIC research capacity, and having an impact on health disparities. The different types of incentives that encouraged proposed projects to have these features are identified and classified by their strength. It is suggested that research funders ought to create and maintain funding schemes with strong incentives for the features identified above in order to more effectively help reduce global health disparities. (shrink)

This open access book presents an ethical approach to utilizing personal medical data. It features essays that combine academic argument with practical application of ethical principles. The contributors are experts in ethics and law. They address the challenges in the re-use of medical data of the deceased on a voluntary basis. This pioneering study looks at the many factors involved when individuals and organizations wish to share information for research, policy-making, and humanitarian purposes. -/- Today, it is easy (...) to donate blood or even organs, but it is virtually impossible to donate one’s own medical data. This is seen as ethically unacceptable. Yet, data donation can greatly benefit the welfare of our societies. This collection provides timely interdisciplinary research on biomedical big data. Topics include the ethics of data donation, the legal and regulatory challenges, and the current and future collaborations. -/- Readers will learn about the ethical and regulatory challenges associated with medical data donations. They will also better understand the special nature of using deceased data for research purposes with regard to ethical principles of autonomy, beneficence, and justice. In addition, the contributors identify the key governance issues of such a scheme. The essays also look at what we can learn in terms of best practice from existing medical data schemes. (shrink)

In Britain before 1911, the vast majority of the population provided medical care for themselves and had evolved a variety of schemes that checked the power of organized medicine and encouraged a steady improvement in standards. The evidence is that at the end of the nineteenth century about 5–6 percent of the population relied on the poor law, 10–15 percent on free care from charitable institutions, 75 percent on mutual aid, and the remainder paid fees to private doctors.

An ‘Information Centre’ has recently been established by law which has the power to collect, collate and provide access to the medical information forall patients treated by the National Health Service in England, whether in hospitals or by General Practitioners. This so-called ‘care.data’ scheme has given rise to major and ongoing controversies. We will sketch the background of the scheme and look at the responses it has elicited from citizens and medical professionals. In Autumn 2013, NHS England set (...) up a care.data website where citizens could record their concerns regarding the collection of health-related data by the Information Centre. We have reviewed all the comments on this website up until June 2015. We have also analysed the readers’ comments on the coverage of the care.data scheme in one of the main national UK newspapers. When discussing the responses of citizens, we will make a distinction between the problems that citizens detect and the solutions they propose. The solutions that are being perceived as the most relevant ones can be summarized as follows: citizens wish to further the common good without being manipulated into doing it, while at the same time being safeguarded against various abuses. The issue of trust turns out to figure prominently. Our analysis of reactions to the scheme in no way pretends to be exhaustive, yet it provides various relevant insights into the concerns identified by citizens as well as medical professionals. These concerns, moreover, have a more general relevance in relation to other contexts of medical data-mining as well as biobank research. Our analysis also offers important pointers as to how those concerns might be addressed. (shrink)

In the early 2000s, Esteban Burchard and his colleagues defended a controversial route to the view that there’s a racial classification of people that’s useful in medicine. The route, which I call ‘Burchard’s route,’ is arguing that there’s a racial classification of people that’s useful in medicine because, roughly, there’s a racial classification with medically relevant genetic differentiation :1170–1175, 2003). While almost all scholars engaged in this debate agree that there’s a racial classification of people that’s useful in medicine in (...) some way, there’s tremendous controversy over whether any racial scheme is useful in medicine because there are medically relevant genetic differences among those races : 564–565, 2016). The goal of this paper will be to show that Burchard’s route is basically correct. However, I will use a slightly different argument than Burchard et al.’s in order to provide a firmer foundation for the thesis, both metaphysically and genetically. I begin by reviewing Burchard’s route and its critics. Second, I present an original argument for establishing Burchard et al.’s conclusion using a Burchard-like route. I call it ‘Spencer’s route’. I reply to major objections along the way, and I end with a summary. (shrink)

This is the introduction to a special issue of 'Science in Context' on vitalism that I edited. The contents are: 1. Guido Giglioni — “What Ever Happened to Francis Glisson? Albrecht Haller and the Fate of Eighteenth-Century Irritability” 2. Dominique Boury— “Irritability and Sensibility: Two Key Concepts in Assessing the Medical Doctrines of Haller and Bordeu” 3. Tobias Cheung — “Regulating Agents, Functional Interactions, and Stimulus-Reaction-Schemes: The Concept of “Organism” in the Organic System Theories of Stahl, Bordeu and (...) Barthez” 4. Charles T. Wolfe & Motoichi Terada — “The Animal Economy as Object and Program in Montpellier Vitalism” 5. Timo Kaitaro — “Can Matter Mark the Hours? – Eighteenth-Century Vitalist Materialism and Functional Properties” 6. Elizabeth Williams —“Of Two Lives One? Jean-Charles-Marguerite-Guillaume Grimaud and the Question of Holism in Vitalist Medicine” 7. Philippe Huneman — “Montpellier Vitalism and the Emergence of Alienism in France (1750-1800): The Case of the Passions” 8. Elke Witt —“Form – A Matter of Generation. The Relation of Generation, Form and Function in the Epigenetic Theory of C.F. Wolff” . (shrink)

Recent economic and political advances in developing countries on the African continent and South East Asia are threatened by the rising death and morbidity rates of HIV/AIDS. In the first part of this paper we explain the reasons for the absence of affordable access to essential AIDS medication. In the second part we take a closer look at some of the pivotal frameworks relevant for this situation and undertake an ethical analysis of these frameworks. In the third part we discuss (...) a few of the proposed solutions to the problem and conclude with an argument in support of our preferred course of action. In this article we argue for compulsory licensing of essential AIDS medications in the current conditions of public health emergency. We argue on broadly consequentialist grounds that compulsory licensing is preferable both morally and pragmatically to the alternatives, notably the currently offered price cuts and drug donation schemes. (shrink)

This open access book presents an ethical approach to utilizing personal medical data. It features essays that combine academic argument with practical application of ethical principles. The contributors are experts in ethics and law. They address the challenges in the re-use of medical data of the deceased on a voluntary basis. This pioneering study looks at the many factors involved when individuals and organizations wish to share information for research, policy-making, and humanitarian purposes. Today, it is easy to (...) donate blood or even organs, but it is virtually impossible to donate one’s own medical data. This is seen as ethically unacceptable. Yet, data donation can greatly benefit the welfare of our societies. This collection provides timely interdisciplinary research on biomedical big data. Topics include the ethics of data donation, the legal and regulatory challenges, and the current and future collaborations. Readers will learn about the ethical and regulatory challenges associated with medical data donations. They will also better understand the special nature of using deceased data for research purposes with regard to ethical principles of autonomy, beneficence, and justice. In addition, the contributors identify the key governance issues of such a scheme. The essays also look at what we can learn in terms of best practice from existing medical data schemes. (shrink)

Objectives: To present an analysis of “futility” that is useful in the clinical setting.Design: Literature review.Material and methods: According to Medline more than 750 articles have been published about medical futility. Three criteria singled out 43 of them. The authors' opinions about futility were analysed using the scheme: “If certain conditions are satisfied, then a particular measure is futile” and “If a particular measure is futile, then certain moral consequences are implied”.Results: Regarding conditions, most authors stated that judgments about (...) futility should be made by physicians. The measure was usually some kind of medical treatment, and the goals related to quality of life, physiological improvement, or prolongation of life. The probability of success in reaching the goal was in most cases described in semiquantitative terms. Regarding consequences, the authors stated that health care professionals may withhold or withdraw a futile measure, most often after a dialogue with the patient , but sometimes without informing the patient , or with one-way information . Over time more and more articles recommend that the patient should be involved in joint decision making. Based on this literature review a clinical model was developed.Conclusions: The model, requiring that conditions and consequences should be made explicit, may, in “futility situations”, facilitate both the collection of the necessary information and make the moral implications visible. It also makes communication about measures considered to be futile possible without using such ambiguous terms as “futile”. (shrink)

This paper analyses the ethical considerations using the stakeholder theory on two specific domains of the newly implemented ‘Ayushman Bharat-Pradhan Mantri Jan Arogya Yojna ’ scheme by the Government of India. The paper recommends a solidarity-based approach over an entitlement based one that focuses on out-of-pocket expenses for the most vulnerable and a stewardship role from the private sector to ensure equity, accountability, and sustainability of PM-JAY scheme.

Development-oriented funding schemes such as the UK Global Challenges Research Fund (GCRF) have opened up opportunities for collaborations between low-middle income countries (LMICs) and high-income country (HIC) researchers. In particular, funding for medical technology research has seen a rise in previously under-represented disciplines such as physics and engineering. These collaborations have considerable potential to advance healthcare in LMICs, yet can pose challenges experienced to researchers undertaking these collaborations. Key challenges include a lack of tradition of HIC/LMIC collaborations within (...) participating departments, lack of experience with development agendas, designing contextually-appropriate technologies and ensuring long-term viability of research outputs. This paper reflects on these key challenges, using the experiences of the authors on the Open Laboratory Instrumentation (OLI) project as a focalizing lens. This project was a GCRF-funded collaboration between physicists in the UK and engineers in Tanzania to develop an open-source, 3D-printed, fully-automated laboratory microscope. The paper highlights key ethics lessons learnt. (shrink)

Development-oriented funding schemes such as the UK Global Challenges Research Fund (GCRF) have opened up opportunities for collaborations between low-middle income countries (LMICs) and high-income country (HIC) researchers. In particular, funding for medical technology research has seen a rise in previously under-represented disciplines such as physics and engineering. These collaborations have considerable potential to advance healthcare in LMICs, yet can pose challenges experienced to researchers undertaking these collaborations. Key challenges include a lack of tradition of HIC/LMIC collaborations within (...) participating departments, lack of experience with development agendas, designing contextually-appropriate technologies and ensuring long-term viability of research outputs. This paper reflects on these key challenges, using the experiences of the authors on the Open Laboratory Instrumentation (OLI) project as a focalizing lens. This project was a GCRF-funded collaboration between physicists in the UK and engineers in Tanzania to develop an open-source, 3D-printed, fully-automated laboratory microscope. The paper highlights key ethics lessons learnt. (shrink)

Development-oriented funding schemes such as the UK Global Challenges Research Fund (GCRF) have opened up opportunities for collaborations between low-middle income countries (LMICs) and high-income country (HIC) researchers. In particular, funding for medical technology research has seen a rise in previously under-represented disciplines such as physics and engineering. These collaborations have considerable potential to advance healthcare in LMICs, yet can pose challenges experienced to researchers undertaking these collaborations. Key challenges include a lack of tradition of HIC/LMIC collaborations within (...) participating departments, lack of experience with development agendas, designing contextually-appropriate technologies and ensuring long-term viability of research outputs. This paper reflects on these key challenges, using the experiences of the authors on the Open Laboratory Instrumentation (OLI) project as a focalizing lens. This project was a GCRF-funded collaboration between physicists in the UK and engineers in Tanzania to develop an open-source, 3D-printed, fully-automated laboratory microscope. The paper highlights key ethics lessons learnt. (shrink)

In Holding Health Care Accountable , E. Haavi Morreim differentiates between duties of expertise and resource duties, arguing for tort liability respecting the former and contract liability respecting the latter. Though Morreim's book addresses ordinary clinical medicine, her liability scheme may also be relevant elsewhere. Focusing on disaster medicine, and especially the medical management of violent mass disasters (e.g., where terrorists have deployed weapons of mass destruction), I argue in this essay that Morreim's classification of duties still fits, but (...) that it is difficult to hold government powers accountable for their many resource and expertise duties. This difficulty is compounded by political arrangements that foist under-funded mandates for disaster services on healthcare providers. As a result of such arrangements, hospitals and clinicians are prone to liability for expenditures and clinical interventions that are beyond their scope. This problem can be mitigated, I argue, by examining and clarifying the apparent social compact between society and healthcare. (shrink)

This book questions the notions of person, personality, dignity, and other connected notions such as consent, and discusses new perspectives on categories that allow ethical debates in medicine to overcome morals and ordinary religious schemes. The book states that one has to be careful when thinking about situations in terms of notions and principles that have been obtained in similar situations. Though this book is mostly philosophical, it is also of great practical interest to healthcare givers. It warns caregivers (...) not to rely too much on notions such as person, autonomy, and consent, which are supposedly firm but can be proven to be unreliable in spite of appearances. Furthermore, this work warns against a narrow anthropologisation of ethics which would make technophobian positions unavoidable. On the contrary, this book is open to robotics and offers – among other things - a sustained exploration of the notion of intimacy. (shrink)

The healthcare systems of the United States and United Kingdom are vastly different. The former relies primarily on private sector incentives and market forces to allocate medical care services, while the latter is a centrally planned system funded almost entirely by the public sector. Therefore, each nation represents divergent views on the relative efficacy of the market or government in achieving social objectives in the area of medical care policy. Since its inception in 1948, the National Health Services (...) of the United Kingdom has consistently emphasized equity in the allocation of medical services. It has done so by creating a system whereby services are universally free of charge at the point of entry. Conversely, the United States has relied upon the evolution of a perplexing array of public and private sector insurance schemes centered more around consumer choice than equity in allocation. (shrink)

At present, most of the research in the field of medical-assisted diagnosis is carried out based on image or electronic medical records. Although there is some research foundation, they lack the comprehensive consideration of comprehensive image and text modes. Based on this situation, this article proposes a fusion classification auxiliary diagnosis model based on GoogleNet model and Bi-LSTM model, uses GoogleNet to process brain computed tomographic images of ischemic stroke patients and extract CT image features, uses Bi-LSTM model (...) to extract the electronic medical record text, integrates the two features using the full connection layer network and Softmax classifier, and obtains a method that can assist the diagnosis from two modes. Experiments show that the proposed scheme on average improves 3.05% in accuracy compared to individual image or text modes, and the best performing GoogleNet + Bi-LSTM model achieves 96.61% accuracy; although slightly less in recall, it performs better on F1 values, and has provided feasible new ideas and new methods for research in the field of multi-model medical-assisted diagnosis. (shrink)

Shortages of life-saving medical resources caused by COVID-19 have prompted hospitals, healthcare systems, and governmentsto develop crisis standards of care, including 'triage protocols' to potentially ration medical supplies during the public health emergency. At the same time, the pandemic has highlighted and exacerbated racial, ethnic, and socioeconomic health disparities that together constitute a form of structural racism. These disparities pose a critical ethical challenge in developing fair triage systems that will maximize lives saved without perpetuating systemic inequities. Here (...) we review alternatives to 'utilitarian' triage, including first-come first-served, egalitarian, and prioritarian systems of allocating scarce medical resources. We assess the comparative advantages and disadvantages of these allocation schemes. Ultimately, we argue that while triage protocols should not exacerbate disparities, they are not an adequate mechanism for redressing systemic health inequities. Entrenched health disparities must be addressed through broader social change. (shrink)

As a result of the epidemiological situation in Poland that occurred as a consequence of the SARS-CoV-2 pandemic, all classroom study was suspended in March 2020 and schools were required to deliver online education. There number of teachers who create educational resources for medical e-education, also those including interactive elements, is still insufficient. Teachers’ IT skills must be continuously improved and they have to take part in e-learning course design training programmes, taking into account the characteristics of the teaching (...) process in medical sciences and health studies. The existing examples of effective e-classes, particularly for medical training, are important sources of knowledge on how to build e-learning courses for beginners and an inspiration for others in subsequent implementations. This knowledge is needed immediately, and the time available for acquiring it is shorter than previously, as the epidemic does not allow for full-range training schemes. This paper presents such results, collected from the period from March to June 2020 at the Poznan University of Medical Sciences by teachers who had started working on e-learning resources in 2019 and are successfully implementing these in the educational offer made available to their students as part of various curricula. (shrink)

Cadaveric transplantation and living transplantation exist side by side. Both practices help to alleviate organ need. They provide us with two separate moral schemes. Is it rational to keep them apart? The cadaveric system is organised along strict, impartial lines, while the living system is inherently partial and local. The ethical justification for this partial scheme seems to be that it merely supplements the cadaveric scheme: partial transplants do not come at the expense of cadaveric impartiality, but in fact (...) significantly reduce the waiting time for patients on the list for a cadaveric transplant.This seemingly peaceful coexistence is challenged by new initiatives, among them living donation list exchange, and also the LifeSharers initiative, leading to practices that undermine cadaveric impartiality. Should we bemoan this fact, or should we move on towards a new balance in the relationship between cadaveric and living transplantation practices, towards a new moral weighing of impartial and partial values? I argue, against the background of a rapid growth of living donations, that we have good, ethical reasons—not only utilitarian ones—for giving the value of partiality a more prominent place in our policies. (shrink)

In the mid-1970s, the biomedical model of medicine gave way to the biopsychosocial model of medicine; it was billed as a more comprehensive and compassionate model of medicine. After more than a century of disentangling medicine from religion, the medicine and spirituality movement is attempting to bring religion and spirituality back into medicine. It is doing so under a biopsychosociospiritual model. I unpack one model for allowing religion back into medicine called the RCOPE. RCOPE is an instrument designed to categorize (...) religion and spirituality as psychological coping mechanisms. I explore how such instruments are related to the history of statistical measurement and demonstrate the political impetus that governs such enterprises. The biopsychosociospiritual medicine is billed as a more holistic and comprehensive model. This new model of medicine offers total care. However, I demonstrate how this total care becomes totalizing, indeed totalitarian, admitting religion and spirituality back into the fold of medicine under a new secularized medical control. (shrink)

BackgroundAustralian health and medical research funders support substantial research efforts, and incentives within grant funding schemes influence researcher behaviour. We aimed to determine to what extent Australian health and medical funders incentivise responsible research practices.MethodsWe conducted an audit of instructions from research grant and fellowship schemes. Eight national research grants and fellowships were purposively sampled to select schemes that awarded the largest amount of funds. The funding scheme instructions were assessed against 9 criteria to determine (...) to what extent they incentivised these responsible research and reporting practices: publicly register study protocols before starting data collection, register analysis protocols before starting data analysis, make study data openly available, make analysis code openly available, make research materials openly available, discourage use of publication metrics, conduct quality research, collaborate with a statistician, and adhere to other responsible research practices. Each criterion was answered using one of the following responses: “Instructed”, “Encouraged”, or “No mention”.ResultsAcross the 8 schemes from 5 funders, applicants were instructed or encouraged to address a median of 4 of the 9 criteria. Three criteria received no mention in any scheme. Importantly, most incentives did not seem strong as applicants were only instructed to register study protocols, discourage use of publication metrics and conduct quality research. Other criteria were encouraged but were not required.ConclusionsFunders could strengthen the incentives for responsible research practices by requiring grant and fellowship applicants to implement these practices in their proposals. Administering institutions could be required to implement these practices to be eligible for funding. Strongly rewarding researchers for implementing robust research practices could lead to sustained improvements in the quality of health and medical research. (shrink)

Watermarking is one of the most common techniques used to protect data’s authenticity, integrity, and security. The obfuscation in the frequency domain used in the watermarking method makes the watermarking stronger than the obfuscation in the spatial domain. It occupies an important place in watermarking works in imperceptibility, capacity, and robustness. Finding the optimal location to hide the watermarking is one of the most challenging tasks in these methods and affects the method’s performance. In this article, sample identification information is (...) processed with the method of watermaking on the hiding environment created by using a chaos-based random number generator on biomedical data to provide solutions to problems such as visual attack, identity theft, and information confusion. In order to obtain biomedical data, a lensless digital in-line holographic microscopy setup was designed, and holographic data of human blood and cancer cell lines, which are widely used in the laboratory environment, were obtained. The standard USAF 1951 target was used to evaluate the resolution of our imaging setup. Various QR codes were generated for medical sample identification, and the captured medical data were processed by watermarking it with chaos-based random number generators. A new method using chaos-based discrete wavelet transform and singular value decomposition has been developed and applied to high-resolution data to eliminate the problem of encrypted data being directly targeted by third-party attacks. The performance of the proposed new watermarking method has been demonstrated by various robustness and invisibility tests. Experimental results showed that the proposed scheme reached an average PSNR value of 564588 dB and SSIM value of 0.9972 against several geometric and destructive attacks, which means that the proposed method does not affect the image quality and also ensures the security of the watermarking information. The results of the proposed method have shown that it can be used efficiently in various fields. (shrink)

James Lorimer Halliday (1897–1983) pioneered the development of the concept of psychosocial medicine in Britain in the 1930s and 1940s. He worked in Glasgow, first as a public health doctor, and then as part of the corporatist National Health Insurance scheme. Here he learned about links between poverty, the social environment, emotional stress and psychological and physical ill-health, and about statistical tools for making such problems scientifically visible. The intellectual development of his methodologically and epistemologically integrated medicine – a hybrid (...) of biomedical and psychological approaches – was embedded in the context of this practice with its particular medical culture and socio-economic circumstances. Halliday’s ideas are part of the wider, heterogeneous turn towards medical modernism and holism within mainstream medicine in Britain, western Europe and the United States in the inter-war period, and their evolution underlines the varied nature of contemporary anti-reductionist thinking in medicine. It also points to the diversity of the sources of holism and the many routes by which psychological and especially psychosocial discourses about health and illness entered professional and public arenas in Britain in this period. (shrink)

James Lorimer Halliday pioneered the development of the concept of psychosocial medicine in Britain in the 1930s and 1940s. He worked in Glasgow, first as a public health doctor, and then as part of the corporatist National Health Insurance scheme. Here he learned about links between poverty, the social environment, emotional stress and psychological and physical ill-health, and about statistical tools for making such problems scientifically visible. The intellectual development of his methodologically and epistemologically integrated medicine – a hybrid of (...) biomedical and psychological approaches – was embedded in the context of this practice with its particular medical culture and socio-economic circumstances. Halliday’s ideas are part of the wider, heterogeneous turn towards medical modernism and holism within mainstream medicine in Britain, western Europe and the United States in the inter-war period, and their evolution underlines the varied nature of contemporary anti-reductionist thinking in medicine. It also points to the diversity of the sources of holism and the many routes by which psychological and especially psychosocial discourses about health and illness entered professional and public arenas in Britain in this period. (shrink)

This article considers the ethical implications of prospective payment from the perspective of physicians and other health care practitioners. It focuses on the argument that prospective payment creates ethical conflict by giving physicians an economic incentive to do less for their patients. This argument is criticized in two respects. First, available evidence is reviewed which suggests that the incentives actually created by different prospective payment schemes and their effect on "optimal" patterns of practice is uncertain. Further, it is pointed (...) out that ethical conflict originates in the dual role of physicians as agents and suppliers of service. Recognizing that such conflict exists under any payment mechanism, a better focus for the ethical evaluation of prospective payment is suggested that considers whether the incentive to do less is likely to have adverse effects on physician decisions, relative to decisions made under other payment mechanisms. Keywords: incentives, utilization, conflict of interest, efficiency, justice, agent CiteULike Connotea Del.icio.us What's this? (shrink)

Cadaveric transplantation and living transplantation exist side by side. Both practices help to alleviate organ need. They provide us with two separate moral schemes. Is it rational to keep them apart? The cadaveric system is organised along strict, impartial lines, while the living system is inherently partial and local. The ethical justification for this partial scheme seems to be that it merely supplements the cadaveric scheme: partial transplants do not come at the expense of cadaveric impartiality, but in fact (...) significantly reduce the waiting time for patients on the list for a cadaveric transplant.This seemingly peaceful coexistence is challenged by new initiatives, among them living donation list exchange, and also the LifeSharers initiative, leading to practices that undermine cadaveric impartiality. Should we bemoan this fact, or should we move on towards a new balance in the relationship between cadaveric and living transplantation practices, towards a new moral weighing of impartial and partial values? I argue, against the background of a rapid growth of living donations, that we have good, ethical reasons—not only utilitarian ones—for giving the value of partiality a more prominent place in our policies. (shrink)

The paper relates to the actual extent of the “margin of appreciation” of national law-making power in Europe when it takes ethical issues into consideration. This occurs when the use of technoscience may affect fundamental interests. The discretion of the legislature is limited, particularly by the transnational system arising from the European legal integration within both the European Union and the Council of Europe. The two schemes of integration, although there are differences between them, converge to put national legislation (...) under pressure, particularly when it considers ethical matters. As a matter of fact, ethical issues cannot be approached at the national level alone but must be addressed at least at the continental level. An important role in the work of shaping the ethical rules from a continental perspective is played not by the national legislatures, but by the dialogue between the different levels of the judiciary. This role is inescapable and cannot be replaced by legislation, even if it is approved in a transnational plan. The function of the case law in regulating phenomena with ethical implications is studied, taking into consideration the case of Italian Law no. 40 of 2004 concerning medically assisted reproduction. Over the last 15 years, this law, which is inconsistent with many fundamental ethical principles, but has not been amended by the legislature, has been in the process of being corrected by the dialogue between European and national case law. (shrink)

There is currently no international consensus around post-trial obligations toward research participants, community members, and host countries. This literature review investigates arguments and attitudes toward post-trial access. The literature review found that academic discussions focused on the rights of research participants, but offered few practical recommendations for addressing or improving current practices. Similarly, there are few regulations or legislation pertaining to post-trial access. If regulatory changes are necessary, we need to understand the current arguments, legislation, and attitudes towards post-trial access (...) and participants and community members. Given that clinical trials conducted in low-income countries will likely continue, there is an urgent need for consideration of post-trial benefits for participants, communities, and citizens of host countries. While this issue may not be as pressing in countries where participants have access to healthcare and medicines through public schemes, it is particularly important in regions where this may not be available. (shrink)

Private medical aids are essentially non-profit organisations that aim to deliver speedy treatment and should prevent members from unexpected, out of pocket expenses for medical care. However, although the latest statistics show that 16.2% of individuals in South Africa were members of medical aid schemes, making the promise of private healthcare accessible to a small percentage of the population, they are not without their own unique set of challenges. The restrictions that exist within the private sector (...) have a direct bearing on the types of healthcare services patients can access, which in turn impacts on the fundamental right to access healthcare. Using a recent High Court Case decision, this article seeks to explore whether there is justice in the provision of healthcare services, specifically within the private sector in South Africa. (shrink)

Organs for transplantation are a scarce resource. Markedly, the transplant community’s primary challenge is the stark disparity between the number of patients awaiting deceased donor organ transplants and the rate at which organs become available. However, the allocation of a limited number of organs poses another constant challenge: maintaining an equilibrium between renal transplant utility and equity, that is, striking a balance between the utilitarian argument of medical efficiency and the principle of equity. In this comprehensive overview, the authors (...) delve into the challenge of maintaining an acceptable balance between equity and efficiency and elaborate on some of the factors that might inform a decisionmaker’s evaluation of the extent to which a given allocation scheme is efficient or equitable. (shrink)

Suddenly unable to walk, I found resources for facing disability in the works of Aristotle and Nietzsche, even though their respective ethical schemes are incommensurable. Implementing Amélie Rorty's notion of crop rotation, I show how each scheme offers the patient something quite indispensable, having to do with how each has its own judgmentally-motivated psychological underpinnings. Aristotle's notion of empathy, wherein the moral move occurs whenever we take up someone else's good as our own, is empowering, especially to those who (...) face an imperiled embodiment. However, Nietzsche teaches us that pity is demeaning both to the pitier and to the pitied, because it falsely assumes that life should be easy so that we are filled with ressentiment when it isn't. Those facing disability need empathy, not pity. The richness of this distinction is vividly conveyed in narratives that show how empathy and pity play out in lived situations, thereby avoiding the dissociation that too often characterizes ethical theorizing. By honoring narrative accounts of how these relational moves are either snagged or successfully made, the attuned moral agency of medical practitioners can be fostered. (shrink)

Background Policy decisions about childhood vaccination require consideration of multiple, sometimes conflicting, public health and ethical imperatives. Examples of these decisions are whether vaccination should be mandatory and, if so, whether to allow for non-medical exemptions. In this article we argue that these policy decisions go beyond typical public health mandates and therefore require democratic input.Methods We report on the design, implementation, and results of a deliberative public forum convened over four days in Ontario, Canada, on the topic of (...) childhood vaccination.Results 25 participants completed all four days of deliberation and collectively developed 20 policy recommendations on issues relating to mandatory vaccinations and exemptions, communication about vaccines and vaccination, and AEFI (adverse events following immunization) compensation and reporting. Notable recommendations include unanimous support for mandatory childhood vaccination in Ontario, the need for broad educational communication about vaccination, and the development of a no-fault compensation scheme for AEFIs. There was persistent disagreement among deliberants about the form of exemptions from vaccination (conscience, religious beliefs) that should be permissible, as well as appropriate consequences if parents do not vaccinate their children.Conclusions We conclude that conducting deliberative democratic processes on topics that are polarizing and controversial is viable and should be further developed and implemented to support democratically legitimate and trustworthy policy about childhood vaccination. (shrink)

Segmentation of the medical image plays a significant role when it comes to diagnosis using computer aided system. This article focuses on the human corneal endothelium’s health, which is one of the filed research interests, especially in the human cornea. Various pathological environments fasten the extermination of the endothelial cells, which in turn decreases the cell density in an abnormal manner. Dead cells worsen the hexagonal design. The mutilated endothelial cells can no longer revive back and that gives room (...) for neighbouring cells to migrate and expand so that they can fill in the space. The latter results in cell elongation that is unpredictable as well as increase in size and thinning. Cell density and shape are therefore considered major parameters when it comes to explaining the health condition attributed to corneal endothelium. In this study, medical feature extraction was obtained depending on the segmentation of the endothelial cell boundary, and the task of segmentation of such objects especially the thin, transparent, and unclear cell boundary is considered challenging due to the nature of the image capture during endothelium layer examination by ophthalmologists using confocal or specular microscopy. The resulting image suffers from various issues that affect the quality of the image. Low quality is due to non-uniformity of illumination and the presence of a lot of noise and artefacts resulting from high amounts of distortion, and most of these limitations are present because of the nature of the imaging modality. Usually, images contain certain kind of noise and also continuous shadow. Furthermore, the cells are separated by poor border, thereby leading to great difficulty in the segmentation of the images. The irregular shape of cell and also the contrast of such images seem to be low as they possess blurry boundaries with diverse objects existing in addition to the lack of homogeneity. The main aim of the study is to propose and develop a totally automatic, robust, and real-time model for the segmentation of endothelial cells of the human cornea obtained by in vivo microscopy and computation of different clinical features of endothelial cells. To achieve the aim of this study a new scheme of image enhancement was proposed such as the Contrast-Limited Adaptive Histogram Equalisation technique to enhance contrast. After that, a new image denoising technique called Wavelet Transform Filter and Butterworth Bandpass for Segmentation is used. Subsequently, brightness level correction is applied by using the moving average filter and the CLAHE to reduce the effects of the non-uniform image lighting produced as a result of the previous step. The main aim of this article is the segmentation of endothelial cells, which involves precise detection of the endothelial contours. So a new segmentation model was proposed such that the shape of the cells will be extracted, and the contours were highlighted. This stage is followed by clinical feature extraction and uses the features for diagnosis. In this stage, several relevant clinical features such as pleomorphism mean cell perimeter, mean cell density, mean cell area, and polymegathism are extracted. The role of these clinical features is crucial for the early detection of corneal pathologies as well as the evaluation of the health of the corneal endothelium layer. The findings of this study were promising. (shrink)

Collaborative learning with cases characteristically involves discussing and developing shared explanations. We investigated the argumentation scheme which learners use in constructing shared explanations over evidence. We observed medical students attempting to explain how a judge had arrived at his verdict in a case of medical negligence. The students were learning within a virtual learning environment and their communication was computer mediated. We identify the dialogue type that these learners construct and show that their argumentation conforms with an abductive (...) form of argumentation scheme (‘inference to the best explanation’). We also assessed the students’ learning and propose that it is related to particular features of this argumentation scheme. (shrink)

MedDRA (the Medical Dictionary for Regulatory Activities Terminology) is a controlled vocabulary widely used as a medical coding scheme. However, MedDRA’s characterization of its structural hierarchy exhibits some confusing and paradoxical features. The goal of this paper is to examine these features, determine whether there is a coherent view of the MedDRA hierarchy that emerges, and explore what lessons are to be learned from this for using MedDRA and similar terminologies in a broad medical informatics context that (...) includes relations among multiple disparate terminologies, thesauri, and ontologies. (shrink)

This article evaluates New Zealand’s Medicines Amendment Bill 2011. This Bill is currently before Parliament and will amend the Medicines Act 1981. On June 20, 2011, the Australian and New Zealand governments announced their decision to proceed with a joint scheme for the regulation of therapeutic products such as medicines, medical devices, and new medical interventions. Eventually, the joint arrangements will be administered by a single regulatory agency: the Australia New Zealand Therapeutic Products Agency. The medicines regulations in (...) Australia and New Zealand will be updated as part of this process. The Medicines Amendment Bill addresses some of the well-recognised deficiencies in the Medicines Act 1981. However, a comprehensive overhaul of the Act is not being undertaken. I argue that repealing and replacing the Medicines Act 1981 would be preferable and advisable, given the number of legal difficulties with the Act and, in particular, where it does not align with equivalent current international law. (shrink)

The British Medical Association (BMA) has called upon the General Medical Council (GMC) to instruct all medical schools to provide identifiable and substantial courses on medical ethics in their undergraduate curricula. The author reviews a postgraduate scheme of study in the ethics of health-care and suggests that it could provide some useful guidelines for teaching the subject at the undergraduate level.

Both developing and developed countries face an increasing mismatch between what patients expect to receive from healthcare and what the public healthcare systems can afford to provide. Where there has been a growing recognition of the entitlement to receive healthcare, the frustrated expectations with regards to the level of provision has led to lawsuits challenging the denial of funding for health treatments by public health systems. This book analyses the impact of courts and litigation on the way health systems set (...) priorities and make rationing decisions. In particular, it focuses on how the judicial protection of the right to healthcare can impact the institutionalization, functioning and centrality of Health Technology Assessment (HTA) for decisions about the funding of treatment. Based on the case study of three jurisdictions - Brazil, Colombia, and England - it shows that courts can be a key driver for the institutionalization of HTA. These case studies show the paradoxes of judicial control, which can promote accountability and impair it, demand administrative competence and undermine bureaucratic capacities. The case studies offer a nuanced and evidence-informed understanding of these paradoxes in the context of health care by showing how the judicial control of priority-setting decisions in health care can be used to require and control an explicit scheme for health technology assessment, but can also limit and circumvent it. (shrink)

The Pharmaceutical Benefits Scheme, operating in Australia under the National Health Act 1953, provides citizens equal access to subsidised pharmaceuticals. With ever-increasing costs of medicines and global financial pressure on all commodities, the sustainability of the PBS is of crucial importance on many social and political fronts. Direct-to-consumer advertising (DTCA) of prescription medicines is fast expanding, as pharmaceutical companies recognise and reinforce marketing potentials not only in healthcare professionals but also in consumers. DTCA is currently prohibited in Australia, but pharmaceutical (...) companies continuously lobby for the ban to be lifted. There is evidence that such marketing strategies influence consumer behaviour and concerns have been raised about whether DTCA could affect government expenditure on the PBS in Australia. This pharmacy-based study explored Australian consumer attitudes towards DTCA and whether consumer attitudes regarding DTCA differ based on socioeconomic status, measured in terms of income and education. Consumers from different socioeconomic areas in Sydney were asked to respond to a survey about an advertisement created specifically for the promotion of a mock prescription medicine. Their views about the intent, value and reliability of the advertisement were explored. The study found that consumers of lower socioeconomic status were more likely to perceive DTCA as a source of valuable and reliable medical information, and that they were more likely to request an advertised medication from their physician. If DTCA of prescription medicines was to be introduced in Australia, an increase in government expenditure on the PBS would be anticipated. Findings of this study also expose a deficit in respect for patients’ right to autonomy and informed consent which should be based on evidence-based, unbiased, information rather than advertisements. (shrink)

The foundations of research ethics are riven with fault lines emanating from a fear that if research is too closely connected to weighty social purposes an imperative to advance the common good through research will justify abrogating the rights and welfare of study participants. The result is an impoverished conception of the nature of research, an incomplete focus on actors who bear important moral responsibilities, and a system of ethics and oversight highly attuned to the dangers of research but largely (...) silent about threats of ineffective, inefficient, and inequitable medical practices and health systems. -/- In For the Common Good: Philosophical Foundations of Research Ethics, Alex John London defends a conception of the common good that grounds a moral imperative with two requirements. The first is to promote research that generates the information necessary to enable key social institutions to effectively, efficiently, and equitably safeguard the basic interests of individuals. The second is to ensure that research is organized as a voluntary scheme of social cooperation that respects its various contributors' moral claims to be treated as free and equal. Connecting research to the goals of a just social order grounds a framework for assessing and managing research risk that reconciles these requirements and justifies key oversight practices in non-paternalistic terms. Reconceiving research ethics as resolving coordination problems and providing credible assurance that these requirements are being met expands the issues and actors that fall within the purview of the field and provides the foundation for a more unified and coherent approach to domestic and international research. -/- This is an open access title available under the terms of a CC BY-NC-ND 4.0 license. It is free to read at Oxford Scholarship Online and offered as a free PDF download from OUP and selected open access locations. (shrink)

In a democratic society, the social rules are imposed by all upon each. As “recipients” of the rules, we tend to think that they should be designed to engender the best attainable distribution of goods and ills or quality of life. We are inclined to assess social institutions by how they affect their participants. But there is another, oft-neglected perspective which the topic of health equity raises with special clarity: As imposers of the rules, we are inclined to think that (...) harms we inflict through the rules have greater moral weight than like harms we merely fail to prevent or to mitigate. What matters morally is not merely how we affect people, but how we treat them through the rules we impose. While current (consequentialist and Rawlsian) theorizing is dominated by the first perspective and thus supports purely recipient-oriented moral conceptions, an adequate approach to social justice requires a balancing of both. Such balancing results in a relational conception of justice, which distinguishes various ways in which an institutional scheme may causally affect the quality of life of its participants.This essay argues that the strength of our moral reason to prevent or mitigate particular medical conditions depends not only on what one might call distributional factors, such as how badly off the people affected by these conditions are in absolute and relative terms, how costly prevention or treatment would be, and how much patients would benefit from given treatment. Rather, it depends also on relational factors, that is, on how we are related to the medical conditions they suffer. It then discusses some implications of this view for understanding responsibilities for international health outcomes. (shrink)

Newton’s impact on Enlightenment natural philosophy has been studied at great length, in its experimental, methodological and ideological ramifications. One aspect that has received fairly little attention is the role Newtonian “analogies” played in the formulation of new conceptual schemes in physiology, medicine, and life science as a whole. So-called ‘medical Newtonians’ like Pitcairne and Keill have been studied; but they were engaged in a more literal project of directly transposing, or seeking to transpose, Newtonian laws into quantitative (...) models of the body. I am interested here in something different: neither the metaphysical reading of Newton, nor direct empirical transpositions, but rather, a more heuristic, empiricist construction of Newtonian analogies. Figures such as Haller, Barthez, and Blumenbach constructed analogies between the method of celestial mechanics and the method of physiology. In celestial mechanics, they held, an unknown entity such as gravity is posited and used to mathematically link sets of determinate physical phenomena (e.g., the phases of the moon and tides). This process allows one to remain agnostic about the ontological status of the unknown entity, as long as the two linked sets of phenomena are represented adequately. Haller et. al. held that the Newtonian physician and physiologist can similarly posit an unknown called ‘life’ and use it to link various other phenomena, from digestion to sensation and the functioning of the glands. These phenomena consequently appear as interconnected, goal-oriented processes which do not exist either in an inanimate mechanism or in a corpse. In keeping with the empiricist roots of the analogy, however, no ontological claims are made about the nature of this vital principle, and no attempts are made to directly causally connect such a principle and observable phenomena. The role of the “Newtonian analogy” thus brings together diverse schools of thought, and cuts across a surprising variety of programs, models and practices in natural philosophy. (shrink)

continent. 1.1 : 3-13. / 0/ – Introduction I want to propose, as a trajectory into the philosophically weird, an absurd theoretical claim and pursue it, or perhaps more accurately, construct it as I point to it, collecting the ground work behind me like the Perpetual Train from China Mieville's Iron Council which puts down track as it moves reclaiming it along the way. The strange trajectory is the following: Kant's critical philosophy and much of continental philosophy which has followed, (...) has been a defense against horror and madness. Kant's prohibition on speculative metaphysics such as dogmatic metaphysics and transcendental realism, on thinking beyond the imposition of transcendental and moral constraints, has been challenged by numerous figures proceeding him. One of the more interesting critiques of Kant comes from the mad black Deleuzianism of Nick Land stating, “Kant’s critical philosophy is the most elaborate fit of panic in the history of the Earth.” And while Alain Badiou would certainly be opposed to the libidinal investments of Land's Deleuzo-Guattarian thought, he is likewise critical of Kant's normative thought-bureaucracies: Kant is the one author for whom I cannot feel any kinship. Everything in him exasperates me, above all his legalism—always asking Quid Juris? Or ‘Haven’t you crossed the limit?’—combined, as in today’s United States, with a religiosity that is all the more dismal in that it is both omnipresent and vague. The critical machinery he set up has enduringly poisoned philosophy, while giving great succour to the academy, which loves nothing more than to rap the knuckles of the overambitious [….] That is how I understand the truth of Monique David-Menard’s reflections on the properly psychotic origins of Kantianism. I am persuaded that the whole of the critical enterprise is set up to to shield against the tempting symptom represented by the seer Swedenborg, or against ‘diseases of the head’, as Kant puts it. An entire nexus of the limits of reason and philosophy are set up here, namely that the critical philosophy not only defends thought from madness, philosophy from madness, and philosophy from itself, but that philosophy following the advent of the critical enterprise philosophy becomes auto-vampiric; feeding on itself to support the academy. Following Francois Laruelle's non-philosophical indictment of philosophy, we could go one step further and say that philosophy operates on the material of what is philosophizable and not the material of the external world. [1] Beyond this, the Kantian scheme of nestling human thinking between our limited empirical powers and transcendental guarantees of categorical coherence, forms of thinking which stretch beyond either appear illegitimate, thereby liquefying both pre-critical metaphysics and the ravings of the mad in the same critical acid. In rejecting the Kantian apparatus we are left with two entities – an unsure relation of thought to reality where thought is susceptible to internal and external breakdown and a reality with an uncertain sense of stability. These two strands will be pursued, against the sane-seal of post-Kantian philosophy by engaging the work of weird fiction authors H.P. Lovecraft and Thomas Ligotti. The absolute inhumanism of the formers universe will be used to describe a Shoggothic Materialism while the dream worlds of the latter will articulate the mad speculation of a Ventriloquil Idealism. But first we must address the relation of philosophy to madness as well as philosophy to weird fiction. /1/ – Philosophy and Madness There is nothing that the madness of men invents which is not either nature made manifest or nature restored. Michel Foucault. Madness and Civilization. The moment I doubt whether an event that I recall actually took place, I bring the suspicion of madness upon myself: unless I am uncertain as to whether it was not a mere dream. Arthur Schopenhauer. The World as Will and Idea, Vol. 3. Madness is commonly thought of as moving through several well known cultural-historical shifts from madness as a demonic or otherwise theological force, to rationalization, to medicalization psychiatric and otherwise. Foucault's Madness and Civilization is well known for orientating madness as a form of exclusionary social control which operated by demarcating madness from reason. Yet Foucault points to the possibility of madness as the necessity of nature at least prior to the crushing weight of the church. Kant’s philosophy as a response to madness is grounded by his humanizing of madness itself. As Adrian Johnston points out in the early pages of Time Driven pre-Kantian madness meant humans were seized by demonic or angelic forces whereas Kantian madness became one of being too human. Madness becomes internalized, the external demonic forces become flaws of the individual mind. Foucault argues that, while madness is de-demonized it is also dehumanized during the Renaissance, as madmen become creatures neither diabolic nor totally human reduced to the zero degree of humanity. It is immediately clear why for Kant, speculative metaphysics must be curbed – with the problem of internal madness and without the external safeguards of transcendental conditions, there is nothing to formally separate the speculative capacities for metaphysical diagnosis from the mad ramblings of the insane mind – both equally fall outside the realm of practicality and quotidian experience. David-Menard's work is particularly useful in diagnosing the relation of thought and madness in Kant's texts. David-Menard argues that in Kant's relatively unknown “An Essay on the Maladies of the Mind” as well as his later discussion of the Seer of Swedenborg, that Kant formulates madness primarily in terms of sensory upheaval or other hallucinatory theaters. She writes: “madness is an organization of thought. It is made possible by the ambiguity of the normal relation between the imaginary and the perceived, whether this pertains to the order of sensation or to the relations between our ideas” Kant's fascination with the Seer forces Kant between the pincers of “aesthetic reconciliation” – namely melancholic withdrawal – and “a philosophical invention” – namely the critical project. Deleuze and Guattari's schizoanalysis is a combination and reversal of Kant's split, where an aesthetic over engagement with the world entails prolific conceptual invention. Their embrace of madness, however, is of course itself conceptual despite all their rhizomatic maneuvers. Though they move with the energy of madness, Deleuze and Guattari save the capacity of thought from the fangs of insanity by imbuing materiality itself with the capacity for thought. Or, as Ray Brassier puts it, “Deleuze insists, it is necessary to absolutize the immanence of this world in such a way as to dissolve the transcendent disjunction between things as we know them and as they are in themselves”. That is, whereas Kant relied on the faculty of judgment to divide representation from objectivity Deleuze attempts to flatten the whole economy beneath the juggernaut of ontological univocity. Speculation, as a particularly useful form of madness, might fall close to Deleuze and Guattari’s shaping of philosophy into a concept producing machine but is different in that it is potentially self destructive – less reliant on the stability of its own concepts and more adherent to exposing a particular horrifying swath of reality. Speculative madness is always a potential disaster in that it acknowledges little more than its own speculative power with the hope that the gibbering of at least a handful of hysterical brains will be useful. Pre-critical metaphysics amounts to madness, though this may be because the world itself is mad while new attempts at speculative metaphysics, at post-Kantian pre-critical metaphysics, are well aware of our own madness. Without the sobriety of the principle of sufficient reason we have a world of neon madness: “we would have to conceive what our life would be if all the movements of the earth, all the noises of the earth, all the smells, the tastes, all the light – of the earth and elsewhere, came to us in a moment, in an instant – like an atrocious screaming tumult of things”. Speculative thought may be participatory in the screaming tumult of the world or, worse yet, may produce its spectral double. Against theology or reason or simply commonsense, the speculative becomes heretical. Speculation, as the cognitive extension of the horrorific sublime should be met with melancholic detachment. Whereas Kant's theoretical invention, or productivity of thought, is self -sabotaging, since the advent of the critical project is a productivity of thought which then delimits the engine of thought at large either in dogmatic gestures or non-systematizable empirical wondrousness. The former is celebrated by the fiction of Thomas Ligotti whereas the latter is espoused by the tales of H.P. Lovecraft. /2/ – Weird Fiction and Philosophy. Supernatural horror, in all its eerie constructions, enables a reader to taste treats inconsistent with his personal welfare. Thomas Ligotti Songs of a Dead Dreamer. I choose weird stories because they suit my inclination best—one of my strongest and most persistent wishes being to achieve,momentarily, the illusion of some strange suspension or violation of the galling limitations of time, space, and natural law which forever imprison us and frustrate our curiosity about the infinite cosmic spaces beyond the radius of our sight and analysis H.P. Lovecraft. “Notes on Writing Weird Fiction” Lovecraft states that his creation of a story is to suspend natural law yet, at the same time, he indexes the tenuousness of such laws, suggesting the vast possibilities of the cosmic. The tension that Lovecraft sets up between his own fictions and the universe or nature is reproduced within his fictions in the common theme of the unreliable narrator; unreliable precisely because they are either mad or what they have witnessed questions the bounds of material reality. In “The Call of Cthulhu” Lovecraft writes: The most merciful thing in the world, I think, is the inability of the human mind to correlate all its contents. We live on a placid island of ignorance in the midst of black seas of infinity, and it was not meant that we should voyage far. The sciences, each straining in its own direction, have hitherto harmed us little; but some day the piecing together of dissociated knowledge will open up such terrifying vistas of reality, and of our frightful position therein, that we shall either go mad from the revelation or flee from the deadly light into the peace and safety of a new dark age. Despite Lovecraft's invocations of illusion, he is not claiming that his fantastic creations such as the Old Ones are supernatural but, following Joshi, are only ever supernormal. One can immediately see that instead of nullifying realism Lovecraft in fact opens up the real to an unbearable degree. In various letters and non-fictional statements Lovecraft espoused strictly materialist tenets, ones which he borrowed from Hugh Elliot namely the uniformity of law, the denial of teleology and the denial of non-material existence. Lovecraft seeks to explore the possibilities of such a universe by piling horror upon horror until the fragile brain which attempts to grasp it fractures. This may be why philosophy has largely ignored weird fiction – while Deleuze and Guattari mark the turn towards weird fiction and Lovecraft in particular, with the precursors to speculative realism as well as contemporary related thinkers have begun to view Lovecraft as making philosophical contributions. Lovecraft's own relation to philosophy is largely critical while celebrating Nietzsche and Schopenhauer. This relationship of Lovecraft to philosophy and philosophy to Lovecraft is coupled with Lovecraft's habit of mercilessly destroying the philosopher and the figure of the academic more generally in his work, a destruction which is both an epistemological destruction and an ontological destruction. Thomas Ligotti's weird fiction which he has designated as a kind of “confrontational escapism” might be best described in the following quote from one of his shortstories, “The human phenomenon is but the sum of densely coiled layers of illusion each of which winds itself on the supreme insanity. That there are persons of any kind when all there can be is mindless mirrors laughing and screaming as they parade about in an endless dream”. Whereas Lovecraft's weirdness draws predominantly from the abyssal depths of the uncharted universe, Ligotti's existential horror focuses on the awful proliferation of meaningless surfaces that is, the banal and every day function of representation. In an interview, Ligotti states: We don't even know what the world is like except through our sense organs, which are provably inadequate. It's no less the case with our brains. Our whole lives are motored along by forces we cannot know and perceptions that are faulty. We sometimes hear people say that they're not feeling themselves. Well, who or what do they feel like then? This is not to say that Ligotti sees nothing beneath the surface but that there is only darkness or blackness behind it, whether that surface is on the cosmological level or the personal. By addressing the implicit and explicit philosophical issues in Ligotti's work we will see that his nightmarish take on reality is a form of malevolent idealism, an idealism which is grounded in a real, albeit dark and obscure materiality. If Ligotti's horrors ultimately circle around mad perceptions which degrade the subject, it takes aim at the vast majority of the focus of continental philosophy. While Lovecraft's acidic materialism clearly assaults any romantic concept of being from the outside, Ligotti attacks consciousness from the inside: Just a little doubt slipped into the mind, a little trickle of suspicion in the bloodstream, and all those eyes of ours, one by one, open up to the world and see its horror [...] Not even the solar brilliance of a summer day will harbor you from horror. For horror eats the light and digests it into darkness. Clearly, the weird fiction of Lovecraft and Ligotti amount to a anti-anthrocentric onslaught against the ramparts of correlationist continental philosophy. /3/ – Shoggothic Materialism or the Formless Formless protoplasm able to mock and reflect all forms and organs and processes—viscous agglutinations of bubbling cells—rubbery fifteen-foot spheroids infinitely plastic and ductile—slaves of suggestion, builders of cities—more and more sullen, more and more intelligent, more and more amphibious, more and more imitative—Great God! What madness made even those blasphemous Old Ones willing to use and to carve such things? H.P. Lovecraft. “At the Mountains of Madness” On the other hand, affirming that the universe resembles nothing and is only formless amounts to saying that the universe is something like a spider or spit. Georges Bataille. “Formless”. The Shoggoths feature most prominently in H.P. Lovecraft's shortstory “At the Mountains of Madness” where they are described in the following manner: It was a terrible, indescribable thing vaster than any subway train – a shapeless congeries of protoplasmic bubbles, faintly self -luminous, and with myriads of temporary eyes forming and un-forming as pustules of greenish light all over the tunnel-filling front that bore down upon us, crushing the frantic penguins and slithering over the glistening floor that it and its kind had swept so evilly free of all litter. The term is a litmus test for materialism itself as the Shoggoth is an amorphous creature. The Shoggoths were living digging machines bio engineered by the Elder Things, and their protoplasmic bodies being formed into various tools by their hypnotic powers. The Shoggoths eventually became self aware and rose up against their masters in an ultimately failed rebellion. After the Elder Ones retreated into the oceans leaving the Shoggoths to roam the frozen wastes of the Antarctic. The onto-genesis of the Shoggoths and their gross materiality, index the horrifyingly deep time of the earth a concept near and dear to Lovecraft's formulation of horror as well as the fear of intelligences far beyond, and far before, the ascent of humankind on earth and elsewhere. The sickly amorphous nature of the Shoggoths invade materialism at large, where while materiality is unmistakably real ie not discursive, psychological, or otherwise overly subjectivist, it questions the relation of materialism to life. As Eugene Thacker writes: The Shoggoths or Elder Things do not even share the same reality with the human beings who encounter them—and yet this encounter takes place, though in a strange no-place that is neither quite that of the phenomenal world of the human subject or the noumenal world of an external reality. Amorphous yet definitively material beings are a constant in Lovecraft's tales. In his tale “The Dream-Quest of Unknown Kadatth” Lovecraft describes Azathoth as, “that shocking final peril which gibbers unmentionably outside the ordered universe,” that, “last amorphous blight of nethermost confusion which blashphemes and bubbles at the centre of all infinity,” who, “gnaws hungrily in inconceivable, unlighted chambers beyond time”. Azathoth's name may have multiple origins but the most striking is the alchemy term azoth which is both a cohesive agent and a acidic creation pointing back to the generative and the decayed. The indistinction of generation and degradation materially mirrors the blur between the natural and the unnatural as well as life and non-life. Lovecraft speaks of the tension between the natural and the unnatural is his short story “The Unnameable.” He writes, “if the psychic emanations of human creatures be grotesque distortions, what coherent representation could express or portray so gibbous and infamous a nebulousity as the spectre of a malign, chaotic perversion, itself a morbid blasphemy against Nature?”. Lovecraft explores exactly the tension outlined at the beginning of this chapter, between life and thought. At the end of his short tale Lovecraft compounds the problem as the unnameable is described as “a gelatin—a slime—yet it had shapes, a thousand shapes of horror beyond all memory”. Deleuze suggests that becoming-animal is operative throughout Lovecraft's work, where narrators feel themselves reeling at their becoming non-human or of being the anomalous or of becoming atomized. Following Eugene Thacker however, it may be far more accurate to say that Lovecraft's tales exhibit not a becoming-animal but a becoming-creature. Where the monstrous breaks the purportedly fixed laws of nature, the creature is far more ontologically ambiguous. The nameless thing is an altogether different horizon for thought. The creature is either less than animal or more than animal – its becoming is too strange for animal categories and indexes the slow march of thought towards the bizarre. This strangeness is, as aways, some indefinite swirling in the category of immanence and becoming. Bataille begins “The Labyrinth” with the assertion that being, to continue to be, is becoming. More becoming means more being hence the assertion that Bataille's barking dog is more than the sponge. This would mean that the Shoggotth is altogether too much being, too much material in the materialism. Bataille suggests that there is an immanence between the eater and the eaten, across the species and never within them. That is, despite the chaotic storm of immanence there must remain some capacity to distinguish the gradients of becoming without reliance upon, or at least total dependence upon, the powers of intellection to parse the universe into recognizable bits, properly digestible factoids. That is, if we undo Deleuze's aforementioned valorization of sense which, for his variation of materialism, performed the work of the transcendental, but refuse to reinstate Kant's transcendental disjunction between thing and appearance, then it must be a quality of becoming-as-being itself which can account for the discernible nature of things by sense. In an interview with Peter Gratton, Jane Bennett formulates the problem thusly: What is this strange systematicity proper to a world of Becoming? What, for example, initiates this congealing that will undo itself? Is it possible to identify phases within this formativity, plateaus of differentiation? If so, do the phases/plateaus follow a temporal sequence? Or, does the process of formation inside Becoming require us to theorize a non-chronological kind of time? I think that your student’s question: “How can we account for something like iterable structures in an assemblage theory?” is exactly the right question. Philosophy has erred too far on the side of the subject in the subject-object relation and has furthermore, lost the very weirdness of the non-human. Beyond this, the madness of thought need not override. /4/ - Ventriloquial Idealism or the Externality of Thought My aim is the opposite of Lovecraft's. He had an appreciation for natural scenery on earth and wanted to reach beyond the visible in the universe. I have no appreciation for natural scenery and want the objective universe to be a reflection of a character. Thomas Ligotti. “Devotees of Decay and Desolation.” Unless life is a dream, nothing makes sense. For as a reality, it is a rank failure [….] Horror is more real than we are. Thomas Ligotti. “Professor Nobody's Little Lectures on Supernatural Horror”. Thomas Ligotti's tales are rife with mannequins, puppets, and other brainless entities which of replace the valorized subject of philosophy – that of the free thinking human being. His tales such as “The Dream of the Manikin” aim to destroy the rootedness of consciousness. James Trafford has connected the anti-egoism of Ligotti to Thomas Metzinger – where the self is at best an illusion and we plead desperately for someone else to acknowledge that we are real. Trafford has stated it thus, “Life is played out as an inescapable puppet show, an endless dream in which the puppets are generally unaware that they are trapped within a mesmeric dance of whose mechanisms they know nothing and over which they have no control”. An absolute materialism, for Ligotti, implies an alienation of the idea which leads to a ventriloquil idealism. As Ligotti notes in an interview, “the fiasco and nightmare of existence, the particular fiasco and nightmare of human existence, the sense that people are puppets of powers they cannot comprehend, etc.” And then further elaborates that,“[a]ssuming that anything has to exist, my perfect world would be one in which everyone has experienced the annulment of his or her ego. That is, our consciousness of ourselves as unique individuals would entirely disappear”. The externality of the idea leads to the unfortunate consequence of consciousness eating at itself through horror which, for Ligotti, is more real than reality and goes beyond horror-as-affect. Beyond this, taking together with the unreality of life and the ventriloquizing of subjectivity, Ligotti's thought becomes an idealism in which thought itself is alien and ultimately horrifying. The role of human thought and the relation of non-relation of horror to thought is not completely clear in Ligotti's The Conspiracy Against the Human Race. Ligotti argues in his The Conspiracy Against the Human Race,that the advent of thought is a mistake of nature and that horror is being in the sense that horror results from knowing too much. Yet, at the same time, Ligotti seems to suggest that thought separates us from nature whereas, for Lovecraft, thought is far less privileged – mind is just another manifestation of the vital principal, it is just another materialization of energy. In his brilliant “Prospects for Post-Copernican Dogmatism” Iain Grant rallies against the negative definition of dogmatism and the transcendental, and suggests that negatively defining both over-focuses on conditions of access and subjectivism at the expense of the real or nature. With Schelling, who is Grant's champion against the subjectivist bastions of both Fichte and Kant, Ligotti's idealism could be taken as a transcendental realism following from an ontological realism. Yet the transcendental status of Ligotti's thought move towards a treatment of the transcendental which may threaten to leave beyond its realist ground. Ligotti states: Belief in the supernatural is only superstition. That said, a sense of the supernatural, as Conrad evidenced in Heart of Darkness, must be admitted if one's inclination is to go to the limits of horror. It is the sense of what should not be- the sense of being ravaged by the impossible. Phenomenally speaking, the super-natural may be regarded as the metaphysical counterpart of insanity, a transcendental correlative of a mind that has been driven mad. Again, Ligotti equates madness with thought, qualifying both as supernatural while remaining less emphatic about the metaphysical dimensions of horror. The question becomes one of how exactly the hallucinatory realm of the ideal relates to the black churning matter of Lovecraft's chaos of elementary particles. In his tale “I Have a Special Plan for This World” Ligotti formulates thus: A: There is no grand scheme of things. B: If there were a grand scheme of things, the fact – the fact – that we are not equipped to perceive it, either by natural or supernatural means, is a nightmarish obscenity. C: The very notion of a grand scheme of things is a nightmarish obscenity. Here Ligotti is not discounting metaphysics but implying that if it does exist the fact that we are phenomenologically ill-equipped to perceive that it is nightmarish. For Ligotti, nightmare and horror occur within the circuit of consciousness whereas for Lovecraft the relation between reality and mind is less productive on the side of mind. It is easier to ascertain how the Kantian philosophy is a defense against the diseases of the head as Kant armors his critical enterprise from too much of the world and too much of the mind. The weird fiction of both Lovecraft and Ligotti demonstrates that there is too much of both feeding into one another in a way that corrodes the Kantian schema throughly, breaking it down into a dead but still ontologically potentiated nigredo. The haunting, terrifying fact of Ligotti's idealism is that the transcendental motion which brought thought to matter, while throughly material and naturalized, brings with it the horror that thought cannot be undone without ending the material that bears it either locally or completely. Thought comes from an elsewhere and an elsewhen being-in-thought. The unthinkable outside thought is as maddening as the unthought engine of thought itself within thought which doesn't exist except for the mind, the rotting décor of the brain. /5/ - Hyperstitional Transcendental Paranoia or Self -Expelled Thought Weird fiction has been given some direct treatment in philosophy in the mad black Deleuzianism of Nick Land. Nick Land along with others in the 1990s created the Cyber Culture Research Unit as well as the research group Hyperstition. The now defunct hyperstitional website, an outgrowth of the Cyber Culture Research Unit, defined hyperstition in the following fourfold: 1-Element of effective culture that makes itself real. 2-Fictional quantity functional as a time-traveling device. 3-Coincidence intensifier. 4-Call to the Old Ones. The distinctively Lovecraftian character of hyperstition is hard to miss as is its Deleuzo-Guattarian roots. In the opening pages of A Thousand Plateaus Deleuze and Guattari write, “We have been criticized for over-quoting literary authors. But when one writes, the only question is which other machine the literary machine can be plugged into”. The indisinction of literature and philosophy mirrors the mess of being and knowing as post-correlationist philosophy, where philosophy tries to make itself real where literature, especially the weird, aims itself at the brain-circuit of horror. The texts of both Lovecraft and Ligotti work through horror as epistemological plasticity meeting with proximity as well as the deep time of Lovecraft and the glacially slow time of paranoia in Ligotti. Against Deleuze, and following Brassier, we cannot allow the time of consciousness, the Bergsonian time of the duree, to override natural time, but instead acknowledge that it is an unfortunate fact of existence as a thinking being. Horror-time, the time of consciousness, with all its punctuated moments and drawn out terrors, cannot compare to the deep time of non-existence both in the unreachable past and the unknown future. The crystalline cogs of Kant's account of experience as the leading light for the possibility of metaphysics must be throughly obliterated. His gloss of experience in Prolegomena to any Future Metaphysics could not be more sterile: Experience consists of intuitions, which belong to the sensibility, and of judgments, which are entirely a work of the understanding. But the judgments which the understanding makes entirely out of sensuous intuitions are far from being judgments of experience. For in the one case the judgment connects only the perceptions as they are given in sensuous intuition [....] Experience consists in the synthetic connection of appearances in consciousness, so far as this connection is necessary. Here it is difficult to dismiss the queasiness that Kant's legalism induces upon sight for both Badiou and David-Menard. Kant's thought becomes, as Foucault says when reflecting on Sade's text in relation to nature, “the savage abolition of itself”. For Badiou, Kant's philosophy simply closes off too much of the outside, freezing the world of thought in an all too limited formalism. Critical philosophy is simply the systematized quarantine on future thinking, on thinking which would threaten the formalism which artificially grants thought its own coherency in the face of madness. Even the becoming-mad of Deleuze, while escaping the rumbling ground, makes grounds for itself, mad grounds but grounds which are thinkable in their affect. The field of effects allows for Deleuze's aesthetic and radical empiricism, in which effects and/or occasions make up the material of the world to be thought as a chaosmosis of simulacra. Given a critique of an empiricism of aesthetics, of the image, it may be difficult to justify an attack on Kantian formalism with the madness of literature, which does not aim to make itself real but which we may attempt to make real. That is, how do Lovecraft's and Ligotti's materials, as materials for philosophy to work on, differ from either the operative formalisms of Kant or the implicitly formalized images of Deleuzian empiricism? It is simply that such texts do not aim to make themselves real, and make claims to the real which are more alien to us than familiar, which is why their horror is immediately more trustworthy. This is the madness which Blanchot discusses in The Infinite Conversation through Cervantes and his knight – the madness of book-life, of the perverse unity of literature and life a discussion which culminates in the discussion of one of the weird's masters, that of Kafka. The text is the knowing of madness, since madness, in its moment of becoming-more-mad, cannot be frozen in place but by the solidifications of externalizing production. This is why Foucault ends his famous study with works of art. Furthermore extilligence, the ability to export the products of our maligned brains, is the companion of the attempts to export, or discover the possibility of intelligences outside of our heads, in order for philosophy to survive the solar catastrophe. To borrow again from Deleuze, writing is inseparable from becoming. The mistake is to believe that madness is reabsorbed by extilligence, by great works, or that it could be exorcised by the expelling of thought into the inorganic or differently organic. Going out of our heads does not guarantee we will no longer mean we cannot still go out of our minds. This is simply because of the outside, of matter, or force, or energy, or thing-in-itself, or Schopenhauerian Will. In Lovecraft’s “The Music of Erich Zahn” an “impoverished student of metaphysics” becomes intrigued by strange viol music coming from above his room. After meeting the musician the student discovers that each night he plays frantic music at a window in order to keep some horridness at bay, some “impenetrable darkness with chaos and pandemonium”. The aesthetic defenses provided by the well trained brain can bear the hex of matter for so long, the specter of unalterability within it which too many minds obliterate, collapsing everything before the thought of thought as thinkable or at least noetically mutable on our own terms. Transcendental paranoia is the concurrent nightmare and promise of Paul Humphrey's work, of being literally out of our minds. It is the gothic counterpart of thinking non-conceptually but also of thinking never belonging to any instance of purportedly solid being. As Bataille stated, “At the boundary of that which escapes cohesion, he who reflects within cohesion realizes there is no longer any room for him” Thought is immaterial only to the degree that it is inhuman, it is a power that tries, always with failure, to ascertain its own genesis. Philosophy, if it can truly return to the great outdoors, if it can leave behind the dead loop of the human skull, must recognize not only the non-priority of human thought, but that thought never belongs to the brain that thinks it, thought comes from somewhere else. To return to the train image from the beginning “a locomotive rolling on the surface of the earth is the image of continuous metamorphosis” this is the problem of thought, and of thinking thought, of being no longer able to isolate thought, with only a thought-formed structure. [1] One of the central tenets of Francois Laruelle's non-philosophy is that philosophy has traditionally operated on material already presupposed as thinkable instead of trying to think the real in itself. Philosophy, according to Laruelle, remains fixated on transcendental synthesis which shatters immanence into an empirical datum and an a prori factum which are then fused by a third thing such as the ego. For a critical account of Laruelle's non-philosophy see Ray Brassier's Nihil Unbound. (shrink)

Is it morally acceptable to instigate criminal offenders to participate in rehabilitative treatment by offering treatment in return for early release from prison? Some theorists have supported such treatment schemes by pointing to the beneficial consequences that follow from the treatment. Others have suggested that the schemes are unacceptably coercive, which implies that consent becomes an illusion. This paper argues that the discussion—with clear parallels to debates of other healthcare treatment offers in medical ethics—has adopted a too (...) narrow focus. By failing to consider the question as a penal theoretical problem, the arguments—both by proponents and critics of coercive treatment—become premature. (shrink)