In this book, T. M. Scanlon offers new answers to these questions, as they apply to the central part of morality that concerns what we owe to each other.

Public health ethics, like the field of public health it addresses, traditionally has focused more on practice and particular cases than on theory, with the result that some concepts, methods, and boundaries remain largely undefined. This paper attempts to provide a rough conceptual map of the terrain of public health ethics. We begin by briefly defining public health and identifying general features of the field that are particularly relevant for a discussion of public health ethics.Public health is primarily concerned with (...) the health of the entire population, rather than the health of individuals. Its features include an emphasis on the promotion of health and the prevention of disease and disability; the collection and use of epidemiological data, population surveillance, and other forms of empirical quantitative assessment; a recognition of the multidimensional nature of the determinants of health; and a focus on the complex interactions of many factors—biological, behavioral, social, and environmental—in developing effective interventions. (shrink)

When a patient fails to follow the advice or prescription of a physician, she is termed to be "noncompliant" by the medical community. The medical community’s response to and understanding of patient noncompliance fails to acknowledge noncompliance as either a relational failure between physician and patient or as a patient choice. I offer an analysis of Immanuel Kant and Emmanuel Levinas that refocuses the issue of noncompliance by examining the physician role, the doctor–patient relationship, and the nature of responsibility.

Motivationally unconscious (M-unconscious) states are unconscious states that can directly motivate a subject’s behavior and whose unconscious character typically results from a form of repression. The basic argument for M-unconscious states claims that they provide the best explanation to some seemingly non rational behaviors, like akrasia, impulsivity or apparent self-deception. This basic argument has been challenged on theoretical, empirical and conceptual grounds. Drawing on recent works on apparent self-deception and on the ‘cognitive unconscious’ I assess those objections. I argue that (...) (i) even if there is a good theoretical argument for its existence, (ii) most empirical vindications of the M-unconscious miss their target. (iii) As for the conceptual objections, they compel us to modify the classical picture of the M-unconscious. I conclude that M-unconscious states and processes must be affective states and processes that the subject really feels and experiences —and which are in this sense conscious— even though they are not, or not well, cognitively accessible to him. Dual process psychology and the literature on cold-hot empathy gaps partly support the existence of such M-unconscious states. (shrink)

What grounds and justifies conclusions in medical ethics? Is the source external or internal to medicine? Thee influential types of answer have appeared in recent literature: an internal account, an external account, and a mixed internal / external account. The first defends an ethic derived from either the ends of medicine or professional practice standards. The second maintains that precepts in medical ethics rely upon and require justification by external standards such as those of public opinion, law, religious ethics, or (...) philosophical ethics. The third claims that distinct medical ethics have emerged from distinct cultural frameworks, each with norms that govern physicians. There is merit in each perspective, but each overreaches its supporting arguments and fails to appreciate what is legitimate in the theses of its competitors. I propose a fourth account that offers a way to escape limitations of the other three, while retaining their most attractive features. (shrink)

It is my view that one essential difference between persons and other creatures is to be found in the structure of a person's will. Besides wanting and choosing and being moved to do this or that, men may also want to have certain desires and motives. They are capable of wanting to be different, in their preferences and purposes, from what they are. Many animals appear to have the capacity for what I shall call "first-order desires" or "desires of the (...) first order," which are simply desires to do or not to do one thing or another. No animal other than man, however, appears to have the capacity for reflective self-evaluation that is manifested in the formation of second-order desires. (shrink)

The illusory appeal of double effect -- The significance of intent -- Means and ends -- Blame.

In the article by Kristin Voigt in the April 2013 issue of Cambridge Quarterly of Healthcare Ethics, quotation marks around certain phrases were deleted.

The notion of individual responsibility has gained prominence in recent debates about health care. First, responsibility has been proposed as a rationing criterion; second, some policies use rewards and sanctions to encourage individuals to ‘take responsibility’ for their health; finally, acting responsibly within the health care system is portrayed as a requirement of reciprocity. The aim of this paper is two-fold. First, I assess these different kinds of appeal to individual responsibility from the perspective of equality. The literature has identified (...) important concerns about equality and fairness with proposals to use individual responsibility as a rationing criterion; I suggest that there are similar concerns about incentive schemes and reciprocity-based appeals to individual responsibility. The analysis will draw on luck egalitarian accounts of equality, which emphasise the importance of individual responsibility. This allows me to pursue the second objective for paper: to reconsider the luck egalitarian perspective on these different appeals to responsibility. Applying the arguments of recent contributions to the luck egalitarian literature to the health arena suggests that luck egalitarians need not support the use of responsibility as a rationing criterion, and they can also identify problems with incentives and reciprocity-based arguments. However, the language of individual responsibility and its prominence in public debates may have implications for individuals’ health and well-being, which raises challenging issues for luck egalitarians as they attempt to apply their theory to the real world. (shrink)

Over the past several decades, medical ethics has gained a solid foothold in medical education and is now a required course in most medical schools. Although the field of medical ethics is by nature eclectic, moral philosophy has played a dominant role in defining both the content of what is taught and the methodology for reasoning about ethical dilemmas. Most educators largely rely on the case‐based method for teaching ethics, grounding the ethical reasoning in an amalgam of theories drawn from (...) moral philosophy, including consequentialism, deontology, and principlism.In this article we hope to make a case for augmenting the focus of education in medical ethics. We propose complementing the traditional approach to medical ethics with a more embedded approach, one that has been described by others as “microethics,” the ethics of everyday clinical practice. (shrink)

Self-deception poses tantalizing conceptual conundrums and provides fertile ground for empirical research. Recent interdisciplinary volumes on the topic feature essays by biologists, philosophers, psychiatrists, and psychologists (Lockard & Paulhus 1988, Martin 1985). Self-deception's location at the intersection of these disciplines is explained by its significance for questions of abiding interdisciplinary interest. To what extent is our mental life present--or even accessible--to consciousness? How rational are we? How is motivated irrationality to be explained? To what extent are our beliefs subject to (...) our control? What are the determinants of belief, and how does motivation bear upon belief? In what measure are widely shared psychological propensities products of evolution? (shrink)

What do the terms “profession, professional, professionalism” mean in 2002? One dictionary defines profession as “a calling requiring specialized knowledge and often long and intensive academic preparation,” and it defines professionalism as “the conduct, aims, or qualities that characterize or make a profession or professional person.” These definitions are appealingly simple. Complexity arises when we add the term “medical” as in the medical profession, a medical professional, or medical professionalism; and, here a specific understanding of “the conduct, aims, and qualities (...) that characterize” the field of medicine is required. To complicate matters, professionalism applies to both the profession as a whole as well as the individual professional persons, such as the physicians. (shrink)

Mele's modified definition of self-deception is consistent with evolutionary theory. Self-deception is most likely whenever ignorance confers (reproductive) advantage, namely, in impression management, deception, conformity, social norms, reproductive knowledge, and existential conflicts. Second-order self-deception (unawareness of unawareness) perpetuates self-deception and may be the reason for our misguided definitions.

Next SectionFollowing the influential Gifford and Reith lectures by Onora O’Neill, this paper explores further the paradigm of individual autonomy which has been so dominant in bioethics until recently and concurs that it is an aberrant application and that conceptions of individual autonomy cannot provide a sufficient and convincing starting point for ethics within medical practice. We suggest that revision of the operational definition of patient autonomy is required for the twenty first century. We follow O’Neill in recommending a principled (...) version of patient autonomy, which for us involves the provision of sufficient and understandable information and space for patients, who have the capacity to make a settled choice about medical interventions on themselves, to do so responsibly in a manner considerate to others. We test it against the patient–doctor relationship in which each fully respects the autonomy of the other based on an unspoken covenant and bilateral trust between the doctor and patient. Indeed we consider that the dominance of the individual autonomy paradigm harmed that relationship. Although it seems to eliminate any residue of medical paternalism we suggest that it has tended to replace it with an equally (or possibly even more) unacceptable bioethical paternalism. In addition it may, for example, lead some doctors to consider mistakenly that unthinking acquiescence to a requested intervention against their clinical judgement is honouring “patient autonomy” when it is, in fact, abrogation of their duty as doctors. (shrink)

The Virtue of Defiance and Psychiatric Engagement argues that defiance sometimes is a virtue even for those with mental illnesses. It also argues that defiance is sometimes mistaken as a sign of mental disorder when it may have other, reasonable explanations. This book offers a nuanced and complex look at defiance, taking seriously issues of mental disorders while also attending to social contexts in which defiant behaviour may arise. Arguments are presented for how to understand defiance as different from noncompliance, (...) resistance, and other related concepts, and how defiance is related to living a life with a realistic understanding of a flourishing life and its limits in our everyday world. A framework for differentiating different forms of defiance is offered, and a realistic picture of phronesis—practical reasoning—is presented that makes room for clinicians as well as patients to assess the degree to which defiance is reasonable. The concept of intersectionality as it related to child development is worked through to highlight some of the challenges clinicians face when interpreting defiant behavior. Particular attention is given to issues of race and gender as factors that need to be considered when evaluating defiant behavior as reasonable, virtuous, bad, or symptomatic. Those who work with defiant patients are invited to engage in different ways with defiant people so as to better understand and respond to those who express that defiance. This involves the learning to cultivate what the author calls the virtue of giving uptake. Because giving uptake is difficult to do well, the author employs theoretical work on epistemic resistance—resistance that, despite thoughtful and well-intended--clinicians may grapple with in being responsible knowers and that can impede their understanding and responsiveness to those who are, or seem to be, defiant. Practical applications for psychiatric engagement are threaded throughout this book through case studies and personal narratives. (shrink)

In which a scientist searches for an empirical explanation for phenomenal experience, spurred by his instinctual belief that life is meaningful. What links conscious experience of pain, joy, color, and smell to bioelectrical activity in the brain? How can anything physical give rise to nonphysical, subjective, conscious states? Christof Koch has devoted much of his career to bridging the seemingly unbridgeable gap between the physics of the brain and phenomenal experience. This engaging book--part scientific overview, part memoir, part futurist speculation--describes (...) Koch's search for an empirical explanation for consciousness. Koch recounts not only the birth of the modern science of consciousness but also the subterranean motivation for his quest--his instinctual belief that life is meaningful. Koch describes his own groundbreaking work with Francis Crick in the 1990s and 2000s and the gradual emergence of consciousness as a legitimate topic for scientific investigation. Present at this paradigm shift were Koch and a handful of colleagues, including Ned Block, David Chalmers, Stanislas Dehaene, Giulio Tononi, Wolf Singer, and others. Aiding and abetting it were new techniques to listen in on the activity of individual nerve cells, clinical studies, and brain-imaging technologies that allowed safe and noninvasive study of the human brain in action. Koch gives us stories from the front lines of modern research into the neurobiology of consciousness as well as his own reflections on a variety of topics, including the distinction between attention and awareness, the unconscious, how neurons respond to Homer Simpson, the physics and biology of free will, dogs, Der Ring des Nibelungen, sentient machines, the loss of his belief in a personal God, and sadness. All of them are signposts in the pursuit of his life's work--to uncover the roots of consciousness. (shrink)

This book is aimed primarily at the practitioners of morals such as psychiatrists,lawyers and policy-makers. My professional background is clinical psychiatry It is divided into three parts. The first of these provides an overview of moral theory, morality in non-human species and recent developments in neuroscience that are of relevance to moral and legal responsibility. In the second part I offer a new paradigm of free action based on the overlaps between free will, moral value and art. In the overlap (...) between free will and moral value we find moral responsibility and moral autonomy. Free will and art share characteristics of originality, spontaneity and creativity. Art and moral value are related by way of the moral content of art and the formal similarities of moral and aesthetic judgments. In the overlap between art, free will and moral value we find religious belief, the creation of moral value and the creation of moral identity. In the third part, I discuss the application of these ideas to common clinical conditions such as eating disorders, addictions, personality disorders, post-traumatic stress disorder and the dissociative disorders. Wherever possible, I illustrate the points that are made with real-life clinical examples. I finish by considering how ideas of free will and responsibility are relevant to psychotherapy. (shrink)

Demands by Patients or their Families for treatment thought to be inappropriate by health care providers constitute an important set of moral problems in clinical practice. A variety of approaches to such cases have been described in the literature, including medical futility, standard of care and negotiation. Medical futility fails because it confounds morally distinct cases: demand for an ineffective treatment and demand for an effective treatment that supports a controversial end (e.g., permanent unconsciousness). Medical futility is not necessary in (...) the first case and is harmful in the second. Ineffective treatment falls outside the standard of care, and thus health care workers have no obligation to provide it. Demands for treatment that supports controversial ends are difficult cases best addressed through open communication, negotiation and the use of conflict-resolution techniques. Institutions should ensure that fair and unambiguous procedures for dealing with such cases are laid out in policy statements. (shrink)

This review essay examines H. Tristram Engelhardt, Jr.'s The Foundations of Bioethics, a contemporary nonfeminist text in mainstream biomedical ethics. It focuses upon a central concept, Engelhardt's idea of the moral community and argues that the most serious problem in the book is its failure to take account of the political and social structures of moral communities, structures which deeply affect issues in biomedical ethics.