A high level of confidence in the identity of individuals is required to let them die as ordered by an advance directive. Thus, if we are animalists, then we should lack the confidence required to apply lethal advance directives to the cheerfully demented, or so I argue. In short, there is consensus among animalists that the best way to avoid serious objections to their account is to adopt an ontology that denies the existence of brains, hands, tables, (...) chairs, iced-tea, and lemonade. The adoption of such an ontology reduces the justificatory force of commonsense, which is key in arguing that we are animals and that we persist as long as we are biologically alive. With this loss of justification comes the loss of a high level of confidence that Quinn-pre-dementia’s lethal advanced directive applies to Quinn-post-dementia, via identity. If we do not have a high level of confidence that Quinn-pre-dementia’s advanced directive applies to Quinn-post- dementia, then it is not enough (on its own) to let Quinn-post-dementia die. (shrink)

In this commentary, I critique three aspects of Emily Walsh's proposal to reduce the moral and legal weight of advance directives: (1) the ambiguity of its initial thesis, (2) its views about the ethics and legality of clinical practice, and (3) its interpretation and application of Ronald Dworkin’s account of advance directives and L.A. Paul's view on transformative experience. I also consider what Walsh’s proposal would mean for people facing the prospect of dementia. I conclude that (...) our reasons to honor many advance directives survive the move to a transformative experience framework. (shrink)

Advance directives typically have two defects. First, most advance directives fail to enable people to effectively avoid unwanted medical intervention. Second, most of them have the potential of ending your life in ways you never intended, years before you had to die.

This paper takes a novel approach to the active bioethical debate over whether advance medical directives have moral authority in dementia cases. Many have assumed that advance directives would lack moral authority if dementia truly produced a complete discontinuity in personal identity, such that the predementia individual is a separate individual from the postdementia individual. I argue that even if dementia were to undermine personal identity, the continuity of the body and the predementia individual’s rights over (...) that body can support the moral authority of advance directives. I propose that the predementia individual retains posthumous rights over her body that she acquired through historical embodiment in that body, and further argue that claims grounded in historical embodiment can sometimes override or exclude moral claims grounded in current embodiment. I close by considering how advance directives grounded in historical embodiment might be employed in practice and what they would and would not justify. (shrink)

After 41 years from the approval of the first living will law in 1976 in California, on December 22nd 2017 the bill on “Rules on in- formed consent and advance directives” has been approved in Italy. The applicability of the law highlights a lack of a univocal methodol- ogy regarding the recovery process of the patient’s subjective dimension under a testamentary will; so, it seemed useful to highlight the passages that occur between the drafting and the use of (...) an advance directive in an existential phenomenological prospective. Is the individual who freely drafts an A.D., choosing to decide now for the future, the same per- son for which the provisions were outlined? The goal of this paper is to offer an ethical reading of the ontological issue that illness can raises. (shrink)

Advance directives are intended to extend patient autonomy by enabling patients to prospectively direct the care of their future incapacitated selves. There has been much discussion about issues such as whether the future incompetent self is identical to the agent who issues the advance directives or whether advance directives can legitimately secure patient autonomy. However, there is another important question to ask: to what extent and in what conditions is it ethically appropriate for one (...) to limit the liberty or agency of one’s future incompetent self by issuing an advance directive? -/- In this paper, I use a virtue-ethical approach to explore this question, focusing on the case of an advance directive for the future self with moderate dementia. First, I examine virtuous attitudes with regard to autonomy and argue that one can manifest vices or ethically undesirable character traits in trying to intervene in the future self’s life. In particular, I argue that this case can manifest vices such as disdainfulness, intellectual arrogance, and self-dictatorship, which is the vice of trying to control one’s life to an excessive degree, and that a self-dictator fails to give due moral consideration to the future self’s liberty or agency. I then introduce the Daoist idea of wu-wei, which recommends embracement of what happens in one’s life, as one of the possible remedies for the overemphasis on the value of autonomy and control. (shrink)

Although advance directives are widely believed to be a key way to safeguard the autonomy of incompetent medical patients, significant questions exist about their moral authority. The main philosophical concern involves cases in which an incompetent patient no longer possesses the desires on which her advance directive was based. The question is, does that entail that prior expressions of medical choices are no longer morally binding? I believe that the answer is “yes.” I argue that a patient’s (...) autonomy is not respected by honoring the desires she used to have but no longer does. I also consider and reject the view that honoring an advance directive that reflects the patient’s previous values must be in that patient’s best interests. If that is correct, then advance directives in the kind of case at issue are not morally binding. (shrink)

Ronald Dworkin argued that Advance Directives informed by a principle of autonomy ought to guide decisions in relation to the treatment of those in care for dementia. The principle of autonomy in play presupposes a form of competence that is tied to the individual person making the Directive. This paper challenges this individualist assumption. It does so by pointing out that the competence of a patient is inherently relational, and the key illustrative case to make this point is (...) the case of music therapy. In music therapy, a relatively recent treatment modality in aged care, patients previously thought to be permanently unresponsive are shown on the contrary to be capable of significant levels of social agency. The conclusion to draw is that Advance Directives that fail to acknowledge the real possibility of such relational competence are misapplied. (shrink)

Feminist bioethicists of a variety of persuasions discuss the 2013 case of Marlise Munoz, a pregnant woman whose medical care was in dispute after she became brain dead.

The fourth amendment to the German Medicinal Products Act (Arzneimittelgesetz) states that nontherapeutic research in incompetent populations is permissible under the condition that potential research participants expressly declare their wish to participate in scientific research in an advance research directive. This article explores the implementation of advance research directives in Germany against the background of the international legal and ethical framework for biomedical research. In particular, it addresses a practical problem that arises from the disclosure requirement for (...) advance research directives. We show that, if the disclosure standard for advance research directives is set at a token level, nontherapeutic research in incompetent populations becomes practically impossible. To resolve this issue, we suggest the disclosure standard be set at a type level. (shrink)

For people with Bipolar Affective Disorder, a self-binding (advance) directive (SBD), by which they commit themselves to treatment during future episodes of mania, even if unwilling, can seem the most rational way to deal with an imperfect predicament. Knowing that mania will almost certainly cause enormous damage to themselves, their preferred solution may well be to allow trusted others to enforce treatment and constraint, traumatic though this may be. No adequate provision exists for drafting a truly effective SBD and (...) efforts to establish such provision are hampered by very valid, but also paralysing ethical, clinical and legal concerns. Effectively, the autonomy and rights of people with bipolar are being 'protected' through being denied an opportunity to protect themselves. From a standpoint firmly rooted in the clinical context and experience of mania, this article argues that an SBD, based on a patient-centred evaluation of capacity to make treatment decisions (DMC-T) and grounded within the clinician-patient relationship, could represent a legitimate and ethically coherent form of self-determination. After setting out background information on fluctuating capacity, mania and advance directives, this article proposes a framework for constructing such an SBD, and considers common objections, possible solutions and suggestions for future research. (shrink)

The study of belief is expanding and involves a growing set of disciplines and research areas. These research programs attempt to shed light on the process of believing, understood as a central human cognitive function. Computational systems and, in particular, what we commonly understand as Artificial Intelligence (AI), can provide some insights on how beliefs work as either a linear process or as a complex system. However, the computational approach has undergone some scrutiny, in particular about the differences between what (...) is distinctively human and what can be inferred from AI systems. The present article investigates to what extent recent developments in AI provide new elements to the debate and clarify the process of belief acquisition, consolidation, and recalibration. The article analyses and debates current issues and topics of investigation such as: different models to understand belief, the exploration of belief in an automated reasoning environment, the case of religious beliefs, and future directions of research. (shrink)

The personal identity relation is of great interest to philosophers, who often consider fictional scenarios to test what features seem to make persons persist through time. But often real examples of neuroscientific interest also provide important tests of personal identity. One such example is the case of Phineas Gage – or at least the story often told about Phineas Gage. Many cite Gage’s story as example of severed personal identity; Phineas underwent such a tremendous change that Gage “survived as a (...) different man.” I discuss a recent empirical finding about judgments about this hypothetical. It is not just the magnitude of the change that affects identity judgment; it is also the negative direction of the change. I present an experiment suggesting that direction of change also affects neuroethical judgments. I conclude we should consider carefully the way in which improvements and deteriorations affect attributions of personal identity. This is particularly important since a number of the most crucial neuroethical decisions involve varieties of cognitive enhancements or deteriorations. (shrink)

When medical assistance in dying (MAiD) was legalized in Canada in June 2016, the question of allowing decisionally capable persons to make advance requests in anticipation of later incapacity was reserved for further consideration during the mandatory parliamentary review originally scheduled to begin in June 2020 (but since delayed by COVID-19). In its current form the legislation does not permit such requests, since it stipulates that at the time at which the procedure is to be administered the patient must (...) give “express consent” to receiving it. Since express consent presupposes decisional capacity, this requirement rules out administering MAiD to a patient who has lost capacity. Amendments to the legislation passed by Parliament in March 2021 open the door slightly by allowing advance requests by patients after they have been approved for MAiD, if they fear losing capacity before the procedure can be administered. But this provision would apply only to patients whose natural death was deemed to be “reasonably foreseeable”, and would continue to exclude (a) requests made after diagnosis of a “grievous and irremediable medical condition” but in advance of approval for MAiD, and (b) requests made before such a diagnosis. My aim in this paper is twofold: to explore the ethical and legal issues concerning advance requests for MAiD, and to argue for expanding provision for such requests to include both of these further scenarios. (shrink)

Summary Background Self-binding directives instruct clinicians to overrule treatment refusal during future severe episodes of illness. These directives are promoted as having potential to increase autonomy for individuals with severe episodic mental illness. Although lived experience is central to their creation, service users’ views on self-binding directives have not been investigated substantially. This study aimed to explore whether reasons for endorsement, ambivalence, or rejection given by service users with bipolar disorder can address concerns regarding self-binding directives, (...) decision-making capacity, and human rights. Methods This study used qualitative data from an internet-based survey distributed to the mailing list of the UK charity Bipolar UK, which contained multiple closed and open questions on advance decision-making in bipolar disorder. Quantitative analysis of a closed question about self-binding directives had already demonstrated endorsement amongst a very high proportion of participants with bipolar disorder who completed the survey. We conducted thematic analysis of responses from those participants who answered a subsequent open question about reasons for their view. Research was co-produced within a multi-disciplinary team, with clinical, legal, and ethical expertise, and lived experience of bipolar disorder. Ideas and methodologies associated with all these areas of expertise were used in the analysis of these reasons and to gain insight into the thoughts of individuals with bipolar disorder about self-binding directives and associated issues. Findings Between Oct 23 and Dec 5, 2017, 932 individuals with a self-reported clinical diagnosis of bipolar disorder completed the internet survey, with 565 (154 men; 400 women; 11 transgender or other) providing free text answers to the open question. A large majority of respondents endorsed self-binding directives, nearly all describing a determinate shift to types of distorted thinking and decision-making when unwell as their key justification. Responses indicating ambivalence were dominated by logistical concerns about the drafting and implementation of self-binding directives, while those who rejected self-binding directives also cited logistical concerns, validity of their thinking when unwell, and potential contravention of human rights. Interpretation This study is, to our knowledge, the first large study of reasons why mental health service users might endorse or reject the use of self-binding directives. The findings provide empirical support for introducing self-binding directives into mental health advance decision-making practice and policy and may help to address enduring ethical concerns surrounding possible implementation of the directive while a person retains decision-making capacity. The opinions expressed here in responses given by multiple service users with bipolar disorder challenge a prominent view within international disability rights debates that involuntary treatment and recognition of impaired mental capacity constitute inherent human rights violations. Funding The Wellcome Trust . (shrink)

The fourteen papers in this collection offer a variety of original contributions to the epistemology of modality. In seeking to explain how we might account for our knowledge of possibility and necessity, they raise some novel questions, develop some unfamiliar theoretical perspectives, and make some intriguing proposals. Collectively, they advance our understanding of the field. In Part I of this Introduction, I give some general background about the contemporary literature in the area, by sketching a timeline of the main (...) tendencies of the past twenty-five years or so, up to the present debates. Next, I focus on four features that largely characterize the latest literature, and the papers in the present collection in particular: (i) an endorsement of the importance of essentialism; (ii) a shift to a “metaphysics-first” approach to modal epistemology; (iii) a focus on metaphysical modality as opposed to other kinds of modality; and (iv) a preference for non-uniform modal epistemology. In Part II, I present the individual papers in the volume. These are organized around the following four chapters, based on their topic: (A) Skepticism & Deflationism; (B) Essentialism; (C) Non-Essentialist Accounts; (D) Applications. -/- LIST OF CONTRIBUTORS: Francesco Berto; Stephen Biggs & Jessica Wilson; Justin Clark-Doane; Philip Goff; Bob Hale; Frank Jackson; Mark Jago; Boris Kment; Antonella Mallozzi; Graham Priest; Gabriel Rabin; Amie Thomasson; Anand Vaidya & Michael Wallner; Jennifer Wang. -/- The volume is dedicated to the memory of Bob Hale. -/- . (shrink)

Background: Critically ill patients often require complex clinical care by highly trained staff within a specialized intensive care unit (ICU) with advanced equipment. There are currently limited data on the costs of critical care in low-and middle-income countries (LMICs). This study aims to investigate the direct-medical costs of key infectious disease (tetanus, sepsis, and dengue) patients admitted to ICU in a hospital in Ho Chi Minh City (HCMC), Vietnam, and explores how the costs and cost drivers can vary between the (...) different diseases. -/- Methods: We calculated the direct medical costs for patients requiring critical care for tetanus, dengue and sepsis. Costing data (stratified into different cost categories) were extracted from the bills of patients hospitalized to the adult ICU with a dengue, sepsis and tetanus diagnosis that were enrolled in three studies conducted at the Hospital for Tropical Diseases in HCMC from January 2017 to December 2019. The costs were considered from the health sector perspective. The total sample size in this study was 342 patients. -/- Results: ICU care was associated with significant direct medical costs. For patients that did not require mechanical ventilation, the median total ICU cost per patient varied between US$64.40 and US$675 for the different diseases. The costs were higher for patients that required mechanical ventilation, with the median total ICU cost per patient for the different diseases varying between US$2,590 and US$4,250. The main cost drivers varied according to disease and associated severity. -/- Conclusion: This study demonstrates the notable cost of ICU care in Vietnam and in similar LMIC settings. Future studies are needed to further evaluate the costs and economic burden incurred by ICU patients. The data also highlight the importance of evaluating novel critical care interventions that could reduce the costs of ICU care. (shrink)

The rapid advancement of artificial intelligence systems has generated a means whereby assistive bionic prosthetics can become both more effective and practical for the patients who rely upon the use of such machines in their daily lives. However, de lege lata remains relatively unspoken as to the legal status of patients whose devices contain self-learning CIS that can interface directly with the peripheral nervous system. As a means to reconcile for this lack of legal foresight, this article approaches the topic (...) of CIS-nervous system interaction and the impacts it may have on the legal definition of “persons” under the law. While other literature of this nature centres upon notions of transhumanism or self-enhancement, the approach herein approached is designed to focus solely upon the legal nature of independent CIS actions when operating alongside human subjects. To this end, it is hoped that further discussion on the topic can be garnered outside of transhumanist discourse to expedite legal consideration for how these emerging relationships ought to be received by law-generating bodies internationally. (shrink)

Drawing on the literature on the support of small businesses and case studies, this article advances the case for the support of African immigrant-owned businesses in South Africa which is currently neglected. In the past justification for the institution of support policies in favour of small businesses was predominantly based on the fact that they disproportionately encountered more obstacles than their larger counterparts. Shying away from the traditional “business focus” justification for the support of small business, this study advances an (...) “owner focus” justification - one that is based on the unique needs of the owner, rather than that of the business itself. Following similar logic, given that most immigrants start small businesses as a means of survival in their host countries, this study advances an even more compelling reason why immigrant-owned businesses should be supported. Acknowledging the role that a supported small business sector in general and immigrant-owned business, in particular, can play in the economy and taking steps to strengthen this sector would be in the right direction for the South Africa government. (shrink)

There are scenarios in which letting one’s own views on the question whether p direct one’s inquiry into that question brings about individual and collective epistemic benefits. However, these scenarios are also such that one’s evidence doesn’t support believing one’s own views. So, how to vindicate the epistemic benefits of directing one’s inquiry in such an asymmetric way, without asking one to hold a seemingly irrational doxastic attitude? To answer this question, the paper understands asymmetric inquiry direction in terms of (...) having one’s inquiry be guided by a doxastic attitude, which I call hypothesis, that’s governed by the following norm: One’s hypothesis that p is rational just in case it is a manifestation of the best feasible way to form a doxastic attitude regarding p that promotes the best feasible ways to advance towards settling the question of p’s (or of any other suitably related proposition’s) truth-value. (shrink)

As detailed in The Evolutionary Manifesto and Evolution’s Arrow, an understanding of the large-scale processes that govern the evolution of life is capable of making sense of human existence. This evolutionary worldview is revealing that we are not just meaningless accidents in a universe that is indifferent to our existence. Instead it shows that humanity has a critical role to play in the future evolution of life on this planet and in the universe. -/- But what specifically do we need (...) to do to advance the evolutionary process and ensure that humanity successfully fulfils its role in the future evolution of life? This paper uses the direction of evolution to answer this fundamental question. It identifies the next great steps in evolution on Earth, and devises strategies that will help actualize those steps. (shrink)

As systems based on opaque Artificial Intelligence (AI) continue to flourish in diverse real-world applications, understanding these black box models has become paramount. In response, Explainable AI (XAI) has emerged as a field of research with practical and ethical benefits across various domains. This paper not only highlights the advancements in XAI and its application in real-world scenarios but also addresses the ongoing challenges within XAI, emphasizing the need for broader perspectives and collaborative efforts. We bring together experts from diverse (...) fields to identify open problems, striving to synchronize research agendas and accelerate XAI in practical applications. By fostering collaborative discussion and interdisciplinary cooperation, we aim to propel XAI forward, contributing to its continued success. Our goal is to put forward a comprehensive proposal for advancing XAI. To achieve this goal, we present a manifesto of 27 open problems categorized into nine categories. These challenges encapsulate the complexities and nuances of XAI and offer a road map for future research. For each problem, we provide promising research directions in the hope of harnessing the collective intelligence of interested stakeholders. (shrink)

Gaining a high level of proficiency is the ultimate aspiration of all language learners, and the use of apology and politeness strategies is consistently associated with the levels of language proficiency. Owing to the significance of speech acts, politeness strategies, and level of proficiency, this study aimed to investigate the realization of apology speech acts and politeness strategies among Iranian EFL learners to examine and compare the lower-intermediate and advanced learners’ use of apology and politeness strategies. To achieve this goal, (...) 320 learners were selected out of 390 EFL learners who took a test of English language proficiency and were then divided into lower-intermediate and advanced levels. The findings of the study revealed significant differences between lower-intermediate and advanced Iranian EFL learners in the realization of the speech act of apology and politeness strategies. Advanced learners preferred to use more indirect and complicated forms of apology speech acts and tended to apply negative politeness and off-record strategies more than the lower-intermediate learners did. However, lower-intermediate learners preferred to use simple and more direct forms of apology and politeness strategies. It can be concluded that as learners increase their knowledge in the target language, and as their interlanguages get closer to the target language, they tend to apply more complicated and native-like speech acts and strategies . (shrink)

The contention raised in this research is to showcase that indigenous African languages are imperative tools in advancing African philosophy and thought. By extension the genuiness and originality of African philosophical thought is best advanced when it is vocalized and transliterated in the mother tongue of the philosopher. When African philosophical thought is done and articulated in language foreign to the philosopher, then that philosophical thought is weakened within the conceptual expression and foundation. It is also contended that, indigenous languages (...) would address perennial problem of inadequacies of languages especially where there are no direct replacement of concept and terms to explain reality and other state of affairs. (shrink)

General Relativity says gravity is a push caused by space-time's curvature. Combining General Relativity with E=mc2 results in distances being totally deleted from space-time/gravity by future technology, and in expansion or contraction of the universe as a whole being eliminated. The road to these conclusions has branches shining light on supersymmetry and superconductivity. This push of gravitational waves may be directed from intergalactic space towards galaxy centres, helping to hold galaxies together and also creating supermassive black holes. Together with the (...) waves' possible production of "dark" matter in higher dimensions, there's ample reason to believe knowledge of gravitational waves has barely begun. Advanced waves are usually discarded by scientists because they're thought to violate the causality principle. Just as advanced waves are usually discarded, very few physicists or mathematicians will venture to ascribe a physical meaning to Wick rotation and "imaginary" time. Here, that maths (when joined with Mobius-strip and Klein-bottle topology) unifies space and time into one space-time, and allows construction of what may be called "imaginary computers". This research idea you're reading is not intended to be a formal theory presenting scientific jargon and mathematical formalism. (shrink)

Health policy changes in Nepal displayed struggles against a poor political, geographical, and economic setting; Millennium Development Goal #4 demanded improved infant and child mortality, as well as adequate measles vaccine coverage by the year 2015. Research in this report presents progress and direction of child health care policy across more than a decade of time in attempts of attaining MDG #4 and general child health care advancements. Subsequent observations and suggestions were delineated and offered. Progress since the 1990’s up (...) to 2012 was analyzed by review of serial national survey and report data. Trends and variations between regions were mostly analyzed amongst various child health care determinants. Results indicated many improved factors; Nepal will likely achieve MDG regarding child under-5 mortality, but may not achieve measles vaccine coverage or infant mortality goals. Furthermore, severe regional disparities were evident within Nepal, particularly in the Mid and Far-Western regions. A call for integrated community-based primary health care (CB-PHC) for infants and children became an ultimate ideal. A comprehensive, multidisciplinary, and community based primary care delivery service would address many of the deficits identified as well as reach rural and remote areas that still suffered. Risk and data-based resource allocation promise improved utilization, but also demands more frequent and better data reporting. Coordinated, multi-sector health policy initiatives have been underway; this demonstrated a strong direction in improving child health care from urban to every village. (shrink)

Many enthusiasts of theistic evolution willingly accept Aquinas’s distinction between primary and secondary causes, to describe theologically “the mechanics” of evolutionary transformism. However, their description of the character of secondary causes in relation to God’s creative action oftentimes lacks precision. To some extent, the situation within the Thomistic camp is similar when it comes to specifying the exact nature of secondary and instrumental causes at work in evolution. Is it right to ascribe all causation in evolution to creatures—acting as secondary (...) and instrumental causes? Is there any space for a more direct divine action in evolutionary transitions? This article offers a new model of explaining the complexity of the causal nexus in the origin of new biological species, including the human species, analyzed in reference to both the immanent and transcendent orders of causation. (shrink)

DNA evidence is one of the most significant modern advances in the search for truth since the cross examination, but its format as a random-match-probability makes it difficult for people to assign an appropriate probative value (Koehler, 2001). While Frequentist theories propose that the presentation of the match as a frequency rather than a probability facilitates more accurate assessment (e.g., Slovic et al., 2000), Exemplar-Cueing Theory predicts that the subjective weight assigned may be affected by the frequency or probability format, (...) and how easily examples of the event, i.e., ‘exemplars’, are generated from linguistic cues that frame the match in light of further evidence (Koehler & Macchi, 2004). This paper presents two juror research studies to examine the difficulties that jurors have in assigning appropriate probative value to DNA evidence when contradictory evidence is presented. Study 1 showed that refuting evidence significantly reduced guilt judgments when exemplars were linguistically cued, even when the probability match and the refuting evidence had the same objective probative value. Moreover, qualitative reason for judgment responses revealed that interpreting refuting evidence was found to be complex and not necessarily reductive; refutation was found indicative of innocence or guilt depending on whether exemplars have been cued or not. Study 2 showed that the introduction of judges’ directions to linguistically cue exemplars, did not increase the impact of refuting evidence beyond its objective probative value, but less guilty verdicts were returned when jurors were instructed to consider all possible explanations of the evidence. The results are discussed in light of contradictory frequentist and exemplar-cueing theoretical positions, and their real-world consequences. (shrink)

To approach the issue of the recent proposal of an Extended Evolutionary Synthesis (EES) put forth by Massimo Pigliucci and Gerd Müller, I suggest to consider the EES as a metascientific view: a description of what’s new in how evolutionary biology is carried out, not only a description of recently learned aspects of evolution. Knowing ‘what is it to do research’ in evolutionary biology, today versus yesterday, can aid training, research and career choices, establishment of relationships and collaborations, decision of (...) funding and research policies, in order to make the field advance for the better. After reviewing the concepts associated to the EES proposal (categorized for convenience as mechanisms, measures, fields, perspectives and applications), I show their transience, and sketch out ongoing disagreements about the EES. Then I examine the deep difficulties, i.e., the enormity and complexity of the covered field, affecting the achievement of trusted metascientific views; the insufficiency of conceptual analysis to capture the substance of scientific research; the entanglement between empirical and metascientific concepts, between multiple chronologies, and between descriptive and normative intentions; and the ineliminable stakeholding of any reviewer involved in the reviewed field. I propose that disciplines such as scientometrics, ethnography, sociology, economics and history, combined with conceptual analysis, inspire a more rigorous approach to the evolutionary biology scientific community, more grounded and shared, confirming or transforming claims for ‘synthesis’ while preserving their maintenance goals. (shrink)

Response to commentaries on Savulescu and Dickenson article on preferences and advance directives.

I argue that a version of Pascal's Wager applies to the persistent vegetative state with sufficient force that it ought to part of advance directives.

When talking about personal identity in the context of medical ethics, ethicists tend to borrow haphazardly from different philosophical notions of personal identity, or to abjure these abstract metaphysical concerns as having nothing to do with practical questions in medical ethics. In fact, however, part of the moral authority for respecting a patient’s self-regarding decisions can only be made sense of if we make certain assumptions that are central to a particular, psychological picture of personal identity, namely, that patients will (...) remain psychologically connected to a certain degree with their future selves. I draw this out, show problems with approaches in medical ethics based on alternate theories of personal identity that do not recognise this, and explore some important implications. Namely, I show how this recognition can better explain the circumstances under which we should respect advance directives and why, and how it can better make sense of patient fears that they will not "survive" personality-altering deep brain stimulation procedures, and provide guidance on approaching patient decisions concerning this type of procedure in a manner that captures and addresses such concerns. (shrink)

Mackenzie Graham has made an important contribution to the literature on decisionmaking for patients with disorders of consciousness. He argues, and I agree, that decisions for unresponsive patients who are known to retain some degree of covert awareness ought to focus on current interests, since such patients likely retain the kinds of mental capacities that in ordinary life command our current respect and attention. If he is right, then it is not appropriate to make decisions for such patients by appealing (...) to the values they had in the past, either the values expressed in an advance directive or the values recalled by a surrogate. There are two things I wish to add to the discussion. My first point is somewhat critical, for although I agree with his general conclusion about how, ideally, such decisions should be approached, I remain skeptical about whether his conclusion offers decisionmakers real practical help. The problem with these cases is that the evidence we have about the nature of the patient’s current interests is minimal or nonexistent. However—and this is important—Graham’s conclusion will be extremely relevant if in the future, our ability to communicate with such patients improves, as I hope it will. This leads to my second point. Graham’s conclusion illustrates a more general problem with our standard framework for decisionmaking for previously competent patients, a problem that has not been adequately recognized. So, in what follows, I explain the problem I see and offer some brief thoughts about solutions. (shrink)

In this paper, I answer the following question: suppose that two individuals, C and D, have been in a long-term committed relationship, and D now has dementia, while C is competent; if D agrees to have sex with C, is it permissible for C to have sex with D? Ultimately, I defend the view that, under certain conditions, D can give valid consent to sex with C, rendering sex between them permissible. Specifically, I argue there is compelling reason to endorse (...) the following thesis: -/- Prior Consent Thesis: D, when competent, can give valid prior consent to sex with her competent partner (C) that will take place after she has dementia, assuming that D is the same person as she was when she gave prior consent, meaning that, if D, when competent, gave prior consent to sex with C, then C may permissibly have sex with D. In section I, I explain both the background and the existing literature on this issue. In section II, I outline relevant stipulations about the kinds of cases I will be examining. In section III, I defend the Prior Consent Thesis. And, in section IV, I address objections to the Prior Consent Thesis. (shrink)

It is widely accepted among medical ethicists that competence is a necessary condition for informed consent. In this view, if a patient is incompetent to make a particular treatment decision, the decision must be based on an advance directive or made by a substitute decision-maker on behalf of the patient. We call this the competence model. According to a recent report of the United Nations (UN) High Commissioner for Human Rights, article 12 of the UN Convention on the Rights (...) of Persons with Disabilities (CRPD) presents a wholesale rejection of the competence model. The High Commissioner here adopts the interpretation of article 12 proposed by the Committee on the Rights of Persons with Disabilities. On this interpretation, CRPD article 12 renders it impermissible to deny persons with mental disabilities the right to make treatment decisions on the basis of impaired decision-making capacity and demands the replacement of all regimes of substitute decision-making by supported decision-making. In this paper, we explicate six adverse consequences of CRPD article 12 for persons with mental disabilities and propose an alternative way forward. The proposed model combines the strengths of the competence model and supported decision-making. (shrink)

The standard of care in the United States favors stabilizing any adult who arrives in an emergency department after a failed suicide attempt, even if he appears decisionally capacitated and refuses life-sustaining treatment. I challenge this ubiquitous practice. Emergency clinicians generally have a moral obligation to err on the side of stabilizing even suicide attempters who refuse such interventions. This obligation reflects the fact that it is typically infeasible to determine these patients’ level of decisional capacitation—among other relevant information—in this (...) unique setting. Nevertheless, I argue, stabilizing suicide attempters over their objection sometimes violates a basic yet insufficiently appreciated right of theirs—the right against bodily invasion. In such cases, it is at least prima facie wrong to stabilize a patient who wants to die even if they lack a contrary advance directive or medical order and suffer from no terminal physical illness. (shrink)

Commentary on Walsh, E. 2020. Cognitive transformation, dementia, and the moral weight of advance directives. The American Journal of Bioethics. 20(8): 54–64.

Typical philosophical discussions of physician-assisted death have focused on whether the practice can be permissible. We address a different question: assuming that pad can be morally permissible, how far does that permission extend? We will argue that granting requests for pad may be permissible even when the pad recipient can no longer speak for themselves. In particular, we argue against the ‘competency requirement’ that constrains pad-eligibility to presently-competent patients in most countries that have legalized pad. We think pad on terminally (...) ill, incapacitated patients can be morally permissible in cases where advance directives or suitable surrogate decision-makers are available, and should be legally permissible in such cases as well. We argue that this view should be accepted on pain of inconsistency: by allowing surrogate decision-makers to request withdrawal of life-sustaining care on behalf of patients and by allowing patients to request pad, we rule out any plausible justification for imposing a competency requirement on pad. (shrink)

Loss of personal identity in dementia can raise a number of ethical considerations, including the applicability of advance directives and the validity of patient preferences that seem incongruous with a previous history of values. In this chapter, we first endorse the self-concept view as the most appropriate approach to personal continuity in healthcare. We briefly describe two different types of dementia, Alzheimer’s dementia (AD) and behavioral-variant frontotemporal dementia (bv-FTD). We identify elements considered important for the continuation of a (...) self-concept, including continuation of memories, consistency in personality traits and personal preferences, and continued endorsement of certain moral tenets. We show that, depending on which element is considered most important for personal identity, continuity of a self-concept for individuals with distinct types of dementia will be affected and assessed differently. Utilizing a variety of empirical evidence, we argue that persistence of memory, personality traits, and preferences are not the most important for the maintenance of personal identity. Instead, as studies aimed to capture the folk-psychological view of personal continuity demonstrate, judgements about continuity depend primarily on the persistent commitment to widely shared moral beliefs. Because of that, we argue that individuals with bv-FTD are more likely to lose their sense of self than individuals whose dementia primarily affects memory, such as Alzheimer’s disease. We end the chapter by showing how the importance of moral beliefs for continuity of self can be used to provide guidance to health-care professionals when considering changes in preference by individuals with dementia. (shrink)

What I call medically enabled suicides have four distinctive features: 1. They are instigated by actions of a suicidal individual, actions she intends to result in a physiological condition that, absent lifesaving medical interventions, would be otherwise fatal to that individual. 2. These suicides are ‘completed’ due to medical personnel acting in accordance with recognized legal or ethical protocols requiring the withholding or withdrawal of care from patients (e.g., following an approved advance directive). 3. The suicidal individual acts purposefully (...) to ensure that medical personnel will act on these protocols. 4. These suicides do not involve medical personnel providing aid in dying in the standard sense, either through (a) active voluntary euthanasia, or (b) assistance by means of prescriptions, etc. -/- Regardless of how common medically enabled suicides are, they raise compelling questions at the interface of medicine and individual choice. After first clarifying the concept of medically enabled suicide and exploring some of the reasons why it might be attractive to suicidal individuals, I then investigate two apparent dilemmas that medically enabled suicides raise for medical care providers. The first alleges that medical care providers may not contribute to harming their patients, and so they may not contribute to their patients’ suicides. The second alleges that if care providers, as a matter of personal conscience, believe that suicide is wrong, then they may not be compelled to contribute to their patient’s acting wrongly by assenting to the wishes of a patient pursuing medically enabled suicide. Both dilemmas arise from the fact that while medical personnel are bound by widely accepted precepts of medical ethics to honor the competent wishes of their patients, medically enabled suicides entangle them in their patients’ suicidal plans in ways that result in their contributing to those suicides. I conclude that neither dilemma should be resolved in the direction of medical personnel having the right to refrain from involvement in medically enabled suicides. Thus, while we may find medically enabled suicide distasteful or exploitative, a strong case cannot be made that medical personnel refusing to involve themselves in such suicides is ethically permissible. (shrink)

Abstract:Respect for persons protects patients regarding their own healthcare decisions. Patient informed choice for altruism (PICA) is a proposed means for a fully autonomous patient with decisionmaking capacity to limit his or her own treatment for altruistic reasons. An altruistic decision could bond the patient with others at the end of life. We contend that PICA can also be an advance directive option. The proxy, family, and physicians must be reminded that a patient’s altruistic treatment refusal should be respected.

Patient preference predictors aim to solve the moral problem of making treatment decisions on behalf of incapacitated patients. This commentary on a case of an unrepresented patient at the end of life considers 3 related problems of such predictors: the problem of restricting the scope of inputs to the models (the “scope” problem), the problem of weighing inputs against one another (the “weight” problem), and the problem of multiple reasonable solutions to the scope and weight problems (the “multiple reasonable models” (...) problem). Each of these problems poses challenges to reliably implementing patient preference predictors in important, high-stakes health care decision making. This commentary also suggests a way forward. (shrink)

Advanced medical imaging, such as CT, fMRI and PET, has undergone enormous progress in recent years, both in accuracy and utilization. Such techniques often bring with them an illusion of immediacy, the idea that the body and its diseases can be directly inspected. In this paper we target this illusion and address the issue of the reliability of advanced imaging tests as knowledge procedures, taking positron emission tomography in oncology as paradigmatic case study. After individuating a suitable notion of reliability, (...) we argue that PET is a highly theory-laden and non-immediate knowledge procedure, in spite of the photographic-like quality of the images it delivers; the diagnostic conclusions based on the interpretation of PET images are population-dependent; PET images require interpretation, which is inherently observer-dependent and therefore variable. We conclude with a three-step methodological proposal for enhancing the reliability of advanced medical imaging. (shrink)

Technological advances are bringing new light to privacy issues and changing the reasons for why privacy is important. These advances have changed not only the kind of personal data that is available to be collected, but also how that personal data can be used by those who have access to it. We are particularly concerned with how information about personal attributes inferred from collected data (such as online behaviour), can be used to tailor messages and services to specific individuals or (...) groups. This kind of ‘personalised targeting’ has the potential to influence individuals’ perceptions, attitudes, and choices in unprecedented ways. In this paper, we argue that because it is becoming easier for companies to use collected data for influence, threats to privacy are increasingly also threats to personal autonomy—an individual’s ability to reflect on and decide freely about their values, actions, and behaviour, and to act on those choices.4 While increasing attention is directed to the ethics of how personal data is collected, we make the case that a new ethics of privacy needs to also think more rigorously about how personal data may be used, and its potential impact on personal autonomy. (shrink)

While this article sets out to advance our knowledge about the characteristics of Nigerian cybercriminals (Yahoo-Boys), it is also the first study to explore the narratives of the Economic and Financial Crimes Commission (EFCC) officers concerning them. It appraises symbolic interactionist insights to consider the ways in which contextual factors and worldview may help to illuminate officers’ narratives of cybercriminals and the interpretations and implications of such accounts. Semi-structured interviews of forty frontline EFCC officers formed the empirical basis of (...) this study and were subjected to a directed approach of qualitative content analysis. While prior studies, for example, indicated that only a group of cybercriminals deploy spiritual and magical powers to defraud victims (i.e. modus operandi), our data analysis extended this classification into more refined levels involving multiple features. In particular, analysis bifurcates cybercriminals and their operations based on three factors: [a] educational-attainment, [b] modus-operandi, and [c] networks-collaborators. Results also suggest that these cybercriminals and their operations are embedded in “masculinity-and-material-wealth”. These contributions thus have implications for a range of generally accepted viewpoints about these cybercriminals previously taken-for-granted. Since these criminals have victims all over the world, insights from our study may help various local and international agencies [a] to understand the actions/features of these two groups of cybercriminals better and develop more effective response strategies. [b] to appreciate the vulnerabilities of their victims better and develop more adequate support schemes. We also consider the limitations of social control agents’ narratives on criminals. (shrink)

Recent advances in our understanding of visual perception have shown it to be a far more complex and counterintuitive process than previously believed. Several important consequences follow from this. First, the design of an effective statistical graphics system is unlikely to succeed based on intuition alone; instead, it must rely on a more sophisticated, systematic approach. The basic elements of such an approach are outlined here, along with several design principles. An overview is then given of recent advances in our (...) understanding of visual perception, including rapid perception, visual attention, and scene perception. It then is argued that the mechanisms involved can be successfully harnessed to allow data to be displayed more effectively than at present. Several directions of development are discussed, including effective use of visual attention, the display of dynamic information, and the effective use of nonattentional and nonconscious perceptual systems. (shrink)

We advance a theory of the representational role of Euclidean diagrams according to which they are samples of co-exact features. We contrast our theory with two other conceptions, the instantial conception and Macbeth’s iconic view, with respect to how well they accommodate three fundamental constraints on theories of the Euclidean diagrammatic practice— that Euclidean diagrams are used in proofs whose results are wholly general, that Euclidean diagrams indicate the co-exact features that the geometer is allowed to infer from them (...) and that Euclidean diagrams play the same role in both direct proofs and indirect proofs by reductio—and argue that our view is the one best suited to account for them. We conclude by illustrating the virtues of our conception of Euclidean diagrams as samples by means of an analysis of Saccheri’s quadrilateral. (shrink)