Background: This study sought to understand the ethical issues encountered by medical residents during their residencies, evaluate the solutions proffered by them, and present their suggestions. Material/Methods: A survey consisting of 32 questions, including demographic information, was developed and distributed to Intensive Care Unit (ICU) residents from December 2020 to January 2021. A total of 53 completed questionnaires were submitted to the researchers. The data were analyzed using SPSS software version 26.0. Results: Of the participating residents who returned (...) completed forms, 50.9% were male and 49.1% were female, with an overall mean age of 30.5±4.4 years. Most residents’ views on ethical issues concerned themselves, the clinic, and patients/patient relatives. Responses showed a number of commonalities with the views of ICU physicians in other countries. Suggestions for resolving ethical issues solutions included instruction in medical ethics for all staff, increasing and strengthening pathways of communication both inside and outside of the clinics, regular inventory of medical supplies and assessment of equipment to prevent a shortage of resources, and the establishment of a hospital ethics committee. Conclusions: As numerous and varied ethical issues were encountered in the participating ICUs, we propose the following: preparation of an ICU-specific guide for resolving ethical problems, clarification of rules based on legal regulations, determining a hierarchy of responsibilities, and ethics courses for all ICU staff. In addition, hospital managers should support ICU services from both a legal and ethical standpoint. (shrink)

After severe brain injury, one of the key challenges for medical doctors is to determine the patient’s prognosis. Who will do well? Who will not do well? Physicians need to know this, and families need to do this too, to address choices regarding the continuation of life supporting therapies. However, current prognostication methods are insufficient to provide a reliable prognosis. -/- Functional Magnetic Resonance Imaging (MRI) holds considerable promise for improving the accuracy of prognosis in acute brain injury patients. Nonetheless, (...) research on functional MRI in the intensive care unit context is ethically challenging. These studies raise several ethical issues that have not been addressed so far. In this article, Prof. Charles Weijer and his co-workers provide a framework for researchers and ethics committees to design and review these studies in an ethically sound way. (shrink)

This descriptive study explores the views of resident physicians working in intensive care units (ICUs) concerning deceased organ donation and examines the various ethical issues surrounding organ donation encountered by residents. This was a qualitative, descriptive study utilizing solo interviews with participants together with focus group discussions. The participants' experiences and views were elicited via interviews and focus group discussions covering the following topics: ethical thoughts about deceased organ donation, barriers that impede or prevent organ donation, its (...) effect on the next of kin, and its relationship with futile treatment. The discussions were reviewed using qualitative content analysis. The residents commented that deceased organ donation is a complex and stressful process for the family of the potential donor as well as the transplant team, and still lacks wide acceptance in Turkish society. The opt-in system requires informed consent, thus creating a major barrier for both the patient’s family and the ICU team to overcome. The participants stated that new legal, ethical, and medical arrangements are needed to increase organ donation rates in Turkey. In order to increase rates of deceased organ donation and reduce cases of futile treatment, improved communication between the ICU, transplant team, and patient relatives is critical to ensure that ethical issues are properly managed. On a societal level, the subject of deceased organ donation needs to receive greater attention from public health authorities to increase public awareness. Residents can make valuable contributions to the deceased organ donation process as physicians and as psychosocial support for patients and their families. (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 late Robert Veatch, one of the United States’ founders of bioethics, never tired of reminding us that the paradigm-shifting contribution that bioethics made to patient care was to liberate patients out of the hands of doctors, who were traditionally seen to know best, even when they decidedly did not know best. It seems to us that with the advent of COVID-19, health policy has come full-circle on this. COVID-19 gave rise to a large number of purportedly (...) “ethical” guidance documents aiming to assist health care providers and practitioners with responding to the ethical challenges that might arise in their response to the pandemic. Ethics has two primary functions: provide clear action guidance, and provide clear action justification. The documents in question arguably reflect the ultimate policy triumph of bioethical “principlism”, and, perhaps surprisingly, as a corollary, the ultimate triumph of “doctor-knows-best”. (shrink)

How could ectogestative technology disrupt gender roles, parenting practices, and concepts such as ‘birth’, ‘body’, or ‘parent’? In this chapter, we situate this emerging technology in the context of the history of reproductive technologies and analyse the potential social and conceptual disruptions to which it could contribute. An ectogestative device, better known as ‘artificial womb’, enables the extra-uterine gestation of a human being, or mammal more generally. It is currently developed with the main goal of improving the survival chances of (...) extremely premature neonates. We argue that the intended use of the technology in neonatal intensive care units, as an alternative to current incubators (’partial-ectogestation’), challenges concepts such as ‘birth’, ‘fetus’, and ‘neonate’, and has several ethico-legal implications. We moreover address a more futuristic scenario where the entire embryological and fetal development could happen within an artificial womb (’full-ectogestation’). Such a scenario reveals the disruption of gender roles, parenting practices, and concepts such as ‘mother’, ‘father’, and ‘parent’. Both full- and partial-ectogestation would have implications for engineering and design, law-making, ethics, and philosophical anthropology. (shrink)

When hospitals face surges of patients with COVID-19, fair allocation of scarce medical resources remains a challenge. Scarcity has at times encompassed not only hospital and intensive care unit beds—often reflecting staffing shortages—but also therapies and intensive treatments. Safe, highly effective COVID-19 vaccines have been free and widely available since mid-2021, yet many Americans remain unvaccinated by choice. Should their decision to forgo vaccination be considered when allocating scarce resources? Some have suggested it should, while others disagree. (...) We offer a framework for evaluating when it is ethical and briefly discuss its legality in American law. (shrink)

This piece lays out the framework for a special issue on the topic of "Fits and Misfits," published as volume 7, issue 1 of Puncta: A Journal of Critical Phenomenology. We discuss the relationship between the concept of misfitting, coined by Rosemarie Garland-Thomson, and debility, coined by Jasbir Puar, in relationship to scholarship on Merleau-Ponty. We then introduce each of the eight articles in the special issue: Rosemarie Garland-Thomson's "What Misfitting Makes," Susan Bredlau's "Conversational Accessibility: Healthcare, Community, and the (...) class='Hi'>Ethics of Everyday Encounters," Helen A. Fielding's "Being Touched by Wellness: Merleau-Ponty, Nancy, and the Intensive Care Unit," Ann Murphy's "The Spirited Interworld: Caregiving and the Liminal Phenomenology of Dementia," Rachel Elliott's "Sharing Time with Misfits: We-Experience across Bodily Difference," David Morris's "An-Archic Time: Melting the Clock as Hypernorm of the I Can -- and Philosophy," Rebecca Longtin's "Merleau-Ponty's Cézanne as Misfit Artist," and, finally, Laura McMahon's "The Politics of Vulnerability and the School for Peace: Insights from Butler, Merleau-Ponty, and Family Systems Theory.". (shrink)

In response to the COVID‐19 pandemic philosophers and governments have proposed scarce resource allocation guidelines. Their purpose is to advise healthcare professionals on how to ethically allocate scarce medical resources. One challenging feature of the pandemic has been the large numbers of patients needing mechanical ventilatory support. Guidelines have paradigmatically focused on the question of what doctors should do if they have fewer ventilators than patients who need respiratory support: which patient should get the ventilator? There is, however, an important (...) higher level allocation problem. Namely, how are we to ethically distribute newly obtained ventilators across hospitals: which hospital should get the ventilator(s)? In this paper, we identify a set of principles for allocating newly obtained ventilators across hospitals. We focus particularly on low and middle income countries, who frequently have limited pre‐existing intensive care capacity, and have needed to source additional ventilators. We first provide some background. Second, we argue that the main population healthcare aim during the COVID‐19 pandemic should be to save the most lives. Next, we assess a series of potential heuristics or principles that could be used to guide allocation: allocation to the most densely populated cities, random allocation, allocation based on the ratio of patients to ICU personnel, prioritisation in terms of intrahospital mortality, prioritisation of younger populations, and prioritisation in terms of population mortality. We conclude by providing a plausible ranking of the principles, while noting a number of epistemological challenges, in terms of how they best further the aim of increasing the probability of saving the most lives. (shrink)

In the United States, the Presidential Commission for the Study of Bioethical Issues has proposed deliberative democracy as an approach for dealing with ethical issues surrounding synthetic biology. Deliberative democracy might similarly help us as we update the regulation of human subjects research. This paper considers how the values that deliberative democratic engagement aims to realize can be realized in a human subjects research context. Deliberative democracy is characterized by an ongoing exchange of ideas between participants, and an effort to (...) justify decisions that bind participants by appeal to reasons that the participants can understand and share. Even when unanimous agreement is not reached, the active participation of everyone along with the requirement that reasons be made accessible enhances the legitimacy of the ultimate outcome. Importantly, deliberative democratic structures avoid strict hierarchies and place participants, as much as possible, in the position of equals. Human subjects research has some features that may make deliberative democratic principles seem initially unappealing. For one, there are asymmetries in knowledge between expert researchers conducting the research and participants in the research process. For another, statistical validity is made easiest by research paradigms that produce standardized, quantitative data, which can be difficult to achieve if research participants are given the power to deliberatively reshape the research design as it progresses. These and other problems have tended to produce a human subjects research process where subjects do not actively participate in shaping research, but rather consent to a predefined set of interventions designed by expert researchers and vetted by Institutional Review Boards (IRBs). In this paper, I suggest some ways in which human subjects research could do more to realize deliberative democratic values, and, in particular, how a revised Common Rule might help to realize these values. First, research participants could be treated not as passive subjects but instead involved in research design, ethical review, and the ongoing conduct and dissemination of research. Such participation might involve, for instance, including people who have served as research subjects on IRBs, or replacing IRB oversight for certain forms of research exempted from IRB oversight under a revised Common Rule with oversight by a body of community members or research subjects. It might also involve having the oversight of research that uses more participatory models be more participatory and less hierarchical in nature. I also raise questions about the exemption of research on public benefit programs from any research-level oversight and from consent requirements. While IRBs are likely not the correct overseers, there may be good reason to view such research with a critical eye, because of its potential for long-range impacts on the lives of participants. By giving research subjects a greater voice in research that aims at fine-tuning public benefit programs on which subjects rely, a deliberative oversight process has the potential to recast research participation as a form of active democratic participation and to address a “democratic deficit” in public health. Numerous proposals regarding health care have called for greater participation by laypeople and a more nonhierarchical approach to setting health priorities. Involving lay research subjects in the conduct of public benefits research and other forms of public health research may help to further these goals. (shrink)

This article examines the subtle interconnection between the sanctity of life and individual autonomy within the context of assisted dying, as seen through the lens of Orthodox Christianity. It seeks to unravel the complex theological, ethical, and pastoral considerations that inform the Orthodox stance on end-of-life issues, particularly the nuanced understanding of suffering, death, and the redemptive potential encapsulated within them. Orthodox theology, with its profound veneration for life as a divine gift, offers a counter-narrative to contemporary discourses that often (...) prioritize personal autonomy and the alleviation of suffering above all. This tradition emphasizes the transformative power of suffering when united with Christ’s own redemptive suffering, proposing a vision of end-of-life care that is rooted in compassion, dignity, and hope for resurrection. The exploration begins with a historical and theological examination of the Orthodox perspective on life’s sanctity, engaging with the teachings of Church Fathers and contemporary theological and bioethical discussions. It highlights the foundational concepts of Orthodox anthropology, which perceives human beings as an indivisible unity of body and soul, reflecting the imago Dei. This anthropological understanding challenges reductionist views of human existence and informs the Orthodox approach to medical ethics, palliative care, and the spiritual accompaniment of the dying. By critically evaluating arguments for and against assisted dying, the article presents a balanced discourse that respects the depth of individual suffering while upholding the intrinsic value of life. It argues that Orthodox Christianity, through its rich theological heritage and pastoral practice, provides a compassionate and ethically nuanced framework for navigating the moral complexities of assisted dying. This framework advocates for an end-of-life care that honors the fullness of the human person, supports the spiritual journey toward eternal life, and fosters a communal embrace of life’s sacred threshold, offering a dignified passage that aligns with the faith’s deepest convictions about human destiny and divine grace. (shrink)

The COVID-19 pandemic has coincided with the proliferation of ethical guidance documents to assist public health authorities, health care providers, practitioners and staff with responding to ethical challenges posed by the pandemic. Like ethical guidelines relating to infectious disease that have preceded them, what unites many COVID-19 guidance documents is their dependency on an under-developed approach to bioethical principlism, a normative framework that attempts to guide actions based on a list of prima facie, unranked ethical principles. By situating them (...) in relation to the key philosophical debates concerning bioethical principlism, we aim to explore the limits and limitations of pandemic ethical guidance documents as, specifically, ethics documents – documents that fulfil the functions of ethics as a fundamentally normative discipline. This means not only determining whether such ethical guidance documents can, in principle, provide adequate action guidance and action justification, but also, more importantly where pandemics are concerned, determining whether they support consistent decision making and transparent processes of justification. Having highlighted the problems with merely furnishing ethical guidelines with substantive ethical content in terms of principles and values, we argue that organizations that develop these documents should, instead, focus on the procedural dimensions of action guidance and action justification, which extend to questions regarding the make-up of the committees, panels and groups that develop such guidelines, the public transparency of justifications for specific pandemic-related advice or interventions and the development of explicit procedures for transparent and consistent decision making. (shrink)

In this article, part of a special issue on meaning in life and medical ethics, I argue that several issues encountered in a bioethical context are not adequately addressed only with values such as morality and welfare. I maintain, more specifically, that the value of what makes a life meaningful is essential to being able to provide conclusive judgements about which decisions to make. After briefly indicating how meaningfulness differs from rightness and happiness, I point out how it is (...) plausibly central to making decisions in six ‘life and death’ matters. My aim is not to draw any firm conclusions about what to do when it comes to these topics, but rather to show that in order to arrive at any, one cannot plausibly ignore the category of life’s meaning that has, until recently, been nearly absent from Western bioethics since its inception. (shrink)

A principal challenge facing the progressive bioethics project is the crafting of a consistent message on biopolitical issues that divide progressives. -/- The regulation of enhancement technologies is one of the issues central to this emerging biopolitics, pitting progressive defenders of enhancement, “technoprogressives,” against progressive critics. This essay [PDF] will argue that technoprogressive biopolitics express the consistent application of the core progressive values of the Enlightenment: the right of individuals to control their own bodies, brains and reproduction according to (...) their own conscience, under democratic states that work for the public good. -/- Insofar as left bioconservatives want to ensure the safety of therapies and their equitable distribution, these concerns can be addressed by thorough and independent regulation and a universal health care system, and a progressive bioethics of enhancement can unite both enthusiasts and skeptics. Insofar as bioconservative concerns are motivated by deeper hostility to the Enlightenment project however, by assertion of pre-modern reverence for human uniqueness for instance, then a common program is unlikely. -/- imageAfter briefly reviewing the political history and contemporary landscape of biopolitical debates about enhancement, the essay outlines three meta-policy contexts that will impact future biopolicy: the pressure to establish a universal, cost-effective health insurance system, the aging of industrial societies, and globalization. Technoprogressive appeals are outlined that can appeal to key constituencies, and build a majority coalition in support of progressive change. Finally, some guiding principles for a technoprogressive approach to biopolicy are offered. (shrink)

The Disabilities Act of 1990 and the Developmental Disabilities Assistance and Bill of Rights Act of 2000 of United States in act to prevent social exclusion of people with intellectual and developmental disabilities (IDDs) and to cut back on unneeded expenditures to society. However, despite the protective legislation, the rights of adults with neurodevelopmental disorders have not yet been fully realised. There are several obstacles to overcome the neurological development related health care services, including health care usage, educational (...) and career pathways, family and social lives, self-fulfilment, and quality of life. There are significant gaps in the transition process that affect the health care systems. Lack of transition and transfer planning, neurodevelopmental disorder health care pathway services have lack of experience, education, and expertise which result the inadequate growth of the health care quality and create communication gap in between service providers and service users. The aim of this short communication is to mention and clarify the ethical concerns of neurodevelopmental service evaluation. (shrink)

Without doctors being able to explain medical decisions to patients, I argue their use of black box AIs would erode the effective and respectful care they provide patients. In addition, I argue that physicians should use AI black boxes only for patients in dire straits, or when physicians use AI as a “co-pilot” (analogous to a spellchecker) but can independently confirm its accuracy. I respond to A.J. London’s objection that physicians already prescribe some drugs without knowing why they work.

Technological developments involving robotics and artificial intelligence devices are being employed evermore in elderly care and the healthcare sector more generally, raising ethical issues and practical questions warranting closer considerations of what we mean by “care” and, subsequently, how to design such software coherently with the chosen definition. This paper starts by critically examining the existing approaches to the ethical design of care robots provided by Aimee van Wynsberghe, who relies on the work on the ethics (...) of care by Joan Tronto. In doing so, it suggests an alternative to their non-principled approach, an alternative suited to tackling some of the issues raised by Tronto and van Wynsberghe, while allowing for the inclusion of two orientative principles. Our proposal centres on the principles of autonomy and vulnerability, whose joint adoption we deem able to constitute an original revision of a bottom-up approach in care ethics. Conclusively, the ethical framework introduced here integrates more traditional approaches in care ethics in view of enhancing the debate regarding the ethical design of care robots under a new lens. (shrink)

English-speaking research on morally right decisions in a healthcare context over the past three decades has been dominated by two major perspectives, namely, the Four Principles, of which the principle of respect for autonomy has been most salient, and the ethic of care, often presented as a rival to not only a focus on autonomy but also a reliance on principles more generally. In my contribution, I present a novel ethic applicable to bioethics, particularly as it concerns human (...) procreation, that I argue is a promising alternative to these two approaches. According to this new moral theory, an act is right just insofar as it treats people’s capacity to commune with respect, where communing is a matter of identifying with others and exhibiting solidarity with them. This ethic is inspired by relational ideals of communion and harmony from the African philosophical tradition, but is shown to be attractive to a broad, indeed global, audience, with regard to its implications for the morality of reproduction. (shrink)

The nature and role of the patient in biomedicine comprise issues central to bioethical inquiry. Given its developmental history grounded firmly in a backlash against 20th-century cases of egregious human subjects abuse, contemporary medical bioethics has come to rely on a fundamental assumption: the unit of care is the autonomous self-directing patient. In this article we examine first the structure of the feminist social critique of autonomy. Then we show that a parallel argument can be made against relational (...) autonomy as well, demonstrating how this second concept of autonomy fails to take sufficiently into account an array of biological determinants, particularly those from microbial biology. Finally, in light of this biological critique, we question whether or to what extent any relevant and meaningful view of autonomy can be recovered in the contemporary landscape of bioethics. (shrink)

Background The worldwide increase in older persons demands technological solutions to combat the shortage of caregiving and to enable aging in place. Smart home health technologies (SHHTs) are promoted and implemented as a possible solution from an economic and practical perspective. However, ethical considerations are equally important and need to be investigated. Methods We conducted a systematic review according to the PRISMA guidelines to investigate if and how ethical questions are discussed in the field of SHHTs in caregiving for older (...) persons. Results 156 peer-reviewed articles published in English, German and French were retrieved and analyzed across 10 electronic databases. Using narrative analysis, 7 ethical categories were mapped: privacy, autonomy, responsibility, human vs. artificial interactions, trust, ageism and stigma, and other concerns. Conclusion The findings of our systematic review show the (lack of) ethical consideration when it comes to the development and implementation of SHHTs for older persons. Our analysis is useful to promote careful ethical consideration when carrying out technology development, research and deployment to care for older persons. Registration We registered our systematic review in the PROSPERO network under CRD42021248543. (shrink)

In bioethics, the predominant categorization of various types of influence has been a tripartite classification of rational persuasion (meaning influence by reason and argument), coercion (meaning influence by irresistible threats—or on a few accounts, offers), and manipulation (meaning everything in between). The standard ethical analysis in bioethics has been that rational persuasion is always permissible, and coercion is almost always impermissible save a few cases such as imminent threat to self or others. However, many forms of influence fall (...) into the broad middle terrain—and this terrain is in desperate need of conceptual refining and ethical analysis in light of recent interest in using principles from behavioral science to influence health decisions and behaviors. This paper aims to address the neglected space between rational persuasion and coercion in bioethics. First, I argue for conceptual revisions that include removing the “manipulation” label and relabeling this space “nonargumentative]influence,” with two subtypes: “reason-bypassing” and “reason-countering.” Second, I argue that bioethicists have made the mistake of relying heavily on the conceptual categories themselves for normative work and instead should assess the ethical permissibility of a particular instance of influence by asking several key ethical questions, which I elucidate, that relate to (1) the impact of the form of influence on autonomy and (2) the relationship between the influencer and the influenced. Finally, I apply my analysis to two examples of nonargumentative influence in health care and health policy: (1) governmental agencies such as the Food and Drug Administration (FDA) trying to influence the public to be healthier using nonargumentative measures such as vivid images on cigarette packages to make more salient the negative effects of smoking, and (2) a physician framing a surgery in terms of survival rates instead of mortality rates to influence her patient to consent to the surgery. (shrink)

This chapter reviews fundamental ethical controversy surrounding the ongoing effort to revise the Uniform Determination of Death Act in the United States. Instead of focusing on the process of the revision itself, the chapter explores the underlying ethical debate over brain death that has been ongoing for many decades and finally culminated in this revision. Three issues are focused: the requirement for consent and personal exemptions before applying brain death for the diagnosis of death; redefining the areas of the brain (...) that have ceased to function in the definition of brain death; and codifying the American Academy of Neurology as the authority to issue the standards of the diagnosis of brain death. The chapter concludes that allowing the personal choice of death determination gives a pragmatic compromise to the disputed definition and practice of diagnosing brain death. So long as all risks and imperfections of the diagnosis are accepted through the consenting process, there is nothing ethically objectionable to continuing the current practice of diagnosing brain death as a successful tool to facilitate heart-beating organ donation without violating the dead-donor rule. By contrast, precluding personal choice and imposing legal restrictions to consent and exemptions would further erode public trust. (shrink)

In "Frailty Triage: Is Rationing Intensive Medical Treatment on the Grounds of Frailty Ethical?," Wilkinson (2021) argues that the use of frailty scores in ICU triage does not necessarily involve discrimination on the basis of disability. In support of this argument, he claims, “it is not the disability per se that the score is measuring – rather it is the underlying physiological and physical vulnerability." While we appreciate the attention Wilkinson explicitly pays to disability in this piece, we find (...) the distinction between disability and underlying vulnerability untenable both theoretically and practically. In this peer commentary, we begin with a brief overview of research in philosophy of disability concerning the meaning of the concept itself. We argue that this research demonstrates that many forms of disability do not involve underlying vulnerabilities, and, furthermore, that Wilkinson equivocates between "disability" understood as a medical category vs. "disability" understood as a feature of lived experience. We reject Wilkinson’s distinction on these grounds and offer further considerations to avoid disability discrimination in emergency and crisis standards of care contexts. (shrink)

Objectives -/- Surveys in various countries suggest 17% to 80% of doctors prescribe ‘placebos’ in routine practice, but prevalence of placebo use in UK primary care is unknown. Methods -/- We administered a web-based questionnaire to a representative sample of UK general practitioners. Following surveys conducted in other countries we divided placebos into ‘pure’ and ‘impure’. ‘Impure’ placebos are interventions with clear efficacy for certain conditions but are prescribed for ailments where their efficacy is unknown, such as antibiotics for (...) suspected viral infections. ‘Pure’ placebos are interventions such as sugar pills or saline injections without direct pharmacologically active ingredients for the condition being treated. We initiated the survey in April 2012. Two reminders were sent and electronic data collection closed after 4 weeks. Results -/- We surveyed 1715 general practitioners and 783 (46%) completed our questionnaire. Our respondents were similar to those of all registered UK doctors suggesting our results are generalizable. 12% (95% CI 10 to 15) of respondents used pure placebos while 97% (95% CI 96 to 98) used impure placebos at least once in their career. 1% of respondents used pure placebos, and 77% (95% CI 74 to 79) used impure placebos at least once per week. Most (66% for pure, 84% for impure) respondents stated placebos were ethical in some circumstances. Conclusion and implications -/- Placebo use is common in primary care but questions remain about their benefits, harms, costs, and whether they can be delivered ethically. Further research is required to investigate ethically acceptable and cost-effective placebo interventions. (shrink)

Regarding the relation of Plato’s early and middle period dialogues, scholars have been divided to two opposing groups: unitarists and developmentalists. While developmentalists try to prove that there are some noticeable and even fundamental differences between Plato’s early and middle period dialogues, the unitarists assert that there is no essential difference in there. The main goal of this article is to suggest that some of Plato’s ontological as well as epistemological principles change, both radically and fundamentally, between the early and (...) middle period dialogues. Though this is a kind of strengthening the developmentalistic approach corresponding the relation of the early and middle period dialogues, based on the fact that what is to be proved here is a essential development in Plato’ ontology and his epistemology, by expanding the grounds of development to the ontological and epistemological principles, it hints to a more profound development. The fact that the bipolar and split knowledge and being of the early period dialogues give way to the tripartite and bound knowledge and benig of the middle period dialogues indicates the development of the notions of being and knowledge in Plato’s philosophy before the dialogues of the middle period. -/- Keywords Plato; early dialogues; middle dialogues; being; knowledge; development -/- Introduction The differences between two groups of the early and middle period dialogues have always been a matter of dispute. Whereas the developmentalists like Vlastos, Silverman (2002), Teloh (1981), Dancy (2004) and Rickless (2007) think that from the early to the middle dialogues Plato’s philosophy changes, at least in some essential points, the unitarists like Kahn, Cherniss and Shorey believe that there happens no development and the differences must be taken as natural, ignorable and even pedagogic. In his well-known article, Socrates contra Socrates in PLATO, Vlastos lists ten theses of difference between two groups of dialogues. The first group which includes Plato’s early dialogues he divides to 'elenctic' (Apology, Charmides, Crito, Euthyphro, Gorgias, Hippias Minor, Ion, Laches, Protagoras and Republic I) and 'transitional' (Euthydemus, Hippias Major, Lysis, Menexenus and Meno) dialogues. These transitional come after all the elenctic dialogues and before all the dialogues of the second group which compose Plato’s middle period dialogues, including (with Vlastos' chronological order) Cratylus, Phaedo, Symposium, Republic II-X, Phaedrus, Parmenides and Theaetetus (1991, 46-49). Vlastos asserts strictly that his list of differences are 'so diverse in content and method that they contrast as sharply with one another as with any third philosophy you care to mention, beginning with Aristotole’s' (ibid, 46). Vlastos’ list of differences between two Socrateses is considered a view breaking sharply between the early and the middle dialogues. Besides all ten differences between the two Socrateses in Vlastos’ list that can be supportive for our doctrine here, we intend to focus on some ontological as well as epistemological distinctions that have not completely been discussed hitherto. Contrary to the developmentalist theory of Vlastos, unitarian theory of Charles Kahn wishes to eliminate any substantial difference between the early and the middle dialogues. He distinguishes seven 'pre-middle' or 'threshold' dialogues including Laches, Charmides, Euthyphro, Protagoras, Meno, Lysis and Euthydemus from the other Socratic dialogues which he calls 'earliest group' (1996, 41). The threshold dialogues, Kahn thinks, 'embarke upon a sustained project' that is to reach to its climax in the middle period dialogues, namely Phaedo, Symposium and Republic. Believing in that there is no 'fundamental shift'between the early and middle dialogues (ibid, 40), Kahn thinks the Socratic dialogues are just the 'first stage' with a 'deliberate silence' towards the theories of later periods (ibid, 339). One of the reasons of the surprising fact that Plato gives no hint of the metaphysics and epistemology of the Forms in the early dialogues, he thinks, is the pedagogical advantages of aporia. He thinks that Plato 'obscurely', and mostly because of education, hinted to some doctrines and conceptions in his early dialogues and with the aim of clarifying them only in the later ones (ibid, 66). The seven threshold dialogues, Kahn asserts, 'had been designed from the first' to prepare the pupils and readers for the views expounded in the middle period dialogues (ibid, 59-60). To show that the differences of the two Socrateses of the early and middle period dialogue are in their onto-epistemological grounds and thence cannot be explained by a unitaristic view, we try to draw the ontological and epistemological principles of the early dialogues in the first part below in order to show, in the second part, that those principles have been developed in the middle period dialogues. -/- A. The Onto-Epistemologic Principles of the Early Dialogues Socratic dialogues are paradoxical about knowledge because while being knowledge-oriented always searching for knowledge, they deny it and even never discuss it directly. Three elements of Socrates’ way of searching Knowledge throughout the early dialogues, i.e. Socratic 'what is X?' question, his disavowal of knowledge and his elenctic method combined together produce something like a circle which works, more or less, in the same way in these dialogues. Though this circle is an embaressing inquiry always resulting in ignorance instead of knowledge, its motivation is surprisingly Socrates’ passionate enthusiasm for knowledge, an intensive love of wisdom. The starting point of this circle is Socrates’ confession of having no knowledge which might be explicitly asserted or presupposed, maybe because it was one of the famous characteristics of Socrates; a confession always paradoxically accompanied with his intense longing for knowledge (e.g., Gorgias 505e4-5). Every time Socrates encounters with someone who thinks he knows something (οἴεταί τι εἰδέναι) (Apology 21d5) and tries to examine him. This examination seems to be the simplest one asking just what it is that he knows. Socrates’ elenchus, therefore, is always connected with 'what is X?' (τίς ποτέ ἐστιν) question, a question that most of the early dialogues of Plato are concerned with; 'what is courage?' in the Laches, 'what is piety?' in Euthydemus, 'what is temperance?' in Charmides and 'what is beauty?' in Hippias Major. This question we call here 'Socratic question' and probably is the very question the historical Socrates used to employ, is tightly interrelated with both his disavowal and his elenchus. He disclaims knowledge because he cannot find the answer to the question himself and he rejects others’ since they cannot offer the correct answer too. Every interlocutor can claim he knows X, if and only if he can answer the Socratic question. Otherwise, he is more of an ignorant than of a knower of τί ποτέ ἐστι X. Knowing the answer to this question is, thus, knowledge’s criterion for Socrates. Having found out that he cannot answer what it is which he would claim to know, the interlocutor comes to the point Socrates was there at the beginning. The least advantage of this circle is that he becomes as wise as Socrates does about the subject, becoming aware that he does not know it. At the end of the circle they are both still at the beginning, not knowing what X is. So let us first take a glance at these three elements. Socratic disavowal of knowledge is strictly asserted in some passages. At Apology 21b4-5, Socrates says: -/- I do not know of myself being wise at all (οὔτε μέγα οὔτε σμικρὸν σύνοιδα ἐμαυτῷ σοφὸς ὤν) -/- Moreover, at 21d4-6: -/- None of us knows anything worthwhile (καλὸν κἀγαθὸν εἰδέναι) …. I do not know (οἶδα) neither do I think I know. -/- In Charmides Socrates speaks about a fear about his probable mistake of thinking that he knows (εἰδέναι) something when he does not (166d1-2). The somehow generalization of this disavowal can be seen in Gorgias. After calling his disavowal 'an account that is always the same' (509a4-5), Socrates continues (a5-7): -/- I say that I do not know (οἶδα) how these things are, but no one I have ever met, like now, who can say anything else without being absurd. -/- At the end of Hippias Major (304d7-8), Socrates affirms his disavowal of knowledge of 'what is X?' this time about the fine: -/- I do not know (οἶδα) what that is itself (αὐτὸ τοῦτο ὅτι ποτέ ἐστιν). Some other passages, however, made a number of scholars dubious about Socrates’ disavowal. Vlastos mentions Apology 29b6-7 as an evidence : 'that to do wrong and to disobey one’s master, both god and men, I know (οἶδα) to be evil and shameful'. He thinks that if we give this single text 'its full weight' it can suffice to show that Socrates does claim knowledge of a moral truth (1985, 7). Vlastos’ claim is not admittable since it would be too strange, I think, for a man like Socrates to violate his disavowal claim just after emphasizing it. We can see his claim just before the already mentioned passage: -/- And surely it is the most blameworthy ignorance to believe that one knows what one does not know. It is perhaps on this point and in this respect, gentlemen, that I differ from the majority of men and if I were to claim that I am wiser than anyone in anything it world be in this, that, as I have no adequate knowledge (οὐκ εἰδὼς ἱκανῶς) of things in the underworld, so I do not think I have (οὐκ εἰδέναι) (Apology 29b1-6) Vlastos tries to solve what he calls the 'paradox' of Socrates’ disavowal of knowledge distinguishing the 'certain' knowledge from 'elenctic' knowledge (1985, 11) and thinking that when Socrates avows knowledge, we must perceive it as an elenctic knowledge, a knowledge its content 'must be propositions he thinks elenctically justifiable' (ibid, 18). Irwin’s solution is the distinction of knowledge and belief. He approves that Socrates does not 'explicitly' make such a distinction, but still thinks that Socrates’ 'test for knowledge would make it reasonable for him to recognize true belief without knowledge, and his own claims are easily understood if they are claims to true belief alone' (1977, 40). While I agree with Vlastos up to a point, I strongly disagree with Irwin about the early dialogues. As I will try to show below, we are not permitted to consider any kind of distinction within knowledge in Socratic dialogues because only one category of knowledge is alluded to there and the distinction of knowledge and belief thoroughly belongs to the second Sorcates. Although no kind of distinction can be admittable here, I think Vlastos’ distinction can be accepted only if we regard it as a distinction between knowledge, which is unique and without any, even incomparable, rival, and a semi-idiomatic and ordinary one that is a necessary requirement for any argument, and thus, unavoidable even for someone who does not claim any kind of knowledge. An apparent evidence of this is Gorgias 505e6-506a4: -/- I go through the discussion as I think it is (ὡς ἄν μοι δοκῇ ἔχειν), if any of you do not agree with admissions I am making to myself, you must object and refute me. For I do not say what I say as I know (οὐδὲ γάρ τοι ἔγωγε εἰδὼς λέγω ἃ λέγω) but as searching jointly with you (ζητῶ κοινῇ μεθ᾽ ὑμῶν). -/- The minimal degree of knowledge everyone must have to take part in an argument, conduct it and use the phrase "I know" when it is necessary is what Socrates cannot deny. We can call it elenctic knowledge only if we agree that it is not the kind of knowledge that Socrates has always been searching, the one that can be accepted as the answer of Socratic 'what is X?' question. His disavowal of knowledge is applied only to the knowledge which can truly be the answer of Socratic question and pass the elenctic exam; a knowledge that, I believe, is never claimed by first Socrates. Socrates conducts his method of examining his interlocutors’ knowledge, our second element here, by almost the same method repeated in Socratic dialogues. That whether we are allowed to regard all the examinations of Socrates in the early dialogues as based on the same or not has been a matter of dispute. Vlastos himself (1994, 31) distinguished Euthydemas, Lysis, Menexenns and Hippias Major from the other Socratic dialogues because he thinks Socrates has lost his faith to elenchus in there. Irwin (1977, 38) distinguishes Apology and Crito where Socrates’ own convictions is present. Contrary to some scholars like Benson (2002, 107) who take elenchus in all the Socratic dialogues as a unique method, Michelle Carpenter and Ronald M. Polansky (2002, 89-100) argue pro the variety of methods of elenchus. Thomas C. Brickhouse and Nicholas D. Smith (2002, 145-160) even reject such a thing as Socratic elenchus which can gather all of the Socrates’ various arguments under such a heading. There can be no solution for the problem of elenchus, they think, is due to 'the simple reason that there is no such thing as 'the Socratic elenchos"'(p.147). Though we consider elenchus a somehow determined process and a part of Socratic circle in the early dialogues, all we assume is that whatever differences it might have in different dialogues, it has the same onto-epistemological principles and, thus, we are not going to take it necessarily as a unique method. This method sets out to prove that the interlocutors are as ignorant as Socrates himself is. That whether elenchus is constructive, capable of establishing doctrines as Vlastos (1994) or Brickhouse and Smith (1994, 20-21) believe or not is another issue to which this paper is not to claim anything. What is crucial for our discussion here is that elenchus does not reach to the very knowledge Socrates is looking for. This is strictly against Irwin who thinks that not only elenchus leads to positive results, 'it should even yield knowledge to match Socrates’ conditions'(1977, 68, cf. 48). He does not explain where and how they really yield to that kind of knowledge. He explains his elenctic method in his apology in the court (Apology 21-22), that how he used to examine wise men, politicians, poets and all those who had the highest reputation for their knowledge and every time found that they have no knowledge. If we accept, as I strongly do, that Socrates’ disavowal of his knowledge is not irony, it might seem more reasonable to agree that the process that has that disavowal as its first step cannot be irony as well. The key of the circle which can explain why Socrates disclaims knowledge and how he can reject others’ claim of having any kind of knowledge lies in the third element, Socratic question. In Hippias Major (287c1-2), Socrates asks: 'Is it not by Justice that just people are Just? (ἆρ᾽ οὐ δικαιοσύνῃ δίκαιοί εἰσιν οἱ δίκαιοι). He insists at 294b1 that they were searching for that by which (ᾧ) all beautiful things are beautiful (cf. b4-5, 8). At Euthyphro 6d10-11 it is said that the Socratic question is waiting for 'the form itself (αὐτὸ τὸ εἶδος) by which (ᾧ) all the pious actions are pious; and at 6d11-e1: -/- Through one form (που μιᾷ ἰδέᾳ) impious actions are impious and pious actions pious. -/- Since the X itself is that by which X is X, knowing 'X itself' is the only way of knowing X. It is probably because of this that Socrates makes the distinction between the ousia as a right answer to the question and effect as a wrong one: -/- I am afraid, Euthyphro, that when you were asked what piety is (τὸ ὅσιον ὅτι ποτ᾽ ἐστίν) you did not wish to make clear its nature itself (οὐσίαν … αὐτοῦ) to me, but you said some effect (πάθος) about it. (Euthp. 11a6-9) -/- 1. Knowledge of what X is Now it is time to look for the onto-epistemological principles of Socratic circle and its three elements. It cannot reasonably be expected from the first Socrates to present us explicitly and clearly formulated principles of his onto-epistemology when such explications cannot be found even in the second Socrates who has some obviously positive theoris. Since there must be some principles underlying this first systematic inqury of knowledge, we must seek to them and be satisfied with elicitation of the first Socratas’ principle. What will be drawn out as his principles cannot and must not, thus, be taken as very fix and dogmatic principles. Some very slightest principles and grounds suffice for our purposes here. The first principle that is the prima facie significance of the Socratic question and his implementation of all those elenctic arguments I call the principle of 'Knowledge of What X is' (KWX): -/- KWX To know X, it is required to know what X is. -/- Aristotle (Metaphysics 1078b23-25, 27-29, 987b4-8) takes Plato’s τί ἐστι question as seeking the definition of a thing that is the same as historical Socrates’ search but applying to a different field. That Plato’s 'what is X?' question was a search for definition became the prevailed understanding of this question up to now. I am going neither to discuss the answer of Socratic question nor to challenge taking it as definition. What I am to insist is that knowledge is attached firmly to the answer of the question: Knowledge of X is not anything but the knowledge of what X is. It entails, certainly, the priority of this knowledge to any other kind of knowledge about X but it also has something more fundamental about the relation of knowledge and Socratic question. Socrates’ exclusive focus on the answer of his question can authorize the consideration of such an essential role for KWX in his epistemolgoy. The total rejection of his interlocutors’ knowledge when they are unable to answer the question can be regarded as a strong evidence for it. Socrates’ elenctic method and his rejection of others’ knowledge in the early dialogues, which all end aporetically with no one accepted as knower and nothing as knowledge, prevent us from finding any positive evidence for this. We have to be content, therefore, of negative evidences which, I think, can be found wherever Socrates rejects his interlocutors’ knowledge when they are not able to give an acceptable answer to his 'what is X?' question. 2. Bipolar Epistemology Socrates’ rejection of his interlocutors’ knowledge has another epistemological principle as its basis. Let me call this principle Bipolar Epistemology' (BE): BE There is no third way besides knowledge and Ignorance. -/- BE says that about every object of knowledge there are only two subjective statuses: knowledge and Ignorance. Socrates’ disavowal, however, says nothing but that he is ignorant of knowledge of X because he does not know what X is. This means that BE is presupposed here. Socrates’ elenchus and his rejection of interlocutors’ having any kind of knowledge are the necessary results of the fact that he does not let any third way besides knowledge and ignorance. The first Socrates never let anyone partly know X or have a true opinion about it, as he would not let anyone know anything about X when he did not know what X is. -/- 3. Bipolar Ontology The principle of BE in first Socrates’ epistemology is parallel to another principle in his ontology. Plato’s bipolar distinction between being and not being is as strict and perfect as his distinction between knowledge and ignorance. This principle I shall call the principle of 'Bipolar Ontology' (BO): BO Being is and not being is not. BO is apparently the same with the well-known Parmenidean Principle of being and not being (cf. Diels-Kranz (DK) Fr. 2.2-5). Euthydemus’ statement against the possibility of false knowledge can be good evidence for this principle: -/- The things which are not surely do not exist (τὰ δὲ μὴ ὄντα … ἄλλο τι ἢ οὐκ ἔστιν). (Euthydemus 284b3-4) -/- He continues (b4-5): -/- There is nowhere for not being to be there (οὖν οὐδαμοῦ τά γε μὴ ὄντα ὄντα ἐστίν). -/- That BE does not let true opinion as a third option besides knowledge and ignorance seems to be related to BO’s rejecting a third option besides being and not being, which is itself the basis of the impossibility of false belief. Socrates’ elaborate discussion of the problem of false belief in Theatetus that leads to a more decisive discussion and finally to some solutions in Sophist can make our consideration of BO for the first group of dialogues authentive. -/- 4. &5. Split Knowledge and Split Being The fourth principle I shall call the principle of 'Split Knowledge' (SK): -/- SK Knowledge of X is separated from any other knowledge (of anything else) as if the whole knowledge is split to various parts. -/- This Principle is hinted and criticized as Socrates’ way of treating with knowledge in Hippias Major: -/- But Socrates, you do not contemplate the entireties of things, nor do people you have used to talk with (τὰ μὲν ὅλα τῶν πραγμάτων οὐ σκοπεῖς, οὐδ᾽ ἐκεῖνοι οἷς σὺ εἴωθας διαλέγεσθαι). (301b2-4) -/- Contrary to Rankin who regards the passage as 'antilogical, almost eristic in tone rather than presenting a serious philosophy of being' (1983, 54), I think it can be taken as serious. Hippias criticizes Sorcates that he does not contemplate (σκοπεῖς) the entireties of things (ὅλα τῶν πραγμάτων), a critique which Socrates is not its only subject but all those whom Socrates accustomed to talk with (ἐκεῖνοι οἷς σὺ εἴωθας διαλέγεσθαι). This last phrase, I think, extends this critic beyond this dialogue to other Socratic dialogues. Hippias’ use of the perfect tense of the verb ἔθω (to be accustomed) is a good evidence of this extension. We can get, thus, these ἐκεῖνοι as Socrates’ interlocutors in his other dialogues that hints that this criticism has the epistemological groundings of the previous dialogues as its subject. What ἐκεῖνοι οἷς σὺ εἴωθας διαλέγεσθαι points to is that Hippias does not have in mind Socrates’ way of treating things only in this dialogue, but he is also criticizing Socrates’ way throughout his dialogues. At 301b4-5, Socrates and his interlocutors’ way of beholding things is described as such: -/- You people knock (κρούετε) at the fine and each of the beings (ἕκαστον τῶν ὄντων) by taking each being cut up in pieces (κατατέμνοντες) in words (ἐν τοῖς λόγοις). This leads us to our next principle that is parallel to, and the ontological side of, SK, the principle of 'Split Being'(SB): -/- SB Everything (being) is separated from any other thing as if the whole being is split to many beings. -/- Socrates and his interlocutors and thus, as we saw, the Socratic dialogues are accused to regard everything as it is separated from all other things. This separation is en tois logois that, I think, can reasonably be taken as saying that Socratic dialogues (it refers of course to the dialogues before Hippias Major) cut up all things which have the same name/definition from all other things and try to understand them separately, without considering other things that are not in their logos. They, for example in Hippias Major, are cutting up to kalon and try to understand what it and all others inside this logos are by separating it from all other things. This is directed straightly against Socratic question and the way Socratic dialogues follow to find its answer, every time separating one logos. As Meyer (1995, 85) points out, every question 'presupposes that the X in question in a logos is something' and 'every answer to every question aims at unity' (84). The critique of Hippias Major is, therefore, at the same time a critique of SK and SB. It is also a critique of KWX because it is only based on KWX that Socratic dialogues could search for the answer of 'what is X' question supposing that knowing what X is is enough for the knowledge of X. SK and KWX are absolutely interdependent. What Socrates and all his previous interlocutors have neglected in Socratic dialogues, Hippias says, was 'continuous bodies of being' (διανεκῆ σώματα τῆς οὐσίας) (301b6). Either this theory actually belongs to the historical Hippias as it is being said or not, it is strictly criticizing SB. We have the same phrase with changing sūma to logos some lines later at 301e3-4: διανεκεῖ λόγῳ τῆς οὐσίας. Although this theory that can be observed as both an ontological and an epistemological theory is rejected by Socrates (301cff.), it is still against first Socrates’ onto-epistemological principles and might let us look at what is rejected as Socratic prineple. -/- 6. Knowledge is of Being The sixth principle that I think is presupposed by the first Socrates, is the 'Knowledge of Being' Principle (KB): -/- KB Knowledge is of Being. -/- This principle is obviously the source of the problem of false knowledge, a very important problem throughout Plato’s philosophy. We face this problem maybe for the first time in Euthydemus. In less than 20 Stephanus’ pages, 276-295, we are encountered with different interwoven problems about knowledge , all grounded in the problem of false opinion. Having challenged the obvious possibility of telling lies at 283e, at 284 Euthydemus discusses it saying that the man who speaks is speaking about 'one of those things that are (ἓν μὴν κἀκεῖνό γ᾽ ἐστὶν τῶν ὄντων)' (284a3) and thus speaks what is (λέγων τὸ ὄν) (a5). He must necessarily be saying truth when he is speaking what is because he who speaks what is (τὸ ὄν) and the things that are (τὰ ὄντα) speaks truth (τἀληθῆ λέγει) (a5-6). This is based on Parmenidean principle of the impossibility of being of not being which Euthydemus restates (284b3-4) and we mentioned discussing BO principle above. The things that are not are nowhere (οὐδαμοῦ) and there is no possibility for anyone to do (πράξειεν) anything with them because they must be made as being before anything else can be done, which is impossible (b5-7). The words, then, are of things that exist (εἰσὶν ἑκάστῳ τῶν ὄντων λόγοι) (285e9) and as they are (ὡς ἔστιν) (e10). The result is that no one can speak of things as they are not. It is this impossibility of false speach that is extended to thinking (δοξάζειν) at 286d1 and leads to the impossibility of false opinion (ψευδής … δόξα) (286d4). The general conclusion is asserted at 287a extending this impossibility to actions and making any kind of mistake. Not only knowledge is of being but speech, thought and action are of being simply because of the fact that nothing can be of not being. -/- B. First Socrates’ Principles in the Middle Period Dialogues Out of what were presupposed or criticized mostly in five dialogues, Euthyphro, Euthydemus, Hippias Major, Laches and Charmides, we tried to draw the first Socrates’ principles. Our inquiry here is directed to find out the fate of these principles in the three dialogues of the middle period, Meno, Phaedo and Republic. To do this, first we ought to check the situation of Socratic circle in these dialogues. The Socratic circle that was predominant in the early dialogues, does not look like a circle here anymore though they certainly have some features in common. Meno, Phaedo and Republic II-X are not committed to the principles of the circle and the whole circle in disrupted in them. The difference of the two Socrateses towards acquiring knowledge is obvious. The Socrates of Meno, Phaedo and Republic is evidently more self-confident that he can get to some truths during his arguments as he does. They are in their first appearance, as almost all other dialogues, committed to Socrates’ disavowal. All of them try to keep the shape of the Socratikoi Logoi genre, which is committed to the historical Socrates’ way of discussion; a dramatic personage who is to challenge his interlocutors, ask them and refuse the answers. Nevertheless, the fact is that what we have in common between two groups of dialogues is mostly a dramatic structure. Whereas the first group’s arguments are based on Socrates’ disavowal and lead to no positive results, the second group is decisively going to achieve some positive results. The aim of the first Socrates was to show others that they are ignorant of what they thought they knew. The new Socrates of Meno, on the opposite, makes so much efforts to show that the slave boy has within himself true opinions (ἀληθεῖς δόξαι) about the things that he does not know (οἶδε) (85c6-7). Despite his lack of knowledge, he has true opinions nevertheless. The way from these true opinions to knowledge, as Socrates states, is not so long. These true opinions are now like a dream but 'can become knowledge of the same things not less accurate than anyone’s' (οὐδενὸς ἧττον ἀκριβῶς ἐπιστήσεται περὶ τούτων) (c11-d1), if they be repeated by asking the same questions. The most outstanding text regarding Socrates’ disavowal is Meno 98b where he explicitly claims knowledge: -/- And indeed I also speak as (ὡς) one who does not know (εἰδὼς) but is guessing (εἰκάζων). However, [about the fact] that true opinion and knowledge are different, I do not altogether expect (δοκῶ) myself to be guessing (εἰκάζειν), but if I say about anything that I know (εἰδέναι) -which about few things I say- this is one of the things that I know (οἶδα). (98b1-5) This passage is very significant about Plato’s disavowal of knowledge. There can hardly be found, I think, anywhere else in Plato’s corpus where Socrates speaks about his knowledge of something as such. He says first that he speaks as someone who does not know. This ὡς οὐκ εἰδὼς λέγω comparing with what he used to say in the first group, οὐκ οἶδα, has this added ὡς. Socrates does not claim strongly anymore that he does not know anything but speaks only as someone who does not know. He needs this ὡς not only because he is going to accept that he does know some, though few, things immediately after this sentence, but also because he needs his previous disavowal to be loosened from Meno on. He does not merely say here that he knows something. It is then different from the examples mentioned before which could be taken as idiomatic or at least not emphatic. Socrates’ remarkable emphasis on distinguishing εἰδέναι from εἰκάζειν departs it from all other passages where he says only he knows something. Moreover, he claims definitely that he has knowledge about few (ὀλίγα) things. From the early to the middle dialogues, Socrates’ attitude to knowledge has totally renewed its face. He brings forth a new concept, true opinion, and he does not speak of knowledge as he used to before; the rough, perfect and unachievable knowledge of the first group has turned to something more smooth, realistic and achievable. Comparing with the early dialogues that did not set out from the first to reach positive results, the middle ones are extraordinarily and surprisingly positive and hence destroy the basis of the Socratic circle. The questions and answers are purposely directed to some specific new theories; most of them are not directly related to the topics or the main questions of the dialogues. They are suggested when Socrates draws the attention of the interlocutor away from the main question because of the necessity of another discussion. Even if the main question remains unanswered, we have still many positive theories, prominently of metaphysical type. These theories are so abundant and dominant in these dialogues, especially Phaedo and Republic, that one might think that they may appear to be arbitrarily sandwiched in there. This helps dialogues to keep their original Socratic structure while they are suggesting new theories. Hence, the Socratic question of 'what is X?', though is still used to launch the discussion, is loosened and is forgotten for most part of the dialogues. Meno that has first a differently formulated question, 'can virtue be taught?', leads finally to the Socratic question of 'What is virtue?'. Phaedo is dedicated to the demonstration of the immortality of soul and the life after death without having a central Socratic question. The case of Republic is more complicated. The first book, on the one hand, has all the criteria of a Socratic circle: its 'what is justice?' question, Socrates’ strong disavowal (e.g. 337d-e), his rejection of all answers and coming back to the first point without finding out any answer. This Book, considered alone, is a perfect Socratic dialogue, as many scholars regard it as early and separated from other books. The books II-X are, on the other hand, far from implementing a Socratic circle. They have still the 'what is justice?' question as their incentive leading question, but they are, in most of the positive doctrines and methods that encompass the main parts, ignoring the question. Even these books that, I believe, are the farthest discussions from the Socratic circle are so cautious not to break the Socratic structure of the dialogue as long as it is possible. What is changed is not the structure of the dialogue but the ontological and epistemological grounds based on which new theories are suggested. -/- 1. Knowledge of the Good We can clearly see in the second group of dialogues that the KWX principle loses the place it had before in our first group. It is not, of course, rejected, but still we cannot say that it has the same situation. KWX that was based on Socratic question, as we discussed before, was the leading principle of the first Socrates’ epistemology and of the highest position. Other epistemological principles, SK directly and BE indirectly, were relying on Socratic question and therefore on KWX. Such a position does not belong to KWX from Meno on. What makes it different in the second Socrates is another principle that is needed it not only as its complementary principle but also as what is more fundamental. Plato, then, does not reject KWX in this period, but, it seems, he transcends to another more basic principle; a principle we shall call the principle of 'Knowledge of the Good' (KG): -/- KG Knowledge of X requires knowledge of the Good. -/- Whereas all the dialogues of our first group are free from any discuscon about KG, it bears a very important role in the second group so as becomes the superior principle of knowledge in Republic. Trying to solve the problem of teachability of virtue, Socrates says that it can be teachable only if it is a kind of knowledge because nothing can be taught to human beings but knowledge (ἐπιστήμην) (Meno 87c2). The dilemma will be, then, whether virtue is knowledge or not (c11-12) and since virtue is good, we can change the question to: whether is there anything good separate from knowledge (εἰ μέν τί ἐστιν ἀγαθὸν καὶ ἄλλο χωριζόμενον ἐπιστήμης) (d4-5). Therefore, the conclusion will be that if there is nothing good which knowledge does not encompass, virtue can be nothing but knowledge (d6-8). What let us discuss KG as an epistemological principle for the second Secrates is the relation he tries to establish between knowledge and the Good which, though is alongside with the mentioned thesis and the idea of virtue as knowledge, goes much deeper inside epistemology asking to regard the Good as the basis of knowledge. The effort of Phaedo cannot succeed in establishing the Good as the criterion of explanation and knowledge since, I think, it needs a far more complicated ontology of Republic where Socrates can finally announce KG. What is said in Republic is totally compatible with Phaedo 99d–e and the metaphor of watching an eclipse of the sun. In spite of the fact that we do not have adequate knowledge of the Idea of the Good, it is necessary for every kind of knowledge: 'If we do not know it, even if we know all other things, it is of no benefit to us without it' (505a6-7). The problem of our not having sufficient knowledge of the Idea of Good is tried to be solved by the same method of Phaedo 99d-e, that is to say, by looking at what is like instead of looking at thing itself (506d8-e4). It is this solution that leads to the comparison of the Good with sun in the allegory of Sun (508b12-13). What the Good is in the intelligible realm corresponds to what the sun is in the visible realm; as sun is not sight, but is its cause and is seen by it (b9-10), the Good is so regarding knowledge. It has, then, the same role for knowledge that the sun has for sight. Socrates draws our attention to the function of sun in our seeing. The eyes can see everything only in the light of the day being unable to see the same things in the gloom of night (508c4-6). Without the sun, our eyes are dimmed and blind as if they do not have clear vision any longer (c6-7). That the Good must have the same role about knowledge based on the analogy means that it must be considered as a required condition of any kind of knowledge: -/- The soul, then, thinks (νόει) in the same way: whenever it focuses on what is shined upon by truth and being, understands (ἐνόησέν), knows (ἔγνω) and apparently possesses understanding (νοῦν ἔχειν). (508d4-6) -/- Socrates does not use agathon in this paragraph and substitutes it with both aletheia and to on. He links them with the Idea of the Good when he is to assert the conclusion of the analogy: -/- That which gives truth to the objects of knowledge and the power of knowing to the knower, you must say, is the Idea of the Good: being the cause of knowledge and truth (αἰτίαν δ᾽ ἐπιστήμης οὖσαν καὶ ἀληθείας) so far as it is known (ὡς γιγνωσκομένης μὲν διανοοῦ). (508e1-4) Knowledge and truth are called goodlike (ἀγαθοειδῆ) since they are not the same as the Good but more honoured (508e6-509a5). KG, which had been implicitly contemplated and searched in Phaedo, is now explicitly being asserted in Republic. As what was quoted clearly proves, this principle is the very one which we can observe as the most fundamental principle of the second Socrates in Republic, corresponding to the role KWX had in the first Socrates. The Form of the Good in Republic, of which Santas speaks as 'the centerpiece of the canonical Platonism of the middle dialogues, the centerpiece of Plato’s metaphysics, epistemology, ethics and …' (1983, 256) much more can be said. Plato’s Cave allegory in Book VIII dedicates a similar role to the Idea of the Good. The Idea of the Good is there as the last thing to be seen in the knowable realm, something so important that its seeing equals to understanding the fact that it is the cause of all that is correct and beautiful (517b). Producing both light and its source in visible realm, it controls and provides truth and understanding in the intelligible realm (517c). -/- 2. Tripartite Epistemology BE is thoroughy rejected in the second Socrates and substituted by its opposite, the principle of 'Tripartite Epistemolgy' (TE): -/- TE Opinion is an epistemological status between knowledge and ignorance. BE of the first Socrates was denying any third way besides knowledge and ignorance which was the foundation of Socratic circle without which Socrates could not reject his interlocutors’ possessing any kind of knowledge. We cannot say, however, that the first Socrates had a third epistemological status in mind but rejected it. Such a status was unacceptable for him so that one can say that he would reject any kind of such status if suggested. There were only two possibilities about knowledge: either one knows something or he does not know it. TE, thus, was not the first Socrates’ discovery and, I think it is not the second Socrates’discovery. All we can see in our second group of dialouges is that he uses this principle as an already demonstrated one. Having examined the slave boy in Meno for the prupose of showing the working of recollection, it truns out that he has some opinions in him while he still does not know. Without trying to prove it, Socrates takes this as the distinction between knowledge and opinion: -/- So, he who does not know (οὐκ εἰδότι) about what he does not know (περὶ ὧν ἂν μὴ εἰδῇ) has within himself true opinions (ἀληθεῖς δόξαι) about the same things he did not know (περὶ τούτων ὧν οὐκ οἶδε) (85c6-7). -/- The same distinction is set between ὀρθὴν δόξαν and ἐπιστήμην at 97b5-6 ff. (also cf. 97b1-2: ὀρθῶς μὲν δοξάζων … ἐπιστάμενος). He connects then their difference to the myth of Daedalus, the statue that would run away and escape. So are true opinions, not willing to remain long in mind and thus not worthy until one ties them down by αἰτίας λογισμῷ (98a3-4). Socrates says that this tying down is anamnesis. We face, in Phaedo, the same relation is settled between knowledge as the process of being tied down and getting the capability to give an account, on the one hand, and anamnesis, on the other hand. When a man knows, he must be able to give an account of what he knows (Phaedo 76b5-6) and since not all people are able to give such an account, those who recollect, recollect what once they learned (76c4). Although the distinction between knowledge and opinion is not explicitly used in Phaedo, referring to the parallel link between knowledge plus account and anamnesis in Phaedo and Meno, one can say that those who cannot recollect are not able to give account and, thus, are in a state of opinion. What is said at Phaedo 84a, though not yet a definite distinction between knowledge and opinion, makes a distinction between their objects so as we can agree that it is presupposed. The soul of the philosopher, Socrates says, follows reason, stays with it forever and contemplates the divine, which is not the object of opinoin (ἀδόξαστον) (84a8, cf. Meno 98b2-5). The distinction of knowledge and belief in Republic has a significant difference with what we discussed in Meno and Phaedo since the distinction of Meno was based on anamnesis and thus more an epistemological distinction. Even in Phaedo that we do not have any elaborate discussion about the distinction, the only hint to the matter at 76 is bound to the theory of anamnesis. In addition to the relation of the distinction with this theory, there is another evidence that does not permit us to consider the distinction as an ontological distinction. Let’s see Meno 85c6-7: -/- So, he who does not know about what he does not know has within himself true opinions about the same things he did not know (τῷ οὐκ εἰδότι ἄρα περὶ ὧν ἂν μὴ εἰδῇ ἔνεισιν ἀληθεῖς δόξαι περὶ τούτων ὧν οὐκ οἶδε). (85c6-7) -/- This last sentence persists that the objects of knowledge and true opinion are the same. What Socrates is to say here is that whereas he does not know X he has true opinion about the same X. I think Socrates’ sentence that the slave boy οὐκ εἰδότι ἄρα περὶ ὧν ἂν μὴ εἰδῇ and his restatement of it by saying περὶ τούτων ὧν οὐκ οἶδε is because he wants to emphasize that the slave boy who does not know, has true opinion about the same thing. Socrates could say this just with using τούτων and there would be no necessity to bring περὶ ὧν ἂν μὴ εἰδῇ for οὐκ εἰδότι if he did not want to emphasize. -/- 3. Tripartite Ontology The distinction between knowledge and true opinion in Republic, on other side, has nothing to do with recollection, but is based on an ontological principle, 'Tripartite Ontology' (TO): -/- TO There are things that both are and are not. -/- This principle I confine, among our three dialogues of the second group, to Republic not extended to Meno and Phaedo, is obviously the opposite of BO. Speaking about the lovers of sights and sounds in the fifth book, Socrates distinguishes them from philosophers because their thought is unable to understand the nature of beautiful itself besides beautiful things (476a6-8) and hence they can only have opinions. The philosopher who, on the contrary, believes in beautiful itself and can distinguish it from beautiful things (476c9-d3), has knowledge because he knows, contrasting others who have opinion because they only opine (d5-6). Since those whose knowledge were degraded as opinion will complain about Socrates’ such calling their thought, he provides them the following argument (476e7-477b1): -/- - Does the person who knows, knows (γιγνώσκει) something (τὶ) or nothing (οὐδέν)? - He knows something (τί). - Something that is (ὂν) or is not (οὐκ ὄν)? - Something that is (ὂν) for how could something that is not be known (πῶς γὰρ ἂν μὴ ὄν γέ τι γνωσθείη)? - Then we have an adequate grasp of this: No matter how many ways we examine it, what completely is (παντελῶς ὂν) is completely knowable (παντελῶς γνωστόν) and what is in no way (μὴ ὂν δὲ μηδαμῇ) is in every way unknowable (πάντῃ ἄγνωστον). - A most adequate one. - Good. Now, if anything is such as to be and also not to be (ὡς εἶναί τε καὶ μὴ εἶναι), won’t it be intermediate (μεταξὺ) between what purely is (εἰλικρινῶς ὄντος) and what in no way is (μηδαμῇ ὄντος)? - Yes, it’s intermediate. - Then as knowledge (γνῶσις) is set over what is (τῷ ὄντι), while ignorance (ἀγνωσία) is of necessity set over what is not (μὴ ὄντι) mustn’t we find an intermediate between ignorance (ἀγνοίας) and knowledge (ἐπιστήμης) to be set over the intermediate, if there is such a thing? -/- From the third status of being we must reach to the third status of knowledge. The simple reading of this text can be an existential reading, taking the "is" of the mentioned sentences as existence. The problem is that when it is said that there is something that both is and is not reading "is" existentially, it sounds too bizarre to be acceptable. It cannot easily be understandable to have something as both existent and non-existent at the same time. This problem arose so many debates and led many scholars to reject the existential reading of "is" and suggest some other readings like predicative or veridical readings. I think though Plato’s complicated ontology of Republic cannot be correctly understood by a simple existential reading, this "is" cannot be free from existential sense of being and, thus, cannot be reduced to just a predicative or veridical sense of being. -/- 4. Bound Knowledges In addition to KG, the Good is also the basis of another principle in the second Socrates, namely the principle of 'Bound Knowledge' (BK): -/- BK Knowledge of everything is bound to the knowledge of the Good. -/- We distinguished BK from KG because we want to insist, in BK, on what had not been insisted upon in KG, that is, the binding role that the Good plays in the second Socrates, contrasting the absence of such a role in the first Socrates. Socrates remembers, in Phaedo, his wonderful keen on natural philosophers' wisdom when he was young. The origin of this enthusiasm was Socrates’ hope to know the cause of everything as they used to claim. When he was searching the matters of his interest on their basis, Socrates says, he became convinced he can get no acceptable answer from them and found himself blind even to the things he thought he knew before. One day he hears Anaxagoras’ theory that 'it is Mind that arranges and is the cause of everything (ὡς ἄρα νοῦς ἐστιν ὁ διακοσμῶν τε καὶ πάντων αἴτιος)' (Phd. 97c1-2 cf. DK, Fr.15.8-9, 11-12, 12-14) and thinks that he can finally find what he has always expected, i.e. something which can explain all things. What I intend to show here is that what makes Socrates hopeful is that Anaxagoras’ theory tries 1) to explain all things by one thing and 2) this explanation is understood by Socrates as if it is based on the concept of the Good. That Socrates was searching for one explanation for all things can be proved even from what he has been expecting from natural philosophers. The case is, nonetheless, more clearly asserted when he speaks about Anaxagoras’ theory. In addition to διακοσμῶν τε καὶ πάντων αἴτιος of 97c2 mentioned above, we have τὸ τὸν νοῦν εἶναι πάντων αἴτιον (c3-4) and τόν γε νοῦν κοσμοῦντα πάντα κοσμεῖν (c4-5) all emphasizing on the cause of all things (πάντα) which can clearly prove that one of the reasons which caused Socrates to embrace it delightfully was its claim to provide the cause of all things by one thing. Another reason was that Anaxagoras’ Mind, at least in Socrates’ view, was attempting to explain everything by the concept of the Good. This connection between Mind and Good belongs more to the essential relation they have in Socrates’ thinking than Anaxagoras’ theory because there are almost nothing about such a relation in Anaxagoras. The reason for Socrates’ reading can be that Mind is substantially compatible with Socrates’ idea of the relation between good and knowledge. Both the thesis 'no one does wrong willingly' and the theory of virtue as knowledge we pointed to above are evidences of this essential relation. Nobody who knows that something is bad can choose or do it as bad. The reason, when it is reason, that means when it is as it should be, when it is wise or when it knows, works only based on good-choosing. In this context, when Socrates hears that Mind is considered as the cause of everything, it sounds to him like this: good should be regarded as the basis of the explanation of all things. We see him, thus, passing from the former to the latter without any proof. This is done in the second sentence after introducing Mind: -/- I thought that if this were so, the arranging Mind would arrange all things and put each thing in the way that was Best (ὅπῃ ἂν βέλτιστα ἔχῃ). If one then wished to find the cause of each thing by which it either perishes or exists, one needs to find what is the best way (βέλτιστον αὐτῷ ἐστιν) for it to be, or to be acted upon, or to act. On these premises then it befitted a man to investigate only, about this and other things, what is the most excellent (ἄριστον) and best (βέλτιστον). The same man must inevitably also know what is worse (χεῖρον), for that is part of the same knowledge. (97c4-d5) This passage is a good evidence of Socrates’ leap from Anaxagoras’ Mind to his own concept of the Good that can explain why Socrates found Anaxagoras theory after his own heart (97d7). Mind is welcomed because of its capability for explanation on the basis of good to 'explain why it is so of necessity, saying which is better (ἄμεινον), and that it was better (ἄμεινον) to be so' (97e1-3). What Socrates thought he had found in Anaxagoras can indicate what he had been expecting from natural scientists before. Socrates could not be satisfied with their explanations because they were unable to explain how it is the best for everything to be as it is. It can probably be said, then, that it was the lack of the unifying Good in their explanation that had disappointed him. We must insist that we are discussing what Socrates thought that Anaxagoras’ theory of Mind should have been, not about Anaxagoras’ actual way of using Mind. Phaedo 97c-98b, is not about what Socrates found in Anaxagoras but what he thought he could find in it. On the contrary, it should also be noted that it was not this that was dashed at 98b, but Anaxagoras’ actual way of using Mind. It was Anaxagoras’ fault not to find out how to use such an excellent thesis (98b8-c2, cf. 98e-99b). Socrates gives an example to show how not believing in 'good' as the basis of explanation makes people be wanderers between different unreal explanations of a thing. His words δέον συνδεῖν (binding that binds together) as a description for the Good we chose as the name of BK principle: They do not believe that the truly good and binding binds and holds them together (ὡς ἀληθῶς τὸ ἀγαθὸν καὶ δέον συνδεῖν καὶ συνέχειν οὐδὲν οἴονται). (99c5-6) -/- Having in mind Plato’s well-known analogy of the sun and the Good at Republic 508-509, we can dare to say that his warning of the danger of seeing the truth directly like one watching an eclipse of the sun in Phaedo (99d-e) is more about the difficulty of so-called good-based explanation than its insufficiency, a difficulty which is precisely confirmed in Republic (504e-505a, 506d-e). Moreover, BK is asserted in a more explicit way in the Republic, where the Good is considered not only as a condition for the knowledge of X, as was noted above discussing KG, but also as what binds all the objects of knowledge and also the soul in its knowing them. At Republic VI, 508e1-3, when Socrates says that the Form of the Good 'gives truth to the things known and the power to know to the knower (τοῦτο τοίνυν τὸ τὴν ἀλήθειαν παρέχον τοῖς γιγνωσκομένοις καὶ τῷ γιγνώσκοντι τὴν δύναμιν ἀποδιδὸν)', he wants to set the Good at the highest point of his epistemological structure by which all the elements of this structure are bound. This binding aspect of the Good is by no means a simple binding of all knowledges or all the objects of knowledge, but the most complicated kind of binding as it is expected from the author of the Republic. The kind of unity the Good gives to the different knowledges of different things is comparable with the unity which each Form gives to its participants in Republic: as all the participants of a Form are united by referring to the ideas, all different kinds of knowledge are united by referring to the Good. If we observe Aristotle's assertion that for Plato and the believers of Forms, the causative relation of the One with the Forms is the same as that of the Forms with particulars (e.g. Metaphysics 988a10-11, 988b4), that is to say the One is the essence (e.g., ibid, 988a10-11: τοῦ τί ἐστὶν, 988b4-6: τὸ τί ἢν εἶναί) of the Forms besides his statement that for them One is the Good (e.g., ibid, 988b11-13) the relation between the Good and unity may become more understandable. Since the quiddity of the Good (τί ποτ᾽ ἐστὶ τἀγαθὸν) is more than discussion (506d8-e2), we cannot await Socrates to tell us how this binding role is played. All we can expect is to hear from him an analogy by which this unifying role is envisaged, the sun. The kind of unity that the Good gives to the knowledge and its objects in the intelligible realm is comparable to the unity that the sun gives to the sight and its objects in the visible realm (508b-c). The allegory of Line (Republic VI, 509d-511), like that of the Sun, tries to bind all various kinds of knowledges. The hierarchical model of the Line which encompasses all kinds of knowledge from imagination to understanding can clearly be considered as Plato’s effort to bind all kinds of knowledges by a certain unhypothetical principle. The method of hypothesis starts, in the first subsection of the intelligible realm, with a hypothesis that is not directed firstly to a principle but a conclusion (510b4-6). It proceeds, in the other subsection, to a 'principle which is not a hypothesis' (b7) and is called the 'unhypothetical principle of all things' (ἀνυποθέτου ἐπὶ τὴν τοῦ παντὸς ἀρχὴν) (511b6-7). This παντὸς must refer not only to the objects of the intelligible realm but to the sensible objects as well. Plato does posit, therefore, an epistemological principle for all things, a principle that all things are, epistemologically, bound and, thus, unified by. -/- 5. Bound Beings The ontological aspect of BK we shall call the principle of 'Bound Beings' (BB): -/- BB Being of all things are bound by the Good. -/- We saw in our principle of Split Being (SB) how the first Socrates was criticized because of his approach to split being and separate each thing from other things. The principle of Bound Beings intends to make the things more related, a duty which is done again by the Good. In the allegory of Sun, there are two paragraphs that evidently and deliberately extend the binding role of the Good to the ontological scene: -/- You will say that the sun not only makes the visible things have the ability of being seen but also coming to be, growth and nourishment. (509b2-4) -/- This clearly intends to remind the ontological role the sun plays in bringing to being all the sensible things in order to display how its counterpart has the same role in the intelligible realm (b6-10): -/- Not only the objects of knowledge (γιγνωσκομένοις) owe their being known (γιγνώσκεσθαι) to the Good, but also their existence (τὸ εἶναί) and their being (οὐσίαν) are due to it, though the Good is not being but superior to it in rank and power. That the Good is here represented as responsible for being of things in addition to their being known means, in my opinion, that Plato wants to posit BB in addition to BK. The allegory of Cave at the very beginning of the seventh Book (514aff.) can be taken as another evidence. The role of the Good, one might say, is confined to the intelligible realm because it is asserted that the role the Good plays in this realm is corresponding to that of the sun in the visible realm. The fact that Plato wants to observe the Good also as the ontological cause of the sensible things is obvious from his saying, in the allegory of Cave, that the Form of the Good 'produces light and its source (τὸν τούτου κύριον) [i.e. the sun] in the visible realm' (517c3). We can conclude, then, that the ontological function of the Good is not confined to the intelligible realm in which it is the lord and provides truth and understanding (c3-4) because it is also responsible to produce τὸν κύριον of light. 6. Proportionality of Being and Knowledge Insofaras BE and BO principles of the first Socrates gave way to TE and TO principles of the second Socrates, we cannot expect him to preserve KB in the same way as it was in the first Socrates. The new tripartite ontology and epistemology necessitates some modifications in KB which results in the principle of 'Proportionality of Being and Knowledge' (PBK): -/- PBK To every class of being there is a proportionate category of knowledge. -/- This principle, of course, does not entail the refutation of KB and thus is not kind of rejecting PBK but only a more complicated version of it. Based on PBK, we can still agree that knowledge is of being (KB) but the issue is that since none of the concepts of knowledge and being in the second Socrates are as simple as they were for the first Socrates, we need a more complicated principle for their relation here. Although from Meno 97a where the distinction of knowledge and true opinion is drawn out in the second group of the dialogues, we can expect a new relation, it is articulated in its most complete way in Republic and specifically in the allegory of Line. All the beings are divided there hierarchically to four classes, to each of them belongs a class of knowledge: imagination to images, belief to the sensible things (more correctly: the things of which they[in previous class] were images (ᾧ τοῦτο ἔοικεν)), thought to mathematical objects (?) and understanding to the Forms and the first principle. The degree of clarity that each of the classes of knowledge shares in (σαφηνείας ἡγησάμενος μετέχειν) is proportionate to the degree that its object shares in truth (ἀληθείας μετέχει). (511e2-4) -/- Conclusion From the six onto-epistemilogical principles of the first Socrates, four principles turn to their opposite in the middle period dialogues. While bipolar epistemology and ontology of the early dialogues give place to tripartite epistemology in the middle period dialogues and tripartite ontology in Republic, the split knowledge and being of the first Socrates are inclined to be substituted by bound knowledges and bound beings in the second Socrates and specifically in Republic. Not all our system of principles in this article is necessarily determinative. Either they are rightly formulated or not, our result would not be vulnerable if we accept that 1) making the distinction of knowledge and belief, 2) accepting the being of not being and 3) trying to bind both being and knowledge by the concept of the Good happens only in middle period dialogues, having been absent in the early ones. These are the favourite results all those somehow arbitrary and even oversimplified principles were to illustrate; that there is kind of a development in the epistemological as well as the ontological grounds of Plato’s philosophy. -/- Notes . (shrink)

Ethics should guide the design of electronic health records (EHR), and recognized principles of bioethics can play an important role. This approach was adopted recently by a team of informaticists designing and testing a system where patients exert granular control over who views their personal health information. While this method of building ethics in from the start of the design process has significant benefits, questions remain about how useful the application of bioethics principles can be in (...) this process, especially when principles conflict. For instance, while the ethical principle of respect for autonomy supports a robust system of granular control, the principles of beneficence and non-maleficence counsel restraint due to the danger of patients being harmed by restrictions on provider access to data. Conflict between principles has long been recognized by ethicists and has even motivated attacks on approaches that state and apply principles. In this paper we show how using ethical principles can help in the design of EHRs by first, explaining how ethical principles can and should be used generally, and then by, discuss how attention to details in specific cases can show that the tension between principles is not as bad as it initially appeared. We conclude by suggesting further ways in which the application of these (and other) principles can add value to the ongoing discussion of patient involvement in their health care. This is a new approach to linking principles to informatics design that we expect will stimulate further interest. (shrink)

Canada’s Tri-Council Policy Statement: Ethical conduct for research involving humans, first published in 1998, has recently been updated.1 The US Department of Health and Human Services has just issued an Advance Notice of Proposed Rulemaking that would substantially change the 20-year-old Common Rule governing most federally funded research involving human participants.2 A comparison of the two countries’ systems for protecting human research participants is therefore timely. This analysis situates the Canadian system in an international context, with particular attention to its (...) similarities and differences to the US system and their shared challenges going forward with their changes. (shrink)

The intersection between virtue and care ethics is underexplored in contemporary moral philosophy. This thesis approaches care ethics from a neo-Aristotelian virtue ethical perspective, comparing the two frameworks and drawing on recent work on care to develop a theory thereof. It is split into seven substantive chapters serving three major argumentative purposes, namely the establishment of significant intertheoretical agreement, the compilation and analysis of extant and new distinctions between the two theories, and the synthesis of (...) care ethical insights with neo-Aristotelianism to generate a virtue ethical theory of care. In the first two chapters, I outline virtue ethics and care ethics, and argue for considerable agreement over central premises. Chapter 2 summarises the foundational commitments of care ethics, focusing particularly on their relational ontology and its links to the other ethical claims care ethicists universally ascribe to, namely particularism, partialism, the moral salience of emotions, and the rejection of hard public/private distinctions. Chapter 3 lays out the central concepts in neo-Aristotelian virtue ethics, including eudaimonism, virtue, and character traits, and drawing a number of comparisons between virtue and care ethics specifically with regard to relational ontology and the meta-ethical commitments it underpins. In addition to doing the necessary expository work for the remainder of the thesis, Chapters 2 and 3 also argue that care ethics and virtue ethics have much more in common than is typically acknowledged – the first major contribution of this thesis to the literature. Chapters 2 and 3 to provide at least a prima facie justification for pursuit of the questions I confront in the remainder of the thesis. In Chapter 4, I ask what differentiates these two ethical theories. I survey some of the differences which philosophers in either camp have identified and offer some of my own. I suggest that several of those differences either rest on misunderstandings of one ethic or the other, or that in erecting a divide between virtue and care ethics they also disunify ethics of care. I do, however, identify two differences which seem defensible. Specifically, they are that virtue ethics seems to lack an account of care, which I define minimally as a response or responsiveness to need, and that virtue and care ethics organise their meta-ethical and normative concepts differently. This chapter thus presents a second contribution to the literature: a study of the differences between virtue ethics and care ethics. It also serves to set the trajectory for the remaining chapters, where I respond to the claim that virtue ethics lack an account of care. I spend the remainder of the thesis constructing what I take to be a satisfying foundation for a virtue ethical theory of care. In Chapter 5, I offer three initially viable means of incorporating care into virtue ethics, all of which treat care as a virtue. These are the analogical approach, according to which care is analogous to an existing virtue; the additive approach, according to which care is a novel virtue; and the bundling approach, according to which care is a bundle of virtues. I also offer and evaluate reasons to reject the claim that care is a virtue, concluding that the claim is indeed a viable one so long as the concept of care is sufficiently thick, and I contend that analogical approaches, and particularly analogies with charity, outperform the others. Chapter 5 therefore serves two ends. First, it proffers a novel meta-analysis of concepts of care as a virtue, and thus makes a third contribution to the literature. In doing so, it makes an inroad into the second: the development of a neo-Aristotelian theory of care. Chapter 6 continues this project. I attempt to show how care can be construed as an act-type and a practice. I argue in this chapter that practices are a subcategory of actions, and that care qualifies as an Anscombean act-type which aims at the meeting of needs relating to the care-recipient’s flourishing. I go on to consider the implications of this account for ethics which deploy care as a moral concept, maintaining that it not only offers a better account of consequences than theories of care which include success criteria, but also that it affords us interesting insights into the distinction between ‘caring about’ and ‘caring for’ which allow us to make sense of certain tenets of neo-Aristotelianism. This represents a contribution to both discourses, since neither care nor virtue ethicists working at the intersection of their respective normative theories have delved very deeply into the philosophy of action. Chapter 7 discusses caring relations, suggesting that a virtue ethical theory of caring relations can lean on the work care ethicists have done, and adding some necessary refinements, such as a distinction between ideal and non-ideal caring relations, and a theory of caring relations as reasons for action. This final chapter also draws these three concepts of care together by arguing that virtuous caregivers who are invested in the flourishing of those for whom they care are also sensitive to the relations those care-recipients bear to their institutional environment. I argue that because they are caring participants in caring relations, virtuous agents are characteristically motivated by states of need and dependency to engage in certain sorts of conventionally political practices. In other words, the virtue or virtues of caring characteristically manifest in certain sorts of political or social practices, relating specifically to those areas of moral life. This allows us to build upon recent work in feminist virtue ethics of the sort offered by Tessman and Friedman. I also offer a novel analysis of migration, suggesting that the account of care presenting here is analytically useful both when it comes to historical cases of migration such as the underground railroads and escapes from Nazi-occupied Europe, but also for contemporary issues such as the migrations occurring in the Southern United States and in much of Europe. I thus conclude not only that virtue ethicists ought to incorporate care into their normative framework, and that the theory of care presented here is a coherent one, but that this leads us naturally into applied topics such as virtue politics. I conclude the thesis by considering some its implications and by identifying some further avenues for research. (shrink)

Artificial Intelligence (AI) is already having a major impact on society. As a result, many organizations have launched a wide range of initiatives to establish ethical principles for the adoption of socially beneficial AI. Unfortunately, the sheer volume of proposed principles threatens to overwhelm and confuse. How might this problem of ‘principle proliferation’ be solved? In this paper, we report the results of a fine-grained analysis of several of the highest-profile sets of ethical principles for AI. We assess whether these (...) principles converge upon a set of agreed-upon principles, or diverge, with significant disagreement over what constitutes ‘ethical AI.’ Our analysis finds a high degree of overlap among the sets of principles we analyze. We then identify an overarching framework consisting of five core principles for ethical AI. Four of them are core principles commonly used in bioethics: beneficence, non-maleficence, autonomy, and justice. On the basis of our comparative analysis, we argue that a new principle is needed in addition: explicability, understood as incorporating both the epistemological sense of intelligibility (as an answer to the question ‘how does it work?’) and in the ethical sense of accountability (as an answer to the question: ‘who is responsible for the way it works?’). In the ensuing discussion, we note the limitations and assess the implications of this ethical framework for future efforts to create laws, rules, technical standards, and best practices for ethical AI in a wide range of contexts. (shrink)

Biomedical diagnostic science is a great deal less successful than we've been willing to acknowledge in bioethics, and this fact has far-reaching ethical implications. In this article I consider the surprising prevalence of medically unexplained symptoms, and the term's ambiguous meaning. Then I frame central questions that remain answered in this context with respect to informed consent, autonomy, and truth-telling. Finally, I show that while considerable attention in this area is given to making sure not to provide biological (...) class='Hi'>care to patients without a need, comparatively little is given to the competing, ethically central task of making sure never to obstruct access to biological care for those with diagnostically confusing biological conditions. I suggest this problem arises from confusion about the philosophical value of vagueness when it comes to the line between biological and psychosocial needs. (shrink)

As the world population is rapidly aging, stakeholders must address the care of the elderly with great concern. Also, loss of dignity is often associated with aging due to dementia, mobility problems and diminished functional autonomy. However, dignity is a polysemic term that is deemed useless by some ethicists. To counter this claim, we propose four concepts to define it better and make use accurately of this notion. These are human dignity, dignity of identity, dignities of excellence and attributed (...) dignities. Finally, we explain the importance of solicitude and human dignity in the care of the elderly. This will ensure the respect, friendship and dignity of the elderly in providing geriatric ethical care. (shrink)

Not only the direct physical experiences of deployment can severely harm soldiers’ mental health. Witnessing violations of their moral principles by the enemy, or by their fellow soldiers and superiors, can also have a devastating impact. It can cause soldiers’ moral disorientation, increasing feelings of shame, guilt, or hate, and the need for general answers on questions of right and wrong. Various attempts have been made to keep soldiers mentally sane. One is to provide convincing causes for their deployment, which (...) risks an “end justifies the means” way of thinking. The good cause can provide a moral justification for horrible atrocities. Another method, introduced in the USA, Canada, and Australia, aims to strengthen military personnel’s resistance by promoting and maintaining a happy, optimistic state of mind through the use of positive psychology. Alongside making soldiers “morally fit” for all kinds of situations, the focus could also be on moral recovery and forgiveness. Such a care-based military ethics approach, aimed at mutual understanding and interdependence, could help soldiers handle the emotional impact of moral conflicts. This demands that military units reflect on their organizational culture and rethink oaths and codes of conduct that focus mainly on efficiency and readiness, as well as the soldierly self-image with its seemingly still deeply rooted warrior ethos. Today, resilience and positive psychology in the military is apparently mainly geared to assuring its soldiers’ readiness. An appropriate set of virtues and understanding of virtue ethics that are less centered on self-perfection and autonomy could point to a different form of character-building and lead to a better understanding of others. (shrink)

Objective: This main aim of the study is to explore COVID-19 pandemic problems from the perspective of public health-clinical care ethics through online mediareports in Turkey. Method: This research was designed as a descriptive and qualitative study that assesses COVID-19 through online media reports on critics between the periods of March 11, 2020 and April 2 2020 as a quantitative as number of reports and qualitative study, across Turkey. Reports were from Turkish Medical Association websites which included newspaper (...) reports. Study data were presented as statistically and qualitative data case and headlines. No ethical or ofTicial permission was sought as the study was conducted through open access internet news sites. Results: This online reports analysis retrieved about 6723 articles about the COVID-19. According to study data, information about COVID-19 were themed as follows: general deTiciencies in taking action and isolation, lack of isolation, passengers and transport vehicles not quarantined ; insufTicient diagnostic tests, decision to test after healthcare professionals become infected, lack of equipment, lack of evaluation outbreak countries [Table 2]. Conclusion and Suggestions: COVID-19 is a pandemic and is a global public health problem that concerns every individual and needs to be handled carefully. This requires a multi-faceted preparation and education. In this context, healthcare professionals should be well trained in this aspect and have all the necessary equipment throughout the process. Additionally, it should work systematically with the cooperation of all health organizations, the Ministry of Health, local governments and of course the media, in order to inform society, fairly distribute the resources and to implement the safety measures effectively. BrieTly, lack of transparency, insufTicient information, limited resources, lack of public health protection measures such as partial quarantine decision, partial implementation of the scientiTic board's re c ommenda ti on s fo r e c on omi c rea s on s, and contradiction of the explanations are revealed as serious ethical problems. (shrink)

Around 750 a.d., new settlements in Chaco Canyon in the Southwest United States began moving toward intensified urban form, monumental architecture, and increased hierarchical social organization that bordered on nation-state authority. But around 1140 a.d., the relatively concentrated populations in Chaco Canyon dispersed over just a few generations. At new destinations emigrants from the canyon did not reinstate the urban intensities and political hierarchies that had dominated there. Four lessons from this history can be drawn. First, the model of social (...) and political coordination that best fits the history of Chaco Canyon is one of escalating and deescalating gift-giving. Models that instead appeal to purely transactional relations, such as contracts, are historically and philosophically inadequate. Second, and more broadly, the real power of any well-functioning, complex, and urbanized society must be a reserve of generalized social trust. This was true then, and remains true today. Third, while environmental pressures play important roles in the formation of foundational urban settlements such as those in Chaco Canyon, we should be careful not to explain too much by them. As then, our own environmental challenges call upon us to nurture political arrangements, especially in our cities, that can address environmental constraints and challenges. Except perhaps when circumstances become impossibly dire, we should treat environmental constraints as the boundaries into which we must fit ourselves through political means. Finally, philosophers should investigate developments in historical urban settlements. Such cases are indispensable for understanding human cooperation, forms of social authority, and environmental decision making. (shrink)

Recent bioethical issues that have emerged in the field of medicine include, but are not limited to, eugenics (artificial insemination), palliative care (end of life care), euthanasia (medical resuscitation), abortion, and the development of enhanced human body parts. These bioethical issues have raised ethical questions related to the use of modern technology and how it may affect the future of society. These questions consider issues such as: what is the identity of future children? Have human beings become a (...) commodity exchanged by those who have the ability to own them? What is the meaning of justice in medical treatment? How can physicians and nurses perform humanitarian work? -/- Discussions of these questions should begin by determining their relationships with typical social and cultural values in society, such as life and death, marriage, family, fatherhood, motherhood, relatives, and next-of-kin. -/- This paper presents a review of the important Arabic literature that has been written on these bioethical issues to show the contributions of Arab scholars in this field. Arabic studies in bioethics can be classified into three types: original Arabic writings, translated studies, and congresses held in the Arab region. (shrink)

Healthcare is becoming increasingly automated with the development and deployment of care robots. There are many benefits to care robots but they also pose many challenging ethical issues. This paper takes care robots for the elderly as the subject of analysis, building on previous literature in the domain of the ethics and design of care robots. Using the value sensitive design approach to technology design, this paper extends its application to care robots by integrating (...) the values of care, values that are specific to AI, and higher-scale values such as the United Nations Sustainable Development Goals. The ethical issues specific to care robots for the elderly are discussed at length alongside examples of specific design requirements that work to ameliorate these ethical concerns. (shrink)

The pandemic significantly raised the stakes for the translation of bioethics insights into policy. The novelty, range and sheer quantity of the ethical problems that needed to be addressed urgently within public policy were unprecedented and required high‐bandwidth two‐way transfer of insights between academic bioethics and policy. Countries such as the United Kingdom, which do not have a National Ethics Committee, faced particular challenges in how to facilitate this. This paper takes as a case study the brief (...) career of the Ethics Advisory Board (EAB) for the NHS Covid‐19 App, which shows both the difficulty and the political complexity of policy‐relevant bioethics in a pandemic and how this was exacerbated by the transience and informality of the structures through which ethics advice was delivered. It analyses how and why, after EAB's demise, the Westminster government increasingly sought to either take its ethics advice in private or to evade ethical scrutiny of its policies altogether. In reflecting on EAB, and these later ethics advice contexts, the article provides a novel framework for analysing ethics advice within democracies, defining four idealised stances: the pure ethicist, the advocate, the ethics arbiter and the critical friend. (shrink)

Alongside a revival of interest in Thomism in philosophy, scholars have realised its relevance when addressing certain contemporary issues in bioethics. This book offers a rigorous interpretation of Aquinas's metaphysics and ethical thought, and highlights its significance to questions in bioethics. Jason T. Eberl applies Aquinas’s views on the seminal topics of human nature and morality to key questions in bioethics at the margins of human life – questions which are currently contested in the academia, politics and (...) the media such as: When does a human person’s life begin? How should we define and clinically determine a person’s death? Is abortion ever morally permissible? How should we resolve the conflict between the potential benefits of embryonic stem cell research and the lives of human embryos? Does cloning involve a misuse of human ingenuity and technology? What forms of treatment are appropriate for irreversibly comatose patients? How should we care for patients who experience unbearable suffering as they approach the end of life? _Thomistic Principles and Bioethics_ presents a significant philosophical viewpoint which will motivate further dialogue amongst religious and secular arenas of inquiry concerning such complex issues of both individual and public concern. (shrink)

Personal Health Monitoring (PHM) uses electronic devices which monitor and record health-related data outside a hospital, usually within the home. This paper examines the ethical issues raised by PHM. Eight themes describing the ethical implications of PHM are identified through a review of 68 academic articles concerning PHM. The identified themes include privacy, autonomy, obtrusiveness and visibility, stigma and identity, medicalisation, social isolation, delivery of care, and safety and technological need. The issues around each of these are discussed. The (...) system / lifeworld perspective of Habermas is applied to develop an understanding of the role of PHMs as mediators of communication between the institutional and the domestic environment. Furthermore, links are established between the ethical issues to demonstrate that the ethics of PHM involves a complex network of ethical interactions. The paper extends the discussion of the critical effect PHMs have on the patient’s identity and concludes that a holistic understanding of the ethical issues surrounding PHMs will help both researchers and practitioners in developing effective PHM implementations. (shrink)

This article examines a fundamental question of justice in global health. Is it ethically preferable to provide a larger number of people with cheaper treatments that are less effective (or more toxic), or to restrict treatments to a smaller group to provide a more expensive but more effective or less toxic alternative? We argue that choosing to provide less effective or more toxic interventions to a larger number of people is favored by the principles of utility, equality, and priority for (...) those worst-off. Advocates are mistaken to demand that medical care provided in low-income and middle-income countries should be the same as in high-income countries. (shrink)

Recent years have witnessed intensive efforts to specify which requirements ethical artificial intelligence (AI) must meet. General guidelines for ethical AI consider a varying number of principles important. A frequent novel element in these guidelines, that we have bundled together under the term explicability, aims to reduce the black-box character of machine learning algorithms. The centrality of this element invites reflection on the conceptual relation between explicability and the four bioethical principles. This is important because the application of general (...) ethical frameworks to clinical decision-making entails conceptual questions: Is explicability a free-standing principle? Is it already covered by the well-established four bioethical principles? Or is it an independent value that needs to be recognized as such in medical practice? We discuss these questions in a conceptual-ethical analysis, which builds upon the findings of an empirical document analysis. On the example of the medical specialty of radiology, we analyze the position of radiological associations on the ethical use of medical AI. We address three questions: Are there references to explicability or a similar concept? What are the reasons for such inclusion? Which ethical concepts are referred to? (shrink)

Much of the discussion of the role of emerging technologies associated with AI, machine learning, digital simulacra, and relevant ethical considerations such as those discussed in the target article, take a relatively narrow and episodic view of a person’s healthcare needs. There is much speculation about diagnostic, treatment, and predictive applications but relatively little consideration of how such technologies might be used to address a person’s lived experience of illness and ongoing care needs. This is likely due to the (...) greater weight or priority given to acute care needs and the role of medical treatment in care provision, but it may also reflect the limitations of current technologies and our limited vision of their potential application. Such limitations are not surprising given that we are still grappling with the complexities and nuances of achieving the ethical and humanistic ideals of care, namely, care that addresses the hermeneutical, relational, contextual, temporal, and agential dimensions of a person’s health and wellbeing. (shrink)

When many people think of bioethics, they think of gripping issues in clinical medicine such as end-of-life decision-making, controversies in biomedical research such as that over work with stem cells, or issues in allocating scarce health-care resources such as organs or money. The term “bioethics” may evoke images of moral controversies being discussed on news programs and talk shows. But this “controversy of the day” focus often treats ethical issues in medicine superficially, for it addresses them as (...) if they could be examined and discussed in isolation from the context in which they are situated. Such a focus on the latest controversies fails to take into account that medicine is a social institution and that the controversies in bioethics often reflect deeper social and moral issues that transcend the boundaries of medicine and ethics. If one moves beyond the issue-of-the-day approach to bioethics, one can see that the field must address these deeper issues. (shrink)

This article aims to develop a Lacanian approach to bioethics. Point of departure is the fact that both psychoanalysis and bioethics are practices of language, combining diagnostics with therapy. Subsequently, I will point out how Lacanian linguistics may help us to elucidate the dynamics of both psychoanalytical and bioethical discourse, using the movie One flew over the Cuckoo’s Nest and Sophocles’ tragedy Antigone as key examples. Next, I will explain the ‘topology’ of the bioethical landscape with the help (...) of Lacan’s three dimensions: the imaginary, the symbolical and the real. This will culminate in an assessment of the dynamics of bioethical discourse with the help of Lacan’s theorem of the four discourses. Bioethics, I will argue, is not a homogeneous discourse. Rather, four modalities of bioethical discourse can be distinguished, all of them displaying specific weaknesses and strengths, opportunities and threats. This will be elucidated with the help of two case studies, namely the debates on human reproductive technologies and on the use of animals as biomedical research models. (shrink)

Introductory and advanced textbooks in bioethics focus almost entirely on issues that disproportionately affect disabled people and that centrally deal with becoming or being disabled. However, such textbooks typically omit critical philosophical reflection on disability, lack engagement with decades of empirical and theoretical scholarship spanning the social sciences and humanities in the multidisciplinary field of disability studies, and avoid serious consideration of the history of disability activism in shaping social, legal, political, and medical understandings of disability over the last (...) fifty years. For example, longstanding discussions on topics such as euthanasia, physician aid-in-dying, pre-implantation genetic diagnosis, prenatal testing, selective abortion, enhancement, patient autonomy, beneficence, non-maleficence, and health care rationing all tend to be premised on shared and implicit assumptions regarding disability, especially in relation to quality of life, yet with too little recognition of the way that “disability” is itself a topic of substantial research and scholarly disagreement across multiple fields. This is not merely a concern for academic and medical education; as an applied field tied to one of the largest economic sectors of most industrialized nations, bioethics has a direct impact on healthcare education, practice, policy, and, thereby, the health outcomes of existing and future populations. It is in light of these pressing issues that the Disability Bioethics Reader is the first reader to introduce students to core bioethical issues and concepts through the lens of critical disability studies and philosophy of disability. The Disability Bioethics Reader will include over thirty-five chapters covering key areas such as: critical histories and state-of-the-field analyses of modern medicine, bioethics, disability studies, and philosophy of medicine; methods in bioethics; concerns at the edge- and end-of-life; enhancement; disability, quality of life, and well-being; prenatal testing and abortion; invisible disabilities; chronic illness; healthcare justice; genetics and genomics; intellectual disability and neurodiversity; ethics and diagnosis; and epistemic injustice in healthcare. (shrink)

A new world has probably emerged through the progression of technology which has led to significant debates on social, cultural, legal, and ethical issues, especially in the biomedical field in this century. Application of physician-patient relationship, principles of pluralism, autonomy, democracy, human dignity, and human rights is being challenged within the medicine and health-care system of today. Development of technology-based remedies has fostered greater degrees of medicalization. Hence, the automatic application of such technologies risks distorting the nature of medicine. (...) To be sure, there is a cultural shift that is affecting the society that is increasingly unable to adapt to traditional legal systems. This cultural shift, perhaps, demands new ethics. This entry aims to evaluate the gap between traditional deontological nature of medicine and the emerging new ethics and assess why bioethical reflection is needed. (shrink)

Health care providers are expected both to relieve pain and to provide anticipatory guidance regarding how much a procedure is going to hurt. Fulfilling those expectations is complicated by the cognitive modulation of pain perception. Warning people to expect pain or setting expectations for pain relief not only influences their subjective experience, but it also alters how nociceptive stimuli are processed throughout the sensory and discriminative pathways in the brain. In light of this, I reconsider the characterization of placebo (...) analgesia as pharmacologically inert and the use of it as deceptive. I show that placebo analgesia exploits the same physical mechanisms as proven analgesics and argue that it should be utilized to relieve pain. Additionally, I describe factors to help identify situations in which clinicians have the obligation to disclose the potential for pain coupled with ways of mitigating the risk of high-intensity pain by setting positive expectations. (shrink)

When information on a coma patient’s expected outcome is uncertain, a moral dilemma arises in clinical practice: if life-sustaining treatment is continued, the patient may survive with unacceptably poor neurological prospects, but if withdrawn a patient who could have recovered may die. Continuous electroencephalogram-monitoring is expected to substantially improve neuroprognostication for patients in coma after cardiac arrest. This raises expectations that decisions whether or not to withdraw will become easier. This paper investigates that expectation, exploring cEEG’s impacts when it becomes (...) part of a socio-technical network in an Intensive Care Unit. Based on observations in two ICUs in the Netherlands and one in the USA that had cEEG implemented for research, we interviewed 25 family members, healthcare professionals, and surviving patients. The analysis focuses on the way patient outcomes are constructed, the kind of decision support these outcomes provide, and how cEEG affects communication between professionals and relatives. We argue that cEEG can take away or decrease the intensity of the dilemma in some cases, while increasing uncertainty for others. It also raises new concerns. Since its actual impacts furthermore hinge on how cEEG is designed and implemented, we end with recommendations for ensuring responsible development and implementation. (shrink)

The UN Convention against Torture defines torture as “any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person” by someone acting in an official capacity for purposes such as obtaining a confession or punishing or intimidating that person.1 It is unethical for healthcare professionals to participate in torture, including any use of medical knowledge or skill to facilitate torture or allow it to continue, or to be present during torture.2-7 Yet medical participation (...) in torture has taken place throughout the world and was a prominent feature of the US interrogation practice in military and Central Intelligence Agency (CIA) detention facilities in the years after the attacks of 11 September 2001.8-11 Little attention has been paid, however, to how a regime of torture affects the ability of health professionals to meet their obligations regarding routine clinical care for detainees. -/- The 2016 release of previously classified portions of guideline from the CIA regarding medical practice in its secret detention facilities sheds light on that question. These show that the CIA instructed healthcare professions to subordinate their fundamental ethical obligations regarding professional standards of care to further the objectives of the torturers. (shrink)

Background There has been debate on whether a global or unified field of bioethics exists. If bioethics is a unified global field, or at the very least a closely shared way of thinking, then we should expect bioethicists to behave the same way in their academic activities anywhere in the world. This paper investigates whether there is a 'global bioethics' in the sense of a unified academic community. Methods To address this question, we study the web-linking patterns (...) of bioethics institutions, the citation patterns of bioethics papers and the buying patterns of bioethics books. Results All three analyses indicate that there are geographical and institutional differences in the academic behavior of bioethicists and bioethics institutions. Conclusion These exploratory studies support the position that there is no unified global field of bioethics. This is a problem if the only reason is parochialism. But these regional differences are probably of less concern if one notices that bioethics comes in many not always mutually understandable dialects. (shrink)