This paper explores how transformative experience generates decision-making problems of particular seriousness in medical settings. Potentially transformative experiences are especially likely to be encountered in medicine, and the associated decisions are confronted jointly by patients and clinicians in the context of an imbalance of power and expertise. However in such scenarios the principle of informed consent, which plays a central role in guiding clinicians, is unequal to the task. We detail how the principle’s assumptions about autonomy, rationality and information handle (...) transformative experiences poorly, appealing to several difficult cases for medical decision-making to illustrate the resulting problem, and we consider how the existing literature on complications with consent fails to offer a resolution. We argue that recognition of the problem has a role to play in achieving a more effective response to transformative decisions. In Sect. 1 we introduce several representative cases of challenging patient decision-making that clinicians might face. In Sect. 2 we detail how transformative experience has been analysed in the recent literature, before outlining in Sect. 3 the theoretical basis of the principle of informed consent, which plays a central role in how clinicians are expected to support decision-making. In Sect. 4, having laid the groundwork for a clear description, we return to the cases given in Sect. 1 to confirm how their transformative nature presents a problem: either clinicians treat the decisions faced by these patients as ‘normal’, encouraging them to focus on information provision that patients may be unable to act on, or they treat them as transformative, in which case they lack the resources to recognise whether they are helping patients make (subjectively) good decisions. In Sect. 5 we argue that the existing literature does not offer any escape from this problem. We close in Sect. 6 by noting the significant impact that appreciating the problem of transformative experience could have on supporting transformative decisions in medicine and briefly suggesting how we might aim to develop new approaches to dealing with these. (shrink)

Much contemporary ontological inquiry takes place within the so-called ‘Quinean tradition’ but, given that some aspects of Quine’s project have been widely abandoned even by those who consider themselves Quineans, it is unclear what this amounts to. Fortunately recent work in metaontology has produced two relevant results here: a clearer characterisation of the metaontology uniting the aforementioned Quineans, most notably undertaken by Peter van Inwagen, and a raft of criticisms of that metaontology. In this paper I critique van Inwagen’s Quinean (...) metaontology, finding that certain challenges, supplemented by pressure to reflect more closely Quine’s work, should drive Quineans to adopt a stronger metaontology incorporating more of Quine’s radical views. I conclude that while van Inwagen’s Quineanism is problematic there are prospects for a viable, more wholeheartedly Quinean, metaontology. (shrink)

Alongside the direct parallels and contrasts between traditional narrative fiction and games, there lie certain partial analogies that provide their own insights. This article begins by examining a direct parallel between narrative fiction and games—the role of fictional reliefs and reality checks in shaping aesthetic engagement—before arguing that from this a partial analogy can be developed stemming from a feature that distinguishes most games from most traditional fictions: the presence of rules. The relation between rules and fiction in games has (...) heretofore been acknowledged but not examined in detail, giving an impression of a tension that is constant. However, the paired concepts of formal reliefs and representation checks, once introduced, allow us to explain how rules and fiction interact to alter the ways in which players engage with games in a dynamic but limited way. (shrink)