Lately, more and more authors have asserted their belief that one of the criteria which, together with the medical ones, can and should be applied in the policy of selecting and/or prioritizing the patients in need for the allocation of medical resources with limited availability, is the principle of individual responsibility for illness. My intention in this study is to highlight some very serious obstacles looming against the attempt to apply this principle in the distribution of the (...) class='Hi'>medical services with limited availability. Although there are numerous such obstacles, I shall only discuss five of them (the most important, in my opinion). These are: 1) the impossibility to establish with certainty whether a patient got ill due to his lifestyle; 2) the lack of a feasible and reliable method of establishing an individual’s responsibility for his lifestyle; 3) a patient’s right to privacy; 4) some moral requirements and principles and, last but not least, 5) the ethics of the medical profession. (shrink)

That a standard of medical care must outline services that benefit the patient is relatively uncontroversial. However, one must determine how the practices outlined in a medical standard of care should benefit the patient. I will argue that practices outlined in a standard of medical care must not detract from the patient’s well-functioning and that clinicians can refuse to provide services that do. This paper, therefore, will advance the following two claims: (1) a standard of medical (...) care must not cause dysfunction, and (2) if a physician is medically rational to not provide some service which fails to meet the above condition (i.e. fails to be a standard of medical care), then she may refuse to do so. I then apply my thesis to the prescription of puberty blockers to children with gender dysphoria. (shrink)

Some vaccine-hesitant people lack epistemic trust in the COVID-19 vaccine recommendation that because vaccines have been shown to be medically safe and effective, one ought to get vaccinated. Citing what I call exception information, they claim that whatever the general safety and efficacy of vaccines, the vaccines may not be safe and effective for them. Examples include parents citing information about their children's health, pregnant women's concerns about the potential adverse effects of treatment on pregnant women, young people citing their (...) relative invulnerability to extreme COVID-19 symptoms, or members of vulnerable racial groups citing epistemic injustice, such as a lack of representation in COVID-19 vaccine trials. This paper examines the extent to which a lack of epistemic trust in vaccine recommendations, based on such exemption information, is rational. (shrink)

Throughout the COVID-19 pandemic, shortages of scarce healthcare resources consistently presented significant moral and practical challenges. While the importance of vaccines as a key pharmaceutical intervention to stem pandemic scarcity was widely publicized, a sizable proportion of the population chose not to vaccinate. In response, some have defended the use of vaccination status as a criterion for the allocation of scarce medical resources. In this paper, we critically interpret this burgeoning literature, and describe a framework for thinking about vaccine-sensitive (...) resource allocation using the values of responsibility, reciprocity, and justice. Although our aim here is not to defend a single view of vaccine-sensitive resource allocation, we believe that attending critically with the diversity of arguments in favor (and against) vaccine-sensitivity reveals a number of questions that a vaccine-sensitive approach to allocation should answer in future pandemics. (shrink)

Coronavirus disease 2019 can lead to respiratory failure. Some patients require extracorporeal membrane oxygenation support. During the current pandemic, health care resources in some cities have been overwhelmed, and doctors have faced complex decisions about resource allocation. We present a case in which a pediatric hospital caring for both children and adults seeks to establish guidelines for the use of extracorporeal membrane oxygenation if there are not enough resources to treat every patient. Experts in critical care, end-of-life care, bioethics, and (...) health policy discuss if age should guide rationing decisions. (shrink)

“Bodily autonomy” has received significant attention in bioethics, medical ethics, and medical law in terms of the general inviolability of a patient’s bodily sovereignty and the rights of patients to make choices (e.g., reproductive choices) that concern their own body. However, the role of the body in terms of how it can or does contribute to a patient’s capacity for, or exercises of their autonomy in clinical decision-making situations has not been explicitly addressed. The approach to autonomy in (...) this paper is aligned with traditional theories that conceive autonomy in terms of an individual’s capacities for, and exercises of rational reflection. However, at the same time, this paper extends these accounts by arguing that autonomy is, in part, embodied. Specifically, by drawing on phenomenological conceptions of the experience of autonomy, we argue that, in principle, the body is a necessary component of the capacity for autonomy. Secondly, through the presentation of two different cases, we highlight ways in which a patient’s body can contribute to the autonomy of treatment choices. Ultimately, we hope to encourage others to explore additional conditions under which a concept of embodied autonomy should be employed in medical decision making, how its underlying principles might be operationalised in clinical situations, and its consequences for approaches to patient autonomy in healthcare practice, policy, and law. (shrink)

In this paper I present an argument in favour of a parental duty to use preimplantation genetic diagnosis (PGD). I argue that if embryos created in vitro were able to decide for themselves in a rational manner, they would sometimes choose PGD as a method of selection. Couples, therefore, should respect their hypothetical choices on a principle similar to that of patient autonomy. My thesis shows that no matter which moral doctrine couples subscribe to, they ought to conduct the PGD (...) procedure in the situations when it is impossible to implant all of the created embryos and if there is a significant risk for giving birth to a child with a serious condition. (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)

Considerations of autonomy and independence, properly understood, support strictly egalitarian provision of necessary medical treatment. If the financially better-off can purchase access to necessary medical treatments that the financially less well-off cannot purchase without help, then their discretionary power to give or to withhold monetary gifts indirectly gives them the power to make life-and-death or sickness-and-health decisions for others. To prevent private citizens from having this objectionable form of power, government must ensure that citizens’ finances do not affect (...) their access to medical treatments that significantly prolong life, relieve suffering, or cure or mitigate disabilities. Government should ensure this even if doing so involves leveling down and even if it is unclear whether egalitarian provision of necessary treatment would provide better care to the poor than a less egalitarian health care system would. (shrink)

Some early phase clinical studies of candidate HIV cure and remission interventions appear to have adverse medical risk–benefit ratios for participants. Why, then, do people participate? And is it ethically permissible to allow them to participate? Recent work in decision theory sheds light on both of these questions, by casting doubt on the idea that rational individuals prefer choices that maximise expected utility, and therefore by casting doubt on the idea that researchers have an ethical obligation not to enrol (...) participants in studies with high risk–benefit ratios. This work supports the view that researchers should instead defer to the considered preferences of the participants themselves. This essay briefly explains this recent work, and then explores its application to these two questions in more detail. (shrink)

I seek to emphasize Immanuel Kant’s lingering and unsavory impact on medical ethics by emphasizing Kantian ethics’ disregard for non- rational humans. We must be considerate when discussing individuals who have some form of dementia, conditions that irreversibly diminish the ability to use rational thought, sometimes to a degree of severity that hinders essential daily functions. I argue that to consider ourselves proponents of human equality we must treat humans with dementia as members of the kingdom of ends.

The coronavirus disease 2019 (COVID-19) pandemic has motivated medical ethicists and several task forces to revisit or issue new guidelines on allocating scarce medical resources. Such guidelines are relevant for the allocation of scarce therapeutics and vaccines and for allocation of ICU beds, ventilators, and other life-sustaining treatments or potentially scarce interventions. Principles underlying these guidelines, like saving the most lives, mitigating disparities, reciprocity to those who assume additional risk (eg, essential workers and clinical trial participants), and equal (...) access may compete with one another. We propose the use of a “categorized priority system” (also known as a “reserve system”) as an improvement over existing allocation methods, particularly because it may be able to achieve disparity mitigation better than other methods. (shrink)

Age-based rationing remains highly controversial. This question has been paramount during the Covid-19 pandemic. Analyzing the practices, proposals, and guidelines applied or put forward during the current pandemic, three kinds of age-based rationing are identified: an age-based cut-off, age as a tiebreaker, and indirect age rationing, where age matters to the extent that it affects prognosis. Where age is allowed to play a role in terms of who gets treated, it is justified either because this is believed (...) to maximize benefits from scarce resources or because it is believed to be in accordance with the value of fairness understood as (a) fair innings, where less priority is given to those who have lived a full life or (b) an egalitarian concern for the worse off. By critically assessing prominent frameworks and practices for pandemic rationing, this article considers the balance the three kinds of age-based rationing strike between maximizing benefits and fairness. It evaluates whether elements in the proposals are, in fact, contrary to the justifications of these measures. Such shortcomings are highlighted, and it is proposed to adjust prominent proposals to care for the worse off more appropriately and better consider whether the acquired benefits befalls the young or the old. (shrink)

This chapter examines how social- scientific research on public preferences bears on the ethical question of how those resources should in fact be allocated, and explain how social-scientific researchers might find an understanding of work in ethics useful as they design mechanisms for data collection and analysis. I proceed by first distinguishing the methodologies of social science and ethics. I then provide an overview of different approaches to the ethics of allocating scarce medical interventions, including an approach—the complete lives (...) system—which I have previously defended, and a brief recap of social-scientific research on the allocation of scarce medical resources. Following these overviews, I examine different ways in which public preferences could matter to the ethics of allocation. Last, I suggest some ways in which social scientists could learn from ethics as they conduct research into public preferences regarding the allocation of scarce medical resources. (shrink)

In this short response to Kerstein and Bognar, we clarify three aspects of the complete lives system, which we propose as a system of allocating scarce medical interventions. We argue that the complete lives system provides meaningful guidance even though it does not provide an algorithm. We also defend the investment modification to the complete lives system, which prioritizes adolescents and older children over younger children; argue that sickest-first allocation remains flawed when scarcity is absolute and ongoing; and argue (...) that Kerstein and Bognar are mistaken to base their allocation principles on differences in personhood. (shrink)

Reserve systems are a tool to allocate scarce resources when stakeholders do not have a single objective. This paper introduces some basic concepts about reserve systems for pandemic medical resource allocation. At the onset of the Covid-19 pandemic, we proposed that reserve systems can help practitioners arrive at compromises between competing stakeholders. More than a dozen states and local jurisdictions adopted reserve systems in initial phases of vaccine distribution. We highlight several design issues arising in some of these implementations. (...) We also offer suggestions about ways practitioners can take advantage of the flexibility offered by reserve systems. (shrink)

The U.S. FDA has issued emergency use authorizations for monoclonal antibodies for non-hospitalized patients with mild or moderate COVID-19 disease and for individuals exposed to COVID-19 as post-exposure prophylaxis. One EUA for an oral antiviral drug, molnupiravir, has also been recommended by FDA’s Antimicrobial Drugs Advisory Committee, and others appear likely in the near future. Due to increased demand because of the Delta variant, the federal government resumed control over the supply and asked states to ration doses. As future variants (...) with increased infectivity and/or severity emerge, further rationing may be required. We identify relevant ethical principles and priority groups for access to therapies based on an integrated approach to population health and medical factors. Using priority categories to allocate scarce therapies effectively operationalizes important ethical values. This strategy is preferable to the current approach of categorical rules based on vaccination, immunocompromise status, or older age, or the ad hoc consideration of clinical risk factors. (shrink)

The COVID-19 (Coronavirus disease of 2019) pandemic has led to intense conversations about ventilator allocation and reallocation during a crisis standard of care. Multiple voices in the media and multiple state guidelines mention reallocation as a possibility. Drawing upon a range of neuroscientific, phenomenological, ethical, and sociopolitical considerations, the authors argue that taking away someone’s personal ventilator is a direct assault on their bodily and social integrity. They conclude that personal ventilators should not be part of reallocation pools and that (...) triage protocols should be immediately clarified to explicitly state that personal ventilators will be protected in all cases. (shrink)

Glucagon-like peptide-1 (GLP-1) receptor agonists, such as semaglutide, and dual GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) receptor agonists, such as tirzepatide, have been found to be effective for treating obesity and diabetes, significantly reducing weight and the risk or predicted risk of adverse cardiovascular events. There is a global shortage of these medications that could last several years and raises questions about how limited supplies should be allocated. We propose a fair-allocation framework that enables evaluation of the ethics of current (...) practices and could guide governments, professional societies, and physicians in allocation decisions. (shrink)

The realm of non-rational influence, which includes nudging, is home to many other morally interesting phenomena. In this paper, I introduce the term bumping, to discuss the category of unintentional non-rational influence. Bumping happens constantly, wherever people make choices in environments where they are affected by other people. For instance, doctors will often bump their patients as patients make choices about what treatments to pursue. In some cases, these bumps will systematically tend to make patients’ decisions worse. Put another way: (...) doctors will sometimes harm their patients by bumping them in systematic ways. I use the case of medical overuse, the provision of medical services where the likely harm outweighs the likely benefit to the patient, as a touchstone for arguing that doctors who systematically bump their patients towards harm can be blameworthy for their unwitting influence. (shrink)

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)

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)

Jennifer Hawkins (2024) offers two cases that challenge traditional accounts of decision-making capacity, according to which respect for a medical decision turns on an individual’s cognitive capacities at the time the decision is made (Hawkins 2024; Appelbaum and Grisso 1988). In each of her described cases (involving anorexia nervosa and grief, respectively), a patient makes a decision that—although instrumentally rational at the time—does not reflect the patient’s longer-term values due to being in a particular psychological state. Importantly, this state (...) does not impair the patient’s cognition, but rather predisposes them to make a decision that conflicts with their own broader values, beliefs, or desires. (shrink)

As medical technology advances and severely injured or ill people can be kept alive and functioning long beyond what was previously medically possible, the debate surrounding the ethics of end-of-life care and quality-of-life issues has grown more urgent. In this lucid and vigorous book, Craig Paterson discusses assisted suicide and euthanasia from a fully fledged but non-dogmatic secular natural law perspective. He rehabilitates and revitalises the natural law approach to moral reasoning by developing a pluralistic account of just why (...) we are required by practical rationality to respect and not violate key demands generated by the primary goods of persons, especially human life. Important issues that shape the moral quality of an action are explained and analysed: intention/foresight; action/omission; action/consequences; killing/letting die; innocence/non-innocence; person/non-person. Paterson defends the central normative proposition that ‘it is always a serious moral wrong to intentionally kill an innocent human person, whether self or another, notwithstanding any further appeal to consequences or motive’. (shrink)

Shortages of new therapeutics to treat coronavirus disease (COVID-19) have forced clinicians, public health officials, and health systems to grapple with difficult questions about how to fairly allocate potentially life-saving treatments when there are not enough for all patients in need (1). Shortages have occurred with remdesivir, tocilizumab, monoclonal antibodies, and the oral antiviral Paxlovid (2) -/- Ensuring equitable allocation is especially important in light of the disproportionate burden experienced during the COVID-19 pandemic by disadvantaged groups, including Black, Hispanic/Latino and (...) Indigenous communities, individuals with certain disabilities, and low-income persons. However, many health systems have resorted to first-come, first-served approaches to allocation, which tend to disadvantage individuals with barriers in access to care (3). There is mounting evidence of racial, ethnic, and socioeconomic disparities in access to medications for COVID-19 (4, 5). -/- One potential method to promote equitable allocation is to use a weighted lottery, which is an allocation strategy that gives all eligible patients a chance to receive the scarce treatment while also allowing the assignment of higher or lower chances according to other ethical considerations (6). We sought to assess the feasibility of implementing a weighted lottery to allocate scarce COVID-19 medications in a large U.S. health system and to determine whether the weighted lottery promotes equitable allocation. (shrink)

I argue that generic generalizations expressed in language (i.e. ‘generics’) are apt for clinical reasoning. I introduce generics and describe two problems in the use and interpretation of generics: Generics may license inaccurate judgements about the frequency of events or properties within a group (i.e. a problem with the ‘truth-aptness’ of generics) and may facilitate problematic beliefs about social kinds (e.g. prejudice or essentializing). I provide an account of clinical reasoning and describe some features of what I call ‘good’ clinical (...) reasoning. I offer examples of generics in clinical contexts and examine how the two problems with generics (i.e. of truth-aptness and social generics) can harm patients and impair clinical reasoning. However, I ultimately argue that generics are important for good clinical reasoning because they track ‘conspicuous’ features of disease processes (e.g. severe possible outcomes). Further, I argue that prejudicial generics are often irrational to believe. Social generics that are rational to believe need not lead to problematic implicatures about social kinds and can instead facilitate meaningfully articulating societal injustices. I then argue that statistical statements, which are tempting alternatives to generics in clinical reasoning, are no better than generics for good clinical reasoning. (shrink)

According to one influential view, requirements to elicit consent for medical interventions and other interactions gain their rationale from the respect we owe to each other as autonomous, or self-governing, rational agents. Yet the popular presumption that consent has a central role to play in legitimate intervention extends beyond the domain of cases where autonomous agency is present to cases where far from fully autonomous agents make choices that, as likely as not, are going to be against their own (...) best interest. The question how we should understand the rationale for eliciting consent in this range of ‘non-ideal’ cases is comparatively ill understood. In this paper, I explore the prospects of accounting for consent requirements in such ‘non-ideal’ cases by appealing to a set of agency-based interests; including an interest in playing a meaningful part in joint decisions affecting ourselves and others. (shrink)

A lively topic of debate in decision theory over recent years concerns our understanding of the different risk attitudes exhibited by decision makers. There is ample evidence that risk-averse and risk-seeking behaviours are widespread, and a growing consensus that such behaviour is rationally permissible. In the context of clinical medicine, this matter is complicated by the fact that healthcare professionals must often make choices for the benefit of their patients, but the norms of rational choice are conventionally grounded in a (...) decision maker’s own desires, beliefs and actions. The presence of both doctor and patient raises the question of whose risk attitude matters for the choice at hand and what to do when these diverge. Must doctors make risky choices when treating risk-seeking patients? Ought they to be risk averse in general when choosing on behalf of others? In this paper, I will argue that healthcare professionals ought to adopt a deferential approach, whereby it is the risk attitude of the patient that matters in medical decision making. I will show how familiar arguments for widely held anti-paternalistic views about medicine can be straightforwardly extended to include not only patients’ evaluations of possible health states, but also their attitudes to risk. However, I will also show that this deferential view needs further refinement: patients’ higher-order attitudes towards their risk attitudes must be considered in order to avoid some counterexamples and to accommodate different views about what sort of attitudes risk attitudes actually are. (shrink)

When people are making certain medical decisions – especially potentially transformative ones – the specter of regret may color their choices. In this paper, I ask: can predicting that we will regret a decision in the future serve any justificatory role in our present decision-making? And if so, what role? While there are many pitfalls to such reasoning, I ultimately conclude that considering future retrospective emotions like regret in our decisionmaking can be both rational and authentic. Rather than indicating (...) that one is about to make a mistake or that there is some underlying value that one already cares about but is overlooking, the prediction that one will regret a decision in the future makes one confront how her present values and priorities may change as a result of her choice in ways she cannot presently anticipate. (shrink)

If bioethical questions cannot be resolved in a widely acceptable manner by rational argument, and if they can be regulated only on the basis of political decision-making, then bioethics belongs to the political sphere. The particular kind of politics practiced in any given society matters greatly: it will determine the kind of bioethical regulation, legislation, and public policy generated there. I propose approaching bioethical questions politically in terms of decisions that cannot be “correct” but that can be “procedurally legitimate.” Two (...) procedures in particular can deliver legitimate bioethical decisions, once combined: expert bioethics committees and deliberative democracy. Bioethics so understood can exceed bioethics as a moral project or as a set of administrative principles to regulate medical practice; it can now aspire to a democratic project that involves ordinary citizens as far as reasonably possible. I advance this argument in four steps: (1) using the example of human germline gene editing, (2) I propose a general understanding of proceduralism, and (3) then combine two types and (4) conclude with a defense of majoritarian proceduralism. I develop this argument in terms of one example: germline gene editing. (shrink)

The creation of guidelines has long been a popular means of conveying normative requirements in scientific and medical research. The recent case of He Jiankui, whose research flouted both widely accepted ethical standards and a set of field-specific guidelines he co-authored, raises the question of whether guidelines are an effective means of preventing misconduct. This paper advances the theory that guidelines can facilitate moral rationalization, a form of motivated reasoning. Moral rationalization in research occurs when individuals justify their actions (...) with plausible reasons that cohere with their moral standards. This allows them to act as they want while believing in their own goodness. If guidelines facilitate moral rationalization, this has implications for research ethics training and for the work of applied ethicists. Research ethics training ought to incorporate reflection on conative features of reasoning, including incentives to commit misconduct, and applied ethicists ought to be circumspect about their use of ethics guidelines. Otherwise, they are feeding the fire of rationalization with the cognitive material practitioners need to accomplish their desired ends. (shrink)

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

In this paper, I examine the ethics of e - trust and e - trustworthiness in the context of health care, looking at direct computer-patient interfaces (DCPIs), information systems that provide medical information, diagnosis, advice, consenting and/or treatment directly to patients without clinicians as intermediaries. Designers, manufacturers and deployers of such systems have an ethical obligation to provide evidence of their trustworthiness to users. My argument for this claim is based on evidentialism about trust and trustworthiness: the idea that (...) trust should be based on sound evidence of trustworthiness. Evidence of trustworthiness is a broader notion than one might suppose, including not just information about the risks and performance of the system, but also interactional and context-based information. I suggest some sources of evidence in this broader sense that make it plausible that designers, manufacturers and deployers of DCPIs can provide evidence to users that is cognitively simple, easy to communicate, yet rationally connected with actual trustworthiness. (shrink)

Immanuel Kant (1724-1804) had not been a close friend of Johann Daniel Metzger (1739-1805), the most productive professor at the Medical Faculty of Königsberg and specialist for social and forensic medicine. Kant felt, that many somatic diseases needed philosophical support, while severe mental illness should exclusively and safely be treated with the veterinary procedures of medicine as all rational, sensible interventions were in vain. According to Kant, Metzger's outstanding domain, forensic issues, could only be resolved by philosophy. Metzger used (...) his anonymous obituary on Kant to set several things straight. (shrink)

The new field of meta-research investigates industry bias, publication bias, contradictions between studies, and other trends in medical research. I argue that its findings should be used as meta-evidence for evaluating therapies. ‘Meta-evidence’ is evidence about the support that direct ‘first-order evidence’ provides the hypothesis. I consider three objections to my proposal: the irrelevance objection, the screening-off objection, and the underdetermination objection. I argue that meta-research evidence works by rationally revising our confidence in first-order evidence and, consequently, in the (...) hypothesis—typically, downward. (shrink)

Recent increases in the rates of parental refusal of routine childhood vaccination have eroded many countries’ “herd immunity” to communicable diseases. Some parents who refuse routine childhood vaccines do so because they deny the mainstream medical consensus that vaccines are safe and effective. I argue that one reason these vaccine denialists disagree with vaccine proponents about the reasons in favor of vaccination is because they also disagree about the sorts of practices that are conducive to good reasoning about healthcare (...) choices. Vaccine denialists allocate epistemic authority more democratically than do mainstream medical professionals. They also sometimes make truth ascriptions for nonepistemic reasons, fail to recognize legitimate differences in expertiseand competence, and seek uncritical affirmation of their existing beliefs. By focusing on the different epistemic values and practices of vaccine denialists and mainstream medical professionals, I locate my discussion of vaccine denialism within broader debates about rationality. Furthermore, I argue that gender inequality and gendered conceptions of reason are important parts of the explanation of vaccine denialism. Accordingly, I draw upon feminist work—primarily feminist social epistemology—to help explain and evaluate this form of vaccine refusal. (shrink)

How should addictive behavior be explained? In terms of neurobiological illness and compulsion, or as a choice made freely, even rationally, in the face of harmful social or psychological circumstances? Some of the disagreement between proponents of the prevailing medical models and choice models in the science of addiction centres on the notion of “loss of control” as a normative characterization of addiction. In this article I examine two of the standard interpretations of loss of control in addiction, one (...) according to which addicts have lost free will, the other according to which their will is weak. I argue that both interpretations are mistaken and propose therefore an alternative based on a dual-process approach. This alternative neither rules out a capacity in addicts to rationally choose to engage in drug-oriented behavior, nor the possibility that addictive behavior can be compulsive and depend upon harmful changes in their brains caused by the regular use of drugs. (shrink)

At the height of the Covid-19 pandemic, frontline medical professionals at intensive care units around the world faced gruesome decisions about how to ration life-saving medical resources. These events provided a unique lens through which to understand how the public reasons about real-world dilemmas involving trade-offs between human lives. In three studies (total N = 2298), we examined people’s moral attitudes toward triage of acute coronavirus patients, and found elevated support for utilitarian triage policies. These utilitarian tendencies did (...) not stem from period change in moral attitudes relative to pre-pandemic levels--but rather, from the heightened realism of triage dilemmas. Participants favored utilitarian resolutions of critical care dilemmas when compared to structurally analogous, non-medical dilemmas—and such support was rooted in prosocial dispositions, including empathy and impartial beneficence. Finally, despite abundant evidence of political polarization surrounding Covid-19, moral views about critical care triage differed modestly, if at all, between liberals and conservatives. Taken together, our findings highlight people’s robust support for utilitarian measures in the face of a global public health threat, and illustrate how hypothetical scenarios in moral psychology (e.g. trolley cases) should strive for more experiential and psychological realism, otherwise their results might not generalize to real-world moral dilemmas. (shrink)

Disclosure in clinical practice is aimed at promoting patient autonomy, usually culminating in patient choice (e.g., to consent to an operation or not, or between different medications). In medical ethics, there is an implicit background assumption that knowing more about (X) automatically translates to greater, or more genuine, autonomy with respect to one's choices involving (X). I challenge this assumption by arguing that in rare cases, withholding information can promote a patient's autonomy (understood as the capacity for rational choice (...) in alignment with one's values and goals). (shrink)

Abū Bakr al-Rāzī (d. 925), a doctor known not only for his medical expertise but also for his notorious philosophical ideas, has not yet been given due credit for his ideas on the ethical treatment of animals. This paper explores the philosophical and theological background of his remarks on animal welfare, arguing that al-Rāzī did not (as has been claimed) see animals as possessing rational, intellectual souls like those of humans. It is also argued that al-Rāzī probably did not, (...) as is usually believed, endorse human-animal transmigration. His ethical stance does not in any case depend on shared characteristics of humans and animals, but rather on the need to imitate God’s providence and mercy. (shrink)

We live in an age of evidence-based healthcare, where the concept of evidence has been avidly and often uncritically embraced as a symbol of legitimacy, truth, and justice. By letting the evidence dictate healthcare decision making from the bedside to the policy level, the normative claims that inform decision making appear to be negotiated fairly—without subjectivity, prejudice, or bias. Thus, the term ‘‘evidence-based’’ is typically read in the health sciences as the empirically adequate standard of reasonable practice and a means (...) for increasing certainty. Supporters believe that evidence-based medicine (EBM) can introduce rational order to the deliberative processes of healthcare decision making. It is perhaps puzzling, then, to come across critical perspectives (typically arising from the humanities and the more theory-driven social sciences) raising concerns about a seeming technogovernance being introduced by this deferral to the evidence where power interests can be obfuscated by way of technical resolve. The critics holding this minority view argue that technological solutions to problems of knowledge and practice cannot replace medicine’s normative content. Against EBM’s democratic leanings toward transparency and accountability, medical criteria alone cannot decide valueladen ethically charged decisions. This paper attempts to explain and evaluate this important debate in the philosophy of medicine, focusing specifically on the dispute over 'evidence-based women's health'. (shrink)

For over 30 years I have argued, in and out of print that, for both intellectual and humanitarian reasons, we urgently need a revolution in the aims and methods of academic inquiry. Instead of giving priority to the search for knowledge, academia needs to devote itself to seeking and promoting wisdom by rational means, wisdom being the capacity to realize what is of value in life, for oneself and others. Wisdom thus includes knowledge but much else besides. A basic task (...) of academia would be to help humanity learn how to create a better world. Now I find the revolution is underway – entirely independent of my own efforts to promote it. During the last ten to twenty years, all sorts of changes have taken place in academia that amount to putting aspects of wisdom-inquiry into practice – even if in complete ignorance of my work. Perhaps the most significant steps are the creation of departments, institutions and research centres concerned with social policy, with problems of environmental degradation, climate change, poverty, injustice and war, and with such matters as medical ethics and community health. Nevertheless, the revolution is happening with agonizing slowness, in a dreadfully muddled and piecemeal way. It needs academics and non-academics to wake up to what is going on – or what needs to go on – to help give direction, coherence and a rationale to this nascent revolution from knowledge to wisdom. (shrink)

A dilemma exists when a doctor is faced with a child or young person who refuses medically indicated treatment. The Gillick case has been interpreted by many to mean that a child of sufficient age and intelligence could validly consent or refuse consent to treatment. Recent decisions of the Court of Appeal on a child's refusal of medical treatment have clouded the issue and undermined the spirit of the Gillick decision and the Children Act 1989. It is now the (...) case that a child patient whose competence is in doubt will be found rational if he or she accepts the proposal to treat but may be found incompetent if he or she disagrees. Practitioners are alerted to the anomalies now exhibited by the law on the issue of children's consent and refusal. The impact of the decisions from the perspectives of medicine, ethics, and the law are examined. Practitioners should review each case of child care carefully and in cases of doubt seek legal advice. (shrink)

For a long time discussion about scarce health care resource allocation was limited to allocation of medical resources, with the paradigmatic case being kidney transplants. However, a narrow focus on medical resources prevents us from seeing that there are many cases-- perhaps the majority-- in which less dramatic but equally important issues of rationing occur. The allocation of nurses' time is one such issue.

TWENTIETH-CENTURY ETHICS. AFTER NIETZSCHE -/- Preface This book tells the story of twentieth-century ethics or, in more detail, it reconstructs the history of a discussion on the foundations of ethics which had a start with Nietzsche and Sidgwick, the leading proponents of late-nineteenth-century moral scepticism. During the first half of the century, the prevailing trends tended to exclude the possibility of normative ethics. On the Continent, the trend was to transform ethics into a philosophy of existence whose self-appointed task was (...) that of describing the human condition as consisting of choices, as unavoidable as arbitrary, without any attempt at providing criteria for making such choices. In the Anglo-Saxon countries, the heir of ethics was a philosophy of morality, that is, an analysis of the language of morality that intended to clarify valuations without trying to justify them. 1958 was the year of the normative turn that led to the Rehabilitation of practical philosophy, a turn followed by decades of controversies between distinct kinds of normative ethics: utilitarian, Kantian, virtue ethics. While the controversy was raging, a quiet revolution took place, that of applied ethics which surprisingly dissolved the controversy's very subject matter by providing methods for making convergence possible on intermediate principles even when no agreement was available about first principles. The normative turn and the revolution of applied ethics have led us, at the turn of the century, to a goal that was quite far from the starting point. Instead of scepticism and relativism that was the fashion at the beginning of the century, at the beginning of the third millennium impartial and universal moral arguments seem to hold the spot being supported, if not by a final rational foundation, at least by reasonableness, the most precious legacy of the Enlightenment. -/- ● TABLE OF CONTENTS -/- ● I Anglo-Saxon philosophy: naturalism 1. Dewey beyond evolutionism and utilitarianism 2. Dewey and anti-essentialist moral epistemology 3. Dewey and naturalist moral ontology 4. Dewey and normative ethics of conduct and function 5. Perry and semantic naturalism -/- ● II Anglo-Saxon philosophy: ideal utilitarianism and neo-intuitionism 1. Moore's critique of utilitarian empiricism 2. Moore on the naturalistic fallacy 3. Moore on the nature of intrinsic value 4. Moore on ideal utilitarianism 5. Prichard on the priority of the right over the good 6. Ross's coherentist moral epistemology 7. Ross's moral ontology: realism, pluralism, and non-naturalism 8. Ross's normative ethics of prima facie duties -/- The chapter reconstructs the background of ideas, concerns and intentions out of which Moore's early essays, the preliminary version, and then the final version of Principia Ethica originated. It stresses the role of religious concerns, as well as that of the Idealist legacy. It argues that PE is more a patchwork of somewhat diverging contributions than a unitary work, not to say the paradigm of a new school in Ethics. -/- ●III Anglo-Saxon philosophy: non-cognitivism 1. The Scandinavian School, the Vienna circle and proto-emotivism 2. Wittgenstein and the ineffability of ethics 3. Russell's and Ayer's radical emotivism 4. Stevenson and moderate emotivism 5. Stevenson and the pragmatics of moral language 6. Stevenson and the methods for solving ethical disagreement 7. Hare and prescriptivism The chapter reconstructs first the discussion after Moore. The naturalistic-fallacy argument was widely accepted but twisted to prove instead that the intuitive character of the definition of 'good', its non-cognitive meaning, in a first phase identified with 'emotive' meaning. Alfred Julius Ayer is indicated as a typical proponent of such non-cognitivist meta-ethics. More detailed discussion is dedicated to Bertrand Russell's ethics, a more nuanced and sophisticated doctrine, arguing that non-cognitivism does not condemn morality to arbitrariness and that the project of rational normative ethics is still possible, heading finally to the justification of a kind of non-hedonist utilitarianism. Stevenson's theory, another moderate version of emotivism is discussed at some length, showing how the author comes close to the discovery of the role of a pragmatic dimension of language as a basis for ethical argument. A section reconstructs the discussion from the Forties about Hume's law, mentioning Karl Popper's argument and Richard Hare's early non-cognitivist but non-emotivist doctrine named prescriptivism. -/- ●IV Anglo-Saxon philosophy: critics of non-cognitivism 1. Neo-naturalism and its objections to the naturalistic fallacy argument 2. Objections to Hume's law 3. Clarence Lewis and the pragmatic contradiction 4. Toulmin and the good reasons approach 5. Baier and moral reasons 5. Baier, social moralities and the absolute morality 6. Baier and the moral point of view 7. Baier and the contents of absolute ethics -/- ● V Continental philosophy: the philosophy of values 1. Max Weber and the polytheism of values 2. Phenomenology against psychologism and rationalism 3. Reinach and the theory of social acts 4. Scheler and the material ethics of values 5. Hartmann and the ontology of values 6. Plessner, Gehlen and the Philosophische Anthropologie -/- The chapter illustrates first the idea of phenomenology and the Husserl's project of a phenomenological ethic as illustrated in his 1908-1914 lectures. The key idea is dismissing psychology and trying to ground a new science of the apriori of action, within which a more restricted field of inquiry will be the science of right actions. Then the chapter illustrates the criticism of modern moral philosophy conducted in the 1920 lectures, where the main target is naturalism, understood in the Kantian meaning of primacy of common sense. The third point illustrate is Adolph Reinach's theory of social acts as a key the grounding of norms, a view that sketches the ideas 'discovered' later by Clarence I. Lewis, John Searle, Karl-Otto Apel and Jürgen Habermas. A final section discusses Nicolai Hartman, who always refused to define himself a phenomenologist and yet developed a more articulated and detailed theory of 'values' – with surprising affinities with George E. Moore - than philosophers such as Max Scheler, who claimed to be Husserl's legitimate heirs. -/- ● VI Continental philosophy: the critics of the philosophy of values 1. Freud, the Superego and Civilization 2. Heidegger on original ethos against ethics 3. Sartre and de Beauvoir on authenticity and ambiguity 4. Adorno and Horkheimer on emancipation and immoralism -/- ●VII Post-liberal theologians and religious thinkers 1. Barth on the autonomy of faith from ethics 2. Developments of Reformed moral theology after Barth 3. Bonhoeffer on the concrete divine command and ethics of penultimate realities 4. Developments of Reformed and Catholic moral theology after world war II 5. Baeck and the transformation of liberal Judaism 6. Rosenzweig against liberal Judaism 7. Buber and religion as the vital lymph of morality 8. Heschel and Judaism as a science of actions -/- The chapter examines the main protagonists of Christian theology and Jewish religious thinking in the twentieth century. It stresses how the main dilemmas of contemporary philosophical ethics lie at the root of the various path of inquiry taken by these thinkers. -/- ● VIII Normative ethics: neo-Utilitarianism 1. The discussion on act and rule utilitarianism 2. Hare on two-tiered preference utilitarianism 3. Harsanyi, Gauthier and rational choice ethics 4. Parfit, utilitarianism and the idea of a person 5. Brandt and indirect conscience utilitarianism -/- The chapter addresses the issue of the complex process of self-transformation Utilitarianism underwent after Sidgwick's and Moore's fatal criticism and the unexpected Phoenix-like process of rebirth of a doctrine refuted. Two examples give the reader a glimpse at this uproarious process. The first is Roy Harrod Wittgensteinian transformation of utilitarianism in pure normative ethics depurated from hedonism as well as from whatsoever theory of the good. This transformation results in preference utilitarianism combined with a 'Kantian' version of rule utilitarianism. The second is Richard Hare's two-level preference utilitarianism, where act utilitarianism plays the function of the eventual rational justification of moral judgments and rule-utilitarianism that of an action-guiding practical device. -/- ● IX Normative ethics: neo-Aristotelianism and virtue ethics 1. Hannah Arendt, action and judgement 2. Hans-Georg Gadamer and phronesis 3. Alasdair MacIntyre on practices, virtues, and traditions 5. Stuart Hampshire on deliberation 6. Bernard Williams and moral complexity 7. Feminist ethics -/- Sect 1 reconstructs the post-war rediscovery of ethics by many German thinkers and its culmination in the Sixties in the movement named 'Rehabilitation of practical philosophy' is described. Heidegger's most brilliant disciples were the promoters of this Rehabilitation. Hans-Georg Gadamer is a paradigmatic example. His reading of Aristotle's lesson I reconstructed, starting with Heidegger's lesson but then subtly subverting its outcome thanks to the recovery of the significant role of the notion of phronesis. Sect 3 discusses the three theses defended by Anscombe in 'Modern Moral Philosophy'. It argues that: a) her answer to the question "why should I be moral?" requires a solution of the problem of theodicy, and ignores any attempts to save the moral point of view without recourse to divine retribution; b) her notion of divine law is an odd one more neo-Augustinian than Biblical or Scholastic; c) her image of Kantian ethics and intuitionism is the impoverished image manufactured by consequentialist opponents for polemical purposes and that she seems strangely accept it; d) the difficulty of identifying the "relevant descriptions" of acts is not an argument in favour of an ethics of virtue and against consequentialism or Kantian ethics, and indeed the role of judgment in the latter is a response to the difficulties raised by the case of judgment concerning future action. The chapter gives a short look at further developments in the neo-naturalist current trough a reconstruction of Philippa Foot's and Peter Geach's critiques to the naturalist-fallacy argument and Alasdair MacIntyre's grand reconstruction of the origins and allegedly inevitable failure of the Enlightenment project of an autonomous ethic. -/- ● X Normative ethics: Kantian and rights-based ethics 1. Dialogical constructivism 2. Apel, Habermas and discourse ethics 3. Gewirth and rights-based ethics 4. Nagel on agent-relative reasons 5. Donagan and persons as ends in themselves Parallel to the neo-Aristotelian trend, there was in the Rehabilitation of practical philosophy a Kantian current. This current started with the discovery of the pragmatic dimension of language carried out by Charles Peirce and the Oxford linguistic philosophy. On this basis, Karl-Otto Apel singled out as the decisive proponent of the linguistic and Kantian turn in German-speaking ethics, worked out the performative-contradiction argument while claiming that this was able to provide a new rational and universal basis for normative ethics. The chapter offers an examination of his argument in some detail, followed by a more cursory reconstruction of Jürgen Habermas's elaboration on Apel's theory. -/- ● XI The applied ethics renaissance 1. Elisabeth Anscombe on the atom bomb 2. From medical ethics to bioethics 3. Rawls and public ethics 3. Nozick, Dworkin and further developments of public ethics 5. Sen and the revival of economic ethics -/- The chapter presents the revolution of applied ethics while stressing its methodological novelty, exemplified primarily by Beauchamp and Childress principles approach and then by Jonsen and Toulmin's new casuistry. The chapter argues that Rawls's distinction between a "political" and a "metaphysical" approach to the theory of justice, one central part of ethical theory, is a formulation of the same basic idea at the root of both the principles approach and the new casuistry, both discussed in the following chapter. The idea is that it is possible to reach an agreement concerning positive moral judgments even though the discussion is still open – and in Rawls' view never will be close – on the essential criteria for judgment. -/- ● XII Fin-de-siècle metaethics 1. Deontic logics 2. Anti-realism 3. External realism 4. Internal realism 5. Kantian constructivism -/- The chapter illustrates the fresh start of meta-ethical discussion in the Eighties and Nineties and the resulting new alignments: metaphysical naturalism, internal realism, anti-realism, and constructivism. (shrink)

Dr. Strange sees Dr. Stephen Strange abandon his once-promising medical career to become a superhero with the ability to warp time and space, and to travel through various dimensions. In order to make this transition, he is required to abandon many of his previous assumptions about the way the world works and learn to see things in a new way. Importantly, this is not merely a matter of learning a few facts, or of mastering new techniques. Instead, Dr. Strange (...) is required to alter his conception of the basic nature of the world and of how he relates to it. In time, this change extends to his values as well, as Strange comes to embrace his role in safeguarding the human world from interdimensional threats. -/- It is tempting to interpret Dr. Strange’s experience as one that shows the limits of rational, scientific inquiry, or even of human knowledge more generally. However, in this essay, I’d like to explore a different interpretation: that Strange’s experience can most fruitfully be thought of as a scientific revolution, in which Strange moves from one way of carrying out scientific inquiry to a different, incompatible way of doing it. In order to do this, I’ll be exploring the work of philosopher and historian of science Thomas Kuhn, who wrote a book—The Structure of Scientific Revolutions--about just this topic. Among other things, Kuhn’s work introduced the highly useful (though commonly misunderstood) notion of a paradigm shift. -/- We’ll begin by exploring what Kuhn describes as normal science, which consists of applying a set of well-understood concepts and methods to problems of interest. This “puzzle-solving” aspect of science is exemplified by Strange’s early successes in medicine. During this stage, scientists have good reasons to avoid questioning the basic validity of their paradigm, and to instead blame any problems that arise on other factors, such as human error. (As fans will know, Strange is quite good at assigning blame in just this way.) A crisis only occurs when significant, serious anomalies have accrued, such as those that Strange encounters in the aftermath of his accident. Even then, however, the old paradigm will only be abandoned only if a new paradigm can be found. Again, Strange’s experience bears this out, as he is able to move on only when the Sorcerer Supreme introduces him to the Mystic Arts. -/- Along the way, we’ll consider what it means for a practice to count as a scientific paradigm, and why it’s not just “anything goes.” Among other things, a paradigm requires that practitioners agree on which problems are most important, which techniques are appropriate to which problems, and what exemplary models of successful work look like. The Mystic Arts of Strange’s world, unlike the pseudoscientific theories of our own, plausibly do quite well on these sorts of criteria. (shrink)

Issues of personal identity are relevant in biomedical ethics, but in what way? The mainclaim that structures Quante’s book is that the debates about bioethics and medical ethicshave not been sufficiently clear about the different meanings of ‘personal identity’. Hedistinguishes four questions: 1)conditions of personhood (what properties and capacitiesmust a thing have to be a person: consciousness? self-consciousness? consciousness of timeand one’s persistence in time? rationality? capacity to recognize others and communicate with them?), 2) the question of unity or (...) synchronous identity(when can we speak aboutprecisely one person?), 3) the question of persistence or diachronous identity(when is a personat one point in time identical with a person at another point in time?) and 4) the question of personality or biographical identity(the existential conception of identity in the sense that people have identity crises). One can add to these a related question which Quanteaddresses while discussing the other questions: 5)what are we? (are we persons essentially,or are we rather human beings? is the sortal which defines our persistence conditions‘person’ or rather ‘human organism’ or maybe something else?). (shrink)

This paper begins the last instalment of a six-part project correlating the key aspects of Kant’s architectonic conception of philosophy with a special version of the Chinese Book of Changes that I call the “Compound Yijing”, which arranges the 64 hexagrams (gua) into both fourfold and threefold sets. I begin by briefly summarizing the foregoing articles: although Kant and the Yijing employ different types of architectonic reasoning, the two systems can both be described in terms of three “levels” of elements. (...) Starting at an unnumbered level devoid of any element (the tao or thing in itself), the system proceeds by elaborating a key fourfold distinction (or “quaternity”) on the first level, a twelvefold distinction on the second level, and twelve quaternities (grouped in four quadrants, each with a set of three quaternities) on the third level. Each set of three quaternities (i.e., each quadrant) on the third level corresponds to one of the four “faculties” of the university, as elaborated in Kant’s book, The Conflict of the Faculties. Previous papers have examined the correlations between three key quaternities that Kant defends in relation to each of three faculties (philosophy, theology, and law) and the 12 gua that correspond to that faculty in the Compound Yijing. The final step is to explore the fourth quaternity on the third level, the 12 gua corresponding to the medical faculty. The “idea of reason” in Kant’s metaphysics that guides this wing of the comparative analysis is freedom, and the ultimate purpose of this faculty of the university is to train doctors to care for people’s physical well-being, as free agents imbedded in nature. But this paper will focus only on the four gua that correspond to four basic concepts in Kant’s theory of medicine. The two quaternities in the “yin-yang” (medical) quadrant of the Compound Yijing that will be skipped here are as follows. First, Kant’s account of the idea of freedom itself, which gives rise to the area of traditional metaphysics known as rational cosmology, comes in the first Critique’s Dialectic, in the section on the Antinomy of Reason (CPR A405-567/B432- 595). There he examines four irresolvable issues: whether the world has a beginning in time; whether composite substances consist of simple parts; whether a causality of freedom operates in the natural world; and whether an absolutely necessary being exists. Later I will argue that these correspond to the quaternity consisting of gua 15, 22, 36, and 52. (shrink)