In a rigorous systematic review, Dukhanin and colleagues categorize metrics and evaluative tools of the engagement of patient, public, consumer, and community in decision-making in healthcare institutions and systems. The review itself is ably done and the categorizations lead to a useful understanding of the necessary elements of engagement, and a suite of measures relevant to implementing engagement in systems. Nevertheless, the question remains whether the engagement of patient representatives in institutional or systemic deliberations (...) will lead to improved clinical outcomes or increased engagement of individual patients themselves in care. Attention to the conceptual foundations of patient engagement would help make this systematic review relevant to the clinical care of patients. (shrink)

We argue that while digital health technologies (e.g. artificial intelligence, smartphones, and virtual reality) present significant opportunities for improving the delivery of healthcare, key concepts that are used to evaluate and understand their impact can obscure significant ethical issues related to patient engagement and experience. Specifically, we focus on the concept of empowerment and ask whether it is adequate for addressing some significant ethical concerns that relate to digital health technologies for mental healthcare. We frame these concerns using (...) five key ethical principles for AI ethics (i.e. autonomy, beneficence, non-maleficence, justice, and explicability), which have their roots in the bioethical literature, in order to critically evaluate the role that digital health technologies will have in the future of digital healthcare. (shrink)

In contemporary bioethics, the autonomy of the patient has assumed considerable importance. Progressing from a more limited notion of informed consent, shared decision making calls upon patients to voice the desires and preferences of their authentic self, engaging in choice among alternatives as a way to exercise deeply held values. One influential opinion in Jewish bioethics holds that Jewish law, in contradistinction to secular bioethics, limits the patient's exercise of autonomy only in those instances in which treatment choices (...) are sensitive to preferences. Here, we analyze a discussion in the Mishna, a foundational text of rabbinic Judaism, regarding patient autonomy in the setting of religiously mandated fasting, and commentaries in the Babylonian and Palestinian Talmuds, finding both a more expansive notion of such autonomy and a potential metaphysical grounding for it in the importance of patient self-knowledge. (shrink)

In this reply to comments by Neera Badhwar and Barbara Montero, I examine more deeply the nature of cognitive engagement and how it is distinct from other forms of cognitive activity; revisit the distinction between interesting and boring experiences; and present an analysis of all-things-considered value that illustrates the contributions that the interesting makes. I conclude by considering what all-things-considered value becomes for patients with severe cognitive impairments.

Community-based participatory research (CBPR) and community engaged research (CEnR) are key to promoting community and patient engagement in actionable evidence-based strategies to improve research for health equity. Rapid growth of CBPR/CEnR research projects have led to the broad adoption of partnering principles in community-academic partnerships and among some health and academic organizations. Yet, transformation of principles into best practices that foster trust, shared power, and equity outcomes still remain fragmented, are dependent on individuals with long term projects, or (...) are non-existent. This paper describes how we designed our Engage for Equity PLUS intervention that leverages the leadership and membership of champion teams (including community-engaged faculty, community partners and patient advocates) to improve organizational policies and practices to support equity based CBPR/CEnR. (shrink)

The underreporting of suspected adverse drug reactions hinders pharmacovigilance. Solutions to underreporting are oftentimes directed at clinicians and health care professionals. However, given the recent rise of public inclusion in medical science, solutions may soon begin more actively involving patients. I aim to offer an evaluative framework for future possible proposals that would engage patients with the aim of mitigating underreporting. The framework may also have value in evaluating current reporting practices. The offered framework is composed of three criteria that (...) are bioethical, social-epistemic, and pragmatic: (i) patients should not be exposed to undue harms, e.g., nocebo effects; (ii) data should be collected, analyzed, and communicated prioritizing pharmacovigilance’s aims, i.e., free from industry bias; and (iii) proposals should account for existing and foreseeable pragmatic constraints like clinician ‘buy in’ and existing reporting infrastructure. Proposals to engage patients in pharmacovigilance that fulfil or address these criteria are preferable to those that do not. (shrink)

The diagnostic category of borderline personality disorder (BPD) has come under increasing criticism in recent years. In this paper, we analyze the role and impact of epistemic injustice, specifically testimonial injustice, in relation to the diagnosis of BPD. We first offer a critical sociological and historical account, detailing and expanding a range of arguments that BPD is problematic nosologically. We then turn to explore the epistemic injustices that can result from a BPD diagnosis, showing how they can lead to experiences (...) of testimonial injustice which impede patient engagement in meaning-making activities, thereby undermining standard therapeutic goals. We conclude by showing how our arguments bolster ongoing efforts to replace the diagnostic category of BPD with alternatives such as complex post-traumatic stress disorder. (shrink)

Social media has transformed how individuals handle their illnesses. While many patients increasingly use these online platforms to understand embodied information surrounding their conditions, healthcare professionals often frame these practices as negative and do not consider the expertise that patients generate through social media. Through a combination of insights from social epistemology and ignorance studies, this paper problematizes the distinctive understandings of social media between patients and healthcare professionals from a different perspective. A total of four ideas are introduced: (1) (...) healthcare professionals see embodied knowledge that arises from patients’ social media practices as uncomfortable knowledge; (2) healthcare professionals engage in several behaviours to preserve their authority and power in front of embodied knowledge created through these online platforms; (3) failing to consider embodied knowledge can have consequences not only in terms of trust between patients and healthcare professionals but also in connection with epistemological populism and the transition towards patient-centred care; and (4) media and digital health literacy could help healthcare professionals enhance the uses of social media in healthcare. Adopting this framework allows not only to offer valuable insights into how healthcare professionals manage patients’ social media practices, but also opens new avenues to improve healthcare digitisation. (shrink)

Case reports about patients undergoing Deep Brain Stimulation (DBS) for various motor and psychiatric disorders - including Parkinson’s Disease, Obsessive Compulsive Disorder, and Treatment Resistant Depression - have sparked a vast literature in neuroethics. Questions about whether and how DBS changes the self have been at the fore. The present chapter brings these neuroethical debates into conversation with recent research in moral psychology. We begin in Section 1 by reviewing the recent clinical literature on DBS. In Section 2, we consider (...) whether DBS poses a threat to personal identity. In Section 3 we argue for engagement with recent empirical work examining judgements of when identity changes. We conclude in Section 4 by highlighting a range of ethical issues raised by DBS, including various cross-cultural considerations. (shrink)

In this paper, we engage in dialogue with Jonathan Pugh, Hannah Maslen, and Julian Savulescu about how to best interpret the potential impacts of deep brain stimulation on the self. We consider whether ordinary people’s convictions about the true self should be interpreted in essentialist or existentialist ways. Like Pugh et al., we argue that it is useful to understand the notion of the true self as having both essentialist and existentialist components. We also consider two ideas from existentialist philosophy (...) – Jean-Paul Sartre and Simone de Beauvoir’s ideas about “bad faith” and “ambiguity” – to argue that there can be value to patients in regarding themselves as having a certain amount of freedom to choose what aspects of themselves should be considered representative of their true selves. Lastly, we consider the case of an anorexia nervosa-patient who shifts between conflicting mind-sets. We argue that mind-sets in which it is easier for the patient and his or her family to share values can plausibly be considered to be more representative of the patient’s true self, if this promotes a well-functioning relationship between the patient and the family. However, we also argue that families are well-advised to give patients room to figure out what such shared values mean to them, since it can be alienating for patients if they feel that others try to impose values on them from the outside. (shrink)

Innovative practice involves medical interventions that deviate from standard practice in significant ways. For many patients, innovative practice offers the best chance of successful treatment. Because little is known about most innovative treatments, clinicians who engage in innovative practice might consider including extra procedures, such as scans or blood draws, to gather information about the innovation. Such information-gathering interventions can yield valuable information for modifying the innovation to benefit future patients and for designing scientific studies of the innovation. However, existing (...) guidelines do not say when or whether it is appropriate to add potentially risky information-gathering interventions for these purposes. As a result, clinicians may assume that information-gathering interventions are ethically inappropriate and should not be used in innovative practice. This assumption can lead to seriously negative consequences, such as increasing the likelihood that harmful or ineffective innovations will be adopted and creating new barriers to the development of genuinely beneficial treatments. We argue that health care institutions need to promote the responsible use of information-gathering interventions as an adjunct to innovative practice, and that these interventions are not clinical research and should not be subject to research oversight. (shrink)

The rapid increase of the old age people imposes the reconsideration of the rehabilitation techniques and procedures and/or the development of the existing ones, at least from two points of view: the limitation use of the pharmaceutical drugs because of their secondary effects in the debilitated organisms and their avoidance; the high risk of the induced anxiety states, depression or other symptoms as a consequence of the main disease, i.e. the neuro-degenerative or mobility dysfunctions, limiting again the use of such (...) excessive drug medication. Moreover, Alzheimer’s or Parknson’s diseases are otherwise incurable, so the application of rehabilitating procedures like music-based therapy becomes preferential. The advances both in the identification of the specific auditory musical-sensitive circuits and of the non- musical neuro-connections but activated indirectly by music, otherwise inaccessible by other techniques, and in the understanding of consciousness, which can be described by seven cognitive centers, allows to improve and develop the music based therapy. A multitask procedure based on the activation of these cognition centers is presented, allowing to increase the personal psychical engagement of the patient in the recommended music based therapeutic program, addressed both to the rehabilitation of the main degenerative disease and to the secondary induced dysfunctions. This procedure combines the evidence based medicine assisted by laboratory expertise for the determination of a correct diagnostic, and narrative based medicine allowing to quantify the personal engaging qualities of the patient with respect to the proposed music based program, reducing in this way the gap between these two basic procedures and bringing in a first plane the patient care, not only the disease, with beneficial consequence for the therapy efficiency and for the patient-medical care relations. (shrink)

This dissertation examines the idea of _ethical revaluation_ — taking things we normally see as good for our flourishing and seeing them as neutral or bad, and vice versa — in the Mahāyāna Buddhist thinker Śāntideva. It shows how Śāntideva’s thought on the matter is more coherent than it might otherwise appear, first by examining the consistency of Śāntideva’s own claims and then by applying them to contemporary ethical thought. In so doing, it makes four significant contributions. Śāntideva claims that (...) property and relationships are bad for us because they promote attachment, and that others’ wrongdoing is good for us because it allows us to generate patient endurance. Yet he also urges his readers to give property to others, and to prevent their wrongdoing. Is he caught in contradiction? The dissertation argues that he is not, because giving to others is not intended to benefit them materially, but rather to produce beneficial mental states in them, and preventing wrongdoing is intended to benefit the wrongdoer and not the victim. In both cases, Śāntideva emphasizes individual action in a way that makes social or political action more difficult to justify. The dissertation’s first contribution is to show how this interpretation of Śāntideva contrasts notably with standard presentations of Mahāyāna ethics. Its second contribution is to refute claims that Buddhists have no normative ethics. Śāntideva’s resolutions of these apparent contradictions also have relevance for contemporary ethical thought. Martha Nussbaum argues against an ethical revaluation similar to Śāntideva’s, on the grounds that such a revaluation makes it contradictory to argue for providing goods to others, preventing others’ wrongdoing or engaging in political action. Śāntideva’s views show that ethical revaluation is a more sustainable position than these criticisms of Nussbaum’s would imply; if it is to be rejected, it must be rejected on other grounds. To show this point is the dissertation’s third contribution. The fourth contribution is methodological; by finding similarities of concern and differences of opinion between Śāntideva and a contemporary thinker, it helps bridge the gap between normative and comparative religious ethics. (shrink)

In this paper, I investigate in detail one theoretical approach to the symptom of thought insertion. This approach suggests that patients are lead to disown certain thoughts they are subjected to because they lack a sense of active participation in the occurrence of those thoughts. I examine one reading of this claim, according to which the patients’ anomalous experiences arise from a breakdown of cognitive mechanisms tracking the production of occurrent thoughts, before sketching an alternative reading, according to which their (...) experiences have to be explained in terms of a withdrawal, on the part of the patients themselves, from certain forms of active engagement in reasoning. I conclude with a discussion of the relationship between this view and the idea that patients’ reports of thought insertion reflect a situation in which the boundaries between the self and the world have become uncertain. (shrink)

The brain’s intrinsic activity plays a fundamental role in its function. In normal conditions this activity is responsive to behavioural context, changing as an individual switches between directed tasks and task‐free conditions. A key feature of such changes is the movement of the brain between corresponding critical and sub‐critical states, with these dynamics supporting efficient cognitive processing. Breakdowns in processing efficiency can occur, however, in brain disorders such as depression. It was therefore hypothesised that depressive symptoms would be related to (...) reduced intrinsic activity responsiveness to changes in behavioural state. This was tested in a mixed group of major depressive disorder patients (n = 26) and healthy participants (n = 37) by measuring intrinsic EEG activity temporal structure, quantified with detrended fluctuation analysis (DFA), in eyes‐closed and eyes‐open task‐free states and contrasting between the conditions. The degree to which DFA values changed between the states was found to be negatively correlated with depressive symptoms. DFA values did not differ between states at all in those with higher symptom levels, meaning that the brain remained in a less flexible sub‐critical condition. This sub‐critical condition in the eyes‐closed state was further found to correlate with levels of maladaptive rumination. This may reflect a general cognitive inflexibility resulting from a lack in neural activity reactivity that may predispose people to overly engage in self‐directed attention. These results provide an initial link between intrinsic activity reactivity and psychological features found in psychiatric disorders. (shrink)

Exercise-based rehabilitation forms a key part of the UK National Health Service patient-care pathway for cardiac rehabilitation (CR). Only around half of all eligible patients attend core CR, however, with social inequalities affecting participation. Few qualitative studies have explored in-depth the key factors influencing engagement with CR, specifically from a sociological theoretical, and ethnographic perspective. Utilising an ethnographic approach allowed us to get a sense of the embodied experiences of 10 participants attending or declining core CR, together with (...) a further seven family members/significant others. This provided in-depth appreciation of participants’ lifeworld contexts as key influences on CR participation. The article draws on these qualitative data and focuses on 1) participants’ initial thoughts about CR; and 2) navigating the field of CR, analysed via thematic analysis. We utilise a Bourdieusian theoretical perspective to theorise the findings, including salient socio-cultural factors influencing attendance/non-attendance and (non)adherence. The article findings highlight how perceptions of CR and the ability to navigate the field are strongly influenced by habitus and capital, and how personal biographies and socio-material conditions affect adherence to CR programmes. The study provides original insights into embodied experiences of exercise-based CR, and novel understandings of the reasons for drop-out/poor adherence, theorised from a Bourdieusian perspective. (shrink)

Metaphysically speaking, just what is trying? There appear to be two options: to place it on the side of the mind or on the side of the world. Volitionists, who think that to try is to engage in a mental act, perhaps identical to willing and perhaps not, take the mind-side option. The second, or world-side option identifies trying to do something with one of the more basic actions by which one tries to do that thing. The trying is then (...) said to be identical with the physical action. -/- After carefully stating the second, world-side view, I produce two arguments against it. The first relies on the fact that if a=b and b=c, then a=c, sometimes put colloquially as: if something is identical to two things, then the two things must be identical to one another. In the case of trying, one might try to do something by performing a plurality of simultaneous actions, a sure sign that the relation between the trying and the plurality of actions by which one tries must be some relation other than identity. -/- The second argument discusses two cases, recorded in William James’ The Principles of Psychology, of a patient who tries but who performs no action whatever. This is sometimes called ‘naked trying’. A recent attempt at denying that there can be such cases of naked trying is examined and dismissed. (shrink)

In this paper, I identify two major philosophical crises confronting medicine as a global phenomenon. The first crisis is the epistemological crisis of adopting an epistemic attitude, adequate for improving medical knowledge and practice. The second is the ethical crisis, also known as the “quality-of-care crisis,” arising from the traditional patient-physician dyad. I acknowledge the different proposals put forward in the quest for solutions to these crises. However, I observe that most of these proposals remain inadequate given their over-reliance (...) on the Western biomedical tradition and the medical hegemony that underpins the proposals themselves. Contrary to the approach employed in these proposals, I propose medical pluralism as a viable platform for resolving the philosophic crises in medicine, by critically engaging non-Western medical traditions and thought systems. Ultimately, I make a push for the deliberate inauguration of an African philosophy of medicine and bioethics and other context-specific or indigenous philosophies of medicine and bioethics that will ensure continuous investigations into NMTs and their contribution to global medical issues. (shrink)

Efforts by governments, firms, and patients to deliver pioneering drugs for critical health needs face a challenge of diminishing efficiency in developing those medicines. While multi-sectoral collaborations involving firms, researchers, patients, and policymakers are widely recognized as crucial for countering this decline, existing incentives to engage in drug development predominantly target drug manufacturers and thereby do little to stimulate collaborative innovation. In this mini review, we consider the unexplored potential within pharmaceutical regulations to create novel incentives to encourage a diverse (...) set of actors from the public and private spheres to engage in the kind of collaborative knowledge exchange requisite for fostering enhanced innovation in early drug development. (shrink)

Respect for autonomy is a central moral principle in bioethics. It is sometimes argued that authenticity, i.e., being “real,” “genuine,” “true to oneself,” or similar, is crucial to a person’s autonomy. Patients sometimes make what appears to be inauthentic decisions, such as when anorexia nervosa patients refuse treatment to avoid gaining weight, despite that the risk of harm is very high. If such decisions are inauthentic, and therefore non-autonomous, it may be the case they should be overridden for paternalist reasons. (...) However, it is not clear what justifies the judgment that someone or something is inauthentic. This article discusses one recent theory of what justifies judgments of inauthenticity. It is argued that the theory is seriously limited, as it only provides guidance in three out of nine identified cases. There are at least six authenticity-related problems to be solved, and autonomy theorists thus have reason to engage with the topic of authenticity in practical biomedicine. (shrink)

In recent papers, I defend the intrinsic value of the interesting, and the intrinsic disvalue of the boring. My arguments introduce two claims with important implications for discussions of the quality of life. The first is that when it comes to experiences, there’s more value at stake than pleasure alone. The second is that there is value to cognitive engagement itself, even when it is unstructured by desires or reasons. This paper explores the important consequences these conclusions have for (...) how we appraise the quality of life of subjects with dramatically impaired cognitive capacities (such as patients with advanced Alzheimer’s and patients in a persistent vegetive state). I examine whether such groups are capable of experiencing the interesting and, by extension, what degrees of self-awareness are required to experience the kind of cognitive engagement at stake in interesting experiences. (shrink)

In “Flourish,” the psychologist Martin Seligman proposed that psychological well-being consists of “PERMA: positive emotion, engagement, relationships, meaning, and accomplishment.” Although the question of what constitutes flourishing or psychological well-being has been long debated among scholars, the recent literature has suggested that a paradigmatic or prototypical case of psychological well-being would manifest most or all of the aforementioned PERMA factors. The recent literature on poetry therapy has also suggested that poetry practice may be utilized as “an effective therapeutic tool” (...) for patients suffering from a variety of ailments so it seems plausible that practicing poetry can positively contribute to one flourishing with greater psychological well-being. However, recent studies on poetry therapy have not yet been reviewed and integrated under the PERMA framework from positive psychology to further explore and explicate this possibility. This article therefore contributes to extant work by reviewing recent research on poetry therapy and psychological well-being and offering support for the claim that practicing poetry can positively contribute to one flourishing with greater psychological well-being by positively influencing their emotions, engagement or “flow” experiences, social relationships, sense of meaning or purpose in life, and personal accomplishments. (shrink)

Most mental health research largely ignores or minimises gender and age differences in depression. In ‘Don't mind the gap: Why do we not care about the gender gap in mental health?’, Patalay and Demkowicz identify a dearth of research on the causal factors of depression in young women. They attribute this to an over-reliance on biological accounts of gender differences in depression. Patalay and Demkowicz conclude that a person-centred approach that meaningfully engages with the reports of young women with depression (...) is more likely to expose the social drivers of depression that impact this group. This commentary focuses on Patalay and Demkowicz's call to examine the patient's lived experience. We argue that there is an urgent need to reflect upon the methodologies involved in examining lived experience and how they can be best utilised. Ultimately, we advocate for an approach known as ‘phenomenological psychopathology’, through a phenomenological investigation of depression in young women, we can go some way towards closing the gender gap. (shrink)

What process ought to guide decision making for pediatric patients? The prevailing view is that decision making should be informed and guided by the best interest of the child. A widely discussed structural model proposed by Buchanan and Brock focuses on parents as surrogate decision makers and examines best interests as guiding and/or intervention principles. Working from two recent articles by Ross on “constrained parental autonomy” in pediatric decision making (which is grounded in the Buchanan and Brock model), I discuss (...) (supportively) features of Ross’s effort visa-vis the best interest standard. I argue that any pediatric decision-making model that brackets or formally limits an engagement with the child patient assumes too much. Further, any model that under appreciates the place of parents and their autonomy, and the dynamic parent-child relationship, misses an opportunity to broaden the clinical encounter by considering questions of justice for the child (Rawls) and within a family (Ross). In this context, I focus on the child’s emerging and ongoing emotional and intellectual development and autonomy—their capabilities and identifying primary goods. (shrink)

Evidence-based medicine (EBM) calls for medical practitioners to “integrate” our best available evidence into clinical practice. A significant amount of the literature on EBM takes this integration to be unproblematic, focusing on questions like how to interpret evidence and engage with patient values, rather than critically looking at how these features of EBM can be implemented together. Other authors have also commented on this gap in the literature, for example, identifying the lack of clarity about how patient preferences (...) and evidence from trials is supposed to be integrated in practice. In this paper, I look at this issue from an epistemological perspective, (looking at how different types of knowledge in EBM can be used to make sounds judgements). In particular, I introduce an epistemological issue for this integration problem, which I call the epistemic integration problem. This is essentially the problem of how we can use information that is both general (eg, about a population sample) and descriptive (eg, about what expected outcomes are) to reach clinical judgements that are individualized (applying to a particular patient) and normative (about what is best for their health). (shrink)

Even when brain scans fail to detect a striate lesion, functional evidence for blindsight can be adduced. In the aftermath of an automobile accident, JK became blind. Results of ophthalmic exams indicated that the blindness must be cortical. Nevertheless, multiple MRI scans failed to detect structural damage to the striate cortex. Prior to the accident JK had been an athlete; after the accident he retained some athletic abilities, arousing suspicions that he might be engaged in fraud. His residual athletic abilities—e.g., (...) hitting a handball or baseball, or catching a Frisbee—coupled with his experienced blindness, suggested blindsight. But due to the apparent absence of striate lesions, we designed a series of tasks for temporal and spatial dimensions in an attempt to detect functional evidence of his disability. Indeed, test results revealed compelling neural evidence that comport with his subjective reports. This spatiotemporal task-related method that includes contrasts with healthy controls, and detailed understanding of the patient's conscious experience, can be generalized for clinical, scientific and forensic investigations of blindsight. -/- . (shrink)

Background Healthcare is predicated on the use of biotechnology and medical technology, both of which are indispensable in diagnosis, treatment, and most aspects of patient care. It is therefore imperative that justifications for use of new technologies are appropriate, with the technologies working as advertised. In this paper, I consider philosophical accounts of how such justifications are made. Methods Critical philosophical reflection and analysis. Results I propose that justification in many prominent accounts is based on the designer’s professional experience (...) and on expert testimony. I argue, however, that professional designers are not in a position to justify a new biotechnology or medical device if the justification is based on testimony or past experience of presumably similar technologies. I argue (1) that similarity judgments offered by instantaneous experts cannot be viewed as contributing (epistemically) to evidential justification of new and unproven technologies; and (2) that designers and manufacturers cannot endorse a technology’s effective function in a patient-care context until it has been successfully used in that context. Conclusion I show that an expert’s past professional experiences can never predict or justify the impact of a novel technology on human health. This is because any new technology leads to the introduction of new mechanisms with unprecedented functions. The new technology therefore needs to be studied in situ and justified as a newly created mechanism within the relevant healthcare setting. Ultimately, justifications of this type rely on the scientific community and society engaging in repeated experimentation and observation of the technology, and confirming its successful use. (shrink)

Preface/Introduction: The question under discussion is metaphysical and truly elemental. It emerges in two aspects — how did we come to be conscious of our own existence, and, as a deeper corollary, do existence and awareness necessitate each other? I am bold enough to explore these questions and I invite you to come along; I make no claim to have discovered absolute answers. However, I do believe I have created here a compelling interpretation. You’ll have to judge for yourself. -/- (...) What follows is the presentation of three essays I have worked on over the past several years seeing publication for the first time. “Hollows of Experience” was written first as an invited chapter for a collection on the ontology of consciousness. However, when cuts became necessary, my chapter got the knife. Its length has prohibited it from publication in any print journal. “Myth and Mind” was written next as a journal article, but as my involvement with it grew so did its length, so it has also idled on my websty awaiting its call. “From Panexperientialism to Conscious Experience” was written most recently, but it is the only one to have been available to the public elsewhere than my own website. Under the name, “The Continuum of Experience”, it was Target Article #95 on the recently closed Karl Jaspers Forum (for discussion purposes only). -/- I have put them in a different sequence here, for reasons of logical sense. Up first, “Panexperientialism” deals with an idea difficult for many to accept, namely that conscious experience is a particular mode of symbolically reflected experience that is largely unique to our species. However, I aver that experienced sensation in itself (as found, for example, in autonomic sensory response systems) goes “all the way down” into nature, and thus the title, panexperientialism. -/- Understanding this idea is helpful to dealing with the focus on language in Part I of “Hollows”, next, since here speech and general symbolic interaction in general are found to be the catalysts for the creation of our consciously experienced world (our “lived reality”). In Part II, however, I explore how experienced sensations must be coeval with existence, and, with even greater temerity, how all this sensational existence might have arisen within some literally inconceivable background of awareness-in-itself that yet has a dynamism that occasionally breaks into existence as experiential events and entities. (The latter may sound wacky, but physicists and cosmologists are themselves attempting to come to terms with that which seethes with vast potential energy in what they refer to as the quantum vacuum.) -/- “Myth and Mind” was put third since it deals with a major lacuna in “Hollows” — that presumed prehistoric period when members of our species made the painful crossing of the symbolic threshold into the beginnings of cultural consciousness. Speech plays a central role here, too, but I look more at narrative structures from the dawn of self-awareness when ritual and myth became vital to human survival. Why would fantastic stories and bizarre rituals be necessary? I speculate that growing foresight led to the unavoidable realization of certain mortality, from which, in turn, emerged the secondary realization that we were now alive. In contrast to our yet-to-come death, we have life here and now, and by ritually identifying with a symbolically expanded mythic, i.e., sacred, reality, we may continue to live on after bodily death, just as our ancestors and loved ones must also do. Language and mythmaking are necessary to avoid mortal despair and they remain at the core of human consciousness. -/- As Ernst Cassirer (1944) has noted, language and myth are “twin creatures”, both metaphoric webs over a reality we can never wholly comprehend. We live in the symbolic and construct our works of imagination and wars of conquest to make life meaningful, to feel immortal, and to sense that we ourselves participate in a reality greater than ourselves. No doubt we do, but this does not mean our culturally constructed self-identities survive the death of our bodies, and it does not imply that our symbolic concepts can ever indicate the ultimate truth. We simply must symbolize an extended reality that was sacred to our ancestors: “Is it not our way, as illusory as it may be, to force continuance on our world and our life in the face of their inevitable ending? Are we not compelled to extend those imaginary horizons as far as we can despite the terror and the sometime joy their extension incites? Is their closure not a form of death?” (Crapanzano, p. 210) -/- Of course, this leaves me in the uncomfortable position of being forced to admit that this venture of mine must inevitably be another attempt at meaningful mythmaking. But what else could it be? This is certainly not a scientific proof though it is indeed an academically rigorous exploration. (Just try to count the citations!) I hope the reader will judge my thesis on the basis of its coherence, the sense of meaning it evokes, my intellectual responsibility, and, finally, the engagement it inspires. If you have read my expositions and found yourself immersed in the timeless questions I here call forth, I would call these writings successful (even if you violently disagree with my answers). -/- I am very grateful to Huping Hu for granting me this special issue of JCER in which to present my ideas in some detail. He has patiently dealt with my exuberant approach and allowed the many changes I kept coming up with right until the final publication date. I also wish to thank the many potential commentators who politely replied to my invitation, and, even more, I thank those who made time to write actual commentaries. -/- References -/- Cassirer, E. (1944). An Essay on Man: An Introduction to a Philosophy of Human Culture. New Haven/London: Yale UP. -/- Crapanzano, V. (2004). Imaginative Horizons: An Essay in Literary-Philosophical Anthropology. Chicago: U of Chicago Press. -/- Gregory M. Nixon University of Northern British Columbia Prince George, British Columbia, Canada Email: [email protected] Websty: http://members.shaw.ca/doknyx. (shrink)

The paper reports results of the very first survey-based study on the prevalence, frequency and nature of ethical or other non-medical difficulties faced by Polish physicians in their everyday clinical practice. The study involved 521 physicians of various medical specialties, practicing mainly in inpatient healthcare. The study showed that the majority of Polish physicians encounter ethical and other non-medical difficulties in making clinical decisions. However, they confront such difficulties less frequently than their foreign peers. Moreover, Polish doctors indicate different circumstances (...) as a source of the experienced problems. The difficulties most often reported relate to (i) patients (or their proxies) requests for medically non-indicated interventions; (ii) problems with communication with patients (or their proxies) due to the patients’ negative attitude, unwillingness to cooperate, or aggression; and (iii) various difficulties with obtaining informed consent. Polish physicians report difficulties associated with disagreements among care givers or scarcity of resources less frequently than doctors from other countries. The study’s findings provide support for the thesis that a significant portion of Polish physicians still follow a traditional, paternalistic, and hierarchical model of healthcare practice. Instead of promoting patient’s empowerment, engagement, and rights, they often consider these ideas as a threat to physicians’ professional authority and autonomy. The study leads to the conclusion that due to insufficient training in medical ethics, communication skills, and medical law, many Polish physicians lack the knowledge and competence necessary to adequately respond to challenges posed by modern healthcare practice. (shrink)

Clinical delusions have traditionally been characterized as beliefs in psychiatry. However, philosophers have recently engaged with the empirical literature and produced a number of objections to the so-called doxastic status of delusion, stemming mainly from the mismatch between the functional role of delusions and that expected of beliefs. In response to this, an appeal to dispositionalism about the nature of belief has been proposed to vindicate the doxastic status of delusion. In this paper, I first present the objections to attributing (...) beliefs to delusional patients and the application of dispositionalism in the attempt to vindicate doxasticism. I then assess this application and some responses to the objections to the doxastic characterization. Finally, I offer some conclusions about the limits of folk-psychological concepts in the characterization and explanation of complex psychological phenomena such as delusions. (shrink)

In this paper I examine the ways in which our language and terminology predetermine how we approach, investigate and conceptualise mental illness. I address this issue from the standpoint of hermeneutic phenomenology, and my primary object of investigation is the phenomenon referred to as “mania”. Drawing on resources from classical phenomenology, I show how phenomenologists attempt to overcome their latent presuppositions and prejudices in order to approach “the matters themselves”. In other words, phenomenologists are committed to the idea that in (...) our everyday, natural attitude, we take for granted a number of prejudices and presuppositions that predetermine how we conceive of and understand what we experience. In order to properly approach the phenomena themselves, we need to find ways of neutralising our presuppositions and prejudices in order to develop new (and hopefully more accurate) accounts of the phenomena under investigation. One of the most popular examples of such an attempt at neutralisation is what Edmund Husserl calls the epoché, which is the practice of bracketing out or suspending presuppositions. However, later phenomenologists developed alternative approaches. Martin Heidegger, for instance, engaged in etymological analyses to discover latent meanings in our language and terminology. Hans-Georg Gadamer also engaged in historical analyses of how our traditions sediment into latent prejudices. After discussing the various ways in which phenomenologists have attempted to neutralise presuppositions and prejudices prior to engaging in their investigations, I apply some of these principles and methods to the domain of psychopathology, and discuss some of the prejudices inherent in contemporary discussions of the phenomenon of mania. I examine recent attempts to link the phenomenon that we today refer to as “mania” with the ancient Greek concept of “μανία” (mania), and argue that the practice of linking contemporary and historical concepts can be detrimental to attempts at reclassifying disorders. In addition, I consider the implications of the shift in terminology from “manic depressive illness” to “bipolar disorder” – especially how conceiving of mania as one of two “poles” predetermines its description by both clinicians and patients. Finally, I address the implications of the headings under which mania and bipolar disorder are discussed within diagnostic manuals. For example, I discuss the removal of the headings of affective and mood disorders in the DSM-5, and the explicit decision by the authors to place bipolar disorder between depressive disorders and schizophrenia. What I aim to accomplish in this paper is not so much a phenomenological investigation of mania as it is a pre-phenomenological investigation. In other words, I offer a preparatory investigation of the phenomenon (or phenomena) referred to as “mania” in contemporary discourse, with the intention of laying the groundwork for further phenomenological and psychological research. (shrink)

Kant has famously argued that human beings or persons, in virtue of their capacity for rational and autonomous choice and agency, possess dignity, which is an intrinsic, final, unconditional, inviolable, incomparable and irreplaceable value. This value, wherever found, commands respect and imposes rather strict moral constraints on our deliberations, intentions and actions. This paper deals with the question of whether, as some Kantians have recently argued, certain types of (physician-assisted) suicide and active euthanasia, most notably the intentional destruction of the (...) life of a terminally-ill, but rational and autonomous patient in order to prevent certain serious harms, such as enduring or recurring pain or the loss of the meaning in life, from befalling him really are inconsistent with respect for the patient’s human dignity. I focus on two independent, though interrelated explications of the rather vague initial idea that the patient (as well as the doctor), in intending and bringing about his death, treats his person or rational nature merely as a means and so denigrates his dignity: (i) that in doing what he is doing, he does not act for the sake of his person, but for the sake of something else; (ii) that, by trading his person for pain relief, he engages himself in an irrational and hence immoral exchange. After critically discussing some suggestions about how to understand this charge, I eventually find Kantian objections to suicide and (active) euthanasia, based on the idea of human dignity, less than compelling. For all the paper proves, suicide and (active) euthanasia may still be morally impermissible, but then this must be so for some other reason than the one given above. (shrink)

Introduction In 2013, Dr. J. Muizelaar and Dr. R. Schrot, two neurosurgeons at the University of California Davis Medical Center (UCDMC), were found guilty of research misconduct due to failure to comply with institutional policies as well as Food and Drug Administration (FDA) regulations governing human subjects research. At issue here, however, is the difference between research and innovative therapy in the clinical setting of patient care where clinical judgment is reasonably to be privileged. Methods The UCDMC investigative document (...) is reviewed along with standard literature on clinical ethics and clinical data about glioblastoma multiforme (GBM) cancer. Results In this paper I argue that, by tendentiously focusing on policies, regulations, and procedures governing human subjects research, the UCDMC investigation failed to account for the centrality of clinical judgment and clinical ethics pertinent to judicious review of this matter, especially given the unique clinical context of terminally ill patients having exhausted standard care treatment options for glioblastoma multiforme (GBM) cancer. Conclusions The UCDMC investigation raises serious problems for clinicians who are engaged in innovative therapy in the clinical setting, requiring a regulatory framework separate from the normal Institutional Review Board (IRB) process. (shrink)

Semantic interoperability requires the use of standards, not only for Electronic Health Record (EHR) data to be transferred and structurally mapped into a receiving repository, but also for the clinical content of the EHR to be interpreted in conformity with the original meanings intended by its authors. Accurate and complete clinical documentation, faithful to the patient’s situation, and interoperability between systems, require widespread and dependable access to published and maintained collections of coherent and quality-assured semantic resources, including models such (...) as archetypes and templates that would (1) provide clinical context, (2) be mapped to interoperability standards for EHR data, (3) be linked to well specified, multi-lingual terminology value sets, and (4) be derived from high quality ontologies. Wide-scale engagement with professional bodies, globally, is needed to develop these clinical information standards. (shrink)

The prospect of neurotechnologies for mood manipulation alarms some people who worry about the pernicious effects they might have. In particular there is a concern that individuals will be pressured to make themselves inauthentically happy, and tolerant of things that should make them sad or angry. The most common result of social pressures to adjust mood will likely be far more beneficial both for the individual and society. This essay reviews research on the stresses of "emotion work" and the personality (...) correlates of "subjective wellbeing" to argue that social pressures will generally encourage individuals to be happy by encouraging them to be more friendly, patient, and engaged. Several more pernicious kinds of social pressures for mood control are then reviewed to illustrate the need for democratic scrutiny of the use of neurotechnologies, guided by a goal of encouraging an engaged, dynamic, flourishing personality in each citizen. (shrink)

In 1992, Peter Ochs and a few Christian and Muslim colleagues began to gather small groups, in and outside the classroom, to practice close and attentive reading of the sacred Scriptures of the Jewish, Muslim, and Christian traditions. The hope was that members of different religions could hear one another through the patient, respectful reading of each other's Scripture. Hearing each other, participants might enter into interreligious relationships that might point a way to the peaceful engagement of religions--especially (...) those who, after September 11, 2001, too often found themselves at each other's throats. It was a hope for religion without violence. In Religion without Violence, Ochs reflects on the practical and philosophic lessons he has learned from hosting hundreds of Scriptural Reasoning engagements. He introduces the "scriptural pragmatism" of Scriptural Reasoning." He painstakingly recounts instances of successful scriptural reasoning and warns where and how it might fail. He provides guidance on how to introduce and facilitate Scriptural Reasoning in the classroom. He shows how reading out of the "hearth" of a faith can contribute to peace building across religions. And, drawing on the resources of rabbinic tradition, Augustine, and Charles Peirce, he moves beyond practice to reflect on the implications of Scriptural Reasoning for discerning what kinds of "reasoning" best address and help repair societal crises like religion-related violent conflict. (shrink)

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

I discuss Young’s “asymmetrical reciprocity” and apply it to an ethics of mental health care. Due to its emphasis on engaging with others through respectful dialogue in an inclusive manner, asymmetrical reciprocity serves as an appropriate framework for guiding caregivers to interact with their patients and to understand them in a morally responsible and appropriate manner. In Section 1, I define empathy and explain its benefits in the context of mental health care. In Section 2, I discuss two potential problems (...) surrounding empathy: the difficulty of perspectivetaking and “compassion fatigue.” In Section 3, I argue that these issues can be resolved if examined through the lens of an ethics of care. Reciprocal relationships between patients and caregivers are an important element in the development of an ethics of care. In Section 4, I introduce two models of reciprocity that can be applied to a health care context: Benhabib’s symmetrical reciprocity and Young’s asymmetrical reciprocity. In Section 5, I demonstrate how asymmetrical reciprocity cultivates empathy and, in Section 6 and Section 7, I show how it overcomes the objections of empathy and improves therapeutic relationships. (shrink)

While it is often assumed that fictions must be informative or morally improving in order to be of any real benefit to us, certain texts defy this assumption by functioning as training grounds for the capacities: in engaging with them, we stand to become not more knowledgeable or more virtuous but more skilled, whether at rational thinking, at maintaining necessary illusions, at achieving tranquility of mind, or even at religious faith. Instead of offering us propositional knowledge, these texts yield know-how; (...) rather than attempting to instruct by means of their content, they hone capacities by means of their form; far from seducing with the promise of instantaneous transformation, they recognize, with Aristotle, that change is a matter of sustained and patient practice. (shrink)

PT. A noção de “pessoa”, pensada a partir do legado antropológico e filosófico do ocidente, afirma-se como uma unidade corporal e espiritual que determina a sua singularidade no seio da comunidade. A “pessoa” assim perspectivada assume uma importância destacada na reflexão ética das aplicações científicas de artificialização da vida humana. Muito concretamente, a noção de “pessoa” deve contribuir para a fundamentação ética das terapêuticas de transplantação. A transplantação representa um dos mais notáveis avanços da medicina do século XX e com (...) um impacto incontornável na prestação de cuidados de saúde. Os transplantes são considerados o tratamento mais eficaz para patologias crónicas que afectam a funcionalidade de determinados órgãos vitais, restituindo ao doente uma melhoria na sua saúde e/ou qualidade de vida. O sucesso desta terapêutica é, no entanto, condicionado pela disponibilização de pessoas que queiram fazer dádiva de si, do seu próprio corpo, para o bem-estar de outrem. Deste modo, a doação, realizada após a morte da pessoa ou ainda em vida, enfrenta vários desafios técnicos, mas também, e principalmente, desafios éticos. A nossa dissertação centra-se na reflexão ética da doação de órgãos e tecidos para transplante e no impacto que a dádiva de uma parte específica do corpo pode comportar na noção de “pessoa”. Deste modo, ao mesmo tempo em que se procura promover a doação de órgãos para aumentar o número de transplantes, também se vão delineando estratégias para salvaguardar a integridade corporal do dador e a eminente dignidade que o constitui como pessoa. As estratégias consistem fundamentalmente num diálogo entre o princípio de autonomia, que determina a singularidade da pessoa, e o princípio de solidariedade, que é desencadeado pela relação com o outro. Estes princípios éticos, articulados e uma vez cumpridos, são os alicerces da doação voluntária e altruísta, e impedem a instrumentalização e exploração da pessoa dadora. -/- EN. The western anthropological and philosophical notion of ‘person’ emerges as a corporal and spiritual entity, which determines his singularity at the level of community. From this perspective, the notion of ‘person’ holds an important place in ethical considerations concerning the scientific applications of artificial manipulation of human life. More precisely, the notion of ‘person’ must contribute towards the ethical basis of transplant therapeutics. The transplantation of human organs and tissues is one of the most notable advances in twentieth century medicine, and, as such, has had an unquestionable impact on health care practice. Transplants are now seen as the best treatment for chronic diseases that impair the function of some vital organs, improving the patient health and/or quality of life. The success of organs transplantation depends entirely upon the altruism of people giving their bodies for the well-being of others. Organ donation, performed during life or after death, raises not only technical, but also mainly ethical challenges. This work focuses on the ethical considerations associated with human organs and tissue donation for transplantation and on the impact that a donation of an organ has on the notion of ‘person’. At the same time that one recognizes the need to increase the number of organs for transplanting, there is also the need to preserve the donor’s corporal integrity and his eminent dignity. Strategies to preserve the donor’s corporal integrity and dignity must take into consideration the dialogue between the principle of autonomy, which is characterized by the singular entity, and the principle of solidarity, born out of one’s relationship with those around you. These ethical principles, once engaged and fulfilled, are the bases of a voluntary and altruistic donation, and prevent the donor from becoming a mere instrument and being exploited as such. (shrink)

COVID-19 demonstrated a global catastrophe that touched everybody, including the scientific community. As we respond and recover rapidly from this pandemic, there is an opportunity to guarantee that the fabric of our society includes sustainability, fairness, and care. However, approaches to environmental health attempt to decrease the population burden of COVID-19, toward saving patients from becoming ill along with preserving the allocation of clinical resources and public safety standards. This paper explores environmental and public health evidence-based practices toward responding to (...) Covid-19. A literature review tried to do a deep dive through the use of various search engines such as Mendeley, Research Gate, CAB Abstract, Google Scholar, Summon, PubMed, Scopus, Hinari, Dimension, OARE Abstract, SSRN, Academia search strategy toward reretrieving research publications, “grey literature” as well as reports from expert working groups. To achieve enhanced population health, it is recommended to adopt widespread evidence-based strategies, particularly in this uncertain time. As only together can evidence-informed decision-making (EIDM) can become a reality which includes effective policies and practices, transparency and accountability of decisions, and equity outcomes; these are all more relevant in resource-constrained contexts, such as Nigeria. Effective and ethical EIDM though requires the production as well as use of high-quality evidence that are timely, appropriate and structured. One way to do so is through co-production. Co-production (or co-creation or co-design) of environmental/public health evidence considered as a key tool for addressing complex global crises such as the high risk of severe COVID-19 in different nations. A significant evidence-based component of environmental/public health (EBEPH) consist of decisions making based on best accessible, evidence that is peer-reviewed; using data as well as systematic information systems; community engagement in policy making; conducting sound evaluation; do thorough program-planning frameworks; as well as disseminating what is being learned. As researchers, scientists, statisticians, journal editors, practitioners, as well as decision-makers strive to improve population health, having a natural tendency toward scrutinizing the scientific literature aimed at novel research findings serving as the foundation for intervention as well as prevention programs. The main inspiration behind conducting research ought to be toward stimulating and collaborating appropriately on public/environmental health action. Hence, there is need for a “Plan B” of effective behavioural, environmental, social as well as systems interventions (BESSI) toward reducing transmission. (shrink)

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

Phenomenology gives rise to certain ontological considerations that have far-reaching implications for standard conceptions of patient autonomy in medical ethics, and, as a result, the obligations of and to patients in clinical decision-making contexts. One such consideration is the phenomenological reduction in classical phenomenology, a core feature of which is the characterisation of our primary experiences as immediately and inherently meaningful. This paper builds on and extends the analyses of the phenomenological reduction in the works of Husserl, Heidegger, and (...) Merleau-Ponty in order to identify and explain its implications for our current understanding of the principle of respect for patient autonomy and the norms of clinical decision making. (shrink)

Paul Ricoeur argues that narration is lived life. Therefore, human experience has a narrative dimension, ie, it has a narrative structure and every effort you want to make for the human need to consider the narrative. For this reason, the text theory is converted to Ricoeur in a general model for the study of human action, since this is conceived as an open work to anyone who can read it. Given this general framework for discussion, we have deepened the notion (...) of the patient as “text”, and described their richness for reflection of bioethics and medical act, rescuing the value of listening, prudence, responsibility and rediscovering a place for the principle of autonomy and casuistry. -/- Paul Ricoeur sostiene que la narración es vida vivida. Por lo tanto, la experiencia humana posee una dimensión narrativa, es decir, tiene una estructura narrativa y todo esfuerzo que quiera dar cuenta de lo humano tendrá que contar con lo narrativo. Por esta razón, la teoría del texto se convierte para Ricoeur en un modelo general para el estudio de la acción humana, pues esta es concebida como una obra abierta a cualquiera que pueda leer. Teniendo en cuenta este marco general de reflexión, hemos profundizado en la noción del paciente como “texto”, y describimos su riqueza para la reflexión de la bioética y el actuar médico, rescatando el valor de la escucha, la prudencia, la responsabilidad y redescubriendo un lugar para el principio de autonomía y la casuística. (shrink)

It is common to distinguish moral rules, reasons, or values that are agent-relative from those that are agent-neutral. One can also distinguish moral rules, reasons, or values that are moment-relative from those that are moment-neutral. In this article, I introduce a third distinction that stands alongside these two distinctions—the distinction between moral rules, reasons, or values that are patient-relative and those that are patient-neutral. I then show how patient-relativity plays an important role in several moral theories, gives (...) us a better understanding of agent-relativity and moment-relativity, and provides a novel objection to Derek Parfit’s “appeal to full relativity” argument. (shrink)

I propose an account of aesthetic value, where aesthetic value lies in the process of aesthetic engagement: in our activity of perceiving, guiding our attention, interpreting, and otherwise wrestling with aesthetic objects. It also includes our social activities of engagement: arguing with each other, writing criticism, making top-ten lists. (This is a short summary of a view developed in greater detail elsewhere.).

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)

Recently, Jardas _et al_ have convincingly defended the patient preference predictor (PPP) against a range of autonomy-based objections. In this response, I propose a new autonomy-based objection to the PPP that is not explicitly discussed by Jardas _et al_. I call it the ‘objection from higher-order preferences’. Even if this objection is not sufficient reason to reject the PPP, the objection constitutes a pro tanto reason that is at least as powerful as the ones discussed by Jardas _et al._.

Patient centred diagnosis is best practised through shared decision making; an iterative dialogue between doctor and patient, whichrespects a patient’s needs, values, preferences, and circumstances. -/- Shared decision making for diagnostic situations differs fundamentally from that for treatment decisions. This has important implications when considering its practical application. -/- The nature of dialogue should be tailored to the specific diagnostic decision; scenarios with higher stakes or uncertainty usually require more detailed conversations.

Background: Patient participation in clinical ethics support services has been marked as an important issue. There seems to be a wide variety of practices globally, but extensive theoretical or empirical studies on the matter are missing. Scarce publications indicate that, in Europe, patient participation in CESS varies from region to region, and per type of support. Practices vary from being non-existent, to patients being a full conversation partner. This contrasts with North America, where PP seems more or less (...) standard. While PP seems to be on the rise in Europe, there is no data to confirm this. This study sought a deep understanding of both habits and the attitudes towards PP in the Netherlands, including respondents’ practical and normative perspectives on the matter. Methods and Results: We developed a national survey on PP for Dutch CESS staff. Our survey comprised a total of 25 open and close-ended questions, focused on four topics related to PP goals of CESS, status quo of PP, ideas and ideals concerning PP, and obstacles for PP. Discussion: The four most important findings were that: Patient participation in Dutch CESS is far from standard. Views on patient participation are very much intertwined with the goals of ethics support. Hesitations, fears and perceived obstacles for PP were not on principle and Most respondents see PP as a positive opportunity, yet requiring additional training, practical guidance and experience. Conclusions: Various normative reasons require PP. However, PP seems far from standard and somewhat rare in Dutch CESS settings. Our respondents did not raise many principled objections to PP. Instead, reasons for the lack of PP are intertwined with viewpoints on the goals of CESS, which seemingly focus on supporting health care professionals. Training and practical guidance was thought to be helpful for gaining experience for both CESS staff and HCPs. (shrink)