Shared decision-making involves health professionals and patients/clients working together to achieve true person-centred health care. However, this goal is infrequently realized, and most barriers are unknown. Discussion between philosophers, clinicians, and researchers can assist in confronting the epistemic and moral basis of health care, with benefits to all. The aim of this paper is to describe what shared decision-making is, discuss its necessary conditions, and develop a definition that can be used in practice to (...) support excellence in maternity care. Discussion between the authors, with backgrounds in philosophy, clinical maternity care, health care management, and maternity care research, assisted the team to confront established norms in maternity care and challenge the epistemic and moral basis of decision-making for caesarean section. The team concluded that shared decision-making must start in pregnancy and continue throughout labour and birth, with equality in discourse facilitated by the clinician. Clinicians have a duty of care for the adequacy of women's knowledge, which can only be fulfilled when relevant knowledge is offered freely and when personal beliefs and biases that may impinge on decision-making (defeaters) are disclosed. Informed consent is not shared decision-making. Key barriers include existing cultural norms of “the doctor knows best” and “patient acquiescence” that prevent defeaters being acknowledged and discussed and can lead to legal challenges, overuse of medical intervention and, in some areas, obstetric violence. Shared decision-making in maternity care can thus be defined as an enquiry by clinician and expectant woman aimed at deciding upon a course of care or none, which takes the form of a dialogue within which the clinician fulfils their duty of care to the client's knowledge by making available their complete knowledge (based on all types of evidence) and expertise, including an exposition of any relevant and recognized potential defeaters. Research to develop measurement tools is required. (shrink)

According to many of its proponents, shared decision making ("SDM") is the right way to interpret the clinician-patient relationship because it respects patient autonomy in decision-making contexts. In particular, medical ethicists have claimed that SDM respects a patient's relational autonomy understood as a capacity that depends upon, and can only be sustained by, interpersonal relationships as well as broader health care and social conditions. This paper challenges that claim. By considering two primary approaches to relational (...) autonomy, this paper argues that standard accounts of SDM actually undermine patient autonomy. It also provides an overview of the obligations generated by the principle of respect for relational autonomy that have not been captured in standard accounts of SDM and which are necessary to ensure consistency between clinical practice and respect for patient autonomy. (shrink)

In recent years there has been an explosion of interest in Artificial Intelligence (AI) both in health care and academic philosophy. This has been due mainly to the rise of effective machine learning and deep learning algorithms, together with increases in data collection and processing power, which have made rapid progress in many areas. However, use of this technology has brought with it philosophical issues and practical problems, in particular, epistemic and ethical. In this paper the authors, with backgrounds in (...) philosophy, maternity care practice and clinical research, draw upon and extend a recent framework for shared decision-making (SDM) that identified a duty of care to the client's knowledge as a necessary condition for SDM. This duty entails the responsibility to acknowledge and overcome epistemic defeaters. This framework is applied to the use of AI in maternity care, in particular, the use of machine learning and deep learning technology to attempt to enhance electronic fetal monitoring (EFM). In doing so, various sub-kinds of epistemic defeater, namely, transparent, opaque, underdetermined, and inherited defeaters are taxonomized and discussed. The authors argue that, although effective current or future AI-enhanced EFM may impose an epistemic obligation on the part of clinicians to rely on such systems' predictions or diagnoses as input to SDM, such obligations may be overridden by inherited defeaters, caused by a form of algorithmic bias. The existence of inherited defeaters implies that the duty of care to the client's knowledge extends to any situation in which a clinician (or anyone else) is involved in producing training data for a system that will be used in SDM. Any future AI must be capable of assessing women individually, taking into account a wide range of factors including women's preferences, to provide a holistic range of evidence for clinical decision-making. (shrink)

Shared Decision Making (‘SDM’) is one of the most significant developments in Western health care practices in recent years. Whereas traditional models of care operate on the basis of the physician as the primary medical decision maker, SDM requires patients to be supported to consider options in order to achieve informed preferences by mutually sharing the best available evidence. According to its proponents, SDM is the right way to interpret the clinician-patient relationship because it fulfils the (...) ethical imperative of respecting patient autonomy. However, there is no consensus about how decisions in SDM contexts relate to the principle of respect for autonomy. In response, I demonstrate that in order to make decisions about what treatment they will or will not receive, patients will be required to meet different conditions depending on the approach proponents of SDM take to understanding personal autonomy. Due to the fact that different conceptions of autonomy yield different obligations, I argue that if physicians and patients satisfied all the conditions described in standard accounts of SDM, then SDM would undermine patient autonomy. (shrink)

Stephanie Collins’ Group Duties offers interesting new arguments and brings together numerous interconnected issues that have hitherto been treated separately. My critical commentary focuses on two particularly original and central claims of the book: (1) Only groups that are united under a group-level decision-making procedure can bear duties. (2) Attributions of duties to other groups should be understood as attributions of “coordination duties” to each member of the group, duties to take steps responsive to the others with a (...) view to the group’s φ-ing or express willingness to do so. In support of the first claim, Collins argues that only groups that can make decisions can bear duties, and that the ability to make decisions requires the relevant sort of decision-making procedure. I suggest that both parts of this argument remain in need of further support. I furthermore argue that Collins’ account of coordination duties gets certain kinds of cases wrong, and suggest that attributions of duties to groups without decision-making procedures are more plausibly understood as attributing shared duties. (shrink)

Advanced AI systems are rapidly making their way into medical research and practice, and, arguably, it is only a matter of time before they will surpass human practitioners in terms of accuracy, reliability, and knowledge. If this is true, practitioners will have a prima facie epistemic and professional obligation to align their medical verdicts with those of advanced AI systems. However, in light of their complexity, these AI systems will often function as black boxes: the details of their contents, (...) calculations, and procedures cannot be meaningfully understood by human practitioners. When AI systems reach this level of complexity, we can also speak of black-box medicine. In this paper, we want to argue that black-box medicine conflicts with core ideals of patient-centered medicine. In particular, we claim, black-box medicine is not conducive for supporting informed decision-making based on shared information, shared deliberation, and shared mind between practitioner and patient. (shrink)

In response to the Royal Society report’s claim that “the acceptability of geo­engineering will be determined as much by social, legal, and political issues as by scientific and technical factors” (Geoengineering the Climate: Science, Governance and Uncertainty [London: Royal Society, 2009], ix), a number of authors have suggested the key to this challenge is to engage the public in geoengineering decision-making. In effect, some have argued that inclusion of the public in geoengineering decision-making is necessary for (...) any geoengineering project to be morally permissible. Yet, while public engagement on geoengineering comes in various forms, the discussion in geoengineering governance and the ethics of geoengineering have too often conceptualized it exclusively in terms of public participation in decision-making, and supported it by various liberal democratic values. However, if the predominant understanding of public engagement on—or, the role of the public in—geoengineering decision-making is indeed only grounded on liberal democratic values, then its normative relevance could be challenged by and in other ethical-political traditions that do not share those values. In this paper, I shall explore these questions from a Confucian perspective. I argue that the liberal democratic values invoked in support of the normative importance of public participation are, at least, foreign to Confucian political philosophy. This presents a prima facie challenge to view public participation in geoengineering decision-making as a universal moral requirement, and invites us to reconsider the normative significance of this form of public engagement in Confucian societies. Yet, I contend that the role of the public remains normatively significant in geoengineering governance and the ethics of geoengineering from a Confucian perspective. Drawing from recent work on Confucian political philosophy, I illustrate the potential normative foundation for public engagement on geoengineering decision-making. (shrink)

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.

The process of decision making is predictable and irrational according to Daniel Ariely and other economic behaviorists, historians, and philosophers such as Daniel Kahneman or Yuval Noah Harari. Decisions made anteriorly can be, but don’t have to be, present in the actions of a person. Stories and shared belief in myths, especially those that arise from a system of human norms and values and are based on a belief in a “supernatural” order (religion) are important. Because of (...) this, mass cooperation amongst strangers is possible. (shrink)

It is argued that the design of decisions is a process that in many ways is shaped by social factors such as identities, values, and influences. To be able to understand how these factors impact organizational decisions, the focus must be set on the management level. It is the management that shoulders the chief responsibility for designing collective actions, such as decisions. Our propositions indicate that the following measures must be taken in order to improve the quality of organizational decisions: (...) 1. The identity of the people, involved in organizational decision making, affects the quality of decisions and should be taken into account in the design of decisions. 2. The decision maker or designer of decisions should engage the members of an organization to create a shared vision. 3. Getting the members of an organization to express and share common values should improve the decision making process. 4. Being able to socially influence the members of an organization, or other stakeholders involved, as well as letting them participate in the process, should improve the quality of decisions. (shrink)

In a context of imperfect risk protection, households may protect against the impact of a health shock by employing various financial and non-financial coping mechanisms, such as foregoing or reducing needed medical care, labor substitution, consumption reduction, borrowing money, dissaving, and selling assets. However, leveraging certain coping mechanisms may reduce future productivity, potentially trapping households in chronic or persistent poverty. Resources and risk are not necessarily shared equitably within a household; the ability and willingness of the household to leverage (...) coping mechanisms, or the choice of coping mechanism may depend on the social protection policy context, household socioeconomic status, and type of intrahousehold risk sharing. Vietnam has been making policy changes aimed towards achieving Universal Health Coverage for the past several decades, culminating in a 2015 change mandating universal insurance coverage. This can potentially influence both providers in making decisions around service delivery and households around financing care. This research aims to contribute to the literature exploring the relationships among direct and indirect health care costs, potentially maladaptive coping mechanisms, and household living standards, within the particular health financing and social protection environment in Vietnam. (shrink)

BACKGROUND: Little is known about how hospitalized patients share decisions with physicians. METHODS: We conducted an observational study of patient-doctor communication on an inpatient medicine service among 18 hospitalized patients and 9 physicians. A research assistant (RA) approached newly hospitalized patients and their physicians before morning rounds and obtained consent. The RA audio recorded morning rounds, and then separately interviewed both patient and physician. Coding was done using integrated analysis. RESULTS: Most patients were white (61%) and half were female. Most (...) physicians were male (66%) and of Southeast Asian descent (66%). All physicians explained the plan of care to the patients; most believed that their patient understood. However, many patients did not. Physicians rarely asked the patient for their opinion. In all those cases, the decision had been made previously by the doctors. No decisions were made with the patient. Patients sometimes disagreed. CONCLUSIONS: Shared decision-making may not be the norm in hospital care. Although physicians do explain treatment plans, many hospitalized patients do not understand enough to share in decisions. When patients do assert their opinion, it can result in conflict. PRACTICE IMPLICATIONS: Some hospitalized patients are interested in discussing treatment. Improving hospital communication can foster patient autonomy. (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)

This paper proposes a philosophically informed decision-making methodology, inspired by Aristotle, that encourages constructive discussions amongst employers and employees; is directed towards shared higher-level goals; is consistent with planning frameworks already in place in many businesses; can be amended over time without disruptive disputes; and accounts for the particularities of each industry, enterprise, workplace, and job. It seeks to establish a more fundamental basis for discussions about remote vs. in-person office work: specifically, the purpose and nature of (...) the work of those affected. If these matters can be decided, then subsequent discussions might be focused more upon the shared outcomes to which stakeholders are committed and less upon individual preferences and ‘hunches.’. (shrink)

In this essay we collect and put together a number of ideas relevant to the under- standing of the phenomenon of creativity, confining our considerations mostly to the domain of cognitive psychology while we will, on a few occasions, hint at neuropsy- chological underpinnings as well. In this, we will mostly focus on creativity in science, since creativity in other domains of human endeavor have common links with scientific creativity while differing in numerous other specific respects. We begin by briefly (...) introducing a few basic notions relating to cognition, among which the notion of ‘concepts’ is of basic relevance. The myriads of concepts lodged in our mind constitute a ‘conceptual space’ of an enormously complex structure, where con- cepts are correlated by beliefs that are themselves made up of concepts and are as- sociated with emotions. The conceptual space, moreover, is perpetually in a state of dynamic evolution that is once again of a complex nature. A major component of the dynamic evolution is made up of incessant acts of inference, where an inference occurs essentially by means of a succession of correlations among concepts set up with beliefs and heuristics, the latter being beliefs of a special kind, namely, ones relatively free of emotional associations and possessed of a relatively greater degree of justification. Beliefs, along with heuristics, have been described as the ‘mind’s software’, and con- stitute important cognitive components of the self-linked psychological resources of an individual. The self is the psychological engine driving all our mental and physical activity, and is in a state of ceaseless dynamics resulting from one’s most intimate ex- periences of the world accumulating in the course of one’s journey through life. Many of our psychological resources are of a dual character, having both a self-linked and a shared character, the latter being held in common with larger groups of people and imbibed from cultural inputs. We focus on the privately held self-linked beliefs of an individual, since these are presumably of central relevance in making possible inductive inferences – ones in which there arises a fundamental need of adopting a choice or making a decision. Beliefs, decisions, and inferences, all have the common link to the self of an individual and, in this, are fundamentally analogous to free will, where all of these have an aspect of non-determinism inherent in them. Creativity involves a major restructuring of the conceptual space where a sustained inferential process eventually links remote conceptual domains, thereby opening up the possibility of a large number of new correlations between remote concepts by a cascading process. Since the process of inductive inference depends crucially on de- cisions at critical junctures of the inferential chain, it becomes necessary to examine the basic mechanism underlying the making of decisions. In the framework that we attempt to build up for the understanding of scientific creativity, this role of decision making in the inferential process assumes central relevance. With this background in place, we briefly sketch the affect theory of decisions. Affect is an innate system of response to perceptual inputs received either from the exter- nal world or from the internal physiological and psychological environment whereby a positive or negative valence gets associated with a perceptual input. Almost every sit- uation faced by an individual, even one experienced tacitly, i.e., without overt aware-ness, elicits an affective response from him, carrying a positive or negative valence that underlies all sorts of decision making, including ones carried out unconsciously in inferential processes. Referring to the process of inferential exploration of the conceptual space that gener- ates the possibility of correlations being established between remote conceptual do- mains, such exploration is guided and steered at every stage by the affect system, analogous to the way a complex computer program proceeds through junctures where the program ascertains whether specified conditions are met with by way of generating appropriate numerical values – for instance, the program takes different routes, depending on whether some particular numerical value turns out to be positive or negative. The valence generated by the affect system in the process of adoption of a choice plays a similar role which therefore is of crucial relevance in inferential processes, especially in the exploration of the conceptual space where remote domains need to be linked up – the affect system produces a response along a single value dimension, resembling a number with a sign and a magnitude. While the affect system plays a guiding role in the exploration of the conceptual space, the process of exploration itself consists of the establishment of correlations between concepts by means of beliefs and heuristics, the self-linked ones among the latter having a special role in making possible the inferential journey along alternative routes whenever the shared rules of inference become inadequate. A successful access to a remote conceptual domain, necessary for the creative solution of a standing problem or anomaly – one that could not be solved within the limited domain hitherto accessed – requires a phase of relatively slow cumulative search and then, at some stage, a rapid cascading process when a solution is in sight. Representing the conceptual space in the form of a complex network, the overall process can be likened to one of self-organized criticality commonly observed in the dynamical evolution of complex systems. In order that inferential access to remote domains may actually be possible, it is necessary that restrictions on the exploration process – necessary for setting the context in ordinary instances of inductive inference – be relaxed and a relatively free exploration in a larger conceptual terrain be made possible. This is achieved by the mind going into the default mode, where external constraints – ones imposed by shared beliefs and modes of exploration – are made inoperative. While explaining all these various aspects of the creative process, we underline the supremely important role that analogy plays in it. Broadly speaking, analogy is in the nature of a heuristic, establishing correlations between concepts. However, analo- gies are very special in that these are particularly effective in establishing correlations among remote concepts, since analogy works without regard to the contiguity of the concepts in the conceptual space. In establishing links between concepts, analogies have the power to light up entire terrains in the conceptual space when a rapid cas- cading of fresh correlations becomes possible. The creative process occurs within the mind of a single individual or of a few closely collaborating individuals, but is then continued by an entire epistemic community, eventually resulting in a conceptual revolution. Such conceptual revolutions make pos- sible the radical revision of scientific theories whereby the scope of an extant theory is broadened and a new theoretical framework makes its appearance. The emerging theory is characterized by a certain degree of incommensurability when compared with the earlier one – a feature that may appear strange at first sight. But incommen- surability does not mean incompatibility and the apparently contrary features of the relation between the successive theories may be traced to the multi-layered structureof the conceptual space where concepts are correlated not by means of single links but by multiple ones, thereby generating multiple layers of correlation, among which some are retained and some created afresh in a conceptual restructuring. We conclude with the observation that creativity occurs on all scales. Analogous to correlations being set up across domains in the conceptual space and new domains being generated, processes with similar features can occur within the confines of a domain where a new layer of inferential links may be generated, connecting up sub- domains. In this context, insight can be looked upon as an instance of creativity within the confines of a domain of a relatively limited extent. (shrink)

One relatively straightforward way in which academics could have more impact on global poverty is by doing more to help people make wise decisions about issues relevant to such poverty. Academics could do this by conducting appropriate kinds of research on those issues and sharing what they have learned with the relevant decision makers in accessible ways. But aren’t academics already doing this? In the case of many of those issues, I think the appropriate answer would be that they (...) could do so much better. As an illustration, I examine the academic input into one decision about an issue concerning global poverty in some detail in this paper. I argue that that input has been seriously deficient, and suggest some ways in which it might be improved. Building on this discussion, I then formulate two questions that can be applied to any such decision, answers to which would indicate the quality of the input academics are currently providing. In cases where that input is deficient, and the decision in question an important one, I suggest that academics consider organising themselves in ways that will improve that input. I finish by briefly discussing how Academics Stand Against Poverty might help them do so. (shrink)

In Two Minds is a practical casebook of problem solving in psychiatric ethics. Written in a lively and accessible style, it builds on a series of detailed case histories to illustrate the central place of ethical reasoning as a key competency for clinical work and research in psychiatry. Topics include risk, dangerousness and confidentiality; judgements of responsibility; involuntary treatment and mental health legislation; consent to genetic screening; dual role issues in child and adolescent psychiatry; needs assessment; cross-cultural and gender issues; (...) rational and irrational suicide; shared decision making in multi-agency teams, and the growing role of the user's voice in psychiatry. Key ethical concepts are carefully introduced and explained. The text is richly supported by detailed guides for further reading. There are separate chapters on teaching psychiatric ethics, including a sample seminar, and on writing a research ethics application. Each case history and discussion is followed by a critical commentary from a practitioner with relevant experience. Jim Birley adds a comparative international perspective on psychiatric ethics. Cartoons by Johnny Cowee provide punchy counterpoint! In Two Minds is the sister volume to the third edition of Sidney, Paul Chodoff and Steven Green's highly successful Psychiatric Ethics. In providing a bridge between theory and practice, it will be essential reading for everyone concerned with improving standards in mental health care. (shrink)

Ethical decision-making frameworks assist in identifying the issues at stake in a particular setting and thinking through, in a methodical manner, the ethical issues that require consideration as well as the values that need to be considered and promoted. Decisions made about the use, sharing, and re-use of big data are complex and laden with values. This paper sets out an Ethics Framework for Big Data in Health and Research developed by a working group convened by the Science, (...) Health and Policy-relevant Ethics in Singapore Initiative. It presents the aim and rationale for this framework supported by the underlying ethical concerns that relate to all health and research contexts. It also describes a set of substantive and procedural values that can be weighed up in addressing these concerns, and a step-by-step process for identifying, considering, and resolving the ethical issues arising from big data uses in health and research. This Framework is subsequently applied in the papers published in this Special Issue. These papers each address one of six domains where big data is currently employed: openness in big data and data repositories, precision medicine and big data, real-world data to generate evidence about healthcare interventions, AI-assisted decision-making in healthcare, public-private partnerships in healthcare and research, and cross-sectoral big data. (shrink)

Philosophers have predominantly regarded morality and aesthetics judgments as fundamentally different. However, whether this claim is empirically founded has remained unclear. In a novel task, we measured brain activity of participants judging the aesthetic beauty of artwork or the moral goodness of actions depicted. To control for the content of judgments, participants assessed the age of the artworks and the speed of depicted actions. Univariate analyses revealed whole-brain corrected, content-controlled common activation for aesthetics and morality judgments in frontopolar, dorsomedial and (...) ventrolateral prefrontal cortex. Temporoparietal cortex showed activation specific for morality judgments, occipital cortex for aesthetics judgments. Multivariate analyses revealed both common and distinct whole-brain corrected representations for morality and aesthetics judgments in temporoparietal and prefrontal regions. Overall, neural commonalities are more pronounced than predominant philosophical views would predict. They are compatible with minority accounts that stress commonalities between aesthetics and morality judgments, such as sentimentalism and a valuation framework. (shrink)

An important philosophical issue in the study of addiction is what difference the fact that a person is addicted makes to attributions of autonomy (and responsibility) to their drug-oriented behavior. In spite of accumulating evidence suggesting the role of emotional dysregulation in understanding addiction, it has received surprisingly little attention in the debate about this issue. I claim that, as a result, an important aspect of the autonomy impairment of many addicted individuals has been largely overlooked. A widely shared (...) assumption in the philosophical literature is that for addiction to impair a person’s autonomy it has to make them (in some sense) take drugs against their will. So-called “willing addicts” are therefore usually seen as exempted from the autonomy impairment believed to characterize “unwilling addicts”, the latter being those who ‘truly want’ to stop using drugs but find their attempts repeatedly derailed by failures of self-control. In this article, I argue that the association between addiction and emotional dysregulation shows why this assumption is false. Emotional dysregulation is not only consistent with the possibility that many addicts take drugs ‘willingly’, it supports the hypothesis that they use drugs because they truly want to. The article proposes an explanation for why emotional dysregulation should nevertheless be seen as an aspect of their loss of control and an important reason why they have impaired autonomy. I end by exploring some implications of this account for addict’s decision-making capacity when they are prescribed the drugs to which they are addicted. -/- . (shrink)

[A revised and updated version of an earlier article 'Understanding Creativity: Affect Decision and Inference' (unpublished), posted at PhilArchive in 2021.] -/- This book looks at the creative process in the human mind. -/- Creativity involves a major restructuring of the conceptual space where a sustained inferential process eventually links remote conceptual domains, thereby opening up the possibility of a large number of new correlations between remote concepts by a cascading process. Since the process of inductive inference depends crucially (...) on decisions at critical junctures of the inferential chain, it becomes necessary to examine the basic mechanism underlying the making of decisions. In the framework that we attempt to build up for the understanding of scientific creativity, this role of decision making in the inferential process assumes central relevance. -/- Referring to the process of inferential exploration of the conceptual space that generates the possibility of correlations being established between remote conceptual domains, such exploration is guided and steered at every stage by the affect system, -/- While the affect system plays a guiding role in the exploration of the conceptual space, the process of exploration itself consists of the establishment of correlations between concepts by means of beliefs and heuristics, the self-linked ones among the latter having a special role in making possible the inferential journey along alternative routes whenever the shared rules of inference become inadequate. -/- Representing the conceptual space in the form of a complex network, the overall process can be likened to one of self-organised criticality commonly observed in the dynamical evolution of complex systems. An instance of self-organised criticality is found in the avalanche set up in a slowly growing sand-pile. (shrink)

BACKGROUND Patients with chronic pain face significant barriers in finding clinicians to manage long-term opioid therapy (LTOT). For patients on LTOT, it is increasingly common to have them sign opioid treatment agreements (OTAs). OTAs enumerate the risks of opioids, as informed consent documents would, but also the requirements that patients must meet to receive LTOT. While there has been an ongoing scholarly discussion about the practical and ethical implications of OTA use in the abstract, little is known about how clinicians (...) use them and if OTAs themselves modify clinician prescribing practices. OBJECTIVE To determine how clinicians use OTAs and the potential impacts of OTAs on opioid prescribing. DESIGN We conducted qualitative analysis of four focus groups of clinicians from a large Midwestern academic medical center. Groups were organized according to self-identified prescribing patterns: two groups for clinicians who identified as prescribers of LTOT, and two who did not. PARTICIPANTS 17 clinicians from General Internal Medicine, Family Medicine, and Palliative Care were recruited using purposive, convenience sampling. APPROACH Discussions were recorded, transcribed, and analyzed for themes using reflexive thematic analysis by a multidisciplinary team. KEY RESULTS Our analysis identified three main themes: (1) OTAs did not influence clinicians’ decisions whether to use LTOT generally but did shape clinical decision-making for individual patients; (2) clinicians feel OTAs intensify the power they have over patients, though this was not uniformly judged as harmful; (3) there is a potential misalignment between the intended purposes of OTAs and their implementation. CONCLUSION This study reveals a complicated relationship between OTAs and access to pain management. While OTAs seem not to impact the clinicians’ decisions about whether to use LTOT generally, they do sometimes influence prescribing decisions for individual patients. Clinicians shared complex views about OTAs’ purposes, which shows the need for more clarity about how OTAs could be used to promote shared decision-making, joint accountability, informed consent, and patient education. (shrink)

In modern hospitals in developed countries, deaths are determined usually after a prearranged schedule of resuscitative efforts. By default, death is diagnosed and determined after “full code” or after the failure of intensive resuscitation. In end-of-life contexts, however, various degrees of less-than-full resuscitation and sometimes no resuscitation are allowed after the consent and shared decision-making of the patient and/or surrogates. The determination of brain death is a unique exception in these contexts because such an end-of-life care plan (...) is usually not offered until after brain death is declared. This essay analyzes and critiques three arguments for denying the family and/or surrogate a chance to consent to or forego the diagnostic protocol of brain death and choose an alternative end-of-life plan. First, opponents of consent for the determination of brain death argue that presenting it as a selectable end-of-life plan undermines the integrity of death determination. The second argument is that it is inconsistent to allow foregoing the determination of brain death when the determination of circulatory death is non-negotiable. The third argument is that allowing the patient/surrogate to forego the determination of brain death would jeopardize the fair and appropriate utilization of intensive care resources and potentially reduce organ donor pools. After closer conceptual examinations of these three arguments, this essay concludes that these arguments are conceptually and morally problematic. It defends an alternative patient-centered end-of-life care plan based on consent and shared decision-making. (shrink)

The paper focuses on the kind of expertise required by doctors in health communication and argues that such an expertise is twofold: both epistemological and communicative competences are necessary to achieve compliance with the patient. Firstly, we introduce the specific epistemic competences that deal with diagnosis and its problems. Secondly, we focus on the communicative competences and argue that an inappropriate strategy in communicating the reasons of diagnosis and therapy can make patient compliance unworkable. Finally, we focus on the case (...) of diabetes metaphor and propose the deliberate use of metaphors in health communication as an educational tool. On the one hand, metaphors might help doctors in explaining the disease in simpler terms and framing the experience of illness according to patient’s specific needs. On the other hand, metaphors might encourage a change in patient’s beliefs on their own experience of illness, and enable them to reach a shared decision making with doctors. (shrink)

In this article, I argue that stability is one of the enabling conditions for epistocratic arrangements to function well and justify their claim right to rule. Against this backdrop, I demonstrate that advocates of strategies to allocate exclusive decision-making power to knowledgeable citizens fail to demonstrate that in a context marked by the fact of pluralism, liberal epistocracies will be stable. They could argue that liberal epistocracies will be stable because epistocratic arrangements are better equipped than democratic (...) class='Hi'>decision-making bodies to produce outcomes that approximate the common good. They could argue that liberal epistocracies will be stable because there is a shared meritocratic set of values and ideas. Furthermore, they could opt for two standard liberal strategies, such as overlapping consensus and modus vivendi. Yet, in all cases, the argument for the stability of liberal epistocracies is not persuasive. (shrink)

This study’s objective was to understand Colombian adolescents’ experiences and preferences regarding access to sexual and reproductive health services (SRHS), either alone or accompanied. A mixed-method approach was used, involving a survey of 812 participants aged eleven to twenty-four years old and forty-five semi-structured interviews with participants aged fourteen to twenty-three. Previous research shows that adolescents prefer privacy when accessing SRHS and often do not want their parents involved. Such findings align with the longstanding tendency to frame the ethical principle (...) of autonomy as based on independence in decision-making. However, the present study shows that such a conceptualization and application of autonomy does not adequately explain Colombian adolescent participants’ preferences regarding access to SRHS. Participants shared a variety of preferences to access SRHS, with the majority of participants attaching great importance to having their parents involved, to varying degrees. What emerges is a more complex and non-homogenous conceptualization of autonomy that is not inherently grounded in independence from parental involvement in access to care. We thus argue that when developing policies involving adolescents, policymakers and health professionals should adopt a nuanced “relational autonomy” approach to better respect the myriad of preferences that Colombian (and other) adolescents may have regarding their access to SRHS. (shrink)

Algorithm Decision Making (ADM) systems designed to augment or automate human decision-making have the potential to produce better decisions while also freeing up human time and attention for other pursuits. For this potential to be realised, however, algorithmic decisions must be sufficiently aligned with human goals and interests. We take a Principal-Agent (P-A) approach to the questions of ADM alignment and trust. In a broad sense, ADM is beneficial if and only if human principals can trust (...) algorithmic agents to act faithfully on their behalf. This mirrors the challenge of facilitating P-A relationships among humans, but the peculiar nature of human-machine interaction also raises unique issues. The problem of asymmetric information is omnipresent but takes a different form in the context of ADM. Although the decision-making machinery of an algorithmic agent can in principle be laid bare for all to see, the sheer complexity of ADM systems based on deep learning models prevents straightforward monitoring. We draw on literature from economics and political science to argue that the problem of trust in ADM systems should be addressed at the level of institutions. Although the dyadic relationship between human principals and algorithmic agents is our ultimate concern, cooperation at this level must rest against an institutional environment which allows humans to effectively evaluate and choose among algorithmic alternatives. (shrink)

In the growing literature on decision-making under moral uncertainty, a number of skeptics have argued that there is an insuperable barrier to rational "hedging" for the risk of moral error, namely the apparent incomparability of moral reasons given by rival theories like Kantianism and utilitarianism. Various general theories of intertheoretic value comparison have been proposed to meet this objection, but each suffers from apparently fatal flaws. In this paper, I propose a more modest approach that aims to identify (...) classes of moral theories that share common principles strong enough to establish bases for intertheoretic comparison. I show that, contra the claims of skeptics, there are often rationally perspicuous grounds for precise, quantitative value comparisons within such classes. In light of this fact, I argue, the existence of some apparent incomparabilities between widely divergent moral theories cannot serve as a general argument against hedging for one's moral uncertainties. (shrink)

Decision-making Capacity matters to whether a patient’s decision should determine her treatment. But why it matters in this way isn’t clear. The standard story is that dmc matters because autonomy matters. And this is thought to justify dmc as a gatekeeper for autonomy – whereby autonomy concerns arise if but only if a patient has dmc. But appeals to autonomy invoke two distinct concerns: concern for authenticity – concern that a choice is consistent with an individual’s commitments; (...) and concern for sovereignty – concern that an individual exercises control over that which is hers to control. Here, I argue, neither concern can alone explain why dmc matters. Instead, dmc matters because it indicates a harmony between the two concerns – the demands of each concern are more likely to agree if a patient has dmc. This vindicates the standard story, but also makes clear that dmc is an inappropriate gatekeeper for autonomy. (shrink)

There is wide consensus among bioethicists about the importance of autonomy when determining whether or not a patient has the right to refuse life-saving treatment (LST). In this context, autonomy has typically been understood in terms of the patient’s ability to make an informed decision. According to the traditional view, decision-making capacity (DMC) is seen as both necessary and sufficient for the right to refuse LST. Recently, this view has been challenged by those who think that considerations (...) of authenticity and putative counterexamples should lead us to revise the traditional account. In this paper, we respond to these revisionist arguments, and we defend the traditional view according to which we have autonomy-based reasons to respect a patient’s decision to refuse LST if and only if she has DMC. (shrink)

Evaluativism (Carruthers 2018) and reflexive imperativism (Barlassina and Hayward 2019) agree that valence—the (un)pleasantness of experiences—is a natural kind shared across all affective states. But they disagree about what valence is. For evaluativism, an experience is pleasant/unpleasant in virtue of representing its worldly object as good/bad; for reflexive imperativism, an experience is pleasant/unpleasant in virtue of commanding its subject to get more/less of itself. I argue that reflexive imperativism is superior to evaluativism according to Carruthers’s own standards. He maintains (...) that a theory of valence should account for its phenomenology and role in imagination-based decision-making. I show that it is reflexive imperativism, rather than evaluativism, that fits this explanatory bill. (shrink)

Political theorists have offered many accounts of collective decision-making under pluralism. I discuss a key dimension on which such accounts differ: the importance assigned not only to the choices made but also to the reasons underlying those choices. On that dimension, different accounts lie in between two extremes. The ‘minimal liberal account’ holds that collective decisions should be made only on practical actions or policies and that underlying reasons should be kept private. The ‘comprehensive deliberative account’ stresses the (...) importance of giving reasons for collective decisions, where such reasons should also be collectively decided. I compare these two accounts on the basis of a formal model developed in the growing literature on the ‘discursive dilemma’ and ‘judgment aggregation’ and address several questions: What is the trade-off between the (minimal liberal) demand for reaching agreement on outcomes and the (comprehensive deliberative) demand for reason-giving? How large should the ‘sphere of public reason’ be? When do the decision procedures suggested by the two accounts agree and when not? How good are these procedures at truthtracking on factual matters? What strategic incentives do they generate for decision-makers? My discussion identifies what is at stake in the choice between minimal liberal and comprehensive deliberative accounts of collective decisionmaking, and sheds light not only on these two ideal-typical accounts themselves, but also on many characteristics that intermediate accounts share with them. (shrink)

Decision-making capacity (DMC) plays an important role in clinical practice—determining, on the basis of a patient’s decisional abilities, whether they are entitled to make their own medical decisions or whether a surrogate must be secured to participate in decisions on their behalf. As a result, it’s critical that we get things right—that our conceptual framework be well-suited to the task of helping practitioners systematically sort through the relevant ethical considerations in a way that reliably and transparently delivers correct (...) verdicts about who should and should not have the authority to make their own medical decisions. Unfortunately, however, the standard approach to DMC does not get things right. It is of virtually no help in identifying and clarifying the relevant ethical considerations. And, embedded in the prevailing anti-paternalist paradigm, DMC assessments obfuscate and distort the underlying ethical justification for granting or withholding decisional authority. Here, we describe the core commitments of the standard approach to DMC and then highlight three problems with it. We then argue that these problems are significant enough that they call for more than merely tinkering and fine tuning—variations of the standard approach cannot adequately address them. Instead, we should ditch DMC. (shrink)

Discussions of the non-identity problem presuppose a widely shared intuition that actions or policies that change who comes into existence don't, thereby, become morally unproblematic. We hypothesize that this intuition isn’t generally shared by the public, which could have widespread implications concerning how to generate support for large-scale, identity-affecting policies relating to matters like climate change. To test this, we ran a version of the well-known dictator game designed to mimic the public's behavior over identity-affecting choices. We found (...) the public does seem to behave more selfishly when making identity-affecting choices, which should be concerning. We further hypothesized that one possible mechanism is the notion of harm the public uses in their decision-making and find that substantial portions of the population seem to each employ distinct notions of harm in their normative thinking. These findings raise puzzling features about the public’s normative thinking that call out for further empirical examination. (shrink)

I review recent work from armchair and cross-cultural epistemology on whether humans possess a knowledge concept as part of a universal “folk epistemology.” The work from armchair epistemology fails because it mischaracterizes ordinary knowledge judgments. The work from cross-cultural epistemology provides some defeasible evidence for a universal folk epistemology. I argue that recent findings from comparative psychology establish that humans possess a species-typical knowledge concept. More specifically, recent work shows that knowledge attributions are a central part of primate social cognition, (...) used to predict others’ behavior and guide decision-making. The core primate knowledge concept is that of truth detection (across different sensory modalities) and retention (through memory) and may also include rudimentary forms of indirect truth discovery through inference. In virtue of their evolutionary heritage, humans inherited the primate social-cognitive system and thus share this core knowledge concept. (shrink)

While there is an extensive literature on how the precautionary principle should be interpreted and when precautions should be taken, relatively little discussion exists about the fair distribution of costs of taking precautions. We address this issue by proposing a general framework for deciding how costs of precautions should be shared, which consists of a series of default principles that are triggered according to desert, rights, and ability to pay. The framework is developed with close attention to the pragmatics (...) of how distributions will affect actual behaviours. It is intended to help decision-makers think more systematically about distributional consequences of taking precautionary measures, thereby to improve decision-making. Two case studies—one about a ban on turtle fishing in Costa Rica, and one about a deep-sea mining project in Papua New Guinea—are given to show how the framework can be applied. (shrink)

In this study, we propose a new approach based on fuzzy TODIM (Portuguese acronym for interactive and multicriteria decision-making) for decision-making problems in uncertain environments. Our method incorporates group utility and individual regret, which are often ignored in traditional multicriteria decision-making (MCDM) methods. To enhance the analysis and application of fuzzy sets in decision-making processes, we introduce novel entropy and distance measures for q-rung picture fuzzy sets. These measures include an entropy measure (...) based on the sine function and a distance measure derived from the Jensen-Shannon divergence. In our methodology, incorporating the sine function into the entropy measure stands out as a distinctive decision, grounded in a profound understanding of the inherent characteristics of fuzzy sets. Utilizing the sine function proves especially advantageous when handling fuzzy sets that exhibit cyclical variations or fluctuations in their membership degrees. We effectively weight the criteria for an improved evaluation by using this new entropy measure. The introduced distance measure finds application in the TODIM approach, allowing the execution of TODIM method steps within a fuzzy environment until the determination of one alternative’s dominance over another—an advancement beyond traditional approaches. We apply our enhanced fuzzy TODIM method to a real-life construction project management problem from the literature and compare the results with those in the literature and obtained from other MCDM methods. Our proposed measures are robust, as demonstrated by the sensitivity analysis that varied the weights of group utility and individual regret, with the results visualized in a 3D sensitivity plot. The findings demonstrate the superiority of our method in providing a more comprehensive evaluation of alternatives, making it a useful tool for decision-makers facing complex and uncertain decision-making problems. (shrink)

The US-Australia strategic relationship has evolved from more or less an adversarial position in the 19th century to an Australia largely dependent on the US during the Cold War to the interdependent partnership we see today. Strategic interdependence means that the US-Australia relationship is not merely a one-sided affair; that Australia has something of substance to offer the strategic relationship. Part of the reason that the relationship is strong is because of a shared language, similar social values, and compatible (...) political-legal systems. Moreover, the relationship has been thoroughly institutionalised via intelligence cooperation, defence science collaboration, and extensive personal relationships. But what the US really seems to value is Australia’s reliability as an ally. I argue that Australia best demonstrates its reliability as an ally, however, when it follows US strategic decision-making for the right reasons. This sense of reliability is more akin to trustworthiness than it is to loyalty. History demonstrates that Australia has not always agreed with the US. But agreeing doesn’t matter so much when Australia has established a track record of consistently applying sound reasoning to its strategic decisions and it has made substantive contributions to jointly sought after strategic outcomes. (shrink)

‘‘COGNITIVE ECOLOGY’’ is a fruitful model for Shakespearian studies, early modern literary and cultural history, and theatrical history more widely. Cognitive ecologies are the multidimensional contexts in which we remember, feel, think, sense, communicate, imagine, and act, often collaboratively, on the fly, and in rich ongoing interaction with our environments. Along with the anthropologist Edwin Hutchins,1 we use the term ‘‘cognitive ecology’’ to integrate a number of recent approaches to cultural cognition: we believe these approaches offer productive lines of engagement (...) with early modern literary and historical studies.2 The framework arises out of our work in extended mind and distributed cognition.3 The extended mind hypothesis arose from a post-connectionist philosophy of cognitive science. This approach was articulated in Andy Clark’s Being There: Putting Brain, Body, and World Together Again, and further developed by Susan Hurley and Mark Rowlands, among others.4 The distributed cognition approach arose independently, from work in cognitive anthropology, HCI (Human-Computer Interaction), the sociology of education and work, and science studies. The principles of distributed cognition were articulated in Hutchins’s ethnography of navigation, Cogni- tion in the Wild,5 and developed by theorists such as David Kirsh and Lucy Suchman.6 These models share an anti-individualist approach to cognition. In all these views, mental activities spread or smear across the boundaries of skull and skin to include parts of the social and material world. In remembering, decision making, and acting, whether individually or in small groups, our complex and structured activities involve many distinctive dimensions: neural, affective, kines-. (shrink)

The mental health crisis and loneliness epidemic have sparked a growing interest in leveraging artificial intelligence (AI) and chatbots as a potential solution. This report examines the benefits and risks of incorporating chatbots in mental health treatment. AI is used for mental health diagnosis and treatment decision-making and to train therapists on virtual patients. Chatbots are employed as always-available intermediaries with therapists, flagging symptoms for human intervention. But chatbots are also sold as stand-alone virtual therapists or as friends (...) and lovers. There is evidence that these uses of AI and chatbots can provide better quality service, improve accessibility, and lower costs. The systems can reduce the stigma and shame of sharing their problems and leverage a mass of biometric and behavioral data to supplement self-reports. As the systems' intelligence rapidly improves, they will need to be rigorously tested for the accuracy and precision of their diagnoses and the quality of their interactions with patients. As chatbots become indistinguishable from humans and leverage their superhuman capacity to detect affect and draw on knowledge of a patient’s life, patients will be drawn to attribute personality to and relationship with the chatbot. Consequently, it will be essential to study what the “therapeutic alliance” with an actual human counselor provides and the risks of patients attributing such a relationship to a one-sided or “parasocial” relationship. (shrink)

Equal Justice explores the role of the idea of equality in liberal theories of justice. The title indicates the book’s two-part thesis: first, I claim that justice is the central moral category in the socio-political domain; second, I argue for a specific conceptual and normative connection between the ideas of justice and equality. This pertains to the age-old question concerning the normative significance of equality in a theory of justice. The book develops an independent, systematic, and comprehensive theory of equality (...) and egalitarianism. The principal question is about the importance of equality in a theory of justice. More precisely, we should pose questions in four contracting circles: 1. Is justice the supreme value guiding our setup of the basic structure of society, or are there other, equally important values, such as recognition, care, communal belonging? 2. If justice is the highest guiding principle, which competing ideals—especially equality and freedom—ought to have precedence in a policy oriented toward justice? What status does the ideal of equality have in that framework? 3. If equality is a basic ideal of just policy, how should it be practically realized? What sort of equality (equal opportunity, equality of welfare, resource equality) should be demanded? 4. What patterned distribution of which specific goods does the ideal of equality demand? Which principles of distribution can be justified according to our justice ideal? To conclude and summarize: 5. What is the essential core of an egalitarian theory of justice, as opposed to an inegalitarian theory? These five questions structure the work’s order of argumentation. Part A elaborates the conceptual foundations and basic moral principles of justice and equality. Chapter I sets out to install justice as the central moral category in the socio-political domain. At the beginning of the first chapter, the conceptual foundations of justice are clarified. While not eliminating the classical distinctions between different forms of justice, I argue that the distributive paradigm is of primary importance. The primacy of justice in the socio-political domain is developed out of a confrontation with alternative positions, those which maintain either that justice generally, or distributive justice in particular, are subsidiary virtues. At the end of Chapter I, the first of the questions mentioned above is answered in a way that establishes justice as the guiding normative concept for the foundation and evaluation of any social order. To clarify the role of equality in a theory of justice, Chapter II separates the idea of equality into four different principles. They are organized in a way that begins with the most general and uncontroversial principle of equality, and progresses towards increasingly detailed and contested principles. There are two theses that articulate and defend the significance of equality for justice: First there is a conceptual connection between justice and equality, in that principles of formal and proportional equality are necessary in order to explicate the concept of justice. These two principles establish an unbreakable bond between justice and equality. Justice can only be explained—or so I argue—by reference to these and other (normative) principles of equality. The second thesis posits a normative relationship between justice and equality, which is disclosed by three substantive principles of equality: moral equality, the presumption of equality, and the principle of responsibility. I argue that the normative core of an egalitarian theory of justice is expressed by the latter two principles, which are themselves based on the first principle, that of moral equality. When we view one another as persons, what form of equality or equal treatment is normatively demanded? I argue that the answer to this question is given by the procedural principle of the presumption of equality: regardless of their apparent differences, all persons deserve strictly equal treatment, unless certain kinds of differences have whatever particular relevance would justify, on generally acceptable grounds, unequal treatment or unequal distribution. The justification of the presumption of equality is central to this work and has considerable importance. If the presumption principle’s validity can be justified by enlisting the principle of general justification, then the primacy of equality, and the essential argument for an egalitarian theory of justice, is established. This would likewise provide a procedure for the construction of a material theory of justice. The second question is answered thereby at the end of Chapter II: Equality should have primacy over competing ideals within a justice-oriented policy. The presumption of equality establishes this primacy and, at the same time, offers an appropriate metric and guideline for the construction of a material theory of distributive justice. The presumption of equality in Part B offers an elegant procedure for the development of a theory of distributive justice. Chapter III clearly sets out the necessary prerequisites that a theory of distribution must satisfy in order to determine a liberal-egalitarian distributional framework. We need to specify in which situation the distribution takes place; which goods are and are not to be distributed; in which respect the presumptive equality is to be produced; and by and to whom, and for what period, the relevant goods are to be distributed. The distribution is based on resources understood as general-purpose means. It is necessary to divide goods into different categories, since the justification for unequal treatment in one domain will not carry over into another. This makes presumptive equality necessarily complex. To that end, four spheres of justice are distinguished: (1) the political sphere, which involves allocating rights through the distribution of civil liberties; (2) the democratic sphere, in which political power and the rights of political participation are regulated; (3) the economic sphere, in which income and property are distributed; (4) the social sphere, in which social positions and opportunities are distributed. This framework of distributive justice answers the third of our guiding questions, about the nature of equality, in terms of equality of resources. Chapters IV and V set out the egalitarian distributive criteria for each sphere. I argue that the generally accepted, fundamental rights of classical liberalism are more effectively reconstructed by reference to the equal resource distribution presumptively required in those spheres. Chapter IV shows that when it comes to the first two spheres, those involving basic rights and freedoms and entitlement political participation, there can be no justified exceptions to the equal distribution of the relevant goods. That section argues, contrary to what we commonly find in theories of freedom or popular sovereignty, that the value of freedom and self-determination as the political basis of autonomy is best realized through the presumption of equal distribution. Chapter V deals with the other two spheres, those of economic goods and social positions, and argues for justified exceptions to equal distribution. In the economic sphere we find one principal reason favouring unequal distribution of resources, and three restrictions and compensations limiting that inequality. The basic exception to equal economic distribution arises from the unequal consequences of personal responsibility. From a suitably egalitarian standpoint, the principle of responsibility is the normative principle that determines which reasons justify economic inequality. Here the basic idea is that unequal shares of social goods are fair if they result from the choices and deliberate actions of the relevant parties. That individuals have to bear the costs of their own choices is a condition of autonomy. However, benefits or disadvantages arising from arbitrary and unmerited differences in social circumstances or natural endowments is unfair. The unequal consequences of independent decision-making and action must therefore be limited by compensating first for preferences, secondly for disadvantages, and thirdly by redistributing wealth in aid of the worse-off. I situations of emergency, compensating for disadvantages has priority over all other claims, owing to the urgency of the situation. Social inequalities go beyond the permissible limit if it is possible to improve the long-term social or economic situation of the worse-off by redistributing wealth to them. These exceptions lead to a complex system of free economic action within a framework of compensatory tax and transfer mechanisms. Finally, in the social sphere, the distribution of social positions, offices and opportunities must be structured to ensure that equally talented and motivated citizens have roughly equal chances of obtaining those offices or positions, irrespective of their economic or social class backgrounds. This compromise is permissible for reasons of freedom and prudence, and it makes a certain measure of inequality acceptable. The fourth of our guiding questions is answered accordingly. There are five principles of justice for the basic structure of society, and five legal principles that govern the special distribution of goods in the respective spheres—all are ranked according to their most defensible grounds of priority, ensuring that everyone is accorded equal justice. Chapter VI recapitulates the initial question of equality’s value. The conception of equal justice developed in this work postulates five principles of equality and five principles of law; these constitute an egalitarian framework because they support and promote social justice. Equality has value with respect to them, but is not given any independent, intrinsic value. That is why I call the account developed here a form of constitutive egalitarianism: justice is realized through the realization of equality, itself accomplished by applying the five postulates of equality and five distributive principles of law. This is an egalitarianism on two levels. The first level is involves the claim that morality or justice is conceptually connected with equality. The second level gives equality a substantial weight in what is conceptually validated at the first level, namely the presumption of equality, and constructs an appropriate interpretation and conception of distributive justice through principles of distribution for the individual spheres. The weight and importance of equality is shown by the distributive criteria applied to those spheres. This answers our final guiding question about the nature of an egalitarian theory. (shrink)

I argue that the debate concerning the nature of first-person moral judgment, namely, whether such moral judgments are inherently motivating or whether moral judgments can be made in the absence of motivation, may be founded on a faulty assumption: that moral judgments form a distinct kind that must have some shared, essential features in regards to motivation to act. I argue that there is little reason to suppose that first-person moral judgments form a homogenous class in this respect by (...) considering an ordinary case: student readers of Peter Singer’s “Famine, Affluence, and Morality”. Neither internalists nor externalists can provide a satisfying account as to why our students fail to act in this particular case, but are motivated to act by their moral judgments in most cases. I argue that the inability to provide a satisfying account is rooted in this shared assumption about the nature of moral judgments. Once we consider rejecting the notion that first-person moral decision- making forms a distinct kind in the way it is typically assumed, the internalist/externalist debate may be rendered moot. (shrink)

Recently, bioethicists and the UNCRPD have advocated for supported medical decision-making on behalf of patients with intellectual disabilities. But what does supported decision-making really entail? One compelling framework is Anita Silvers and Leslie Francis’ mental prosthesis account, which envisions supported decision-making as a process in which trustees act as mere appendages for the patient’s will; the trustee provides the cognitive tools the patient requires to realize her conception of her own good. We argue that (...) supported decision-making would be better understood as a collaborative process, giving patients with intellectual disabilities the opportunity to make decisions in a respectful relationship with trusted others. We offer an alternative account of supported decision-making where the primary constraint is to protect the patient from domination by the trustee. This is advantageous in its preservation of the prospects for genuine collaboration, for the mental prosthesis approach ultimately reinforces a problematic ideal of isolated patient self-determination. (shrink)

Machine intelligence already helps medical staff with a number of tasks. Ethical decision-making, however, has not been handed over to computers. In this proof-of-concept study, we show how an algorithm based on Beauchamp and Childress’ prima-facie principles could be employed to advise on a range of moral dilemma situations that occur in medical institutions. We explain why we chose fuzzy cognitive maps to set up the advisory system and how we utilized machine learning to train it. We report (...) on the difficult task of operationalizing the principles of beneficence, non-maleficence and patient autonomy, and describe how we selected suitable input parameters that we extracted from a training dataset of clinical cases. The first performance results are promising, but an algorithmic approach to ethics also comes with several weaknesses and limitations. Should one really entrust the sensitive domain of clinical ethics to machine intelligence? (shrink)

Many democratic theorists hold that when a decision is collectively made in the right kind of way, in accordance with the right procedure, it is permissible to enforce it. They deny that there are further requirements on the type of reasons that can permissibly be used to justify laws and policies. In this paper, I argue that democratic theorists are mistaken about this. So-called public reason requirements follow from commitments that most of them already hold. Drawing on the democratic (...) ideal of civic equality, I show that it can successfully explain why political decision-making must have the right sort of procedure-independent justification. However, contra standard accounts of public reason, I argue that laws and policies need to be justified with convergence accessible, not shared, reasons. Public reasons are those that are accessible in light of evaluative standards shared by all, or in light of every citizen’s private evaluative standards. Since this will make the set of public reasons wider, it makes the theory more palatable to sceptics while retaining the framework’s justificatory potential. (shrink)

Public reason liberalism demands that political decisions be publicly justified to the citizens who are subjected to them. Much recent literature emphasises the differences between the two main interpretations of this requirement, justificatory and political liberalism. In this paper, I show that both views share structural democratic deficits. They fail to guarantee political autonomy, the expressive quality of law, and the justification to citizens, because they allow collective decisions made by incompletely theorised agreements. I argue that the result can only (...) be avoided by changing public reason’s role in collective decision-making. Instead of incompletely theorised agreements, we should demand agreement both on the public reasons themselves and on the other premises that justify political decisions. In this way, it is always possible to point to a procedure-independent reason that justifies democratic decisions, and the reasoning of the state is public and contestable. Finally, I explain how this, in turn, implies that only political liberalism can be rescued—by accepting what I will call strong political liberalism. Modifying justificatory liberalism in the necessary way will inevitably open the door to an objectionable form of perfectionism. (shrink)

Decisions are made under uncertainty when there are distinct outcomes of a given action, and one is uncertain to which the act will lead. Decisions are made under indeterminacy when there are distinct outcomes of a given action, and it is indeterminate to which the act will lead. This paper develops a theory of (synchronic and diachronic) decision-making under indeterminacy that portrays the rational response to such situations as inconstant. Rational agents have to capriciously and randomly choose how (...) to resolve the indeterminacy relevant to a given choice-situation, but such capricious choices once made constrain how they will choose in the future. The account is illustrated by the case of self-interested action in situations where it is indeterminate whether you yourself will survive to benefit or suffer the consequences. The conclusion emphasizes some distinctive anti-hedging predictions of the account. (shrink)

Across two studies the hypotheses were tested that stressful situations affect both leadership ethical acting and leaders' recognition of ethical dilemmas. In the studies, decision makers recruited from 3 sites of a Swedish multinational civil engineering company provided personal data on stressful situations, made ethical decisions, and answered to stress-outcome questions. Stressful situations were observed to have a greater impact on ethical acting than on the recognition of ethical dilemmas. This was particularly true for situations involving punishment and lack (...) of rewards. The results are important for the Corporate Social Responsibility (CSR) of an organization, especially with regard to the analysis of the Stressors influencing managerial work and its implications for ethical behavior. (shrink)

In medical settings, machines are in close proximity with human beings: with patients who are in vulnerable states of health, who have disabilities of various kinds, with the very young or very old, and with medical professionals. Machines in these contexts are undertaking important medical tasks that require emotional sensitivity, knowledge of medical codes, human dignity, and privacy. -/- As machine technology advances, ethical concerns become more urgent: should medical machines be programmed to follow a code of medical ethics? What (...) theory or theories should constrain medical machine conduct? What design features are required? Should machines share responsibility with humans for the ethical consequences of medical actions? How ought clinical relationships involving machines to be modeled? Is a capacity for empathy and emotion detection necessary? What about consciousness? -/- The essays in this collection by researchers from both humanities and science describe various theoretical and experimental approaches to adding medical ethics to a machine, what design features are necessary in order to achieve this, philosophical and practical questions concerning justice, rights, decision-making and responsibility, and accurately modeling essential physician-machine-patient relationships. -/- This collection is the first book to address these 21st-century concerns. (shrink)

Can new technology enhance purpose-driven, democratic dialogue in groups, governments, and societies? Online Deliberation: Design, Research, and Practice is the first book that attempts to sample the full range of work on online deliberation, forging new connections between academic research, technology designers, and practitioners. Since some of the most exciting innovations have occurred outside of traditional institutions, and those involved have often worked in relative isolation from each other, work in this growing field has often failed to reflect the full (...) set of perspectives on online deliberation. This volume is aimed at those working at the crossroads of information/communication technology and social science, and documents early findings in, and perspectives on, this new field by many of its pioneers. -/- CONTENTS: -/- Introduction: The Blossoming Field of Online Deliberation (Todd Davies, pp. 1-19) -/- Part I - Prospects for Online Civic Engagement -/- Chapter 1: Virtual Public Consultation: Prospects for Internet Deliberative Democracy (James S. Fishkin, pp. 23-35) -/- Chapter 2: Citizens Deliberating Online: Theory and Some Evidence (Vincent Price, pp. 37-58) -/- Chapter 3: Can Online Deliberation Improve Politics? Scientific Foundations for Success (Arthur Lupia, pp. 59-69) -/- Chapter 4: Deliberative Democracy, Online Discussion, and Project PICOLA (Public Informed Citizen Online Assembly) (Robert Cavalier with Miso Kim and Zachary Sam Zaiss, pp. 71-79) -/- Part II - Online Dialogue in the Wild -/- Chapter 5: Friends, Foes, and Fringe: Norms and Structure in Political Discussion Networks (John Kelly, Danyel Fisher, and Marc Smith, pp. 83-93) -/- Chapter 6: Searching the Net for Differences of Opinion (Warren Sack, John Kelly, and Michael Dale, pp. 95-104) -/- Chapter 7: Happy Accidents: Deliberation and Online Exposure to Opposing Views (Azi Lev-On and Bernard Manin, pp. 105-122) -/- Chapter 8: Rethinking Local Conversations on the Web (Sameer Ahuja, Manuel Pérez-Quiñones, and Andrea Kavanaugh, pp. 123-129) -/- Part III - Online Public Consultation -/- Chapter 9: Deliberation in E-Rulemaking? The Problem of Mass Participation (David Schlosberg, Steve Zavestoski, and Stuart Shulman, pp. 133-148) -/- Chapter 10: Turning GOLD into EPG: Lessons from Low-Tech Democratic Experimentalism for Electronic Rulemaking and Other Ventures in Cyberdemocracy (Peter M. Shane, pp. 149-162) -/- Chapter 11: Baudrillard and the Virtual Cow: Simulation Games and Citizen Participation (Hélène Michel and Dominique Kreziak, pp. 163-166) -/- Chapter 12: Using Web-Based Group Support Systems to Enhance Procedural Fairness in Administrative Decision Making in South Africa (Hossana Twinomurinzi and Jackie Phahlamohlaka, pp. 167-169) -/- Chapter 13: Citizen Participation Is Critical: An Example from Sweden (Tomas Ohlin, pp. 171-173) -/- Part IV - Online Deliberation in Organizations -/- Chapter 14: Online Deliberation in the Government of Canada: Organizing the Back Office (Elisabeth Richard, pp. 177-191) -/- Chapter 15: Political Action and Organization Building: An Internet-Based Engagement Model (Mark Cooper, pp. 193-202) -/- Chapter 16: Wiki Collaboration Within Political Parties: Benefits and Challenges (Kate Raynes-Goldie and David Fono, pp. 203-205) -/- Chapter 17: Debian’s Democracy (Gunnar Ristroph, pp. 207-211) -/- Chapter 18: Software Support for Face-to-Face Parliamentary Procedure (Dana Dahlstrom and Bayle Shanks, pp. 213-220) -/- Part V - Online Facilitation -/- Chapter 19: Deliberation on the Net: Lessons from a Field Experiment (June Woong Rhee and Eun-mee Kim, pp. 223-232) -/- Chapter 20: The Role of the Moderator: Problems and Possibilities for Government-Run Online Discussion Forums (Scott Wright, pp. 233-242) -/- Chapter 21: Silencing the Clatter: Removing Anonymity from a Corporate Online Community (Gilly Leshed, pp. 243-251) -/- Chapter 22: Facilitation and Inclusive Deliberation (Matthias Trénel, pp. 253-257) -/- Chapter 23: Rethinking the ‘Informed’ Participant: Precautions and Recommendations for the Design of Online Deliberation (Kevin S. Ramsey and Matthew W. Wilson, pp. 259-267) -/- Chapter 24: PerlNomic: Rule Making and Enforcement in Digital Shared Spaces (Mark E. Phair and Adam Bliss, pp. 269-271) -/- Part VI - Design of Deliberation Tools -/- Chapter 25: An Online Environment for Democratic Deliberation: Motivations, Principles, and Design (Todd Davies, Brendan O’Connor, Alex Cochran, Jonathan J. Effrat, Andrew Parker, Benjamin Newman, and Aaron Tam, pp. 275-292) -/- Chapter 26: Online Civic Deliberation with E-Liberate (Douglas Schuler, pp. 293-302) -/- Chapter 27: Parliament: A Module for Parliamentary Procedure Software (Bayle Shanks and Dana Dahlstrom, pp. 303-307) -/- Chapter 28: Decision Structure: A New Approach to Three Problems in Deliberation (Raymond J. Pingree, pp. 309-316) -/- Chapter 29: Design Requirements of Argument Mapping Software for Teaching Deliberation (Matthew W. Easterday, Jordan S. Kanarek, and Maralee Harrell, pp. 317-323) -/- Chapter 30: Email-Embedded Voting with eVote/Clerk (Marilyn Davis, pp. 325-327) -/- Epilogue: Understanding Diversity in the Field of Online Deliberation (Seeta Peña Gangadharan, pp. 329-358). -/- For individual chapter downloads, go to odbook.stanford.edu. (shrink)