This paper continues the discussion of three values of sport (safety, fairness, inclusion) that has developed around the theme of inclusion of transwomen in the female category in World Rugby, as discussed by Pike, Burke and Imbrišević. In contrast to their discussion, in which these three values have been seen from the limited perspective of the inclusion of one group of athletes into a specific category of one sport, they are here discussed in the context of the categorization in sport (...) in general, with a focus on constitutive and eligibility rules. Constitutive rules give a strong foundation for eligibility rules. From the perspective of eligibility rules, the value of inclusion is identified as the underlying main value, while fairness and safety are its functions. This view rehabilitates the value of inclusion and has implications for how we think about the inclusion of athletes in sport, and for the creation of categories. (shrink)

According to the eligibility theory of meaning, often attributed to David Lewis, the referent of a predicate is the property that best balances the twin constraints of charity and eligibility, where eligibility is a function of metaphysical naturalness. This sort of metasemantics, which is motivated by its ability to resolve problems of indeterminacy and secure shared reference between disputing parties, can be somewhat friendly towards revisionary theories, since highly natural properties can act as “reference magnets,” securing our (...) reference despite some mismatch with usage. In this paper, I apply these considerations to normative ethics and argue that the theory of rule utilitarianism achieves a high balance of charity and eligibility. I proceed by comparing rule utilitarianism to two of its well-known rivals, act utilitarianism and Rossian pluralism. I show how the former achieves a high degree of eligibility but only at a significant cost of charity, while the latter does the opposite, fitting very nicely with our considered judgments but at the price of very low eligibility. Rule utilitarianism, on the other hand, strikes a good balance between these extremes; it assigns to our core moral term a relatively natural property without doing too much damage to our moral convictions. Thus, rule utilitarianism should be regarded as a promising moral theory by any philosopher who takes seriously considerations of eligibility and naturalness. (shrink)

In emergency situations and while medical resources are sufficient, doctors are expected to prioritize and treat patients according to medical criteria only. In MASSCAL situations and when medical resources become insufficient, patient selection and prioritization changes. Rules of triage are applied with the aim of getting the best result possible under the circumstances, e.g., saving the largest number; collective health outweighs individual health. Still, according to the standard ethical principles, non-medical criteria should never influence the doctors’ decision of who (...) will be treated. In military contexts, so-called medical rules of eligibility (MROE) provide rules that include non-medical criteria. This chapter aims to analyze if, why, and under what circumstances it may be ethically acceptable to prioritize patients according to non-medical criteria. (shrink)

Medical rules of eligibility permit severely injured Iraqi and Afghan nationals to receive care in Coalition medical facilities only if bed space is available and their injuries result directly from Coalition fire. The first rule favors Coalition soldiers over host-nation nationals and contradicts the principle of impartial, needs-based medical care. To justify preferential care for compatriots, wartime medicine invokes associative obligations of care that favor friends, family, and comrades-in-arms. Associative obligations have little place in peacetime medical care but (...) significantly affect wartime medicine. The second rule suggests liability for collateral harm that is unsupported by international law and military ethics. Absent liability, there are pragmatic reasons to offer medical care to injured local civilians if it quells resentment and cements support for Coalition forces. In contrast to peacetime medicine, military necessity and associative obligations outweigh distributive principles based on medical need during war. (shrink)

This book focuses on resource allocation in military and humanitarian medicine during times of scarcity and austerity. It is in these times that health systems bend, break, and even collapse and where resource allocation becomes a paramount concern and directly impacts clinical decision-making. Such times are challenging and this book covers this very important, yet, scarcely researched topic within the field of bioethics. This work brings together experts and practitioners in the fields of military health care, philosophy, ethics, and other (...) disciplines to provide analysis on a variety of related topics ranging from case studies and first-hand experiences to policy and philosophical analysis. It is of great interest to to academics, practitioners, policy makers and students who are looking for analyses and guidance regarding the fair provision of medical care and the use of medical rules of eligibility under adverse conditions. (shrink)

Recent debate by feminist scholars in philosophy of sport has been focused on the status of women’s sport as a protected category. Positions have varied significantly, from no need for a protected category anymore—to allow women’s sport to flourish and to give them a fair opportunity, given that men’s sport still dominates, just as it has in the past.It will be argued that: i) the concept of a ‘protected category’ is tied logically to the concept of fair play and has (...) been defined and enforced through the rules in sport and generally requires some kind of certification for inclusion. These specific rules will be analyzed in detail. Having separate women’s events means that logically it must be possible to exclude, and exclusion is not a popular stance as many have argued that the onus is on inclusion from a human rights perspective. Thus, sport policy makers are truly in an intractable position. On the one hand, no qualifying athlete should have to ‘dope down’ (or ‘dope up’) to compete in the Olympic Games. On the other hand, women athletes have argued that sex equality in competitive sport is a legitimate goal and that separating athletes in competition by biological sex traits is the only way to achieve this goal. It seems criminal to ask athletes to ‘dope down’ to be able to compete in the Olympic Games, however, although a new auxiliary rule creating new sub-classification of women athletes with testosterone higher than the stipulated cut off seems logical on the face of it, these cases are statistically rare. It is concluded that the community of women athletes should have the most significant voice, as historically, the criteria for the women’s sport-protected category have been predominantly determined by men. That is not to say that men’s voices, or voices outside of the women’s sports community of practitioners, cannot be heard, but they should not be the deciding factor. (shrink)

The subject of gender discrimination in language and the relation between language and social structures is well known and widely debated. Nevertheless, everyday experiences show, over and over, the linguistic hierarchy at work when men and women are concerned. This paper has two main parts. The first one concerns the image of women in language and the other one treats the manner in which women usually use the language. Despite the fact that these social unwritten rules and deep rooted (...) preconceptions are, in my opinion, difficult to ignore, the initiative of analyzing such facts represents an important first step in reducing the negative effects of the phenomenon. Obviously, we are aware of the fact that the problem is extremely profound and the imposed usage of certain nondiscriminatory terms represents not a very efficient solution, but, all in all, this analysis is the first phase of a much profound change that hopefully will occur. (shrink)

Rules of origin (ROO) are pivotal element of the Greater Arab Free Trade Area (GAFTA). ROO are basically established to ensure that only eligible products receive preferential tariff treatment. Taking into consideration the profound implications of ROO for enhancing trade flows and facilitating the success of regional integration, this article sheds light on the way that ROO in GAFTA are designed and implemented. Moreover, the article examines the extent to which ROO still represents an obstacle to the full implementation (...) of GAFTA. In addition, the article provides ways to overcome the most important shortcomings of ROO text in the agreement and ultimately offering possible solutions to those issues. Bashar H. Malkawi and Mohammad I. El-Shafie. (shrink)

John Searle’s distinction between regulative and constitutive rules is an enduringly important contribution to our understanding of rules, of language, and of rule-based or rule-bounded institutions. It is important to add to Searle’s account, however, by pointing out the regulative function of constitutive rules. Many human activities and goals can be pursued in multiple ways, but constituting the approved or official way of doing things, as is so common in law, has the effect of making alternatives less (...) eligible, less available, or less permitted, all of which can be seen as the regulative overhang of constitutive rules. (shrink)

The Telecommunications Act of 1996 is considered landmark legislation, especially in the area of universal service. However, the FCC performed even more groundbreaking activity. The FCC was given wide latitude by the Act to interpret the universal service provisions of the Act either narrowly or broadly; the FCC chose the latter. The FCC's interpretation of the Act will have a significant impact on the level of technology implementation and use in American classrooms and libraries. In March 1996, the FCC issued (...) a Notice of Proposed Rulemaking on Universal Service. The NPRM also established a Federal-State Joint Board composed of three FCC Commissioners, four state public service commission representatives nominated by the National Association of Regulatory Utility Commissioners, and one utility consumer advocate nominated by the National Association of State Utility Consumer Advocates. On November 8, 1996, the Joint Board released its Recommended Decision and the FCC adopted its rules based on that recommendation in May 1997. The FCC ruled that all eligible schools and libraties should receive discounts of between 20 and 90 percent on all telecommunications services, Internet access, and internal connections, subject to a $2.25 billion annual cap. In addition, any funds not disbursed in a given year may be carried forward and disbursed in subsequent years without regard to the cap. This provision, according to the FCC, will provide schools and libraries with the maximum flexibility to purchase the services that will meet their communications needs most effectively. In a separate section of the rules, the FCC defined "core services" as: • Voice-grade access to the public switched network, with the ability to place and receive calls • Dual Tone Multifrequency signaling or its functional equivalent • Single-party service • Access to emergency services • Access to operator services • Access to interexchange services • Access to directory assistance. • Support for toll limitation services for low-income consumers. However, as stated in the Act, the FCC was given the latitude to include additional services for schools and libraries. It could have chosen to provide schools and libraries with discounts on only core telecommunications services; core services plus some complement of additional services; or all telecommunications services. The FCC adopted the third option, that discounts be provided on all telecommunications services. It stated that this guideline would provide schools and libraries the maximum flexibility to purchase whatever package of telecommunications services they believe would meet their telecommunications service needs most effectively and efficiently. _Current Status:_ The FCC ruled that it will permit schools to begin using discounted services on January 1, 1998. The presentation will discuss the current status of this legislation. (shrink)

The Puṣṭipravāhamaryādābheda (PPM) by Vallabhācārya (1479–1531?) is a brief work (25 verses) written in Sanskrit in about the year 1500, which is accompanied by four Sanskrit commentaries and one Hindi (Brajbhāṣạ) commentary. The most important and authoritative commentary is by Puruṣottama, written about two centuries after the original text. The article contains a translation of the PPM with long extracts from the commentaries, particularly the one composed by Puruṣottama. After an introduction placing the PPM’s doctrine of the hierarchy of embodied (...) souls (jīvas) and their eligibility to obtain states of devotion (bhakti) in a wider context of Vaiṣṇava sectarian and philosophical schools, the text is presented along with the translation and notes to the text (including extracts from the commentaries). The article concludes with reflections on the PPM’s doctrine of predestination, comparing it with those of other Indian religious sects and within the wider context of predestination in Western religions, where these discussions have been ongoing for more than 1500 years. An extensive bibliography is included at the end. (shrink)

We propose 4 equity-advancing operational improvements to eligibility and sign-up processes at mass vaccination sites: (1) preregistration using existing information, (2) eligibility rules that recognize the greater burden of COVID-19 in underserved neighborhoods, (3) appointment assignment that prioritizes those with disadvantage, and (4) socioculturally informed outreach to lottery selectees.

Both trolleys and war leave innocent victims to suffer death and injury. Trolley problems accounting for the injured, and not only the dead, tease out intuitions about liability that enhance our understanding of the obligation to provide compensation and medical care to civilian victims of war. Like many trolley victims, civilians in war may suffer justifiable, excusable, or negligent harms that demand compensation. Chief among these is collateral harm befalling civilians. Collateral harm is endemic to war and comprises permissible but (...) unavoidable death or injury following necessary and proportionate military operations. Although state armies sometimes offer condolence payments for civilian death, injury, and property loss, they deny liability. Instead, they use compensation to enhance counterinsurgency efforts and assuage feelings of agent regret. As part of the medical rules of eligibility, Coalition forces in Iraq and Afghanistan also provided medical care to victims of collateral harm. However, they denied care to similarly sick or injured civilians. While compensation is often justified to cure the harm civilians suffer, the differential use of medical resources is not. Rather, medical care remains subject to the principle of beneficence and medical need. The duty to provide civilian healthcare in war, particularly in wars of humanitarian intervention, is far-reaching and imposes significant costs that military and medical ethics are yet to recognize. (shrink)

The dead donor rule (DDR) regulates current practice for vital organ donation, which means that organs may only be retrieved from people who are already dead (or brain dead). However, several authors criticize the DDR and argue that we should instead adopt a rule that allows us to retrieve vital organs before people are dead. They call this proposal organ donation euthanasia (ODE). While I am sympathetic to this proposal I do not think it goes far enough. In this paper, (...) I show that the key reasons put forward in favor of permitting ODE actually justify a more far‐reaching suggestion for regulation, permitting people to become living vital organ donors even when they are not about to die for other reasons. Further, I argue that only accepting imminently dying people as eligible donors for living vital organ donation would be objectionably paternalistic. (shrink)

Nationality, citizenship and eligibility have become increasingly relevant in sport, especially under current conditions where there is an increasing number of players who change their ?allegiances? for international sporting purposes. While it is reasonable to link such trends to wider processes of globalisation and accelerated migratory flows, it is also evident that national sporting representation is subject to the venal power of commercialism. The concern is that national representation has developed into a more strategic, planned and economically driven activity (...) that involves the overt collusion of national governing bodies and individual athletes. This paper evaluates the moral status of current international sporting representation (ISR) rules and practices as they relate to the Olympics. By drawing on de Coubertin's notion of ?sincere internationalism? and Walsh and Guilianotti's (2007) work on hyper-commercialisation in sport, we will attempt to demonstrate how some of the current practices and regulations of ISR are ethically problematic. We conclude that current ISR regulations are drawn too loosely and need to be amended in order to limit the moral pathologies identified. Our critique is informed by empirical data collected from members of the Welsh sports practice community. (shrink)

This thesis studies the formation of rules of experience in Weberian methodology and its adequacy to scientific validation criteria. It was sought to investigate, in the first part of the work, a proposal of justification for the so-called eligibility criteria. It was also tried to explain the meaning used in this research of the term “reason”, which is based on the theoretical conception of the operative reason exposed by Newton da Costa. Again, with the help of the writings (...) of the same author, we have examined those, so named by him, pragmatic principles of scientific reason. The second section of this study presented the three eligibility criteria, namely: i) the difference between to be (sein) and to ought to be (sollen); ii) the possibility of subsumption of individual action; iii) the construction of concepts as ideal types. In the third part of this work, rationally correct action was justified as an anticipated conjecture for a reflexive operation. However, it was supported that there is a significant difference in relation to the rules of experience when applied for the construction of the agent’s actions and in their use for validating the imputation of causal links between social phenomena. In order to validate the results of the research, the rules of experience must be cleverly designed to be general propositions of the experiment, and for this, the characterization of these rules was based in the so-called “Fermi solution”. Subsequent to this methodological proposal, we pondered how the scientist conducts a thought experiment in the empirical sciences of action and the judgment of objective possibility as a counterfactual proposition was logically structured. Thus, we tried to demonstrate the logical structure of the validation mode of knowledge produced in the empirical sciences of action from Weberian pattern. (shrink)

There is a fundamental tension in many sports: human sex is not binary, but there are only two categories in which people can compete: male and female. Over the past 10 years, the International Association of Athletics Federations (IAAF) regulations have been at the centre of two notable legal disputes. The Court of Arbitration for Sport (CAS) reached two contradictory rulings: in the first case (Dutee Chand vs Athletics Federation India and IAAF), the IAAF regulations for the eligibility of (...) athletes to compete in the female category were suspended (24 July 2015) on grounds of "discrimination against the female category"; in the latter (Caster Semenya and Athletics South Africa vs IAAF), the regulations were reaffirmed (1 May 2019) on grounds that although discriminatory, they are necessary to maintain a "level playing field" and to “protect” the female category. Although Semenya’s case has paved the way for questioning existing gender norms in sport, a new stable norm has yet to emerge from her case. The pharmacological solution put forward by IAAF to the tension between fairness and inclusivity of bodies non-conforming to two sexes is not, however, the only possible solution/resolution to the case, as I aim to show in this paper. Here I present some reflections on this topic and suggest how CAS should approach the case if it hopes to resolve it. (shrink)

There are basic traffic rules as well as rules that must be followed personally and socially. Depending on the drivers, positive and negative behaviors occur in traffic. Because of negative behaviors in traffic, there are loss of life and property, as well as moral/psychological prob-lems. It is seen that moral behavior, empathy and religious values are important in traffic. There are many studies that reveal the relationship between religiousness, traffic behaviors, and empathy. It can be predicted that there (...) are relationships between religiosity, driver behav-ior and empathy. Moreover, according to studies based on correlation relations, it can be stated that those with high religiousness, inner religiosity and empathy scores are more careful and respectful in traffic. Empathic tendencies and religious values might lead to be more civilized, more respectful, and to comply with the traffic rules. The aim of the current study was to analyze the relationship between religiosity, traffic behavior, and empathy. Under the guidance of literature, the following hypotheses were tested: There is a differentiation in traffic errors and violations and positive driver behavior by gender. Positive driver behaviors and traffic errors and violations differ according to the accident rate. There is a statistically positive rela-tionship between religiousness and empathy and positive driver behavior. There is a negative relationship between religiousness and traffic errors and violations. Religiousness predicts empathetic tendencies and positive driver behavior. Empathy mediates in the relationship between religiosity and positive driver behavior. Research methods of the current study were documentation and relational survey method. Data collection was made by means of various social media and messengers etc. A total of 201 volunteers participated in the current study. According to gender, 104 (51.7%) of the partici-pants were men and 97 (48.3%) were women. The age range of the sample varied between 20 and 58 and the average age is 33. 199 (99%) of the participants had a driver’s license, 2 (1%) had not any driver’s license. In terms of accident rates, 100 of the participants (49.8%) had an accident, 101 of them (50.2%) never had an accident. The data was analyzed using SPSS and AMOS program. Descriptive analysis, t-test, Pearson correlation test, multiple regression based on structural equation model, intermediate variable analysis, and reliability analysis tests were performed in the analyzes. The questionnaire of the study consisted of the personal infor-mation form and the consent form created by the researcher, the driver behavior scale devel-oped by Reason et al., adapted to Turkish by Sümer et al., the positive driver behavior scale developed by Özkan and Lajunen, the empathic tendency scale developed by Dökmen and the religiousness scale developed by Ayten. According to gender, there is a statistically significant differentiation in terms of traffic errors and violations (t (199) = 4.731; p 0.001), and errors and violations (β = -, 120; p> 0.001). Regarding the regression weights according to the structural equation model, in terms of relationships between varia-bles, it is not statistically eligible to analyze the mediator. (shrink)

Since the mid-1800s, clergy, doctors, other clinicians, and military personnel who specifically facilitate their work have been designated “non-combatants”, protected from being targeted in return for providing care on the basis of clinical need alone. While permitted to use weapons to protect themselves and their patients, they may not attempt to gain military advantage over an adversary. The rationale for these regulations is based on sound arguments aimed both at reducing human suffering, but also the ultimate advantage of the nation-state (...) fielding non-combatant staff. However, this is sometimes not immediately apparent to combatant colleagues. Clinicians in the armed force are also military officers, owing a “dual loyalty” that can create conflict if their non-combatant status is not well understood. Historical examples of doctors breaching their responsibilities include prioritisation of combat capability over the rights of individual soldiers (as occurred when scarce medical resources were allocated to soldiers more likely to return to battle in preference to those most likely to die without them), use of physicians to facilitate prisoner interrogation, medical research or treatment to enhance physical performance at the expense of health, application of Medical Rules of Eligibility according to factors other than clinical need, provision of treatment contingent upon support for military objectives, and use of medical knowledge to enhance weapons. However, not being a combatant party to a conflict does not imply that the non-combatant clinician cannot act in the national interest. Indeed, by adhering to the same universal ethics as their civilian colleagues, military clinicians provide optimal care to their own troops, facilitate freedom of action in host nations, and build positive international relationships during the conflict and in the post-conflict state. (shrink)

BackgroundFollowing several landmark rulings and increasing public support for physician-assisted death, in 2016, Canada became one of a handful of countries legalising medical assistance in dying (MAiD) with Bill C-14. However, the revised Bill C-7 proposes the specific exclusion of MAiD where a mental disorder is the sole underlying medical condition (MAiD MD-SUMC).AimThis review explores how some persons with serious and persistent mental illness (SPMI) could meet sensible and just criteria for MAiD under the Canadian legislative framework.MethodsWe review the proposed (...) Bill C-7 criteria (capacity, voluntariness, irremediability and suffering) as well as the nuances involved in separating a well-reasoned request for assisted suicide from what might be solely a manifestation of a SPMI.FindingsIn this paper, we argue against the absolute exclusion of patients with SPMIs from accessing MAiD. Instead, we propose that in some circumstances, MAiD MD-SUMC may be justifiable while remaining the last resort. Conducting MAiD eligibility assessments removes the need to introduce diagnosis-specific language into MAiD legislation. Competent psychiatric patients who request MAiD should not be treated any differently from other eligible candidates. Many individuals with psychiatric disorders will be incapable of consenting to MAiD. The only ethical option is to assess eligibility for MAiD on an individual basis and include as legitimate candidates those who suffer solely from psychiatric illness who have the decisional capacity to consent to MAiD. (shrink)

Canada is six years into a new era of legalized medical assistance in dying (MAiD). The law continues to evolve, following a pattern in which Canadian courts rule that legal restrictions on eligibility for MAiD are unconstitutional and Parliament responds by gradually expanding eligibility for MAiD. The central tension underlying this dialogue between courts and government has focused on two conceptions of how to best promote and protect the interests of people who are vulnerable by virtue of intolerable (...) and irremediable suffering due to an illness, disease, or disability. Do we, as a society, have a duty to protect vulnerable people from seeking certain medical procedures that are contrary to their interests, as those are perceived by others? Or do we have a duty to uphold their rights to autonomy, including the right to make choices within a range that may be constrained by many factors, some of which may be socially unjust? This is a recurrent problem in bioethics and medical law, which we explore through the lens of how Canadian courts and Parliament have grappled with defining eligibility for MAiD. (shrink)

Algorithmic decision-making based on profiling may significantly affect people’s destinies. As a rule, however, explanations for such decisions are lacking. What are the chances for a “right to explanation” to be realized soon? After an exploration of the regulatory efforts that are currently pushing for such a right it is concluded that, at the moment, the GDPR stands out as the main force to be reckoned with. In cases of profiling, data subjects are granted the right to receive meaningful information (...) about the functionality of the system in use; for fully automated profiling decisions even an explanation has to be given. However, the trade secrets and intellectual property rights (IPRs) involved must be respected as well. These conflicting rights must be balanced against each other; what will be the outcome? Looking back to 1995, when a similar kind of balancing had been decreed in Europe concerning the right of access (DPD), Wachter et al. (2017) find that according to judicial opinion only generalities of the algorithm had to be disclosed, not specific details. This hardly augurs well for a future right of access let alone to explanation. Thereupon the landscape of IPRs for machine learning (ML) is analysed. Spurred by new USPTO guidelines that clarify when inventions are eligible to be patented, the number of patent applications in the US related to ML in general, and to “predictive analytics” in particular, has soared since 2010—and Europe has followed. I conjecture that in such a climate of intensified protection of intellectual property, companies may legitimately claim that the more their application combines several ML assets that, in addition, are useful in multiple sectors, the more value is at stake when confronted with a call for explanation by data subjects. Consequently, the right to explanation may be severely crippled. (shrink)

Accepted medical practice already violates the dead donor rule. Explicitly jettisoning the rule—allowing vital organs to be extracted, under certain conditions, from living patients—is a radical change only at the conceptual level. But it would expand the pools of eligible organ donors.

This paper discusses the predicament of Oscar Pistorius. He is a Paralympic gold medallist who wishes to participate in the Olympics in Beijing in 2008. Following a brief introductory section, the paper discusses the arguments that could be, and have been, deployed against his participation in the Olympics, should he make the qualifying time for his chosen event (400m). The next section discusses a more hypothetical argument based upon a specific understanding of the fair opportunity rule. According to this, there (...) may be a case for allowing Pistorius to compete even if he should fail to make the official qualifying time. The final part of the paper reviews the situation at the time of writing and offers some assessment of the strategy of the IAAF in responding to it. It is argued below that the proper focus for assessment of Pistorius's eligibility to compete should not be on whether his blades lead to his having an unfair advantage over his competitors, but instead should focus on whether what he does counts as running. (shrink)

Effective November 1, 2002, the federal Department of Health and Human Services reclassified developing fetuses as “unborn children,” thereby providing health insurance benefits for prenatal care under the State Children's Health Insurance Program. By broadening the current definition of “child” —and thus expanding SCHIP insurance coverage — DHHS hopes to increase the number of low-income pregnant women who receive prenatal services. As noted by one commentator, the new rule represents the first time “any federal policy has defined childhood as beginning (...) at conception.”In an attempt to improve access to publicly funded health insurance for poor children not covered by Medicaid, Congress established SCHIP a 10-year, $40 billion program jointly funded by federal and state governments. Through a series of block grants, SCHIP allows states to either expand income-eligibility for their existing Medicaid program or to create a separate child health program to decrease the number of uninsured poor and near-poor children. (shrink)

Photo ID 222412412 © US Navy Medicine | Dreamstime.com ABSTRACT In a non-military setting, the answer is clear: it would be unethical to treat someone based on non-medical considerations such as nationality. We argue that Battlefield Triage is a moral tragedy, meaning that it is a situation in which there is no morally blameless decision and that the demands of justice cannot be satisfied. INTRODUCTION Medical resources in an austere environment without quick recourse for resupply or casualty evacuation are often (...) limited. The shortage extends not only to supplies like blood products and drugs, but physicians and other medical personnel. In the midst of a mass casualty scenario, such as a battle that includes intense ground fighting, the medical staff will stretch scarce resources and triage casualties according to specific criteria. Typically, they proceed by providing care for the most severely wounded first, referred to here as conventional triage. At times, though, the staff may reverse the triage so that soldiers with minor wounds can return to the fight. In a mass casualty situation, when medical personnel apply conventional triage and treat casualties from opposing forces, a dilemma may arise. We argue that it can be permissible for military physicians to prioritize their own soldiers over enemy combatants in a mass casualty triage, where reverse triage does not apply. The case we will focus on is as follows: Battlefield Triage: During combat operations on a remote island in the Pacific Ocean, a compatriot soldier and an enemy combatant arrive at the compatriot soldier country’s medical treatment facility. Both have similar gunshot wounds to the abdomen, and they arrive with similar conditions. Both have low oxygen saturation and excessive blood loss. The sole physician only has enough time to stabilize one person. The scenario is brief, and we are aware that medical rules of eligibility will most often dictate how the physician proceeds,[1] but this scenario is useful in setting up the question we focus on in this paper: would it be wrong to favor the stabilization of a soldier just because the soldier is the physician’s compatriot? In other words, can nationality serve as an ethically justified tiebreaker in a situation such as Battlefield Triage?[2] In a non-military setting, the answer is clear: it would be unethical to treat someone based on non-medical considerations such as nationality. The AMA’s Code of Medical Ethics asserts that physicians have “ethical obligations to place patients’ welfare above their self-interest and above obligations to other groups.”[3] The World Medical Association’s Declaration of Tokyo affirms that “no motive, whether personal, collective or political, shall prevail against this higher purpose” of alleviating distress.[4] Physicians are taught early on that triage decisions must be medically indicated and made without consideration of factors such as race, ethnicity, religion, social status, and nationality. They are taught that public trust and obligations of justice grounded in equality demand that only medical indications be considered. But military physicians in a military setting are beholden to obligations, duties, and responsibilities as members of the military, and when these obligations, duties, and responsibilities conflict, as they do in Battlefield Triage, which loyalties win out and why?[5] Critics of partiality on national grounds argue that partiality undermines public trust in medicine and justice because everyone should be treated equally regardless of nationality.[6] Proponents of partiality argue that military obligations supersede equality and that justice requires partiality in such cases.[7] Despite the critics’ disagreement, both agree that there is a morally right, perhaps even blameless, course of action. Drawing on insights from virtue ethics, we argue that Battlefield Triage is a moral tragedy in which justice is unattainable and there is no action without moral cost. The assumption that there is a morally right choice is flawed. We argue that while no decision in this scenario is free from moral blame, there are reasons to favor treating one’s soldiers over enemy combatants. I. The Case Against Partiality There is a common assumption that there is a morally right or just decision in Battlefield Triage. A number of organizations and scholars claim that it is wrong for military physicians to favor their own soldiers on the grounds of nationality or some form of ‘group membership.’ (In a conflict involving service members from multiple nations working as a coalition, a soldier from an allied country may receive the same priority as the US service member due to ‘group membership.’) The World Medical Association’s WMA Declaration of Lisbon on the Rights of the Patient, which was reaffirmed in 2015, posits that, “[i]n circumstances where a choice must be made between potential patients for a particular treatment that is in limited supply, all such patients are entitled to a fair selection procedure for that treatment. That choice must be based on medical criteria and made without discrimination.”[8] This echoes what was set forth in Article 12 of the Geneva Conventions, which states that “[o]nly urgent medical reasons will authorize priority in the order of treatment to be administered.”[9] The argument for impartiality in Battlefield Triage is that every person is morally equal, and equality entails that medical distribution is, “based on a combination of medical need and urgency.”[10] This is in keeping with the bioethical principles that are generally applied.[11] II. The Case for Partiality On the other side, there are arguments that favoritism is the ethically right decision in Battlefield Triage.[12] The argument asserts that members of the military form a morally significant community of friends and participation in these relationships demands partiality. Just as parents have strong ethical duties to their children and not just any children, military personnel have ethical duties to their group, a group that involves an affirmation of mutual aid and support. Some have termed these ‘associative duties. According to Michael Gross, obligations of friendship, care, and solidarity “leave very little room for generally applicable principles of justice that would obligate a medic to treat enemy or non-compatriot wounded ahead of their compatriots.”[13] This is true in Battlefield Triage, but it may also be true even if the enemy’s soldier were more seriously wounded: “the ethics of small group cohesion, largely an ethics of care, mostly replaces the demands of impartial justice.”[14] In a more recent article, Gross explains that preferential treatment is ethically justified based on fighting capability and “the special obligations people owe friends, family, and, no less, comrades-in-arms.”[15] To not show partiality to the US soldier would be morally wrong on the grounds of friendship and mutual care.[16] III. The Moral Tragedy of Battlefield Triage Defenders and critics of Battlefield Triage favoritism based on nationality both frame their position as just or fair. For example, Justin List argues that physicians are “bound to practice medical neutrality,”[17] Marcus Adams denies that physicians “possess special ethical obligations” to enemy combatants because of their profession.[18] These perspectives assume that there is a morally right decision and that justice is attainable. The assumption that there is or can be a morally right Battlefield Triage decision, and we need to put our heads together to figure it out, remains strongly entrenched. However, the facts of the situation should give us pause; there are too many people and too few resources, and this demands a decision-making process that determines who will receive scarce resources. By its very nature, a battlefield triage decision has to be made based on some characteristic or value, a characteristic or value that will inevitably favor some at the expense of others. This is precisely why competing analyses “in the military context struggle to resolve these conflicts satisfactorily.”[19] Drawing on the insights of virtue ethics, we suggest that Battlefield Triage is a moral tragedy. Virtue ethics suggests that morality is about acting virtuously, which is to say that we should do what a virtuous person would do in the situation. Ethics is about figuring out how a just, wise, compassionate, loving, and fair person would act, and then doing that, as one grows in virtue. But life is not always clear cut, and it is possible that virtuous people may find themselves in a moral tragedy, a situation in which, through no fault of one’s own, a person must make a morally objectionable decision. After the action the virtuous person “emerges having done a terrible thing, the very sort of thing that the callous, dishonest, unjust, or in general vicious agent would characteristically do.”[20] Stated differently, a moral tragedy presents a virtuous person with two or more courses of action, all of which have a moral cost.[21] In Battlefield Triage, no matter how the physician goes about deciding, there is going to be defensible concern from those not saved. The fact that there are more people than can be helped fosters competing values in battlefield triage: maximize lives saved, treat people equally, treat the worse off, and support the war effort. Treating people equally may create tension between treating the worse off, maximizing lives saved, and supporting the war effort. Reverse triage is a case in point, as supporting the war effort conflicts with treating the worse off first, as is a fair lottery system since deploying a lottery may not maximize lives saved or support the war effort. There can be reasons why one person is selected over another, to be sure. Yet, there are reasons for making a decision, and that the decision is subject to legitimate moral concern is another. To recognize the moral tragedy of Battlefield Triage is to recognize the impossibility of acting blamelessly in the situation. In this situation, the virtuous military physician is going to have to sacrifice important values such as justice, compassion, and respect for others, even with a defensible criterion in hand. The physician will grieve this sacrifice accordingly. The physician may find her decision difficult or stressful, and rightly so, because of what her circumstances require of her. This kind of moral tragedy results “in actions which betray and violate the rights of persons to whom there may be a strong duty of care. When this happens, it properly triggers an appropriate moral emotion since our moral integrity has been violated and this affects how we think of ourselves and what we have become.”[22] Rather than view her triage decision as the morally superior choice, the virtuous military physician will view her decisions in these circumstances in a different light: it is the least bad option in a terrible situation, and she did something ethically problematic, something that is contrary to her moral character. She deeply regrets the circumstances in which she had to act. IV. Virtue Ethics A virtue ethicist has insight into how one should go about deciding what to do in a moral tragedy, although virtue ethics may not be as helpful as one may hope. The goal of the virtuous military physician in Battlefield Triage is to adopt the best course of action or the action that she feels she ought to do, all things considered. This does not make her choice devoid of serious wrongdoing—a decision must be made, but that does not make it just. The virtuous military physician will approach the situation with courage, responsibility, and insight. She will think about the decision carefully, wisely, and conscientiously; she will weigh the goods and harms of the choices before her, in conjunction with a proper conception of the good life, human worth, and understanding of her obligations to others—including chain of command, fellow soldiers, and the medical community. She is attuned to the value of human life and has a reasonable idea of the various ways her decisions will affect others. She recognizes that she is in this non-ideal situation through no fault of her own: she is not the one fighting in battles; she is serving her country as a physician, whose job it is to save lives, treat everyone justly, and promote military objectives. She regrets the decision she is forced to make in battlefield triage, acting “with immense regret and pain,” Hursthouse explains, “instead of indifferently or gladly.”[23] This is because, no matter what decision is made, the virtuous military physician “does something terrible or horrible,” something she otherwise would not do and is contrary to her values.[24] V. A Resolvable Moral Tragedy Instead of asking whether there is a morally right decision, in which a decision is morally blameless and above reproach, the virtue ethicist asks whether there is a decision with a convincing rationale, knowing that a decision can have a clear rationale but still be morally tragic. It is perfectly reasonable to think that different virtuous persons will arrive at different courses of action: “two virtuous agents, in the same situation,” Hursthouse writes, “may act differently” in irresolvable moral tragedies, in cases in which there is no clear course of action.[25] Because a person must act in a moral tragedy, one goal is to identify reasons for choosing the chosen action. Some decisions are clearly indefensible—treating neither the compatriot soldier nor the enemy combatant in Battlefield Triage would be wrong—and some decisions are more problematic than others. If the military physician selects to treat the soldier because she does not like the enemy combatant’s skin color, such a reason would be deeply problematic. But much of the debate over how to act in a moral tragedy is not over clearly indefensible or problematic criteria. Instead, the literature is largely about different standards or implementations of justice. Some scholars defend nation-impartial triage as right, while others defend nation-aware triage as right, and each argues that the other side is promoting an unjust or otherwise wrong solution to Battlefield Triage. We suggest that Battlefield Triage is a resolvable moral tragedy and that virtue ethics offers convincing reasons to prefer the treatment of the compatriot soldier rather than the enemy combatant on the grounds of national identity. Virtues are integral to living a good life, a flourishing life, but as Aristotle observed long ago, human beings are inherently social, interdependent and interconnected in profound ways.[26] This goes beyond the obvious fact that we need each other to survive day to day (one person makes clothes, another farms, and another makes tools); the claim is that a good or flourishing life depends in large part on one’s social network or community. This is why many of Aristotle’s moral virtues are other facing: justice, friendship, generosity, and magnanimity, to name a few. Courage, a typically self-facing virtue, is understood by Aristotle to be the virtue that regards one’s fear of death in battle, a battle fought on behalf of one’s city.[27] All of this remains true today. Namely, there is an important sense in which our community matters to our lives: it is easier to live a good, flourishing life if one is part of a good, flourishing community. Our community is made up of smaller groups, and it is more accurate to say that we are simultaneous members of different groups within a broader community. A person may be part of a family, friend group, research team, large state university, city, state, and nation. Groups can function well or not, as we all have experienced, and this suggests that there are virtues or excellences that groups can instantiate. Good groups are unified in purpose, with each member doing their duty alongside others for the attainment of that purpose. Good groups manifest solidarity among their members. Although Aristotle does not list solidarity as a virtue, a number of modern-day virtue ethicists have begun examining how group solidarity can be a virtue that contributes to a good or flourishing life.[28] Solidarity is not conceptualized as an individual virtue, a virtue possessed by a person in isolation of others; instead, it is a collective virtue, a virtue that is shared among members of a defined group with particular ends.[29] “A group has solidarity to the extent that its members are disposed to: (1) share values, aims, or goals; (2) care about those values, aims, or goals; (3) act in accordance with those values, aims, or goals; (4) trust the testimony of other group members with respect to those values, aims, and goals; and (5) feel a sense of belonging to the group.”[30] The virtue of collective or group solidarity involves individuals having special concern for each other, shared aims and values, trust, loyalty, and a sense of belonging with these specific others. There is a oneness to the group in the pursuit of a definite goal or purpose, involving mutual support and affirmation of each member. As such, the group has ends and goods above and beyond the good of each individual person. Sometimes solidarity requires personal sacrifice for the collective (for example, a father sacrificing food so his child can eat). The virtue of collective or group solidarity is important to the military and medical community at every level, and for clear reasons. In the military, there is a clear hierarchy of command, unity of purpose and end, mutual trust and support in complex settings, and so on. Soldiers need to know they can count on one another, and solidarity grounds a soldier’s ability to trust others and be assured of mutual aid. In medicine, solidarity maintains self-regulation of the profession, shared values and goals, as well as public support, not to mention that day-to-day operations require physician trust, engagement, and effort toward the ends of clinical care. Physicians need to work together, along with others, in pursuit of health, and disunity is sowed when there is mistrust, selfishness, or disengagement among the healthcare team and organization. Importantly, just as we are all members of various groups and hence may manifest group solidarity in different settings, the virtuous military physician instantiates collective solidarity with both the medical profession and the military. Her dual loyalty contributes to the moral difficulty of acting in Battlefield Triage. The military physician has competing obligations to distinct groups and cannot satisfy all obligations in Battlefield Triage. Solidarity with the military supports the consideration of favoring the soldier for reasons of national identity, whereas solidarity with the medical community does not. Something has to give, which is why it is a moral tragedy. The virtuous military physician, therefore, must weigh the costs of each course of action. To fulfill her obligations to the medical community would require that she does not use nationality and other non-medical considerations in Battlefield Triage. Since the soldier and enemy combatant are equally injured, justice would demand a random process, perhaps a flip of the coin. Although this may satisfy obligations the military physician has to the medical community, this would be costly to the physician’s military group. If word gets out that the physician decides who to treat based on a coin toss, soldiers, families, and citizens may become frustrated and angry. Soldier morale may go down if it becomes known that a coin flip led to the preventable death of a soldier and the saving of an enemy combatant who had killed (or attempted to kill) other soldiers. As Gross highlights, military solidarity involves a mutual aid promise that military personnel promise to help one another.[31] A military physician is part of the military and, as such, is part of the mutual aid promise, which would appear to be violated if the physician flips a coin. Treating a member of one’s own team may be psychologically more beneficial than treating an enemy combatant and may lead to less moral distress.[32] Finally, treating soldiers rather than enemy combatants promotes broader military and social aims, including returning soldiers to health, maintaining unity of purpose, and minimizing community suffering from a soldier’s death. Favoring members of one’s group, that is, triage based on nationality in Battlefield Triage, would fulfill obligations of military group loyalty, which is contrary to the values and duties of medicine. It does not seem as though showing favoritism in this particular situation is very costly to the medical community or general public, but this is because there is recognition that the physician is in the military. Medicine is impartial to non-medical indications partly because of fairness and to promote public trust in medicine. However, Battlefield Triage is unique, as medicine is being practiced in a non-public, wartime setting. In ordinary circumstances, a patient’s identity is irrelevant, and physicians ought not play favorites. Since Battlefield Triage is not an ordinary circumstance, decisions based on patient identity may not undermine public trust in medicine. In addition, it is contestable that fairness in Battlefield Triage requires that no consideration be paid to one’s nationality. Fairness is about giving each person their due, what is owed to them, and the case can be made that soldiers who place themselves in danger for the sake of the common good or a just cause are owed special attention when they suffer harm in the line of duty. In other words, soldiers voluntarily undergo risk to themselves for the greater good, and society owes them for this sacrifice. This plausibly includes preferential treatment in a situation such as Battlefield Triage. So, while the medical community affirms justice demands non-preferential treatment, the military community can affirm the opposite. The demands of fairness are unclear at best or in conflict in this situation: demands of physician justice decry favoritism, while demands of military justice support favoritism. Triage not based on nationality is arguably unfair and triage based on nationality may not undermine public trust, after all. All things considered, there is a clear rationale for favoring nationality-based preferential treatment in Battlefield Triage. Adopting a nationality-based preference in this situation is more defensible than not. This does not make such a decision ethically right or just. Preference based on nationality is the least bad decision, but it is not morally blameless. It involves one in a serious moral wrong, a wrong otherwise avoided and contrary to one’s character. The virtuous military physician is in a situation in which obligations conflict, and we disagree with Gross, who posits that care of fellow soldiers “is important to the near exclusion of all else.”[33] Gross fails to appreciate the collective virtue of solidarity as applied to those in medicine. The military physician has duties to fellow soldiers but also to fellow physicians, to the medical community, and humanity. To favor a soldier on grounds of nationality violates her duties and responsibilities to this latter group. She is involved in a moral tragedy and can only seek the most just action given the circumstances, yet, at least in virtue ethics, the action remains far from blameless. CONCLUSION We argue that Battlefield Triage is a moral tragedy, meaning that it is a situation in which there is no morally blameless decision and that the demands of justice cannot be satisfied. As such, the virtuous military physician incurs a moral cost to acting as she does—there is a moral residue. However, despite being a moral tragedy, there are clear reasons to act in favor of treating one’s own, considering group solidarity. As such, these kinds of tragedies are resolvable: virtuous military physicians should favor treatment of their own, although they would do so with sorrow. - [1] Militaries set forth medical rules of eligibility or guidelines used to determine whether a person qualifies for specific medical interventions or treatments in certain circumstances, and these guidelines are binding for a military physician. For example, despite opposition from medical organizations, militaries have adopted reverse triage guidelines for military physicians to follow. For ethical discussion, see Falzone, Elisabeth, P. Pasquier, C. Hoffmann, O. Barbier, M. Boutonnet, A. Salvadori, A. Jarrassier, J. Renner, B. Malgras, and S. Mérat. "Triage in military settings." Anaesthesia Critical Care & Pain Medicine 36, no. 1 (2017): 43-51. https://doi.org/10.1016/j.accpm.2016.05.004 [2] There are issues that are related to this, including the triage of civilians and allied soldiers. We set related issues aside for purposes of this paper [3] American Medical Association, Code of Medical Ethics: Current Opinions with Annotations, 2004–2005 ed. (Chicago, IL: AMA, 2004), 300. [4] American Medical Association, Code of Medical Ethics: Current Opinions with Annotations, 2004–2005 ed. (Chicago, IL: AMA, 2004), 300. [5] This is termed the “dual loyalty” dilemma in military medicine and has been described at length elsewhere: Institute of Medicine (US) Board on Health Sciences Policy. Military Medical Ethics: Issues regarding Dual Loyalties: Workshop Summary. Washington (DC): National Academies Press (US); 2008. Toward a Framework for Resolving Dual Loyalties. Available from: https://www.ncbi.nlm.nih.gov/books/NBK214853/ [6] See Kenneth G. Swan and K.G. Swan, Jr., “Triage: The Past Revisited,” Military Medicine 161:8 (1996): 448–452. https://doi.org/10.1093/milmed/161.8.448; Jerome A. Singh, “American Physicians and dual loyalty obligations in the ‘war on terror,’” BMC Medical Ethics 4.4 (2003): 1–10. https://doi.org/10.1186/1472-6939-4-4; Beam, Thomas E. "Medical Ethics on the Battlefield." Military Medical Ethics: Sect. IV. Medical ethics in the military. Medical ethics on the battlefield: the crucible of military medical ethics 2 (2003): 369-402; Hereth, Blake. "Health justice for unjust combatants." Journal of Military Ethics 20, no. 1 (2021): 67-81. https://doi.org/10.1080/15027570.2021.1949782. [7] See Adams, Marcus P. "Triage priorities and military physicians." In Physicians at war: The dual-loyalties challenge, pp. 215-236. Dordrecht: Springer Netherlands, 2008. Gross, Michael L. "Comradery, community, and care in military medical ethics." Theoretical medicine and bioethics 32 (2011): 337-350. https://doi.org/10.1007/s11017-011-9189-6. Gross, Michael L. "The limits of impartial medical treatment during armed conflict." In Military medical ethics for the 21st century, pp. 71-84. Routledge, 2016. [8] World Medical Association, WMA Declaration of Lisbon on the Rights of the Patient. 5 December 2022, https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/ [9] Geneva Convention for the Amelioration of the Condition of Wounded, Sick in Armed Forces in the Field. 12 August 1949. https://www.un.org/en/genocideprevention/documents/atrocity-crimes/Doc.30_GC-I-EN.pdf. [10] List, Justin M. "Medical neutrality and political activism: physicians' roles in conflict situations." In Physicians at war: The dual-loyalties challenge, pp. 237-253. Dordrecht: Springer Netherlands, 2008. 240 [11] Beauchamp, T., and J. Childress. 2013. Principles of Biomedical Ethics, 7th ed. Oxford, United Kingdom: Oxford University Press. [12] Adams, Marcus P. "Triage priorities and military physicians." In Physicians at war: The dual-loyalties challenge, pp. 215-236. Dordrecht: Springer Netherlands, 2008. [13] Gross, "Comradery, community, and care in military medical ethics," 347. [14] Gross, “Comradery, community, and care in military medical ethics,” 349. [15] Gross, Michael L. "When medical ethics and military ethics collide." Narrative inquiry in bioethics 13, no. 3 (2023): 199-204. 202 https://dx.doi.org/10.1353/nib.2023.a924191 [16] Our argument draws on virtue ethics, from which care ethics derives, and it is worth clarifying how our argument relates to Gross’s. We do not think that the virtue of friendship grounds triage decisions, for we think it is unlikely that the physician and wounded soldier are friends. Instead, as explained below, we think the collective virtue of group solidarity better captures the moral significance of group loyalty and that Gross would agree with us. But since military physicians are part of distinct groups, with competing obligations, the military physician will be forced to sacrifice a value in battlefield triage cases. In other words, we think Gross downplays the dual group membership of a military physician. [17] List,”Medical neutrality and political activism,” 250. [18] Adams,”Triage priorities and military physicians,” 235. [19] London, Leslie, Leonard S. Rubenstein, Laurel Baldwin-Ragaven, and Adriaan Van Es. "Dual loyalty among military health professionals: human rights and ethics in times of armed conflict." Cambridge Quarterly of Healthcare Ethics 15, no. 4 (2006): 381-391. 383. [20] Hursthouse, R. On Virtue Ethics. OUP 1999. 74 [21] Nussbaum, Martha C. "The costs of tragedy: Some moral limits of cost-benefit analysis." The Journal of Legal Studies 29, no. S2 (2000): 1005-1036, 1007. [22] De Wijze, S. (2005). Tragic-remorse–the anguish of dirty hands. Ethical theory and moral practice, 7(5), 453-471, 457. https://doi.org/10.1007/s10677-005-6836-x [23] Hursthouse, 73 [24] Hursthouse, 81 [25] Hursthouse, 72 [26] Aristotle, Politics 1253a8. Reeve, C. D. C., Indianapolis: Hackett Publishing Co., 2017 [27] Aristotle, Nicomachean Ethics. III.6.114a, 34-35. 2002, Nicomachean Ethics, Christopher Rowe (trans.), Oxford: Oxford University Press [28] Byerly, T. Ryan, and Meghan Byerly. "Collective virtue." The Journal of Value Inquiry 50, no. 1 (2016): 33-50. https://doi.org/10.1007/s10790-015-9484-y; Federico, Veronica. "Conclusion: solidarity as a public virtue." Solidarity as a Public Virtue (2018): 495-542. https://doi.org/10.5771/9783845290058. Rehg, William. "Solidarity and the common good: An analytic framework." Journal of Social Philosophy 38, no. 1 (2007): 7-21. https://doi.org/10.1111/j.1467-9833.2007.00363.x [29] Byerly and Byerly. "Collective virtue." 43 [30] Battaly, Heather. "Solidarity: Virtue or vice?." In Social virtue epistemology, pp. 303-324. Routledge, 2022. 304 [31] Ibid., 2011: 341 [32] It might be thought that displaying altruism by helping an enemy combatant at the expense of one’s fellow soldier may be psychologically satisfiying. For evidence that military physicians find it difficult to treat enemy combatants, see Lundberg, Kristina, Sofia Kjellström, Anders Jonsson, and Lars Sandman. "Experiences of Swedish military medical personnel in combat zones: adapting to competing loyalties." Military medicine 179, no. 8 (2014): 821-826. https://doi.org/10.7205/MILMED-D-14-00038. Lamblin, Antoine, Clément Derkenne, Marion Trousselard, and Marie-Ange Einaudi. "Ethical challenges faced by French military doctors deployed in the Sahel (Operation Barkhane): a qualitative study." BMC Medical Ethics 22 (2021): 1-13. https://doi.org/10.1186/s12910-021-00723-2 [33] Ibid., 2011: 344. (shrink)

Medical assistance in dying (MAID) legislation in Canada followed much deliberation after the Supreme Court of Canada’s ruling inCarterv.Canada. Included in this deliberation was the Special Joint Committee on Physician Assisted Dying’s recommendation to extend MAID legislation beyond the inclusion of adults to mature minors. Children's agency is a construct advanced within childhood studies literature which entails eliciting children’s voices in order to recognise children as active participants in constructing their own childhoods. Using this framework, we consider the possible extension (...) of MAID legislation to most minors. We highlight important questions regarding how insights from children’s voices could be mobilised in the life or death context of MAID. We conclude that children’s voices have the potential to help determine their eligibility for MAID; however, incorporating children's voices in the context of MAID requires careful consideration due to the complexity of voice. (shrink)

In 2011 the IAAF introduced the Hyperandrogenism Regulations in an attempt to deal with a difficult problem; that of ensuring ‘fair’ competition in female athletics as a result of athletes with differences in sexual development competing against women without such conditions. In 2015, following a challenge to those regulations by Indian athlete, Dutee Chand, The Court of Arbitration for Sport (CAS) considered the merit of the regulations and determined that there was insufficient scientific evidence to justify their imposition. The regulations (...) were suspended by the CAS, until more convincing evidence could be provided (CAS 2014/A/3759 _Chand v AFI and IAAF_). The IAAF duly commissioned further research (Bermon and Garnier, 2017) and introduced amended regulations (the Eligibility Regulations for Female Classification (the DSD Regulations)). Although not universal, the IAAF has faced significant criticism from several angles about its approach to the problem. In particular, there has been criticism of the value of the scientific research on which the regulations are based (Franklin et al., 2018; Karkazis et al., 2012; Koh et al., 2018; Sőnksen et al., 2018; Tucker, 2017, Pielke, Tucker & Boye 2019) and also from those in the ethical and human rights fields seeking to ensure that the rights of individual athletes are protected (Adair, 2011; Buzuvis, 2016; Koh et al., 2018). In light of such criticism, this paper considers the IAAF’s approach in dealing with the perceived problem and considers its conduct against an objective framework of ‘good sporting governance’ (Geeraert, 2013; Henry and Lee 2004). It is this paper’s contention that the IAAF’s approach to rule creation in this area demonstrates less than ideal governance practice and, in doing so, notes the role of historical, cultural and institutional barriers as well as an over-reliance on insufficiently conclusive scientific evidence to provide a seemingly objective solution to a fundamentally more complex problem. (shrink)

Pakatan Harapan won the 14thGeneral Election held in May, 2018 in Malaysia. PH thus ended sixty-one years rule of Barisan Nasional.While the slogan of Malaysia Bahru, indicating changes to come in the country, became a popular slogan, one thing remained constant. This was the number of women contesting the GE-14 as candidates and the number of them who were elected was much less than the number of men contesting and getting elected in GE-14 although women represented slightly more than 50% (...) of the total registered voters in that election. The main objective of this paper is to examine the main factors that influenced the female voters in GE-14. Two states in the northern Malaysia were selected with 200 eligible female voters. They were clustered and conveniently sampled and were given self-administered questionnaires. Demographic variables were cross-tabbed while asking the women which factors had influenced their votes. The findings show that majority of the female voters were influenced by the candidates’ social background. Younger women were very concerned with the issues directly affecting them. Significantly, preference for political party was of least interest to them while voting. While the majority of women voters from the three main ethnic groups supported more women to be nominated as candidates in elections, the Malay women showed the highest level of disagreement on that matter as compared to the rest. The study also shows that majority of the female voters, whether young or old, rural or urban, use social media as the main and the most trusted source of news on election. These findings have concluded that, their demographic background interplayed with each other constructing their voting preferences. Female voters are crucial and each contesting parties need to pay closer attention to the women’s concerns in order to secure their votes. (shrink)

Much research about organic foods standards and certification in the United States employs a critical political economic perspective to interrogate links between certification politics and the “conventionalization” of organic agriculture. While helpful, this literature tends towards a dualistic framework, which emphasizes conflicts between movement-oriented and agribusiness wings of the organic community but obscures deliberative processes that sustain the organic market as an alternative economic space. This article develops a different approach by taking up E. Melanie DuPuis and Sean Gillon’s invitation (...) to “begin a conversation about the everyday forms of civic engagement” involved in the governance of the organic foods market and other alternative economies (DuPuis and Gillon in Agric Hum Values 26:43, 2009). I merge DuPuis and Gillon’s analysis of civic “modes of governance” in the organic sector with a theory of deliberative discourse developed by the cultural sociologist Jeffrey Alexander. I then apply this approach to examine a 2017 dispute about whether hydroponic growing operations were eligible for certification under the National Organic Program rules. The data indicate that (1) several features of this dispute did not follow the lines of movement/agribusiness conflict emphasized by political economic research and (2) both supporters and opponents of hydroponic certification drew from a common discursive repertoire to advocate for their preferred outcomes. I argue that while this common repertoire does not prevent conflict over the organic standards, it does sustain the importance of civic—as opposed to purely economic or technical—considerations in the sector’s governance. (shrink)

ABSTRACT Legislation recently adopted by the United States Congress provides producers of pandemic vaccines with near‐total immunity from civil lawsuits without making individuals injured by those vaccines eligible for compensation through the Vaccine Injury Compensation Program. The unusual decision not to provide an alternative mechanism for compensation is indicative of a broader problem of inconsistency in the American approach to vaccine‐injury compensation policy. Compensation policies have tended to reflect political pressures and economic considerations more than any cognizable set of principles. (...) This article identifies a set of ethical principles bearing on the circumstances in which vaccine injuries should be compensated, both inside and outside public health emergencies. A series of possible bases for compensation rules, some grounded in utilitarianism and some nonconsequentialist, are discussed and evaluated. Principles of fairness and reasonableness are found to constitute the strongest bases. An ethically defensible compensation policy grounded in these principles would make a compensation fund available to all individuals with severe injuries and to individuals with less‐severe injuries whenever the vaccination was required by law or professional duty. (shrink)

Background and Objectives Primary care providers (PCPs) report decreased job satisfaction and high levels of burnout, yet little is known about their experience of moral distress. The aim of this study was to gain insight into the experiences of PCPs regarding moral distress including causative factors and proposed mitigation strategies. Methods This qualitative pilot study used semi-structured interviews to identify causes of moral distress in PCPs in an academic family medicine department. Interviews were analyzed using conventional content analysis. Results Of (...) 35 eligible participants, 12 completed the study (34% participation rate). Most were white, female, and had practiced for less than 10 years. Four PCPs had considered leaving their position due to moral distress. Participants identified five causes of moral distress: policies and procedures that conflict with patient needs, the unpredictable nature of primary care, need to “bend the rules,” lack of accountability, and lack of support staff. Six internal conflicts made resolving morally distressing situations difficult: perceived powerlessness, sense of responsibility, socialization to follow orders, emotional toll of the job, competing obligations, and fear of mistakes. Conclusions These findings matched themes in the current literature and identified an unbending infrastructure. This, coupled with the chaotic nature of primary care, resulted in frequent moral distress. Participants offered solutions to reduce and mitigate moral distress (also similar with current literature) and suggested moral distress and burnout are closely linked. (shrink)

This essay offers a defence of the non-cognitivist approach to the interpretation of moral judgments as disguised imperatives corresponding to social rules. It addresses the body of criticism that faced R. M. Hare, and that currently faces moral anti-realists, on two levels, by providing a full semantic analysis of evaluative judgments and by arguing that anti-realism is compatible with moral aspiration despite the non-existence of obligations as the externalist imagines them. A moral judgment consists of separate descriptive and prescriptive (...) components and is to be understood as a declarative statement prefaced by an 'ideality operator'. Moral beliefs are genuinely representational, but their truth conditions can only be stated with reference to imaginary ideal worlds. Moral judgments are neither confirmed nor verified, but alternative moral positions are preferentially endorsed and adopted by individual agents on the basis of their perceived all-things-considered optimality. High aspiration moralities are normally very costly to agents in terms of their prudential and aesthetic interests, but they are theoretically as eligible as the adoption of other, less demanding sets of rules. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Update on Waiving Informed Consent in Emergency ResearchCharles R. McCarthyMadam: The closing statement of my article on Waiving Informed Consent in Emergency Research published in the June 1995 issue of the Kennedy Institute of Ethics Journal was: "No doubt we shall hear more of this issue."Indeed, we have heard much more on this issue. (1) In May 1995, after my article had already gone to press, the Food and (...) Drug Administration (FDA) and the National Institutes of Health (NIH) jointly published a report on the Public Forum on Informed Consent in Clinical Research Conducted in Emergency Circumstances. (2) On July 26, 1995, the Department of Health and Human Services (HHS) published in the Federal Register a Notice of Action Related to Emergency Research Activity (60 FR 38353-54). This action constituted a waiver of the requirement to obtain prior informed consent from subjects, as required by the Department's Regulations for the Protection of Human Subjects (45 CFR 46), for one specific NIH-funded project under strictly defined circumstances. (3) On September 21, 1995, FDA published a proposed rule to amend its current informed consent regulations (21 CFR 50) to permit harmonization of federal policies on emergency research and to reduce confusion as to when such research can proceed without obtaining prior informed consent from research subjects. The proposed regulation provides a narrow exception to the requirement for obtaining and documenting informed consent from each human research subject.The HHS waiver (a harbinger of a proposed amendment to its regulations) and the FDA proposed rule are intended to be harmonized so that an Institutional Review Board (IRB) in compliance with one set of regulations relative to the waiver of informed consent will be, ipso facto, in compliance with the other set of regulations.In brief: The FDA proposed amendments will allow an IRB to waive informed consent in emergency situations when:1. The human subjects are in a life threatening condition;2. Obtaining informed consent is not feasible because: (i) the subjects will not be able to provide consent because of their medical condition, (ii) the intervention must be administered before consent from legally authorized representatives is feasible, (iii) there is no reasonable way to identify prospectively the individuals likely to become eligible for the research because the emergence of the condition to be studied cannot be predicted reliably in particular individuals; [End Page 385]3. The opportunity to participate is in the interest of the subjects because: (i) a life threatening situation necessitates intervention, (ii) the risk of the intervention is reasonable in the light of what is known about the medical condition and the patient, the risks and benefits of current therapy, if any, and what is known about the risks and benefits of the proposed intervention or activity;4. The research could not practicably be carried out without the waiver;5. Additional protection of the rights and welfare of the subjects will be provided including, at least: (i) consultation (which may include consultation carried out by the IRB itself) with representatives of the communities from which the subjects will be drawn, (ii) public disclosure prior to commencement of the study sufficient to describe the study and its risks and benefits, (iii) public disclosure of sufficient information following completion of the study to apprise the community and researchers of the study and its results, and (iv) the establishment of an independent data and safety monitoring board;6. The IRB has reviewed and approved an informed consent document for use with subjects or legal representatives in situations in which obtaining such consent may be feasible for some subjects.The preamble to the proposed amendments to the regulations and the amendments themselves contain much more information than is presented here. Readers are therefore encouraged to study the proposals carefully. The public comment period ended November 6, and the FDA is expected to issue a final rule in 1996.Charles R. McCarthyKennedy Institute of Ethics Georgetown University Washington, DCCopyright © 1995 The Johns Hopkins University Press... (shrink)

The “welcome return” to “substantive political philosophy” that Rawls'sA Theory of Justicewas said to herald has resulted in forty years of proposals seeking to show that philosophical reflection leads to the demonstrable truth of almost every and any conceivable view of the justice of property rights. Select any view—from the justice of unregulated capitalist markets to the most extreme forms of egalitarianism—and one will find that some philosophers have proclaimed that rational reflection uniquely leads to its justice. This is, I (...) believe, a sort of ideological thinking masquerading as philosophizing. In this paper, using some tools from game theory as well as experimental findings, I seek to sketch a non-ideological approach to the question of the justification of property rights. On this approach the aim of political philosophy is, first and foremost, to reflect on whether our social rules of property are within the “optimal eligible set” of rules acceptable to all. (shrink)

BackgroundBeta thalassemia major is a severe inherited form of hemolytic anemia that results from ineffective erythropoiesis. Allogenic hematopoietic stem cell transplantation (HSCT) remains the only potentially curative therapy. Unfortunately, the subgroup of adult thalassemia patients with hepatomegaly, portal fibrosis and a history of irregular iron chelation have an elevated risk for transplantation-related mortality that is currently estimated to be about 29 percent.DiscussionThalassemia patients may be faced with a difficult choice: they can either continue conventional transfusion and iron chelation therapy or (...) accept the high mortality risk of HSCT in the hope of obtaining complete recovery.Throughout the decision making process, every effort should be made to sustain and enhance autonomous choice. The concept of conscious consent becomes particularly important. The patient must be made fully aware of the favourable and adverse outcomes of HSCT. Although it is the physician's duty to illustrate the possibility of completely restoring health, considerable emphasis should be put on the adverse effects of the procedure. The physician also needs to decide whether the patient is eligible for HSCT according to the "rule of descending order". The patient must be given full details on self-care and fundamental lifestyle changes and be fully aware that he/she will be partly responsible for the outcome.SummaryOnly if all the aforesaid conditions are satisfied can it be considered reasonable to propose unrelated HSCT as a potential cure for high risk thalassemia patients. (shrink)

Military doctors and nurses, working neither as pure soldiers nor as merely doctors or nurses, may face a ‘role conflict between the clinical professional duties to a patient and obligations, express or implied, real or perceived, to the interests of a third party such as an employer, an insurer, the state, or in this context, military command’. This conflict is commonly called dual loyalty. This chapter gives an overview of the military and the medical ethic and of the resulting dual (...) loyalty problem for medical personnel working in the military. It considers how dual loyalties relate to being a professional, something medical personnel are the paradigmatic examples of, but also something military personnel claim to be. Against that background, the chapter elaborates on the medical rules of eligibility used in Afghanistan, and on the policies concerning military involvement in local healthcare, to see what the existing rules and policies are, and whose interests they serve. (shrink)

When is commodification acceptable?Preimplantation genetic diagnosis is usually restricted to couples who are eligible for in vitro fertilisation —infertile couples or those with a history of genetic disease. The Human Fertilisation and Embryology Authority in England and the Infertility Treatment Authority in Australia have both given permission for PGD with tissue typing to detect human leucocyte antigen compatibility in order to save an existing sibling with a life threatening condition. The procedure has also been carried out in the United States.1Heavy (...) criticism followed the February 2002 ruling of England’s HFEA to allow a family to try for a child who is free of thalassaemia and a “perfect match” for a sick sibling.2 Then in August …. (shrink)

Typical philosophical discussions of physician-assisted death have focused on whether the practice can be permissible. We address a different question: assuming that pad can be morally permissible, how far does that permission extend? We will argue that granting requests for pad may be permissible even when the pad recipient can no longer speak for themselves. In particular, we argue against the ‘competency requirement’ that constrains pad-eligibility to presently-competent patients in most countries that have legalized pad. We think pad on (...) terminally ill, incapacitated patients can be morally permissible in cases where advance directives or suitable surrogate decision-makers are available, and should be legally permissible in such cases as well. We argue that this view should be accepted on pain of inconsistency: by allowing surrogate decision-makers to request withdrawal of life-sustaining care on behalf of patients and by allowing patients to request pad, we rule out any plausible justification for imposing a competency requirement on pad. (shrink)

Abstract:This essay criticizes recent trends in disability policy as restrictive of individual liberty and informed by too narrow a definition of what constitutes human flourishing. I defend the value of intentional community settings as one legitimate residential option for people with intellectual and developmental disabilities. Recent federal regulations (HCBS Final Rule) define intentional communities or disability-specific housing as presumptively institutional in nature, misunderstanding the positive, noninstitutional features of intentional, integrated communities created by and for people with developmental disabilities. In addition, (...) current disability policy, despite its stated concern for the autonomy of people with intellectual and developmental disabilities, limits individual liberty by strictly defining the types of settings eligible for Medicaid waiver funding, expressly excluding agricultural communities, disability-specific residential settings, and intentional communities. A robust commitment to the autonomy of people receiving Medicaid waiver services would allow them to choose to direct their program dollars, recognizing that some individuals may choose a life in intentional community or with others facing similar challenges to themselves over an illusory “integration” into a wider society that remains too often unwelcoming and difficult to navigate. (shrink)

The project of public-reason liberalism faces a basic problem: publicly justified principles are typically too abstract and vague to be directly applied to practical political disputes, whereas applicable specifications of these principles are not uniquely publicly justified. One solution could be a legislative procedure that selects one member from the eligible set of inconclusively justified proposals. Yet if liberal principles are too vague to select sufficiently specific legislative proposals, can they, nevertheless, select specific legislative procedures? Based on the work of (...) Gerald Gaus, this article argues that the only candidate for a conclusively justified decision procedure is a majoritarian or otherwise ‘neutral’ democracy. If the justification of democracy requires an equality baseline in the design of political regimes and if justifications for departure from this baseline are subject to reasonable disagreement, a majoritarian design is justified by default. Gaus’s own preference for super-majoritarian procedures is based on disputable specifications of justified liberal principles. These procedures can only be defended as a sectarian preference if the equality baseline is rejected, but then it is not clear how the set of justifiable political regimes can be restricted to full democracies. (shrink)

On 27 September 2002, the Bush administration issued final rules allowing states to define a fetus as a child eligible for government‐subsidized health care under the Children's Health Insurance Program. CHIP does not cover any illegal immigrants and only covers legal immigrants who have been in the country for five years. Babies born in the United States, however, are citizens and therefore eligible for assistance. The response from women's groups and pro‐choice advocates was swift and unanimously negative.

Legitimate expectations should be considered in the transition to a low-carbon society. After explaining under what conditions and circumstances expectations are legitimate, this paper shows that those expectations whose frustration undermines the ability to plan, infringes basic moral rights, or is extremely costly for its bearer might justify a deviation in the baseline of justice in favour of the expectation holder. People should be notified about the likely frustration of their expectations so that they can avoid the frustration of their (...) expectations, adapt their life plans and minimise costs. Since the frustration of legitimate expectations seems unavoidable in the transformation to a low-carbon society, priority should be given to the protection of the expectations of those who cannot be materially compensated. Still, if two groups are eligible for material compensation, we should give priority to protecting the expectation of those who cannot continue with the same life plan as before if their expectations are frustrated. (shrink)