Baumard proposes a model to explain the dramatic rise in innovation that occurred during the Industrial Revolution, whereby rising living standards led to slower life history strategies, which, in turn, fostered innovation. We test his model explicitly using time series data, finding limited support for these proposed linkages. Instead, we find evidence that rising living standards appear to have a time-lagged bidirectional relationship with increasing innovation.

The emerging field of synthetic biology, the designing and construction of biological parts, devices and systems for useful purposes, may simultaneously resolve some issues and raise others. In order to develop applications robustly and in the public interest, it is important to organize reflexive strategies of assessment and engagement in early stages of development. Against this backdrop, initiatives related to the concept of Responsible Research and Innovation have also appeared. This paper describes such an initiative: the construction of future scenarios (...) to explore the plausibility and desirability of potential synthetic biology innovations. We guided teams of synthetic biology students who participated in the large international Genetically Engineered Machines competition, in constructing scenarios aimed at exploring the plausibility and desirability of potential synthetic biology innovations. In this paper we aim to examine to what extent, and how, constructing such future scenarios contributes to RRI. In order to do so, we conducted observations and interviews to understand what kind of learning and reflection was promoted by constructing the scenarios in terms of four dimensions, which are discussed prominently in the literature on RRI: anticipation, inclusion, reflexivity and responsiveness. While we focus on how constructing future scenarios can contribute to strengthening RRI at a project level, we also consider how far our experiment may foster RRI in the iGEM competition in general, and perhaps even inspire constructive collaboration between ‘social scientists’ and ‘natural scientists’ in the context of larger scientific research programmes. (shrink)

This book is a collection of secondary essays on America's most important philosophic thinkers—statesmen, judges, writers, educators, and activists—from the colonial period to the present. Each essay is a comprehensive introduction to the thought of a noted American on the fundamental meaning of the American regime.

© 2016 Regents of the University of California.The Review summarizes much of particle physics and cosmology. Using data from previous editions, plus 3,062 new measurements from 721 papers, we list, evaluate, and average measured properties of gauge bosons and the recently discovered Higgs boson, leptons, quarks, mesons, and baryons. We summarize searches for hypothetical particles such as supersymmetric particles, heavy bosons, axions, dark photons, etc. All the particle properties and search limits are listed in Summary Tables. We also give numerous (...) tables, figures, formulae, and reviews of topics such as Higgs Boson Physics, Supersymmetry, Grand Unified Theories, Neutrino Mixing, Dark Energy, Dark Matter, Cosmology, Particle Detectors, Colliders, Probability and Statistics. Among the 117 reviews are many that are new or heavily revised, including those on Pentaquarks and Inflation. The complete Review is published online in a journal and on the website of the Particle Data Group. The printed PDG Book contains the Summary Tables and all review articles but no longer includes the detailed tables from the Particle Listings. A Booklet with the Summary Tables and abbreviated versions of some of the review articles is also available. (shrink)

The Scottish Enlightenment provided the fledgling United States of America and its emerging universities with a philosophical orientation. For a hundred years or more, Scottish philosophers were both taught and emulated by professors at Princeton, Harvard and Yale, as well as newly founded colleges stretching from Rhode Island to Texas. This volume in the Library of Scottish Philosophy demonstrates the remarkable extent of this philosophical influence. Selections from William Smith, John Witherspoon, Samuel Stanhope Smith, Archibald Alexander, Alexander Campbell, W.E. Channing, (...) James McCosh, and C.S. Peirce, together with the editor's introductory and explanatory material, provide the modern reader with unprecedented access to this period of intellectual formation. (shrink)

Both the target article and the precommentary demonstrate that relatively simple biobehavioral processes have the cumulative effect of fostering behavioral outcomes characteristic of attention-deficit/hyperactivity disorder (ADHD). As such, the articles illustrate a central theme of Darwinian thinking – basic processes acting over time can produce complex and diverse outcomes. In this commentary, we indicate that tracing the action of processes over time can be facilitated by quantitative methods such as artificial neural networks.

From the late eighteenth through the end of the nineteenth century, educational philosophers and practitioners debated the benefits and shortcomings of the use of emulation in schools. During this period, “emulation” referred to a pedagogy that leveraged comparisons between students as a tool to motivate them to higher achievement. Many educationists praised emulation as a necessary and effective motivator. Other educationists condemned it for its tendency to foster invidious competition between students and to devalue learning. Ultimately, by the late (...) nineteenth century emulation as a specific pedagogical practice had disappeared in American educational culture. In this article, Mark Jonas and Drew Chambers ask whether the disappearance of emulation is something to be celebrated or lamented. To answer this question they examine the historical concept of educational emulation and analyze the bases on which proponents and opponents argued. Parties on both sides of the debate framed their arguments in close relation to the way emulation was being used at that time, which prioritized actual competitions and prizes. In that context, the opponents made a better case, which presumably contributed to emulation's disappearance in schools afterwards. However, as earlier proponents of emulation argued, emulation need not be restricted to competitions and prizes. Instead, these proponents offered a philosophically and psychologically rich defense of emulation, but these were not carried through to an appropriate degree. The authors conclude that, construed appropriately, emulation not only had tremendous educational potential then, but still does today. With intentional effort on the part of teachers, emulation can greatly enrich students' lives and act as a powerful learning motivator. (shrink)

Throughout the biological and biomedical sciences there is a growing need for, prescriptive ‘minimum information’ (MI) checklists specifying the key information to include when reporting experimental results are beginning to find favor with experimentalists, analysts, publishers and funders alike. Such checklists aim to ensure that methods, data, analyses and results are described to a level sufficient to support the unambiguous interpretation, sophisticated search, reanalysis and experimental corroboration and reuse of data sets, facilitating the extraction of maximum value from data sets (...) them. However, such ‘minimum information’ MI checklists are usually developed independently by groups working within representatives of particular biologically- or technologically-delineated domains. Consequently, an overview of the full range of checklists can be difficult to establish without intensive searching, and even tracking thetheir individual evolution of single checklists may be a non-trivial exercise. Checklists are also inevitably partially redundant when measured one against another, and where they overlap is far from straightforward. Furthermore, conflicts in scope and arbitrary decisions on wording and sub-structuring make integration difficult. This presents inhibit their use in combination. Overall, these issues present significant difficulties for the users of checklists, especially those in areas such as systems biology, who routinely combine information from multiple biological domains and technology platforms. To address all of the above, we present MIBBI (Minimum Information for Biological and Biomedical Investigations); a web-based communal resource for such checklists, designed to act as a ‘one-stop shop’ for those exploring the range of extant checklist projects, and to foster collaborative, integrative development and ultimately promote gradual integration of checklists. (shrink)

Background: When adolescent boys experience close, secure relationships with their parents and peers, the implications are potentially far reaching, including lower levels of mental health problems in adolescence and young adulthood. Here we use rare prospective intergenerational data to extend our understanding of the impact of adolescent attachments on subsequent postpartum mental health problems in early fatherhood.Methods: At age 17–18 years, we used an abbreviated Inventory of Parent and Peer Attachment to assess trust, communication, and alienation reported by 270 male (...) participants in their relationships with mothers, fathers, and peers. More than a decade later, we assessed the adult males, now fathers, at 12 months postpartum for symptoms of depression, anxiety, and stress. Logistic regression was used to examine the extent to which attachment dimensions predicted paternal postpartum mental health, adjusting for potential confounding, and with assessment for interactions between parent and peer attachments.Results: Trust in mothers and peers, and good communication with fathers during adolescence, were associated with 5 to 7 percentage point reductions in postpartum mental health symptoms in early fatherhood. Weak evidence of parent-peer interactions suggested secure attachments with either parent or peer may compensate for an insecure attachment with the other.Conclusions: Our results suggest that fostering trust and communication in relationships that adolescent boys have with parents and peers may have substantial effects on rates of paternal postpartum mental health problems. The protective benefits may be preventative in intergenerational cycles of risk for mental health problems. (shrink)

In this collection of essays, the author develops a new philosophy of life, which has in fact a long tradition. It goes back to some ancient Western thinkers, such as the Milesians, Heraclitus, Empedocles and Plato, for whom philosophy presupposes an affective engagement with the world and not merely its theoretical description or explanation. This classical tradition has been challenged by ideas of modernity, particularly by the idea that modern scientific knowledge is the highest form of human knowledge. However, as (...) the author argues, this idea is questionable. In his view, scientific knowledge represents merely a partial knowledge. Science looks at the world indifferently as if it were an object, an “It”, but in fact the world is not that. Love, an affective engagement, and not indifference, is the way to full knowledge. Furthermore, it is lov e that fosters life and brings all things into unity. Love and life are thus closely connected. Life is the central concept around which humanity can unite, forming a unity in diversity. The author claims that global solidarity among human beings can be achieved if there is the growing common understanding of what is right for life. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Narcissism, Empathy and Moral ResponsibilityRonald W. Pies, MD (bio)Professor Fatic’s timely and wide-ranging essay demonstrates how the topic of narcissism has undergone a resurgence of interest in recent decades. This may owe, in part, to the controversial claim that narcissism is on the rise in the United States, at least among American college students (Twenge & Foster, 2010). As I discuss presently, the term “narcissism” is open to (...) many interpretations, and differs somewhat from the specific designation, Narcissistic Personality Disorder (NPD), as defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (American Psychiatric Association, 2013). As Fatic rightly notes,Narcissism as a personality structure may or may not be diagnosed as NPD, depending on various criteria, perhaps most importantly on whether the narcissistic person actually encounters functional and emotional difficulties and shows up for diagnosis and evaluation.As Professor Fatic’s essay clearly shows, narcissism (variously defined) has important “ethical ramifications.” Fatic is primarily interested in exploring the relationship between what he calls the narcissist’s “emotional incompetence” and that person’s degree of moral responsibility. To oversimplify Fatic’s complex set of interlinked arguments, Fatic concludes that “emotional incompetence does not in fact reduce the moral responsibility of a narcissist person, whether diagnosed with Narcissistic Personality Disorder or not.” Drawing on the moral theories of Philip Pettit and Michael Slote—in particular, Slote’s “sentimentalist ethics” with its emphasis on empathy (Slote, 2004)—Fatic argues that narcissism is both “a moral failure and a psychopathology.” Nevertheless, for Fatic, narcissists remain “fully morally responsible for their insensitivity and interpersonal emotional incompetence.” Why? Because they have the moral duty “to acquire the moral and emotional competence required for the making of moral choices.”Some Philosophical ConcernsAs I understand Fatic’s argument, he is asserting that the narcissist ought to be held responsible for a kind of self-education process that will ameliorate his or her emotional incompetence. Fatic writes,[W]e develop our morality through constant moral education and testing, which we receive both through socialization and through our own efforts later in life, as autonomous human beings. [End Page 173]We are thus responsible for what kind of moral actors we are and are becoming based on our way of life, and have a moral duty to improve our own moral senses and sensibilities by constantly working on the development of virtues.It seems to me that this line of reasoning assumes that all, or most, narcissists possess the capacity to seek and acquire this “moral education.” Perhaps so—but I am not sure Fatic has demonstrated this. It seems at least plausible that, in virtue of the adverse developmental and perhaps even neurological factors that may generate the narcissistic personality (Fan et al., 2011), some narcissists may lack the capacity to modify their psychopathology by means of “moral education.” This leads me to wonder whether Professor Fatic has adequately explored the very heterogeneous nature of narcissism. Indeed, Fatic’s thesis seems to point toward a kind of Platonic “essence” of narcissism, conveyed by his frequent allusion to “the narcissist”—one of whose defining or essential features is said to be a lack of empathy.But, as I will suggest presently, this is at best an oversimplification of narcissism as psychiatrists understand the term. Indeed, there are degrees and varieties of narcissism, differing in their capacity for empathy—which is itself a psychologically complex term. Recent research suggests that “narcissistic personality disorder symptomatology does not reflect a “narcissist” category but rather a continuum of narcissistic pathology” (Aslinger, Manuck, S. Pilkonis, Simms, & Wright, 2018).Furthermore, Professor Fatic’s thesis seems to view “moral responsibility” as a binary construct; i.e., either one possesses, or does not possess, full moral responsibility. But as I have argued elsewhere, moral responsibility may be viewed as lying along a continuum that reflects varying degrees of voluntariness for any given individual (Pies, 2007).Consequently, in my view, any valid assessment of the “the narcissist’s” moral responsibility must consider both the heterogeneity of narcissism and the non-binary (i.e., continuous) nature of moral responsibility.One way of conceptualizing this “two-track” model is... (shrink)

Over the last decades, Interdisciplinarity (ID) has become one of the leading research practices. Traditionally, cognitive science is considered one of the most prominent examples of ID research by including disciplines such as philosophy, psychology, artificial intelligence (AI), neuroscience, anthropology and linguistics. Recently, however the ID character of cognitive science has become under pressure. According to a study by Leydesdorff and Goldstone (2013), research in this domain gets more and more absorbed by cognitive psychology and the interdisciplinary character of cognitive (...) science is steadily fading away. In this paper, we will examine this claim and argue that its conclusion is premature. We will show that there are reasons to think that the interdisciplinary character of cognitive science is more robust and that the configuration of ID relations may be more dynamic than portrayed by ID skeptics. The reason, or so we will argue, is that ID research is a consequence of the theoretical framework(s) in place, i.e. it is in the nature of ID that fluctuations occur depending on what is held to be the nature of cognition. Our findings are twofold. On the one hand, we will show that the reintegration of cognitive science into cognitive psychology – and with it an approximation towards biology and neuroscience – is, as a matter of fact, the fruit of past ID research. On the other hand, we will demonstrate that novel conceptual frameworks open the possibility for restoring ID relations and foster new ID research. (shrink)

We provide a short review on the recent and near-future developments of computational processing of emotion in the voice, highlighting (a) self-learning of representations moving continuously away from traditional expert-crafted or brute-forced feature representations to end-to-end learning, (b) a movement towards the coupling of analysis and synthesis of emotional voices to foster better mutual understanding, (c) weakly supervised learning at a large scale, (d) transfer learning from related domains such as speech recognition or cross-modal transfer learning, and (e) reinforced (...) learning through interactive applications at a large scale. For each of these trends, we shortly explain their implications and potential use such as for interpretation in psychological studies and usage in digital health and digital psychology applications. We also discuss further potential development. (shrink)

A modern form of narrative, comic books are used to communicate, discuss, and critique issues in business ethics and social issues in management. A description of comic books as a legitimate medium is followed by a discussion of the pedagogical uses of comic books and assessment techniques. The strengths of the pedagogy include crossing cultural barriers, understanding the complexity of individual decision-making and organizational influences, and the universality of dilemmas and values. We provide an initial source for educators on the (...) topics, comic books, plotlines, and other commentary for consideration of use in the classroom from high school to graduate business ethics and social issues in management courses. (shrink)

BackgroundClinical Ethics Support (CES) services are offered to support healthcare professionals in dealing with ethically difficult situations. Evaluation of CES is important to understand if it is indeed a supportive service in order to inform and improve future implementation of CES. Yet, methods to measure outcomes of CES are scarce. In 2014, the European Moral Case Deliberation Outcomes Instrument (Euro-MCD) was developed to measure outcomes of Moral Case Deliberation (MCD). To further validate the instrument, we tested it in field studies (...) and revised it. This paper presents the Euro-MCD 2.0 and describes the revision process.MethodsThe revision process comprised an iterative dialogue among the authors as Euro-MCD-project team, including empirical findings from six Euro-MCD field-studies and input from European experts in CES and theory. Empirical findings contained perceptions and experiences of MCD outcomes among healthcare professionals who participated in MCDs in various settings in Norway, Sweden and the Netherlands. Theoretical viewpoints on CES, literature on goals of CES and MCD and ethics theory guided the interpretation of the empirical findings and final selection of MCD outcomes.ResultsThe Euro-MCD 2.0 Instrument includes three domains: Moral Competence, Moral Teamwork and Moral Action. Moral Competence consists of items about moral sensitivity, analytical skills and virtuous attitude. Moral Teamwork includes open dialogue and supportive relationships and Moral Action refers to moral decision-making and responsible care. During the revision process, we made decisions about adding and reformulating items as well as decreasing the number from 26 to 15 items. We also altered the sentence structure of items to assess the current status of outcomes (e.g. ‘now’) instead of an assumed improvement over time (e.g. ‘better’) and we omitted the question about perceived importance.ConclusionsThe Euro-MCD 2.0 is shorter, less complex and more strongly substantiated by an integration of empirical findings, theoretical reflections and dialogues with participants and experts. Use of the Euro-MCD 2.0 will facilitate evaluation of MCD and can thereby monitor and foster implementation and quality of MCD. The Euro-MCD 2.0 will strengthen future research on evaluation of outcomes of MCD. (shrink)

Background Implementing person-centred care (PCC) in nursing homes is challenging due to a gap between theory and practice. Bridging this gap requires suitable education, which focuses on learning how to attune care to the values and preferences of residents and take moral, relational, and situational aspects into account. Staff’s stories about the care they provide (i.e. caring stories) may deliver valuable insights for learning about these aspects. However, there is limited research on using staff's narratives for moral learning. Objective This (...) study aims to provide insight into the perspectives of nursing staff on using their caring stories to learn about PCC. Research design In this qualitative research, we conducted two rounds of interviews with 17 participants working in nursing homes. We wanted to obtain nursing staff’s perceptions of working with their caring stories and the impact on PCC. Ethical considerations Participation was voluntary, and participants provided written consent. The study protocol is approved by The Institutional Review Board of the Medical Ethical Committee Leiden-Den Haag-Delft. Findings Working with caring stories enables nursing staff to provide PCC and improves job satisfaction. It increases awareness of what matters to residents, fosters information rich in context and meaning, and enhances voice and vocabulary. Through in-depth team reflections, nursing staff discussed the significant moments for residents, which centralizes the discussions on the moral quality of care. Discussion Working with caring stories fosters dialogue on PCC and enhances reflection on ethical situations in daily encounters, contributing to the moral development of nursing staff. Putting nursing staff’s narratives at the centre of learning suits their daily practice and intrinsic motivation. Therefore, the outcomes of this study are an addition to the existing literature about using narratives in long-term care. Conclusion Using nursing staff's narratives contributes to PCC and positively impacts nursing staff. We recommend using staff's caring stories as a vehicle for moral learning in the transition to PCC. (shrink)

Stress and anxiety can both influence risk-taking in decision-making. While stress typically increases risk-taking, anxiety often leads to risk-averse choices. Few studies have examined both stress and anxiety in a single paradigm to assess risk-averse choices. We therefore set out to examine emotional decision-making under stress in socially anxious participants. In our study, individuals (N= 87) high or low in social anxiety completed an expanded variation of theBalloon Analogue Risk Task(BART). While inflating a balloon to a larger degree is rewarded, (...) a possible explosion leads to (a) a loss of money and (b) it is followed by an emotional picture (i.e., a calm vs. an angry face). To induce stress before this task, participants were told that they would have to deliver a speech. We operationalized risk-taking by the number of pumps during inflation and its functionality by the amount of monetary gain. In addition, response times were recorded as an index of decisional conflict. Without the stressor, high socially anxious compared to low socially anxious participants did not differ in any of the dependent variables. However, under stress, the low socially anxious group took more risk and earned more money, while high socially anxious individuals remained more cautious and did not change their risk-taking under social stress. Overall, high socially anxious individuals made their decisions more hesitantly compared to low socially anxious individuals. Unexpectedly, there were no main effects or interactions with the valence of the emotional faces. This data shows that stress affects socially anxious individuals differently: in low socially anxious individuals stress fosters risk-taking, whereas high socially anxious individuals did not alter their behavior and remained risk-averse. The noveleBARTis a promising research tool to examine the specific factors that influence decision-making. (shrink)

A modern form of narrative, comic books, are used to communicate, discuss, and critique issues in business and society. A description of comic books as a legitimate medium is followed by a discussion of the pedagogical uses of comic books. The strengths of the pedagogy include crossing cultural barriers, understanding the complexity of individual decision-making and organizational influences, and the universality of dilemmas and values. We provide an initial source for educators on the topics, comic books, plotlines, and other commentary (...) for consideration of use in the classroom from high school to graduate business ethics courses. (shrink)

Colour constancy refers to the ability to extract information about surface colours independently of illumination conditions. A ripe strawberry, for example, appears the same red when viewed under a blue sky or a reddish sunset. Since Land's pioneering work, discussion has centred on the issue whether colour constancy is achieved primarily in the retina or visual cortex. Recently, the debate has shifted to a consideration of the constraints imposed by various psychophysical tasks and instructions. Humans can judge illuminant colour, reflected-light (...) colour, surface colour, and the relationship between surface colours within a scene. Such observations suggest that colour constancy may not be a unitary phenomenon, and that its different aspects may be mediated at different levels in the visual system. Several questions therefore arise: are the tasks of surface estimation and illuminant estimation complementary, insofar as good performance in one implies poor performance in the other? How does retinal adaptation alter performance? Is colour vision tuned to the statistical composition of natural surfaces and illuminants? What role does colour-opponent processing in retina and cortex play in colour constancy? These and related questions are explored here in order to better understand what we mean when we ask: "Why do strawberries look red?". (shrink)

PHOTO ID 121339257© Designer491| Dreamstime.com ABSTRACT When physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be apparent conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters future physicians’ commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. We use an ethical dilemma that was presented to a group of third-year medical students to examine how ethics education might be causing (...) them to give undue deference to autonomy, thereby undermining their commitment to beneficence. INTRODUCTION The right of patients to choose which treatments they prefer is rooted in today’s social mores and taught as a principle of medical ethics as respect for autonomy. Yet, when physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be a conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters a commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. I. An Ethical Dilemma The impetus for this paper arose when students who were completing their third clinical year discussed a real-life ethical dilemma. A middle-aged man developed a pulmonary hemorrhage while on blood thinners for a recently placed coronary stent. The bleeding was felt to be reversible, but the patient needed immediate intubation or he would die. The cardiologist was told that the patient previously expressed to other physicians that he never wanted to be intubated. However, the cardiologist made the decision to intubate the patient anyway, and the patient eventually recovered.[1] Students were asked if they believed that the cardiologist had acted ethically. Their overwhelming response was, “No, the patient should have been allowed to die.” We looked into how students applied ethical reasoning to conclude that this outcome was ethically preferred. To explore how the third-year clinical experience might have formed the students’ judgment, we presented the same case to students who were just beginning their third year. Their responses were essentially uniform in recommending intubation. While there is likely more than one reasonable view in this case, we agree with the physician and the younger medical students that intubation was the ethically appropriate decision and will present an argument for it. But first, we explain the reasoning behind the more advanced medical students’ decision to choose patient autonomy at the expense of beneficence. II. Medical Ethics Education and the Priority of Autonomy Beauchamp and Childress’s Principles of Biomedical Ethics, first published in 1979 and now in its 8th edition, is a significant part of the formal ethics education in medical school.[2] Students learn an ethical decision-making approach based on respect for four ethical principles: autonomy, beneficence, nonmaleficence, and justice. While Beauchamp and Childress officially afford no prima facie superiority to any principle, the importance of respect for patient autonomy has increased through the editions of their book. For example, early editions of their book opposed the legalization of physician-assisted death compared to recent editions that defended it.[3] As another example, Beauchamp and Childress make paternalism harder to justify by adding an autonomy-protecting condition to the list of conditions for acceptable paternalism.[4] Authority, they contend, need not conflict with autonomy—provided the authority is autonomously chosen.[5] “The main requirement,” they write, “is to respect a particular patient’s or subject’s autonomous choices, whatever they may be.[6] In the principlism of Beauchamp and Childress, autonomy now seems to have a kind of default priority.[7] However, the bioethics discourse has strong counternarratives, noting some movement to elevate the role of beneficence and to respect the input of stakeholders, including the family and the healthcare team. Ethics education achieves particular relevance in the third clinical year when students become embedded in the care of patients and learn from what has been called the informal curriculum. They observe how attending physicians approach day-to-day ethical problems at the patient’s bedside. In this context, students observe the importance of informed consent for serious treatments or invasive procedures, a practice that highlights the principle of patient autonomy. In both the formal and informal curriculum, medical students observe how, in the words of Paul Wolpe, “patient autonomy has become the central and most powerful principle in ethical decision-making in American medicine.”[8] In short, students appear to learn a deference for patient autonomy. This curricular shift in favor of autonomy coincides with legal developments that protect patients’ rights and decision-making with respect to their healthcare choices. The priority of autonomy in medicine benefits patients by reflecting their choices and, in some cases, their fundamental liberty. III. The Practice of Medicine and the Commitment to Beneficence There are many critiques of the dominant place that autonomy has in biomedical ethics,[9] especially considering that autonomy seems to be biased toward individualistic, Western, and somewhat American culture-driven values.[10] In addition, many bioethical dilemmas are cast as a conflict between autonomy and beneficence. Our point is that medical students bring to their study of medicine a commitment to beneficence that seems to be suppressed by practical ethics education. We think this commitment is rationally defensible and should be nurtured. It is striking that young medical students have a pre-reflective commitment to beneficence at all. For, as we mentioned, it is not just medicine but Western culture generally that prioritizes autonomy in settling ethical dilemmas. In wanting to act for the good of others (rather than simply agreeing to what others want), physicians are already swimming somewhat against the cultural tide.[11] However, doing so makes sense, given the nature of medicine and the profession of healing. When prospective medical students are asked why they wish to become physicians, the usual answer is some variation on caring for the sick and preventing disease. It is unlikely that a reason to become a physician is to respect a patient’s autonomy. It would be easy to dismiss medical students’ commitment to beneficence as a mere intuition and contrary to a more reasoned and deliberative approach. Beauchamp and Childress seem to minimize the value of physician intuition, stating that justifications for certain procedures are “…supported by good reasons. They need not rest merely in intuition or feeling.”[12] Henry Richardson writes that “situational or perceptive intuition…leaves the reasons for decision unarticulated.”[13] We think this is a crude and rather thin way of understanding intuition. Some bioethicists have defended intuition as essential to the practice of medicine and not something opposed to reason.[14] In the case we describe, we believe the ethical justifications s for the patient’s intubation are fundamentally sound: the patient did not have a “do not intubate” order written in the chart, the emergency intubation had not been foreseen, so the patient did not have the opportunity to consent to or reject intubation; the patient had consented to the treatment for his cardiac disease so his consent for intubation could have been assumed;[15] and the consequences of respecting his autonomy did not justify allowing him to die.[16] While it is possible to have more than one reasonable view on this case, we think the case for beneficence is strong and certainly should not be dismissed out of hand. We do not deny that if a patient makes a clearly documented, well-informed decision to forgo intubation that this decision ought to be respected by the physician (even if the physician disagrees with the patient’s decision). But, in this situation, as in many others in the practice of medicine, the patient’s real wishes and preferences are not well-articulated in advance. There are many cases where a physician acts based on what she believes the patient, or the surrogate, would want, sometimes in situations that do not allow much time for reflection. An example might be resuscitation of a newborn at the borderline of viability. In their ethics education, beneficence would mean acting first to save a life. If the patient or surrogate makes an informed decision to the contrary, a beneficent physician respects that autonomous decision. In the case presented, the patient expressed gratitude to the cardiologist when extubated. But what if he had expressed anger at the physician for violating his autonomy? There are those who could argue that not only was intubation ethically wrong but that the cardiologist put himself in legal jeopardy by his actions (especially if there had been a written refusal applicable to the specific situation). In the example we use, we point out that the cardiologist may not have escaped a lawsuit if the patient had died without intubation. His family, when hearing the circumstances, may have sued for failure to act and dereliction of the cardiologist’s duty to save him. Beyond a potential legal challenge for either action or inaction, there is an overriding ethical question the cardiologist had to address: what course would be most satisfying to his conscience? Would he rather allow a patient to die for fear of recrimination, or act to save his life, regardless of the personal consequences? In the absence of real knowledge about the patient’s considered wishes, it is most reasonable to err on the side of promoting patient well-being. A physician’s commitment to beneficence is not necessarily a way of undermining a patient’s autonomy. In acting for the patient's good, physicians are also acting on what it is reasonable to believe a patient (or most patients, perhaps) would want, which is obviously connected to what a patient does want. Pellegrino and Thomasma argue that beneficence includes respect for a patient’s autonomy since “the best interests of the patient are intimately linked with their preferences.”[17] Instead of conceptualizing ethical dilemmas in medicine as conflicts between autonomy and beneficence, it is possible that medical schools could teach students that truly practicing beneficence is a way of valuing patient autonomy, especially when the patient’s wishes are not specific to the situation and are not clearly expressed. CONCLUSION It is important for students and practicing physicians to understand the principle of respect for patient autonomy in a pluralistic society that demands personal self-determination. However, the role of the physician as a beneficent healer should not be diminished by this respect for autonomy. Respecting a patient’s autonomy is grounded in and manifested by physician beneficence.[18] That is, seeking what is good for the patient can only be good if it respects their personhood and dignity. We propose that a commitment to beneficence, incipient in young medical students, should be developed over time with their other clinical reasoning skills. Such a commitment need not be sacrificed on the altar of patient autonomy. Beneficence needs greater relative moral weight with students as they proceed in their ethics education. - [1] S. Jauhar, “When Doctors Need to Lie,” New York Times, February 22, 2014, https://www.nytimes.com/2014/02/23/opinion/sunday/when-doctors-need-to-lie.html. [2] T. L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019). [3] Louise A. Mitchell, “Major Changes in Principles of Biomedical Ethics,” The National Catholic Bioethics Quarterly 14, no. 3 (2014): 459–75, https://doi.org/10.5840/ncbq20141438. [4] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019), 238. [5] Beauchamp and Childress, 103. [6] Beauchamp and Childress, p. 108. [7] For other accounts that prioritize autonomy, see e.g. Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of Surrogate Decision Making (Cambridge University Press, 1989), 38–39; R Gillon, “Ethics Needs Principles—Four Can Encompass the Rest—and Respect for Autonomy Should Be ‘First among Equals,’” Journal of Medical Ethics 29, no. 5 (October 2003): 307–12, https://doi.org/10.1136/jme.29.5.307. For examples of critiques of these accounts, see footnote 9. [8] P. R. Wolpe, “The Triumph of Autonomy in American Bioethics: A Sociological View,” in Bioethics and Society: Constructing the Ethical Enterprise, p. 43. [9] V. A. Entwistle et al., “Supporting Patient Autonomy: The Importance of Clinician-Patient Relationships,” Journal of General Internal Medicine 25, no. 7 (July 2010): 741–45; C. Foster, Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law, 1st ed. (Oxford ; Hart Publishing, 2009); O. O’Neill, Autonomy and Trust in Bioethics, The Gifford Lectures, University of Edinburgh 2001 (Cambridge, UK: Cambridge University Press, 2002). [10] P. Marshall and B. Koenig, “Accounting for Culture in a Globalized Bioethics,” The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics 32, no. 2 (2004): 252–66; R. Fan, “Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy,” Bioethics 11, no. 3–4 (1997): 309–22. [11] Arguments stressing the importance of beneficence, as ours does here, certainly approach paternalistic arguments. We set aside the complex issue of paternalism for purposes of this paper and simply note that the principle of beneficence as such does not say anything specifically about acting against the patient’s will. In the case study that focuses this paper, we do not believe the patient’s will or wishes were clearly indicated. [12] Beauchamp and Childress, Principles of Biomedical Ethics, p. 20, see note 2 above. [13] H. S. Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 25, no. 3 (January 1, 2000): 285–307, p. 287. [14] H. D. Braude, Intuition in Medicine a Philosophical Defense of Clinical Reasoning (Chicago ; University of Chicago Press, 2012). [15] R. Kukla, “Conscientious Autonomy: Displacing Decisions in Health Care,” The Hastings Center Report 35, no. 2 (2005): 34–44. [16] M. Schermer, The Different Faces of Autonomy: Patient Autonomy in Ethical Theory and Hospital Practice, vol. 13, Library of Ethics and Applied Philosophy (Dordrecht: Springer Netherlands, 2002). [17] E. D. Pellegrino and D. C. Thomasma, For the Patient’s Good - the Restoration of Beneficence in Health Care (New York, NY: Oxford University Press, 1988), p. 29. [18] Pellegrino and Thomasma, For the Patient’s Good. 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This paper is based on a semantic foundation of quantum logic which makes use of dialog-games. In the first part of the paper the dialogic method is introduced and under the conditions of quantum mechanical measurements the rules of a dialog-game about quantum mechanical propositions are established. In the second part of the paper the quantum mechanical dialog-game is replaced by a calculus of quantum logic. As the main part of the paper we show that the calculus of quantum logic (...) is complete and consistent with respect to the dialogic semantics. Since the dialoggame does not involve the 'excluded middle' the calculus represents a calculus of effective (intuitionistic) quantum logic. In a forthcoming paper it is shown that this calculus is equivalent to a calculus of sequents and more interestingly to a calculus of propositions. With the addition of the 'excluded middle' the latter calculus is a model for the lattice of subspaces of a Hilbert space. (shrink)