In the “Appendix” to the Treatise, Hume claims that he has discovered a “very considerable” mistake in his earlier discussion of the self. Hume's expression of the problem is notoriously opaque, leading to a vast scholarly debate as to exactly what problem he identified in his earlier account of the self. I propose a new solution to this interpretive puzzle. I argue that a tension generated by Hume's conceptual skepticism about real “principles of union” and his account of fictions of (...) the imagination is the defect identified in the “Appendix.”. (shrink)

Tort and contract law have not kept pace with the stunning changes in medicine's economics. Physicians are still expected to deliver the same standard of care to everyone, regardless whether it is paid for. Health plans increasingly face liability for unfortunate outcomes, even those stemming from society's mandate to keep costs down while improving population health. This book sorts through the chaos. After reviewing the inadequacies of current tort and contract law, Morreim proposes that an intelligent assignment of legal (...) liability must rest on an intelligent division of labor between health plans and providers, beginning with the question "who should be doing what, for the best delivery of health care." She also provides a comprehensive reference source of case law, commentary, and empirical literature. (shrink)

As managed care organizations provide an increasing proportion of citizens' health care, the move toward asking individuals to help control costs by taking more responsibility for their health is likely to intensify. Economic, medical, and legal responses to lifestyle‐induced health care costs raise concerns as well as possibilities for using resources responsibly.

Traditional medical approaches to moral issues found in the clinical setting can, if properly understood, enlighten our philosophical understanding of moral issues. Moral problem-solving, as distinct from ethical and metaethical theorizing, requires that one reckon with practical complexities and uncertainties. In this setting the quality of one's answer depends not so much upon its content as upon the quality of reasoning which supports it. As the discipline which especially focuses upon the attributes of good-quality reasoning, philosophy therefore has much to (...) contribute to the clinical enterprise of moral (and medical) problem-solving. (shrink)

Many major medical institutions have now embraced the idea that it is best to be honest with patients and families when an error causes harm that could have been avoided. This kind of disclosure improves patient safety and quality of care; enhances satisfaction for patients, families, and providers; and reduces malpractice litigation costs. The University of Michigan has perhaps the best‐known program. Since 2001, that institution has seen more than a 55 percent drop in the number of new malpractice claims (...) filed, a comparable reduction in lawsuits, and a dramatic drop in both defense costs and malpractice payouts—money then redirected toward quality improvement. A few states have also embraced this approach, sometimes known as “Candor” (for “communication and optimal resolution”). Yet all of these efforts face a major challenge. Although many physicians would like very much to achieve insight, reconciliation, and quality improvement in just this way, many fear that money paid to resolve an incident in which they were involved can result in a lifelong black mark in the National Practitioner Data Bank. (shrink)

In response to rapidly rising health care costs in the United States, federal and state governments and private industry are instituting numerous and diverse cost-containment plans. As devices for coping with a scarcity of resources, such plans present serious challenges to physicians' traditional single-minded devotion to patient welfare. Those which contain costs by directly limiting medical options or by controlling physicians' daily clinical decisions can threaten the quality of medical care by allowing economic authorities to make essentially medical judgments. In (...) contrast, other plans coax compliance by arranging incentives, e.g., offering financial rewards for successful cost containment. While they allow for clinical freedom, these plans create conflicts between physicians' fiduciary obligations to their patients and the competing interests of the payers. Such conflicts arise as physicians try to work within governmental or corporate cost containment policies, and also as they attempt to streamline clinical efficiency. Throughout, issues of justice emerge as physicians seek to reconcile their own patients' claims upon limited common resources with others' equally legitimate claims. (shrink)

To provide effective care physicians must attend, not just to medical issues, but also to the social determinants of health — racial factors, food insecurity, housing instability, transportation barriers and beyond. Social determinants also include a largely underrecognized dimension: legal vulnerabilities such as rental evictions and debt adjudications. Yet rarely do medical trainees have an opportunity to witness legal vulnerabilities, firsthand.

Expounds on the ethical hazards of advertising cosmetic surgery. Impact of physician entrepreneurialism on the fiduciary concept of physician-patient relationship; Expectation on physician's non-abuse of superior position; Physician's responsibility to inform patient to enhance the latter's control over personal life and health care; Exacerbation of patient's vulnerability through misleading advertising.

It is such a treat and a privilege to have been at the “Defining Health Law for the Future” symposium and to have met Charity’s family. She was dear to me.

A new economic phenomenon, in which physicians refer their patients to ancillary facilities of which they themselves are owners or substantial investors, presents a ‘laboratory’ for assessing philosophers' potential contributions to public policy issues. In this particular controversy, ‘prohibitionists’ who wish to ban all such self-referral focus on the dangers that patients and payers may receive or be billed for unnecessary or poor-quality care. ‘Laissez-fairists’, in contrast, argue that self-referral should be freely permitted, with a reliance on personal ethics and (...) internal professional monitoring to guard against abuse. Undue government regulation, they argue, infringes providers' and patients' economic freedom, and stifles the competition that can yield better quality care at lower prices. As this debate features basic values and large amounts of money, it has been marked by rancorous rhetoric, shallow argument, and muddled reasoning. The philosopher's first contribution, therefore, is to expose simplistic and fallacious arguments, whether empirical, conceptual, moral, or legal. Beyond this, the philosopher can help to identify the important values at stake and, perhaps, to identify resolutions that honor those values better than the more simplistic answers proffered previously. For abusive self-referral, as distinguished from kickbacks, the author recommends that civil remedies be favored over criminal prohibitions. She suggests that the doctrine of ‘bad faith breach of contract’ might appropriately be extended into this new area to provide a powerful means by which aggrieved patients and payers can hold physicians personally accountable for abusive self-referrals. Keywords: bad faith breach of contract, civil law, criminal law, self-referral, simplistic reasoning CiteULike Connotea Del.icio.us What's this? (shrink)

Conflicts in the clinical setting can spiral downward with remarkable speed, as parties become ever more incensed and entrenched in their positions. Productive conversations seem unlikely at best. Nevertheless, such situations can sometimes be turned into collaborative problem solving with equally remarkable speed. For this to happen, those providing conflict-resolution services such as mediation need to bring, not just a set of skills, but also some key norms: the process must be voluntary for all; the mediator must abjure giving advice (...) or taking sides, and must honor the privacy of privately offered thoughts. This article describes a conflict that had reached the point of a hospital’s requesting judicial coercion. However, a conflict-resolution process was then initiated that, in the end, led to amicable resolution and mended relationships, obviating the need for court orders. This article describes that conflict and the resolution process in detail, along the way annotating specific strategies that are often highly effective. (shrink)

The ongoing economic overhaul of medicine creates two basic imperatives – boosting profits and containing costs – that pose special ethical and philosophical challenges for psychiatry. Because insurance coverage still favors inpatient care, pressures to raise renevues translate into a corresponding pressure on psychiatry as a whole to expand its diagnostic categories, and on individual psychiatrists to ascribe these diagnoses liberally and to hospitalize as many patients as possible. Reciprocally, cost containment requires all physicians to justify their care as clearly (...) as possible and to eliminate those interventions that are not of demonstrable value. Scientific outcome studies are markedly more difficult in psychiatry than elsewhere in medicine, particularly for psychotherapeutic as opposed to pharmacologic modes of care. An emphasis on biological over psychological conceptions of mental illness and treatment might result, not because it is more likely to be correct, but because it is easier to document in conventional ways and less expensive to deliver. An economicsdriven reorganization of psychiatry therefore poses serious philosophical challenges, not only for the profession and its future, but for the clinical care of patients. Keywords: cost containment, epistemology, ethics, economics, metaphysics, psychiatry CiteULike Connotea Del.icio.us What's this? (shrink)

Storchak, Ehlis, and Fallgatter provide an extensive literature review on electrophysiological measurements, which indicate that general predictive deficits in self‐monitoring are associated with various positive symptoms in patients with schizophrenia.

Book reviewed in this article: Balancing Act: The New Medical Ethics of Medicine's New Economics. By E. Haavi Morreim.

Human clinical research trials, by which corporations, universities, and research scientists bring new drugs, devices, and procedures into the practice and marketplace of medicine, have become a huge business. The National Institutes of Health doubled its spending over the past five years, while in the private sector the top twenty pharmaceutical companies have more than doubled their investment in research and development over a roughly comparable period. To date, some twenty million Americans have participated in clinical research trials that now (...) are as common in the private practice setting as in academia.For many years human clinical trials received relatively little public attention. In the wake of several well-publicized research abuses, Congress created in 1974 the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research to formulate recommendations to protect human research subjects. The Commission’s 1979 Belmont Report helped to guide the Institutional Review Boards that review the ethics of federally funded research. (shrink)

That Socrates took himself to possess a divine sign is well attested by ancient sources. Both Plato and Xenophon mention Socrates’ daimonion on numerous occasions. What is problematic for contemporary scholars is that Socrates unfailingly obeys the warnings of his sign. Scholars have worried that Socrates seems to ascribe greater epistemic authority to his sign than his own critical reasoning. Moreover, he never so much as questions the authority of his sign to guide his actions, much less its divine nature. (...) Socrates’ unquestioning obedience to his sign thus appears to be in conflict with another of Socrates’ defining characteristics: namely, his relentless rationality. However, Socrates does not seem to recognize such inconsistency. The problem of the daimonion, then, is this: is Socrates’ professed commitment to rationality consistent with his unquestioning deference to his daimonion’s warnings? And if so, how? In this paper, I first discuss several solutions to the problem of the daimonion. I aim to show that none of the accounts of Socrates’ sign that have appeared in the scholarly literature are adequate. I then propose a new account of the daimonion, which, I argue, secures the rationality of Socrates’ obedience to his divine sign. (shrink)

Confucian education is best captured by the programme described in the Great Learning. Education is presented first as the process of self-cultivation for the sake of developing virtuous character. Self-cultivation then allows for virtue to be cultivated in the familial, social and international dimensions. My central thesis is that Confucianism can serve as a universal framework of educating people for the common good in its promotion of personal cultivation for the sake of human progress. On this account the common good (...) specifically refers to the social order accomplished by the virtuous behaviour found in the members of society. In this paper I argue that the Confucian notion of “lesser learning” sheds light on the concept of general education and the notion of “greater learning” improves our understanding of liberal education. Under this analysis the necessity of general education is assured although its importance should not be overly exaggerated. Furthermore, the objectives of liberal education deserve greater emphasis due to their historical importance and enduring relevance to promoting the common good of universal humanity. (shrink)

As they struggle to maintain high‐quality health care in the face of new economic limitations, physicians should not endanger their relationships with patients. But they should collectively revise the informal protocols that guide clinical decision making.

This paper aims to clarify Locke’s distinction between simple and complex ideas. I argue that Locke accepts what I call the “compositional criterion of simplicity.” According to this criterion, an idea is simple just in case it does not have another idea as a proper part. This criterion is prima facie inconsistent with Locke’s view that there are simple ideas of extension. This objection was presented to Locke by his French translator, Pierre Coste, on behalf of Jean Barbeyrac. Locke responded (...) to Barbeyrac’s objection, but his response, along with a passage from Chapter XV of Book II of the Essay, “Of Duration and Expansion, considered together,” has been taken to show that he did not accept the compositional criterion. I examine these passages and argue that they are not in tension with but rather affirm that criterion. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Hume on the Self and Personal Identity ed. by Dan O’BrienBridger EhliDan O’Brien, ed. Hume on the Self and Personal Identity. Cham: Palgrave Macmillan, 2022. Pp. xxiv + 321. Softcover. ISBN: 9783031042751. $129.99This is an engaging collection of essays on a central topic in Hume’s philosophy. Perhaps Hume’s best-known contribution to the philosophy of the self is his denial, in section 1.4.6 of the Treatise, “Of personal identity,” (...) of the existence of a simple, enduring self that is accessible by reflection. But as his distinction between personal identity “as it regards our thought or imagination” and personal identity “as it regards our passions or the concern we take for ourselves” suggests, he has more to say about the self and personal identity than the skeptical doctrines presented in T 1.4.6 (T 1.4.6.5). One virtue of the collection is that it strives to capture the breadth and complexity of Hume’s thinking about the self.The collection, which focuses primarily on the Treatise, is divided into three parts. The essays in Part 1 consider Book 1 and the Appendix. Andrew Ward’s “How Sceptical is Hume’s Theory of Personal Identity?” argues for the provocative thesis that Hume’s intention in the Appendix is not to express dissatisfaction with either his metaphysics of the self or his psychological explanation of ascriptions of identity and simplicity to the self. According to Ward, Hume’s aim is rather to “clarify and strengthen his sceptical position” by reinforcing his rejection of realist accounts of personal identity (13). To my mind, Ward does not adequately address the textual evidence that has led other commentators to believe that the Appendix identifies a defect in T 1.4.6’s discussion of the self, such as Hume’s complaint that he does not “know how to correct [his] former opinions, nor how to render them consistent” (T App 10).Donald Ainslie’s “Hume’s Bundle” is also chiefly concerned with the interpretation of the Appendix. Ainslie has defended an influential reading according to which Hume’s problem in the Appendix concerns his psychological explanation of ascriptions of unity to the self. Here, he argues against interpretations according to which Hume’s problem concerns his metaphysical account of the self as a bundle of perceptions. According to Ainslie, Hume did not worry about how one’s perceptions come to be bundled together, because he treated the fact that perceptions come in distinct bundles as brute. This argument against the bundling interpretation seems less than decisive. At least some versions of that interpretation can be understood to hold that Hume’s problem in the Appendix arises from his being unable to answer a causal question: what is the cause of one’s perceptions’ being bundled together? In the “Letter from a Gentleman,” Hume suggests that the maxim according to which everything has a cause enjoys moral, albeit neither intuitive nor demonstrative, certainty [End Page 377] (LG 26). Insofar as he accepts this maxim, he would hold that the question of the cause of the bundling of one’s perceptions has an answer and, accordingly, that the bundling of one’s perceptions is not brute.The themes of Galen Strawson’s “What I Call Myself ” will be familiar to readers of his The Evident Connexion. Strawson argues against a traditional reading of Hume according to which he both holds that the self is nothing more than a bundle of perceptions and denies the existence of subjects of experience. Central to Straw-son’s case is what he calls the “Experience/Experiencer Thesis,” which says that the existence of an experience requires the existence of a subject of experience. Strawson takes Hume to endorse this “necessary truth” and, hence, to hold that no perception can exist without its being experienced by a subject (48). But there is a text that tells against Hume’s endorsing the Experience/Experiencer Thesis. In section 1.4.2, “Of scepticism with regard to the senses,” Hume argues that “the continu’d existence of... perceptions involves no contradiction” (T 1.4.2.40). Because what it is for perceptions... (shrink)

In wrongful life litigation a congenitally impaired child brings suit against those, usually physicians, whose negligence caused him to be born into his suffering existence. A key conceptual question is whether we can predicate harm in such cases. While a few courts have permitted it, many courts deny that we can, and thus have refused these children standing to sue. In this article the author examines the wrongful life cases and literature enroute to a broader consideration of harm. This literature, (...) and philosophical discussions of harm generally, rely on a definition which ascribes harm by comparing an individual's current condition with that in which he would otherwise have been, but for the allegedly harmful event. The author shows this definition to be conceptually and morally flawed. A superior general definition is offered which, when then applied to wrongful life cases, shows that we can easily ascribe harm in these cases and can find clear potential for tort liability. (shrink)

Responding to the failings of peers can be difficult, but as professionals physicians should not leave the moral management of errant colleagues to chance. Distinguishing levels of adverse outcomes helps physicians more clearly assess each others' conduct and respond appropriately to those who threaten the integrity of the profession.