In this article, we analyse the novel case of Phoenix, a non-binary adult requesting ongoing puberty suppression to permanently prevent the development of secondary sex characteristics, as a way of affirming their gender identity. We argue that the aim of OPS is consistent with the proper goals of medicine to promote well-being, and therefore could ethically be offered to non-binary adults in principle; there are additional equity-based reasons to offer OPS to non-binary adults as a group; and the ethical defensibility (...) of facilitating individual requests for OPS from non-binary adults also depends on other relevant considerations, including the balance of potential benefits over harms for that specific patient, and whether the patient’s request is substantially autonomous. Although the broadly principlist ethical approach we take can be used to analyse other cases of non-binary adults requesting OPS apart from the case we evaluate, we highlight that the outcome will necessarily depend on the individual’s context and values. However, such clinical provision of OPS should ideally be within the context of a properly designed research study with long-term follow-up and open publication of results. (shrink)

The sacred or holy is central to Heidegger’s later writings, “The Thing” and “Building Dwelling Thinking” taking it as their focus. This aspect of his philosophy is often viewed as lacking in coherence1 or an attempt to return to Ancient Greek religion.2 Heideggerian notions of the gods or the sacred have frequently been dismissed or neglected, with even sympathetic commentators like Julian Young playing down their importance.Heidegger’s later thought, however, represents one of the most radical attempts to critically rethink (...) divinity in Western thought, presenting the possibility of dialogue with the non-Western notions of divinity. Focusing on the Shinto notion of divinity,3 in this essay I will... (shrink)

This month's issue presents arguments on three longstanding ethical issues: prostitution, euthanasia and organ donation. It also addresses three issues perhaps more directly linked to daily practice across clinical care and research: resource allocation, consent, and, in an interesting pair of papers, how a clinician's own experiences might affect their ethical judgement and therefore clinical care.In a provocative article, Ole Martin Moen argues that our increasing acceptance of casual sex, that is, sexual encounters which do not involve an emotional connection, (...) render our assumption that prostitution is always harmful out of date. If one form of impersonal encounter is acceptable, then why not another? Naturally, prostitution involves some degree of risk of harm. However, he argues that many occupations we do accept are likewise risky, or are also subject to similar objections to prostitution. He allows there is one remaining harm, which is genuine today, but which is open to change: the legal and social stigma, which we impose on prostitution due to our mistaken beliefs .Our two invited commentators, Anderson and McDougall focus on the empirical evidence of harm. When a new drug is developed, a plausible theory as to its effects, mechanism and safety is required. We might test that in a computer model. But until it is tested in real life, we cannot know its real benefits or harms. The same might be true of ethical arguments. As McDougall says: "Moen presents a compelling argument that the exchange of sex for money need not be intrinsically harmful to the seller, but for the individuals actually involved in prostitution, does this conclusion really matter?"The reader might ask why a journal of medical ethics is publishing an article on prostitution. There are clearly potential and …. (shrink)

This paper asks whether we should accept a weakened version of the truthmaker principle: namely, the claim that truth supervenes on being, in which 'being' is understood as whether things are. I consider a number of positive answers to this question, including the following: that the truthmaker principle is a requirement of any plausible explanation of truth; that the principle must be accepted, if we are to do justice to the Wittgensteinian insight that the world is the totality of facts, (...) not of things; and that the correctness of the principle is a necessary condition of a realist metaphysics. In my view, none of these attempts to motivate the truthmaker principle is satisfactory. (shrink)

Artificial intelligence (AI) is increasingly being developed for use in medicine, including for diagnosis and in treatment decision making. The use of AI in medical treatment raises many ethical issues that are yet to be explored in depth by bioethicists. In this paper, I focus specifically on the relationship between the ethical ideal of shared decision making and AI systems that generate treatment recommendations, using the example of IBM’s Watson for Oncology. I argue that use of this type of system (...) creates both important risks and significant opportunities for promoting shared decision making. If value judgements are fixed and covert in AI systems, then we risk a shift back to more paternalistic medical care. However, if designed and used in an ethically informed way, AI could offer a potentially powerful way of supporting shared decision making. It could be used to incorporate explicit value reflection, promoting patient autonomy. In the context of medical treatment, we need value-flexible AI that can both respond to the values and treatment goals of individual patients and support clinicians to engage in shared decision making. (shrink)

Drawing on a wide range of Kant's recorded thought beyond his Groundwork for the Metaphysics of Morals, this essay presents an overview of Kant's account of practical agency as embodied practical agency and argues against the intellectualized interpretations of Kant's account of practical agency presented by Christine Korsgaard and Henry Sidgwick. In both Kant's empirical-psychological and metaphysical descriptions of practical agency, he presents a recognizably human practical agent that is broader and deeper than the faculty of reason alone. This agent (...) chooses action from a reflective distance, but not from the complete affective distance of reason. We choose neither as reason alone, nor even as the sum of all of our ‘higher’ faculties, of cognition (including reason), feeling, and desire, in Kant's view. Instead, we choose as an agent that also has ‘lower’, ‘sensible’ faculties, of cognition (including sense), feeling, and desire, which together comprise our ‘sensibility’. These mental states of sensibility are not merely confused versions of our higher cognitions, feelings, or desires, and so different from them in degree only, but are instead distinct from our higher states in kind also; and these distinct sensible states are not dependent on our higher states and so on a commitment to the value of humanity, for example. For this reason, a choice in favour of sensible states and in opposition to the moral law need in no way undermine its own foundations and thus be incoherent, as Korsgaard and Sidgwick argue, but instead only immoral. Because Kant does not reduce the problem of immoral choice to one of insufficient reflection and ensuing confusion, he does not view moral progress in cognitive terms alone, whether in the form of a clearer understanding of the moral law, improved judgment in applying it, or deeper insight into our own nature as practical agents. Kant instead recognizes the crucial importance of cultivating our feelings and desires over the course of a lifetime both as a way to make ourselves worthy of the humanity within us directly and also as a way to facilitate future moral choices. (shrink)

In a recent paper, Robert Stecker proposes the following test for whether a value possessed by an artwork is artistic or not: ‘Does one need to understand the work to appreciate its being valuable in that way? If so, it is an artistic value. If not, it is not.’ An important question here is what Stecker means by ‘appreciation’ in this context. Stecker himself says little about this, but I offer him two accounts of the nature of appreciation, both of (...) which are suggested by remarks of his own. It turns out that Stecker’s proposed test is flawed on either understanding of ‘appreciation’. (shrink)

The recent interest in systematic review methods in bioethics has highlighted the need for greater transparency in all literature review processes undertaken in bioethics projects. In this article, I articulate features of a good bioethics literature review that does not aim to be systematic, but rather to capture and analyse the key ideas relevant to a research question. I call this a critical interpretive literature review. I begin by sketching and comparing three different types of literature review conducted in bioethics (...) scholarship. Then, drawing on Dixon-Wood's concept of critical interpretive synthesis, I put forward six features of a good critical interpretive literature review in bioethics: answering a research question, capturing the key ideas relevant to the research question, analysing the literature as a whole, generating theory, not excluding papers based on rigid quality assessment criteria, and reporting the search strategy. (shrink)

According to the free energy principle all living systems aim to minimise free energy in their sensory exchanges with the environment. Processes of free energy minimisation are thus ubiquitous in the biological world. Indeed it has been argued that even plants engage in free energy minimisation. Not all living things however feel alive. How then did the feeling of being alive get started? In line with the arguments of the phenomenologists, I will claim that every feeling must be felt by (...) someone. It must have mineness built into it if it is to feel a particular way. The question I take up in this paper asks how mineness might have arisen out of processes of free energy minimisation, given that many systems that keep themselves alive lack mineness. The hypothesis I develop in this paper is that the life of an organism can be seen as an inferential process. Every living system embodies a probability distribution conditioned on a model of the sensory, physiological, and morphological states that are highly probably given the life it leads and the niche it inhabits. I argue for an ecological and enactive interpretation of free energy. I show how once the life of an organism reaches a certain level of complexity mineness emerges as an intrinsic part of the process of life itself. (shrink)

According to Bertrand Russell, Nietzsche's only value is the flourishing of the exceptional individual. The well-being of ordinary people is, in itself, without value. Yet there are passages in Nietzsche that appear to regard the flourishing of the community as a whole alongside, perhaps even above, that of the exceptional individual. The ten essays that comprise this volume wrestle with the tension between individual and community in Nietzsche's writings. Some defend a reading close to Russell's. Others suggest that Nietzsche's highest (...) value is the flourishing of the community as a whole and that exceptional individuals find their highest value only in promoting that flourishing. In viewing Nietzsche from the perspective of community, the essays also cast new light on other aspects of his philosophy, for instance, his ideal of scientific research and his philosophy of language. (shrink)

There has recently been interest in applying the techniques of systematic review to bioethics literature. In this paper, I identify the three models of systematic review proposed to date in bioethics: systematic reviews of empirical bioethics research, systematic reviews of normative bioethics literature, and systematic reviews of reasons. I argue that all three types yield information useful to scholarship in bioethics, yet they also face significant challenges particularly in relation to terminology and time. Drawing on my recent experience conducting a (...) systematic review, I suggest that complete comprehensiveness may not always be an appropriate goal of a literature review in bioethics, depending on the research question. In some cases, all the relevant ideas may be captured without capturing all the relevant literature. I conclude that systematic reviews in bioethics have an important role to play alongside the traditional broadbrush approach to reviewing literature in bioethics. (shrink)

This paper aims to provide a theoretical framework for explaining the subjective character of pain experience in terms of what we will call ‘embodied predictive processing’. The predictive processing (PP) theory is a family of views that take perception, action, emotion and cognition to all work together in the service of prediction error minimisation. In this paper we propose an embodied perspective on the PP theory we call the ‘embodied predictive processing (EPP) theory. The EPP theory proposes to explain pain (...) in terms of processes distributed across the whole body. The prediction error minimising system that generates pain experience comprises the immune system, the endocrine system, and the autonomic system in continuous causal interaction with pathways spread across the whole neural axis. We will argue that these systems function in a coordinated and coherent manner as a single complex adaptive system to maintain homeostasis. This system, which we refer to as the neural-endocrine-immune (NEI) system, maintains homeostasis through the process of prediction error minimisation. We go on to propose a view of the NEI ensemble as a multiscale nesting of Markov blankets that integrates the smallest scale of the cell to the largest scale of the embodied person in pain. We set out to show how the EPP theory can make sense of how pain experience could be neurobiologically constituted. We take it to be a constraint on the adequacy of a scientific explanation of subjectivity of pain experience that it makes it intelligible how pain can simultaneously be a local sensing of the body, and, at the same time, a more global, all-encompassing attitude towards the environment. Our aim in what follows is to show how the EPP theory can meet this constraint. (shrink)

The feeling of the sublime is, says Kant, the bitter-sweet combination of fear and utter security that one experiences in the face of, for instance, the night sky or the raging torrent. Fear of what? Fear of - this, I suggest, was Kant's seminal insight - death. But how can these feelings co-exist? Surely the one cancels the other out? Schopenhauer's great insight, I argue, was that the explanation of the sublime requires a division of the personality into two - (...) a threatened self and an unthreatened one. The feeling of "being safe whatever happens" comes from a primary identification with the individual-transcending self. The trouble, however, with Schopenhauer's account is that, based as it is on his version of idealism, it represents the entire world of nature as being absorbed into the content of the transcendent subject's consciousness. This makes the feeling of the sublime a kind of egoism, a contraction of the vastness of nature into the content of "my" consciousness. And this gets things precisely wrong, I suggest, since the feeling of the sublime is, in truth, an "oceanic" feeling, an expansion of the self into the vastness of being. What this shows, I conclude, is that to understand the sublime we actually need not idealism but a kind of realism; specifically, Heidegger's, as I call it, "magic" realism. (shrink)

Clinical ethics has been developing in paediatric healthcare for several decades. However, information about how paediatricians use clinical ethics case consultation services is extremely limited. In this project, we analysed a large set of case records from the clinical ethics service of one paediatric hospital in Australia. We applied a paediatric-specific typology to the case referrals, based on the triadic doctor–patient–parent relationship. We reviewed the 184 cases referred to the service in the period 2005–2014, noting features including the type of (...) case, the referring department(s) and the patient9s age at referral. The two most common types of referral involved clinician uncertainty about the appropriate care pathway for the child (26% of total referrals) and situations where the child9s parents disagreed with the doctors’ recommendations for the child9s care (22% of total referrals). Referrals came from 28 different departments. Cancer, cardiology/cardiac surgery and general medicine referred the highest numbers of cases. The most common patient age groups were children under 1, and 14–15 years old. For three controversial areas of paediatric healthcare, clinicians had initiated processes of routine review of cases by the clinical ethics service. These insights into the way in which one very active paediatric clinical ethics service is used further our understanding of the work of paediatric clinical ethics, particularly the kinds of ethically challenging cases that paediatricians view as appropriate to refer for clinical ethics support. (shrink)

Models for clinical ethics case consultation often make reference to ‘balancing’ or ‘weighing’ moral considerations, without further detail. In this paper, we investigate balancing in clinical ethics case consultation. We suggest that, while clinical ethics services cannot resolve ongoing deep philosophical debates about the nature of ethical reasoning, clinical ethicists can and should be more systematic and transparent when balancing considerations in case consultations. We conceptualise balancing on a spectrum from intuitive to deliberative, and argue that good balancing in case (...) consultation involves articulating reasons for giving something more or less weight. We develop a framework of four practical strategies for better balancing in clinical ethics case consultation: intuitions as a launchpad, drilling down, pairwise comparison and group deliberation. (shrink)

In The Gift Relationship, Richard Titmuss argued that the practice of altruistic blood donation fosters social solidarity while markets in blood erode it. This paper considers the implications of this line of argument for the organ market debate. I defend Titmuss’ arguments against a number of criticisms and respond to claims that Titmuss’ work is not relevant to the context of live donor organ transplantation. I conclude that Titmuss’ arguments are more resilient than many advocates of organ markets suggest, and (...) more relevant to the debate than is commonly appreciated. (shrink)

Two definitions of Mach’s principle are proposed. Both are related to gauge theory, are universal in scope and amount to formulations of causality that take into account the relational nature of position, time, and size. One of them leads directly to general relativity and may have relevance to the problem of creating a quantum theory of gravity.

This paper argues that doctors' ethical challenges can be usefully conceptualised as role virtue conflicts. The hospital environment requires doctors to be simultaneously good doctors, good team members, good learners and good employees. I articulate a possible set of role virtues for each of these four roles, as a basis for a virtue ethics approach to analysing doctors' ethical challenges. Using one junior doctor's story, I argue that understanding doctors' ethical challenges as role virtue conflicts enables recognition of important moral (...) considerations that are overlooked by other approaches to ethical analysis. (shrink)

Machine learning-driven decision support systems (ML_CDSS) are poised for increasing presence and influence in clinical contexts. Salloch and Eriksen (2024) make two key arguments, that together bu...

Suppose that Eleanor is drowsy. Truth's asymmetry is illustrated by the following fact: while we accept that <Eleanor is drowsy> is true because Eleanor is drowsy, we do not accept that Eleanor is drowsy because <Eleanor is drowsy> is true. This asymmetry requires an explanation, but it has been alleged, notably by David Liggins, that the minimalist about truth cannot provide one. This paper counteracts this pessimism by arguing that the minimalist can successfully explain the asymmetry conceptually, rather than metaphysically. (...) It then goes on to defend this account against objections, in the end concluding that explaining truth's asymmetry is no problem for the minimalist. (shrink)

This richly detailed biography captures both the personal life and the scientific career of Isaac Newton, presenting a fully rounded picture of Newton the man, the scientist, the philosopher, the theologian, and the public figure. Professor Westall treats all aspects of Newton's career, but his account centers on a full description of Newton's achievements in science. Thus the core of the work describes the development of the calculus, the experimentation that altered the direction of the science of optics, and especially (...) the investigations in celestial dynamics that led to the law of universal gravitation. (shrink)

Genomic research can reveal ‘unsolicited’ or ‘incidental’ findings that are of potential health or reproductive significance to participants. It is widely thought that researchers have a moral obligation, grounded in the duty of easy rescue, to return certain kinds of unsolicited findings to research participants. It is less widely thought that researchers have a moral obligation to actively look for health-related findings. This paper examines whether there is a moral obligation, grounded in the duty of easy rescue, to actively hunt (...) for genomic secondary findings. We begin by showing how the duty to disclose individual research findings can be grounded in the duty of easy rescue. Next, we describe a parallel moral duty, also grounded in the duty of easy rescue, to actively hunt for such information. We then consider six possible objections to our argument, each of which we find unsuccessful. Some of these objections provide reason to limit the scope of the duty to look for secondary findings, but none provide reason to reject this duty outright. We argue that under a certain range of circumstances, researchers are morally required to hunt for these kinds of secondary findings. Although these circumstances may not currently obtain, genomic researchers will likely acquire an obligation to hunt for secondary findings as the field of genomics continues to evolve. (shrink)

Alderson critiques our recent book on the basis that it overlooks children’s own views about their medical treatment. In this response, we discuss the complexity of the paediatric clinical context and the value of diverse approaches to investigating paediatric ethics. Our book focuses on a specific problem: entrenched disagreements between doctors and parents about a child’s medical treatment in the context of a paediatric hospital. As clinical ethicists, our research question arose from clinicians’ concerns in practice: What should a clinician (...) do when he or she thinks that parents are choosing a treatment pathway that does not serve the child’s best interests? Alderson’s work, in contrast, focuses on the much broader issue of children’s role in decision-making about treatment and research. We argue that these different types of work are zooming in on different aspects of paediatric ethics, with its complex mix of agents, issues and relationships. Paediatric ethics overall needs a rich mix of approaches,... (shrink)

According to recent empirical research (Transparency International, 2013), nearly 15% of people worldwide admitted to having paid a bribe in an educational setting. Given the nature of corruption,...

Nietzsche writes that the 'real task' of The Birth of Tragedy is to 'solve the puzzle of Wagner's relation to Greek tragedy'. The 'puzzle', I suggest, is the intermingling in his art and writings of earlier socialist optimism with later Schopenhauerian pessimism. According to the former the function of the 'rebirth of Greek tragedy' in the 'collective artwork' is to 'collect', and so create, community. According to the second the function of the artwork is to intimate a realm 'beyond' this (...) world of pain and death. The audacity of The Birth is that it attempts to show that Wagner can have his cake and eat it: the 'Dionysian', musical, element provides a 'metaphysical comfort', while the 'Apollonian', verbal, element draws a 'veil of oblivion' over the metaphysical, thereby allowing the artwork to solidify community. Contrary to the standard Anglophone view, this perspective on The Birth shows that Nietzsche's intimate association with Wagner during the period of its creation lies at the heart of its philosophical content. (shrink)

In their account of the value of parental permission, Navin and Wasserman see families as “collective agents” who “form identities” and have interests as a “family unit” that sometimes justify subo...

El objetivo de este texto es una aproximación teórica de la infancia en las principales concepciones de la filosofía occidental, la nueva historia social de la infancia en el continente y las principales poéticas estéticas del cine latinoamericano durante la segunda mitad del siglo XX. Para este propósito se analizan las nociones de la infancia desde trabajos con un enfoque histórico-hermenéutico, de análisis crítico de discurso y evaluación de las nociones con base en los aportes de los campos teóricos abordados. (...) Estos cruces permiten pensar los lugares de la infancia como instrumento para lograr un sueño político, las concepciones del tiempo, los derechos liberales de la Ilustración, y el acontecimiento fenomenológico. El fin de esta revisión crítica es un llamado a tejer líneas de fuga de la historia, a recrear mecanismos de resistencia audiovisual que apueste por una estética imperfecta, que desdibuje herencias, que marque procesos sociales en los que la infancia tenga una voz auténtica. Al enfocar la imagen de la infancia resulta crucial que el cine, más allá de mostrar realidades fácticas concretas, tenga un margen de ficción que aprovecha para darnos una poética sentimental de las infancias olvidadas y reinventar la estetización de las nuevas infancias en re-existencias autónomas desde la pluralidad de miradas del continente. (shrink)

Este ensayo se ocupa del tratamiento dado por René Descartes al descubrimiento de la circulación de la sangre hecho por William Harvey y sus diferencias respecto al papel del corazón en este proceso. Tomando distancia de la interpretación tradicional de la controversia, se concluye que, si bien Harvey fue un declarado aristotélico y Descartes un filósofo de estirpe materialista, los postulados de este último exhiben varios prejuicios escolásticos y una fuerte carga teórica en las observaciones. Por el contrario, la propuesta (...) de Harvey, aunque inspirada en el Estagirita, termina librando a la fisiología de consideraciones propias del pensamiento de Aristóteles. (shrink)

In their analysis of the eligibility criteria for assisted dying in Canada, Downie and Schuklenk put forward a strong argument for the ethical defensibility of including mental illnesses and disabilities as underlying conditions driving a person’s request for assisted dying.1 In this commentary, we add a view on these debates from our home state of Victoria, Australia, where voluntary assisted dying has been legal since June 2019. We highlight the more conservative approach to eligibility in our setting compared with Canada, (...) and argue for debates about eligibility criteria to be conceptualised as part of a broader discussion about access to assisted dying that includes clinicians’ roles and perspectives. In our view, clinicians’ perspectives may have a significant impact on individuals’ ability to access assisted dying, regardless of legislative or other changes made to any system. ‘Voluntary assisted dying’ is the terminology used in our context, rather than Medical Assistance in Dying, so we will use that term when referring to the Victorian system. There are several key differences between the Canadian and Victorian approaches that are important in relation to the debates addressed by Downie and Schuklenk. First, the emphasis in Victoria is on patient self-administration of the VAD …. (shrink)

The idea that an individual has a ‘right not to know’ genetic information about himself or herself is entrenched in both the policy sphere and the genetic counselling ethos. In this paper, I interrogate this idea of a ‘right not to know’, questioning particularly its status as a right. I identify the conception of rights that seems to underlie the posited ‘right not to know’ as a conception of rights in which they are prioritised non-outweighable interests. Turning to a series (...) of hypothetical situations in which the ‘right not to know’ is invoked, I argue that the ‘right not to know’ is not a right consistent with such a conception. The ‘right not to know’ can only exist in a framework of rights in which they lack significant moral weight. Thus, considering the gravity of rights in popular understanding, I suggest caution in the continuing use of the phrase ‘right not to know’ in the context of genetic testing. This investigation suggests that structuring the debate around genetic ignorance in terms of the ‘right not to know’ is not conducive to moving forward ethical thinking in this area. (shrink)

Citizenship is a multiform concept that still needs to be cleared. This is necessary because various authors try to understand this concept so that they can define the future model of European citizenship. If there exist different forms of citizenship, one of the tasks of investigation is to determine reasons for these differences. This article redraws the history of this current thoughts in a comparative perspective to be able to deal with its meaning in the context of the European construction. (...) This attitude obliges us to mark out the different contextual models white showing consideration for the real historical and political situations. (shrink)