ABSTRACT It is accepted that treatment of previously competent, now incompetent patients can be limited if that is what the patient would desire, if she were now competent. Expressed past preferences or an advance directive are often taken to constitute sufficient evidence of what a patient would now desire. I distinguish between desires and rational desires. I argue that for a desire to be an expression of a person's autonomy, it must be or satisfy that person's rational desires. A person (...) rationally desires a course of action if that person desires it while being in possession of all available relevant facts, without committing relevant error of logic, and “vividly imagining” what its consequences would be like for her. I argue that some competent, expressed desires obstruct autonomy. I show that several psychological mechanisms operate to prevent a person rationally evaluating what future life in a disabled state would be like. Rational evaluation is difficult. However, treatment limitation, if it is to respect autonomy, must be in accord with a patient's rational desires, and not merely her expressed desires. I illustrate the implications of these arguments for the use of advance directives and for the treatment of competent patients. (shrink)

In an article in this journal, Christopher Cowley argues that we have ‘misunderstood the special nature of medicine, and have misunderstood the motivations of the conscientious objectors’. We have not. It is Cowley who has misunderstood the role of personal values in the profession of medicine. We argue that there should be better protections for patients from doctors' personal values and there should be more severe restrictions on the right to conscientious objection, particularly in relation to assisted dying. We argue (...) that eligible patients could be guaranteed access to medical services that are subject to conscientious objections by: removing a right to conscientious objection; selecting candidates into relevant medical specialities or general practice who do not have objections; demonopolizing the provision of these services away from the medical profession. (shrink)

In order to prevent the rapid spread of COVID-19, governments have placed significant restrictions on liberty, including preventing all non-essential travel. These restrictions were justified on the basis the health system may be overwhelmed by COVID-19 cases and in order to prevent deaths. Governments are now considering how they may de-escalate these restrictions. This article argues that an appropriate approach may be to lift the general lockdown but implement selective isolation of the elderly. While this discriminates against the elderly, there (...) is a morally relevant difference—the elderly are far more likely to require hospitalisation and die than the rest of the population. If the aim is to ensure the health system is not overwhelmed and to reduce the death rate, preventing the elderly from contracting the virus may be an effective means of achieving this. The alternative is to continue to keep everyone in lockdown. It is argued that this is levelling down equality and is unethical. It suggests that in order for the elderly to avoid contracting the virus, the whole population should have their liberty deprived, even though the same result could be achieved by only restricting the liberty of the elderly. Similar arguments may also be applied to all groups at increased risk of COVID-19, such as men and those with comorbidities, the obese and people from ethnic minorities or socially deprived groups. This utilitarian concern must be balanced against other considerations, such as equality and justice, and the benefits gained from discriminating in these ways must be proportionately greater than the negative consequences of doing so. Such selective discrimination will be most justified when the liberty restriction to a group promotes the well-being of that group (apart from its wider social benefits). (shrink)

It may soon be possible to generate human organs inside of human-pig chimeras via a process called interspecies blastocyst complementation. This paper discusses what arguably the central ethical concern is raised by this potential source of transplantable organs: that farming human-pig chimeras for their organs risks perpetrating a serious moral wrong because the moral status of human-pig chimeras is uncertain, and potentially significant. Those who raise this concern usually take it to be unique to the creation of chimeric animals with (...) ‘humanised’ brains. In this paper, we show how that the same style of argument can be used to critique current uses of non-chimeric pigs in agriculture. This reveals an important tension between two common moral views: that farming human-pig chimeras for their organs is ethically concerning, and that farming non-chimeric pigs for food or research is ethically benign. At least one of these views stands in need of revision. (shrink)

If a doctor is trying to decide whether or not to provide a medical treatment, does it matter ethically whether that treatment has already been started? Health professionals sometimes find it harder to stop a treatment (withdraw) than to refrain from starting the treatment (withhold). But does that feeling correspond to an ethical difference? In this article, we defend equivalence—the view that withholding and withdrawal of treatment are ethically equivalent when all other factors are equal. We argue that preference for (...) withholding over withdrawal could represent a form of cognitive bias—withdrawal aversion. Nevertheless, we consider whether there could be circumstances in which there is a moral difference. We identify four examples of conditional nonequivalence. Finally, we reflect on the moral significance of diverging intuitions and the implications for policy. We propose a set of practical strategies for helping to reduce bias in end-of-life decision making, including the equivalence test. (shrink)

The smooth integration of the natural sciences with everyday lived experience is an important ambition of radical embodied cognitive science. In this paper we start from Koffka’s recommendation in his Principles of Gestalt Psychology that to realize this ambition psychology should be a “science of molar behaviour”. Molar behavior refers to the purposeful behaviour of the whole organism directed at an environment that is meaningfully structured for the animal. Koffka made a sharp distinction between the “behavioural environment” and the “geographical (...) environment”. We show how this distinction picks out the difference between the environment as perceived by an individual organism, and the shared publicly available environment. The ecological psychologist James Gibson was later critical of Koffka for inserting a private phenomenal reality in between animals and the shared environment. Gibson tried to make do with just the concept of affordances in his explanation of molar behaviour. We argue however that psychology as a science of molar behaviour will need to make appeal both to the concepts of shared publicly available affordances, and of the multiplicity of relevant affordances that invite an individual to act. A version of Koffka’s distinction between the two environments remains alive today in a distinction we have made between the field and landscape of affordances. Having distinguished the two environments, we go on to provide an account of how the two environments are related. Koffka suggested that the behavioural environment forms out of the causal interaction of the individual with a pre-existing, ready-made geographical environment. We argue that such an account of the relation between the two environments fails to do justice to the complex entanglement of the social with the material aspects of the geographical environment. To better account for this sociomaterial reality of the geographical environment, we propose a process-perspective on our distinction between the landscape and field of affordances. While the two environments can be conceptually distinguished, we argue they should also be viewed as standing in a relation of reciprocal and mutual dependence. (shrink)

Defending a procedural conception of global justice that calls for the establishment of reasonably democratic arrangements within and beyond the state, this book argues for a justice-based understanding of social development and justifies why a democracy-promoting international development practice is a requirement of global justice.

I argue that pregnant women have a duty to refrain from behaviours or to allow certain acts to be done to them for the sake of their foetus if the foetus has a reasonable chance of living and being in a harmed state if the woman does not refrain from those behaviours or allow those things to be done to her. There is a proviso: that her refraining from acting or allowing acts to be performed upon her does not significantly (...) harm her. This duty does not presuppose that the foetus is a person. It is grounded on principles of respect for the interests of sentient beings and prevention of harm to future individuals. I give an argument for a general duty of easy rescue. (shrink)

In the age of neoliberalism, feminists strongly disagree on the ideal legal status of prostitution while the pro-prostitution lobby endeavours to keep their male-dominated business running smoothly. Feminist debates should be concerned with the sex buyers' belief system about women, which is likely to have practical consequences in the way they behave with women (prostituted and non-prostituted) in terms of sexuality and, therefore, for feminist purposes of equality, on a broader scale. A Critical Discourse Analysis of buyer-authored online reviews of (...) prostituted women provides the opportunity to verify whether the relationship they establish with them is based on democratic mutual equality or gendered power relations driven by domination and subordination.En la era del neoliberalismo, no hay consenso entre las feministas acerca del estatus legal que debería tener la prostitución; mientras, el lobby pro-prostitución intenta proteger tan lucrativo negocio. Los debates feministas deben abordar críticamente el sistema de creencias de los sujetos prostituyentes, en tanto que afecta a cómo actúan con las mujeres (prostituidas y no prostituidas) dentro del marco de la sexualidad y, por tanto, al potencial logro de la igualdad fáctica a nivel social. El análisis crítico del discurso online de los sujetos prostituyentes sobre las mujeres prostituidas permite comprobar si las relaciones que establecen con ellas están basadas en términos igualitarios o en la dicotomía dominación-subordinación característica de las relaciones de poder de género. (shrink)

In her excellent and comprehensive article, Friesen argues that utilising personal responsibility in healthcare is problematic in several ways: it is difficult to ascribe responsibility to behaviour; there is a risk of prejudice and bias in deciding which behaviours a person should be held responsible for; it may be ineffective at reducing health costs. In this short commentary, I will elaborate the critique of personal responsibility in health but suggest one way in which it could be used ethically. In doing (...) so, I will introduce the concepts of reasonable risk and golden opportunity. I previously argued that it is both difficult to disentangle responsibility and that we risk prejudice and bias in singling out behaviours that are socially disapproved of.1 So I am sympathetic to Friesen’s concerns. I also discussed another way in which ascribing personal responsibility for health is problematic which Friesen does not discuss and which, in my view, is the most concerning and further supports her arguments. It represents a back door assault on liberalism and neutrality towards concepts of the good life. Even if one were to accurately and in an unbiased way divine the personal contribution to disease, the greatest problem would remain: those who voluntarily take on risk would be penalised. That is, such a system would be risk-averse. Those lives which avoided risk would be prioritised, while those who chose to take on risky activities in their conception of the good life would be penalised. Yet risk is necessary, both for the good life, and social progress. Columbus, Edmund Hilary, Florence Nightingale, Ernest Hemingway and countless monumental figures in human history took risks in order to achieve something great. Should we aim for a society of trembling, teetotalling health nuts? Surely that prospect is horrific. It is horrific because it elevates health …. (shrink)

Some of my colleagues will sadly not be attending the IAB World Congress in Qatar. Amongst other things, they wish to take a stand against Qatar’s human rights record and the treatment of women and...

Criminal behaviour is but one behavioural tendency for which a genetic influence has been suggested. Whilst this research certainly raises difficult ethical questions and is subject to scientific criticism, one recent research project suggests that for some families, criminal tendency might be predicted by genetics. In this paper, supposing this research is valid, we consider whether intervening in the criminal tendency of future children is ethically justifiable. We argue that, if avoidance of harm is a paramount consideration, such an intervention (...) is acceptable when genetic selection is employed instead of genetic enhancement. Moreover, other moral problems in avoiding having children with a tendency to criminal behaviour, such as the prospect of social discrimination, can also be overcome. (shrink)

We examine the philosophical and ethical issues associated with conjoined twins and their surgical separation. In cases in which there is an extensive sharing of organs, but nevertheless two distinguishable functioning brains, there are a number of philosophical and ethical challenges. This is because such conjoined twins: 1. give rise to puzzles concerning our identity, about whether we are identical to something psychological or biological;2. force us to decide whether what matters from an ethical point of view is the biological (...) life of our organisms or the existence of our consciousness or mind; 3. raise questions concerning when, if ever, it is morally acceptable to sacrifice one of us to save another;4. force us to reflect on the conditions for ownership of organs and the justification of removal of organs for transplantation which causes the death of the donor; 5. raise questions about who should take decisions about life-risking treatments when this cannot be decided by patients themselves.We examine and suggest answers to these questions. (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)

Examples of uniformly moving charge distributions that possess conserved electromagnetic stress tensors are exhibited. These constitute stable systems with covariantly characterized electromagnetic mass. This note, on a topic to which Paul Dirac made a significant contribution in 1938, is dedicated to him for his 80th birthday.

In Unreliability and Point of View in Filmic Narration, Emar Maier makes a distinction between reliable and unreliable narrators. The latter, Maier claims, must be a first-person narrator, as an impersonal, third-person narrator lacks an individual perspective that can be unreliable. He concludes that most film adaptations of unreliably narrated novels are not themselves unreliably narrated, for they feature third person perspectives. I take Maier’s major claims to be that there is a strict distinction between reliable and unreliable narration; and (...) that film shots displaying both a character and that character's hallucinations are not unreliable narration. I will challenge both. (shrink)

Here, a moral case is presented as to why sign languages such as Auslan should be made compulsory in general school curricula. Firstly, there are significant benefits that accrue to individuals from learning sign language. Secondly, sign language education is a matter of justice; the normalisation of sign language education and use would particularly benefit marginalised groups, such as those living with a communication disability. Finally, the integration of sign languages into the curricula would enable the flourishing of Deaf culture (...) and go some way to resolving the tensions that have arisen from the promotion of oralist education facilitated by technologies such as cochlear implants. There are important reasons to further pursue policy proposals regarding the prioritisation of sign language in school curricula. (shrink)

Hughes offers a consequentialist response to our rejection of accommodation of conscientious objection in medicine. We argue here that his compromise proposition has been tried in many jurisdictions and has failed to deliver unimpeded access to care for eligible patients. The compromise position, entailing an accommodation of conscientious objection provided there is unimpeded access, fails to grasp that the objectors are both determined not to provide services they object to as well as to subvert patient access to the objected to (...) services. Unpredictable future developments in drug R&D and resulting treatment and prevention options in medicine make the compromise position unrealistic. (shrink)

La última publicación de Antonio Rivera, El dios de los tiranos, es un archivo filosófico completo de las tentaciones del Estado de alcanzar una soberanía absoluta entre la Edad Media y Contemporánea. Su análisis de las doctrinas políticas fundamentales pone de manifiesto tres pasiones históricas —absolutismo, contrarrevolución y totalitarismo— culminadas en el nacionalsocialismo y en la transfiguración teórica de Carl Schmitt. La parte polémica con esta aportación demanda explicar cómo la secularización de ciertos conceptos políticos —representación, demos, soberanía del pueblo, (...) división de poderes...— en las democracias modernas exige lealtad, confianza o algún credo para la democracia liberal como contrapunto necesario de los absolutismos de todos los tiempos. (shrink)

ABSTRACT Isobel Ross rightly points out that providing information is not enough to guarantee that patients will choose the best course of action. She argues that to adequately protect patients’interests, we need practice guidelines to‘ensure that dangerous and unnecessarily risky procedures are excluded from practice’. What constitutes an‘unnecessarily risky procedure’is to be determined by a group of reasonable doctors. At one point, Ross suggests that such guidelines are‘presumptive’rather than ‘absolute’. But this is really a concession to patient variability. She intends (...) that certain procedures are ruled out on paternalistic grounds. I will argue that practice guidelines are desirable but should not determine practice. We should not rule out procedures on paternalistic grounds. (shrink)

In 2002, I wrote an editorial in this Journal arguing that it was time to review the structure and function of ethics committees in the USA, Australia and the UK.1 This followed the deaths of Ellen Roche and Jesse Gelsinger, which were at least in significant part due to the poor functioning of research ethics committees in the USA.2 In the case of Ellen Roche, it was the failure to require a systematic review of the existing literature which led to (...) her death. Iain Chalmers and I had previously documented in 1996 the failure of ethics committees to require systematic review.3 In 1998, at the time of revising the previous guidelines and forming the first Australian National Statement on Research Ethics, I made a public submission to the Australian Health Ethics Committee arguing that the new guidelines for RECs should include a person with skills in conducting systematic reviews of the literature and that the requirement to have a religious representative on the committee be replaced with the requirement to have an ethicist. Neither of these changes was made. I argued, ‘It is time to ask whether institutional RECs should be abandoned in favour of expert committees that cover many institutions—suprainstitutional specialist committees. Supraregional specialist ethics committees could specialise—for example, in genetic research, cancer clinical trials, dermatology, respiratory physiology and each of the specialist areas of medical research. An example of such a committee is provided by the Thoracic Society of Australia and New Zealand research ethics committee, which reviews multicentre trials of respiratory drugs’.4 Around that time, I was involved ‘at the coal face’ as Chair of the Department of Human Services Ethics Committee in Victoria. In a public presentation, I arguedThere are two philosophical views of what ethics review is. On the …. (shrink)

Over the past 10 years, John Harris has made important contributions to thinking about distributive justice in health care. In his latest work, Harris controversially argues that clinicians should stop prioritising patients according to prognosis. He argues that the good or benefit of health care is providing each individual with an opportunity to live the best and longest life possible for him or her. I call this thesis, opportunism. For the purpose of distribution of resources in health care, Harris rejects (...) welfarism (the thesis that the good of health care is well-being) and argues that utilitarianism in general may lead to de facto discrimination against groups of people needing health care. I argue that well-being is a superior theory of the good of health care to Harris' opportunism. Harris' concerns about utilitarianism can be better addressed by: (i) relating justice more closely to reasons for action; (ii) by conceptualising the relationship between reasons for action and the value of the consequences of those actions as a plateau rather than scalar relationship. Justice can be understood as satisfying as many equally rational claims on resources as possible. The rationality of a person's claim on health resources turns on the strength of that person's reasons to promote certain health-related states of affairs. I argue that the strength of that reason does not track the expected value of that state of affairs in a fully scalar fashion. Rather a person can have most reason to promote some state of affairs, even though he or she could promote other more valuable states of affairs. Thus there can be equal reason for a distributor of public resources to save either of two people, even though one will have a better and more valuable life. This approach, while addressing many of Harris' concerns about utilitarianism, does not imply that doctors should give up prioritising patients according to prognosis altogether, but it does allow that patients with lower but reasonable prognosis should have a share of public resources. (shrink)

Médecins Sans Frontières (MSF) is an independent medical humanitarian organisation working in over 70 countries. It has provided medical assistance for over 35 years to populations vulnerable through conflict, disease and inadequate health systems. Medical ethics define the starting point of the relationship between medical staff and patients. The ethics of humanitarian interventions and of research in conflict settings are much debated. However, less is known about the ethical dilemmas faced by medical humanitarian staff in their daily work. Ethical dilemmas (...) can be intensified in humanitarian contexts by insecure environments, lack of optimum care, language barriers, potentially heightened power discrepancies between care providers and patients, differing cultural values and perceptions of patients, communities and medical staff. Time constraints, stressful conditions and lack of familiarity with ethical frameworks can prevent reflection on these dilemmas, as can frustration that such reflection does not necessarily provide instant solutions. Lack of reflection, however, can be distressing for medical practitioners and can reduce the quality of care. Ethical reflection has a central role in MSF, and the organisation uses ethical frameworks to help with clinical and programmatic decisions as well as in deliberations over operational research. We illustrate and discuss some real ethical dilemmas facing MSF teams. Only by sharing and seeking guidance can MSF and similar actors make more thoughtful and appropriate decisions. Our aim in sharing these cases is to invite discussion and dialogue in the wider medical community working in crisis, conflict or with severe resource limitations. (shrink)

We consider whether intervening in the criminal tendency of future children is ethically justifiable. We argue that, if avoidance of.

This paper reviews the evolutionary history and biology of love and marriage. It examines the current and imminent possibilities of biological manipulation of lust, attraction and attachment, so called neuroenhancement of love. We examine the arguments for and against these biological interventions to influence love. We argue that biological interventions offer an important adjunct to psychosocial interventions, especially given the biological limitations inherent in human love.

I argue that Brierley et al are wrong to claim that parents who request futile treatment are acting against the interests of their child. A better ethical ground for withholding or withdrawing life-prolonging treatment is not that it is in the interests of the patient to die, but rather on grounds of the limitation of resources and the requirements of distributive justice. Put simply, not all treatment that might be in a person's interests must ethically be provided.

This chapter contains sections titled: Possibility, Extent and Significance of Genetic Enhancement Should Human Genetic Enhancement Occur? Conclusion References.

The concept “truth under an interpretation” simply expresses the formal structure of truth assignations in any type of statement. In the particular case of empirical statements, interpretations consist of sets of material objects whose extent can only be determined by criteria of correspondence with facts. Such correspondence thus constitutes a substantive, non-formal aspect of empirical truth, outside the model theory. The existence of other types of truth also structured by the idea of “truth under an interpretation”, but outside the notion (...) of correspondence with facts, reinforces the existence of a line of demarcation between these two categories. (shrink)

La tradición republicana y la tradición liberal no aportan un marco de entendimiento entre culturas diversas. El diseño ético y político de la sociedad plural, capaz de acomodar el "collage" de culturas en el que vivimos, tiene que ser creado. Las concepciones morales más preponderantes, en este sentido, son el relativismo, el universalismo y el fundamentalismo. Todas estas posiciones poseen límites y posibilidades diferentes. El autor opta por defender un "modus vivendi" entre culturas que no acabe en la indiferencia o (...) la condescendencia hacia el otro, el extranjero -inmigrante o refugiado-. El "modus vivendi" defendido debe superar la mera coexistencia entre culturas para adoptar un cosmopolitismo que exige sacrificios solidarios en beneficio de los que nos son culturalmente extraños. Este "modus vivendi" abierto a los otros puede favorecer un diálogo auténtico entre culturas a partir del reconocimiento de sus diversidades, no homologables o priorizables en diferente grado desde el "etnocentrismo" occidental. (shrink)

El concepto de 'banalidad del mal' fue introducido por Hannah Arendt a fin de caracterizar una forma inédita de perversidad que ella vio encarnada en Adolf Eichmann y otros criminales nazis. Arendt consideraba que esa forma de perversidad estaba muy alejada de la noción de 'mal radical' que Kant había acuñado y la propia Arendt había empleado en trabajos anteriores. El objetivo principal del artículo es mostrar que hay más afinidades entre el mal radical kantiano y la banalidad del mal (...) de lo que la propia Arendt reconoce. (shrink)