We argue that contemporary psychiatry adopts a defensive strategy vis-à-vis various external sources of pressure. We will identify two of these sources – the plea for individual autonomy and the idea of Managed Care – and explain how they have promoted a strict biomedical conception of disease. The demand for objectivity, however, does not take into account the complexity of mental illness. It ignores that the psychiatrist’s profession is essentially characterized by fragility: fluctuating between scientific reduction and the irreducible complexity (...) of reality. Therefore, the psychiatrist is not in need of hard and fast rules, but of judgment. At the end, we suggest that philosophy could inject some healthy uncertainty within psychiatry in order to restore its fragile identity. Our examples are drawn from the Dutch situation but we are confident that they apply to other countries as well. (shrink)

Nous nous inscrivons dans une culture, nous sommes les heritiers de multiples traditions. Le romantisme qui a su remettre la tradition a l'honneur, aussi bien que les Lumieres avec leur mefiance - allant jusqu'au refus - vis-a-vis de toute tradition, sont pour nous de telles traditions. Nous devons nous rapporter a nos traditions en Aufklarer, les soumettre a l'examen critique, mais nous devons savoir egalement que l'elucidation de la tradition ne peut se resoudre dans la pure maitrise de la critique, (...) qu'elle est reflexion a partir d'une appartenance. (shrink)

Looking times and gaze behavior indicate that infants can predict the goal state of an observed simple action event (e.g., object‐directed grasping) already in the first year of life. The present paper mainly focuses on infants’ predictive gaze‐shifts toward the goal of an ongoing action. For this, infants need to generate a forward model of the to‐be‐obtained goal state and to disengage their gaze from the moving agent at a time when information about the action event is still incomplete. By (...) about 6 months of age, infants show goal‐predictive gaze‐shifts, but mainly for familiar actions that they can perform themselves (e.g., grasping) and for familiar agents (e.g., a human hand). Therefore, some theoretical models have highlighted close relations between infants’ ability for action‐goal prediction and their motor development and/or emerging action experience. Recent research indicates that infants can also predict action goals of familiar simple actions performed by non‐human agents (e.g., object‐directed grasping by a mechanical claw) when these agents display agency cues, such as self‐propelled movement, equifinality of goal approach, or production of a salient action effect. This paper provides a review on relevant findings and theoretical models, and proposes that the impacts of action experience and of agency cues can be explained from an action‐event perspective. In particular, infants’ goal‐predictive gaze‐shifts are seen as resulting from an interplay between bottom‐up processing of perceptual information and top‐down influences exerted by event schemata that store information about previously executed or observed actions. (shrink)

Are causal explanations (e.g., “she switched careers because of the COVID pandemic”) treated differently from the corresponding claims that one factor caused another (e.g., “the COVID pandemic caused her to switch careers”)? We examined whether explanatory and causal claims diverge in their responsiveness to two different types of information: covariation strength and mechanism information. We report five experiments with 1,730 participants total, showing that compared to judgments of causal strength, explanatory judgments tend to bemoresensitive to mechanism andlesssensitive to covariation – (...) even though explanatory judgments respond to both types of information. We also report exploratory comparisons to judgments of understanding, and discuss implications of our findings for theories of explanation, understanding, and causal attribution. These findings shed light on the potentially unique role of explanation in cognition. (shrink)

Bioethics has been in existence now for more than twenty years. Much has changed, however, since Van Rensselaer Potter2 first used the term bioethics in 1971. For Potter, bioethics was an applied science with its roots in the biological sciences and its orientation towards the betterment of human life. Today the concept is used in a different context. It has become the name given to the ethical research that has become necessary in light of the new possibilities created by revolutionary (...) developments in medical science. Generally speaking, bioethics is concerned with the beginning and the end of life. In a certain sense, however, this is merely a de facto definition which does not possess a great deal of internal logical consistency.If we attempt to reconstruct the incredibly rapid evolution of bioethics we quickly realize how the times were truly ripe for this new discipline to begin to mature. In a very short space of time bioethics was taken seriously in just about every University and medical centre the world over. There is no part of the world which has not organised a colloquium or developed a study programme or created a Centre for Biomedical Ethics. Yet this advance is hardly surprising if we consider the fact that there have been revolutionary developments in themedical world in the 1960’s which have made it necessary to engage in serious ethical reflection on the borderline questions of human life.From the start, bioethicists have concerned themselves primarily with ethical problems related to reproductive technology such as in vitro fertilization, medically assisted fertilization with donor gametes, pregnancy termination, and the status of the embryo. More recently, however, questions concerning the end of life have entered the bioethicist’s field of interest, e.g. ethical questions related to euthanasia and the problems surrounding the artificial nutrition and hydration of persistently vegetative patients. In the meantime, of course, bioethics has broadened its field of interest beyond questions related to the beginning and end of life. Serious ethical and juridical reflection has resulted from the problems surrounding organ transplantation, transplantation of brain tissue, and the problem of AIDS.With the many recent developments in genetics, the first applications of gene therapy, and the world-wide human genome research project bioethics is assured an exciting future. It is clear that the issues which grab the bioethicist’s attention are rather disparate. Moreover, we are now beginning to realize that a whole gamut of specific questions cannot be addressed unless the broader context of the ethics of health care in general is taken into account. Such a realization has led to something of a new movement within the bioethical sphere which is interested in widening the notion of ‘medical ethics’ or ‘ethics of health’.The purpose of this article is to help familiarize the reader with the world of bioethics. Such a task is both simple and complex; bioethics has become a house with many rooms, a house, furthermore, which is being constantly renovated and rebuilt. By way of introduction, we shall take an investigative and evaluative stroll through the broad landscape bioethics has traced in the first twenty years of its existence. (shrink)

Bioethics has been in existence now for more than twenty years. Much has changed, however, since Van Rensselaer Potter2 first used the term bioethics in 1971. For Potter, bioethics was an applied science with its roots in the biological sciences and its orientation towards the betterment of human life. Today the concept is used in a different context. It has become the name given to the ethical research that has become necessary in light of the new possibilities created by revolutionary (...) developments in medical science. Generally speaking, bioethics is concerned with the beginning and the end of life. In a certain sense, however, this is merely a de facto definition which does not possess a great deal of internal logical consistency.If we attempt to reconstruct the incredibly rapid evolution of bioethics we quickly realize how the times were truly ripe for this new discipline to begin to mature. In a very short space of time bioethics was taken seriously in just about every University and medical centre the world over. There is no part of the world which has not organised a colloquium or developed a study programme or created a Centre for Biomedical Ethics. Yet this advance is hardly surprising if we consider the fact that there have been revolutionary developments in themedical world in the 1960’s which have made it necessary to engage in serious ethical reflection on the borderline questions of human life.From the start, bioethicists have concerned themselves primarily with ethical problems related to reproductive technology such as in vitro fertilization, medically assisted fertilization with donor gametes, pregnancy termination, and the status of the embryo. More recently, however, questions concerning the end of life have entered the bioethicist’s field of interest, e.g. ethical questions related to euthanasia and the problems surrounding the artificial nutrition and hydration of persistently vegetative patients. In the meantime, of course, bioethics has broadened its field of interest beyond questions related to the beginning and end of life. Serious ethical and juridical reflection has resulted from the problems surrounding organ transplantation, transplantation of brain tissue, and the problem of AIDS.With the many recent developments in genetics, the first applications of gene therapy, and the world-wide human genome research project bioethics is assured an exciting future. It is clear that the issues which grab the bioethicist’s attention are rather disparate. Moreover, we are now beginning to realize that a whole gamut of specific questions cannot be addressed unless the broader context of the ethics of health care in general is taken into account. Such a realization has led to something of a new movement within the bioethical sphere which is interested in widening the notion of ‘medical ethics’ or ‘ethics of health’.The purpose of this article is to help familiarize the reader with the world of bioethics. Such a task is both simple and complex; bioethics has become a house with many rooms, a house, furthermore, which is being constantly renovated and rebuilt. By way of introduction, we shall take an investigative and evaluative stroll through the broad landscape bioethics has traced in the first twenty years of its existence. (shrink)

I. General introduction to philosophy, by Cardinal Mercier. Cosmology, by D. Nys. Psychology, by Cardinal Mercier. Criteriology, by Cardinal Mercier. General metaphysics; or, Ontology, by Cardinal Mercier. Appendix to Cosmology, by D. Nys.--II. Natural theology; or, Theodicy, by Cardinal Mercier. Logic, by Cardinal Mercier. Ethics: General ethics, by A. Arendt (based on Cardinal Mercier's notes); Special ethics, by J. Halleux. History of philosophy, by M. de Wulf. Synopsis in the form of the principal theses. Glossary of scholastic terms, by G. (...) Simons. (shrink)

Psychotherapy, Meditation and Health: A Cognitive-Behavioural Perspective. Edited by Maurits G. T. Kwee. East-West Publications, The Hague 1990. 319 pp. £18.95.

Több politikatudománnyal foglalkozó kötettel jelentkezett már Szabó Márton, aki eddigi kutatásait összegezve, egy alternatív szemléletű politikatudomány szemléletébe és kutatásába kívánja bevezetni olvasóit. Célja, hogy bizonyítsa: a politika reális valóságában meghatározó módon jelen van az egyének nyilvános és közös értelmezése és diskurzusa. Hogy a politika ezért nem tekinthető pusztán csak objektív rendszernek, hanem emberek által teremtett és értelmezett valóság. A szerző ezen szemlélet jegyében hét nagyobb egységben mutatja be a politika minden fontos területét, kezdve a politikai tények összetett természetével, folytatva a (...) politikai cselekvések és megismerési módok sajátosságaival. Külön vizsgálja az intézményi kereteket, a politika szereplőit, a politikai ügyeket. Kritikailag elemzi az empirikus politikatudományi kutatás meghatározó területeit, végül a politikatudomány sokféleségével foglalkozik. A vaskos kötetet forrás- és irodalomjegyzék zárja. (shrink)

A szabadság dilemmái -- A megrendült öntudat mítoszai -- Irás az éthoszról.

Dialogus a tudatról, az ösztönről meg az alkalmazkodásról -- A szabadság és az érték -- Az ember magasabbrendű érzelmi viszonyairól -- Az ember "szubsztancionális" és "funkcionális" szükségleteiről -- Teremtés és programozás -- A szép pszichológiája -- Modern szerelem vagy cinizmus? -- Freud és a modern emberfelfogás -- A konfliktusról.

Yaygın din eğitimi örgün din eğitimin dışında bireylerin dini ihtiyaçlarını gidermek için resmi ya da özel kuruluşlar vasıtasıyla her bireye planlı ve amaçlı olarak verilen eğitimdir. Günümüzde yaygın din eğitimini şekillendiren temel kurum Diyanet İşleri Başkanlığıdır. Diyanet İşleri Başkanlığı yaygın din eğitimini cami içi ve cami dışı olarak yerine getirmektedir. Cami içi yaygın din eğitimi ise; vaaz, hutbe ve kuran öğretimi ile yapılmaktadır. Bu eğitimlerden olan hutbe, Müslümanları ilgilendiren bütün konuları ele alarak topluma dini bilgileri öğretmek; insanlarda olumlu yönde davranış (...) değişikliği oluşturmak, hedef kitlenin iman, ahlak ve toplumsal farkındalık bakımından duyarlı hale gelmesini sağlamak için bireylere yardımcı olmaktır. Yaklaşık olarak aynı dönemlerde doğmuş, aynı dönemin özelliklerini paylaşmış, benzer sorumluluklara sahip bireyler aynı kuşak bireyleri olarak tanımlanır. 1990-2015 yılları arasında doğmuş büyümüş bireyler Z kuşağı bireyleri olarak adlandırılmaktadır. Bu kuşak bireyleri interneti kullanma, teknolojiyi sevme, görsele aşina, üretken ve eşitlikçi gibi özelliklere sahiptir. Bu durum Z kuşağının sosyalleşmesinde, yaşam alışkanlıklarında ve öğrenme sitillerinde farklıları beraberinde getirmiştir. Yaygın din eğitim nesiller arasındaki bu farklılıkları dikkate alarak bireylerin kendilerini geliştirmelerine ve bilgilerini güncellemelerine yardım etmelidir. Bu sebeple yaygın din eğitimi Z kuşağının ihtiyaçlarını dikkate alarak farklı metot ve etkinlikleri geliştirmesi gerekir. Bu bağlamda Z kuşağının gözüyle Cuma hutbelerinin nasıllığı önemli hale gelmektedir. Buradan hareketle Z kuşağının Cuma hutbelerine karşı tutumlarını incelemek için Cuma hutbeleri değerlendirilmiştir. Araştırmamız, Z kuşağının Cuma Hutbelerini algılamalarını incelemek amacıyla tanımlayıcı araştırma tasarımı ile yürütülmüştür. Araştırmanın evrenini Konya İli Seydişehir, Beyşehir ilçesinde 14-25 yaş aralığındaki 175 birey oluşturmaktadır. Veriler araştırmacılar tarafından hazırlanan ‘Birey Tanılama Formu’ ve ‘Cuma Hutbelerine İlişkin Bilgi Formu’ aracılığıyla toplanmıştır. Araştırmada, verilerin analizinde IBM SPSS (IBM Statistical Package for Social Sciences Corp.; Armonk, NY, ABD) 25.0 programı kullanılmıştır. Araştırma verileri değerlendirilirken kategorik değişkenler için frekans dağılımı (sayı, yüzde), sayısal değişkenler için tanımlayıcı istatistikler (ortalama, standart sapma) kullanılmıştır. Araştırmaya katılan katılımcıların yaş ortalamaları 17.04’dir. Katılımcıların çoğunluğunun lise öğrencisi olduğu görülmüştür. Araştırmada Z kuşağının Cuma hutbelerine katılım sağladığı, hutbelerden umut bekledikleri, olumlu yönden etkilendikleri görülmüştür. Ancak Cuma hutbelerindeki konuların yerel ve güncel konuları ele almadığı ifade ederek anlatılan konuların hatırlamadıkları, aynı konuların tekrar ettiği, gençlere yönelik olmadığına ulaşılmıştır. Ayrıca hutbelerin sunumu, süresi ve imamların yaklaşımlarından dolayı problemler yaşandığı tespit edilmiştir. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Gospel of Mark: A Mahayana ReadingDonald G. LuckThe Gospel of Mark: A Mahayana Reading. By John P. Keenan. Maryknoll, NY: Orbis Books, 1995.This is the latest effort of society member John Keenan to “pass over” (as John Dunne puts it) from one tradition to another in order to return to one’s point of departure with fresh perspective and heightened awareness. This book reflects impressive scholarship and builds on (...) the theological indebtedness to Madhyamika [End Page 210] and Yogacara thought that shaped Keenan’s earlier work, The Meaning of Christ: A Mahayana Theology, also published by Orbis. The noses of academic purists may be put out of joint by what some might construe as a blurring of boundaries between Buddhism and Christianity, but Keenan places himself right in the thick of current hermeneutical discussions to establish the fruitfulness of Mahayana perspective in interpreting the “charter document of the Christian Gospel” (p. 4). He finds methodological legitimization both in the arguments of narrative criticism and in the lines of connection he discerns between deconstruction and the Mahayana recognition of emptiness. And in so arguing, he finds himself able to account for forms of New Testament criticism such as those advanced by John Dominic Crossan and Werner Kelber that not only undermine forms of essentialism but also resort to conventional modes of thinking and discourse without justifying the latter.What is unwittingly going on, argues Keenan, is parallel to the Mahayana identification of emptiness (shunyata) with dependent co-arising (pratitya samutpada). Like deconstructionist hermenuetics, emptiness destablizes all fixed views by recognizing that ultimate truth is ineffable and silent. However, unlike deconstruction, emptiness avoids the vertigo of a text lost in the interplay of interpretations doubling back on themselves. “That is emptiness ineptly apprehended as itself an essentialist viewpoint that there are no viewpoints” (p. 7). Instead, Mahayana analysis connects recognition of the total otherness of ultimate meaning with the affirmation of worldly convention in its limitation. The result is a hermeneutic of nonabsolutizing suggestiveness shaped by upaya, which leads the reader to the possibility of enlightenment —or, in the case of Mark, disclosure.According to Keenan, this Mahayana recognition of the identity of emptiness and dependent co-arising not only has hermeneutical legitimation but also is the key for unlocking a fresh appreciation of Mark’s contents. Accounting for this is the fact that “the Marcan rhetoric of indirection and irony is the narrative analogue to the Madhyamika dialectical rhetoric employed in Nagarjuna’s Stanzas on the Middle” and the fact that “Mahayana eschews precisely those clarifying elements that Matthew and Luke have added to domesticate Mark’s story and discourse, preferring the opacity of ultimate meaning to the full explication of stated truths, opting for the emptying of all themes and ideas in order to reclaim them with an awakened mind” (p. 4).Keenan’s approach is coherent with Crossan’s observation that while mythos creates a universe of meaning, parable undermines established cosmoi. In this respect, Jesus not only speaks parable, he is parable. Utilizing the Mahayana identification of emptiness with dependent co-arising as a heuristic device and paying close attention to the Greek text, Keenan traces the simultaneously destablizing and restorative effect that Jesus has on his hearers—and that the evangelist potentially can have on his readers. Jesus’ “desert spirituality,” that is, his radically unconventional vision, undermines the expectations and securities of both hearer and reader. But it also reconnects those effected by the liberation he works “not to the ultimate glory of a false kingdom imagined by the disciples and the readers, but to the conventional realm of human living in which alone the kingdom may be established” (p. 73; italics added). Indeed, Jesus’ crucifixion makes clear that the transformation wrought [End Page 211] by the Gospel is an existential reappropriation of ordinary life in the face of ultimate mystery, not some supernatural deliverance within or from it. Appropriately, Mark ends with the women being confronted by both the jarring and ineffable mystery of Jesus’ empty tomb and the promise that he will see the disciples again in the familiar—and open-ended—context of life in Galilee.Keenan has done more... (shrink)

This book constitutes the refereed proceedings of the International Conference on Spatial Information Theory, COSIT 2005, held in Elliottville, NY, USA in September 2005. The 30 revised full papers presented were carefully reviewed and selected from 82 submissions. The papers are organized in topical sections on vagueness, uncertainty, and gradation; paths and routes; ontologies and semantics; ontologies and spatial relations; spatial reasoning: cognitive maps and spatial reasoning; time, change, and dynamics; landmarks and navigation; geographic information, and spatial behaviour.

While many philosophers agree that evolutionary theory has important implications for the study of ethics, there has been no consensus on what these implications are. I argue that we can better understand these implications by examining two related yet distinct issues in evolutionary theory: the evolution of our moral beliefs and the evolution of cooperative behavior. While the prevailing evolutionary account of morality poses a threat to moral realism, a plausible model of how altruism evolved in human beings provides the (...) grounding for a research program that focuses on achieving some of the more practical goals shared by ethicists. †To contact the author, please write to: Department of Political Science, Economics, and Philosophy, College of Staten Island/City University of New York, 2800 Victory Blvd., Staten Island, NY 10314; e‐mail: stephen.morris@csi.cuny.edu. (shrink)

Chloë G. K. Atkins, My Imaginary Illness: A Journey into Uncertainty and Prejudice in Medical Diagnosis, Ithaca, NY: Cornell University Press, 2010, reviewed by Frances R. Batzer.

This study examined how Puerto Rican parents living in the United States reason about illnesses and remedies. Special focus is placed on the influence of Puerto Rican cultural, religious, and spiritual beliefs due to the influence of Taino, West African, Spanish, and U.S. beliefs and customs. Parents of 3.5 to 12-year-old children from the Rochester, NY area were asked to complete a questionnaire centered on their beliefs and an open-ended interview that explored how one could get sick and treated for (...) biological illnesses (e.g., the common cold, COVID-19, cancer). Although participants reported religious, spiritual, and mystical beliefs in the questionnaire, they provided scientific explanations for illness and remedies in the interview. This study provides novel findings on how individuals of Puerto Rican descent understand illnesses and remedies and the variation across individuals. This study provides strong evidence for the variation in coexistence of beliefs within this population. (shrink)

The article is devoted to present Polish research on the literary work and philosophical thought of Hryhorii Skovoroda. The scientific reflection on Skovoroda’s legacy was initially carried out on the historical and literary level. It was initiated by Adam Honory Kirkor in 1874. In the context of the history of Ukrainian literature, Józef Tretiak, Ivan Franko and Bohdan Lepkyi presented the general characteristics of Skovoroda’s work, seeing in it only the original style and compilation character of thoughts. Ivan Mirtchuk started (...) his research on Skovoroda’s thoughts from the history of national philosophy, seeing in Skovoroda’s philosophy the features charac- teristic of Ukrainian philosophy, differing it fundamentally from Russian philosophy. As part of the research, it was possible to find an extensive article by Jarosław Ulwański, Philosophy of G.S. Skovoroda, published in 1930, in which the author presented arguments for a pantheistic interpretation of the Ukrainian philosopher’s thoughts. A breakthrough event was the publication of a monograph by Dmytro Tschižewskij, who formulated a view on the mystical philosophy of Skovoroda similar to the Western European mysticism of the 17th and 18th centuries. The interwar period ends with the work of Czesław Jastrzębiec-Kozłowski, in which the work of Skovoroda was analyzed against the background of Józef Hoene-Wronski’s messianic philosophy. After World War II and the 1990s, research on Skovoroda’s legacy was conducted primarily by philologists. Ryszard Łużny and Włodzimierz Mokry treated Skovoroda’s work as a Christian philosopher. In the 21st century, Polish research increasingly refers to philosophical interpretation. Denys Pilipowicz researched the ancient and patristic sources of Skovoroda’s mystical thought and compared it with the teachings of Paisij Velyczkovskyi. Iryna Betko analyzed his poetry from the perspective of Jung’s theory of archetypes. Michał Handzel conducted an in-depth historical and philosophical analysis of Skovoroda’s philosophy, seeing Skovoroda as a representative of the panentheistic trend, and Pavlo Snopkov examined the concept of Skovoroda’s self-knowledge from the perspective of Jung’s and Maslow’s psychological theories. (shrink)

A kolozsvári filozófus az elmúlt három esztendőben született tanulmányait egybe szerkesztve készítette új könyvét. Célja mintegy in statu nascendi bemutatni a politikai filozófiát, hogyan reflektálnak a kortárs politikai filozófiák a társadalmat érő politikai kihívásokra. Címéhez híven valóban egyfajta bevezetés Korunk politikai filozófiájába, mégpedig olyan csomóponti és tagadhatatlanul ma is aktuális, eleven témák kapcsán, mint az emberi jogok doktrínája, nemzeti szuverenitás vs. Európai integráció, multikulturalizmus és a bevándorlás problémája. A szerző legfőbb eszmei iránytűje ezúttal is Hannah Arendt, rá hivatkozva vallja, hogy (...) a politikában maximum arra törekedhetünk, hogy véleményünk reprezentatív legyen. A teljes igazság platóni ideájának megragadása helyett a filozófus feladat, hogy a szókratészi kételyt tanítsa, a politikai filozófia értelme pedig annak megmutatása, hogy ahogyan mi magunk a politikáról gondolkodunk, minden, csak nem evidens. A nyolc tanulmány bibliográfiával és névmutatóval kiegészített gyűjteménye elsősorban a szakemberekhez szól, de a saját politikai meggyőződéseik megkérdőjelezésére nyitott művelt nagyközönségnek is ajánlható. (shrink)

Restraint as a Source of Judicial ‘Apoliticality’: A Functional Reconstruction Few legal theorists today would argue that the domain of law exists in isolation from other normative spheres governing society, notably from the domain of ‘politics’. Nevertheless, the implicit norm that judges should not act ‘politically’ remains influential and widespread in the debates surrounding controversial court cases. This article aims to square these two observations. Taking the Miller v. Secretary of State and Urgenda cases as illustrative case studies, the article (...) demonstrates that what it means for judges to adjudicate cases ‘apolitically’ is itself a matter of controversy. In reflecting on their own constitutional role, courts are forced to take a stance on substantive questions of political philosophy. Nevertheless, that does not mean that the ‘norm of judicial apoliticality’ should therefore be rejected. The norm’s coherence lies in its intersocial function: its role in declaring certain modes of judicial interpretation and intervention legitimate (‘legal’/‘judicial’) or illegitimate (‘political’). (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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