In bioethics, the predominant categorization of various types of influence has been a tripartite classification of rational persuasion (meaning influence by reason and argument), coercion (meaning influence by irresistible threats—or on a few accounts, offers), and manipulation (meaning everything in between). The standard ethical analysis in bioethics has been that rational persuasion is always permissible, and coercion is almost always impermissible save a few cases such as imminent threat to self or others. However, many forms of influence fall into the (...) broad middle terrain—and this terrain is in desperate need of conceptual refining and ethical analysis in light of recent interest in using principles from behavioral science to influence health decisions and behaviors. This paper aims to address the neglected space between rational persuasion and coercion in bioethics. First, I argue for conceptual revisions that include removing the “manipulation” label and relabeling this space “nonargumentative]influence,” with two subtypes: “reason-bypassing” and “reason-countering.” Second, I argue that bioethicists have made the mistake of relying heavily on the conceptual categories themselves for normative work and instead should assess the ethical permissibility of a particular instance of influence by asking several key ethical questions, which I elucidate, that relate to (1) the impact of the form of influence on autonomy and (2) the relationship between the influencer and the influenced. Finally, I apply my analysis to two examples of nonargumentative influence in health care and health policy: (1) governmental agencies such as the Food and Drug Administration (FDA) trying to influence the public to be healthier using nonargumentative measures such as vivid images on cigarette packages to make more salient the negative effects of smoking, and (2) a physician framing a surgery in terms of survival rates instead of mortality rates to influence her patient to consent to the surgery. (shrink)

An original examination of the relevance of behavioral economics for the practice of medical ethics.

Policymakers, employers, insurance companies, researchers, and health care providers have developed an increasing interest in using principles from behavioral economics and psychology to persuade people to change their health-related behaviors, lifestyles, and habits. In this article, we examine how principles from behavioral economics and psychology are being used to nudge people (the public, patients, or health care providers) toward particular decisions or behaviors related to health or health care, and we identify the ethically relevant dimensions that should be considered for (...) the utilization of each principle. (shrink)

In his article “Nudging and Informed Consent,” Shlomo Cohen (2013) argues, among other things, that 1) “to the extent that the nudge-influenced decision making is rational—in whatever sense,” there...

Little Vast Rooms of Undoing explores the relationship between identity and embodiment in public toilet spaces.

The past four decades of research in the social sciences have shed light on two important phenomena. One is that human decision-making is full of predicable errors and biases that often lead individuals to make choices that defeat their own ends (i.e., the bad choice phenomenon), and the other is that individuals’ decisions and behaviors are powerfully shaped by their environment (i.e., the influence phenomenon). Some have argued that it is ethically defensible that the influence phenomenon be utilized to address (...) the bad choice phenomenon. They propose that “choice architects” learn about the various ways in which choices can be influenced and directed by the environment, and then work to design environments, broadly construed, that influence individuals towards choices that make them better off. Those who advocate intentionally creating choice environments that lead people to better choices believe that doing so is ethically permissible because (1) it makes people better off, and (2) it does so in a way that is entirely compatible with individual liberty. The evaluation of these two claims is the main focus of this paper. (shrink)

The phenomenon of ambivalence is an important one for any philosophy of action. Despite this importance, there is a lack of a fully satisfactory analysis of the phenomenon. Although many contemporary philosophers recognize the phenomenon, and address topics related to it, only Harry Frankfurt has given the phenomenon full treatment in the context of action theory - providing an analysis of how it relates to the structure and freedom of the will. In this paper, I develop objections to Frankfurt's account, (...) all revolving around the charge that his account contains a serious ambiguity between willing and identifying. With such objections in place, I then develop an analysis that avoids the difficulties and ambiguities that Frankfurt's analysis is prey to. I briefly distinguish ambivalence from other types of internal conflict. This paper aims to offer conceptual clarification on the phenomenon of ambivalence, which will then allow for discussions about the normative merits and demerits of ambivalence, the effects of ambivalence on autonomous action, and methods of resolution of ambivalence. (shrink)

Volume 19, Issue 9, September 2019, Page 54-56.

In some views in the history, philosophy and social studies of chemistry, Joseph Priestley is at least as well-known and cited for his objections to the new chemistry and his promotion of his own late version of the theory of phlogiston, as for his early series of discoveries about types of air for which he had become famous. These citations are generally not associated with any detailed indications about his late work from 1788 onwards and his late phlogistic theory, of (...) which there has not been a detailed study. This paper undertakes a detailed study of Priestley’s late work on water and related airs. He put forward a theory to support which his apparatus and initial substances would have needed to exclude impurities altogether. His theory did not take into account the solutions to the difficulties with the experiment which had been comprehensively understood and published by the phlogistian Cavendish several years previously, and with which the Lavoisians were in agreement. Priestley readily and fundamentally changed his interpretations of experiments in order to support the theory he currently favoured, and he was highly selective about replying about the criticisms of any opponent. This detailed analysis shows many divergences between his own practices and aspects of his objections to the new chemistry, which have implications for those stances in the secondary literature which do not question his objections. Accordingly, this study has implications concerning the nature of chemistry and other sciences, how they do progress and how they should progress. (shrink)

The concept of personhood has been central to bioethics debates about abortion, the treatment of patients in a vegetative or minimally conscious states, as well as patients with advanced dementia. More recently, the concept has been employed to think about new questions related to human-brain organoids, artificial intelligence, uploaded minds, human-animal chimeras, and human embryos, to name a few. A common move has been to ask what these entities have in common with persons (in the normative sense), and then draw (...) conclusions about what we do (or do not) owe them. This paper argues that at best the concept of “personhood” is unhelpful to much of bioethics today and at worst it is harmful and pernicious. I suggest that we (bioethicists) stop using the concept of personhood and instead ask normative questions more directly (e.g., how ought we to treat this being and why?) and use other philosophical concepts (e.g., interests, sentience, recognition respect) to help us answer them. It is time for bioethics to end talk about personhood. (shrink)

An analysis of the identity issues involved in facial allograft transplantation is provided in this paper. The identity issues involved in organ transplantation in general, under both theoretical accounts of personal identity and subjective accounts provided by organ recipients, are examined. It is argued that the identity issues involved in facial allograft transplantation are similar to those involved in organ transplantation in general, but much stronger because the face is so closely linked with personal identity. Recipients of facial allograft transplantation (...) have the potential to feel that their identity is a mix between their own and the donor’s, and the donor’s family is potentially likely to feel that their loved one ‘‘lives on’’. It is also argued that facial allograft transplantation allows the recipients to regain an identity, because they can now be seen in the social world. Moreover, they may regain expressivity, allowing for them to be seen even more by others, and to regain an identity to an even greater extent. Informing both recipients and donors about the role that identity plays in facial allograft transplantation could enhance the consent process for facial allograft transplantation and donation. (shrink)

Although I agree with Sabine Muller’s conclusion that we should first seek to find alternatives to amputation for patients suffering from Body Integrity Identity Disorder (BIID), I disagree with one of the major premises that she uses to argue for her claim. Muller argues that patients with BIID are likely not autonomous when they request that the limb be amputated. Muller’s argument that BIID suffers are not autonomous is flawed because she conflates philosophical conceptions of autonomy with the conception of (...) autonomy that is operative in the context of medicine. (shrink)

I published my first article in the Journal of Medical Ethics back in 2007 as an (almost) newly minted PhD. It was a proud moment. I respected the JME as a journal where I had read some of the most tightly argued and challenging essays in the literature. They inspired me to specialise in medical ethics and rethink some of my fundamental positions on various topics. This has been the case since, and I am proud now to join the editorial (...) team as an associate editor focusing on increasing North American presence and on the journal’s feature articles. The journal has included feature articles for several years now, and because they have worked so well, the editorial team wants to build on and invest in their success. Feature articles are primarily selected from the best extended essays or research papers. They are among the most highly cited and accessed articles in the field. On average, they have twice as many citations as a regular article published in the journal (and five times as many citations as an article in Ethics, a top philosophy journal). This may be due, in part, to the journal’s practice of making feature articles open access so that all scholars can access them. In addition, the JME is committed to helping promote these articles and their commentaries on its …. (shrink)

In some views, philosophy’s glory days in bioethics are over. While philosophers were especially important in the early days of the field, so the argument goes, the majority of the work in bioethics today involves the “simple” application of existing philosophical principles or concepts, as well as empirical work in bioethics. Here, we address this view head on and ask: What is the role of philosophy in bioethics today? This paper has three specific aims: (1) to respond to skeptics and (...) make the case that philosophy and philosophers still have a very important and meaningful role to play in contemporary bioethics, (2) to discuss some of the current challenges to the meaningful integration of philosophy and bioethics, and (3) to make suggestions for what needs to happen in order for the two fields to stay richly connected. We outline how bioethics center directors, funders, and philosopher bioethicists can help. (shrink)

This is the second of a pair of papers, of which the first showed how each of the main late phlogistic theories effectively reached impasses due to internal problems or included features which made them unacceptable even to other phlogistians. This paper deals with theory comparison and theory change. It gives an unprecedentedly detailed comparison between the available theories in 1790–1791, and shows that this was overwhelmingly in favour of the new chemistry. This time period correlates well with many chemists (...) changing to the new theory. There was a plurality of views held by individuals and there was freedom of individual choice concerning theories, yet there was also a widespread and rational change to the new chemistry. (shrink)

Richard Thaler and Cass Sunstein define a nudge as “any aspect of the choice architecture that alters people's behavior in a predictable way without forbidding any options or significantly changing their economic incentives.” Much has been written about the ethics of nudging competent adult patients. Less has been written about the ethics of nudging surrogates’ decision‐making and how the ethical considerations and arguments in that context might differ. Even less has been written about nudging surrogate decision‐making in the context of (...) pediatrics, despite fundamental differences that exist between the pediatric and adult contexts. Yet, as the field of behavioral economics matures and its insights become more established and well‐known, nudges will become more crafted, sophisticated, intentional, and targeted. Thus, the time is now for reflection and ethical analysis regarding the appropriateness of nudges in pediatrics. We argue that there is an even stronger ethical justification for nudging in parental decision‐making than with competent adult patients deciding for themselves. We give three main reasons in support of this: (1) child patients do not have autonomy that can be violated (a concern with some nudges), and nudging need not violate parental decision‐making authority; (2) nudging can help fulfill pediatric clinicians’ obligations to ensure parental decisions are in the child's interests, particularly in contexts where there is high certainty that a recommended intervention is low risk and of high benefit; and (3) nudging can relieve parents’ decisional burden regarding what is best for their child, particularly with decisions that have implications for public health. (shrink)

> ‘The fact about himself that the bullshitter hides, on the other hand, is that the truth-values of his statements are of no central interest to him; what we are not to understand is that his intention is neither to report the truth nor conceal it. It is just this lack of connection to a concern with truth—this indifference to how things really are—that is the essence of bullshit.’1 > —Harry Frankfurt In his paper, Nudging, informed consent, and bullshit, William (...) Simkulet accuses doctors of being bullshitters when they knowingly influence patient decision making through means other than argument and reasoning, that is, through ‘nudges.’ In these instances, he contends that they care little about patient understanding or communicating the truth about the options and, instead, care only about presenting alternatives in ways that cause patients to do what the physicians think they should do.2 However, doctors can intend to enhance patient understanding at the same time that they try to influence patients’ choices. Consider a physician who wants her patient to get a vaccine. …. (shrink)

Cognitive scientists have identified a wide range of biases and heuristics in human decision making over the past few decades. Only recently have bioethicists begun to think seriously about the implications of these findings for topics such as agency, autonomy, and consent. This article aims to provide an overview of biases and heuristics that have been identified and a framework in which to think comprehensively about the impact of them on the exercise of autonomous decision making. I analyze the impact (...) that these biases and heuristics have on the following dimensions of autonomy: understanding, intentionality, absence of alienating or controlling influence, and match between formally autonomous preferences or decisions and actual choices or actions. (shrink)

Bioethicists often draw sharp distinctions between hope and states like denial, self-deception, and unrealistic optimism. But what, exactly, is the difference between hope and its more suspect cousins? One common way of drawing the distinction focuses on accuracy of belief about the desired outcome: Hope, though perhaps sometimes misplaced, does not involve inaccuracy in the way that these other states do. Because inaccurate beliefs are thought to compromise informed decision making, bioethicists have considered these states to be ones where intervention (...) is needed either to correct the person’s mental state or to persuade the person to behave differently, or even to deny the person certain options. In this article, we argue that it is difficult to determine whether a patient is really in denial, self-deceived, or unrealistically optimistic. Moreover, even when we are confident that beliefs are unrealistic, they are not always as harmful as critics contend. As a result, we need to be more permissive in our approach to patients who we believe are unrealistically optimistic, in denial, or self-deceived—that is, unless patients significantly misunderstand their situation and thus make decisions that are clearly bad for them, we should not intervene by trying to change their mental states or persuade them to behave differently, or by paternalistically denying them certain options. (shrink)

This study investigated whether musical training and bilingualism are associated with enhancements in specific components of executive function, namely, task switching and dual-task performance. Participants belonging to one of four groups were matched on age and socioeconomic status and administered task switching and dual-task paradigms. Results demonstrated reduced global and local switch costs in musicians compared with non-musicians, suggesting that musical training can contribute to increased efficiency in the ability to shift flexibly between mental sets. On dual-task performance, musicians also (...) outperformed non-musicians. There was neither a cognitive advantage for bilinguals relative to monolinguals, nor an interaction between music and language to suggest additive effects of both types of experience. These findings demonstrate that long-term musical training is associated with improvements in task switching and dual-task performance. (shrink)

Just last week (October 4, 2022), the U.S. White House released a blueprint for an A.I. Bill of Rights, consisting of “five principles and associated practices to help guide the design, use, and de...

Questions about when to limit unhelpful treatments are often raised in general medicine but are less commonly considered in psychiatry. Here we describe a survey of U.S. psychiatrists intended to characterize their attitudes about the management of suicidal ideation in patients with severely treatment-refractory illness. Respondents (n = 212) received one of two cases describing a patient with suicidal ideation due to either borderline personality disorder or major depressive disorder. Both patients were described as receiving all guideline-based and plausible emerging (...) treatments. Respondents rated the expected helpfulness and likelihood of recommending each of four types of intervention: hospitalization, additional medication changes, additional neurostimulation, and additional psychotherapy. Across both cases, most respondents said they were likely to provide each intervention, except for additional neurostimulation in borderline personality disorder, while fewer thought each intervention would be helpful. Substantial minorities of respondents indicated that they would provide an intervention they did not think was likely to be helpful. Our results suggest that while most psychiatrists recognize the possibility that some patients are unlikely to be helped by available treatments, many would continue to offer such treatments. (shrink)

The introduction of the Diagnostic and statistical manual of mental disorders in May 2013 is being hailed as the biggest event in psychiatry in the last 10 years. In this paper I examine three important issues that arise from the new manual: Expanding nosology: Psychiatry has again broadened its nosology to include human experiences not previously under its purview . Consequence-based ethical concerns about this expansion are addressed, along with conceptual concerns about a confusion of “construct validity” and “conceptual validity” (...) and a failure to distinguish between “disorder” and “non disordered conditions for which we help people.” The role of claims about societal impact in changes in nosology: Several changes in the DSM-5 involved claims about societal impact in their rationales. This is due in part to a new online open comment period during DSM development. Examples include advancement of science, greater access to treatment, greater public awareness of condition, loss of identify or harm to those with removed disorders, stigmatization, offensiveness, etc. I identify and evaluate four importantly distinct ways in which claims about societal impact might operate in DSM development. Categorisation nosology to spectrum nosology: The move to “degrees of severity” of mental disorders, a major change for DSM-5, raises concerns about conceptual clarity and uniformity concerning what it means to have a severe form of a disorder, and ethical concerns about communication. (shrink)

The idea of a ‘right to mental integrity’, sometimes referred to as a ‘right against mental interference,’ is a relatively new concept in bioethics, making its way into debates about neurotechnological advances and the establishment of ‘neurorights.’ In this paper, we interrogate the idea of a right to mental integrity. First, we argue that some experts define the right to mental integrity so broadly that rights violations become ubiquitous, thereby trivialising some of the very harms the concept is meant to (...) address. Second, rights-based framing results in an overemphasis on the normative importance of consent, implying that neurointerventions are permissible in cases where people consent to have their mental states influenced or read off, a confidence in consent that we argue is misguided. Third, the concept often collapses the ethics of brain inputs and brain outputs, potentially resulting in a loss of important conceptual nuance. Finally, we argue that the concept of a right to mental integrity is superfluous—what is wrong with most violations of mental integrity can be explained by existing concepts such as autonomy, manipulation, privacy, bodily rights, surveillance, harm and exploitation of vulnerabilities. We conclude that bioethicists and policy-makers ought to either make use of these concepts rather than arguing for the existence of a new right, or they need to avoid making rights violations ubiquitous by settling on a narrower and more rigorous definition of the right. (shrink)

One way to test vaccines is through human challenge trials in which participants are intentionally infected with a contagious organism to expedite the process of assessing the vaccine’s effectiveness. Some experts believe challenge trials may play an important role in fighting COVID-19, especially if the vaccines under current study do not demonstrate sufficient efficacy, if spread of COVID-19 is controlled to a point that radically slows down traditional trials, or if new vaccines need to be rapidly developed for specific subpopulations.1 (...) Challenge trials involve significant time, burden and risk, requiring participants to spend 3–6 weeks in legal quarantine for 24 hours a day in a high-security facility. During this time, no inperson visitors will be allowed, except for very limited inperson contact from researchers collecting necessary data and checks. Following the quarantine period, participants will be asked to attend numerous outpatient follow-up visits over the course of months, to further monitor their response to the vaccine. Participation involves being away from family who may themselves become sick during the global pandemic, as well as potential fear and mental anguish around being a ‘first’ subject. Because there is no definitive treatment for COVID-19, participants could experience serious illness. But even with milder illness, medical experts know very little about the long-term consequences of COVID-19 infection. This raises the question of how much people should be paid for their participation in COVID-19 challenge trials. Most think participants should be paid something, but many contend that we should be …. (shrink)

CHAPTER INTRODUCTION At first sight Plotinus' philosophy is full of contradictions. The same entity will appear with different characteristics in different ...

The COVID-19 pandemic will generate vexing ethical issues for the foreseeable future and many journals will be open to content that is relevant to our collective effort to meet this challenge. While the pandemic is clearly the critical issue of the moment, it’s important that other issues in medical ethics continue to be addressed as well. As can be seen in this issue, the Journal of Medical Ethics will uphold its commitment to publishing high quality papers on the full array (...) of medical ethics. At the same time, JME aims to be a premiere home for ground-breaking scholarship on the ethical issues raised by COVID-19. Toward this end, we have a number of papers that are freely available online and for which production has been fast-tracked.1–5 A challenge for authors who want to write about the pandemic is the rapidly evolving nature of the situation and the time it takes for journal content to be reviewed and published, even when fast-tracked. For that reason, all authors who would like to submit a paper on the pandemic can also submit a post to the JME blog prior to submitting a full paper to the journal. Those interested in writing for the JME blog should contact one of its editors, Hazem Zohny or Mike King. Over the last 3 weeks, 30 high-quality commentaries on the pandemic have been posted to the blog. These posts are circulated widely via the JME Twitter and Facebook feeds and have stimulated significant …. (shrink)

This is the first of a pair of papers. It focuses on the development of the most notable phlogistic theories during the period 1766–1791, including the main experiments that their proponents proposed them to interpret. There was a rapid proliferation of late phlogistic theories, particularly from 1784, and the accounts of composition and important implications of the main theories are set out and their issues analysed. Each of them either reached impasses due to internal problems, or included features that made (...) them unacceptable even to other phlogistians. The expositions and analyses of these theories are given in terms of details that were in the literature at the time or otherwise potentially understandable by the participants given contemporary practice. Some relevant methodological aspects of the history of science are discussed, and the secondary literature is briefly surveyed. The second paper deals with the contemporary development of the new chemistry, and with theory comparison and theory choice in the same period. (shrink)

The application of machine learning in health care holds great promise for improving care. Indeed, our own team is collaborating with experts in machine learning and statistical modeling to bu...

This paper deals with the ethics of using knowledge about a person’s particular psychological make-up, or about the psychology of judgment and decision-making in general, to shape that person’s decisions and behaviors. Various moral concerns emerge about this practice, but one of the more elusive and underdeveloped concerns is the charge of manipulation. It is this concern that is the focus of this paper. I argue that it is not the case that any of the practices traditionally labeled as “manipulation” (...) are ipso facto morally wrong, nor is it even the case that any of these practices always has a single wrong making feature (e.g., infringement on autonomy) that is always present but may be outweighed by other morally relevant factors and be all things considered ethically permissible or morally right. I argue that the moral status depends on the extent to which the instance of influence (1) threatens or promotes autonomy, (2) has good aims and virtuous overtones or bad ones, and (3) fulfills or fails to fulfill duties, obligations, and expectations that arise out of the relationship between the influencer and influenced. I will explain in detail the moral relevance of these factors, showing why each is necessary, criteria for evaluation each, and demonstrating how they work in specific cases. (shrink)

Introduction: why the De anima commentaries? This book will concentrate on interpretations of the De anima in late antiquity, and what we can learn from ...

In his paper, ‘Patients, doctors and risk attitudes,’ Nicholas Makins1 argues that healthcare professionals should defer to a patient’s higher-order risk attitudes (ie, the risk attitudes they desire to have or endorse within themselves upon reflection) when making medical decisions. We argue against Makins’ deference to higher-order risk attitudes on the basis that (1) there are significant practical concerns regarding our ability to easily and consistently access and verify the higher-order risk attitudes of patients, (2) there is a lack of (...) a theoretical limit on higher-order risk attitudes (eg, second, third, fourth order), and (3) the consideration of higher-order risk attitudes is actually more paternalistic than Makins suggests because it narrows what counts as an autonomous preference to the limited occasions in which an individual actually reflects on his or her own risk attitude. On the issue of practicality, we can reasonably expect that healthcare professionals would find difficulty eliciting the higher-order risk attitudes of their patients. Take for example the patient who has never expressed his higher-order desire to be more risk adverse and who is not willing nor comfortable expressing this desire. What is the healthcare professional expected to do in this situation? This is even more of a concern for the incapacitated patient, to which Makins seems to imply that …. (shrink)

The American Board of Internal Medicine (ABIM) Foundation has recently initiated a campaign called “Choosing Wisely,” which is aimed at reducing “low-value” care services. Lists of low-value care services are being developed and the ABIM Foundation is urging the American Medical Association and other organizations to get behind the lists, disseminate them, and implement them. Yet, there are many ethical questions that remain about the development, dissemination, and implementation of these low-value care lists. In this paper I argue for conceptual (...) clarity with respect to the label “low-value care.” Thus far it has not been precisely defined, and I argue that there are actually 10 distinct categories of low-value care. I discuss the ethical challenges and considerations associated with each category. I also provide arguments that can be used to justify the reduction of some of these categories of low-value care. These arguments rely on Rawlsian and Hegelian notions of justice, as well as on concepts about the fiduciary obligations of physicians. Finally, I outline the various mechanisms that could be utilized for the reduction of low-value care (i.e., incentives, punishments, nonrational influences such as appeals to social norms, emotions, or ego, and creation of conditions that make avoidance easy such as defaults and reminders). I provide normative guidelines for the use of each. (shrink)