This chapter contains sections titled: Justified and Compensated Suffering and Death Afterlife A Theistic Variation on the Hypothesis of Indifference Verdict on the Greater‐Good Defense Suggested Reading.

This chapter contains sections titled: Hick and Swinburne Moral Evil and the Free‐Will Defense Natural Disasters and other Terrible Things, and the Free‐Will Defense Suggested Reading.

Moves from is to good—that is, principles that link fact to value—are fundamental to environmental ethics. The upshot is fourfold: (1) for nonanthropogenic goods, only those moves from is to good are defensible which conceive goodness as goodness for biotic entities; (2) goodness for nonsentient biotic entities is contribution to their autopoietic functioning; (3) biotic entities also function “exopoietically” to benefit related entities, and these exopoietic benefits are on average greater than their own goods; and (4) the most general is-to-good (...) principles that are defensible (and hence the ones of greatest importance for environmental ethics) concern a realm of nonanthropogenic goodness that encompasses both living and nonliving nature. (shrink)

This concise, well-structured survey examines the problem of evil in the context of the philosophy of religion. One of the core topics in that field, the problem of evil is an enduring challenge that Western philosophers have pondered for almost two thousand years. The main problem of evil consists in reconciling belief in a just and loving God with the evil and suffering in the world. Michael Peterson frames this issue by working through questions such as the following: What is (...) the relation of rational belief to religious faith? What different conceptual moves are possible on either side of the issue? What responses have important thinkers advanced and which seem most promising? Is it possible to maintain religious commitment in light of evil? Peterson relies on the helpful distinction between moral and natural evil to clarify our understanding of the different aspects of the problem as well as avenues for response.The overall format of the text rests on classifying various types of argument from evil: the logical, the probabilistic, the evidential, and the existential arguments. Each type of argument has its own strategy which both theists and nontheists must recognize and develop. Giving both theistic and nontheistic perspectives fair representation, the text works through the issues of whether evil shows theistic belief to be inconsistent, improbable, discredited by the evidence, or threatened by personal crisis.Peterson explains how defensive strategies are particularly geared for responding to the logical and probabilistic arguments from evil while theodicy is an appropriate response to the evidential argument. Theodicy has traditionally been understood as the attempt to justify belief in a God who is all-powerful and all-good in light of evil. The text discusses the theodicies of Augustine, Leibniz, Hick, and Whitehead as enlightening examples of theodicy. This discussion allows Peterson to identify and evaluate a rather dominant theme in most theodicies: that evil can be justified by designating a greater good. In the end, Peterson even explores how certain types of theodicy, based on specifically Christian renditions of theism, might provide a basis for addressing the existential problem of evil. The reader of this book gains not only an intellectual grasp of the debate over God and evil in professional philosophy but also the personal benefit of thinking through one of the most important issues in human life. (shrink)

Several defences, viewed in this study as specifications or 'offspring' of the 'parent' greater-good defence, have been formulated in response to the charge that Christianity is untenable because God's existence is incompatible with evil's existence. In this first book-length study of the parent defence, Stewart begins with careful definitions of the omni-attributes central to the dispute: omnipotence, omniscience, omnibenevolence. The parent defence is traced to tenets of theism and variant accounts of the defence considered. Plantinga's modal free-will defence and Hick's (...) and Yandell's soul-growth specifications are carefully analyzed and several difficulties resolved. An original formulation of a redemption specification and an original account of the origin of moral evil are offered. Stewart argues that the defences are rightly viewed as a family of defences falling under the greater-good heading, and that they comprise a complementary apologetic complex that refutes the claim of inconsistency. (shrink)

Attempts to resolve the problem of evil often appeal to a greater good, according to which God’s permission of moral and natural evil is justified because (and just in case) the evil that is permitted is necessary for the realization of some greater good. In the extensive litany of greater good theodicies and defenses, the appeal to the greater good of an afterlife of infinite reward or pleasure has played a minor role in Christian thought but a more important (...) role in Islamic thought. In a recent article, Seyyed Jaaber Mousavirad invites us to reconsider a greater good theodicy of compensation. He contends that not only are all evils justified in that God compensates the sufferer in an afterlife, but because evils experienced produce some good, God has reason for bringing about or allowing evils in the first place (Mousavirad 211). In what follows I argue that this modified compensation theodicy is flawed in its premises, faces serious problems about its concept of justice, treats people as means only and not as intrinsically valuable, and ultimately fails to show that an afterlife compensation, along with some good produced here and now by evil, justify God bringing about or allowing evil. (shrink)

Photo ID 222412412 © US Navy Medicine | Dreamstime.com ABSTRACT In a non-military setting, the answer is clear: it would be unethical to treat someone based on non-medical considerations such as nationality. We argue that Battlefield Triage is a moral tragedy, meaning that it is a situation in which there is no morally blameless decision and that the demands of justice cannot be satisfied. INTRODUCTION Medical resources in an austere environment without quick recourse for resupply or casualty evacuation are often (...) limited. The shortage extends not only to supplies like blood products and drugs, but physicians and other medical personnel. In the midst of a mass casualty scenario, such as a battle that includes intense ground fighting, the medical staff will stretch scarce resources and triage casualties according to specific criteria. Typically, they proceed by providing care for the most severely wounded first, referred to here as conventional triage. At times, though, the staff may reverse the triage so that soldiers with minor wounds can return to the fight. In a mass casualty situation, when medical personnel apply conventional triage and treat casualties from opposing forces, a dilemma may arise. We argue that it can be permissible for military physicians to prioritize their own soldiers over enemy combatants in a mass casualty triage, where reverse triage does not apply. The case we will focus on is as follows: Battlefield Triage: During combat operations on a remote island in the Pacific Ocean, a compatriot soldier and an enemy combatant arrive at the compatriot soldier country’s medical treatment facility. Both have similar gunshot wounds to the abdomen, and they arrive with similar conditions. Both have low oxygen saturation and excessive blood loss. The sole physician only has enough time to stabilize one person. The scenario is brief, and we are aware that medical rules of eligibility will most often dictate how the physician proceeds,[1] but this scenario is useful in setting up the question we focus on in this paper: would it be wrong to favor the stabilization of a soldier just because the soldier is the physician’s compatriot? In other words, can nationality serve as an ethically justified tiebreaker in a situation such as Battlefield Triage?[2] In a non-military setting, the answer is clear: it would be unethical to treat someone based on non-medical considerations such as nationality. The AMA’s Code of Medical Ethics asserts that physicians have “ethical obligations to place patients’ welfare above their self-interest and above obligations to other groups.”[3] The World Medical Association’s Declaration of Tokyo affirms that “no motive, whether personal, collective or political, shall prevail against this higher purpose” of alleviating distress.[4] Physicians are taught early on that triage decisions must be medically indicated and made without consideration of factors such as race, ethnicity, religion, social status, and nationality. They are taught that public trust and obligations of justice grounded in equality demand that only medical indications be considered. But military physicians in a military setting are beholden to obligations, duties, and responsibilities as members of the military, and when these obligations, duties, and responsibilities conflict, as they do in Battlefield Triage, which loyalties win out and why?[5] Critics of partiality on national grounds argue that partiality undermines public trust in medicine and justice because everyone should be treated equally regardless of nationality.[6] Proponents of partiality argue that military obligations supersede equality and that justice requires partiality in such cases.[7] Despite the critics’ disagreement, both agree that there is a morally right, perhaps even blameless, course of action. Drawing on insights from virtue ethics, we argue that Battlefield Triage is a moral tragedy in which justice is unattainable and there is no action without moral cost. The assumption that there is a morally right choice is flawed. We argue that while no decision in this scenario is free from moral blame, there are reasons to favor treating one’s soldiers over enemy combatants. I. The Case Against Partiality There is a common assumption that there is a morally right or just decision in Battlefield Triage. A number of organizations and scholars claim that it is wrong for military physicians to favor their own soldiers on the grounds of nationality or some form of ‘group membership.’ (In a conflict involving service members from multiple nations working as a coalition, a soldier from an allied country may receive the same priority as the US service member due to ‘group membership.’) The World Medical Association’s WMA Declaration of Lisbon on the Rights of the Patient, which was reaffirmed in 2015, posits that, “[i]n circumstances where a choice must be made between potential patients for a particular treatment that is in limited supply, all such patients are entitled to a fair selection procedure for that treatment. That choice must be based on medical criteria and made without discrimination.”[8] This echoes what was set forth in Article 12 of the Geneva Conventions, which states that “[o]nly urgent medical reasons will authorize priority in the order of treatment to be administered.”[9] The argument for impartiality in Battlefield Triage is that every person is morally equal, and equality entails that medical distribution is, “based on a combination of medical need and urgency.”[10] This is in keeping with the bioethical principles that are generally applied.[11] II. The Case for Partiality On the other side, there are arguments that favoritism is the ethically right decision in Battlefield Triage.[12] The argument asserts that members of the military form a morally significant community of friends and participation in these relationships demands partiality. Just as parents have strong ethical duties to their children and not just any children, military personnel have ethical duties to their group, a group that involves an affirmation of mutual aid and support. Some have termed these ‘associative duties. According to Michael Gross, obligations of friendship, care, and solidarity “leave very little room for generally applicable principles of justice that would obligate a medic to treat enemy or non-compatriot wounded ahead of their compatriots.”[13] This is true in Battlefield Triage, but it may also be true even if the enemy’s soldier were more seriously wounded: “the ethics of small group cohesion, largely an ethics of care, mostly replaces the demands of impartial justice.”[14] In a more recent article, Gross explains that preferential treatment is ethically justified based on fighting capability and “the special obligations people owe friends, family, and, no less, comrades-in-arms.”[15] To not show partiality to the US soldier would be morally wrong on the grounds of friendship and mutual care.[16] III. The Moral Tragedy of Battlefield Triage Defenders and critics of Battlefield Triage favoritism based on nationality both frame their position as just or fair. For example, Justin List argues that physicians are “bound to practice medical neutrality,”[17] Marcus Adams denies that physicians “possess special ethical obligations” to enemy combatants because of their profession.[18] These perspectives assume that there is a morally right decision and that justice is attainable. The assumption that there is or can be a morally right Battlefield Triage decision, and we need to put our heads together to figure it out, remains strongly entrenched. However, the facts of the situation should give us pause; there are too many people and too few resources, and this demands a decision-making process that determines who will receive scarce resources. By its very nature, a battlefield triage decision has to be made based on some characteristic or value, a characteristic or value that will inevitably favor some at the expense of others. This is precisely why competing analyses “in the military context struggle to resolve these conflicts satisfactorily.”[19] Drawing on the insights of virtue ethics, we suggest that Battlefield Triage is a moral tragedy. Virtue ethics suggests that morality is about acting virtuously, which is to say that we should do what a virtuous person would do in the situation. Ethics is about figuring out how a just, wise, compassionate, loving, and fair person would act, and then doing that, as one grows in virtue. But life is not always clear cut, and it is possible that virtuous people may find themselves in a moral tragedy, a situation in which, through no fault of one’s own, a person must make a morally objectionable decision. After the action the virtuous person “emerges having done a terrible thing, the very sort of thing that the callous, dishonest, unjust, or in general vicious agent would characteristically do.”[20] Stated differently, a moral tragedy presents a virtuous person with two or more courses of action, all of which have a moral cost.[21] In Battlefield Triage, no matter how the physician goes about deciding, there is going to be defensible concern from those not saved. The fact that there are more people than can be helped fosters competing values in battlefield triage: maximize lives saved, treat people equally, treat the worse off, and support the war effort. Treating people equally may create tension between treating the worse off, maximizing lives saved, and supporting the war effort. Reverse triage is a case in point, as supporting the war effort conflicts with treating the worse off first, as is a fair lottery system since deploying a lottery may not maximize lives saved or support the war effort. There can be reasons why one person is selected over another, to be sure. Yet, there are reasons for making a decision, and that the decision is subject to legitimate moral concern is another. To recognize the moral tragedy of Battlefield Triage is to recognize the impossibility of acting blamelessly in the situation. In this situation, the virtuous military physician is going to have to sacrifice important values such as justice, compassion, and respect for others, even with a defensible criterion in hand. The physician will grieve this sacrifice accordingly. The physician may find her decision difficult or stressful, and rightly so, because of what her circumstances require of her. This kind of moral tragedy results “in actions which betray and violate the rights of persons to whom there may be a strong duty of care. When this happens, it properly triggers an appropriate moral emotion since our moral integrity has been violated and this affects how we think of ourselves and what we have become.”[22] Rather than view her triage decision as the morally superior choice, the virtuous military physician will view her decisions in these circumstances in a different light: it is the least bad option in a terrible situation, and she did something ethically problematic, something that is contrary to her moral character. She deeply regrets the circumstances in which she had to act. IV. Virtue Ethics A virtue ethicist has insight into how one should go about deciding what to do in a moral tragedy, although virtue ethics may not be as helpful as one may hope. The goal of the virtuous military physician in Battlefield Triage is to adopt the best course of action or the action that she feels she ought to do, all things considered. This does not make her choice devoid of serious wrongdoing—a decision must be made, but that does not make it just. The virtuous military physician will approach the situation with courage, responsibility, and insight. She will think about the decision carefully, wisely, and conscientiously; she will weigh the goods and harms of the choices before her, in conjunction with a proper conception of the good life, human worth, and understanding of her obligations to others—including chain of command, fellow soldiers, and the medical community. She is attuned to the value of human life and has a reasonable idea of the various ways her decisions will affect others. She recognizes that she is in this non-ideal situation through no fault of her own: she is not the one fighting in battles; she is serving her country as a physician, whose job it is to save lives, treat everyone justly, and promote military objectives. She regrets the decision she is forced to make in battlefield triage, acting “with immense regret and pain,” Hursthouse explains, “instead of indifferently or gladly.”[23] This is because, no matter what decision is made, the virtuous military physician “does something terrible or horrible,” something she otherwise would not do and is contrary to her values.[24] V. A Resolvable Moral Tragedy Instead of asking whether there is a morally right decision, in which a decision is morally blameless and above reproach, the virtue ethicist asks whether there is a decision with a convincing rationale, knowing that a decision can have a clear rationale but still be morally tragic. It is perfectly reasonable to think that different virtuous persons will arrive at different courses of action: “two virtuous agents, in the same situation,” Hursthouse writes, “may act differently” in irresolvable moral tragedies, in cases in which there is no clear course of action.[25] Because a person must act in a moral tragedy, one goal is to identify reasons for choosing the chosen action. Some decisions are clearly indefensible—treating neither the compatriot soldier nor the enemy combatant in Battlefield Triage would be wrong—and some decisions are more problematic than others. If the military physician selects to treat the soldier because she does not like the enemy combatant’s skin color, such a reason would be deeply problematic. But much of the debate over how to act in a moral tragedy is not over clearly indefensible or problematic criteria. Instead, the literature is largely about different standards or implementations of justice. Some scholars defend nation-impartial triage as right, while others defend nation-aware triage as right, and each argues that the other side is promoting an unjust or otherwise wrong solution to Battlefield Triage. We suggest that Battlefield Triage is a resolvable moral tragedy and that virtue ethics offers convincing reasons to prefer the treatment of the compatriot soldier rather than the enemy combatant on the grounds of national identity. Virtues are integral to living a good life, a flourishing life, but as Aristotle observed long ago, human beings are inherently social, interdependent and interconnected in profound ways.[26] This goes beyond the obvious fact that we need each other to survive day to day (one person makes clothes, another farms, and another makes tools); the claim is that a good or flourishing life depends in large part on one’s social network or community. This is why many of Aristotle’s moral virtues are other facing: justice, friendship, generosity, and magnanimity, to name a few. Courage, a typically self-facing virtue, is understood by Aristotle to be the virtue that regards one’s fear of death in battle, a battle fought on behalf of one’s city.[27] All of this remains true today. Namely, there is an important sense in which our community matters to our lives: it is easier to live a good, flourishing life if one is part of a good, flourishing community. Our community is made up of smaller groups, and it is more accurate to say that we are simultaneous members of different groups within a broader community. A person may be part of a family, friend group, research team, large state university, city, state, and nation. Groups can function well or not, as we all have experienced, and this suggests that there are virtues or excellences that groups can instantiate. Good groups are unified in purpose, with each member doing their duty alongside others for the attainment of that purpose. Good groups manifest solidarity among their members. Although Aristotle does not list solidarity as a virtue, a number of modern-day virtue ethicists have begun examining how group solidarity can be a virtue that contributes to a good or flourishing life.[28] Solidarity is not conceptualized as an individual virtue, a virtue possessed by a person in isolation of others; instead, it is a collective virtue, a virtue that is shared among members of a defined group with particular ends.[29] “A group has solidarity to the extent that its members are disposed to: (1) share values, aims, or goals; (2) care about those values, aims, or goals; (3) act in accordance with those values, aims, or goals; (4) trust the testimony of other group members with respect to those values, aims, and goals; and (5) feel a sense of belonging to the group.”[30] The virtue of collective or group solidarity involves individuals having special concern for each other, shared aims and values, trust, loyalty, and a sense of belonging with these specific others. There is a oneness to the group in the pursuit of a definite goal or purpose, involving mutual support and affirmation of each member. As such, the group has ends and goods above and beyond the good of each individual person. Sometimes solidarity requires personal sacrifice for the collective (for example, a father sacrificing food so his child can eat). The virtue of collective or group solidarity is important to the military and medical community at every level, and for clear reasons. In the military, there is a clear hierarchy of command, unity of purpose and end, mutual trust and support in complex settings, and so on. Soldiers need to know they can count on one another, and solidarity grounds a soldier’s ability to trust others and be assured of mutual aid. In medicine, solidarity maintains self-regulation of the profession, shared values and goals, as well as public support, not to mention that day-to-day operations require physician trust, engagement, and effort toward the ends of clinical care. Physicians need to work together, along with others, in pursuit of health, and disunity is sowed when there is mistrust, selfishness, or disengagement among the healthcare team and organization. Importantly, just as we are all members of various groups and hence may manifest group solidarity in different settings, the virtuous military physician instantiates collective solidarity with both the medical profession and the military. Her dual loyalty contributes to the moral difficulty of acting in Battlefield Triage. The military physician has competing obligations to distinct groups and cannot satisfy all obligations in Battlefield Triage. Solidarity with the military supports the consideration of favoring the soldier for reasons of national identity, whereas solidarity with the medical community does not. Something has to give, which is why it is a moral tragedy. The virtuous military physician, therefore, must weigh the costs of each course of action. To fulfill her obligations to the medical community would require that she does not use nationality and other non-medical considerations in Battlefield Triage. Since the soldier and enemy combatant are equally injured, justice would demand a random process, perhaps a flip of the coin. Although this may satisfy obligations the military physician has to the medical community, this would be costly to the physician’s military group. If word gets out that the physician decides who to treat based on a coin toss, soldiers, families, and citizens may become frustrated and angry. Soldier morale may go down if it becomes known that a coin flip led to the preventable death of a soldier and the saving of an enemy combatant who had killed (or attempted to kill) other soldiers. As Gross highlights, military solidarity involves a mutual aid promise that military personnel promise to help one another.[31] A military physician is part of the military and, as such, is part of the mutual aid promise, which would appear to be violated if the physician flips a coin. Treating a member of one’s own team may be psychologically more beneficial than treating an enemy combatant and may lead to less moral distress.[32] Finally, treating soldiers rather than enemy combatants promotes broader military and social aims, including returning soldiers to health, maintaining unity of purpose, and minimizing community suffering from a soldier’s death. Favoring members of one’s group, that is, triage based on nationality in Battlefield Triage, would fulfill obligations of military group loyalty, which is contrary to the values and duties of medicine. It does not seem as though showing favoritism in this particular situation is very costly to the medical community or general public, but this is because there is recognition that the physician is in the military. Medicine is impartial to non-medical indications partly because of fairness and to promote public trust in medicine. However, Battlefield Triage is unique, as medicine is being practiced in a non-public, wartime setting. In ordinary circumstances, a patient’s identity is irrelevant, and physicians ought not play favorites. Since Battlefield Triage is not an ordinary circumstance, decisions based on patient identity may not undermine public trust in medicine. In addition, it is contestable that fairness in Battlefield Triage requires that no consideration be paid to one’s nationality. Fairness is about giving each person their due, what is owed to them, and the case can be made that soldiers who place themselves in danger for the sake of the common good or a just cause are owed special attention when they suffer harm in the line of duty. In other words, soldiers voluntarily undergo risk to themselves for the greater good, and society owes them for this sacrifice. This plausibly includes preferential treatment in a situation such as Battlefield Triage. So, while the medical community affirms justice demands non-preferential treatment, the military community can affirm the opposite. The demands of fairness are unclear at best or in conflict in this situation: demands of physician justice decry favoritism, while demands of military justice support favoritism. Triage not based on nationality is arguably unfair and triage based on nationality may not undermine public trust, after all. All things considered, there is a clear rationale for favoring nationality-based preferential treatment in Battlefield Triage. Adopting a nationality-based preference in this situation is more defensible than not. This does not make such a decision ethically right or just. Preference based on nationality is the least bad decision, but it is not morally blameless. It involves one in a serious moral wrong, a wrong otherwise avoided and contrary to one’s character. The virtuous military physician is in a situation in which obligations conflict, and we disagree with Gross, who posits that care of fellow soldiers “is important to the near exclusion of all else.”[33] Gross fails to appreciate the collective virtue of solidarity as applied to those in medicine. The military physician has duties to fellow soldiers but also to fellow physicians, to the medical community, and humanity. To favor a soldier on grounds of nationality violates her duties and responsibilities to this latter group. She is involved in a moral tragedy and can only seek the most just action given the circumstances, yet, at least in virtue ethics, the action remains far from blameless. CONCLUSION We argue that Battlefield Triage is a moral tragedy, meaning that it is a situation in which there is no morally blameless decision and that the demands of justice cannot be satisfied. As such, the virtuous military physician incurs a moral cost to acting as she does—there is a moral residue. However, despite being a moral tragedy, there are clear reasons to act in favor of treating one’s own, considering group solidarity. As such, these kinds of tragedies are resolvable: virtuous military physicians should favor treatment of their own, although they would do so with sorrow. - [1] Militaries set forth medical rules of eligibility or guidelines used to determine whether a person qualifies for specific medical interventions or treatments in certain circumstances, and these guidelines are binding for a military physician. For example, despite opposition from medical organizations, militaries have adopted reverse triage guidelines for military physicians to follow. For ethical discussion, see Falzone, Elisabeth, P. Pasquier, C. Hoffmann, O. Barbier, M. Boutonnet, A. Salvadori, A. Jarrassier, J. Renner, B. Malgras, and S. Mérat. "Triage in military settings." Anaesthesia Critical Care & Pain Medicine 36, no. 1 (2017): 43-51. https://doi.org/10.1016/j.accpm.2016.05.004 [2] There are issues that are related to this, including the triage of civilians and allied soldiers. We set related issues aside for purposes of this paper [3] American Medical Association, Code of Medical Ethics: Current Opinions with Annotations, 2004–2005 ed. (Chicago, IL: AMA, 2004), 300. [4] American Medical Association, Code of Medical Ethics: Current Opinions with Annotations, 2004–2005 ed. (Chicago, IL: AMA, 2004), 300. [5] This is termed the “dual loyalty” dilemma in military medicine and has been described at length elsewhere: Institute of Medicine (US) Board on Health Sciences Policy. Military Medical Ethics: Issues regarding Dual Loyalties: Workshop Summary. Washington (DC): National Academies Press (US); 2008. Toward a Framework for Resolving Dual Loyalties. Available from: https://www.ncbi.nlm.nih.gov/books/NBK214853/ [6] See Kenneth G. Swan and K.G. Swan, Jr., “Triage: The Past Revisited,” Military Medicine 161:8 (1996): 448–452. https://doi.org/10.1093/milmed/161.8.448; Jerome A. Singh, “American Physicians and dual loyalty obligations in the ‘war on terror,’” BMC Medical Ethics 4.4 (2003): 1–10. https://doi.org/10.1186/1472-6939-4-4; Beam, Thomas E. "Medical Ethics on the Battlefield." Military Medical Ethics: Sect. IV. Medical ethics in the military. Medical ethics on the battlefield: the crucible of military medical ethics 2 (2003): 369-402; Hereth, Blake. "Health justice for unjust combatants." Journal of Military Ethics 20, no. 1 (2021): 67-81. https://doi.org/10.1080/15027570.2021.1949782. [7] See Adams, Marcus P. "Triage priorities and military physicians." In Physicians at war: The dual-loyalties challenge, pp. 215-236. Dordrecht: Springer Netherlands, 2008. Gross, Michael L. "Comradery, community, and care in military medical ethics." Theoretical medicine and bioethics 32 (2011): 337-350. https://doi.org/10.1007/s11017-011-9189-6. Gross, Michael L. "The limits of impartial medical treatment during armed conflict." In Military medical ethics for the 21st century, pp. 71-84. Routledge, 2016. [8] World Medical Association, WMA Declaration of Lisbon on the Rights of the Patient. 5 December 2022, https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/ [9] Geneva Convention for the Amelioration of the Condition of Wounded, Sick in Armed Forces in the Field. 12 August 1949. https://www.un.org/en/genocideprevention/documents/atrocity-crimes/Doc.30_GC-I-EN.pdf. [10] List, Justin M. "Medical neutrality and political activism: physicians' roles in conflict situations." In Physicians at war: The dual-loyalties challenge, pp. 237-253. Dordrecht: Springer Netherlands, 2008. 240 [11] Beauchamp, T., and J. Childress. 2013. Principles of Biomedical Ethics, 7th ed. Oxford, United Kingdom: Oxford University Press. [12] Adams, Marcus P. "Triage priorities and military physicians." In Physicians at war: The dual-loyalties challenge, pp. 215-236. Dordrecht: Springer Netherlands, 2008. [13] Gross, "Comradery, community, and care in military medical ethics," 347. [14] Gross, “Comradery, community, and care in military medical ethics,” 349. [15] Gross, Michael L. "When medical ethics and military ethics collide." Narrative inquiry in bioethics 13, no. 3 (2023): 199-204. 202 https://dx.doi.org/10.1353/nib.2023.a924191 [16] Our argument draws on virtue ethics, from which care ethics derives, and it is worth clarifying how our argument relates to Gross’s. We do not think that the virtue of friendship grounds triage decisions, for we think it is unlikely that the physician and wounded soldier are friends. Instead, as explained below, we think the collective virtue of group solidarity better captures the moral significance of group loyalty and that Gross would agree with us. But since military physicians are part of distinct groups, with competing obligations, the military physician will be forced to sacrifice a value in battlefield triage cases. In other words, we think Gross downplays the dual group membership of a military physician. [17] List,”Medical neutrality and political activism,” 250. [18] Adams,”Triage priorities and military physicians,” 235. [19] London, Leslie, Leonard S. Rubenstein, Laurel Baldwin-Ragaven, and Adriaan Van Es. "Dual loyalty among military health professionals: human rights and ethics in times of armed conflict." Cambridge Quarterly of Healthcare Ethics 15, no. 4 (2006): 381-391. 383. [20] Hursthouse, R. On Virtue Ethics. OUP 1999. 74 [21] Nussbaum, Martha C. "The costs of tragedy: Some moral limits of cost-benefit analysis." The Journal of Legal Studies 29, no. S2 (2000): 1005-1036, 1007. [22] De Wijze, S. (2005). Tragic-remorse–the anguish of dirty hands. Ethical theory and moral practice, 7(5), 453-471, 457. https://doi.org/10.1007/s10677-005-6836-x [23] Hursthouse, 73 [24] Hursthouse, 81 [25] Hursthouse, 72 [26] Aristotle, Politics 1253a8. Reeve, C. D. C., Indianapolis: Hackett Publishing Co., 2017 [27] Aristotle, Nicomachean Ethics. III.6.114a, 34-35. 2002, Nicomachean Ethics, Christopher Rowe (trans.), Oxford: Oxford University Press [28] Byerly, T. Ryan, and Meghan Byerly. "Collective virtue." The Journal of Value Inquiry 50, no. 1 (2016): 33-50. https://doi.org/10.1007/s10790-015-9484-y; Federico, Veronica. "Conclusion: solidarity as a public virtue." Solidarity as a Public Virtue (2018): 495-542. https://doi.org/10.5771/9783845290058. Rehg, William. "Solidarity and the common good: An analytic framework." Journal of Social Philosophy 38, no. 1 (2007): 7-21. https://doi.org/10.1111/j.1467-9833.2007.00363.x [29] Byerly and Byerly. "Collective virtue." 43 [30] Battaly, Heather. "Solidarity: Virtue or vice?." In Social virtue epistemology, pp. 303-324. Routledge, 2022. 304 [31] Ibid., 2011: 341 [32] It might be thought that displaying altruism by helping an enemy combatant at the expense of one’s fellow soldier may be psychologically satisfiying. For evidence that military physicians find it difficult to treat enemy combatants, see Lundberg, Kristina, Sofia Kjellström, Anders Jonsson, and Lars Sandman. "Experiences of Swedish military medical personnel in combat zones: adapting to competing loyalties." Military medicine 179, no. 8 (2014): 821-826. https://doi.org/10.7205/MILMED-D-14-00038. Lamblin, Antoine, Clément Derkenne, Marion Trousselard, and Marie-Ange Einaudi. "Ethical challenges faced by French military doctors deployed in the Sahel (Operation Barkhane): a qualitative study." BMC Medical Ethics 22 (2021): 1-13. https://doi.org/10.1186/s12910-021-00723-2 [33] Ibid., 2011: 344. (shrink)

During the coronavirus disease 2019 (COVID‐19) pandemic, bioethical analyses often emphasized population health and societal benefit. Hospital policies frequently focused on reducing risk of transmitting SARS‐CoV‐2 by restricting visitors; requiring protective equipment; and screening staff, patients and visitors. While restrictions can be burdensome, they are often justified as essential measures to protect the whole population against a virus with high rates of transmission, morbidity and mortality. Yet communities are not monolithic, and the impacts of these restrictions affect different groups differently. (...) An ophthalmological unit outreach program in Ethiopia serves to illustrate. Pre‐operative screening policies were designed to protect as many patients as possible but had adverse impacts on underserved communities. As this case study demonstrates, creating hospital policies that truly serve the good of the society may require a more holistic review of impacts on inequitably positioned communities. (shrink)

In this book, Garth L. Hallett offers the best book of its kind available today. Unlike many other apologiae for proportionalism, Hallet fully engages numerous contemporary moral philosophers, among them Robert Merrihew Adams, Alan Donagan, Judith Thomson, and Alan Gewirth, in addition to engaging Catholic theorists including Aquinas, Germain Grisez, and John Finnis. Hallet also merits commendation for breaking ranks with other proportionalists, particularly Peter Knauer, about not a few matters, most significantly the extent to which proportionalism governs the moral (...) life and the importance of the distinction between the "moral" and the "premoral.". (shrink)

"Hallett's fine book defends his earlier accounts of the right-making characteristics of moral acts."-Religious Studies Review.

The paper investigates how greater good theodicies are supposed to work, and argues that, in principle, appeal to greater goods can explain why God, if he exists, is justified in refraining from ensuring that there is little or no evil. (Readers interested in objections from alternative goods might also want to look at the rather different discussion of them in Section 7.11 of my book God, The Best, and Evil (OUP 2008).

With cutting-edge insights from leading European and North American scholars, this authoritative book addresses the fundamental problems of business in an age of crisis whilst presenting radical, but practical, solutions. The contributors explore three main value shifts: from inequality to equality, from the technical-materialistic to the ecological-spiritual, and from compliance and enforcement to autonomy and responsibility. A number of striking issues are addressed including the doctrine of self-interest, the purpose of business, codes of conduct, personal responsibility, existential perspectives on business (...) ethics and the development of ethical competence. This book will be an essential point of reference for academic researchers and postgraduate students in business ethics and corporate social responsibility, as well as practitioners interested in the relevance of business ethics to leadership, management, strategy and finance. (shrink)

Thomas Talbott has recently argued in this journal that the three propositions 1) God wills universal salvation 2) God has the power to produce universal salvation and 3) some persons are not saved are inconsistent. I contend that this claim is only true if God has no overriding purposes that would place restrictions on the means God uses to achieve God’s ends. One possible example of such an overriding purpose would be God’s aim to produce the most good. I end (...) by suggesting that while God’s purpose of universal salvation does render the achievement of this end probable, it is by no means necessary. (shrink)

The Good Life and the Greater Good in a Global Context brings together scholars working in the fields of the humanities and social sciences who critically examine the notion of the "good life," understood in all of its dimensions--material, psychological, moral, emotional, and spiritual--and in relation to the greater good. In so doing, the authors provide interdisciplinary insights into what the good life means today and how a viable vision of it can be achieved to benefit not just individuals but (...) our interdependent world as well. (shrink)

Cicero’s first speeches as consul, de lege agraria I and II, delivered to the senate and the people respectively, are virtually identical in outline and broad argument. That allows the rhetorical technique of individual sections to be compared closely. This article uses such comparisons to probe the tactics and ideology of the speeches. In both Cicero’s choice of word and phrase might suggest that he is simply addressing his audiences as suits their stations. But a consideration of the circumstances of (...) the speeches reveals instead that Cicero is directing his audiences to alternate ways of imagining their social and political positions; in effect, Cicero propounds distinct, principled, and communalist definitions of dignitas and libertas, core values of each audience – though sometimes at the price of distorting the intent of the bill. (shrink)

Epistemological theories of knowledge and justification draw a crucial distinction between one's simply havinggood reasons for some belief, and one's actually basingone's belief on good reasons. While the most natural kind of account of basing is causal in nature--a belief is based on a reason if and only if the belief is properly caused by the reason--there is hardly any widely-accepted, counterexample-free account of the basing relation among contemporary epistemologists. Further inquiry into the nature of the basing relation is therefore (...) of paramount importance for epistemology. Without an acceptable account of the basing relation, epistemological theories remain both crucially incomplete and vulnerable to errors that can arise when authors assume an implausible view of what it takes for beliefs to be held on the basis of reasons. Well-Founded Beliefbrings together seventeen essays written by leading epistemologists to explore this important topic in greater detail. The collection is divided thematically to cover a wide range of issues related to the epistemic basic relation. The first section of essays covers the nature of the basing relation and attempts to articulate defensible accounts of what it takes to believe on the basis of a reason. Section II explores the kind of things that can be reasons on the basis of which we hold beliefs. Finally, the last section addresses the basing relation as it bears on particular problems in epistemology, such as skepticism, the analysis of knowledge, and the contingencies of our epistemic upbringing. (shrink)

People often judge it unacceptable to directly harm a person, even when this is necessary to produce an overall positive outcome, such as saving five other lives. We demonstrate that similar judgments arise when people consider damage to owned objects. In two experiments, participants considered dilemmas where saving five inanimate objects required destroying one. Participants judged this unacceptable when it required violating another’s ownership rights, but not otherwise. They also judged that sacrificing another’s object was less acceptable as a means (...) than as a side-effect; judgments did not depend on whether property damage involved personal force. These findings inform theories of moral decision-making. They show that utilitarian judgment can be decreased without physical harm to persons, and without personal force. The findings also show that the distinction between means and side-effects influences the acceptability of damaging objects, and that ownership impacts utilitarian moral judgment. (shrink)

As the crisis around Covid-19 evolves, it becomes clear that there are numerous negative side-effects of the lockdown strategies implemented by many countries. Currently, more evidence becomes available that the lockdowns may have more negative effects than positive effects. For instance, many measures taken in a lockdown aimed at protecting human life may compromise the immune system, and purpose in life, especially of vulnerable groups. This leads to the paradoxical situation of compromising the immune system and physical and mental health (...) of many people, including the ones we aim to protect. Also, it is expected that hundreds of millions of people will die from hunger and postponed medical treatments. Other side effects include financial insecurity of billions of people, physical and mental health problems, and increased inequalities. The economic and health repercussions of the crisis will be falling disproportionately on young workers, low-income families and women, and thus exacerbate existing inequalities. As the virus outbreak and media coverage spread fear and anxiety, superstition, cognitive dissonance reduction and conspiracy theories are ways to find meaning and reduce anxiety. These behavioral aspects may play a role in the continuance of lockdown decisions. Based on theories regarding agnotology (i.e. the ways ignorance or doubt about certain topics is created by means of withholding or presenting information in a certain way), social influence, superstition and stress and coping, I seek to explain the social and behavioral aspects of human behavior in times of crises. Both the Covid-19 crisis itself as well as the resulting economic and (mental) health crisis are global problems that may require global solutions. I present a model of drivers and outcomes of lockdown behaviors and offer suggestions and a tool to counteract the negative psychological effects by means of online life crafting therapeutic writing interventions. (shrink)

"Contents "--"Introduction: Diving into the Wreck" -- "1. Trial of the Archangels" -- "2. Epicurus at the Scaffold" -- "3. Nasty, British, and Short" -- "4. The Monkey in the Panopticon" -- "5. In Which We Wonder Who Is Crazy" -- "6. Epicurus Unchained" -- "Afterword: The Restoration of the Monarchy" -- "Notes" -- "Bibliography.

The central theme of this paper is that the development of a technology that is predicted to have a major impact on the way we transact with each other should be a matter where the needs of society at large are taken into account. Where the technology is one that emerges from the domain of the Internet, inclusivity becomes even more acute in order to avoid widening the already existing gap in reaping the “digital dividend.” With blockchain, the obligation could (...) even be seen as a moral one, as blockchain is said to have the potential to negate the scope for the abuse of trust by states and institutions. This could be a game changer in areas such as public procurement and the conduct of elections where abuse can lead to the denial of essential resources and a concomitant loss of life, or to conflict and mass killings. Blockchain presents an opportunity for the Internet development community to claim a degree of recognition in the human rights realm by aiding civil intervention in areas where military intervention has been deemed inappropriate. (shrink)

J.L. Schellenberg argues that one reason to think that God does not exist is that there are people who fail to believe in Him through no fault of their own. If God were all loving, then He would ensure that these people had evidence to believe in Him so that they could enter into a personal relationship with Him. God would not remain ‘hidden’. But in the world, we actually do find people who fail to believe that God exists, and (...) their nonbelief does not seem to be due to their resisting God. I argue that if there are valuable goods brought about by God’s hiddenness, then even if each of those goods might obtain without hiddenness, God would have a sufficient reason for remaining hidden so long as enough of those goods would be made sufficiently more valuable because of God’s hiddenness. If this is the case, then the existence of ‘nonresistant nonbelievers’ in the actual world does not entail that God does not exist. (shrink)

New Threats to Freedom In the twentieth century, free people faced a number of mortal threats,ranging from despotism, fascism, and communism to the looming menace of global terrorism. While the struggle against some of these overt dangers continues, some insidious new threats seem to have slipped past our intellectual defenses. These often unchallenged threats are quietly eroding our hard-won freedoms and, in some cases, are widely accepted as beneficial. In New Threats to Freedom, editor and author Adam Bellow has (...) assembled an all-star lineup of innovative thinkers to challenge these insidious new threats. Some leap into already raging debates on issues such as Sharia law in the West, the rise of transnationalism, and the regulatory state. Others turn their attention to less obvious threats, such as the dogma of fairness, the failed promises of the blogosphere, and the triumph of behavioral psychology. These threats are very real and very urgent, yet this collection avoids projecting an air of doom and gloom. Rather, it provides a blueprint for intellectual resistance so that modern defenders of liberty may better understand their enemies, more effectively fight to preserve the meaning of freedom, and more surely carry its light to a new generation. What are the new threats to freedom? when has authority not claimed, when imposing trammels and curbs on liberty, that it does so for a wider good and a greater happiness?” —Christopher Hitchens “The regulatory state amounts to a regressive tax that penalizes small independent producers and protects the status quo.” —Max Borders “Europe tends to favor stability over democracy, America democracy over stability.” —Daniel Hannan “The value of free expression is perceived to be at odds with goals that were considered ‘more important,’ like inclusiveness, diversity, nondiscrimination, and tolerance.” —Greg Lukianoff “The masses cannot ultimately be free: only the individual can be.” —Robert D. Kaplan “That old bugbear of postwar sociology—the mob-self—is now a reality. In a participatory/popularity culture, the freedom to think and act for ourselves becomes harder and harder to achieve.” —Lee Siegel “As traditional marriage declines, the ranks of single women are growing, and increasingly these women are substituting the security of a husband with the security of the state.” —Jessica Gavora “Ending the freedom to fail is a mean-spirited attack on the freedom to succeed.” —Michael Goodwin “The only solution to the new threats to American press freedom lies in organized resistance.” —Katherine Mangu-Ward “The new behaviorism isn’t interested in protecting people’s freedom to choose; on the contrary, its core principle is the idea that only by allowing an expert elite to limit choice can individuals learn to break their bad habits.” —Christine Rosen “There’s a world of Travis Bickles out there, and they’re not driving cabs. They’re reading blogs.” —Ron Rosenbaum “The first amendment ensures not that speech will be fair, but that it will be free. It cannot be both.” —David Mamet Join the conversation about these issues at www.newthreatstofreedom.com. (shrink)

Given the increasing complexity of living in a global village, countries and regions that are parts of larger political entities frequently have considered the option of separating or seceding an ideal solution to their problems with a larger center of power. Isolation, a form of “freedom from,” has the potential of offering them free rein or “freedom to” manage their affairs for their own sake. Francophone playwrights and filmmakers have found the dialectical interplay between “freedom from” and “freedom to” fertile (...) dramatic soil for plays and films. Some of them work in both of these and other genres. These works seem to ask the same question: Is it desirable or possible to achieve both, even in ideal isolation, without suffering cultural stagnation or repeating the abuse of power on the part of the political center that led to the separation? This article explores the answers to this question given in the plays of Aimée Césaire, Anne Hébert, and Wajdi Mouawad within the greater context for this issue found in J. M. Coetzee’s Waiting for the Barbarians and Azouz Begag’s Un Mouton dans la baignoire and in francophone films by Raoul Peck, Bertrand Tavernier, Claire Denis, Rachid Bouchareb, Ousmane Sembène, Michael Haneke, and Mathieu Kasovitz. (shrink)

Gordon Knight recently challenged my assumption, which I made for the purpose of organizing and classifying certain theological disputes, that a specific set of three propositions is logically inconsistent . In this brief rejoinder, I explain Knight’s objection and show why it rests upon a misunderstanding.

In Paths of Glory (Stanley Kubrick, 1957) the individual's moral intent is distorted, compromised, and eventually co-opted by the overriding utilitarian ethic of ensuring the survival of the system – the ultimate ‘greater good’ – at all costs. The individual may challenge the system in a noble quest for justice, like Dax. He may hypocritically seek professional advancement from striving to serve it, like Mireau. Or he may cynically manipulate it for political purposes, like Broulard. In each case, the consequences (...) are ultimately the same – the individual is forced to align his particular moral vision, however noble or ignoble, with the imperative of the greater good. The individual may resist or affirm the system and achieve some level of moral consistency and purity, but only momentarily and with limited success. In the end, whatever the value or relevance of the individual conscience to a particular situation, it is overridden by the demands of the greater good. -/- . (shrink)

This paper considers the arguments that could support the proposition that intellectual property rights as applied to softwarehave a moral basis. Undeniably, ownership rights were first applied to chattels and land and so we begin by considering the moral basis of these rights. We then consider if these arguments make moral sense when they are extended to intellectual phenomenon. We identified two principal moral defenses: one based on utilitarian concerns relating to human welfare, the other appeals to issues of (...) individual autonomy and private control. We conclude that intellectual property rights could not be defended from a moral perspective that emphasizes autonomy and individual control because copyright and patent restrict fundamental freedoms to transfer and redistribute one’s property. We also find it difficult to defend intellectual property in software from a utilitarian perspective because of the current structure of the market. We mention two characteristics of the software market that make it distinct and promote monopolistic conditions and excessive profit taking: the facility of replication, and the need for compatibility in operating systems. We conclude that there are good reasons to reverse the current market’s structure. We suggest three possible remedies. The government could rigorously enforce antitrust legislation, impose greater monitoring and price controls, or obviate the commercial aspect altogether by denying the application of intellectual property rights to software. (shrink)

John Schellenberg argues that God would never withhold the possibility of conscious personal relationship with Him from anyone for the sake of greater goods, since there simply would not be greater goods than a conscious personal relationship with God. Given that nonresistant nonbelief withholds the possibility of such relationship, this entails that God would not allow nonresistant nonbelief for the sake of greater goods. Thus, if Schellenberg is right, all greater goods responses to the hiddenness argument must fail in principle. (...) I argue that there are good reasons for thinking that greater goods responses do not, for the above reason, fail in principle. (shrink)

An orthodox view in marketing ethics is that it is morally impermissible to market goods to specially vulnerable populations in ways that take advantage of their vulnerabilities. In his signature article “Marketing and the Vulnerable,” Brenkert (Bus Ethics Q Ruffin Ser 1:7–20, 1998) provided the first substantive defense of this position, one which has become a well-established view in marketing ethics. In what follows, we throw new light on marketing to the vulnerable by critically evaluating key components of Brenkert’s general (...) arguments. Specifically, we contend that Brenkert has failed to offer us any persuasive reasons to think that it is immoral to market to the vulnerable in ways that take advantage of their vulnerability. Although Brenkert does highlight the fact that the specially vulnerable are at greater risk of being harmed by already immoral marketing practices (e.g., deception, manipulation), he fails to establish that the specially vulnerable are a unique moral category of market clients or that there are special moral standards that apply to them. Moreover, even if Brenkert’s position were theoretically defensible, the practical implications of his position are far less tenable than he suggests. If our criticisms are sound, then Brenkert and others who endorse his position are seriously mistaken regarding how one can permissibly market products to vulnerable populations, and, in addition, they have improperly categorized certain morally permissible marketing practices as being immoral. (shrink)

Existing public relations ethics literature often proves inadequate when applied to social movement campaigns, considering the special communication challenges activists face as marginalized moral visionaries in a commercial public sphere. The communications of counter-hegemonic movements is distinct enough from corporate, nonprofit, and governmental organizations to warrant its own ethical guidelines. The unique communication guidelines most relevant to social movement organizations include promoting asymmetrical advocacy to a greater extent than is required for more powerful organizations and building flexibility into the TARES (...) principles to privilege social responsibility over respect for audience values in activist campaigns serving as ideological critique. (shrink)

According to a well-known objection to consequentialism, the answer to the preceding question is alarmingly straightforward: your consequentialist friend will abandon you the minute that she can more efficiently promote goodness via options that do not include her maintaining a relationship with you. The most prominent response to this objection is to emphasize the profound value of friendship for human agents and to remind critics of the distinction between the theory’s criterion of rightness and an effective decision-making procedure. Whether or (...) not this response is viable remains a contentious issue within the now considerable literature generated on the topic, yet it is a curious fact that the debate has unfolded in such a way that the question of when a consequentialist agent ought to break from her indirect methods of promoting the good and revert back to a direct form of consequentialist decision-making has not been decisively settled. In this paper, I claim that the empirical considerations at stake for resolving this question are more complicated than is normally acknowledged; however, I argue that this should not deter sophisticated consequentialists from endorsing flexible psychological dispositions in order to monitor these empirical considerations as best as can be expected for agents with our distinctly human faculties and limitations. (shrink)

Understanding defensive internationalism: black, white, or shades of gray -- Clubs, identities, and institutions: a tale of overlapping interests -- Domestic support for contributions: how stable and strong? -- International development assistance -- International debt management and relief -- United Nations peacekeeping operations -- Pursuing international environmental quality -- A global prognosis of muted optimism?

Is there such a thing as “a/the greater good”? Could it be conceived in radically ecological terms? By critically drawing on skeptical insights presented by Slavoj Žižek and Hans Sluga, the article articulates what I am calling “a/the greater ecological good” as an end and as the ethico-political means to this end. I begin by describing this good as an aim: the survival-flourishing of earthly entities and environs. Its contours and limits are outlined, and various Žižekian objections are addressed. Next, (...) the ethical and political means for this good’s realization are delineated. We are summoned to allow things to survive-thrive. But the existing order excessively disallows things from surviving-flourishing, so we are compelled to struggle against it and foster a society of letting-be. The article concludes by proffering an outline of a possible strategy for this political struggle. It would involve the collaborative conception of a blueprint of this envisioned society; popularizing and building mass solidarity around the blueprint; and leveraging this solidarity to, ideally, peacefully implement the blueprint; otherwise, ethico-political violence may be required in order to realize this greater ecological good. (shrink)

Troubled times in education means that philosophers of education, who seem to never stop making defenses of our field, have to do so with more flexibility and a greater understanding of how peripheral we may have become. The only thing worse than a defensive philosopher is a confident and certain philosopher, so it may be that our very marginality will give us renewed energies for problematizing education. Occupying our marginal position carefully and in concert with other marginal inquiries, I (...) think, will do our field good. Because of its attention to what it takes to be willing to learn and to approach theoretical and real world obstacles with open if cautious interest, philosophy of education is about holding concepts and movements in tension, bending the implications of commonplace, commonsensical ideas about education, and carefully examining the all of these maneuvers for the exclusions they wittingly and unwittingly produce. Problematizing the certainties derived from majoritarian positions, be it whiteness, Westernness, or any other dominant perspective, can provide us with a diversity of claims to scrutinize and epistemological positions to be wary of. (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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Crowdsourcing innovation community has become an important platform for enterprises to gather group wisdom. However, how the crowdsourcing innovation community plays a reference role in creative crowdsourcing participation is unclear. Based on the reference group theory, taking online impression management as the explanatory framework, this study explores the impact of crowdsourcing innovation community reference on the creative territory behavior, and the differences in the crowdsourcing innovation community reference effect among members of different community age groups. A total 524 valid two-stage (...) questionnaires were collected. The empirical analysis results show that under the influence of informational reference and utilitarian reference of the crowdsourcing innovation community, community members are significantly more likely to adopt acquired impression management than defensive impression management ; under the influence of value expressive reference of the crowdsourcing innovation community, the possibility of adopting DIM behavior is significantly greater than that of adopting AIM behavior; compared with DIM behavior, AIM behavior has a more inhibitory effect on creative territory behavior. Interestingly, there are different community reference effects among members of different community age groups. In particular, the positive contribution of the elder members is not as good as that of the newcomers. The above research conclusions not only confirm the influence of crowdsourcing community reference on crowd participation decision making but also provide theoretical and practical enlightenment for exploring the cooperation mechanism of crowdsourcing innovation. (shrink)

This study investigates specific behavioral perceptual differences of ethics between practitioners and students enrolled in sales classes. Respondents were asked to indicate their beliefs to issues related to ethics in sales. A highly significant difference was found between mean responses of students and sales personnel. Managers indicated a greater concern for ethical behavior and less attention to sales than did the students. Students indicated a strong desire for success regardless of ethical constraints violated.

Beliefs once limited to the extremes of the North American gun culture have become mainstream, while the US Supreme Court’s ruling in District of Columbia v. Heller and a spate of right-to-carry laws have contributed to the proliferation of guns in public life. These changes in political discourses, legislative agendas, and social practices are indicative of an emergent and pernicious form of subjectivity, which is here defined as self-defensive. Such subjectivity is characterized by a pathological identification with the right of (...) self-defense, which undermines the social conditions of individual freedom and renders subjects unable to comprehend the function of abstract rights within an informal normative order. Practically speaking, this raced and gendered subjectivity relies on extra-legal relations of domination for its reproduction. The rapid expansion of gun rights and the recent loosening of restrictions on self-defensive violence are argued to be responses to a perceived threat to these identity-constituting relations, rather than to the threat of violent crime, which has long been on the decline. (shrink)