A fundamental fact about human minds is that they are never truly alone: all minds are steeped in situated interaction. That social interaction matters is recognized by any experimentalist who seeks to exclude its influence by studying individuals in isolation. On this view, interaction complicates cognition. Here, we explore the more radical stance that interaction co-constitutes cognition: that we benefit from looking beyond single minds toward cognition as a process involving interacting minds. All around the cognitive sciences, there are approaches (...) that put interaction center stage. Their diverse and pluralistic origins may obscure the fact that collectively, they harbor insights and methods that can respecify foundational assumptions and fuel novel interdisciplinary work. What might the cognitive sciences gain from stronger interactional foundations? This represents, we believe, one of the key questions for the future. Writing as a transdisciplinary collective assembled from across the classic cognitive science hexagon and beyond, we highlight the opportunity for a figure-ground reversal that puts interaction at the heart of cognition. The interactive stance is a way of seeing that deserves to be a key part of the conceptual toolkit of cognitive scientists. (shrink)

Figure-Ground Duality in Humour: A Multi-Modal Perspective Creativity with words or pictures is not simply a matter of communicating a message, but of communicating it well, in a way that is effective, original and which defies convention. Effectiveness here pertains to the pragmatic goals of the communicator, and the extent to which these are achieved, while originality pertains to the manner in which the message is framed. Language, for instance, provides a wealth of conventions for framing a message; (...) indeed, the vast part of language is a solidified body of culturally received conventions, which fix the meaning of words and phrases and determine the contextual appropriateness of specific terms, topics and conversational strategies. To frame a message in a novel manner that stretches or even subverts these conventions, a communicator must imbue the elements of communication—whether words, gestures or pictorial elements—with additional meanings. This duality of meaning is not arbitrary, however, or communication cannot succeed. Rather, a creative communicator must draw out secondary meanings that are already implicit in the stock elements of communication, in a way that the audience can understand, appreciate and replicate. Duality thus lies at the heart of creative communication, allowing a communicator to say one thing and simultaneously convey another, secondary message that may augment or subvert the overt content of the communication. This mechanism, which draws out and gives prominence to that which is normally unseen or implicit, is Figure-Ground Reversal. (shrink)

A broad evolutionary perspective is essential to fully reverse figure and ground in the rationality debate. Humans' evolved psychological architecture was designed to produce inferences that were adaptive, not normatively logical. This perspective points to several predictable sources of errors in modern laboratory reasoning tasks, including inherent, systematic biases in information-processing systems explained by Error Management Theory.

The notion of ontography is characterizable as open-source, both due to its collaborative development, its heterogeneous backgrounds and its broad applicability. In my paper, I concretize these open-source aspects of ontography firstly by redefining it with reference to E. Winkler’s dialogue Die Erkundung der Linie and secondly by applying it to the Gestalttheoretical topics of figure-ground reversals and bidirectional part-whole relations.

We examine the spiral structure of the thinking and the work of Marshall McLuhan, which we believe will provide a new way of viewing McLuhan’s work. In particular, we believe that the way he reversed figure and ground, reversed content and medium, reversed cause and effect, and the relationship he established between the content of a new medium and the older media it obsolesced all contain a spiral structure going back and forth in time. Finally, the time structure (...) of his Laws of Media in which a new medium obsolesced an older medium, while retrieving an even older medium and then when pushed far enough flipped into a still newer medium has the feeling of a spiral. We will also examine the spiral structure of the thinking and work of those thinkers and artists that most influenced McLuhan such as Vico, Hegel, Marx, Freud, Joyce, TS Eliot, Wyndham Lewis and the Vorticism movement. (shrink)

The alphabet effect that showed that codified law, alphabetic writing, monotheism, abstract science and deductive logic are interlinked, first proposed by McLuhan and Logan, is revisited. Marshall and Eric McLuhan’s insight that alphabetic writing led to the separation of figure and ground and their interplay, as well as the emergence of visual space, are reviewed and shown to be two additional effects of the alphabet. We then identify more additional new components of the alphabet effect by demonstrating that (...) alphabetic writing also gave rise to Duality, and reductionism or the linear sequential relationship of causes followed by effects. We then review McLuhan’s claim that electrically configured information reversed the dominance of visual space over acoustic space and led to the reversals of cause and effect, and figure and ground. We then demonstrate that General System Theory first formulated by Ludwig von Bertalanffy, which also includes chaos theory, complexity theory and emergence and Jakob von Uexküll’s notion of umwelt also entail the reversal of many aspects of the alphabet effect such as the reversals of cause and effect, and figure and ground. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The “Figure” of God and the Limits to Liberalism: A Rereading of Locke’s Essay and Two TreatisesVivienne BrownI. A current interpretative issue in reading John Locke’s texts is the relationship between Locke’s theology and political philosophy. 1 Reacting against the secular interpretations of C. B. Macpherson and Leo Strauss, John Dunn argued that Locke’s theology was axiomatic for the political philosophy of the Two Treatises of Government in (...) that Locke’s liberalism was based on a religious individualism. 2 Dunn thus decisively reoriented Lockean scholarship away from seeing Locke as an apologist for a new capitalist economic order, and James Tully and Richard Ashcraft have since substantiated the view that theological presuppositions were foundational for Locke’s political writings but they emphasized the radical nature of Locke’s political position. 3 This view has in turn been challenged by more recent contextual studies of the development of Locke’s thought. John Marshall has argued that the political argument in the Two Treatises of Government is not dependent on religious individualism in [End Page 83] that Locke’s natural theology was itself driven by epistemological investigations, and that it was this epistemological impetus which inclined the Christian Locke towards the Socinian tendencies of his later years. 4 Ian Harris accepts that theological explanation was central to Locke’s writings in ethics and government, but he also emphasizes the reverse process of determination where Locke’s theology, particularly with respect to revealed religion, is in turn reliant upon Locke’s broader thinking. Harris argues therefore that there is a continuity of substantive thought such that theological concerns mesh into, rather than exclusively determine, the broader pattern of Locke’s political and moral ideas. 5 Recent studies thus share a considerable common ground in their recognition of the importance of the relationship between Locke’s theology and political philosophy, but disagreements remain over the precise nature of this relationship and its implications for Locke’s writings.This paper will address the question of the relationship between Locke’s theology and political philosophy by examining the figurative expressions by means of which God is represented in Locke’s Essay Concerning Human Understanding and Two Treatises of Government. 6 The paper will argue that the ways in which this metaphorical “figure” of God is inscribed in Locke’s epistemology and political philosophy 7 suggest a different approach to reading the intricate relationship between God and mankind, and that this casts doubt on the widely-received understanding of Locke’s contribution to classic liberal arguments within political philosophy. It will be argued further that the different formulations of the figure of God in these two texts result in problematizing the historiographic notions of theoretical determination and historicized authorial intent which have so far largely informed the interpretative debate in this area. 8 [End Page 84]II. In the Essay it is argued that mankind has no knowledge of real essences, even of such a simple thing as a pebble or a fly, and certainly cannot know the real essence of God which is immeasurably more inaccessible. 9 Descriptions of God in the Essay are not, therefore, literal statements of God’s characteristics but necessarily inadequate attempts to conceptualize him from within the linguistic and mental constraints of the finite world of men. Two possibilities are available to mankind in its attempt to mediate this fundamental state of ignorance. One is to try to form a complex idea made up of the simple ideas received from sensation or reflection upon itself and then to magnify this to an infinite degree:And even the most advanced Notion we have of God, is but attributing the same simple Ideas which we have got from Reflection on what we find in our selves, and which we conceive to have more Perfection in them, than would be in their absence, attributing, I say, those simple Ideas to him in an unlimited degree. 10God’s postulated qualities are thus valued human qualities writ infinitely large, even though elsewhere the anthropomorphism of the “ignorant and uninstructed” is rejected: 11[H]aving from what we experiment in our selves, got the Ideas of Existence and Duration; of... (shrink)

The concept of simultaneous masking in visual field is discussed, in the light of classical examples, of the various kinds of the phenomenon, of a modal completion, of the figure/ground phenomenon, of ambiguous and reversible figures, of mimicry and camouflage and eventually of the complexity of the stimulus. There is some reference to masking in auditory field. The “reality” of the masked configuration is discussed, drawing the conclusion that it is perceptually unreal. The fact that the masking phenomenon (...) cannot take place without comparison between two perceptual acts – what we see at one moment and what we see a moment after LATER – and the fact that the masked configuration pops out with some surprise, lead to the conclusion that simultaneous masking in visual field is not a bare perceptual phenomenon, but a psychological process not unlike insight. (shrink)

This paper discusses the problem of inconsistencies in the metaphorical conceptualizations of time that involve motion within the framework of conceptual metaphor theory (CMT). It demonstrates that the TIME AS A PURSUER metaphor contrasts with the reverse variant TIME AS AN OBJECT OF PURSUIT, just as the MOVING TIME metaphor contrasts with the MOVING OBSERVER variant. Such metaphorical conceptualizations of time functioning as pairs of minimally differing variants based on Figure-Ground reversal are, strictly speaking, inconsistent with one (...) another. Looking at these inconsistencies from a wider perspective suggests that time may belong to a separate category of conceptual phenomena. This paper puts forward a proposal to approach time from the perspective of “phenomena of the third kind”, which according to Keller’s thesis include conceptual establishments resulting from human cognition, but not of human design. (shrink)

This paper explores the topic of meaning and its relation to symbolism through a contrastive reading of Whitehead’s 1927 Barbour-Page Lectures alongside the contemporary anthropologist Roy Wagner’s Symbols that Stand for Themselves. Despite their adoption of different registers of inquiry, a complementary relation may be posited between the two approaches. In particular, Whitehead’s emphasis on the foundational nature of symbolic reference within experience and its extendedness beyond merely human contexts may be grafted productively onto Wagner’s discussion of the “orders of (...) trope’”and “figure-ground reversal” within the formation of meaning in language. The argument is exemplified through reference to two contexts within Western culture where the play of symbol and meaning is strikingly evident—the Christian Eucharist and the contemporary sociological pervasiveness of motifs of screens and screening. (shrink)

The paper is focused on the concept of perceptual relation according to experimental phenomenology, belonging to Gestaltist and ecological traditions. First of all, it will be shown the meaning of “relation” in the perceptual domain, including a specific definition of object and subject. For this purpose, the paper will present the difference with the representationalist perspective, which challenges immediate experience and the perception of unified objects. Secondly, the concept of “perceptual relation” will be compared to the idea of Gestalttheorie’s “intrinsic (...) relation”. It will be sustained that perceptual relations do not concern only connections between the parts and the whole of a configuration, but they extend to otherness, namely perceptual object, other subjects, and the Umwelt. For this purpose, the paper will provide some examples of ambiguity of the relation ground-figure, especially reversible and bistable figures. (shrink)

The aim of a comparison of two traditions is not an aim in itself. In the paper the,approximation" of two cultures has the role of a mirror of self-comprehension. Merleau-Ponty's intention to bring philosophy,down to earth" is implemented by the boundaries of ,,inner-outer" and crossing subjectivity and objectivity in the Cartesian paradigm. His phenomenology of the body is,understandable" or, better to say ,,elucidatory" through the term of pranayama - the yogic breath control. Emphasis on experiencing ,,movement in space" - dimensionality, (...) is endorsing this relationship. Moreover, both approaches have a common point: reversibility - switch, or reverse - of the figure and the ground back and forth at will. In Merleau-Ponty's concept of the Jived body" the reversibility is a continuum of the world and the body and in yoga it is pranic inspiration-expiration experience. (shrink)

Marshall McLuhan’s Laws of Media, which describe the evolution of artifacts in terms of enhancement, obsolescence, retrieval, and reversal are extended to create Laws of Media Environments and Laws of Media Users. It is shown that the environment or ground in which the figures of the artifacts in the LOM operate and the users of those artifacts undergo, respectively, a similar evolution of enhancement, obsolescence, retrieval, and reversal paralleling McLuhan’s original LOM.

In lectures and writings in the decades following the publication of Studies in Ethnomethodology [1967], Harold Garfinkel, the founder of ethnomethodology, developed what he called a “misreading” of the phenomenological writings of Aron Gurwitsch, Maurice Merleau-Ponty and others. Garfinkel’s “misreading” included a selective and creative treatment of themes that Gurwitsch drew from Gestalt psychology, such as figure-ground, Gestalt contexture, and the phenomenal field. Rather than identifying these themes with visual perception demonstrated with picture-puzzles (for example, of animals hidden (...) in foliage) and line drawings of reversible figures, Garfinkel used them to demonstrate praxeological and interactional phenomena: organizations of embodied activity that constitute fields of collective action. Phenomenal fields, for Garfinkel, are formed through embodied work performed in concert with the actions of others. Although Harvey Sacks, the founder of Conversation Analysis, did not explicitly mention Gurwitsch, phenomenology or Gestalt psychology in his writings and transcribed lectures, some of his writings on the sequential organization of conversation seem informed, if only indirectly through his relationship with Garfinkel, by Gurwitsch’s treatment of visual and auditory phenomena. Both Garfinkel and Sacks devised innovative ways to transpose Gestalt phenomena from perceptual psychology to social formations. (shrink)

The author clarifies the existential philosophy that is implicit in Kurt Goldstein's philosophy of organism (Goldstein, 1963; 1995). Situated in response to the growing trend that psychological phenomena are reducible to the nervous system, the author argues for the reverse: that the significance of nervous system activity can only be understood by viewing it as background to foreground performances. Like the organization of perception into meaningful figure-- ground Gestalts, the existential modes of embodiment, sociality, temporality, spatiality, and attunement (...) are organized together to accomplish foreground performances. It is only within this context that the activity of the nervous system may be understood as significant or insignificant. Speech is given as an example. The article concludes with a commentary on how the trend of reducing psychological phenomena to neurological phenomena has impaired our understanding of brain disorders and psychological disorders. (shrink)

Do children’s single words related to motion and change also encode aspects of environmental events highlighted by Talmy’s motion event analysis? If so, these meanings may predict children’s early verb meanings. Analyzing the kinds of meanings expressed in single “dynamic event words” through motion event semantics yields links between early true verbs in sentences and the semantics encoded in these single words. Dynamic event words reflect the sense of temporal and spatial reversibility established in the late sensorimotor period. We propose (...) that these dynamic meanings provide the semantic foundation for the most common verbs included in early sentences, and thus a bootstrap to full development of the verb repertoire. In this study, we followed the spoken language development of five children. We identified dynamic event words as encoding dynamic change in the following dimensions: spatial direction in relation to self; vertical spatial direction; figure/ground relationships; and temporal event sequences. Verbs continuing the semantics previously identified in dynamic event words occurred early and dominated the verb repertoire through 24 months of age. (shrink)

Field-ground reversal underlies Islamic art's use of repeating geometric patterns or tessellations. Encounter with field-ground reversal suggests the notion of ‘oscillationism’ to mean willingness to oscillate between two equally plausible opposites rather than to affirm one or the other of them. This article explores oscillationism as a move for confronting theories of evil and for assessing the merits of foundationalism without succumbing to cognitive dissonance. The article goes on to examine F.D.E. Schleiermacher's suggestion of 1799 that (...) the infinitude of God calls for more, not fewer religions. His reversal of Christian and Muslim assumptions puts contemporary debate in the theology of religions into a postmodernist perspective. Without supplying fresh answers, the spiritual practice of oscillationism provides a fresh way to frame some of the weightiest questions. (shrink)

Summary Based on Clausius’ phrasing of a “transformational content” and the resulting 2nd law of thermodynamics, I demonstrated that Gilbert Simondon’s On the Mode of Existence of Technical Objects is historically situated at the threshold of understanding open systems thermodynamics and the related concepts of balance. Furthermore, I showed that Gestalt theory, as represented by Wolfgang Köhler, at least reproduced, if not partially anticipated or even prepared this development of 20th century thinking. Finally, I gave some short examples of how (...) Simondon applied the figure/ground distinction to human perception, memory, and a general theory of becoming and I introduced his proposal to analyse “the grounds” just as thoroughly as the laws of figuration. (shrink)

The laws which predict how the perceptual quality of figure-ground can be extracted from the most elementary visual signals were discovered by the Gestaltists, and form an essential part of their movement (see especially Metzger, 1930, and Wertheimer, 1923 translated and re-edited by Lothar Spillmann, 2009 and 2012, respectively). Distinguishing figure from ground is a prerequisite for perception of both form and space (the relative positions, trajectories, and distances of objects in the visual field. The human (...) brain has an astonishing capacity for selecting and combining a few critical visual signals to accurately represent both form and space. (shrink)

Poorly saturated colors are closer to a pure grey than strongly saturated ones and, therefore, appear less “colorful”. Color saturation is effectively manipulated in the visual arts for balancing conflicting sensations and moods and for inducing the perception of relative distance in the pictorial plane. While perceptual science has proven quite clearly that the luminance contrast of any hue acts as a self-sufficient cue to relative depth in visual images, the role of color saturation in such figure-ground organization (...) has remained unclear. We presented configurations of colored inducers on grey ‘test’ backgrounds to human observers. Luminance and saturation of the inducers was uniform on each trial, but varied across trials. We ran two separate experimental tasks. In the relative background brightness task, perceptual judgments indicated whether the apparent brightness of the grey test background contrasted with, assimilated to, or appeared equal (no effect) to that of a comparison background with the same luminance contrast. Contrast polarity and its interaction with color saturation affected response proportions for contrast, assimilation and no effect. In the figure-ground task, perceptual judgments indicated whether the inducers appeared to lie in front of, behind, or in the same depth with the background. Strongly saturated inducers produced significantly larger proportions of foreground effects indicating that these inducers stand out as figure against the background. Weakly saturated inducers produced significantly larger proportions of background effects, indicating that these inducers are perceived as lying behind the backgrounds. We infer that color saturation modulates figure-ground organization, both directly by determining relative inducer depth, and indirectly, and in interaction with contrast polarity, by affecting apparent background brightness. The results point towards a hitherto undocumented functional role of color saturation in the genesis of form, and in particular figure-ground percepts in the absence of chromatostereopsis. (shrink)

This paper is a systematic investigation of motion expressions in programmatic music description. To address issues with defining the Source MOTION and the Target MUSIC, we utilize Gestalt models (Figure-Ground and Source-Path-Goal) while also critically examining the ontological complexity of the Target MUSIC. We also investigate music motion descriptions considering the role of the describer’s perspective and communicative goals. As previous research has demonstrated, an attentional Goal-bias is common in physical motion description, yet this has been found also (...) to lessen due to audience accommodation effects. We investigate whether this also occurs in music description. Using cognitive linguistic frameworks, we conducted an analysis of 21 English speakers’ written descriptions of dynamic orchestral excerpts. All participants gave a description of one excerpt reporting their own personal experiences and the other excerpt reporting the events of the excerpt for a fictional future participant. We find that addressee accommodation shapes the choice of the ontological types of Figures used from being more subjective and creative in describing music for oneself versus being more objective in describing music for others. However, our investigation does not find sufficient evidence for a Goal-bias in music like there is in physical motion event descriptions. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy and Literature 28.2 (2004) 324-341 [Access article in PDF] Charles Lamb: Professor of Indifference Tim Milnes University of Edinburgh Nothing puzzles me more than time and space, and yet nothing puzzles me less, for I never think about them.1 I The name of Charles Lamb—essayist, poet, and notorious punster—does not loom large in studies of the philosophy of the English Romantics. The reasons for this initially unsurprising fact (...) range from the personal and obvious to the cultural and curious. Tied for most of his adult life to a clerk's desk at the East India Company, and to the care of his mentally ill sister at home, Lamb was rarely permitted the leisure even to dally in the expansive visionary landscapes explored in the epic works of consciousness of his friends Samuel Taylor Coleridge, William Wordsworth and Robert Southey. And yet, as the 1810 quip to Manning recorded above suggests, his reluctance to engage with philosophy is not merely attributable to the straitened life of the journeyman scribe. Such a remark is quite typical of Lamb's conscious attempt, in the face of a culture increasingly driven by the dissemination of knowledge, to cultivate an imaginative space the reverse of the knowing or "philosophical." It is this attitude that makes him more, not less, interesting alike for the intellectual historian and the philosopher.Lamb's avowed carelessness about matters philosophical is as familiar to his readers as the persona of "Elia" adopted for the essays he wrote for the London Magazine in the early 1820s. It is also just as beguiling and intriguing. Lamb's resistance to philosophy and his epistemic insouciance both trade on the suggestion that the desirable mind is the [End Page 324] ironic mind, reflecting—or, perhaps, refracting—a transitional and forever "imperfect" subjectivity. Correspondingly, his essays frequently invoke figures of liminality, of being in two or more states at once: whether between dreams and consciousness in "Witches, and other Night Fears" (1821); past and present in "Distant Correspondents" (1822); truth and lies in "Imperfect Sympathies" (1821); or literal and figurative selves in the imponderable relationship between "Lamb" of "On Christ's Hospital" (1813) and "Elia" of "Christ's Hospital Five and Thirty Years Ago" (1820).2 Moreover, this self-styled figure of the writer as always between alternate and often contrary conditions, beliefs and identities—what Lamb termed his "bi-parted nature"—has itself become a stock descriptor among Lamb's commentators.3 It is not difficult, for example, to detect its presence in Coleridge's portrayal of his friend as "one hovering between earth and heaven,"4 as well as De Quincey's depiction of a sleeping Lamb as "the image of repose midway between life and death, like the repose of a sculpture."5 More recently, it has shaped Jane Aaron's exploration of his proclaimed "double singleness"6 and Seamus Perry's characterisation of his "borderland," "serious-non-seriousness."7Understandably, critics of a certain bent have sought to link these features of Lamb's work, arguing that the centrifugal properties of his writing display an aversion to categorical "difference" that is directly related to his suspicion of the dualisms of systematic belief-systems. Gerald Monsman, for example, argues that insofar as Lamb's essays undermine "all transcendental reconciliations or definitive closures," they "appear to be sly critiques of the central dogmas of romanticism."8 However, to class Lamb's writing as radically decentred or self-deconstructing is to miss the profound nostalgia it evinces at critical moments for a neutral ground and a sense of belonging. Lamb's indifference to knowledge, and to philosophy as the pursuit of certain knowledge, is constantly challenged by his fear of imaginative dissolution. Correspondingly, Lamb/Elia's indifferent location between the real and the fictive never quite manages completely to repress the desire for truth. And yet, "indifference," quite apart from being a term that both fascinated and repelled Lamb himself, aptly characterises both his attitude to philosophy and knowledge on one hand, and the liminal properties of his prose on the other. Freud provides a... (shrink)

We propose a new masking technique for masking word stimuli. Drawing on the phenomena of metacontrast and paracontrast, we alternately presented two prime displays of the same word with the background color in one display matching the font color in the other display and vice versa. The sequence of twenty alterations was sandwich-masked by structure masks. Using this masking technique, we conducted evaluative priming experiments with positive and negative target and prime words. Significant priming effects were found – for primes (...) and targets drawn from the same as well as from different word sets. Priming effects were independent of prime discrimination performance in direct tests and they were still significant after the sample was restricted to those participants who showed random responding in the direct test. (shrink)

In the article three tragedies: ‘The Battle of Arminius‘ by Christian Dietrich Grabbe, ‘Nibelungs‘ by Friedrich Hebbel, ‘The Ring of the Nibelung‘ by Richard Wagner are considered. The aim of this paper is to investigate how history reception and mythological material correlates with the idea of national identity. The comparative-historical, typological and historical-genetic methods are applied in this publication. The genres of historical, philosophical and mythological tragedy became the most popular genres in the socio-political conditions in the 30s of the (...) 19th century in Germany. Grabbe underlines the idea of the presence of the ‘local‘ regional history within the framework of the ‘big‘ and significant one. Grabbe paid attention to the historical process and historical figures, not to any particular historical event. In his last work, tragedy ‘The Battle of Arminius‘, Grabbe showed his understanding of the country’s historical origins and the creation of a national myth. F. Hebbel and R. Wagner comprehend the images and motifs of Norse mythology as a universal model of human existence. While interpreting the story of Nibelungs, F. Hebbel notes not only its national roots but its universal source; he models the image of the world through the prism of the microcosm of Burgundians/Nibelungs. Wagner’s tetralogy is not so much an interpretation as a creation of the ‘new myth‘. The images of Arminius and Siegfried have the features of the archaic primal forefather, ‘cultural hero‘ of the nation, who intimately related with Nature and home ground. Myth and mythological history are not only the tools of attainment of national identity but the means of reversion the modern man to the lost harmony of the Universe, which pertains to the mythological mind. (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)