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)

In some situations a number of agents each have the ability to undertake an initiative that would have significant effects on the others. Suppose that each of these agents is purely motivated by an altruistic concern for the common good. We show that if each agent acts on her own personal judgment as to whether the initiative should be undertaken, then the initiative will be undertaken more often than is optimal. We suggest that this phenomenon, which we call the unilateralist’s (...) curse, arises in many contexts, including some that are important for public policy. To lift the curse, we propose a principle of conformity, which would discourage unilateralist action. We consider three different models for how this principle could be implemented, and respond to an objection that could be raised against it. (shrink)

In the mid-1980s, Dario Donatelli participated in a laboratory study of the effects of around 800 h of practice on digit-span and increased his digit-span from 8 to 104 digits. This study assessed changes in the structure of his memory skill after around 30 years of essentially no practice on the digit-span task. On the first day of testing, his estimated span was only 10 digits, but over the following 3 days of testing it increased to 19 digits. Further analyses (...) of his recall performance and verbal reports identified which mechanisms of the original memory skill he could retrieve or reacquire over the 3 days of practice. We discuss theoretical implications for the retention of skilled memory performance, the effects of age-related changes in memory on it, and for the future study of the effects of disuse on exceptional performance and complex skill. (shrink)

A scientific paradigm typically embraces research norms and values, such as truth-seeking, critical thinking, disinterestedness, and good scientific practice. These values should prevent a paradigm from introducing defective assumptions. But sometimes, scientists who are also physicians develop clinical norms that are in conflict with the scientific enterprise. As an example of such a conflict, we have analyzed the genesis and development of the shaken baby syndrome paradigm. The point of departure of the analysis is a recently conducted systematic literature review, (...) which concluded that there is very low scientific evidence for the basic assumption held by Child Protection Teams: when certain signs are present the infant has been violently shaken. We suggest that such teams have developed more value-based than scientific-based criteria when classifying SBS cases. Further, we suggest that the teams are victims of “groupthink,” aggravating the difficulties in considering critics’ questioning the criteria established by the teams. (shrink)

miembro del Future of Humanity Institute de la Universidad de Oxford y experto en mejoramiento humano y transhumanismo, sobre cuestiones centrales de su labor investigadora.PALABRAS CLAVETRANSHUMANISMO, MEJORAMIENTO HUMANO, ANDERS SANDBERG, BIOTECNOLOGÍAABSTRACTInterview with Anders Sandberg, member of the Future of Humanity Institute at Oxford University and expert in human enhancement and transhumanism, about central topics in his works.KEYWORDSTRANSHUMANISM, HUMAN ENHANCEMENT, ANDERS SANDBERG,BIOTECHNOLOGY.

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Giving an Account of OneselfChris LundbergGiving an Account of Oneself. Judith Butler. New York: Fordham University Press, 2005. Pp. x + 149. $18.95, softcover.Giving an Account of Oneself, Judith Butler's recent foray into moral philosophy, is a lucid interrogation of the problem of responsibility in the wake of contemporary critiques of the subject. In it, Butler moves beyond her concern with the conditions of subjectivity and its performances (...) towards a fuller consideration of life with others. Butler proffers an answer to the problem of post-subjective responsibility that resonates with the best elements of the rhetorical traditions, [End Page 329] though perhaps Butler's project might also benefit from a more thorough engagement with the problem of rhetoric in its specificity.Though works such as Gender Trouble earned a reputation (perhaps unfairly) for being theoretically dense to the point of obscurity, Giving an Account of Oneself is clearly and elegantly argued. Butler's argument is that moral philosophy relies on the ability of subjects to give an account of themselves and their actions. Such an account seems difficult in the face of blistering critiques of an autonomous, self-possessed, transparent, and naturally given subject of intention. How can one affirm responsibility in the post-subjective moment? As Butler puts it: "does the postulation of a subject who is not self-grounding … whose conditions of emergence can never fully be accounted for, undermine the possibility of responsibility and, in particular, of giving an account of oneself" (19)? What are the assumptions latent in critiques of the humanist subject that might deny the possibility of giving an account of oneself? Inspired by Foucault's interrogation of a naturalized truth of the subject, Lacan's account of a subject produced and dispossessed by the Symbolic Order, and Derrida's critique of presence, such critiques locate the subject as an effect of the operations of discourse, conceived broadly. Despite the force of these critiques, Butler claims that a view of the subject nested in and dispossessed by discourse provides possibilities for ethics. Butler's reframing of ethics draws on two assumptions that underwrite "post" accounts of the subject: that the subject is both an effect of discourse and of differential relation to others.The first assumption is that a subject produced within discourse is also a subject that is dependent on and interpenetrated by others. Drawing on her continuing engagement with Hegel, the work of Adriana Cavarero, Levinas's conception of alterity and Laplanche's theory of seduction, Butler argues that the subject is endowed with a "fundamental sociality" (33). The markers of fundamental sociality differ for each of these theorists: Hegel relies on the concept of recognition; Cavarero appropriates Arendt's space of appearance; Levinas argues for the priority of an ethical relation to the other over ontology; and Laplanche conceives of the emergence of subjectivity as a primal seduction of a child by the adult world. But each of these framings of the subject is united by a basic commitment that subjects are produced in relation to others both as a generative point and as a horizon.The second assumption is that when a subject dependent on other subjects attempts to give an account of itself, it does so within a structure of address. A subject makes a claim for itself only in the presence of others—an account of oneself both aims at the self but also simultaneously aims at presenting the self to another. On this reading, accounts of oneself are not transparent descriptions [End Page 330] of a subject's interiority: rather, an account of oneself must be a narrative, a discursive gathering of the self that can never fully recover the conditions of its emergence. Narrative is not simply a mode of communicating the content and intentions of a self to the other. Narrative is simultaneously the precondition for a subject naming and providing retroactive order to its own subjectivity. But where there are narratives, there is always the risk of narrative closure, or that the narrative is repeated without interruption. Put in terms of Butler's concern with ethics, is there not always a risk that a narrative becomes a self... (shrink)

We explored the relationship between materialism, awareness of environmental consequences and environmental philanthropic behaviour with a web survey (n=2,079) targeted at potential donors living in Finland. Environmental philanthropic behaviour comprise of donations of money and/or time to environmental charities. The awareness of environmental consequences was divided into egoistic, altruistic and biospheric concerns. Biospheric and egoistic concerns were positively, while materialism was negatively related to environmental philanthropic behaviour. Materialism was related to preference of charismatic species when choosing a target for donation. (...) The results have implications for conservation marketing emphasising the importance of taking the different donor segments into account. (shrink)

Background To characterize patients dying in a community hospital with or without attempting cardiopulmonary resuscitation and to describe patient involvement in, documentation of, and compliance with decisions on resuscitation. Methods All patients who died in Kalmar County Hospital during January 1, 2016 until December 31, 2016 were included. All information from the patients’ electronic chart was analysed. Results Of 660 patients female), 30 were pronounced dead in the emergency department after out-of-hospital CPR. Of the remaining 630 patients a DNAR order (...) had been documented in 558 patients. Seventy had no DNAR order and 2 an explicit order to do CPR. In 43 of these 70 patients CPR was unsuccessfully attempted while the remaining 27 patients died without attempting CPR. In 2 of 558 patients CPR was attempted despite a DNAR order in place. In 412 patients the DNAR order had not been discussed with neither patient nor family/friends. Moreover, in 75 cases neither patient nor family/friends were even informed about the decision on code status. Conclusions In general, a large percentage of patients in our study had a DNAR order in place. However, 27 patients died without CPR attempt or DNAR order. DNAR orders had not been discussed with the patient/surrogate in almost three fourths of the patients. Further work has to be done to elucidate the barriers to discussions of CPR decisions with the patient. (shrink)

In recent years, the concept ‘post‐feminism’ and its links to neoliberal economic structures and to the extreme reinforcement of individualization as raison d'etre of Western civilization have been discussed at length by numerous distinguished scholars in feminist cultural studies and feminist philosophy. This article takes its point of departure in this discussion. Drawing on Wendy Brown, Elizabeth Grosz, Angela McRobbie, Wendy Larner, and others, the text is examining the discourse of post‐feminism and neoliberalism, and its effects on overarching political scenarios, (...) as well as on everyday life: What happens to feminist politics when the collective, both as figuration and as virtual political platform, is deemed to be something situated in the discursive outskirts? By drawing on examples form the contemporary cultural imaginaries, from popular culture, economic structures, and public debate, and by pointing out the links between the micro‐perspective of our everyday living and overarching political structures, this article aims at bringing to the fore and critically discuss these issues, and the ways in which they intersect with contemporary Western feminism. The article ends with a discussion of possible points of exit or paths to follow in order to find alternatives. (shrink)

In the past decades a large number of students have taken courses and degrees in Gender Studies around Europe and proceeded to find employment. This article is based on a quantitative and qualitative study carried out in 2012 of Gender Studies students in Sweden, their education and employment. The design of the study was inspired by a large European research project investigating Women’s Studies in Europe and concerned with the motives for doing Gender Studies among Swedish students, as well as (...) who the students were, how they evaluated their Gender Studies education and what work they proceeded to after they left the university. In this article the results are discussed in terms of dilemmas: between Gender Studies’ critique of neoliberalism, employability and the former students’ wishes to be employed, and their evaluation of their studies and employment. The Swedish study is also compared with previous research in order to understand general and particular traits in Swedish Gender Studies education and employment. Analysis points to interesting contradictions within Gender Studies in relation to the labor market, student groups and employability. (shrink)

Linkage of population-based administrative data is a valuable tool for combining detailed individual-level information from different sources for research. While not a substitute for classical studies based on primary data collection, analyses of linked administrative data can answer questions that require large sample sizes or detailed data on hard-to-reach populations, and generate evidence with a high level of external validity and applicability for policy making. There are unique challenges in the appropriate research use of linked administrative data, for example with (...) respect to bias from linkage errors where records cannot be linked or are linked together incorrectly. For confidentiality and other reasons, the separation of data linkage processes and analysis of linked data is generally regarded as best practice. However, the ‘black box’ of data linkage can make it difficult for researchers to judge the reliability of the resulting linked data for their required purposes. This article aims to provide an overview of challenges in linking administrative data for research. We aim to increase understanding of the implications of the data linkage environment and privacy preservation; the linkage process itself and linkage quality and potential bias in linked data. We draw on examples from a number of countries to illustrate a range of approaches for data linkage in different contexts. (shrink)

Parent and preschool teacher ratings of the 10 noun categories of MacArthur-Bates Communication Development Inventory were used to study expressive language in 2–4-year-old children with autism spectrum disorder across the home and preschool context. There was no significant difference in the total number of words the children said in the two contexts, but the children said significantly more words in the noun categories “Furniture and rooms” and “People” at home. Only one third of the words the children said were said (...) both at home and in the preschool, while the other two thirds were said only at home or only in preschool. This suggests that what words the children use across contexts differ substantially and that their vocabulary is larger than it seems when measured only in one context. This novel study highlights the importance of assessing the language in children with ASD in multiple contexts in order to better measure their vocabulary and to design appropriate language interventions. (shrink)

In this article, a number of future energy visions, especially those basing the energy systems on hydrogen, are discussed. Some often missing comparisons between alternatives, from a sustainability perspective, are identified and then performed for energy storage, energy transportation, and energy use in vehicles. It is shown that it is important to be aware of the losses implied by production, packaging, distribution, storage, and end-use of hydrogen when suggesting a “hydrogen economy.” It is also shown that for stationary electric energy (...) storage, fuel cell electrolyzers could be feasible. Zero-tailpipeemission vehicles are compared. The battery electric vehicle has the highest electrical efficiency, but other requirements imply that plug-in hybrids or fuel cell hybrids might be a better option in some types of vehicles. Finally, a simplified example is applied to the overall results and used to discuss the needs and nature of an energy system based on intermittent energy sources. (shrink)

Indledning til “Om spørgsmålet: Hvad er oplysning?” af Moses Mendelssohn.

Empathy is crucial for the quality of social interactions and thus highly relevant in human service professions. At the same time, people belonging to this occupational group are especially vulnerable to developing burnout symptoms. With this study, we aimed to investigate the causal link between burnout symptoms and empathy by using a novel experimental design. Our participants (N = 355; 44.5% women; Mage = 36.37) filled out an online questionnaire; in an autobiographical memory task, the experimental group retrieved previous burnout (...) experiences, whereas one control group retrieved a neutral memory and another control group received no intervention. After measuring current burnout symptoms as a manipulation check, we measured the cognitive and affective empathy of all participants. Findings indicate that the experimental group reported significantly higher burnout symptoms compared to control groups, validating our intervention method. Furthermore, we found that the experimental group scored lower on one of the cognitive empathy measures, suggesting negative effects on the relational skills of burned-out individuals. Results are discussed with regard to ecological validity and implications. (shrink)

This paper examines how different forms of performance evaluation relate to aspects of the creative climate in a major pharmaceutical company. The study was based on a large employee-attitude survey that was distributed to all company employees. The study analyses survey results from 5,333 employees at five R&D sites. The results indicate that management’s evaluation of employees (either dialogue-based or control-based) relates to the type of motivation (intrinsic or extrinsic) that drives employees, to their style of thinking (value-focused thinking) and (...) on their attitudes to organizational creativity. The paper then discusses implications of these findings for HRM. (shrink)

In the initial phase of the COVID-19 pandemic, Sweden’s response stood out as an exception. For example, Sweden did not introduce any lockdowns, while many other countries did. In this paper I take the Swedish Corona Commission’s critique of the initial Swedish response as a point of departure for a general analysis of precaution in relation to pandemics. The Commission points out that in contrast to many other countries Sweden did not follow ‘the precautionary principle’. Based on this critique, the (...) Commission proposes that the precautionary principle should be included among Sweden’s guiding principles for crisis management. However, as the debate on this principle during the last 30 years indicates, the principle is loaded with problems. I discuss one of these problems, namely its lack of clarity. I argue, however, that this problem is not unsurmountable. A principle is lacking clarity precisely by being a principle and not a rule with a well-defined meaning. As a principle it indicates a direction but does not prescribe a specific action. However, to be action-guiding its content needs to be specified by rational deliberation. With this in mind, I propose a framework for specification of the precautionary principle as applied to pandemics. The framework focuses on the principle’s four key elements: threat, uncertainty, action and responsibility. I also suggest certain general ethical restrictions on specification. (shrink)

This essay explores ethical foundations for meeting the digital challenge via a case study of the work, life, and virtues of the greatest mathematician and natural scientist of the eighteenth century, Leonhard Euler. By biography and history one can learn of the gifts of human strength, practices, good will, dependence on others, and friendships which made possible Euler’s own astonishing corpus of work and that of many other scientists, mathematicians, engineers, and technologists. Digital technology results from a combination of science (...) (demonstrable knowledge and method), technology, engineering, and art (forms and artifacts of making and expressing), and mathematics (abstract numerical, algebraic, geometrical, formal, and digital concepts, rules, representations, and logics). Joint reflection on the biographical, historical, and natural sources of mathematics and the digital is essential for any humanization or ascesis in response to the perils and promises of digital technology for human thriving. As ethics enable and embody an ethos, so technologies are means and manifestations of a telos. Thus, thought and action for thriving through the digital needs to contemplate and conciliate the ends of humans and of the digital. (shrink)

Background: When healthcare personnel take part in military operations in combat zones, they experience ethical problems related to dual loyalties, that is, when they find themselves torn between expectations of doing caring and military tasks, respectively. Aim: This article aims to describe how Swedish healthcare personnel reason concerning everyday ethical problems related to dual loyalties between care and military tasks when undertaking healthcare in combat zones. Design: Abductive qualitative design. Participants and research context: Individual interviews with 15 registered nurses and (...) physicians assigned for a military operation in Mali. Ethical considerations: The participants signed up voluntarily, and requirements for informed consent and confidentiality were met. The research was approved by the Regional Ethics Review Board in Gothenburg (D no. 816-14; 24 November 2014). Findings: Three main categories emerged: reasons for not undertaking combat duties, reasons for undertaking combat duties and restricted loyalty to military duties, and 14 subcategories. Reasons for not undertaking combat duties were that it was not in their role, not according to ethical codes or humanitarian law or a breach towards patients. Reasons for undertaking combat duties were that humanitarian law does not apply or has to be treated pragmatically or that it is a case of force protection. Shortage of resources and competence were reasons for both doing and not doing military tasks. Under some circumstances, they could imagine undertaking military tasks: when under threat, if unseen or if not needed for healthcare duties. Discussion/conclusion: These discrepant views suggest a lack of a common view on what is ethically acceptable or not, and therefore we suggest further normative discussion on how these everyday ethical problems should be interpreted in the light of humanitarian law and ethical codes of healthcare personnel and following this, further training in ethical reflection before going on military operations. (shrink)

It has often been said that discourse ethics as developed by Jürgen Habermas can be understood as a dialogical continuation of the monological ethics developed by Immanuel Kant, as formulated in the categorical imperative in Grounding for the Metaphysics of Morals. Like Kant’s categorical imperative, Habermas’ principle of universalization specifies a rule for impartial testing of norms for their moral worthiness. This article will substantiate that discourse ethics develops a dialogical version of the categorical imperative, and will make this explicit. (...) This is done by presenting a new interpretation of the Kantian ethics. Renewing the traditional understanding, four instead of two or three formulations of the categorical imperative are identified. Finally it is shown how this interpretation relates to Jürgen Habermas’ discourse ethics. This analysis shows that one must specify which formulation of the categorical imperative one is talking about when discussing it. (shrink)

Much research aimed at developing measures for normative criteria to guide the assessment of healthcare resource allocation decisions has focused on health maximization, equity concerns and more recently approaches based on health capabilities. However, a widely embraced idea is that health resources should be allocated to meet health needs. Little attention has been given to the principle of need which is often mentioned as an alternative independent criteria that could be used to guide healthcare evaluations. This paper develops a model (...) and indicator of need satisfaction that aggregates the health needs of a population in a particular time period into a single measure that weights individual health needs by the severity of their ill health. The paper provides a first step towards formalizing the principle of need as a measurable objective for healthcare policy and we discuss some challenges for future research, including incorporating the duration of time into need-based health evaluations. (shrink)

This article engages the French pragmatism of Laurent Thévenot, Luc Boltanski and Bruno Latour in debates on how to forge a moral-political sociology of ecological valuation, justification and critique. Picking up the debate initiated by Thévenot on the possible emergence of a novel ‘green’ order of worth, the article juxtaposes the sociology of critical capacity of Boltanski and Thévenot with the actor-network theory of Bruno Latour. In doing so, the article suggests that each of these three pragmatic sociologists succeeds, in (...) characteristically different ways, in theoretically articulating an important but partial socio-political grammar of ecological worth. This claim is substantiated by invoking three case studies into environmental critique and compromise, on transnational carbon markets, urban sustainability projects, and Japanese whaling, respectively. Against this backdrop, the article concludes that – when read together as grammarians of the ecological bond – pragmatic sociology provides important insights into the bounded multiplicity of nature’s worth in political modernity. (shrink)

Anders Pettersson presents a comprehensive account of the foundations of literature, grounded in an original analysis of the interactions between author and reader. Drawing on post-Gricean pragmatics and Nicholas Wolterstorff's notion of presentationality, Pettersson develops the idea of the verbal text and conveys an integrated and nuanced understanding of literary experience, its conditions, and the values it affords. In the second part of Verbal Art he systematically examines the cognitive, affective, and formal aspects of the literary work and explores (...) their interrelations.Pettersson demonstrates the implications and applications of the theory through a series of detailed studies of literary works, taking care to show that his theory is compatible with a broad variety of perspectives. Combining an intimate knowledge of modern literary theory and the aesthetics of literature with innovative applications of linguistics and cognitive psychology to the literary work, he provides a thorough treatment of fundamental problems in the area, including the concept of a text or work, the concept of form, and the distinctiveness of the literary use of language. (shrink)

Wonder is commonly perceived as akin to curiosity, as stimulating inquiry, and as something that enhances pleasure in learning, but there are many experiences of wonder that have a less obvious place in education. In Wonder and Education, Anders Schinkel theorises a kind of wonder which he calls 'contemplative wonder'. Contemplative wonder opens up space for the consideration of (radical) alternatives wherever it occurs, and in many cases is linked with deep experiences of value; therefore, it is not just (...) important for education in general, but also, more specifically, for moral and political education. (shrink)

Today, many liberal philosophers of education worry that certain kinds of education may frustrate the development of personal autonomy, with negative consequences for the individuals concerned, the liberal state, or both. Autonomy liberals hold not only that we should promote the development of autonomy in children, but also that this aim should be compulsory for all schools, private or public, religious or nonreligious. In this article, Anders Schinkel provides a systematic overview, categorization, and analysis of liberal arguments for compulsory (...) autonomy‐promoting education. He finds that none of these arguments can justify compulsory autonomy‐promoting education, whether because they depend on empirical evidence that is not available, because they have as their basis an overly demanding concept of autonomy, or because they are intrinsically flawed in some way or another. Schinkel concludes with some suggestions as to what this means for the direction future research should take. (shrink)

In many biological experiments, due to gene-redundancy or distributed backup mechanisms, there are no visible effects on the functionality of the organism when a gene is knocked out or down. In such cases there is apparently no counterfactual dependence between the gene and the phenotype in question, although intuitively the gene is causally relevant. Due to relativity of causal relations to causal models, we suggest that such cases can be handled by changing the resolution of the causal model that represents (...) the system. By decreasing the resolution of our causal model, counterfactual dependencies can be established at a higher level of abstraction. By increasing the resolution, stepwise causal dependencies of the right kind can serve as a sufficient condition for causal relevance. Finally, we discuss how introducing a temporal dimension in causal models can account for causation in cases of non-modular systems dynamics. (shrink)