sirIn a scholarly and thought-provoking paper, Clarke sets out to debunk the concept of “rational suicide” as nonsensical.1 His motivation in this is to undermine any support that the notion of rational suicide might give to a “categorical right to suicide”. If his enterprise were successful, however, it would go far beyond the “rights issue” and would have a profound impact on all arguments raised in support of euthanasia or physician-assisted suicide.Clarke's major thrust might be termed the argument from posthumous (...) ignorance. He begins with a claim that the process of making a rational decision involves the process of “gaining all possible facts and `imagining' all possible consequences”. He goes on to say that making a rational decision “in the consideration of life or death . . . would seem to be impossible”. It is “impossible” …. (shrink)

Using a longitudinal case study design, we have tracked the recovery of motor function following severe traumatic brain injury (TBI) through a multimodal neuroimaging approach. In 2006, Canadian Soldier Captain (retired) Trevor Greene (TG) was attacked with an axe to the head while on tour in Afghanistan. TG continues intensive daily rehabilitation, which recently included the integration of physical therapy (PT) with neuromodulation using translingual neurostimulation (TLNS) to facilitate neuroplasticity. Recent findings with PT+TLNS demonstrated that recovery of motor function occurred (...) beyond conventional time limits, currently extending past 14-years post-injury. To investigate whether PT+TLNS similarly resulted in associated cognitive function improvements, we examined event-related potentials (ERPs) with the brain vital signs framework. In parallel with motor function improvements, brain vital signs detected significant increases in basic attention (as measured by P300 response amplitude) and cognitive processing (as measured by contextual N400 response amplitude). These objective cognitive improvements corresponded with TG’s self-reported improvements, including a noteworthy and consistent reduction in ongoing symptoms of post-traumatic stress disorder (PTSD). The findings provide valuable insight into the potential importance of non-invasive neuromodulation in cognitive rehabilitation, in addition to initial indications for physical rehabilitation. (shrink)

A crisis continues to brew within the pharmaceutical research and development (R&D) enterprise: productivity continues declining as costs rise, despite ongoing, often dramatic scientific and technical advances. To reverse this trend, we offer various suggestions for both the expansion and broader adoption of modeling and simulation (M&S) methods. We suggest strategies and scenarios intended to enable new M&S use cases that directly engage R&D knowledge generation and build actionable mechanistic insight, thereby opening the door to enhanced productivity. What M&S requirements (...) must be satisfied to access and open the door, and begin reversing the productivity decline? Can current methods and tools fulfill the requirements, or are new methods necessary? We draw on the relevant, recent literature to provide and explore answers. In so doing, we identify essential, key roles for agent-based and other methods. We assemble a list of requirements necessary for M&S to meet the diverse needs distilled from a collection of research, review, and opinion articles. We argue that to realize its full potential, M&S should be actualized within a larger information technology framework—a dynamic knowledge repository—wherein models of various types execute, evolve, and increase in accuracy over time. We offer some details of the issues that must be addressed for such a repository to accrue the capabilities needed to reverse the productivity decline. (shrink)

Progressive supranuclear palsy is a movement disorder with prominent tau neuropathology. Brain diseases with abnormal tau deposits are called tauopathies, the most common of which is Alzheimer's disease. Environmental causes of tauopathies include repetitive head trauma associated with some sports. To identify common genetic variation contributing to risk for tauopathies, we carried out a genome-wide association study of 1,114 individuals with PSP and 3,247 controls followed by a second stage in which we genotyped 1,051 cases and 3,560 controls for the (...) stage 1 SNPs that yielded P ≤ 10-3. We found significant previously unidentified signals associated with PSP risk at STX6, EIF2AK3 and MOBP. We confirmed two independent variants in MAPT affecting risk for PSP, one of which influences MAPT brain expression. The genes implicated encode proteins for vesicle-membrane fusion at the Golgi-endosomal interface, for the endoplasmic reticulum unfolded protein response and for a myelin structural component. © 2011 Nature America, Inc. All rights reserved. (shrink)

Body integrity identity disorder is a very rare condition in which people experience long-standing anguish because there is a mismatch between their bodies and their internal image of how their bodies should be. Most typically, these people are deeply distressed by the presence of what they openly acknowledge as a perfectly normal leg. Some with the condition request that their limb be amputated. 1 We and others have argued that such requests should be acceded to in carefully selected patients.1–4 Consistent (...) with this view, a group at the University of Sydney is developing a programme to better understand and treat BIID and to offer amputation if appropriate. In a recent paper, Patrone argues that such amputations should be prohibited.5 He suggests that authors supporting amputation in BIID depend on analogies with more familiar conditions and then claim that the ‘the desires, choices and requests of BIID patients should be held to exactly the same standards and treated with exactly the same respect as the desires, choices and requests of any more conventional patient’.5 He believes that these analogies are invalid and that therefore the arguments for amputation are invalid.Patrone concentrates a great deal upon whether a decision to have a particular medical intervention is to be regarded as ‘rational’. Unfortunately, he makes no attempt to define what he …. (shrink)

In the last decade the use of advance directives or living wills has become increasingly common. This paper is concerned with those advance directives in which the user opts for withdrawal of active treatment in a future situation where he or she is incompetent to consent to conservative management but where that incompetence is potentially reversible. This type of directive assumes that the individual is able accurately to determine the type of treatment he or she would have adopted had he (...) or she been competent in this future scenario. The paper argues that this assumption is flawed and provides theoretical and empirical evidence for this. If the assumption is false, and those taking out advance directives do not realise this, then the ethical bases for the use of these advance directives-the maximisation of the individual's autonomy and minimisation of harm-are undermined. The paper concludes that this form of advance directive should be abolished. (shrink)

"Neuroscience and Philosophy" begins with an excerpt from "Philosophical Foundations of Neuroscience," in which Maxwell Bennett and Peter Hacker question the ...

Background: Funding organisations and research ethics committees should play a part in strengthening attention to gender equality in clinical research. In the research policy of European Union , funding measures have been taken to realise this, but such measures are lacking in the EU policy regarding RECs.Objective: To explore how RECs in Austria, Germany, Ireland, The Netherlands and Sweden deal with gender equality issues by asking two questions: Do existing procedures promote representation of women and gender expertise in the committee? (...) How are sex and gender issues dealt with in protocol evaluation?Methods: Two RECs were selected from each country. Data were obtained through interviews with key informants and content analysis of relevant documents .Results: All countries have rules to ensure the presence of women on RECs; gender expertise is not required. Drug study protocols are carefully evaluated, sometimes on a formal basis, as regards the inclusion of women of childbearing age. The reason for excluding either one of the sexes or including specific groups of women or making a gender-specific risk–benefit analysis are investigated by some RECs. Such measures are, however, neither defined in the regulations nor integrated in review tools.Conclusions: The RECs investigated in five European member states are found to pay limited attention to gender equality in their working methods and, in particular in protocol evaluation. Policy and regulations of EU are needed to strengthen attention to gender equality in the work of RECs. (shrink)

Is there ever any reason for a doctor to lie to a patient? In this paper, we critically review the literature on lying to patients and challenge the common notion that while lying is unacceptable, a related entity--'benevolent deception' is defensible. Further, we outline a rare circumstance when treating psychotic patients where lying to the patient is justified. This circumstance is illustrated by a clinical vignette.

In this paper we try to answer the question whether diffusion is a possible mechanism to explain mesoderm induction in Amphibians. First the embryological data are discussed and a hypothesis for mesoderm formation is set forth. The blastula being essentially a hollow sphere, we assume that the induction mechanism in an embryo at the blastula stage can be simulated by diffusion-reaction processes on spherical surfaces. A model is constructed for the simple case when the source is held constant with respect (...) to time, the decay proportional to the concentration and the diffusion coefficient a constant, From simulation we find a (best) value for the decay constant to be 6 × 10–5/sec and for the diffusion constant to be 0.24 × 10– 6 cm2/sec. The relation between the parameters is derived from an analytic solution for the diffusion process on a spherical surface with a continuously producing point source and the concentration proportional to the decay. The form and regulative properties of the steady concentration gradient are discussed. (shrink)

The slippery slope argument has been the mainstay of many of those opposed to the legalisation of physician-assisted suicide and euthanasia. In this paper I re-examine the slippery slope in the light of two recent studies that examined the prevalence of medical decisions concerning the end of life in the Netherlands and in Australia. I argue that these two studies have robbed the slippery slope of the source of its power--its intuitive obviousness. Finally I propose that, contrary to the warnings (...) of the slippery slope, the available evidence suggests that the legalisation of physician-assisted suicide might actually decrease the prevalence of non-voluntary and involuntary euthanasia. (shrink)

Cells fine‐tune their DNA repair, selecting some regions of the genome in preference to others. In the paradigm case, excision of UV‐induced pyrimidine dimers in mammalian cells, repair is concentrated in transcribed genes, especially in the transcribed strand. This is due both to chromatin structure being looser in transcribing domains, allowing more rapid repair, and to repair enzymes being coupled to RNA polymerases stalled at damage sites; possibly other factors are also involved. Some repair‐defective diseases may involve repair‐transcription coupling: three (...) candidate genes have been suggested.However, preferential excision of pyrimidine dimers is not uniformly linked to transcription. In mammals it varies with species, and with cell differentiation. In Drosophila embryo cells it is absent, and in yeast, the determining factor is nucleosome stability rather than transcription.Repair of other damage departs further from the paradigm, even in some UV‐mimetic lesions. No selectivity is known for repair of the very frequent minor forms of base damage. And the most interesting consequence of selective repair, selective mutagenesis, normally occurs for UV‐induced, but not for spontaneous mutations. The temptation to extrapolate from mammalian UV repair should be resisted. (shrink)

Through discourse with international groups of physicians, we conducted a cross-cultural analysis of the types of ethical dilemmas physicians face. Qualitative analysis was used to categorise the dilemmas into seven themes, which we compared among the physicians by country of practice. These themes were a-theoretically-driven and grounded heavily within the text. We then subjected the dilemmas to an analysis of moral intensity, which represents an important theoretical perspective of ethical decision making. These constructs represent salient determinants of ethical behaviour and (...) our cross-cultural sample afforded us the opportunity to consider both the pragmatic aspects of culture, as they are perceived by physicians, as well as the theory-driven concept of moral intensity. By examining both culture and moral intensity, we hope to better elucidate the complexities of ethical decision-making determinants among physicians in their daily practice. Doing so may potentially have practical implications for ethics training of medical students and foreign physicians. (shrink)

Objectives: The mental health legislation of most developed countries includes either a dangerousness criterion or an obligatory dangerousness criterion (ODC). A dangerousness criterion holds that mentally ill people may be given treatment without consent if they are deemed to be a risk to themselves or others. An ODC holds that mentally ill people may be given treatment without consent only if they are deemed to be a risk to themselves or others. This paper argues that the dangerousness criterion is unnecessary, (...) unethical and, in the case of the ODC, potentially harmful to mentally ill people and to the rest of the community. Methods: We examine the history of the dangerousness criterion, and provide reasoned argument and empirical evidence in support of our position. Results: Dangerousness criteria are not required to balance the perceived loss of autonomy arising from mental health legislation. Dangerousness criteria unfairly discriminate against the mentally ill, as they represent an unreasonable barrier to treatment without consent, and they spread the burden of risk that any mentally ill person might become violent across large numbers of mentally ill people who will never become violent. Mental health legislation that includes an ODC is associated with a longer duration of untreated psychosis, and probably contributes to a poorer prognosis and an increase risk of suicide and violence in patients in their first episode of psychosis. Conclusions: Dangerousness criteria should be removed from mental health legislation and be replaced by criteria that focus on a patient’s capacity to refuse treatment. (shrink)

This volume, which contains the 1962 lecture "Zeit und Sein," is the most important publication by Heidegger since Unterwegs zur Sprache appeared in 1959. Bearing the same title as the much discussed missing part of the first half of Sein und Zeit, "Zeit und Sein" is the best demonstration we have of how the later Heidegger carries out the program which was outlined in Sein und Zeit, i.e., how the clue which the analytic of Dasein provides--that Being is to be (...) understood in terms of time--is followed out in the later works. Heidegger explicates the temporality of Being in terms of its character as a "gift" and an epochal sending which "is" both as having been and as to come. Being as time is thus the "event of appropriation". In addition to "Zeit und Sein," Zur Sache des Denkens also contains: The notes of a seminar which Heidegger conducted at Todtnauberg in 1962 upon the "Zeit und Sein" lecture. As Professor Alfredo Guzzoni, the editor of these notes, indicates this is the only time that Heidegger has conducted a seminar on a text of his own composition. A lecture entitled "The End of Philosophy and the Problem of Thought," which was delivered at a Kierkegaard colloquium in 1964. An autobiographical description of Heidegger's growing interest in and attraction to Husserl's phenomenological method in the pre-Sein und Zeit period; this was prepared in 1963 for a Festschrift in honor of Hermann Niemeyer.--J. D. C. (shrink)

The present contribution to the continuing translation of the works of Heidegger into English under the editorship of J. Glenn Gray is one of the most valuable. The first-rate translation, preceded by an excellent Introduction, is by Albert Hofstadter, whose popular anthology, Philosophies of Art and Beauty, had included his translation of Heidegger's 1935 essay, "The Origin of the Work of Art." That essay, along with six other pieces, hitherto untranslated, make up the present volume--including the first essay of Unterwegs (...) zur Sprache, which was not included in the English translation, On the Way to Language. The volume also contains a translation of Heidegger's poem "Aus der Erfahrung des Denkens," under the title "The Thinker as Poet." Found here too are the two important essays "Building, Dwelling and Thinking," and "The Thing," which together represent the most important of Heidegger's all too brief but very suggestive treatments of the "world" as the "Foursome". Readers of Being and Time who consult these later essays will be surprised to discover what has come of the "world" in Heidegger's later thought, and in particular of the relationship of God to the world, a theme which was bracketed in Being and Time. As a whole this very valuable collection deals with the later Heidegger's highly aesthetic, highly poetic, view of Being and of Dasein's relationship to Being. These essays represent the final outcome of his use of the phenomenological method to approach Being; and they contain, if anything does, what Heidegger means by "overcoming metaphysics." If Heidegger's later thought is, as has been suggested, a Seinsmystik, it is no less a Seinsdichtung.--J. D. C. (shrink)

This translation of Heidegger's 1929 essay, Vom Wesen des Grundes, is overdue and will be gratefully received by the English-speaking student of Heidegger. The essay is quite technical as it works out the theme of Dasein's ability to transcend beings and comprehend them in their Being. The German text is exceptionally rugged going, even for Heidegger. For example, the important transition that Heidegger makes from umwillen to Wille, has no real correlate in English, but Malick handles such difficulties quite well. (...) One can, however, quarrel with two points in this edition. Malick's assertion that the essay is fundamentally concerned with the theme of the "world" is only quantitatively true. Its deeper interest is surely to go beyond the world and to explain its roots in transcendence and freedom. The most important part of the book is Part III in which the finite and groundless character of Dasein's freedom-transcendence is thematized. The translation of "Grund" as "Reasons" in the title is misleading as it lacks the necessary connotation of "foundation," "basis," "soil." Thus, although unwieldy, "The Essence of Ground" would perhaps be a more accurate translation.--J. D. C. (shrink)

The present volume is one of the few recent works to devote its attention to the "early" Heidegger, yet it contributes significantly to our understanding of Heidegger's later development. "Transcendence" means crossing beyond the being to the horizon within which the being appears. The "transcendental" make-up of Dasein, which is the power of Dasein to make this crossing, is the principal theme of Kant und das Problem der Metaphysik and Vom Wesen des Grundes. "Difference" is the "ontological difference" between Being (...) and beings which is discussed again in Vom Wesen des Grundes and--since Being is not-any-being--in the analysis of the Nothing in Was ist Metaphysik? The pivotal element in Rosales' interpretation is the radical finitude of Dasein's "transcendence." For transcendental-horizonal thinking is unequipped to explain the radical concealment of Being which Dasein experiences. While providing the horizon within which things appear, transcendental-horizonal thinking does not offer an explanation for the recalcitrant hiddenness of Being. Hence Being must be experienced as a-letheia, as the original, independent process of concealing itself, and of revealing itself. And a break with the early transcendental-horizonal or Kantian, and so "subjectivistic" or "metaphysical" perspective of Sein und Zeit is necessitated. While the author owes a clear debt to Marx and Schulz, his interpretation is impressive and a contribution.--J. D. C. (shrink)

This study examined health professionals’ (HPs) experience, beliefs and attitudes towards brain death (BD) and two types of donation after circulatory death (DCD)—controlled and uncontrolled DCD. Five hundred and eighty-seven HPs likely to be involved in the process of organ procurement were interviewed in 14 hospitals with transplant programs in France, Spain and the US. Three potential donation scenarios—BD, uncontrolled DCD and controlled DCD—were presented to study subjects during individual face-to-face interviews. Our study has two main findings: (1) In the (...) context of organ procurement, HPs believe that BD is a more reliable standard for determining death than circulatory death, and (2) While the vast majority of HPs consider it morally acceptable to retrieve organs from brain-dead donors, retrieving organs from DCD patients is much more controversial. We offer the following possible explanations. DCD introduces new conditions that deviate from standard medical practice, allow procurement of organs when donors’ loss of circulatory function could be reversed, and raises questions about “death” as a unified concept. Our results suggest that, for many HPs, these concerns seem related in part to the fact that a rigorous brain examination is neither clinically performed nor legally required in DCD. Their discomfort could also come from a belief that irreversible loss of circulatory function has not been adequately demonstrated. If DCD protocols are to achieve their full potential for increasing organ supply, the sources of HPs’ discomfort must be further identified and addressed. (shrink)

Our world is a world of change. Children are born and grow into adults. Material possessions rust and decay with age and ultimately perish. Yet scepticism about change is as old as philosophy itself. Heraclitus, for example, argued that nothing could survive the replacement of parts, so that it is impossible to step into the same river twice. Zeno argued that motion is paradoxical, so that nothing can alter its location. Parmenides and his followers went even further, arguing that the (...) very concept of qualitative change is inconsistent. Change in any respect is impossible, they argued, as change requires difference and nothing differs from itself. Few today would accept the Eleatic conclusion that change is impossible. But the topic of change continues to be a source of much debate, as it brings together various issues that are central to metaphysics, language, and logic – including identity, persistence, time, tense, and temporal logic. Author Recommends Wasserman, Ryan. 'The Problem of Change.' Philosophy Compass 1 (2006): 1–10. This article presents the problem of change and provides a brief survey of potential solutions. Haslanger, Sally. 'Persistence Through Time.' The Oxford Handbook of Metaphysics . Eds. M. Loux and D. Zimmerman. Oxford: Oxford University Press, 2003. This article presents the problem of change and provides a detailed survey of potential solutions. Heller, Mark. 'Things Change.' Philosophy and Phenomenological Research 52 (1992): 695–704. This article presents, explains, and defends the temporal parts solution to the problem of change. Hinchliff, Mark. 'The Puzzle of Change.' Philosophical Perspectives 10 (1996): 119–36. This article presents, explains, and defends the presentist solution to the problem of change. Wasserman, Ryan. 'The Argument from Temporary Intrinsics.' Australasian Journal of Philosophy 81 (2003): 413–19. This article presents, explains, and defends the relationist solution to the problem of change. Sider, Theodore. Four-Dimensionalism . Oxford: Oxford University Press, 2001. This book provides an introduction to various issues related to the problem of change, including the nature of time, tense, and persistence. Chapter 5 presents, explains, and defends the stage-view solution to the problem of change. Online Materials Change. URL: http://plato.stanford.edu/entries/change/ The Stanford Encyclopedia of Philosophy entry on change, by Chris Mortensen. Time. URL: http://plato.stanford.edu/entries/time/ The Stanford Encyclopedia of Philosophy entry on time, by Ned Markosian. Temporal Parts. URL: http://plato.stanford.edu/entries/temporal-parts/ The Stanford Encyclopedia of Philosophy entry on temporal parts, by Katherine Hawley. Material Constitution. URL: http://plato.stanford.edu/entries/material-constitution/ The Stanford Encyclopedia of Philosophy entry on material constitution, by Ryan Wasserman. Persistence Bibliography. URL: http://tedsider.org/teaching/pp_bibliography.pdf A bibliography on change and related issues, by Theodore Sider. Sample Syllabus Books on Syllabus Rea, Michael. Material Constitution: A Reader . Lanham: Rowman & Littlefield, 1997. Sider, Theodore. Four-Dimensionalism . Oxford: Oxford University Press, 2001. van Inwagen, P. and Zimmerman, D. 2008. Metaphysics: The Big Questions . 2nd ed. Oxford: Blackwell, 2008. Week 1: Time and Tense Four-Dimensionalism , chapters 1 and 2. Markosian, Ned. 'A Defence of Presentism.' Oxford Studies in Metaphysics, Volume 1. Ed. D. Zimmerman. Oxford: Oxford University Press, 2004: 47–82. In van Inwagen, P. and Zimmerman, D. Metaphysics: The Big Questions. 2nd ed. Oxford: Blackwell, 2008: 116-123. In van Inwagen, P. and Zimmerman, D. Metaphysics: The Big Questions. 2nd ed. Oxford: Blackwell, 2008: 124-129. Week 2: Time and Persistence Four-Dimensionalism , chapter 3. McGrath, Matthew. 'Temporal Parts.' Philosophy Compass 2 (2007): 730–48. In van Inwagen, P. and Zimmerman, D. Metaphysics: The Big Questions. 2nd ed. Oxford: Blackwell, 2008: 265-267. Hawthorne, J, Scala, M., and Wasserman, R. 'Recombination, Humean Supervenience, and Causal Constraints: An Argument for Temporal Parts?' Oxford Studies in Metaphysics , Volume 1. Ed. D. Zimmerman, Oxford: Oxford University Press, 2004: 301-318. Week 3: Change and Presentism In van Inwagen, P. and Zimmerman, D. Metaphysics: The Big Questions. 2nd ed. Oxford: Blackwell, 2008: 141-149. In van Inwagen, P. and Zimmerman, D. Metaphysics: The Big Questions. 2nd ed. Oxford: Blackwell, 2008: 267-269. In van Inwagen, P. and Zimmerman, D. Metaphysics: The Big Questions. 2nd ed. Oxford: Blackwell, 2008: 269-281. Week 4: Change and Temporal Parts Four-Dimensionalism , pp. 92–8. Heller, Mark. 'Things Change.' Philosophy and Phenomenological Research 52 (1992): 695–704. Lombard, Lawrence. 'The Doctrine of Temporal Parts and the "No Change" Objection.' Philosophy and Phenomenological Research 54 (1994): 365–72. Week 5: Change, Relationism, and Adverbialism Hawley, Katherine. 'Why Temporary Properties are not Relations between Physical Objects and Times.' Proceedings of the Aristotelian Society 98 (1998): 211–16. Wasserman, Ryan. 'The Argument from Temporary Intrinsics.' Australasian Journal of Philosophy 81 (2003): 413–19. Lewis, David. 'Tensing the Copula.' Mind 111 (2002): 1–13. Caplan, Ben. 'Why so Tense about the Copula?' Mind 114 (2007): 703–8. Week 6: Change and Tropes Ehring, Douglas. 'Lewis, Temporary Intrinsics and Momentary Tropes.' Analysis 57 (1997): 254–8. MacBride, Fraser. 'Four New Ways to Change Your Shape.' Australasian Journal of Philosophy 79 (2001): 81–9. Simons, Peter. 'On Being Spread Out in Time: Temporal Parts and the Problem of Change.' Existence and Explanation . Eds. W. Spohn, B.C. van Fraassen, and B. Skyrms. Dordrecht: Kluwer, 1991: 131-147. Weeks 7 and 8: Special Topic – Material Change Four-Dimensionalism , chapter 5. Selections from Material Constitution: A Reader. Week 9: Special Topic – Change of Position In van Inwagen, P. and Zimmerman, D. Metaphysics: The Big Questions. 2nd ed. Oxford: Blackwell, 2008: 186-195. In van Inwagen, P. and Zimmerman, D. Metaphysics: The Big Questions. 2nd ed. Oxford: Blackwell, 2008: 195-215. Week 10: Special topic – Changing the Past In van Inwagen, P. and Zimmerman, D. Metaphysics: The Big Questions. 2nd ed. Oxford: Blackwell, 2008: 224-235. van Iwagen, Peter. 'Changing the Past.' Oxford Studies in Metaphysics , Volume 5 . Ed. D. Zimmerman. Oxford: Oxford University Press, 2009: 1-22. Hudson, H. and Wasserman, R. 'Van Inwagen on Time Travel and Changing the Past.' Oxford Studies in Metaphysics , Volume 5. Ed. D. Zimmerman. Oxford: Oxford University Press, 2009: 41-49. (shrink)

Photo by Karl Raymund Catabas on Unsplash “After Buddha was dead, they still showed his shadow in a cave for centuries – a tremendous, gruesome shadow. God is dead; but given the way people are, there may still for millennia be caves in which they show his shadow. – And we – we must still defeat his shadow as well!” – Friedrich Nietzsche[1] INTRODUCTION Friedrich Nietzsche famously declared that “God is dead!”[2] but lamented that his contemporaries remained living in the (...) shadow of God. For Nietzsche, the morality of his time was still based in the Christian tradition, even though faith in God was waning. Bioethics lives under a similar shadow: the shadow of Enlightenment Era-rationalism. Bioethics curricula focus on principles derived from Kantian deontology and utilitarianism. The allure of maintaining a moral framework that provides a rational method that can be handily applied to any situation remains strong. The principlist approach advanced by Tom Beauchamp and James Childress is taught to nearly all medical students in the United States,[3] and is essentially the canonical ethical framework of bioethics. In this model, the principle of autonomy is Kantian in nature, and the principles of beneficence and non-maleficence are utilitarian in nature.[4] Moreover, the presented framework is an approach that, when applied rationally to any healthcare scenario, will yield an outcome “considered moral.”[5] This reflects a faulty conception of philosophy that plagues much of bioethics, wherein the only contribution of philosophy pertinent to bioethics is moral philosophy elucidated by European thinkers in the Enlightenment Era. The landscape of moral philosophy has evolved significantly from the 18th century. However, the bioethical world has not kept up with the philosophical world, remaining instead in the shadow of antiquated moral thinking. Also lacking in bioethics are other disciplines of philosophy, such as philosophy of language, existentialism, and aesthetics, which are often given no consideration at all. The inclusion of both modern moral philosophy and other philosophical fields is necessary if bioethics is to survive its transition into modernity. l. The Shadow of Enlightenment Enlightenment Era philosophers such as Immanuel Kant argued that one need only employ reason to obtain knowledge; emotion bore no relevance when determining ethical behavior. Kant’s moral theories thus privileged a duty to act according to moral imperatives over feelings. Other Enlightenment Era philosophers such as John Locke developed systems that attempted to quantify human goods and human ills. This quantification potentially reduces human welfare and suffering to utility. Today, in the world of philosophy, such a “neutral analysis,” as Cora Diamond noted, is “dead or moribund.”[6] Bernard Williams remarked that such moral philosophy is “empty and boring,”[7] and G. E. M. Anscombe stated that it “no longer generally survives.”[8] And yet, just as the atheists in Nietzsche’s world dwelt in the moral code of a dead God, bioethicists still pursue a unified moral system that takes an input, applies some moral rules, and generates a moral outcome, like the four principles approach that Beauchamp and Childress laid out.[9] Some detractors of principlism take issue with their approach for not being unified enough and want to replace it with a procedural framework that is even more systematic and complicated. They argue that the resulting moral framework would be a “comprehensive decision procedure for arriving at answers”[10] that retains the “impartiality that is an essential part of morality.”[11] The shadow of rationalist morality has caused bioethical decision making to become detached and rigid when bioethics should concern itself with the humans whose lives it affects. A rational, divorced-from-emotion way of thinking ultimately fails to yield satisfactory results when decisions are made by and for emotional beings. Dr. Paul Farmer, among others, championed the idea that bioethics should be de-philosophized, as philosophy, cold and calculated, fails to adequately respond to the realities of those worst off.[12] Instead, Dr. Farmer emphasized the inclusion of the social sciences, like sociology and anthropology, in bioethics. Undoubtedly, Dr. Farmer was on the right track; bioethics should certainly engage directly with the people whom its decisions involve. If the narrow band of moral philosophy currently found in bioethics – that of stringent rationalism – were all that philosophy had to offer, I, too, would advocate for a de-philosophization. Ludwig Wittgenstein notes that to attempt to capture the complexity of moral thinking in a manner that employs reason alone and casts aside emotion is a “hopeless task,” like reconstructing a sharp image “from a blurred one.”[13] Unfortunately, bioethics is mired in the remnants of this hopeless task. To Dr. Farmer, the dominant moral framework was too restrictive and was unresponsive to the social and humanitarian needs of those whom bioethics is meant to help. As such, he wished to free bioethics from the shadow of a morality derived from rationalist thinkers. ll. Beyond Rationalism Like Nietzsche, who tried to resolve Europe’s post-religion vacuum by providing his society with a new way to live, Dr. Farmer wanted to replace the rationalist philosophy upon which bioethics was built with a “resocialization” of the field.[14] I agree with Dr. Farmer’s call for resocialization, as well as his denouncement of philosophy as it exists in bioethics. Evaluating risks and benefits along a predetermined array of moral principles is far too rigid and impersonal to guide what are often the most important decisions one will make. For Dr. Farmer, the most needed change was restoring the social element of bioethics. However, in advocating for this resocialization, Dr. Farmer casts philosophy as the antithesis of social science, noting that “few would regard philosophy … as a socializing discipline.”[15] I disagree. Rationalist moral philosophy may be lacking in socializing force, but there are other fields of philosophy that are responsive to our social reality. Rather than de-philosophizing bioethics, it makes more sense to replace the antisocial philosophies predominant in bioethics with prosocial philosophies better suited to it. Of course, the contribution of philosophy to bioethics is more than moral theories from the Enlightenment Era. There are more recent philosophical contributions from outside the field of moral philosophy that have roused bioethical interest. Jennifer Blumenthal-Barby, et al., argue for philosophy’s continued place in bioethics, citing Derek Parfit’s “non-identity problem,” which altered the landscape of reproductive ethics, and David Chalmers’ contributions to philosophy of consciousness, which have implications for the moral status of brain organoids.[16] Still, these are narrow applications of philosophy to highly specialized areas of bioethics, which not all bioethicists are inclined to delve into. Philosophy in bioethics should not be confined to niche applications in specialist fields but should influence all bioethical thought. Fortunately, there remains untapped a wealth of philosophical disciplines that pertains to exactly this. Philosophy of language investigates the nature of meaning and understanding in communication, which is a necessary social action. Successfully deciphering and conveying moral values in discourse is a bioethicist’s bread and butter, as is resolving disagreements and reaching agreements. Indeed, it is often the case that miscommunication lies at the root of an impasse between a doctor and a patient. An understanding of the nature of the disagreement would help resolve the conflict, as different types of disagreements require different interventions for resolution. For instance, a “substantive disagreement,”[17] in which two parties use the same terms in the same ways and have a fundamental disagreement on which outcome is more desirable, can be resolved only if one party yields to the other. On the other hand, a “merely verbal dispute,”[18] in which two parties use the same terms to represent entirely different concepts and values, requires standardization of terminological usage for its resolution. As such, no one can overstate the moral importance of successful communication in bioethics, and an exploration of language itself would prove invaluable to a bioethicist’s training. Existentialism is another subset of philosophy that acknowledges the social nature of human existence, noting that one’s being in the universe is concomitant with the existence of others sharing the same universe.[19] Thus, there is the recognition that whatever existence is, it is not complete without the existence of others. With this as a starting point, existentialists examined how to live meaningfully with others in this world. Since ethics crucially involves others, it is no surprise that existentialists pondered how to live moral lives. Existentialist conceptions of morality did not revolve around acting in accordance with a set of rules, but rather, recognized individual freedom in choosing how to act and emphasized acting authentically. In this vein, bioethicists should commit to doing what is right rather than committing to applying a set of principles. Existentialism, while part of the broader bioethics literature, is less common throughout bioethics curricula and deserves more prominence. Martin Heidegger, for instance, emphasized the difference between two types of thinking: “calculative thinking” and “meditative thinking.” Heidegger characterizes calculative thinking as a computation, wherein from some given starting conditions “definite results”[20] are determined, and contrasts this with meditative thinking, which he describes as “thinking which contemplates the meaning which reigns in everything that is.”[21] Heidegger was critical of the pervasiveness of calculative thinking, seeing it as the “ground of thoughtlessness,”[22] in which we only relate to the world in a meaningless, mechanical way. This is the emphasized type of thinking in rationalist conceptions of morality popular in bioethics; from a set of starting conditions, a series of rules are applied, and a moral outcome is calculated. Such a technique, however, discounts the personal meaning individuals place on the aspects of their lives relevant to their decision making, as well as the meaning in committing to doing what is right. Under calculative thinking, such a commitment is reduced to rote rule-following. A turn to meditative thinking would ensure that bioethical decisions comport with living meaningful lives. Even aesthetics, a discipline devoted to examining beauty and taste,[23] has a place in bioethics. Just as the viewing of a painting, the listening of a song, or the reading of a book elicits an effective response, hearing a patient’s story leaves an emotional imprint. The recounting of a traumatic moment imparts sadness, and a joyous occasion begets joy in the listener as well. As acknowledged in the field of everyday aesthetics, these aesthetic experiences often spur us to act:[24] The unsightly appearance of a polluted riverbank drives us to remove the trash; the presence of sorrow in one’s life drives us to ameliorate it. To be mindful of aesthetic experiences and allow them to affect us emotionally is paramount to the motivation of a bioethicist to serve the patient, not out of an obligation to a job description, but out of a desire to truly avail the patient of their anguish. For example, the new field of narrative medicine utilizes critical reading and literary techniques to train clinicians and bioethicists in emotional understanding and listening skills that stress the social aspects of medicine beyond rational analysis and decision making. CONCLUSION Dr. Farmer is absolutely correct; bioethics is in dire need of resocialization. It should not be the case that the justification for a moral action is essentially that “the rules say so,” or that simply by teaching such rules to medical students, the very act of making bioethical decisions that diverge from those determined by principles can be seen as an act of “bad faith … hubris or, worse, malpractice.”[25] As bioethicists are coming to realize, the rationalist philosophical traditions that bioethics was founded upon are past their expiry, and the time for change is now. Indeed, as Dr. Farmer urges, “socializing disciplines” like anthropology, history, political economy, and sociology are necessary to humanize the field of bioethics.[26] So too, however, can philosophy be a socializing discipline, if we know where to look. Bioethics should evolve. Its new goal should be to focus on meaningful human relationships, and to phase out rigid, impersonal modes of moral thinking. The limited sampling of unsatisfying moral theories from hundreds of years ago leaves many bioethics students cold, and it is easy to see why bioethicists are ready to part ways with philosophy. I believe this is a move in the wrong direction; there is a place for philosophy in the future of bioethics. Just as bioethics needs a resocialization, it is also needs of a re-philosophization. These enrichments complement one another. There is more to bioethics than mechanically determining the right course of action in a healthcare setting. Bioethics engages with the most ancient of philosophical questions: questions of what makes human existence meaningful, what makes us who we are, how we want to relate to others, how and why we feel, what our place in the world is, how we can communicate what we think, and why our moral intuitions are so compelling. We would be remiss if we did not begin to investigate additional contributions to morality from a wider range of philosophies that try to provide answers to such questions, as they offer a richness to moral thinking that cannot be gleaned from traditional bioethical approaches alone. - [1] Friedrich Wilhelm Nietzsche, The Gay Science: With a Prelude in German Rhymes and an Appendix of Songs, ed. Bernard Williams, Josefine Nauckhoff, and Adrian Del Caro, Cambridge Texts in the History of Philosophy, 109. [2] Nietzsche, 120. [3] Daniel C O’Brien, “Medical Ethics as Taught and as Practiced: Principlism, Narrative Ethics, and the Case of Living Donor Liver Transplantation,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 47, no. 1 : 97, https://doi.org/10.1093/jmp/jhab039. [4] K. D. Clouser and B. Gert, “A Critique of Principlism,” Journal of Medicine and Philosophy 15, no. 2 : 219–36, https://doi.org/10.1093/jmp/15.2.219. [5] O’Brien, “Medical Ethics as Taught and as Practiced,” 97. [6] Cora Diamond, “Having a Rough Story about What Moral Philosophy Is,” New Literary History 15, no. 1 : 168, https://doi.org/10.2307/468998. [7] Bernard Williams, Morality: An Introduction to Ethics, Canto ed, xvii. [8] G. E. M. Anscombe, “Modern Moral Philosophy,” Philosophy 33, no. 124 : 1, https://doi.org/10.1017/S0031819100037943. [9] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 7th ed, 13. [10] Clouser and Gert, 233. [11] Clouser and Gert, “A Critique of Principlism,” 235. [12] Paul Farmer and Nicole Gastineau Campos, “Rethinking Medical Ethics: A View from Below,” Developing World Bioethics 4, no. 1 : 17–41, https://doi.org/10.1111/j.1471-8731.2004.00065.x. [13] Ludwig Wittgenstein, Philosophical Investigations, ed. Joachim Schulte, trans. P. M. S. Hacker, 4th edition, 40. [14] Farmer and Campos, “Rethinking Medical Ethics,” 20. [15] Farmer and Campos, 20. [16] Jennifer Blumenthal-Barby et al., “The Place of Philosophy in Bioethics Today,” The American Journal of Bioethics: AJOB, June 30, 2021, 3–5, https://doi.org/10.1080/15265161.2021.1940355. [17] Brendan Balcerak Jackson, “Verbal Disputes and Substantiveness,” Erkenntnis 79, no. S1 : 31–54, https://doi.org/10.1007/s10670-013-9444-5. [18] C. S. I. Jenkins, “Merely Verbal Disputes,” Erkenntnis 79, no. 1 : 11–30, https://doi.org/10.1007/s10670-013-9443-6. [19] Steven Crowell, “Existentialism,” in The Stanford Encyclopedia of Philosophy, ed. Edward N. Zalta, Summer 2020, https://plato.stanford.edu/archives/sum2020/entries/existentialism/; Anita Avramides, “Other Minds,” in The Stanford Encyclopedia of Philosophy, ed. Edward N. Zalta, Winter 2020, https://plato.stanford.edu/archives/win2020/entries/other-minds/. [20] Martin Heidegger, Discourse on Thinking, Harper Torchbooks, 46. [21] Heidegger, 46. [22] Heidegger, 45. [23] Nick Zangwill, “Aesthetic Judgment,” in The Stanford Encyclopedia of Philosophy, ed. Edward N. Zalta, Winter 2021, https://plato.stanford.edu/archives/win2021/entries/aesthetic-judgment/. [24] Yuriko Saito, “Aesthetics of the Everyday,” in The Stanford Encyclopedia of Philosophy, ed. Edward N. Zalta, Spring 2021, https://plato.stanford.edu/archives/spr2021/entries/aesthetics-of-everyday/. [25] O’Brien, “Medical Ethics as Taught and as Practiced,” 112. [26] Farmer and Campos, “Rethinking Medical Ethics,” 20. (shrink)