Context Conflicts over treatment decisions have been linked to physicians' emotional states. Objective To measure the prevalence of emotional exhaustion and conflicts over treatment decisions among US obstetrician/gynaecologists (ob/gyns), and to examine the relationship between the two and the physician characteristics that predict each. Methods Mailed survey of a stratified random sample of 1800 US ob/gyn physicians. Criterion variables were levels of emotional exhaustion and frequency of conflict with colleagues and patients. Predictors included physicians' religious characteristics and self-perceived empathy. Results (...) Response rate among eligible physicians was 66% (1154/1760). 36% of ob/gyns reported high levels of emotional exhaustion, and majorities reported conflict with colleagues (59%) and patients (61%). Those reporting conflict were much more likely to report emotional exhaustion (58% vs 29% who never conflict, OR, 95% CI 2.8, 1.6 to 4.8 for conflict with colleagues; 55% versus 26%, OR, 95% CI 2.2, 1.4 to 3.5 for conflict with patients). Physicians with lower self-perceived empathy were more likely to report physician-patient conflicts (65% vs 58% with higher empathy, OR, 95% CI 1.4, 1.0 to 1.9), as were female ob/gyns (66% vs 57% of males, OR, 95% CI 1.5, 1.1 to 2.0). Foreign-born physicians were less likely to report such conflicts (47% vs 64% of US born, OR, 95% CI 0.5, 0.4 to 0.8). Physicians' religious characteristics were not significantly associated with reporting conflict. Conclusions Conflicts over treatment decisions are associated with physicians' empathy, gender, immigration history and level of emotional exhaustion. With respect to the latter, conflict in the clinical encounter may represent an overlooked source or sign of burnout among ob/gyns. (shrink)

The patient was a woman in her 30s who, until the rapid progression of an ultimately fatal neurologic disease, had been a very successful professional, enjoying athletics and an active social life. In the 6 months of swift deterioration, she had gone from being extremely vibrant and energetic to being totally unable to care for her personal needs. There had been no loss of intellectual capacity. Her sister later recounted to Dr. J., the emergency department physician, that she had found (...) the patient unconscious and unresponsive at home and had immediately called the patient's neurologist in a neighboring city. He directed her to call the paramedics. (shrink)

Over the past two decades we have seen dramatic improvements in the efficacy, safety and availibity of antiretroviral therapy (ART). In the USA and Europe, life expectancy in people living with HIV disease approaches that of the HIV-uninfected.1 Even in regions hardest hit by the HIV epidemic, effective HIV therapy has reversed more than a decade of HIV-related decreased survival. Despite these advances in ART, motivations to pursue HIV cure remain strong due to the toxicity, adherence challenges, cost and access (...) to care issues associated with HIV therapy, as well as the persistant stigma associated with having HIV infection. Further and renewed motivation comes from a single case of HIV cure after stem cell transplantation for acute leukaemia. Given the tremendous improvements in ART, it is important to assess how effective and safe an HIV cure would need to be in order to be a viable option compared to ART. We argue that this should be done prior to the availability of a cure to provide realistic goals for researchers and policy makers. One methodology that has been increasingly popular over the past decade is the use of mathematical simulation modelling to assess the clinical impact, cost-effectiveness and clinical role of different treatment strategies in HIV disease, as well as in medicine broadly.2 Such models provide a framework and approach for using the best available data at any point in time, and assessing the potential impact of emerging innovations. Further, unlike individual trials focused on a single endpoint, these models can integrate multiple data sources to project beyond the timeline or outcomes of individual studies and project long-term outcomes in many domains, including virologic, immunologic, clinical and cost.3 Mathematical models have particular value in their ability to assess uncertainty in clinical care. Examples include parameters determined in …. (shrink)

Agricultural research raises fundamental ethical and value questions going beyond those in other fields both because of its public funding and because its results have significant impacts on habitats and other species. Questions about the sustainability of modern agriculture, which are shared with other sectors, require us to examine alternative visions and structures. These can be seen to range from status quo preserving ideologies to change-oriented utopias. It is argued that at the national level current ideologies—which include positivistic approaches and (...) belief in the neutrality of technology—mask real structural and policy choices as well as their ethical and value implications. At the international level, the export of fossil-fuel based modes of agriculture to the developing countries raises additional structural, policy, value, and ethical issues. (shrink)

In a time when we as a society are in the process of deciding what our basic rights to health care are, it is critically important for us to have a full and complete understanding of what constitutes health. We argue for an analysis of health according to which certain states are healthy not in themselves but because they allow an individual to reach actual goals. Recognizing that the goals of an individual considered from the point of view of biology (...) and the goals of the same individual considered as an agent in the world might be different, we introduce a distinction between the health of an individual qua organism and the health of an individual qua person. We then argue that this distinction characterizes the evaluations made by patients and healthcare providers better than the widely discussed distinction between disease and illness. (shrink)

As a neurodevelopmental condition that affects cognitive functioning, autism has been used as a test case for theories of moral responsibility. Most of the relevant literature focuses on autism’s impact on theory of mind and empathy. Here I examine aspects of autism related to executive function. I apply an account of how we might fail to be reasons responsive to argue that autism can increase the frequency of excuses for transgressive behavior, but will rarely make anyone completely exempt from moral (...) responsibility in general. On this account, although excuses may apply more often to autists than to others, the excuses that apply to autists are just the same excuses that can apply to anyone. (shrink)

The argument in this paper is that the exclusion of empirical research has led to a deficiency in the Positivist model; the neglect of conflict in the form of the trouble-case. In the attempt to define law in a relatively narrow way Positivists have avoided important knowledge about social behavior. In addition the analytical method of Positivism has been connected with a value-position which tends to exaggerate the extent to which law functions within social structures as an orderly system. One (...) consequence of this perspective is that the role of conflict in the law process is hardly appreciated. Studies of law in some primitive societies suggest that although social behavior generally is not regulated in rule-terms, conflict often is institutionalized in a manner capable of providing norms appropriate to new situations. It is suggested that the focus upon the trouble-case is more likely to develop our understanding of conflict as a dynamic element in the law process. (shrink)

This essay examines the syntax of names. It argues that names are a syntactically and not just semantically distinctive class of expressions. Its central claim is that names are a distinguished type of anaphoric device—devices of explicit co-reference. Finally it argues that appreciating the true syntactic distinctiveness of names is the key to resolving certain long-standing philosophical puzzles that have long been thought to be of a semantic nature.

In the article Privacy and Health Practices in the Digital Age, the authors describe current privacy challenges for digital health data and review the theoretical framework on privacy in the contex...

This paper examines two questions. The first is what it would mean for schools to be communities. This question is pursued by examining four metaphors for community: families, congregations, guilds, and democratic polities. Three models of school communities are then sketched. The second question is whether schools that are communities are inherently illiberal. The paper distinguishes between a liberal interpretation of schools as communities, where schools are viewed as limited-purpose free associations, and a communitarian interpretation where community and polity are (...) not adequately distinguished. I argue that, within a framework of liberal pluralism, schools can be communities without being illiberal. (shrink)

Genesis 1:26 announces that God made us in His image and likeness. The paper examines the connection between the divine image and likeness. The love that exists between the Father, Son, and Holy Spirit must be in the image. However, we cannot understand the Trinity so we make use of the divine likeness as a road to the divine image. The dual nature of Christ makes this pilgrimage possible. Christ as God is the divine image whereas Christ as man teaches (...) us how the divine likeness leads to the Father. The love inscribed in the human heart connects the finite to the infinite. The divine Persons exist in relationships. Salvation takes place through a person-making process in the likeness of divine relations. Salvation is the output of relationships taking place at the level of a social self, an environmental self, and an inner self. These processes function as gateway to the structure of the divine image. (shrink)

We glide easily from thought and talk about worldly objects to thought and talk about the contents of our beliefs about such worldly objects all the time. Smith ask Jones about the whereabouts of their pet cat and on the basis of Jones’s assertion that the cat is on the mat, Smith comes to believe that the cat is on the mat. Black in turn may ascribe to Smith the belief that the cat is on the mat. Such transitions from (...) thought and talk about worldly objects to thought and talk about states of mind are so familiar to us as to seem second nature. But there is a long-standing philosophical tradition, originating with Frege, but endorsed by philosophers with otherwise varying philosophical outlooks, which makes the very possibility of such transitions puzzling. That tradition assumes that in making at least certain attitude ascriptions – so-called de dicto or “notionally sensitive” ascriptions -- speakers refer to, describe, quantify over, or somehow pragmatically implicate the notions, representations, or modes of presentations that plausibly figure as constituents of our mental contents -- either to the exclusion of the worldly objects themselves or in addition to those objects. Such attitude ascriptions are widely taken to be the primary or unmarked case of an attitude ascription. But it is seldom acknowledged that twin facts that on this approach worldly objects will relate to the representational items that supposedly serve as ingredients of thought content in a one-many fashion and there is no automatic way “back-up” from worldly objects to modes of presentation thereof together generate a mystery about how possibly we are able execute transitions from thought and talk about worldly objects to thought and talk about representational states of mind. It is argued in this essay that the way around this mystery is to see that de re, rather than de dicto ascriptions are the unmarked form of attitude ascription and that our representations of mental contents are parasitic on our representations of worldly objects. That is, we talk about the contents of our states of mind not by adverting, in the first instance, to talk about peculiarly mental or representational entities like notions or modes of presentations, but primarily by talking about worldly entities themselves. That is, to attribute to another the belief that the cat is on the mat, one need not refer to modes of presentations, or their ilk, of said cat or said mat, but only to the relevant cat and the relevant mat. (shrink)

Green and Shapiro's tour de force fails as a convincing critique of rational choice applications in political science because it locks itself into a statistical form of assessment. Rather than seeing the constructive side of rational choice theory, both as an engine of theoretical development and as a source of non?obvious empirical insights about politics, Green and Shapiro depart from the procedure in most sciences, comparing rational choice against an ideal rather than some concrete alternative. Finally, they fail to note (...) the recent emphasis on sophisticated empirical testing of rational choice hypotheses. (shrink)

I argue that a certain initially appealing Fregean conception of our shared semantic competence in our shared language cannot be made good. In particular, I show that we must reject two fundamental Fregean principles‐what I call Frege's Adequacy Condition and what I call Frege's Cognitive Constraint on Reference Determination. Frege's adequacy condition says that in an adequate semantic theory, sentence meanings must have the same fineness of grain as attitude contents. The Cognitive Constraint on Reference Determination says that in an (...) adequate semantic theory mechanisms of reference determination will fix routes of epistemic access to referents and will mediate one‐sided recognition judgments about referents. I argue against Frege's adequacy condition that if meanings are sliced as finely as it requires there will be too many meanings to go around. I argue against the cognitive constraint on reference determination that even in an adequate theory of reference, mechanisms of reference determination must be sharply distinguished from routes of epistemic access. If so, we have little reason to expect an adequate theory of reference determination to directly illuminate Frege's cognitive puzzles or be sufficient to explain the basis of our one‐sided recognition judgments. (shrink)

This essay some first steps toward the naturalization of what I call rational intentionality or alternatively type II intentionality. By rational or type II intentionality, I mean that full combination of rational powers and content-bearing states that is paradigmatically enjoyed by mature intact human beings. The problem I set myself is to determine the extent to which the only currently extant approach to the naturalization of the intentional that has the singular virtue of not being a non-starter can be aggregated (...) up into an account of rational intentionality. I have in mind a broadly defined family of accounts whose main members are the indicator/information-theoretic approach of Dretske (1988), the asymmetric dependence theory of Jerry Fodor (1987, 1990, 1994) and the teleo-semantics of Ruth Millikan (1984, 1993). Somewhat inaccurately, I will call this family of approaches the information-theoretic family. To be sure, there is only a rough family resemblance among the members of the information-theoretic family. Indeed, several intense quarrels divide the members of that family one from another, but the precise outcome of those internecine struggles is not directly relevant to the aims of this essay. ² Taken collectively, the information-theoretic family yields a compelling picture of the place of at least a crude form of intentionality -- what I call frog-like or type I intentionality -- in the natural order. Though frog-like or type I intentionality is, I think, a genuine species of intentionality, it may subsist in the absence of rational powers. It is that species of intentionality enjoyed by irritable creatures who, following Brandom (1994). (shrink)

The Ethics Consultation Quality Assessment Tool (ECQAT) establishes standards by which the quality of ethics consultation records (ECRs) can be assessed. These standards relate to the ethics question, consultation-specific information, ethical analysis, and recommendations and/or conclusions, and result in a score associated with one of four levels of ethics consultation quality. For the ECQAT to be useful in assessing and improving the quality of healthcare ethics consultations, individuals who rate the quality of ECRs need to be able to reliably use (...) the tool.We developed a short course to train ethics consultants in using the ECQAT, and evaluated whether the participants (1) achieved an acceptable level of calibration in matching expert-established quality scores for a set of ethics consultations, and (2) were satisfied with the course. We recruited 28 ethics consultants to participate in a virtual, six-session course. At each session participants and faculty reviewed, rated, and discussed one to two ECRs. The participants’ calibration in matching expert-established quality scores improved with repeated exposure at all levels of ethics consultation quality. Participants were generally more accurate when assessing consultation quality at the dichotomous level of “acceptable” (scores of three or four) versus “unacceptable” (scores of one or two) than they were with a more specific score. Participants had higher rates of accuracy with the extreme ratings of “strong” (level four) or “poor” (level one). Although participants were highly satisfied with the course, only a minority of participants achieved the prespecified acceptable level of calibration (that is, 80 percent or greater accuracy between their score and expert-established scores). These results suggest that ECQAT training may require more sessions or need modification in the protocol to achieve higher reliability in scoring. Such trainings are an important next step in ensuring that the ECQAT is a tool that can be used to promote improvement in ethics consultation quality. (shrink)

The primary psychological process leading aggressive children to grow into dysfunctional adults is a defensive mindset, which encompasses a pattern of deviant social information processing steps, including hypervigilance to threat; hostile attributional biases; psychophysiological reactivity, experience of rage and testosterone release (in males); aggressive problem-solving styles; aggressogenic decision-making biases; and deficient behavioral skills. These processes are acquired in childhood and predict adult maladjustment outcomes, including incarceration and premature death. The antecedents of defensive mindset lie in early childhood experiences of trauma (...) and threat. The Fast Track (FT) intervention was designed to improve social competence in aggressive children. A randomized controlled trial demonstrated that FT is effective in preventing externalizing psychopathology; the primary mediating factor is the reduction of defensive mindset processes. This Element concludes with insights that defensive mindset might also explain dysfunction in other realms, including school culture, parenting, marriage, the workplace, intergroup relationships, politics, and international relations. (shrink)

By appealing to Paul Ricoeur’s view of interpretation as the dialectical process of understanding through explanation, Kenneth A. Reynhout contributes to the growing field of religion and science by developing an alternative understanding of interdisciplinary theology that is fundamentally hermeneutical.

If reason is a real causal force,operative in some, but not all ofour cognition and conation, then itought to be possible to tell anaturalistic story that distinguishes themind which is moved byreason from the mind which is movedby forces other than reason.This essay proposes some steps towardthat end. I proceed by showingthat it is possible to reconcile certainemerging psychological ideasabout the causal powers of themind/brain with a venerablephilosophical vision of reason as the facultyof norms. My accountof reason is psychologistic, social, (...) and consistent with anevolutionary approach to mind. The account preserves thenormativity by deflating it. But I argue that onlysuch deflated normativity has any chance of beingmade naturalistically respectable. (shrink)

McCoy, Liu, Lutz, and Sisti (2020) raise concerns about “partial representation,” in which nonelected advocates or advocacy organizations fail to engage and hold themselves accountable to the full range of people they purport to represent. They are right to point out that the autism community is vulnerable to partial representation. This open peer commentary notes some elements among those engaged with autism that may not fit under the type of “federated model” of representation McCoy, et al recommend. Advocates should tread (...) carefully to avoid some types of harm that do not arise when forming federations on other topics. The influence of antivaxxers and other questionable or harmful movements might even lead us to think, despite the value of open debate and engagement, that there is benefit to partial representation if it prevents potential harms that could arise from legitimizing dangerous practices. (shrink)

“Imagination may be thought of as a ‘work-around.’ It is a resourceful tactic to ‘undo’ a rule by creating a path around it without necessarily defying it.... Transgression, on the other hand, is rule breaking. There is no pretense of reinterpretation; it is defiance pure and simple. Whether imagination or disobedience is the source, constraints need not constrain, ties need not bind.” So writes Kenneth A. Shepsle in his introduction to Rule Breaking and Political Imagination. Institutions are thought to (...) channel the choices of individual actors. But what about when they do not? Throughout history, leaders and politicians have used imagination and transgression to break with constraints upon their agency. Shepsle ranges from ancient Rome to the United States Senate, and from Lyndon B. Johnson to the British House of Commons. He also explores rule breaking in less formal contexts, such as vigilantism in the Old West and the CIA’s actions in the wake of 9/11. Entertaining and thought-provoking, Rule Breaking and Political Imagination will prompt a reassessment of the nature of institutions and remind us of the critical role of political mavericks. (shrink)

This paper responds to Goodwin Liu's argument in Volume II of this Journal that a pedagogy must be supported by an appropriate theory of knowledge, and that the epistemology which best supports the service-learning pedagogy is anti-foundational pragmatism. The author shows that Liu's characterization of the pragmatist model of knowledge does not avoid the dualism which he sees as a fault of the traditional epistemology. After suggesting a remedy to this, the author then extends Liu's argument by indicating the limits (...) to what the appropriately modified epistemological support will sanction. These limits are shown to be more restrictive than Liu suggests. The result is an improved philosophical justification of the service-learning pedagogy and some suggestions for evaluating proposed curriculum. (shrink)

Schools in liberal societies are responsible for producing liberal citizens. However, if they have too robust a view of citizenship, they may find themselves undermining the view of good lives held by many pacific and law abiding groups. Here I argue against treating citizenship as an educational good that simply trumps private values when they conflict and in favor of a view that seeks a context sensitive balance between such conflicting goods. The paper explores Rawls's distinction between two moral powers (...) as a way of understanding the character of some of the private interests in schooling. (shrink)

Definitions of health and disease are of more than theoretical interest. Understanding what it means to be healthy has implications for choices in medical treatment, for ethically sound informed consent, and for accurate assessment of policies or programs. This deeper understanding can help us create more effective public policy for health and medicine. It is notable that such contentious legal initiatives as the Americans with Disability Act and the Patients' Bill of Rights fail to define adequately the medical terms on (...) which their effectiveness depends. In Ethics and the Metaphysics of Medicine, Kenneth Richman develops an "embedded instrumentalist" theory of health and applies it to practical problems in health care and medicine, addressing topics that range from the philosophy of science to knee surgery."Embedded instrumentalist" theories hold that health is a match between one's goals and one's ability to reach those goals, and that the relevant goals may vary from individual to individual. This captures the normative implications of the term health while avoiding problematic relativism. Richman's embedded instrumentalism differs from other theories of health in drawing a distinction between the health of individuals as biological organisms and the health of individuals as moral agents. This distinction illuminates many difficulties in patient-provider communication and helps us understand conflicts between promoting health and promoting ethically permissible behavior. After exploring, expanding, and defending this theory in the first part of the book, Richman examines its ethical implications, discussing such concerns as the connection between medical beneficence and respect for autonomy, patient-provider communication, living wills, and clinical education. (shrink)

In this essay, I consider three different conceptions of ‘the people’ and what it means to ‘respect’ their collective will and wisdom: (a) the democratic conception of the people as a sprawling demos, (b) the populist conception of the people as an authentic folk (c) and, finally, the vanguardist conception of the people as the semi-mute masses who stand in need of revolutionary transformation. Although my ultimate aim is to defend the democratic conception of the people over both the populist (...) conception and the vanguardist conception, much of this essay is taken up simply spelling out each of these conceptions of the people and outlining their consequences for the conduct of politics. I begin by contrasting the democratic conception with the populist conception. I then turn briefly to the vanguardist conception. I close with a brief, and admittedly incomplete defence of a particular form of democracy – what I call transformative or ameliorative democracy – which conceives of the people as a self-transformative totality. (shrink)

This essay defends three interlocking claims about singular beliefs and their ascriptions. The first is a claim about the nature of such beliefs; the second is a claim about the semantic contents of ascriptions of such beliefs; the third is a claim about the pragmatic significance of such ascriptions. With respect to the nature of singular belief, I claim that the contents of our singular beliefs are a joint product of mind and world, with neither mind nor world enjoying any (...) peculiar priority over the other in the constitution of content. This view amounts to a rejection of the priority of so-called narrow or notional content over wide or referential content for singular beliefs. About the semantics of ascriptions of singular belief, I claim that such ascriptions ascribe what I call predicative doxastic commitments and nothing more. In particular, I will argue that to ascribe a predicative commitment is merely to say what property is being predicated by she who undertakes the relevant commitment to what object. My view has the consequence that ascriptions of singular beliefs typically do not either semantically specify or pragmatically implicate the modes of presentations, notions, or conceptions via which the ascribee cognizes the objects and properties relative to which she undertakes predicative commitments. To be sure, many maintain that at least one class of belief ascriptions -- so called de dicto ascriptions. (shrink)

Philosophers of language have lavished attention on names and other singular referring expressions. But they have focused primarily on what might be called lexicalsemantic character of names and have largely ignored both what I call the lexicalsyntactic character of names and also what I call the pragmatic significance of the naming relation. Partly as a consequence, explanatory burdens have mistakenly been heaped upon semantics that properly belong elsewhere. This essay takes some steps toward correcting these twin lacunae. When we properly (...) distinguish that which belongs to the lexical-syntactic character of names, from that which belongs to the lexical semantic character of names, from that which rests on the pragmatics of the naming relation, we lay to rest many misbegotten claims about names and their presumed semantic behavior. For example, though many believe that Frege’s puzzle about the possibility of informative identity statements motivates a move away from a referentialist semantics for names, I argue that the very possibility of Frege cases has its source not in facts about the lexical-semantic character of names but in facts about the lexical-syntax of the naming relation. If I am right, Frege cases as such are insufficient to justify the introduction of the distinction between sense and reference. In a similar vein, I offer a new diagnosis of the widely misdiagnosed felt invalidity of the substitution of coreferring names within propositional attitude contexts. That felt invalidity has been taken 1 to justify the conclusion that an embedded referring expression must be playing some semantic role either different from or additional to its customary semantic role of standing for its reference. I argue, to the contrary, that failures of substitutivity have their source not in the peculiar semantic behavior of embedded expressions but entirely in certain pragmatic principles. (shrink)