Historically associated with military service, conscientious objection has become a significant phenomenon in health care. Mark Wicclair offers a comprehensive ethical analysis of conscientious objection in three representative health care professions: medicine, nursing and pharmacy. He critically examines two extreme positions: the 'incompatibility thesis', that it is contrary to the professional obligations of practitioners to refuse provision of any service within the scope of their professional competence; and 'conscience absolutism', that they should be exempted from performing any action contrary (...) to their conscience. He argues for a compromise approach that accommodates conscience-based refusals within the limits of specified ethical constraints. He also explores conscientious objection by students in each of the three professions, discusses conscience protection legislation and conscience-based refusals by pharmacies and hospitals, and analyzes several cases. His book is a valuable resource for scholars, professionals, trainees, students, and anyone interested in this increasingly important aspect of health care. (shrink)

Consensus is growing among ethicists and lawyers that medical decision making for incompetent patients who were previously competent should be made in accordance with that person's prior wishes and desires. Moreover, this legal and ethical preference for the substituted judgment standard has found its way into the daily practice of medicine. However, what appears on the surface to be an agreement between jurists, bioethicists, and clinicians obscures the very real differences between disciplines regarding the actual implementation of the sub stituted (...) judgment standard. Ethicists and judges have carefully outlined how substituted judgments ought to be made and evaluated. Although differences arise, especially at the state court level, regarding the scope of the substituted judgment standard and its relation to other standards of surrogate decision making, agreement is fairly widespread on the priority of substituted judgment and on the necessity of sufficient evidence being available in order to support a particular substituted judgment. (shrink)

As with other fields of applied ethics, philosophers engaged in business ethics struggle to carry out substantive philosophical reflection in a way that mirrors the practical reasoning that goes on within business management itself. One manifestation of the philosopher’s struggle is the field’s division into approaches that emphasize moral philosophy and those grounded in the methods of social science. I claim here that the task for those who come to business ethics with philosophical training is to avoid unintentionally widening the (...) gap between philosophical theory and business management by emphasizing the centrality of practical wisdom to both good managment and to the moral life. Distinguishing my own approach from recent emphases on phronesis in management literature, I draw on the concepts of social practice and of narrative to tie practical reasoning to a company’s unique story. Practical reason, social practices and narrative are employed together to give an account of the art of management at Patagonia. The essay hopes to both provide a way for philosophers engaged with business ethics to see family resemblances between their practices and those of business management and to offer a pedagogical example useful for those in any discipline interested in viewing businesses ethically. (shrink)

Electronegativity, described by Linus Pauling described as “The power of an atom in a molecule to attract electrons to itself” (Pauling in The nature of the chemical bond, 3rd edn, Cornell University Press, Ithaca, p 88, 1960), is used to predict bond polarity. There are dozens of methods for empirically quantifying electronegativity including: the original thermochemical technique (Pauling in J Am Chem Soc 54:3570–3582, 1932), numerical averaging of the ionisation potential and electron affinity (Mulliken in J Chem Phys 2:782–784, 1934), (...) effective nuclear charge and covalent radius analysis (Sanderson in J Chem Phys 23:2467, 1955) and the averaged successive ionisation energies of an element’s valence electrons (Martynov and Batsanov in Zhurnal Neorganicheskoi Khimii 5:3171–3175, 1980), etc. Indeed, there are such strong correlations between numerous atomic parameters—physical and chemical—that the term “electronegativity” integrates them into a single dimensionless number between 0.78 and 4.00 that can be used to predict/describe/model much of an element’s physical character and chemical behaviour. The design of the common and popular medium form of the periodic table is in large part determined by four quantum numbers and four associated rules. However, adding electronegativity completes the construction so that it displays the multi-parameter periodic law operating in two dimensions, down the groups and across the periods, with minimal ambiguity. (shrink)

Unfortunately, many people today see the regulation of lies, disinformation, hate speech, and fake news as an infringement of free speech, at least when such speech is ‘political,’ despite the damage that such speech can do. But this very protective attitude toward speech rests on a mistaken understanding of the role of free speech in a liberal society. The right to free speech is based on the liberal value of freedom, and as such can be no broader than freedom itself. (...) And freedom has always been subject to reasonable limits in a liberal society. Indeed, while the principles of toleration and neutrality are often cited as supporting a broad interpretation of the right to free speech, they also tell us that certain limits apply to that right. We need not tolerate speech that encourages intolerance, and while government should be neutral between reasonable conceptions of the good, it need not be neutral between reasonable and unreasonable conceptions. These ideas form the framework of liberal society, and as I shall show, also provide a guide for understanding what kind of speech is protected in a liberal society and what it is not. (shrink)

In response to physicians who refuse to provide medical services that are contrary to their ethical and/or religious beliefs, it is sometimes asserted that anyone who is not willing to provide legally and professionally permitted medical services should choose another profession. This article critically examines the underlying assumption that conscientious objection is incompatible with a physician’s professional obligations (the “incompatibility thesis”). Several accounts of the professional obligations of physicians are explored: general ethical theories (consequentialism, contractarianism, and rights-based theories), internal morality (...) (essentialist and non-essentialist conceptions), reciprocal justice, social contract, and promising. It is argued that none of these accounts of a physician’s professional obligations unequivocally supports the incompatibility thesis. (shrink)

It is argued that the primary aim of institutional management is to protect the moral integrity of health professionals without significantly compromising other important values and interests. Institutional policies are recommended as a means to promote fair, consistent, and transparent management of conscience-based refusals. It is further recommended that those policies include the following four requirements: (1) Conscience-based refusals will be accommodated only if a requested accommodation will not impede a patient’s/surrogate’s timely access to information, counseling, and referral. (2) Conscience-based (...) refusals will be accommodated only if a requested accommodation will not impede a patient’s timely access to health care services offered within the institution. (3) Conscience-based refusals will be accommodated only if the accommodation will not impose excessive burdens on colleagues, supervisors, department heads, other administrators, or the institution. (4) Whenever feasible, health professionals should provide advance notification to department heads or supervisors. Formal review may not be required in all cases, but when it is appropriate, several recommendations are offered about standards and the review process. A key recommendation is that when reviewing an objector’s reasons, contrary to what some have proposed, it is not appropriate to adopt an adversarial approach modelled on military review boards’ assessments of requests for conscientious objector status. According to the approach recommended, the primary function of reviews of objectors’ reasons is to engage them in a process of reflecting on the nature and depth of their objections, with the objective of facilitating moral clarity on the part of objectors rather than enabling department heads, supervisors, or ethics committees to determine whether conscientious objections are sufficiently genuine. (shrink)

There are many different kinds of libertarianism. The first is right libertarianism, which received its most powerful expression in Robert Nozick’s Anarchy, State and Utopia (1974), a book that still sets the baseline for discussions of libertarianism today. The second, I will call faux libertarianism. For reasons I will explain in this paper, most ‘man-on-the-street’ libertarians and most politicians who claim to be libertarians are actually this kind of libertarian. And third, there is left libertarianism, which is what I shall (...) spend most of this paper explicating. But I will not simply be surveying the views of those who identify as left libertarians and put this forth as if I were engaged in an exegetical exercise. Instead, what I shall set forth is a kind of manifesto, a statement of why I consider myself a left libertarian, one that takes this approach to political morality well beyond where it was left around the end of the last century by the previous generation of left libertarians. My hope is to provide those who find certain left libertarian ideas attractive a guide by which they can explain and harmonise their own views, recognise left libertarianism as a distinct comprehensive political doctrine, and feel more open to identify themselves as left libertarian too. (shrink)

For years now, unionization has been under vigorous attack. Membership has been steadily declining, and with it union bargaining power. As a result, unions may soon lose their ability to protect workers from economic and personal abuse, as well as their significance as a political force. In the Name of Liberty responds to this worrying state of affairs by presenting a new argument for unionization, one that derives an argument for universal unionization in both the private and public sector from (...) concepts of liberty that we already accept. In short, In the Name of Liberty reclaims the argument for liberty from the political right, and shows how liberty not only requires the unionization of every workplace as a matter of background justice, but also supports a wide variety of other progressive policies. (shrink)

Recognition of conscientious objection seems reasonable in relation to controversial and contentious issues, such as physician assisted suicide and abortion. However, physicians also advance conscience‐based objections to actions and practices that are sanctioned by established norms of medical ethics, and an account of their moral force can be more elusive in such contexts. Several possible ethical justifications for recognizing appeals to conscience in medicine are examined, and it is argued that the most promising one is respect for moral integrity. It (...) is also argued that an appeal to conscience has significant moral weight only if the core ethical values on which it is based correspond to one or more core values in medicine. Finally, several guidelines pertaining to appeals to conscience and their ethical evaluation are presented. (shrink)

Artificial intelligence, the "science and engineering of intelligent machines", still has yet to create even a simple "Advice Taker" [McCarthy, 1959]. We have previously argued [Waser, 2011] that this is because researchers are focused on problem-solving or the rigorous analysis of intelligence (or arguments about consciousness) rather than the creation of a "self" that can "learn" to be intelligent. Therefore, following expert advice on the nature of self [Llinas, 2001; Hofstadter, 2007; Damasio, 2010], we embarked upon an effort to design (...) and implement a self-understanding, self-improving loop as the totality of a (seed) AI. As part of that, we decided to follow up on Richard Dawkins' [1976] speculation that "perhaps consciousness arises when the brain's simulation of the world becomes so complete that it must include a model of itself" by defining a number of axioms and following them through to their logical conclusions. The results combined with an enactive approach yielded many surprising and useful implications for further understanding consciousness, self, and "free-will" that continue to pave the way towards the creation of safe/moral autopoiesis. (shrink)

Within the evidence-based medicine construct, clinical expertise is acknowledged to be both derived from primary experience and necessary for optimal medical practice. Primary experience in medical practice, however, remains undervalued. Clinicians’ primary experience tends to be dismissed by EBM as unsystematic or anecdotal, a source of bias rather than knowledge, never serving as the “best” evidence to support a clinical decision. The position that clinical expertise is necessary but that primary experience is untrustworthy in clinical decision-making is epistemically incoherent. Here (...) we argue for the value and utility of knowledge gained from primary experience for the practice of medicine. Primary experience provides knowledge necessary to diagnose, treat, and assess response in individual patients. Hierarchies of evidence, when advanced as guides for clinical decisions, mistake the relationship between propositional and experiential knowledge. We argue that primary experience represents a kind of medical knowledge distinct from the propositional knowledge produced by clinical research, both of which are crucial to determining the best diagnosis and course of action for particular patients. (shrink)

This paper examines the varied cultural meanings of computer game play in competitive and professional computer gaming and live-streaming. To do so it riffs off Andrew Feenberg’s 1994 work exploring the changing meanings of the ancient board game of Go in mid-century Japan. We argue that whereas Go saw a de-aestheticization with the growth of newspaper reporting and a new breed of ‘westernized’ player, the rise of professionalized computer gameplay has upset this trend, causing a re-aestheticization of professional game competition (...) as a result of the many informal elements that contribute to the successes, and public perceptions, of professional players. In doing so we open up the consideration of the aesthetics of broadcasted gameplay, how they reflect back upon the players and the game, and locate this shift historically and culturally within the last two decades of computer games as a creative industry, entertainment industry, a media form, and as an embodied practice. (shrink)

What is conscientious objection? -- Should conscientious objectors be accommodated? -- Assessing objectors' beliefs and reasons -- Accommodation and conscientious provision.

Historically, entities with a vested interest in a product that critics have suggested is harmful have consistently used research to back their claims that the product is safe. Prominent examples are: tobacco, lead, bisphenol A, and atrazine. Research literature indicates that about 80–90% of studies with industry affiliation found no harm from the product, while only about 10–20% of studies without industry affiliation found no harm. In parallel to other historical debates, recent studies examining a possible relationship between mercury exposure (...) and autism spectrum disorder show a similar dichotomy. Studies sponsored and supported by industry or entities with an apparent conflict of interest have most often shown no evidence of harm or no “consistent” evidence of harm, while studies without such affiliations report positive evidence of a Hg/autism association. The potentially causal relationship between Hg exposure and ASD differs from other toxic products since there is a broad coalition of entities for whom a conflict of interest arises. These include influential governmental public health entities, the pharmaceutical industry, and even the coal burning industry. This review includes a systematic literature search of original studies on the potential relationship between Hg and ASD from 1999 to August 2015, finding that of the studies with public health and/or industry affiliation, 86% reported no relationship between Hg and ASD. However, among studies without public health and/or industry affiliation, only 21% find no relationship between Hg and ASD. The discrepancy in these results suggests a bias indicative of a conflict of interest. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:DESIRED POSSESSIONS: KARL POLANYI, RENÉ GIRARD, AND THE CRITIQUE OF THE MARKET ECONOMY Mark R. Anspach CREA, Paris! f '""phe most radical critique of liberal capitalism ever:" that is how JL Louis Dumont describes 7Ae Great Transformation, Karl Polanyi's classic work on the rise of the market system. But the French anthropologist goes on to observe that, when one confronts this same critique with the ethnography of tribal (...) societies, "one may ask whether Polanyi did not in fact come up short; having criticized the economy as an idea, he thought he could retain it as a thing..." (Dumont xiv, xvi). Is the economy indeed a "thing" that has always existed in some form everywhere, and if so, what manner of thing is it? In a word, what is an economyfor? Is there a particular aim that any economy must serve? A specific motive that it necessarily brings into play? We will begin by looking at Polanyi's answer to this question. "No human motive is per se economic," Polanyi tells us. "There is no such thing as a sui generis economic experience in the sense in which man may have a religious, aesthetic, or sexual experience." It is market society, with its dependence on a disembedded economic system, which fosters the illusion that the "economic" motives of hunger and gain necessarily underlie every economic system (1968, 63-4). In reality, however, "human beings will labor for a large variety of reasons as long as things are arranged accordingly." For example, "Monks traded for religious reasons... The KuIa trade ofthe Trobriand islanders... is mainly an aesthetic pursuit. Feudal economy was run on customary lines. With the Kwakiutl," industry appears to have been "a point of honor," and 1 82Mark R. Anspach so on (1968, 68). The trick, it seems, is to "arrange things accordingly." An economic system can be "run on noneconomic motives," Polanyi explains, without linking the process of production or distribution "to specific economic interests attached to the possession of goods," as long as "every single step in that process is geared to a number of social interests which eventually ensure that the required step be taken" (2001, 48). Now, there is a danger in this presentation. It could lead a reader to conclude that other societies arrange things cunningly so that all these social interests are harnessed to ensure the performance of the steps necessary to economic processes in a kind ofelaborate ruse—a ruse which the out-in-the-open operation ofthe economy in our society gives us the ability to see through. Very well, such a reader might acknowledge, the economy is an "instituted process," and, yes, the act of instituting it "shifts the place ofthe process in society" (Polanyi 1968, 148), but ifyou track it down to its hiding place and strip away the social contrivances in which it has been embedded, what you will find is still the economy as we know it—indeed, the economy which market society alone lays bare. In this reading, or rather misreading, the "real" economic aims that market society achieves directly are elsewhere accomplished only in the most cumbersomely indirect fashion. This kind of erroneous conclusion will likely be difficult to counter as long as one posits an opposition between multiple, variable and diffuse social interests, on the one hand, and the apparently straightforward individual interest in the possession of goods, on the other. Wherever the economy is submerged in social relationships, Polanyi says, a man "does not act so as to safeguard his individual interest in the possession ofmaterial goods; he acts so as to safeguard his social standing, his social claims, his social assets" (2001, 48). The problem with such an opposition between individual and social is that a market-minded theorist can overcome it simply by broadening the individual interest in the possession ofgoods to include the possession ofreified social goods. Once social interests are conceptualized as "social assets," to use Polanyi's own expression—or as "symbolic capital," to cite a more recent formulation—they lend themselves to "economizing" even in the formal sense, and Polanyi's carefully constructed distinction between the substantive and the formal collapses, apparently confirmingthe universality of the market... (shrink)

A US Department of Health and Human Services Final Rule, Protecting Statutory Conscience Rights in Health Care, and a proposed bill in the British House of Lords, the Conscientious Objection Bill, may well warrant a concern that—to borrow a phrase Daniel Callahan applied to self-determination—conscientious objection in health care has “run amok.” Insofar as there are no significant constraints or limitations on accommodation, both rules endorse an approach that is aptly designated “conscience absolutism.” There are two common strategies to counter (...) conscience absolutism and prevent conscientious objection in medicine from running amok. One, non-toleration, is to decline to accommodate physicians who refuse to provide legal, professionally accepted, clinically appropriate medical services within the scope of their clinical competence. The other, compromise or reasonable accommodation, is to impose constraints on accommodation. Several arguments for non-toleration are critically analyzed, and I argue that none warrants its acceptance. I maintain that non-toleration is an excessively blunt instrument to prevent conscientious objection in medicine from running amok. Instead, I defend a more nuanced contextual approach that includes constraints on accommodation. (shrink)

Previous discussions of the evolution of the self have diverged greatly in their estimates of the date at which the capacity for self-thought emerged, the factors that led self-reflection to evolve, and the nature of the evidence offered to support these disparate conclusions. Beginning with the assumption that human self-awareness involves a set of distinct cognitive abilities that evolved at different times to solve different adaptive problems, we trace the evolution of self-awareness from the common ancestor of humans and apes (...) to the beginnings of culture, drawing upon paleontological, anthropological, biological, and psychological evidence. These data converge to suggest that that modern self-thought appeared just prior to the Middle-Upper Paleolithic transition, approximately 60,000 years ago.Recto running head: Evolution of the Self. (shrink)

A survey of the 37 psychology departments offering courses accredited by the Australian Psychological Society yielded a 92% response rate. Sixty-eight percent of departments employed students as research subjects, with larger departments being more likely to do so. Most of these departments drew their student subject pools from introductory courses. Student research participation was strictly voluntary in 57% of these departments, whereas 43% of the departments have failed to comply with normally accepted ethical standards. It is of great concern that (...) institutional ethics committees apparently continue to condone, or fail to act against, unethical research practices. Although these committees have a duty of care to all subjects, the final responsibility for conducting research in an ethical manner lies with the individual researcher. (shrink)

Historically, conscientious objection has been associated with military service. Currently, however, it does not occur exclusively in response to compulsory military service. With increasing frequency, health care professionals, including those who practice in institutional settings such as hospitals and long-term care facilities, conscientiously object to providing specific medical services. This chapter provides a framework for managing conscientious objection within institutional settings. Criteria are provided for determining when refusals to provide medical services are conscientious objections. Reasons are offered for accommodating conscientious (...) objectors and for denying or limiting accommodation. A reasonable accommodation approach, which consists in five requirements, is explained and defended: (1) Conscience-based refusals will be accommodated only if a requested accommodation will not impede a patient’s/surrogate’s timely access to information, counseling, and referral. (2) Conscience-based refusals will be accommodated only if a requested accommodation will not impede a patient’s timely access to health care services offered within the institution. (3) Conscience-based refusals will be accommodated only if the accommodation will not impose excessive burdens on other clinicians, supervisors, department heads, or the institution. (4) Whenever feasible, health professionals should provide advance notification to department heads or supervisors. (5) Conscience-based refusals will be accommodated only if it will not enable invidious discrimination. (shrink)

Why have hospitals reduced residents' hours, but not those of attending physicians?

Rawls intended the difference principle to be a liberal egalitarian principle of justice. By that I mean he intended it to provide a moral justification for a moderate amount of redistribution of income from the most advantaged members of society to the least. But since the difference principle was introduced, economic inequality has increased dramatically, reaching levels now not seen since just before the Great Depression, levels that Rawls surely would have thought perverse. Many blame this increase on the rise (...) of supply-side economics and the dramatic cuts in marginal tax rates enacted by the supply-siders for corporations and those already at the top of the income distribution. But I contend that the difference principle, or at least the ethos that the difference principle embodies and represents, is also partially to blame. Accordingly, the purpose of this paper is to explain how the difference principle, the ideas and arguments of the supply-siders, and this dramatic rise in inequality are connected, to identify where the difference principle went wrong, and to discuss what those who remain committed to the liberal egalitarian ideals that the difference principle was thought to represent might do about it. (shrink)

Typically, a refusal to provide a medical service is an instance of conscientious objection only when the medical service is legal, professionally accepted, and clinically appropriate. That is, conscientious objection typically occurs only when practitioners reject prevailing norms or practices. Insofar as refusing to provide antibiotics for a viral infection does not violate prevailing clinical norms, there is no need for the physician in Case 1 to justify his refusal to provide antibiotics by appealing to his conscience.1 By contrast, insofar (...) as emergency contraception is legal and does not violate prevailing norms of good medical practice, the physician in Case 6 cannot justify his refusal to provide EC by... (shrink)

The coronavirus disease-2019 (COVID-19) has caused shortages of life-sustaining medical resources, and future waves of the virus may cause further scarcity. The Yale New Haven Health System developed a triage protocol to allocate scarce medical resources during the COVID-19 pandemic, with the primary goal of saving the most lives possible, and a secondary goal of making triage assessments and decisions consistent, transparent, and fair. We outline the process of developing the protocol, summarize the protocol, and discuss the major ethical challenges (...) encountered, along with our answers to the challenges. These challenges include (1) the role of age and chronic comorbidities; (2) evaluating children and pregnant patients; (3) racial, ethnic, and socioeconomic disparities in health; (4) prioritization of healthcare workers; and (5) balancing clinical judgment versus protocolized assessments.We conclude with a review of the limitations of our protocol and the lessons learned. We hope that a robust public discussion of such protocols and the ethical challenges they raise will result in the fairest possible processes, less need for triage, and more lives saved during future waves of the pandemic and similar public health emergencies. (shrink)

In Liberalism with Excellence, Matthew Kramer makes an argument for how excellence may enter in into liberalism, despite liberalism’s strong commitment to neutrality. Kramer seeks to challenge not only the uncompromising rejection of this position by liberals such a Jonathan Quong, but also the so-called “blended” approach of “soft-perfectionist” scholars such as Joseph Raz and George Sher. In this essay, I do not so much challenge Kramer’s approach as offer an alternative for accomplishing the same thing. Under my proposal, certain (...) forms of excellence and neutrality can both be accommodated as long as state support for the form of excellence at issue is proportional to the support for such a form of excellence within the relevant polity, competing forms of excellence are non-rivalrous, and no one is forced to embrace a form of excellence with which they disagree. My proposal is therefore not what Ronald Dworkin derogatively characterized as “a checkerboard solution.” Rather than allowing the state to support contrary moral positions at one and the same time, it is a solution that takes morally compatible but nevertheless competing conceptions of excellence seriously, and exhibits neutrality by giving them proportional rather than full support. This neither forces anyone to pursue the particular forms of excellence the state supports nor prevents them from pursuing some other form of excellence entirely or, if they wish, no form of excellence at all. (shrink)