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)

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)

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)

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)

Those who provide medical care for infants born extremely prematurely, at what is often referred to as borderline viability, have long grown accustomed to working with the parent(s) to reach a deci...

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)

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)

The reality of resource limitation during the Coronavirus Disease 2019 pandemic has deeply challenged established approaches to healthcare system emergency response. Early preparation du...

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

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)

In “Disentangling Conscience Protections,” in this issue of the Hastings Center Report, Nadia Sawicki offers a taxonomy of conscience protection laws (conscience clauses) that highlights the expansive protections they can offer to health professionals who refuse to provide a medical service for reasons of conscience. Conscience clauses can protect health professionals from adverse actions by public actors (such as administrative agencies, prosecutors, and government funders) or private actors (such as employers, private professional associations, and injured patients), and they can also (...) protect health professionals from being subject to adverse actions for their beliefs, their conduct, or harm that results from their conduct. This taxonomy provides an accurate description of the broad range of protections conscience clauses can offer and thereby is a valuable contribution to the scholarly literature on conscientious objection in health care. But it remains to consider whether the distinctions Sawicki identifies disentangle conscience protections beyond merely providing a taxonomy. In particular, does the taxonomy identify relevant distinctions in relation to determining whether a conscience clause is justified? (shrink)

Just as physicians can object to providing services due to their ethical and/or religious beliefs, medical students can have conscience-based objections to participating in educational activities. In 1996, the Medical Student Section of the American Medical Association introduced a resolution calling on the AMA to adopt a policy in support of exemptions for students with ethical or religious objections. In that report, students identified abortion, sterilization, and procedures performed on animals as examples of activities that might prompt requests for conscience-based (...) exemptions. In response to the student initiative, the Council on Medical Education recommended the adoption of seven “principles to guide exemption of medical students from activities based on conscience.” The House of Delegates adopted these principles in their entirety. (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)

Unemployment has been at historically high rates for an extended period, and while it has recently improved in certain countries, the unemployment that remains may be becoming structural. Aside from inequality, unemployment is accordingly the problem that is most likely to put critical pressure on our political institutions, disrupt the social fabric of our way of life, and even threaten the continuation of liberalism itself. Despite the obvious importance of the problem of unemployment, however, there has been a curious lack (...) of attention paid to this issue by contemporary non-Marxist political philosophers. Non-Marxists typically view unemployment as a technical matter, and doing something about it a question of means not ends, with the solution to this question depending on the kind of empirical determinations about what causes what that are best left to economists, not political philosophers. But I think this is a mistake. Because work is a major part of our social life, as well as something that for a great many people grounds their sense of who they are and provides the basis of their sense of self-respect, those unable to find work are missing out on a great deal of what makes for a meaningful life, and not just the economic benefits that social cooperation has to offer. Those who are unemployed accordingly have something to complain about, even if we do not let them starve, and the rest of us (or at least the institutions that represent us) may have some sort of moral obligation to take action to increase the number of employment opportunities currently available regardless of any uncertainty surrounding the effects that any actions open to us might have. The nature and extent of this moral obligation is what On Unemployment is dedicated to exploring. (shrink)

In a provocative 1974 article entitled “Harvesting the Dead,” Willard Gaylin explored potential uses of “neomorts,” or what are currently referred to as “heart-beating cadavers”—that is, humans determined to be dead by neurological criteria and whose cardiopulmonary function is medically maintained by ventilators, vasopressors, and so forth. Medical research was one of the potential uses Gaylin identified. He pointed out that tests of drugs and medical procedures that would have unacceptable health risks if performed on living human subjects could be (...) performed on neomorts without any health risks. According to Gaylin, the potential benefits of such research could be enormous, including not subjecting patients to ineffective or harmful medical procedures and eliminating delays in providing effective therapies to dying patients. (shrink)

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)

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)

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)

The American Journal of Bioethics, Volume 11, Issue 11, Page 17-18, November 2011.

Many people have been enraged lately by the enormous increases in certain generic prescription drugs. But free marketeers defend these prices by arguing that they simply represent what the market will bear, and in a capitalist society there is accordingly nothing wrong with charging them. This paper argues that such a defense is actually contrary to the very principles that free marketeers claim to embrace. These prices are not only unjust and exploitative, but government interference with them would not render (...) the market less free, at least if what it means for a market to be “free” is properly understood. Everyone, even free marketeers with a libertarian or neoliberal bent, should accordingly be against this kind of profiteering. (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)

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)

Volume 20, Issue 7, July 2020, Page 122-124.

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)

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)

Persons registered to vote in Seattle, Washington for the November, 1986 general election and a September, 1987 primary election were randomly assigned to treatments in two telephoneconducted experiments that sought to increase voter tumout. The experiments applied and extended a "self-prophecy” technique, in which respondents are asked simply to predict whether or not they will perform a target action. In the present studies, voting registrants were asked to predict whether or not they would vote in an election that was less (...) than 48 hours away. This technique, which previously increased turnout in a small study done during the 1984 U.S. Presidential election, was again effective among moderate prior-turnout voters in the second of the present much larger experiments. The failure of the effect in Experiment 1 was plausibly a ceiling effect due to very high turnout for a U.S. Senate contest in the 1986 election. Successful applications of the self· prophecy technique are facilitated by social desirability of the target action (which leads subjects to predict that they will perform it). However, social desirability of the target behavior is not a sufficient condition for the effect, as indicated by an unexpected nonoccurrence of the effect among low prior-tumout voters in Experiment 2. (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)

Introduction -- Undermining the hermeneutics of suspicion -- The historical emergence of psychological man -- The "religious" therapeutics -- Rieff on Jung's "language of faith" -- Rieff and the hermeneutics of suspicion -- An alternative hermeneutic -- Applying this hermeneutic to depth psychology -- Concluding remarks -- The historical sources of Jung's psychology -- The young metaphysician -- Tempering metaphysical inclinations with a pragmatic standpoint -- The resurgence of metaphysics in Jung's psychology -- Jung's subjectivist argument -- The influence of (...) vitalism -- Individuation and the prospective method -- From the prospective method to a metaphysics of archetypes -- Jung and the Paracelsian theory of knowledge -- The persistence of metaphysical questions -- Hermeneutics and Jung's psychology -- The re-discovery of the psychogenic -- Towards a more adequate understanding of the psychogenic -- The methodological problems facing depth psychology -- The symbolic life -- The "realism of the East" -- The symbol of the self -- The "two kinds of thinking" -- "The transcendent function" -- From signs to symbols -- The practice of the transcendent function -- Definitions from psychological types (1921) -- The symbolic attitude -- Transcendent presence -- Alignment with the self -- Projective psychology and divine transcendence -- The relevance of the dispute between Jung and Buber -- The still point -- The beyond -- Contemporary psychoanalysis and the still point -- Ogden on potential space. (shrink)