There is nothing more humbling to one’s inner moral compass than to realize that you do not initially know what is right or wrong! I found myself in just such a situation after reading the above case. Much has been written, both in the professional literature and the popular media, about the “Ashley Treatment” since Gunther and Diekema published their article in 2006. It is unclear if others in the United States or around the world have, to any significant degree, (...) adopted growth attenuation therapy and/or surgical intervention for children with severe neurological compromise, but the case quoted above suggests that hospital ethics committees may also be struggling with these decisions. An informal survey of pediatric endocrinologists, mentioned in a recent article on the topic, claims that many physicians are facing this dilemma as well. (shrink)

I would like to present the details of an actual case from my own experience over which I, along with the family, have agonized. I think this case brings into focus some of the unique issues in perinatal medicine where multiple patients, some real and some potential, can enter into a single decision. I hope that through this presentation others may gain insight into the complexities of applied ethics in perinatal medicine.

Standard views on surrogate decision making present alternative ideal models of what ideal surrogates should consider in rendering a decision. They do not, however, explain the physician''s responsibility to a patient who lacks decisional capacity or how a physician should regard surrogates and surrogate decisions. The authors argue that it is critical to recognize the moral difference between a patient''s decisions and a surrogate''s and the professional responsibilities implied by that distinction. In every case involving a patient who lacks decisional (...) capacity, physicians and the treatment team have to make judgments about the appropriateness of both the surrogate and the surrogate''s decision. They have to assess the surrogate''s decisional capacity and attitude toward the patient as well as the reasons that support the surrogate''s decision. This paper provides a model for acceptable surrogate decisions and a standard for blocking inappropriate surrogates. Only decisions based on widely shared reasons are allowable for surrogate refusal of highly beneficial treatment. (shrink)

ABSTRACT I argue that this examination and appreciation for the shift to abductive reasoning should be extended to the intersection of neuroscience and novel brain-computer interfaces too. This paper highlights the implications of applying abductive reasoning to personalized implantable neurotechnologies. Then, it explores whether abductive reasoning is sufficient to justify insurance coverage for devices absent widespread clinical trials, which are better applied to one-size-fits-all treatments. INTRODUCTION In contrast to the classic model of randomized-control trials, often with a large number of (...) subjects enrolled, precision medicine attempts to optimize therapeutic outcomes by focusing on the individual.[i] A recent publication highlights the strengths and weakness of both traditional evidence-based medicine and precision medicine.[ii] Plus, it outlines a tension in the shift from evidence-based medicine’s inductive reasoning style (the collection of data to postulate general theories) to precision medicine’s abductive reasoning style (the generation of an idea from the limited data available).[iii] The paper’s main example is the application of precision medicine for the treatment of cancer.[iv] I argue that this examination and appreciation for the shift to abductive reasoning should be extended to the intersection of neuroscience and novel brain-computer interfaces too. As the name suggests, brain-computer interfaces are a significant advancement in neurotechnology that directly connects someone’s brain to external or implanted devices.[v] Among the various kinds of brain-computer interfaces, adaptive deep brain stimulation devices require numerous personalized adjustments to their settings during the implantation and computation stages in order to provide adequate relief to patients with treatment-resistant disorders. What makes these devices unique is how adaptive deep brain stimulation integrates a sensory component to initiate the stimulation. While not commonly at the level of sophistication as self-supervising or generative large language models,[vi] they currently allow for a semi-autonomous form of neuromodulation. This paper highlights the implications of applying abductive reasoning to personalized implantable neurotechnologies. Then, it explores whether abductive reasoning is sufficient to justify insurance coverage for devices absent widespread clinical trials, which are better applied to one-size-fits-all treatments.[vii] ANALYSIS I. The State of Precision Medicine in Oncology and the Epistemological Shift While a thorough overview of precision medicine for the treatment of cancer is beyond the scope of this article, its practice can be roughly summarized as identifying clinically significant characteristics a patient possesses (e.g., genetic traits) to land on a specialized treatment option that, theoretically, should benefit the patient the most.[viii] However, in such a practice of stratification patients fall into smaller and smaller populations and the quality of evidence that can be applied to anyone outside these decreases in turn.[ix] As inductive logic helps to articulate, the greater the number of patients that respond to a particular therapy the higher the probability of its efficacy. By straying from this logical framework, precision medicine opens the treatment of cancer to more uncertainty about the validity of these approaches to the resulting disease subcategories.[x] Thus, while contemporary medical practices explicitly describe some treatments as “personalized”, they ought not be viewed as inherently better founded than other therapies.[xi] A relevant contemporary case of precision medicine out of Norway focuses on the care of a patient with cancer between the ventricles of the heart and esophagus, which had failed to respond to the standard regimen of therapies over four years.[xii] In a last-ditch effort, the patient elected to pay out-of-pocket for an experimental immunotherapy (nivolumab) at a private hospital. He experienced marked improvements and a reduction in the size of the tumor. Understandably, the patient tried to pursue further rounds of nivolumab at a public hospital. However, the hospital initially declined to pay for it given the “lack of evidence from randomised clinical trials for this drug relating to this [patient’s] condition.”[xiii] In rebuttal to this claim, the patient countered that he was actually similar to a subpopulation of patients who responded in “open‐label, single arm, phase 2 studies on another immune therapy drug” (pembrolizumab).[xiv] Given this interpretation of the prior studies and the patient’s response, further rounds of nivolumab were approved. Had the patient not had improvements in the tumor’s size following a round of nivolumab, then pembrolizumab’s prior empirical evidence in isolation would have been insufficient, inductively speaking, to justify his continued use of nivolumab.[xv] The case demonstrates a shift in reasoning from the traditional induction to abduction. The phenomenon of ‘cancer improvement’ is considered causally linked to nivolumab and its underlying physiological mechanisms.[xvi] However, “the weakness of abductions is that there may always be some other better, unknown explanation for an effect. The patient may for example belong to a special subgroup that spontaneously improves, or the change may be a placebo effect. This does not mean, however, that abductive inferences cannot be strong or reasonable, in the sense that they can make a conclusion probable.”[xvii] To demonstrate the limitations of relying on the abductive standard in isolation, commentators have pointed out that side effects in precision medicine are hard to rule out as being related to the initial intervention itself unless trends from a group of patients are taken into consideration.[xviii] As artificial intelligence (AI) assists the development of precision medicine for oncology, this uncertainty ought to be taken into consideration. The implementation of AI has been crucial to the development of precision medicine by providing a way to combine large patient datasets or a single patient with a large number of unique variables with machine learning to recommend matches based on statistics and probability of success upon which practitioners can base medical recommendations.[xix] The AI is usually not establishing a causal relationship[xx] – it is predicting. So, as AI bleeds into medical devices, like brain-computer interfaces, the same cautions about using abductive reasoning alone should be carried over. II. Responsive Neurostimulation, AI, and Personalized Medicine Like precision medicine in cancer treatment, computer-brain interface technology similarly focuses on the individual patient through personalized settings. In order to properly expose the intersection of AI, precision medicine, abductive reasoning, and implantable neurotechnologies, the descriptions of adaptive deep brain stimulation systems need to deepen.[xxi] As a broad summary of adaptive deep brain stimulation, to provide a patient with the therapeutic stimulation, a neural signal, typically referred to as a local field potential,[xxii] must first be detected and then interpreted by the device. The main adaptive deep brain stimulation device with premarket approval, the NeuroPace Responsive Neurostimulation system, is used to treat epilepsy by detecting and storing “programmer-defined phenomena.”[xxiii] Providers can optimize the detection settings of the device to align with the patient’s unique electrographic seizures as well as personalize the reacting stimulation’s parameters.[xxiv] The provider adjusts the technology based on trial and error. One day machine learning algorithms will be able to regularly aid this process in myriad ways, such as by identifying the specific stimulation settings a patient may respond to ahead of time based on their electrophysiological signatures.[xxv] Either way, with AI or programmers, adaptive neurostimulation technologies are individualized and therefore operate in line with precision medicine rather than standard treatments based on large clinical trials. Contemporary neurostimulation devices are not usually sophisticated enough to be prominent in AI discussions where the topics of neural networks, deep learning, generative models, and self-attention dominate the conversation. However, implantable high-density electrocorticography arrays (a much more sensitive version than adaptive deep brain stimulation systems use) have been used in combination with neural networks to help patients with neurologic deficits from a prior stroke “speak” through a virtual avatar.[xxvi] In some experimental situations, algorithms are optimizing stimulation parameters with increasing levels of independence.[xxvii] An example of neurostimulation that is analogous to the use of nivolumab in Norway surrounds a patient in the United States who was experiencing both treatment-resistant OCD and temporal lobe epilepsy.[xxviii]Given the refractory nature of her epilepsy, implantation of an adaptive deep brain stimulation system was indicated. As a form of experimental therapy, her treatment-resistant OCD was also indicated for the off-label use of an adaptive deep brain stimulation set-up. Another deep brain stimulation lead, other than the one implanted for epilepsy, was placed in the patient’s right nucleus accumbens and ventral pallidum region given the correlation these nuclei had with OCD symptoms in prior research. Following this, the patient underwent “1) ambulatory, patient-initiated magnet-swipe storage of data during moments of obsessive thoughts; (2) lab-based, naturalistic provocation of OCD-related distress (naturalistic provocation task); and (3) lab-based, VR [virtual reality] provocation of OCD-related distress (VR provocation task).”[xxix] Such signals were used to identify when to deliver the therapeutic stimulation in order to counter the OCD symptoms. Thankfully, following the procedure and calibration the patient exhibited marked improvements in their OCD symptoms and recently shared her results publicly.[xxx] In both cases, there is a similar level of abductive justification for the efficacy of the delivered therapy. In the case study in which the patient was treated with adaptive deep brain stimulation, they at least had their neural activity tested in various settings to determine the optimum parameters for treatment to avoid them being based on guesswork. Additionally, the adaptive deep brain stimulation lead was already placed before the calibration trials were conducted, meaning that the patient had already taken on the bulk of the procedural risk before the efficacy could be determined. Such an efficacy test could have been replicated in the first patient’s cancer treatment, had it been biopsied and tested against the remaining immunotherapies in vitro. Yet, in the case of cancer with few options, one previous dose of a drug that appeared to work on the patient may justify further doses. However, as the Norwegian case presents, corroboration with known responses to a similar drug (from a clinical trial) could be helpful to validate the treatment strategy. (It should be noted that both patients were resigned to these last resort options regardless of the efficacy of treatment.) There are some elements of inductive logic seen with adaptive deep brain stimulation research in general. For example, abductively the focus could be that patient X’s stimulation parameters are different from patient Y’s and patient Z’s. In contrast, when grouped as subjects who obtained personalized stimulation, patients X, Y, and Z demonstrate an inductive aspect to this approach’s safety and/or efficacy. The OCD case holds plenty of abductive characteristics in line with precision medicine’s approach to treating cancer and as more individuals try the method, there will be additional data. With the gradual integration of AI into brain-computer interfaces in the name of efficacy, this reliance on abduction will continue, if not grow, over time. Moving forward, if a responsive deep brain stimulation treatment is novel and individualized (like the dose of nivolumab) and there is some other suggestion of efficacy (like clinical similarities to other patients in the literature), then it may justify insurance coverage for the investigative intervention, absent other unrelated reasons to deny it. III. Ethical Implications and Next Steps While AI’s use in oncology and neurology is not yet as prominent as its use in other fields (e.g., radiology), it appears to be on the horizon for both.[xxxi] AI can be found in both the functioning of the neurotechnologies as well as the implementation of precision medicine. The increasing use of AI may serve to further individualize both oncologic and neurological therapies. Given these implications and the handful of publications cited in this article, it is important to have a nuanced evaluation of how these treatments, which heavily rely on abductive justification, ought to be managed. The just use an abductive approach may be difficult as AI infused precision medicine is further pursued. At baseline, such technology relies on a level of advanced technology literacy among the general public and could exclude populations who lack access to basic technological infrastructure or know-how from participation.[xxxii] Even among nations with adequate infrastructure, as more patients seek out implantable neurotechnologies, which require robust healthcare resources, the market will favor patient populations that can afford this complex care.[xxxiii] If patients already have the means to pay for an initial dose/use of a precision medicine product out of pocket, should insurance providers be required to cover subsequent treatments?[xxxiv] That is, if a first dose of a cancer drug or a deep brain stimulator over its initial battery life is successful, patients may feel justified in having the costs of further treatments covered. The Norwegian patient’s experience implies there is a precedent for the idea that some public insurance companies ought to cover successful cancer therapies, however, insurance companies may not all see themselves as obligated to cover neurotechnologies that rely on personalized settings or that are based on precision/abductive research more than on clinical trials. CONCLUSION The fact that the cases outlined above rely on abductive style of reasoning implies that there may not be as strong a justification for coverage by insurance, as they are both experimental and individualized, when compared to the more traditional large clinical trials in which groups have the same or a standardized protocol (settings/doses). If a study is examining the efficacy of a treatment with a large cohort of patients or with different experimental groups/phases, insurance companies may conclude that the resulting symptom improvements are more likely to be coming from the devices themselves. A preference for inductive justification may take priority when ruling in favor of funding someone’s continued use of an implantable neurostimulator. There are further nuances to this discussion surrounding the classifications of these interventions as research versus clinical care that warrant future exploration, since such a distinction is more of a scale[xxxv] than binary and could have significant impacts on the “right-to-try” approach to experimental therapies in the United States.[xxxvi] Namely, given the inherent limitations of conducting large cohort trials for deep brain stimulation interventions on patients with neuropsychiatric disorders, surgically innovative frameworks that blend abductive and inductive methodologies, like with sham stimulation phases, have traditionally been used.[xxxvii] Similarly, for adaptive brain-computer interface systems, if there are no large clinical trials and instead only publications that demonstrate that something similar worked for someone else, then, in addition to the evidence that the first treatment/dose worked for the patient in question, the balance of reasoning would be valid and arguably justify insurance coverage. As precision approaches to neurotechnology become more common, frameworks for evaluating efficacy will be crucial both for insurance coverage and for clinical decision making. ACKNOWLEDGEMENT This article was originally written as an assignment for Dr. Francis Shen’s “Bioethics & AI” course at Harvard’s Center for Bioethics. I would like to thank Dr. Shen for his comments as well as my colleagues in the Lázaro-Muñoz Lab for their feedback. - [i] Jonathan Kimmelman and Ian Tannock, “The Paradox of Precision Medicine,” Nature Reviews. Clinical Oncology 15, no. 6 (June 2018): 341–42, https://doi.org/10.1038/s41571-018-0016-0. [ii] Henrik Vogt and Bjørn Hofmann, “How Precision Medicine Changes Medical Epistemology: A Formative Case from Norway,” Journal of Evaluation in Clinical Practice 28, no. 6 (December 2022): 1205–12, https://doi.org/10.1111/jep.13649. [iii] David Barrett and Ahtisham Younas, “Induction, Deduction and Abduction,” Evidence-Based Nursing 27, no. 1 (January 1, 2024): 6–7, https://doi.org/10.1136/ebnurs-2023-103873. [iv] Vogt and Hofmann, “How Precision Medicine Changes Medical Epistemology,” 1208. [v] Wireko Andrew Awuah et al., “Bridging Minds and Machines: The Recent Advances of Brain-Computer Interfaces in Neurological and Neurosurgical Applications,” World Neurosurgery, May 22, 2024, S1878-8750(24)00867-2, https://doi.org/10.1016/j.wneu.2024.05.104. [vi] Mark Riedl, “A Very Gentle Introduction to Large Language Models without the Hype,” Medium (blog), May 25, 2023, https://mark-riedl.medium.com/a-very-gentle-introduction-to-large-language-models-without-the-hype-5 f67941fa59e. [vii] David E. Burdette and Barbara E. Swartz, “Chapter 4 - Responsive Neurostimulation,” in Neurostimulation for Epilepsy, ed. Vikram R. Rao (Academic Press, 2023), 97–132, https://doi.org/10.1016/B978-0-323-91702-5.00002-5. [viii] Kimmelman and Tannock, 2018. [ix] Kimmelman and Tannock, 2018. [x] Simon Lohse, “Mapping Uncertainty in Precision Medicine: A Systematic Scoping Review,” Journal of Evaluation in Clinical Practice 29, no. 3 (April 2023): 554–64, https://doi.org/10.1111/jep.13789. [xi] Kimmelman and Tannock, “The Paradox of Precision Medicine.” [xii] Vogt and Hofmann, 1206. [xiii] Vogt and Hofmann, 1206. [xiv] Vogt and Hofmann, 1206. [xv] Vogt and Hofmann, 1207. [xvi] Vogt and Hofmann, 1207. [xvii] Vogt and Hofmann, 1207. [xviii] Vogt and Hofmann, 1210. [xix] Mehar Sahu et al., “Chapter Three - Artificial Intelligence and Machine Learning in Precision Medicine: A Paradigm Shift in Big Data Analysis,” in Progress in Molecular Biology and Translational Science, ed. David B. Teplow, vol. 190, 1 vols., Precision Medicine (Academic Press, 2022), 57–100, https://doi.org/10.1016/bs.pmbts.2022.03.002. [xx] Stefan Feuerriegel et al., “Causal Machine Learning for Predicting Treatment Outcomes,” Nature Medicine 30, no. 4 (April 2024): 958–68, https://doi.org/10.1038/s41591-024-02902-1. [xxi] Sunderland Baker et al., “Ethical Considerations in Closed Loop Deep Brain Stimulation,” Deep Brain Stimulation 3 (October 1, 2023): 8–15, https://doi.org/10.1016/j.jdbs.2023.11.001. [xxii] David Haslacher et al., “AI for Brain-Computer Interfaces,” 2024, 7, https://doi.org/10.1016/bs.dnb.2024.02.003. [xxiii] Burdette and Swartz, “Chapter 4 - Responsive Neurostimulation,” 103–4; “Premarket Approval (PMA),” https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P100026. [xxiv] Burdette and Swartz, “Chapter 4 - Responsive Neurostimulation,” 104. [xxv] Burdette and Swartz, 126. [xxvi] Sean L. Metzger et al., “A High-Performance Neuroprosthesis for Speech Decoding and Avatar Control,” Nature 620, no. 7976 (August 2023): 1037–46, https://doi.org/10.1038/s41586-023-06443-4. [xxvii] Hao Fang and Yuxiao Yang, “Predictive Neuromodulation of Cingulo-Frontal Neural Dynamics in Major Depressive Disorder Using a Brain-Computer Interface System: A Simulation Study,” Frontiers in Computational Neuroscience 17 (March 6, 2023), https://doi.org/10.3389/fncom.2023.1119685; Mahsa Malekmohammadi et al., “Kinematic Adaptive Deep Brain Stimulation for Resting Tremor in Parkinson’s Disease,” Movement Disorders 31, no. 3 (2016): 426–28, https://doi.org/10.1002/mds.26482. [xxviii] Young-Hoon Nho et al., “Responsive Deep Brain Stimulation Guided by Ventral Striatal Electrophysiology of Obsession Durably Ameliorates Compulsion,” Neuron 0, no. 0 (October 20, 2023), https://doi.org/10.1016/j.neuron.2023.09.034. [xxix] Nho et al. [xxx] Nho et al.; Erik Robinson, “Brain Implant at OHSU Successfully Controls Both Seizures and OCD,” OHSU News, accessed March 3, 2024, https://news.ohsu.edu/2023/10/25/brain-implant-at-ohsu-successfully-controls-both-seizures-and-ocd. [xxxi] Awuah et al., “Bridging Minds and Machines”; Haslacher et al., “AI for Brain-Computer Interfaces.” [xxxii] Awuah et al., “Bridging Minds and Machines.” [xxxiii] Sara Green, Barbara Prainsack, and Maya Sabatello, “The Roots of (in)Equity in Precision Medicine: Gaps in the Discourse,” Personalized Medicine 21, no. 1 (January 2024): 5–9, https://doi.org/10.2217/pme-2023-0097. [xxxiv] Green, Prainsack, and Sabatello, 7. [xxxv] Robyn Bluhm and Kirstin Borgerson, “An Epistemic Argument for Research-Practice Integration in Medicine,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 43, no. 4 (July 9, 2018): 469–84, https://doi.org/10.1093/jmp/jhy009. [xxxvi] Vijay Mahant, “‘Right-to-Try’ Experimental Drugs: An Overview,” Journal of Translational Medicine 18 (June 23, 2020): 253, https://doi.org/10.1186/s12967-020-02427-4. [xxxvii] Michael S. Okun et al., “Deep Brain Stimulation in the Internal Capsule and Nucleus Accumbens Region: Responses Observed during Active and Sham Programming,” Journal of Neurology, Neurosurgery & Psychiatry 78, no. 3 (March 1, 2007): 310–14, https://doi.org/10.1136/jnnp.2006.095315. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Religion, Psychiatry, and “Radical” Epistemic InjusticesRosa Ritunnano, MD (bio) and Ian James Kidd, PhD (bio)Hermeneutical injustice as a concept has evolved since its original formulation by Miranda Fricker (2007). The concept has been taken up in psychiatry, with its moral, epistemic and clinical premium on the interpretation of extremely complex and difficult experiences (Kidd et al., 2022). There are many varieties of hermeneutical injustice with different forms, sources, degrees, (...) effects, and interpersonal and socio-structural aspects (Medina, 2017). José Eduardo Porcher has proposed the addition of a new form of ‘radical’ hermeneutical injustice, with a case study of psychotic symptoms involving religious content.He offers different characterizations of this injustice:a particularly radical form of injustice, namely, having their own interpretation of their experiences unjustifiably undermined.a form of hermeneutical injustice that occurs when a patient diagnosed with psychosis is denied the opportunity of interpreting their own experiences within their own religious framework.These are different things. Denying someone the opportunity to interpret their experiences in their own, preferred framework is one way of undermining their interpretations. Another is forcing someone to use your own preferred framework and then belittling their own, which seems doubly wrong. Misusing some preferred interpretive framework can be as unjust as not using it. The two definitions could be combined, but then much will depend on what it means to undermine someone’s interpretation of an experience. We think there is a form of radical hermeneutical injustice—different to the one described by Porcher. Some interpretations of kinds of experience with religious content can be undermined if one is committed to a metaphysical naturalism. In these cases, one person cannot regard someone’s interpretive framework as coherent or intelligible (one that involves supernatural entities, for instance).Most discussions of hermeneutical injustice focus on social structures. Fricker notes structural dimensions to hermeneutical injustice. In a standard case, a group has unequal participation in collective practices for making and using interpretive resources (Ritunnano, 2022). In a rich analysis, José Medina describes four ‘axes’ or dimensions for distinguishing forms of hermeneutical injustice [End Page 235] (Medina, 2017). The source of these injustices can be semantic or performative. The dynamics may be structural or interpersonal, or both. Moreover, there are different degrees of breadth and depth, defined here in terms of the ‘reach’ of the injustice across one’s life, and the depth of damage to one’s hermeneutic agency, respectively (Medina, 2017, p. 45). On this model, what might count as ‘radical’ hermeneutical injustices? Deep and broad hermeneutical injustices can be radical when they are very broad in scope and very deeply damaging. This might be what Porcher has in mind. But we think there is a further option, relevant to his case study.Porcher focuses on a case where individuals experience unusual beliefs and perceptions with religious content receive a ‘psychosis’ diagnosis. The alleged injustice is that the possibility of a genuine religious experience is not recognized and validated. The example is Femi, a young man with Christian background, who enters the mental health system following the onset of psychotic ‘symptoms’. After being found “disoriented and depleted in public” – tired and undernourished—Femi is compulsorily admitted to hospital, explaining he undertook fasting and isolation in response to orders from God. During this time, Femi devoted himself to Bible reading and stopped going to work. In hospital, where the authenticity of God’s voice is challenged by clinicians, Femi is treated for acute psychosis with pharmacotherapy. While remission of symptoms follow, there is no functional recovery, and Femi is described as “unmotivated and apathetic”.Femi interpreted his experiences in religious terms, but this interpretation is not accepted or pursued by the clinicians. Is this a hermeneutical injustice? If so, is it a ‘radical’ one? Granted, Femi’s religious interpretation may be psychologically adaptive—enhancing his sense of life as meaningful (Ritunnano & Bortolotti, 2022). But this is consistent with it being a hermeneutical injustice. Plus, a religious framing may be conducive to his functional recovery after being discharged, especially in conjunction with a supportive religious community, able to help him articulate, understand, and respond to those religious experiences (see Cottingham, 2005; Wynn, 2005). However, none of... (shrink)

Abstract Havi Carel has recently argued that one can be ill and happy. An ill person can ?positively respond? to illness by cultivating ?adaptability? and ?creativity?. I propose that Carel's claim can be augmented by connecting it with virtue ethics. The positive responses which Carel describes are best understood as the cultivation of virtues, and this adds a significant moral aspect to coping with illness. I then defend this claim against two sets of objections and conclude that interpreting Carel's phenomenology (...) of illness within a virtue-ethical framework enriches our understanding of how illness can be edifying. (shrink)

Journal of Social Philosophy, EarlyView.

Contrary to the idea that there are fundamental differences between the work of Martin Heidegger and Walter Benjamin, the thesis shows that there exists a profound similarity in the direction of their projects, by exploring how they took up Kant's critical legacy concerning the temporality of language: the belonging together of language and time. The ground of Kant's system and of the necessity of systematicity - the three-fold synthesis which 'generates' time under the direction of conceptuality - is elucidated via (...) the Second Analogy and the Critique of Teleological Judgment. It is argued that Kant's understanding of language and time remains fixed within a circular justification of Newtonian Science, which prevented him from taking up the critical resources of his treatment of teleological concepts and applying it to his idea of the critical system itself. Heidegger's and Benjamin's work may be understood as taking up the hermeneutic circularity of Kant's philosophical system, though freeing it from its appeal to a limited time determination. They both develop notions of a more originary temporality in conjunction with a linguistic phenomenology. They further allow this more critical thinking of language and time to reflexively fall back on the writing of philosophy itself. Their understanding of the temporality of language is explored through the way 'translation' focuses, in each case, a thinking of tradition and of linguistic works. The thesis rejects attempts to separate Heidegger's early work from his later approach, and further rejects a tendency to focus on Benjamin's style of writing in isolation from its theoretical basis. The thesis concludes by arguing that the work of both Heidegger and Benjamin points to a rethinking of Kant's legacy of the necessity of system, in terms of system as the inescapable belonging together of language and time. (shrink)

Deep brain stimulation interventions are novel devices being investigated for the management of severe treatment-resistant psychiatric illnesses. These interventions require the invasive implantation of high-frequency neurostimulatory probes intracranially aiming to provide symptom relief in treatment-resistant disorders including obsessive-compulsive disorder and anorexia nervosa. In the scientific literature, these neurostimulatory interventions are commonly described as reversible and to be used as a last resort option for psychiatric patients. However, the ‘last resort’ status of these interventions is rarely expanded upon. Contrastingly, usages of (...) DBS devices for neurological symptoms have paved the way for established safety and efficacy standards when used earlier in a disease’s timeline. As DBS treatments for these neurological diseases progress to have earlier indications, there is a parallel ethical concern that early implementation may one day become prescribed for psychiatric illnesses. The purpose of this article is to build off contemporary understandings of reversible neurostimulatory interventions to examine and provide clarifications on the ‘last resort’ status of DBS to better address its ethically charged use in psychiatric neurosurgery. To do this, evaluative differences between DBS treatments will be discussed to demonstrate how patient autonomy would be a paramount guiding principle when one day implementing these devices at various points along a psychiatric disease’s timeline. In presenting the clarification of ‘last resort’ status, the ethical tensions of early DBS interventions will be better understood to assist in providing psychiatric patients with more quality of life years in line with their values. (shrink)

Organ transplantation from living related donors in Bangladesh first began in October 1982, and became commonplace in 1988. Cornea transplantation from posthumous donors began in 1984 and living related liver and bone marrow donor transplantation began in 2010 and 2014 respectively. The Human Organ Transplantation Act officially came into effect in Bangladesh on 13th April 1999, allowing organ donation from both brain-dead and related living donors for transplantation. Before the legislation, religious leaders issued fatwa, or religious rulings, in favor of (...) organ transplantation. The Act was amended by the Parliament on 8th January, 2018 with the changes coming into effect shortly afterwards on 28th January. However, aside from a few posthumous corneal donations, transplantation of vital organs, such as the kidney, liver, heart, pancreas, and other body parts or organs from deceased donors, has remained absent in Bangladesh. The major question addressed in this article is why the transplantation of vital organs from deceased donors is absent in Bangladesh. In addition to the collection of secondary documents, interviews were conducted with senior transplant physicians, patients and their relatives, and the public, to learn about posthumous organ donation for transplantation. Interviews were also conducted with a medical student and two grief counselors to understand the process of counseling the families and obtaining consent to obtain posthumous cornea donations from brain-dead patients. An interview was conducted with a professional anatomist to understand the processes behind body donation for the purposes of medical study and research. Their narrative reveals that transplant physicians may be reticent to declare brain death as the stipulations of the 1999 act were unclear and vague. This study finds that Bangladeshis have strong family ties and experience anxiety around permitting separating body parts of dead relatives for organ donation for transplantation, or donating the dead body for medical study and research purposes. Posthumous organ donation for transplantation is commonly viewed as a wrong deed from a religious point of view. Religious scholars who have been consulted by the government have approved posthumous organ donation for transplantation on the grounds of necessity to save lives even though violating the human body is generally forbidden in Islam. An assessment of the dynamics of biomedicine, religion and culture leads to the conclusion that barriers to posthumous organ donation for transplantation that are perceived to be religious may actually stem from cultural attitudes. The interplay of faith, belief, religion, social norms, rituals and wider cultural attitudes with biomedicine and posthumous organ donation and transplantation is very complex. Although overcoming the barriers to organ donation for transplantation is challenging, initiation of transplantation of vital organs from deceased donors is necessary within Bangladesh. This will ensure improved healthcare outcomes, prevent poor people from being coerced into selling their organs to rich recipients, and protect the solidarity and progeny of Bangladeshi families. (shrink)

Sober and Wilson's enthusiasm for a multi-level perspective in evolutionary biology leads to conceptualizations which appropriate all sources of bio-altruistic traits as products of ‘group’ selection. The key biological issue is whether genes enhancing one sub-population's viability in competition with others can thrive, despite inducing some members to lose fitness in intra-group terms. The case for such selection amongst primates remains unproven. Flexible social loyalties required prior evolution of subjective self-definition and self-identification with others. But normative readiness for truly group-serving (...) sacrifices of ego-interests presupposes entitative conceptions of in-groups as collective social units -- only made possible with the emergence of human symbolic language. (shrink)

Journal of Political Philosophy, EarlyView.

In the canonical view of the corporation, management is the agent of the owners of the corporation-the stockholders-and, as such, has a fiduciary duty to manage the corporation in their best interests. Most business ethicists condemn this arrangement as morally indefensible because it fails to respect the right of other corporate constituencies or “stakeholders” to self-deterrnination. By contrast, the modern agency theory of the firm provides a defense of this arrangement on the grounds that it is the result of stakeholders’ (...) right to self-determination. This paper uses the exarnple of managers’ fiduciary duty to stockholders to argue that different normative judgrnents often mask empirical disagreements. (shrink)

Olson (2009) argues that time does not pass because (i) if it did it would have to pass at some rate, and (ii) there is no rate at which it could pass. This paper exposes a confusion about the nature of rates upon which this argument rests.

First published in 1999. Routledge is an imprint of Taylor & Francis, an informa company.

In this paper, I assume, perhaps controversially, that translation into a language of formal logic is not the method by which mathematicians assess mathematical reasoning. Instead, I argue that the actual practice of analyzing, evaluating and critiquing mathematical reasoning resembles, and perhaps equates with, the practice of informal logic or argumentation theory. It doesn’t matter whether the reasoning is a full-fledged mathematical proof or merely some non-deductive mathematical justification: in either case, the methodology of assessment overlaps to a large extent (...) with argument assessment in non-mathematical contexts. I demonstrate this claim by considering the assessment of axiomatic or deductive proofs, probabilistic evidence, computer-aided proofs, and the acceptance of axioms. I also consider Jody Azzouni’s ‘derivation indicator’ view of proofs because it places derivations—which may be thought to invoke formal logic—at the center of mathematical justificatory practice. However, when the notion of ‘derivation’ at work in Azzouni’s view is clarified, it is seen to accord with, rather than to count against, the informal logical view I support. Finally, I pose several open questions for the development of a theory of mathematical argument. (shrink)

The story of liberal democracy over the last half century has been a triumphant one in many ways, with the number of democracies increasing from a minority of states to a significant majority. Yet substantial problems afflict democratic states, and while the number of democratic countries has expanded, democratic practice has contracted. This book introduces a novel framework for evaluating the rise and decline of democratic governance. Examining three mature democratic countries – Britain, Australia and New Zealand – the authors (...) discuss patterns of governance from the emergence of mass democracy at the outset of the twentieth century through to its present condition. The shared political cultures and institutional arrangements of the three countries allow the authors to investigate comparatively the dynamics of political evolution and the possibilities for systemic developments and institutional change. (shrink)

The idea of elegance in science is not necessarily a familiar one, but it is an important one. The use of the term is perhaps most clear-cut in mathematics - the elegant proof - and this is where Ian Glynn begins his exploration. Scientists often share a sense of admiration and excitement on hearing of an elegant solution to a problem, an elegant theory, or an elegant experiment. The idea of elegance may seem strange in a field of endeavour that (...) prides itself in its objectivity, but only if science is regarded as a dull, dry activity of counting and measuring. It is, of course, far more than that, and elegance is a fundamental aspect of the beauty and imagination involved in scientific activity. Ian Glynn, a distinguished scientist, selects historical examples from a range of sciences to draw out the principles of science, including Kepler's Laws, the experiments that demonstrated the nature of heat, and the action of nerves, and of course the several extraordinary episodes that led to Watson and Crick's discovery of the structure of DNA. With a highly readable selection of inspiring episodes highlighting the role of beauty and simplicity in the sciences, the book also relates to important philosophical issues of inference, and Glynn ends by warning us not to rely on beauty and simplicity alone - even the most elegant explanation can be wrong. (shrink)

Proposes a new theory of communication called "comparative media theory.".

The idea that claims about the physical world might be arrived through a priori reasoning has a long history in physics. But it is clear that empiricist notions of the nature of science, and in particular the empirical nature of physics, have held sway in this century. Yet, in the idea of thought experiments in science, we might find the survival of earlier a priori reasoning to the truth of claims about the physical world. This paper challenges the notion that (...) science can be understood as a purely empirical endeavor and points out what reforms would be necessary for teaching the image of science to our young. (shrink)