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.

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)

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)

A set of replies to critics of my 2021 book 'The Fiery Test of Critique: A Reading of Kant's Dialectic' (OUP). -/- The criticisms are based on talks given at an Author-meets-critics symposium at Princeton University on April 22nd, 2023. The critics are: Beatrice Longuenesse, Patricia Kitcher, Allen Wood, Des Hogan, and Anja Jauernig.

A familiar and enduring controversy surrounds the question of whether our phenomenal experience “overflows” availability to cognition: do we consciously see more than we can remember and report? Both sides to this debate have long sought to move beyond naïve appeals to introspection by providing empirical evidence for or against overflow. Recently, two notable studies—Bronfman, Brezis, Jacobson, and Usher and Vandenbroucke, Sligte, Fahrenfort, Ambroziak, and Lamme —have purported to provide compelling evidence in favor of overflow. Here I explain why the (...) data from both studies are wholly consistent with a “no overflow” interpretation. Importantly, when framed purely in representational or informational terms, this “no overflow” interpretation agrees with the interpretations respectively offered by both Bronfman et al. and Vandenbroucke et al.. The difference only emerges when additional assumptions are made concerning which representations correspond to elements in consc.. (shrink)

Reading W.K. Clifford’s “The Ethics of Belief” in evidentialist terms is standard. However, evidentialist accounts face several longstanding interpretive issues over the Shipowner Story and Clifford’s Motto. This article defends an evidentialist reading. But what distinguishes it from others is that it interprets “The Ethics of Belief” according to Clifford’s “first principle of natural ethics”, a principle he articulates in prior writings, and which comes down to social trust. I reorient Clifford’s evidentialism by returning to his core moral principle and (...) argue that doing so can establish coherence across Clifford’s writings on ethics and can help resolve the relevant interpretive issues. (shrink)

What drives organisations to engage in socially responsible purchasing initiatives? To investigate this important question, this article uses a case-study approach to examine the context within which supplier diversity programmes have emerged in both the U.S. and U.K. The analysis identifies legislative and policy developments, economic imperatives, stakeholder pressures and ethical influences as forces shaping organisational responses. It reveals important contextual differences between U.K. and U.S. experience and offers an empirical and theoretical explanation of corporate behaviour.

Within the limited, but growing, literature on small business ethics almost no attention has been paid to the issue of social responsibility within ethnic minority businesses. Using a social capital perspective, this paper reports on an exploratory and qualitative investigation into the attitudinal and behavioural manifestations of CSR within small and medium-sized Asian owned or managed firms in the U.K., with particular reference to the distinctive factors motivating organisational responses. It offers alternative explanations of entrepreneurial behaviour and suggests areas for (...) further research. (shrink)

According to the ‘starting-gate’ interpretation of equality of opportunity, individuals who enjoy equal starts can legitimately become unequal to the extent that their differences derive from choices for which they can be held responsible. There can be no coercive transfers of resources in favour of individuals who disregarded their own futures, and no limits on the right of an individual to distribute resources intrapersonally. This paper assesses two ways in which advocates of equality of opportunity might depart from the starting-gate (...) interpretation. The first involves limiting the degree to which people are liable to pay the costs of their past choices. The second involves limiting their initial opportunities so as to prevent certain risky or apparently short-sighted choices. The paper compares these alternatives in terms of their compatibility with a particular conception of persons as morally equal and temporally extended. It constructs this conception by combining reductionist premises about personal identity with the premise that our status as equals is based on the fundamental requirement of opacity respect. Two conclusions about equality of opportunity are shown to follow from this conception of persons as morally equal and temporally extended: the first is that an individual’s liability to pay the costs of her past choices does not diminish over time; the second is that the individual’s initial scope of choice, in bringing about intrapersonal distributions between her current and future selves, can nevertheless be permissibly limited. The two conclusions are consistent, and the second allows for departures from starting-gate equality of opportunity. (shrink)

Life can be non-ideal in many ways. One of the central ways is in its necessarily embodied, and hence vulnerable, nature. This vulnerability includes our susceptibility to injury and disease, other types of bodily failure, and death. In this chapter, we will describe the moral and epistemic mistreatment common to the experiences of illnesses. We use the term ‘illness’ here to denote serious and life-changing irreversible conditions, which may be chronic or acute. What we say may be applicable, at least (...) in part, to mental illness as well, but there are important differences. (shrink)

Barbados is a center of international genetic research premised on race. Drawing on ethnographic fieldwork following Johns Hopkins studies carried out in Barbados, this article explores this travel for research. This biomedical science relies on a conflicting significance of Barbados: as a site of suffering, due to the disparities of disease, and, conversely, a site of ease, playing on desires and pleasures of escaping too much asceticism in biomedicine. For the American researchers, Barbados becomes a locus of desire to ethically (...) address the African diaspora without the quandaries of accusations and recriminations experienced in carrying out such work in urban America. The concept of cathartic science is used to describe an endeavor that creates a controlled space to know and act on some perceived sufferer without risk of being complicit in the suffering. These medical migrations of researchers to Barbados are paralleled by Bajan families participating in the American studies as a kind of proxy medical migration to the US, bitterly reflecting on the care available to them at home. This article explores the motives of this mutual travel, as a biomedicalized Barbados becomes a spectral figure for patients and researchers fraught with race, injustice, and desire. The article extends the concept of cathartic science from genomics of race to medical anthropology to foreground the desires and anxieties of any science of suffering. (shrink)

In exploring corporate perceptions of the business case for supplier diversity, this paper reports on a cross-national study of large purchasing organisations that had introduced, or were in the process of introducing, purchasing initiatives aimed at ethnic minority businesses. The research investigates how LPOs portray the benefits of this form of socially responsible purchasing and suggests a business case construct based on four component elements. It also highlights a number of contextual factors that appear to have shaped business case rationales. (...) The paper concludes with a discussion of issues of cost and contingent influences affecting SD programmes and points to possible areas for future research. (shrink)

John Henry Newman was a major figure in nineteenth-century religious history. He was one of the major protagonists of the Oxford or Tractarian Movement within the Church of England whose influence continues to be felt within Anglicanism. A high-profile convert to Catholicism, he was an important commentator on Vatican I and is often called 'the Father' of the Second Vatican Council. Newman's thinking highlights and anticipates the central themes of modern theology including hermeneutics, the importance of historical-critical research, the relationship (...) between theology and literature, and the reinterpretation of the nature of faith. His work is characterised by two elements that have come especially to the fore in post-modern theology, namely, the importance of the religious imagination and the fiduciary character of all knowledge. This Companion fills a need for an accessible, comprehensive and systematic presentation of the major themes in Newman's work. (shrink)

This paper focusses on John Toland's influentialHypatia(1720), an account of the neo-Platonist philosopher and mathematician murdered in ancient Alexandria; it also considers segments of hisLetters to Serena(1704), and suggests various conjunctions between the two texts which confirm Toland's genuine and sustained feminist commitment. As I try to establish, Toland's concern is as much about contemporaneous events as it is about ‘disinterested’ history: by promoting Hypatia as the representative of philosophy in its perennial struggle with superstition and priestcraft, Toland is able (...) to underscore the wider case for an inclusive and capacious conception of ‘enlightenment’. (shrink)

Nursing theories are typically anthropocentric and emphasize caring for a person as a unitary whole. They maintain the dualisms of human–nonhuman, natural–social and material–ideal. Recent developments in nonhuman ontology question the utility of that approach. One important philosopher in this new materialism is political theorist Jane Bennett. In this paper, I explore Bennett's vital materialism and enchantment as two concepts arising from the nonhuman turn that should inform nursing philosophy. Vital materialism considers the lively power of matter to affect the (...) world and be affected in relations. Enchantment refers to a sense of wonder and captivation with matter. While summarizing her important contributions, I also describe common criticisms and responses. I consider the human as an assemblage of matter as well as the agency or “thing power” of matter external to humans. This has implications for nursing thought and practice, and it can inform a more capacious research methodology. I also discuss how compassion fatigue or burnout and other professional issues may be seen as a form of disenchantment with the material world. I argue that embracing these and other elements of Bennett's new materialist philosophy can help nurses and other health professionals enrich their theories and practice to advance their disciplines and improve care for persons and populations. (shrink)

The critical environmental justice (CEJ) framework contends that inequalities are sustained through intersecting social categories, multi-scalarity, the perceived expendability of marginalized populations, and state-vested power. While this approach offers new pathways for environmental justice research, it overlooks the role of firms, suggesting a departure from long-standing political-economic theories, such as the treadmill of production (ToP), which elevate the importance of producers. In focusing on firms, we ask: how do firms operationalize diverse social forces to produce environmental injustice? What organizational logics (...) sustain these inequalities? To understand the firm-level dynamics shaping treadmill acceleration and environmental injustice, we utilize two concepts—social embeddedness and managerial authority—from economic sociology research on firms. The former refers to the social and non-economic factors that guide economic decision-making, whereas the latter refers to the power that reinforces worksite hierarchies. This theoretical paper argues that social embeddedness and managerial authority interact within firms to produce an organizational logic that sustains environmental injustice and ecological disorganization. We draw from historical and contemporary evidence on sugarcane plantations in Latin America and the Caribbean, with cases ranging from the colonial period to the present day. By bringing economic sociological concepts to bear on the CEJ and ToP frameworks, we advance debates on how firm-level dynamics shape environmental inequalities. (shrink)

Ancient Angkor. Michael Freeman and Claude Jacques. Thames and Hudson, London 1999. 232 pp. £16.95. ISBN 0 500 97485 3.

Rather than providing a list of "how-tos" and "must dos," this volume is premised on the understanding that by learning more about the current conditions under which teachers and other educators work and learn, it is possible to understand, ...