Literature reviews have repeatedly emphasized the need to further investigate relationships between corporate social responsibility and micro-organizational variables. The present research attempts to address this call by examining the direct and indirect relationship between individual perceptions of CSR and employees’ organizational citizenship behaviors. Multiphasic data from 207 workplace supervisor–subordinate dyads recruited from an online panel were analyzed to show that organizational identification mediated the relationship between CSR and OCBs. Furthermore, supervisor transformational leadership style moderated the mediation, such that the indirect (...) effect of the organizational identification on the relationship between CSR and OCBs became nonsignificant under low transformational leadership. Based on these results, we make suggestions for using embeddedness programs to improve perceptions of CSR. (shrink)

Rare genetic diseases collectively impact millions of individuals in the United States. These patients and their families share many challenges including delayed diagnosis, lack of knowledgeable providers, and limited economic incentives to develop new therapies for small patient groups. As such, rare disease patients and families often must rely on advocacy, including both self-advocacy to access clinical care and public advocacy to advance research. However, these demands raise serious concerns for equity, as both care and research for a given disease (...) can depend on the education, financial resources, and social capital available to the patients in a given community. In this article, we utilize three case examples to illustrate ethical challenges at the intersection of rare diseases, advocacy and justice, including how reliance on advocacy in rare disease may drive unintended consequences for equity. We conclude with a discussion of opportunities for diverse stakeholders to begin to address these challenges. (shrink)

Pulling from theories of social exchange, deonance, and fairness heuristics, this study focuses on the relationship between overall justice climate and both the prosocial and deviant behaviors of groups. Specifically, it considers two contextual boundary conditions on this effect—corporate social responsibility and group moral identity. Results from a laboratory experiment are presented, which show a significant effect for overall justice climate and a two-way interaction between overall justice climate and CSR on group-level prosocial and deviant behaviors, and a marginally significant (...) interaction of group moral identity with overall justice climate on group deviance. The implications of contextual influences on workplace ethics and justice are discussed. (shrink)

Research Ethics, Volume 18, Issue 1, Page 64-83, January 2022. Automated, wearable cameras can benefit health-related research by capturing accurate and objective information about individuals’ daily experiences. However, wearable cameras present unique privacy- and confidentiality-related risks due to the possibility of the images capturing identifying or sensitive information from participants and third parties. Although best practice guidelines for ethical research with wearable cameras have been published, limited information exists on the risks of studies using wearable cameras. The aim of this (...) literature review was to survey risks related to using wearable cameras, and precautions taken to reduce those risks, as reported in empirical research. Forty-five publications, comprising 36 independent studies, were reviewed, and findings revealed that participants’ primary concerns with using wearable cameras included physical inconvenience and discomfort in certain situations. None of the studies reviewed reported any serious adverse events. Although it is possible that reported findings do not include all risks experienced by participants in research with wearable cameras, our findings suggest a low level of risk to participants. However, it is important that investigators adopt recommended precautions, which can promote autonomy and reduce risks, including participant discomfort. (shrink)

Newborn screening (NBS) began in the 1960s by testing all newborns for a single condition—phenylketonuria, or PKU—which, when identified and treated early, significantly reduces morbidity. Over the...

In their paper, “Closed-Loop Neuromodulation and Self-Perception in Clinical Treatment of Refractory Epilepsy,” Haeusermann et al. (2023) note that although responsive neurostimulation (RNS) data v...

Given the need for enforceable guardrails for artificial intelligence (AI) that protect the public and allow for innovation, the U.S. Government recently issued a Blueprint for an AI Bill of Rights which outlines five principles of safe AI design, use, and implementation. One in particular, the right to notice and explanation, requires accurately informing the public about the use of AI that impacts them in ways that are easy to understand. Yet, in the healthcare setting, it is unclear what goal (...) the right to notice and explanation serves, and the moral importance of patient-level disclosure. We propose three normative functions of this right: (1) to notify patients about their care, (2) to educate patients and promote trust, and (3) to meet standards for informed consent. Additional clarity is needed to guide practices that respect the right to notice and explanation of AI in healthcare while providing meaningful benefits to patients. (shrink)

In their paper, “Conversational Artificial Intelligence in Psychotherapy: A New Therapeutic Tool or Agent?” Sedlakova and Trachsel (2023) claim that therapeutic insights and therapeutic changes are...

With the growth of precision medicine research on health data and biospecimens, research institutions will need to build and maintain long-term, trusting relationships with patient-participants. While trust is important for all research relationships, the longitudinal nature of precision medicine research raises particular challenges for facilitating trust when the specifics of future studies are unknown. Based on focus groups with racially and ethnically diverse patients, we describe several factors that influence patient trust and potential institutional approaches to building trustworthiness. Drawing on (...) these findings, we suggest several considerations for research institutions seeking to cultivate long-term, trusting relationships with patients: Address the role of history and experience on trust, engage concerns about potential group harm, address cultural values and communication barriers, and integrate patient values and expectations into oversight and governance structures. (shrink)

Online research offers advantages including recruitment cost, diminished equity-related participation barriers, and convenience; however, there are growing concerns regarding fraudulent participation. Guidance to navigate these challenges exists for online research generally (e.g. surveys), but remains sparse for the specific challenge of fraudulent participation within virtual synchronous interviews. No work has explored this topic within an explicit, detailed ethical framework. Reflecting on our experiences navigating fraudulent participation in virtual synchronous research, we address this gap using the Canadian Code of Ethics for (...) Psychologists as a guiding framework to describe challenges, explore ethical considerations, and identify potential solutions and research directions. (shrink)

Humans, animals, and the environment face a universal crisis: antimicrobial resistance. Addressing AR and its multi-disciplinary causes across many sectors including in human and veterinary medicine remains underdeveloped. One barrier to AR efforts is an inconsistent process to incorporate the plenitude of stakeholders about what AR is and how to stifle its development and spread—especially stakeholders from the animal agriculture sector, one of the largest purchasers of antimicrobial drugs. In 2019, The Wellcome Trust released Reframing Resistance: How to communicate about (...) antimicrobial resistance effectively, which proposed the need to establish a consistent and harmonized messaging effort that describes the AR crisis and its global implications for health and wellbeing across all stakeholders. Yet, Reframing Resistance does not specifically engage the animal agriculture community. This study investigates the gap between two principles recommended by Reframing Resistance and animal agriculture stakeholders. For this analysis, the research group conducted 31 semi-structured interviews with a diverse group of United States animal agriculture stakeholders. Participants reported attitudes, beliefs, and practices about a variety of issues, including how they defined AR and what entities the AR crisis impacts most. Exploration of Reframing Resistance’s Principle 2, “explain the fundamentals succinctly” and Principle 3, “emphasis that this is universal issue; it can affect anyone, including you” reveals disagreement in both the fundamentals of AR and consensus of “who” the AR crisis impacts. Principle 2 may do better to acknowledge that animal agriculture stakeholders espouse a complex array of perspectives that cannot be summed up in a single perspective or principle. As a primary tool to combat AR, behavior change must be accomplished first through outreach to stakeholder groups and understanding their perspectives. (shrink)

Abstrak: Perkembangan yang sangat cepat dalam teknologi komunikasi digital telah mengubah pola-pola adaptasi manusia terhadap lingkungannya. Sudah saatnya filsafat merenungkan ciri manusia di era digital ini bukan sebagai homo sapiens, melainkan sebagai homo digitalis. Homo digitalis, berbeda dari sosok manusia pra-digital, mengalami perubahan tidak hanya dalam cara berkomunikasi, melainkan juga dalam cara merespons dunia dan menangkap kebenaran. Penulis memberi paparan fenomenologis yang kritis tentang kerumitan baru yang timbul akibat digitalisasi masyarakat. Dia berpendirian bahwa dampak revolusi digital bersifat ambivalen, yakni: membuka (...) kebebasan-kebebasan baru dalam komunikasi, tetapi sekaligus juga melepas kebebasan alamiah manusia dalam bentuk brutalitas dalam dunia digital. Sebuah rekomendasi dan kesimpulan diberikan di bagian akhir tulisan ini. Kata-kata kunci: Homo digitalis, kebenaran, digital state of nature, revolusi digital. Abstract: The fast development of digital communication technology has changed the pattern of human adaptation to their environment. Such shift has prompted philosophy to contemplate on the nature of humans in the time of digital era not as homo sapiens but as homo digitalis. Homo digitalis, being different from the figure of humans in the pre- digital world, has seen changes not only in the way of communication but also in the way of responding to the world and capturing the truth. The writer will discuss the new complexity arising from the digital society through the lens of critical phenomenology. He asserts that the impact of digital revolution is ambivalent in nature, i.e.: giving access to freedom in communication on one hand, but unleashing human natural freedom that has driven brutalities in the digital world on the other hand. A recommendation is offered and conclusion drawn at the end of this paper. Keywords: Homo digitalis, digital communication, truth, new freedom, digital revolution. (shrink)

This article engages Kojonen's discussion of scientific explanation. Kojonen claims the best way to conceptualize the relationship between evolutionary explanations and explanation by design is through the proximate-ultimate distinction and the levels metaphor. However, these are not robust explanatory models but examples of how one might differentiate ambiguous explananda contained in why-questions. Disambiguating explananda is a helpful tool for determining when a situation calls for further explanation; however, on this picture, that some further explanation is needed does not, as proponents (...) of design arguments assume, specify design. The question of whether design is a good explanation at all hinges on what precisely we want explained. (shrink)

The popularization of neuroscientific ideas about learning—sometimes legitimate, sometimes merely commercial—poses a real challenge for classroom teachers who want to understand how children learn. Until teacher preparation programs are reconceived to incorporate relevant research from the neuro- and cognitive sciences, teachers need translation and guidance to effectively use information about the brain and cognition. Absent such guidance, teachers, schools, and school districts may waste time and money pursuing so called brain-based interventions that lack a firm basis in research. Meanwhile, the (...) success of our schools will continue to be narrowly defined by achievement standards that ignore knowledge of the neural and cognitive processes of learning. To achieve the goals of neuroeducation, its proponents must address unique ethical issues that neuroeducation raises for five different groups of individuals: a) practicing teachers, b) neuroscience researchers whose work could inform education, c) publishers and the popular media, d) educational policy-makers, and e) university-level teacher educators. We suggest ways in which these ethical challenges can be met and provide a model for teacher preparation that will enable teachers themselves to translate findings from the neuro-and cognitive sciences and use legitimate research to inform how they design and deliver effective instruction. (shrink)

In this article we describe our approach to understanding wrongdoing in medical research and practice, which involves the statistical analysis of coded data from a large set of published cases. We focus on understanding the environmental factors that predict the kind and the severity of wrongdoing in medicine. Through review of empirical and theoretical literature, consultation with experts, the application of criminological theory, and ongoing analysis of our first 60 cases, we hypothesize that 10 contextual features of the medical environment (...) (including financial rewards, oversight failures, and patients belonging to vulnerable groups) may contribute to professional wrongdoing. We define each variable, examine data supporting our hypothesis, and present a brief case synopsis from our study that illustrates the potential influence of the variable. Finally, we discuss limitations of the resulting framework and directions for future research. (shrink)

In “What are Humans Doing in the Loop?” Salloch and Eriksen (2024) argue for a collaborative decision-making approach to using machine learning-based AI decisional support systems in medicine, rece...

Many studies focused on the letter and sound co-occurrences to account for the well-documented syllable-based effects in French in visual (pseudo)word processing. Although these language-specific statistical properties are crucial, recent data suggest that studies which go all-in on phonological and orthographic regularities may be misguided in interpreting how – and why – readers locate syllable boundaries and segment clusters. Indeed, syllable-based effects could depend on more abstract, universal phonological constraints that rule and govern how letter and sound occur and co-occur, (...) and readers could be sensitive to sonority – a universal phonological element – for processing (pseudo)words. Here, we investigate whether French adult skilled readers rely on universal phonological sonority-related markedness continuum across the syllable boundaries for segmentation (e.g., from marked, illegal intervocalic clusters /zl/ to unmarked, legal intervocalic clusters /lz/). To address this question, we ran two tasks with 128 French adult skilled readers using two versions of the illusory conjunction paradigm (Task 1 without white noise; Task 2 with white noise). Our results show that syllable location and segmentation in reading is early and automatically modulated by phonological sonority-related markedness in the absence or quasi-absence of statistical information, and does not require acoustic-phonetic information. We discuss our results towards the overlooked role of phonological universals and the over-trusted role of statistical information during reading processes. (shrink)

Readers assume that commonplace properties of the real world also hold in realistic fiction. They believe, for example, that the usual physical laws continue to apply. But controversy exists in theories of fiction about whether real individuals exist in the story’s world. Does Queen Victoria exist in the world of Jane Eyre, even though Victoria is not mentioned in it? The experiments we report here find that when participants are prompted to consider the world of a fictional individual (“Consider the (...) world of Jane Eyre…”), they are willing to say that a real individual (e.g., Queen Victoria) can exist in the same world. But when participants are prompted to consider the world of a real individual, they are less willing to say that a fictional individual can exist in that world. The asymmetry occurs when we ask participants both if a real person is in the character’s world and if the person would appear there. However, the effect is subject to spatial and temporal constraints. When the person and the character share spatial and temporal settings, interchange is more likely to occur. These results shed light on the author’s implicit contract with the reader, which can license the reader to augment a fictional world with features that the author only implicates as part of the work’s background. (shrink)

Introduction The Defining Issues Test (DIT) aimed to measure one’s moral judgment development in terms of moral reasoning. The Neo-Kohlbergian approach, which is an elaboration of Kohlbergian theory, focuses on the continuous development of postconventional moral reasoning, which constitutes the theoretical basis of the DIT. However, very few studies have directly tested the internal structure of the DIT, which would indicate its construct validity. Objectives Using the DIT-2, a later revision of the DIT, we examined whether a bi-factor model or (...) 3-factor CFA model showed a better model fit. The Neo-Kohlbergian theory of moral judgment development, which constitutes the theoretical basis for the DIT-2, proposes that moral judgment development occurs continuously and that it can be better explained with a soft-stage model. Given these assertions, we assumed that the bi-factor model, which considers the Schema-General Moral Judgment (SGMJ), might be more consistent with Neo-Kohlbergian theory. Methods We analyzed a large dataset collected from undergraduate students. We performed confirmatory factor analysis (CFA) via weighted least squares. A 3-factor CFA based on the DIT-2 manual and a bi-factor model were compared for model fit. The three factors in the 3-factor CFA were labeled as moral development schemas in Neo-Kohlbergian theory (i.e., personal interests, maintaining norms, and postconventional schemas). The bi-factor model included the SGMJ in addition to the three factors. Results In general, the bi-factor model showed a better model fit compared with the 3-factor CFA model although both models reported acceptable model fit indices. Conclusion We found that the DIT-2 scale is a valid measure of the internal structure of moral reasoning development using both CFA and bi-factor models. In addition, we conclude that the soft-stage model, posited by the Neo-Kohlbergian approach to moral judgment development, can be better supported with the bi-factor model that was tested in the present study. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Introduction:Women in Public Life in Republican RomeHarriet I. Flower and Josiah OsgoodThe five articles in this special issue of AJP seek to advance our understanding of republican Rome by paying close attention to women in relation to space. Using a range of sources and approaches, contributors find women throughout the city of Rome—on the streets, in the Forum, in houses (some of which were owned by women), and at (...) temples and sacred structures such as the Regia, a building the Romans believed had once been the house of their kings. Contributors consider how women participated in political and legal discussions, accrued and controlled property, and fulfilled ritual obligations deemed vital to the community's well-being, often side by side with men. Access to different kinds of spaces afforded women social status, recognition, and influence within society at large.A central concern of the authors is to show that public life, broadly defined, involved women as well as men. By public life, we mean, in part, activities that occurred in the open, where large numbers might gather, watch, listen, and respond. In his contribution to the issue, Lewis Webb shows how women of very different statuses held religious roles—some as priestesses—roles that required them to move through the city and carry out sacrifices and other rites in a highly visible manner. In her article studying non-elite women's part in politics in the late Republic, Celia E. Schultz looks at various women who traveled in the entourages of male politicians and the attention they drew to themselves. Josiah Osgood, in his discussion of high-ranking women in the same period, shows how women introduced their concerns into politics, through conversations [End Page 1] held in domestic settings but also by protesting publicly and testifying as key witnesses at criminal trials.Public life encompassed activities that were of concern to the community, such as religious rituals performed on behalf of that same community. As Meghan DiLuzio points out in her article on women in the Regia, "visibility is not the only way of thinking about what made a ritual public." The Romans defined a ritual as public (publicus) if it was "paid for by the community and performed on behalf of the people." In her contribution, Harriet I. Flower points out that political discussions and negotiations could happen in houses (Roman politicians did not have separate offices) and then considers examples of such conversations that are attested in houses owned or controlled by women. In Livy's narrative of the so-called Bacchanalian conspiracy of 186 b.c.e. (39.8–19), Flower investigates how a series of pivotal conversations each took place in women's houses. Narrative historians of Rome often focused on warfare, other activities of magistrates, and formal political debate at contiones and in the Senate, spheres in which women's voluntary participation was typically precluded, and this view of what mattered often gets repeated today, at times in general treatments. Closer attention to women, and to the spaces in which they were present and active, opens up a fuller picture of republican culture. In this culture, religion was not a scholarly sub-field but a central part of social and political experience, and political debate and decision-making comprised far more than individual orators standing on the Rostra or in the Curia.This special issue of AJP grew out of a particular interest in space as a focus for historical analysis. We wanted to ask basic questions about where women spent their time, what discussions and decision-making fora they could be a part of, and how they moved through the city. Meanwhile, no answer to these questions can omit religious activities, which feature heavily in most of the following articles. A third, fundamental topic which joins these papers together is women's influence. Space, religion, and influence are, therefore, interlocking themes of central importance in the lives of women in the Roman Republic, and we briefly introduce each of these three principal areas here, since they inform the papers collected here. In addition, these three themes highlight many connections between the contributions in this volume and link these... (shrink)

Denis Alexander, David Glass, Peter Jeavons, Meghan Page, Bethany Sollereder, and Mats Wahlberg have offered interpretations, critique, and defenses of E. V. R. Kojonen's book The Compatibility of Evolution and Design. Here, Kojonen responds to their comments on wideranging issues related to the teleology and evolution, from models of God as Creator to the meaning of randomness and design.

El propósito de este texto es ofrecer una visión general de la relación entre nación e historia en los debates que se generaron por parte de los historiadores y otros intelectuales de las ciencias sociales a finales del siglo XIX y durante gran parte del siglo XX. La reflexión central que se plantea consiste entonces en estudiar y mostrar cómo al mismo tiempo que las naciones modernas eran objeto de un proceso de redefinición política, en el escenario intelectual de las (...) ciencias sociales, y en particular de los historiadores, fueron apareciendo también un conjunto de debates y obras que intentaban problematizar y someter a consideración las relaciones que pretendían establecerse entre la nación y la historia como un elemento que las justificaba. (shrink)

Photo ID 222412412 © US Navy Medicine | Dreamstime.com ABSTRACT In a non-military setting, the answer is clear: it would be unethical to treat someone based on non-medical considerations such as nationality. We argue that Battlefield Triage is a moral tragedy, meaning that it is a situation in which there is no morally blameless decision and that the demands of justice cannot be satisfied. INTRODUCTION Medical resources in an austere environment without quick recourse for resupply or casualty evacuation are often (...) limited. The shortage extends not only to supplies like blood products and drugs, but physicians and other medical personnel. In the midst of a mass casualty scenario, such as a battle that includes intense ground fighting, the medical staff will stretch scarce resources and triage casualties according to specific criteria. Typically, they proceed by providing care for the most severely wounded first, referred to here as conventional triage. At times, though, the staff may reverse the triage so that soldiers with minor wounds can return to the fight. In a mass casualty situation, when medical personnel apply conventional triage and treat casualties from opposing forces, a dilemma may arise. We argue that it can be permissible for military physicians to prioritize their own soldiers over enemy combatants in a mass casualty triage, where reverse triage does not apply. The case we will focus on is as follows: Battlefield Triage: During combat operations on a remote island in the Pacific Ocean, a compatriot soldier and an enemy combatant arrive at the compatriot soldier country’s medical treatment facility. Both have similar gunshot wounds to the abdomen, and they arrive with similar conditions. Both have low oxygen saturation and excessive blood loss. The sole physician only has enough time to stabilize one person. The scenario is brief, and we are aware that medical rules of eligibility will most often dictate how the physician proceeds,[1] but this scenario is useful in setting up the question we focus on in this paper: would it be wrong to favor the stabilization of a soldier just because the soldier is the physician’s compatriot? In other words, can nationality serve as an ethically justified tiebreaker in a situation such as Battlefield Triage?[2] In a non-military setting, the answer is clear: it would be unethical to treat someone based on non-medical considerations such as nationality. The AMA’s Code of Medical Ethics asserts that physicians have “ethical obligations to place patients’ welfare above their self-interest and above obligations to other groups.”[3] The World Medical Association’s Declaration of Tokyo affirms that “no motive, whether personal, collective or political, shall prevail against this higher purpose” of alleviating distress.[4] Physicians are taught early on that triage decisions must be medically indicated and made without consideration of factors such as race, ethnicity, religion, social status, and nationality. They are taught that public trust and obligations of justice grounded in equality demand that only medical indications be considered. But military physicians in a military setting are beholden to obligations, duties, and responsibilities as members of the military, and when these obligations, duties, and responsibilities conflict, as they do in Battlefield Triage, which loyalties win out and why?[5] Critics of partiality on national grounds argue that partiality undermines public trust in medicine and justice because everyone should be treated equally regardless of nationality.[6] Proponents of partiality argue that military obligations supersede equality and that justice requires partiality in such cases.[7] Despite the critics’ disagreement, both agree that there is a morally right, perhaps even blameless, course of action. Drawing on insights from virtue ethics, we argue that Battlefield Triage is a moral tragedy in which justice is unattainable and there is no action without moral cost. The assumption that there is a morally right choice is flawed. We argue that while no decision in this scenario is free from moral blame, there are reasons to favor treating one’s soldiers over enemy combatants. I. The Case Against Partiality There is a common assumption that there is a morally right or just decision in Battlefield Triage. A number of organizations and scholars claim that it is wrong for military physicians to favor their own soldiers on the grounds of nationality or some form of ‘group membership.’ (In a conflict involving service members from multiple nations working as a coalition, a soldier from an allied country may receive the same priority as the US service member due to ‘group membership.’) The World Medical Association’s WMA Declaration of Lisbon on the Rights of the Patient, which was reaffirmed in 2015, posits that, “[i]n circumstances where a choice must be made between potential patients for a particular treatment that is in limited supply, all such patients are entitled to a fair selection procedure for that treatment. That choice must be based on medical criteria and made without discrimination.”[8] This echoes what was set forth in Article 12 of the Geneva Conventions, which states that “[o]nly urgent medical reasons will authorize priority in the order of treatment to be administered.”[9] The argument for impartiality in Battlefield Triage is that every person is morally equal, and equality entails that medical distribution is, “based on a combination of medical need and urgency.”[10] This is in keeping with the bioethical principles that are generally applied.[11] II. The Case for Partiality On the other side, there are arguments that favoritism is the ethically right decision in Battlefield Triage.[12] The argument asserts that members of the military form a morally significant community of friends and participation in these relationships demands partiality. Just as parents have strong ethical duties to their children and not just any children, military personnel have ethical duties to their group, a group that involves an affirmation of mutual aid and support. Some have termed these ‘associative duties. According to Michael Gross, obligations of friendship, care, and solidarity “leave very little room for generally applicable principles of justice that would obligate a medic to treat enemy or non-compatriot wounded ahead of their compatriots.”[13] This is true in Battlefield Triage, but it may also be true even if the enemy’s soldier were more seriously wounded: “the ethics of small group cohesion, largely an ethics of care, mostly replaces the demands of impartial justice.”[14] In a more recent article, Gross explains that preferential treatment is ethically justified based on fighting capability and “the special obligations people owe friends, family, and, no less, comrades-in-arms.”[15] To not show partiality to the US soldier would be morally wrong on the grounds of friendship and mutual care.[16] III. The Moral Tragedy of Battlefield Triage Defenders and critics of Battlefield Triage favoritism based on nationality both frame their position as just or fair. For example, Justin List argues that physicians are “bound to practice medical neutrality,”[17] Marcus Adams denies that physicians “possess special ethical obligations” to enemy combatants because of their profession.[18] These perspectives assume that there is a morally right decision and that justice is attainable. The assumption that there is or can be a morally right Battlefield Triage decision, and we need to put our heads together to figure it out, remains strongly entrenched. However, the facts of the situation should give us pause; there are too many people and too few resources, and this demands a decision-making process that determines who will receive scarce resources. By its very nature, a battlefield triage decision has to be made based on some characteristic or value, a characteristic or value that will inevitably favor some at the expense of others. This is precisely why competing analyses “in the military context struggle to resolve these conflicts satisfactorily.”[19] Drawing on the insights of virtue ethics, we suggest that Battlefield Triage is a moral tragedy. Virtue ethics suggests that morality is about acting virtuously, which is to say that we should do what a virtuous person would do in the situation. Ethics is about figuring out how a just, wise, compassionate, loving, and fair person would act, and then doing that, as one grows in virtue. But life is not always clear cut, and it is possible that virtuous people may find themselves in a moral tragedy, a situation in which, through no fault of one’s own, a person must make a morally objectionable decision. After the action the virtuous person “emerges having done a terrible thing, the very sort of thing that the callous, dishonest, unjust, or in general vicious agent would characteristically do.”[20] Stated differently, a moral tragedy presents a virtuous person with two or more courses of action, all of which have a moral cost.[21] In Battlefield Triage, no matter how the physician goes about deciding, there is going to be defensible concern from those not saved. The fact that there are more people than can be helped fosters competing values in battlefield triage: maximize lives saved, treat people equally, treat the worse off, and support the war effort. Treating people equally may create tension between treating the worse off, maximizing lives saved, and supporting the war effort. Reverse triage is a case in point, as supporting the war effort conflicts with treating the worse off first, as is a fair lottery system since deploying a lottery may not maximize lives saved or support the war effort. There can be reasons why one person is selected over another, to be sure. Yet, there are reasons for making a decision, and that the decision is subject to legitimate moral concern is another. To recognize the moral tragedy of Battlefield Triage is to recognize the impossibility of acting blamelessly in the situation. In this situation, the virtuous military physician is going to have to sacrifice important values such as justice, compassion, and respect for others, even with a defensible criterion in hand. The physician will grieve this sacrifice accordingly. The physician may find her decision difficult or stressful, and rightly so, because of what her circumstances require of her. This kind of moral tragedy results “in actions which betray and violate the rights of persons to whom there may be a strong duty of care. When this happens, it properly triggers an appropriate moral emotion since our moral integrity has been violated and this affects how we think of ourselves and what we have become.”[22] Rather than view her triage decision as the morally superior choice, the virtuous military physician will view her decisions in these circumstances in a different light: it is the least bad option in a terrible situation, and she did something ethically problematic, something that is contrary to her moral character. She deeply regrets the circumstances in which she had to act. IV. Virtue Ethics A virtue ethicist has insight into how one should go about deciding what to do in a moral tragedy, although virtue ethics may not be as helpful as one may hope. The goal of the virtuous military physician in Battlefield Triage is to adopt the best course of action or the action that she feels she ought to do, all things considered. This does not make her choice devoid of serious wrongdoing—a decision must be made, but that does not make it just. The virtuous military physician will approach the situation with courage, responsibility, and insight. She will think about the decision carefully, wisely, and conscientiously; she will weigh the goods and harms of the choices before her, in conjunction with a proper conception of the good life, human worth, and understanding of her obligations to others—including chain of command, fellow soldiers, and the medical community. She is attuned to the value of human life and has a reasonable idea of the various ways her decisions will affect others. She recognizes that she is in this non-ideal situation through no fault of her own: she is not the one fighting in battles; she is serving her country as a physician, whose job it is to save lives, treat everyone justly, and promote military objectives. She regrets the decision she is forced to make in battlefield triage, acting “with immense regret and pain,” Hursthouse explains, “instead of indifferently or gladly.”[23] This is because, no matter what decision is made, the virtuous military physician “does something terrible or horrible,” something she otherwise would not do and is contrary to her values.[24] V. A Resolvable Moral Tragedy Instead of asking whether there is a morally right decision, in which a decision is morally blameless and above reproach, the virtue ethicist asks whether there is a decision with a convincing rationale, knowing that a decision can have a clear rationale but still be morally tragic. It is perfectly reasonable to think that different virtuous persons will arrive at different courses of action: “two virtuous agents, in the same situation,” Hursthouse writes, “may act differently” in irresolvable moral tragedies, in cases in which there is no clear course of action.[25] Because a person must act in a moral tragedy, one goal is to identify reasons for choosing the chosen action. Some decisions are clearly indefensible—treating neither the compatriot soldier nor the enemy combatant in Battlefield Triage would be wrong—and some decisions are more problematic than others. If the military physician selects to treat the soldier because she does not like the enemy combatant’s skin color, such a reason would be deeply problematic. But much of the debate over how to act in a moral tragedy is not over clearly indefensible or problematic criteria. Instead, the literature is largely about different standards or implementations of justice. Some scholars defend nation-impartial triage as right, while others defend nation-aware triage as right, and each argues that the other side is promoting an unjust or otherwise wrong solution to Battlefield Triage. We suggest that Battlefield Triage is a resolvable moral tragedy and that virtue ethics offers convincing reasons to prefer the treatment of the compatriot soldier rather than the enemy combatant on the grounds of national identity. Virtues are integral to living a good life, a flourishing life, but as Aristotle observed long ago, human beings are inherently social, interdependent and interconnected in profound ways.[26] This goes beyond the obvious fact that we need each other to survive day to day (one person makes clothes, another farms, and another makes tools); the claim is that a good or flourishing life depends in large part on one’s social network or community. This is why many of Aristotle’s moral virtues are other facing: justice, friendship, generosity, and magnanimity, to name a few. Courage, a typically self-facing virtue, is understood by Aristotle to be the virtue that regards one’s fear of death in battle, a battle fought on behalf of one’s city.[27] All of this remains true today. Namely, there is an important sense in which our community matters to our lives: it is easier to live a good, flourishing life if one is part of a good, flourishing community. Our community is made up of smaller groups, and it is more accurate to say that we are simultaneous members of different groups within a broader community. A person may be part of a family, friend group, research team, large state university, city, state, and nation. Groups can function well or not, as we all have experienced, and this suggests that there are virtues or excellences that groups can instantiate. Good groups are unified in purpose, with each member doing their duty alongside others for the attainment of that purpose. Good groups manifest solidarity among their members. Although Aristotle does not list solidarity as a virtue, a number of modern-day virtue ethicists have begun examining how group solidarity can be a virtue that contributes to a good or flourishing life.[28] Solidarity is not conceptualized as an individual virtue, a virtue possessed by a person in isolation of others; instead, it is a collective virtue, a virtue that is shared among members of a defined group with particular ends.[29] “A group has solidarity to the extent that its members are disposed to: (1) share values, aims, or goals; (2) care about those values, aims, or goals; (3) act in accordance with those values, aims, or goals; (4) trust the testimony of other group members with respect to those values, aims, and goals; and (5) feel a sense of belonging to the group.”[30] The virtue of collective or group solidarity involves individuals having special concern for each other, shared aims and values, trust, loyalty, and a sense of belonging with these specific others. There is a oneness to the group in the pursuit of a definite goal or purpose, involving mutual support and affirmation of each member. As such, the group has ends and goods above and beyond the good of each individual person. Sometimes solidarity requires personal sacrifice for the collective (for example, a father sacrificing food so his child can eat). The virtue of collective or group solidarity is important to the military and medical community at every level, and for clear reasons. In the military, there is a clear hierarchy of command, unity of purpose and end, mutual trust and support in complex settings, and so on. Soldiers need to know they can count on one another, and solidarity grounds a soldier’s ability to trust others and be assured of mutual aid. In medicine, solidarity maintains self-regulation of the profession, shared values and goals, as well as public support, not to mention that day-to-day operations require physician trust, engagement, and effort toward the ends of clinical care. Physicians need to work together, along with others, in pursuit of health, and disunity is sowed when there is mistrust, selfishness, or disengagement among the healthcare team and organization. Importantly, just as we are all members of various groups and hence may manifest group solidarity in different settings, the virtuous military physician instantiates collective solidarity with both the medical profession and the military. Her dual loyalty contributes to the moral difficulty of acting in Battlefield Triage. The military physician has competing obligations to distinct groups and cannot satisfy all obligations in Battlefield Triage. Solidarity with the military supports the consideration of favoring the soldier for reasons of national identity, whereas solidarity with the medical community does not. Something has to give, which is why it is a moral tragedy. The virtuous military physician, therefore, must weigh the costs of each course of action. To fulfill her obligations to the medical community would require that she does not use nationality and other non-medical considerations in Battlefield Triage. Since the soldier and enemy combatant are equally injured, justice would demand a random process, perhaps a flip of the coin. Although this may satisfy obligations the military physician has to the medical community, this would be costly to the physician’s military group. If word gets out that the physician decides who to treat based on a coin toss, soldiers, families, and citizens may become frustrated and angry. Soldier morale may go down if it becomes known that a coin flip led to the preventable death of a soldier and the saving of an enemy combatant who had killed (or attempted to kill) other soldiers. As Gross highlights, military solidarity involves a mutual aid promise that military personnel promise to help one another.[31] A military physician is part of the military and, as such, is part of the mutual aid promise, which would appear to be violated if the physician flips a coin. Treating a member of one’s own team may be psychologically more beneficial than treating an enemy combatant and may lead to less moral distress.[32] Finally, treating soldiers rather than enemy combatants promotes broader military and social aims, including returning soldiers to health, maintaining unity of purpose, and minimizing community suffering from a soldier’s death. Favoring members of one’s group, that is, triage based on nationality in Battlefield Triage, would fulfill obligations of military group loyalty, which is contrary to the values and duties of medicine. It does not seem as though showing favoritism in this particular situation is very costly to the medical community or general public, but this is because there is recognition that the physician is in the military. Medicine is impartial to non-medical indications partly because of fairness and to promote public trust in medicine. However, Battlefield Triage is unique, as medicine is being practiced in a non-public, wartime setting. In ordinary circumstances, a patient’s identity is irrelevant, and physicians ought not play favorites. Since Battlefield Triage is not an ordinary circumstance, decisions based on patient identity may not undermine public trust in medicine. In addition, it is contestable that fairness in Battlefield Triage requires that no consideration be paid to one’s nationality. Fairness is about giving each person their due, what is owed to them, and the case can be made that soldiers who place themselves in danger for the sake of the common good or a just cause are owed special attention when they suffer harm in the line of duty. In other words, soldiers voluntarily undergo risk to themselves for the greater good, and society owes them for this sacrifice. This plausibly includes preferential treatment in a situation such as Battlefield Triage. So, while the medical community affirms justice demands non-preferential treatment, the military community can affirm the opposite. The demands of fairness are unclear at best or in conflict in this situation: demands of physician justice decry favoritism, while demands of military justice support favoritism. Triage not based on nationality is arguably unfair and triage based on nationality may not undermine public trust, after all. All things considered, there is a clear rationale for favoring nationality-based preferential treatment in Battlefield Triage. Adopting a nationality-based preference in this situation is more defensible than not. This does not make such a decision ethically right or just. Preference based on nationality is the least bad decision, but it is not morally blameless. It involves one in a serious moral wrong, a wrong otherwise avoided and contrary to one’s character. The virtuous military physician is in a situation in which obligations conflict, and we disagree with Gross, who posits that care of fellow soldiers “is important to the near exclusion of all else.”[33] Gross fails to appreciate the collective virtue of solidarity as applied to those in medicine. The military physician has duties to fellow soldiers but also to fellow physicians, to the medical community, and humanity. To favor a soldier on grounds of nationality violates her duties and responsibilities to this latter group. She is involved in a moral tragedy and can only seek the most just action given the circumstances, yet, at least in virtue ethics, the action remains far from blameless. CONCLUSION We argue that Battlefield Triage is a moral tragedy, meaning that it is a situation in which there is no morally blameless decision and that the demands of justice cannot be satisfied. As such, the virtuous military physician incurs a moral cost to acting as she does—there is a moral residue. However, despite being a moral tragedy, there are clear reasons to act in favor of treating one’s own, considering group solidarity. As such, these kinds of tragedies are resolvable: virtuous military physicians should favor treatment of their own, although they would do so with sorrow. - [1] Militaries set forth medical rules of eligibility or guidelines used to determine whether a person qualifies for specific medical interventions or treatments in certain circumstances, and these guidelines are binding for a military physician. For example, despite opposition from medical organizations, militaries have adopted reverse triage guidelines for military physicians to follow. For ethical discussion, see Falzone, Elisabeth, P. Pasquier, C. Hoffmann, O. Barbier, M. Boutonnet, A. Salvadori, A. Jarrassier, J. Renner, B. Malgras, and S. Mérat. "Triage in military settings." Anaesthesia Critical Care & Pain Medicine 36, no. 1 (2017): 43-51. https://doi.org/10.1016/j.accpm.2016.05.004 [2] There are issues that are related to this, including the triage of civilians and allied soldiers. We set related issues aside for purposes of this paper [3] American Medical Association, Code of Medical Ethics: Current Opinions with Annotations, 2004–2005 ed. (Chicago, IL: AMA, 2004), 300. [4] American Medical Association, Code of Medical Ethics: Current Opinions with Annotations, 2004–2005 ed. (Chicago, IL: AMA, 2004), 300. [5] This is termed the “dual loyalty” dilemma in military medicine and has been described at length elsewhere: Institute of Medicine (US) Board on Health Sciences Policy. Military Medical Ethics: Issues regarding Dual Loyalties: Workshop Summary. Washington (DC): National Academies Press (US); 2008. Toward a Framework for Resolving Dual Loyalties. Available from: https://www.ncbi.nlm.nih.gov/books/NBK214853/ [6] See Kenneth G. Swan and K.G. Swan, Jr., “Triage: The Past Revisited,” Military Medicine 161:8 (1996): 448–452. https://doi.org/10.1093/milmed/161.8.448; Jerome A. Singh, “American Physicians and dual loyalty obligations in the ‘war on terror,’” BMC Medical Ethics 4.4 (2003): 1–10. https://doi.org/10.1186/1472-6939-4-4; Beam, Thomas E. "Medical Ethics on the Battlefield." Military Medical Ethics: Sect. IV. Medical ethics in the military. Medical ethics on the battlefield: the crucible of military medical ethics 2 (2003): 369-402; Hereth, Blake. "Health justice for unjust combatants." Journal of Military Ethics 20, no. 1 (2021): 67-81. https://doi.org/10.1080/15027570.2021.1949782. [7] See Adams, Marcus P. "Triage priorities and military physicians." In Physicians at war: The dual-loyalties challenge, pp. 215-236. Dordrecht: Springer Netherlands, 2008. Gross, Michael L. "Comradery, community, and care in military medical ethics." Theoretical medicine and bioethics 32 (2011): 337-350. https://doi.org/10.1007/s11017-011-9189-6. Gross, Michael L. "The limits of impartial medical treatment during armed conflict." In Military medical ethics for the 21st century, pp. 71-84. Routledge, 2016. [8] World Medical Association, WMA Declaration of Lisbon on the Rights of the Patient. 5 December 2022, https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/ [9] Geneva Convention for the Amelioration of the Condition of Wounded, Sick in Armed Forces in the Field. 12 August 1949. https://www.un.org/en/genocideprevention/documents/atrocity-crimes/Doc.30_GC-I-EN.pdf. [10] List, Justin M. "Medical neutrality and political activism: physicians' roles in conflict situations." In Physicians at war: The dual-loyalties challenge, pp. 237-253. Dordrecht: Springer Netherlands, 2008. 240 [11] Beauchamp, T., and J. Childress. 2013. Principles of Biomedical Ethics, 7th ed. Oxford, United Kingdom: Oxford University Press. [12] Adams, Marcus P. "Triage priorities and military physicians." In Physicians at war: The dual-loyalties challenge, pp. 215-236. Dordrecht: Springer Netherlands, 2008. [13] Gross, "Comradery, community, and care in military medical ethics," 347. [14] Gross, “Comradery, community, and care in military medical ethics,” 349. [15] Gross, Michael L. "When medical ethics and military ethics collide." Narrative inquiry in bioethics 13, no. 3 (2023): 199-204. 202 https://dx.doi.org/10.1353/nib.2023.a924191 [16] Our argument draws on virtue ethics, from which care ethics derives, and it is worth clarifying how our argument relates to Gross’s. We do not think that the virtue of friendship grounds triage decisions, for we think it is unlikely that the physician and wounded soldier are friends. Instead, as explained below, we think the collective virtue of group solidarity better captures the moral significance of group loyalty and that Gross would agree with us. But since military physicians are part of distinct groups, with competing obligations, the military physician will be forced to sacrifice a value in battlefield triage cases. In other words, we think Gross downplays the dual group membership of a military physician. [17] List,”Medical neutrality and political activism,” 250. [18] Adams,”Triage priorities and military physicians,” 235. [19] London, Leslie, Leonard S. Rubenstein, Laurel Baldwin-Ragaven, and Adriaan Van Es. "Dual loyalty among military health professionals: human rights and ethics in times of armed conflict." Cambridge Quarterly of Healthcare Ethics 15, no. 4 (2006): 381-391. 383. [20] Hursthouse, R. On Virtue Ethics. OUP 1999. 74 [21] Nussbaum, Martha C. "The costs of tragedy: Some moral limits of cost-benefit analysis." The Journal of Legal Studies 29, no. S2 (2000): 1005-1036, 1007. [22] De Wijze, S. (2005). Tragic-remorse–the anguish of dirty hands. Ethical theory and moral practice, 7(5), 453-471, 457. https://doi.org/10.1007/s10677-005-6836-x [23] Hursthouse, 73 [24] Hursthouse, 81 [25] Hursthouse, 72 [26] Aristotle, Politics 1253a8. Reeve, C. D. C., Indianapolis: Hackett Publishing Co., 2017 [27] Aristotle, Nicomachean Ethics. III.6.114a, 34-35. 2002, Nicomachean Ethics, Christopher Rowe (trans.), Oxford: Oxford University Press [28] Byerly, T. Ryan, and Meghan Byerly. "Collective virtue." The Journal of Value Inquiry 50, no. 1 (2016): 33-50. https://doi.org/10.1007/s10790-015-9484-y; Federico, Veronica. "Conclusion: solidarity as a public virtue." Solidarity as a Public Virtue (2018): 495-542. https://doi.org/10.5771/9783845290058. Rehg, William. "Solidarity and the common good: An analytic framework." Journal of Social Philosophy 38, no. 1 (2007): 7-21. https://doi.org/10.1111/j.1467-9833.2007.00363.x [29] Byerly and Byerly. "Collective virtue." 43 [30] Battaly, Heather. "Solidarity: Virtue or vice?." In Social virtue epistemology, pp. 303-324. Routledge, 2022. 304 [31] Ibid., 2011: 341 [32] It might be thought that displaying altruism by helping an enemy combatant at the expense of one’s fellow soldier may be psychologically satisfiying. For evidence that military physicians find it difficult to treat enemy combatants, see Lundberg, Kristina, Sofia Kjellström, Anders Jonsson, and Lars Sandman. "Experiences of Swedish military medical personnel in combat zones: adapting to competing loyalties." Military medicine 179, no. 8 (2014): 821-826. https://doi.org/10.7205/MILMED-D-14-00038. Lamblin, Antoine, Clément Derkenne, Marion Trousselard, and Marie-Ange Einaudi. "Ethical challenges faced by French military doctors deployed in the Sahel (Operation Barkhane): a qualitative study." BMC Medical Ethics 22 (2021): 1-13. https://doi.org/10.1186/s12910-021-00723-2 [33] Ibid., 2011: 344. (shrink)