Decision making for incompetent patients is a much-discussed topic in bioethics. According to one influential decision making standard, the substituted judgment standard, a surrogate decision maker ought to make the decision that the incompetent patient would have made, had he or she been competent. Empirical research has been conducted in order to find out whether surrogate decision makers are sufficiently good at doing their job, as this is defined by the substituted judgment standard. This research investigates to what (...) extent surrogates are able to predict what the patient would have preferred in the relevant circumstances. In this paper we address a methodological shortcoming evident in a significant number of studies. The mistake consists in categorizing responses that only express uncertainty as predictions that the patient would be positive to treatment, on the grounds that the clinical default is to provide treatment unless it is refused. We argue that this practice is based on confusion and that it risks damaging the research on surrogate accuracy. (shrink)

Part of the standard protection of decisionally incapacitated research subjects is a prohibition against enrolling them unless surrogate decision makers authorize it. A common view is that surrogates primarily ought to make their decisions based on what the decisionally incapacitated subject would have wanted regarding research participation. However, empirical studies indicate that surrogate predictions about such preferences are not very accurate. The focus of this article is the significance of surrogate accuracy in the context of research (...) that is not expected to benefit the research subject. We identify three morally relevant asymmetries between being enrolled and not being enrolled in such non-beneficial research, and conclude that when there is a non-negligible probability that surrogates’ predictions are wrong, it will generally be better to err on the side of not authorizing enrollment. (shrink)

The American Journal of Bioethics, Volume 12, Issue 10, Page 41-43, October 2012.

To what extent are people able to make predictions about other people’s preferences and values? We report two experiments that present a novel method assessing some of the basic processes in surrogate decision-making, namely surrogate-utility estimation. In each experiment participants formed dyads who were asked to assign utilities to health related items and commodity items, and to predict their partner’s utility judgments for the same items. In experiment one we showed that older adults in long-term relationships were able (...) to accurately predict their partner’s wishes. In experiment two we showed that younger adults who were relatively unfamiliar with one another were also able to predict other people’s wishes. Crucially we demonstrated that these judgments were accurate even after partialling out each participant’s own preferences indicating that in order to make surrogate utility estimations people engage in perspective-taking rather than simple anchoring and adjustment, suggesting that utility estimation is not the cause of inaccuracy in surrogate decision-making. The data and implications are discussed with respect to theories of surrogate decision-making. (shrink)

The increasing accuracy of algorithms to predict values and preferences raises the possibility that artificial intelligence technology will be able to serve as a surrogate decision-maker for incapacitated patients. Following Camillo Lamanna and Lauren Byrne, we call this technology the autonomy algorithm. Such an algorithm would mine medical research, health records, and social media data to predict patient treatment preferences. The possibility of developing the AA raises the ethical question of whether the AA or a relative ought to (...) serve as surrogate decision-maker in cases where the patient has not issued a medical power of attorney. We argue that in such cases, and against the standard practice of vesting familial surrogates with decision making authority, the AA should have sole decision-making authority. This is because the AA will likely be better at predicting what treatment option the patient would have chosen. It would also be better at avoiding bias and, therefore, choosing in a more patient-centered manner. Furthermore, we argue that these considerations override any moral weight of the patient’s special relationship with their relatives. (shrink)

As medical technology continues to improve, more people will live longer lives with multiple chronic illnesses with increasing cumulative debilitation, including cognitive dysfunction. Combined with the aging of society in most developed countries, an ever-growing number of patients will require surrogate decision-makers. While advance care planning by patients still capable of expressing their preferences about medical interventions and end-of-life care can improve the quality and accuracy of surrogate decisions, this is often not the case, not infrequently leading (...) to demands for ineffective, inappropriate and prolonged interventions. In 1980 LaFollette called for the licensing of prospective parents, basing his argument on the harm they can do to vulnerable people. In this paper, I apply his arguments to surrogate decision-makers for cognitively incapacitated patients, rhetorically suggesting that we require potential surrogates to qualify for this position by demonstrating their ability to make reasonable and rational decisions for others. I employ this theoretical approach to argue that the loose criteria by which we authorize surrogates’ generally unchallenged power should be reconsidered. (shrink)

The authority of surrogates—often close family members—to make treatment decisions for previously capacitated patients is said to come from their knowledge of the patient, which they are to draw on as they exercise substituted judgment on the patient’s behalf. However, proxy accuracy studies call this authority into question, hence the Patient Preference Predictor (PPP). We identify two problems with contemporary understandings of the surrogate’s role. The first is with the assumption that knowledge of the patient entails knowledge of (...) what the patient’s choice of treatment would be. The second is with the assumption that a good decision reproduces the content of that choice. If we are right, then the PPP, helpful though it might be in guiding surrogates’ decisions, nevertheless would hold them to the wrong standards and in that way could add to, rather than relieve, the stress they experience as they try to do their job. (shrink)

Incompetent patients need to have someone else make decisions on their behalf. According to the Substituted Judgment Standard the surrogate decision maker ought to make the decision that the patient would have made, had he or she been competent. Objections have been raised against this traditional construal of the standard on the grounds that it involves flawed counterfactual reasoning, and amendments have been suggested within the framework of possible worlds semantics. The paper shows that while this approach may circumvent (...) the alleged problem, the way it has so far been elaborated reflects insufficient understanding of the moral underpinnings of the idea of substituted judgment. Proper recognition of these moral underpinnings has potentially far-reaching implications for our normative assumptions about accuracy and objectivity in surrogate decision making. (shrink)

Substituted judgment assumes adequate knowledge of patient’s mind-set. However, surrogates’ prediction of individual healthcare decisions is often inadequate and may be based on shared background rather than patient-specific knowledge. It is not known whether surrogate’s prediction of patient’s integrative life-story narrative is better. Respondents in 90 family pairs rank-ordered 47 end-of-life statements as life-story narrative measure and completed instruments on decision-control preference and healthcare-outcomes acceptability as control measures, from respondent’s view and predicted pair’s view. They also scored their confidence (...) in surrogate’s decision-making and familiarity with pair’s healthcare-preferences. Life-story narratives’ prediction was examined by calculating correlation of statements’ ranking scores between respondent-personal and respondent-surrogate Q-sorts and between respondent-surrogate and pair-personal Q-sorts before and after controlling for correlation with respondent-personal scores, and by comparing percentages of respondent-surrogate Q-sorts co-loading with pair-personal vs. respondent-personal Q-sorts. Accuracy in predicting decision-control preference and healthcare-outcomes acceptability was determined by percent concordance. Results were compared among subgroups defined by intra-pair relationship, surrogate’s decision-making confidence, and healthcare-preferences familiarity. Mean age was 35.4 years, 69% were females, and 73 and 80% reported ≥ very good health and life-quality, respectively. Mean surrogate’s decision-making confidence score was 3.35 and 75% were ≥ familiar with pair’s healthcare-preferences. Mean projection, simulation, and adjusted-simulation correlations were 0.68, 0.42, and 0.26, respectively. Out of 180 respondent-surrogate Q-sorts, 24, 9, and 32% co-loaded with respondent-personal, pair-personal, or both Q-sorts, respectively. Accuracy in predicting decision-control preference and healthcare-outcomes acceptability was 47 and 52%, respectively. Surrogate’s decision-making confidence score correlated with adjusted-simulation’s correlation score. There were significant differences among the husband-wife, parent-child, and sibling-sibling subgroups in percentage of respondent-surrogate Q-sorts co-loading with pair-personal Q-sorts and percent agreement on healthcare-outcomes acceptability. Despite high self-reported surrogate’s decision-making confidence and healthcare-preferences familiarity, family surrogates are variably inadequate in simulating life-story narratives. Simulation accuracy may not follow the next-of-kin concept and is 38% based on shared background. (shrink)

BackgroundHealthcare providers have to make ethically complex clinical decisions which may be a source of stress. Researchers have recently introduced Artificial Intelligence (AI)-based applications to assist in clinical ethical decision-making. However, the use of such tools is controversial. This review aims to provide a comprehensive overview of the reasons given in the academic literature for and against their use.MethodsPubMed, Web of Science, Philpapers.org and Google Scholar were searched for all relevant publications. The resulting set of publications was title and abstract (...) screened according to defined inclusion and exclusion criteria, resulting in 44 papers whose full texts were analysed using the Kuckartz method of qualitative text analysis.ResultsArtificial Intelligence might increase patient autonomy by improving the accuracy of predictions and allowing patients to receive their preferred treatment. It is thought to increase beneficence by providing reliable information, thereby, supporting surrogate decision-making. Some authors fear that reducing ethical decision-making to statistical correlations may limit autonomy. Others argue that AI may not be able to replicate the process of ethical deliberation because it lacks human characteristics. Concerns have been raised about issues of justice, as AI may replicate existing biases in the decision-making process.ConclusionsThe prospective benefits of using AI in clinical ethical decision-making are manifold, but its development and use should be undertaken carefully to avoid ethical pitfalls. Several issues that are central to the discussion of Clinical Decision Support Systems, such as justice, explicability or human–machine interaction, have been neglected in the debate on AI for clinical ethics so far.Trial registrationThis review is registered at Open Science Framework (https://osf.io/wvcs9). (shrink)

Background: Research involving adults lacking mental capacity relies on the involvement of a proxy or surrogate, although this raises a number of ethical concerns. Empirical studies have examined attitudes towards proxy decision-making, proxies’ authority as decision-makers, decision accuracy, and other relevant factors. However, a comprehensive evidence-based account of proxy decision-making is lacking. This systematic review provides a synthesis of the empirical data reporting the ethical issues surrounding decisions made by research proxies, and the development of a conceptual framework (...) of proxy decision-making for research. Methods: A systematic review was conducted according to PRISMA guidelines. Databases including MEDLINE, EMBASE, and CINAHL were searched using a combination of search terms, and empirical data from eligible studies were retrieved. The review followed the framework synthesis approach to refine and develop a conceptual framework. Results: Thirty-four studies were included in the review. Two dimensions of proxy decision-making emerged. The ethical framing criteria of decision-making used by proxies: use of a substituted judgement, use of a best interests approach, combination of substituted judgement and best interests, and ‘something else’, and the active elements of proxy decision-making: ‘knowing the person’, patient-proxy relationship, accuracy of the decision, and balancing risks, benefits and burdens, and attitudes towards proxy decision-making. Interactions between the framing criteria and the elements of decision-making are complex and contextually-situated. Conclusions: The findings from this systematic review challenge the accepted reductionist account of proxy decision-making. Decision-making by research proxies is highly contextualized and multifactorial in nature. The choice of proxy and the relational features of decision-making play a fundamental role: both in providing the proxy’s authority as decision-maker, and guiding the decision-making process. The conceptual framework describes the relationship between the framing criteria used by the proxy, and the active elements of decision-making. Further work to develop, and empirically test the proposed framework is needed. (shrink)

The Patient Preference Predictor (PPP) proposal places a high priority on the accuracy of predicting patients’ preferences and finds the performance of surrogates inadequate. However, the quest to develop a highly accurate, individualized statistical model has significant obstacles. First, it will be impossible to validate the PPP beyond the limit imposed by 60%–80% reliability of people’s preferences for future medical decisions—a figure no better than the known average accuracy of surrogates. Second, evidence supports the view that a sizable (...) minority of persons may not even have preferences to predict. Third, many, perhaps most, people express their autonomy just as much by entrusting their loved ones to exercise their judgment than by desiring to specifically control future decisions. Surrogate decision making faces none of these issues and, in fact, it may be more efficient, accurate, and authoritative than is commonly assumed. (shrink)

This paper is divided in two parts. In part I, I argue against two attempts to naturalise the notion of scientific representation, by reducing it to isomorphism and similarity. I distinguish between the means and the constituents of representation, and I argue that isomorphism and similarity are common (although not universal) means of representation; but that they are not constituents of scientific representation. I look at the prospects for weakened versions of these theories, and I argue that only those that (...) abandon the aim to naturalise scientific representation are likely to be successful. In part II of the paper, I present a deflationary conception of scientific representation, which minimally characterises it by means of two necessary conditions: representation is essentially intentional and it has the capacity to allow surrogate reasoning and inference. I then defend this conception by showing that it successfully meets the objections and difficulties that make its competitors, such as isomorphism and similarity, untenable. In addition the inferential conception explains the success of various means of representation in their appropriate domains, and it sheds light on the truth and accuracy of scientific representations. (shrink)

ObjectiveTo determine whether gait and accelerometric features can predict disorientation events in young and older adults.MethodsCognitively healthy younger and older participants navigated on a treadmill through a virtual representation of the city of Rostock featured within the Gait Real-Time Analysis Interactive Lab system. We conducted Bayesian Poisson regression to determine the association of navigation performance with domain-specific cognitive functions. We determined associations of gait and accelerometric features with disorientation events in real-time data using Bayesian generalized mixed effect models. The (...) class='Hi'>accuracy of gait and accelerometric features to predict disorientation events was determined using cross-validated support vector machines and Hidden Markov models.ResultsBayesian analysis revealed strong evidence for the effect of gait and accelerometric features on disorientation. The evidence supported a relationship between executive functions but not visuospatial abilities and perspective taking with navigation performance. Despite these effects, the cross-validated percentage of correctly assigned instances of disorientation was only 72% in the SVM and 63% in the HMM analysis using gait and accelerometric features as predictors.ConclusionDisorientation is reflected in spatiotemporal gait features and the accelerometric signal as a potentially more easily accessible surrogate for gait features. At the same time, such measurements probably need to be enriched with other parameters to be sufficiently accurate for individual prediction of disorientation events. (shrink)

Background Artificial intelligence (AI) has revolutionized various healthcare domains, where AI algorithms sometimes even outperform human specialists. However, the field of clinical ethics has remained largely untouched by AI advances. This study explores the attitudes of anesthesiologists and internists towards the use of AI-driven preference prediction tools to support ethical decision-making for incapacitated patients. Methods A questionnaire was developed and pretested among medical students. The questionnaire was distributed to 200 German anesthesiologists and 200 German internists, thereby focusing on physicians who (...) often encounter patients lacking decision-making capacity. The questionnaire covered attitudes toward AI-driven preference prediction, availability and utilization of Clinical Ethics Support Services (CESS), and experiences with ethically challenging situations. Descriptive statistics and bivariate analysis was performed. Qualitative responses were analyzed using content analysis in a mixed inductive-deductive approach. Results Participants were predominantly male (69.3%), with ages ranging from 27 to 77. Most worked in nonacademic hospitals (82%). Physicians generally showed hesitance toward AI-driven preference prediction, citing concerns about the loss of individuality and humanity, lack of explicability in AI results, and doubts about AI’s ability to encompass the ethical deliberation process. In contrast, physicians had a more positive opinion of CESS. Availability of CESS varied, with 81.8% of participants reporting access. Among those without access, 91.8% expressed a desire for CESS. Physicians' reluctance toward AI-driven preference prediction aligns with concerns about transparency, individuality, and human-machine interaction. While AI could enhance the accuracy of predictions and reduce surrogate burden, concerns about potential biases, de-humanisation, and lack of explicability persist. Conclusions German physicians frequently encountering incapacitated patients exhibit hesitance toward AI-driven preference prediction but hold a higher esteem for CESS. Addressing concerns about individuality, explicability, and human-machine roles may facilitate the acceptance of AI in clinical ethics. Further research into patient and surrogate perspectives is needed to ensure AI aligns with patient preferences and values in complex medical decisions. (shrink)

PurposeThe information technology related ethical issues will only increase in frequency and complexity with the increasing diffusion of IT in economies and societies. The purpose of this paper is to explore Egyptian students' attitudes towards the information ethics issues of privacy, access, property, and accuracy, and it evaluates the possible impact of a number of personal characteristics on such attitudes.Design/methodology/approachThis research utilized a cross‐sectional sample and data set to test five hypotheses. It adopted an instrument to collect the respondents' (...) background information and assess their attitudes towards the information ethics issues of privacy, property, accuracy, and access. Egyptian business students at Alexandria University were asked to participate in the survey. A total of 305 responses were collected and analyzed.FindingsThe analysis revealed that students are sensitive to the ethicality of information privacy, information accuracy, and information access. However, students are insensitive to the ethicality of property right. In addition, years of education have a main effect on students' attitudes towards property, and gender and age have an interaction effect on students' attitudes towards access.Research limitations/implicationsThe findings of this research are based on a cross‐sectional data set collected from a sample of business students at a public university. Students, however, may make poor surrogates for business or IT professionals. Future similar research designs that employ large samples from Egyptian working professionals and students in other private and public universities are needed to verify the findings of this research.Practical implicationsThe findings suggest that the investigated university as well as the other similar Egyptian universities should consider integrating ethics education into their curricula. Teaching information ethics, especially from an Islamic perspective, is expected to positively influence students' information ethical attitudes. The enforcement of the existing property right protection laws should also curb software piracy in the Egyptian market.Originality/valueIt is vital to expand the ethical research currently being performed in IT in order to help bridge the gap between behavior and IT. The findings of this research extend the understanding of students' attitudes towards the information ethics issues in Egyptian culture and contribute to the growing body of knowledge on global information ethics. (shrink)

Classic conceptions of model simplicity for machine learning are mainly based on the analysis of the structure of the model. Bayesian, Frequentist, information theoretic and expressive power concepts are the best known of them, which are reviewed in this work, along with their underlying assumptions and weaknesses. These approaches were developed before the advent of the Big Data deluge, which has overturned the importance of structural simplicity. The computational simplicity concept is presented, and it is argued that it is more (...) encompassing and closer to actual machine learning practices than the classic ones. In order to process the huge datasets which are commonplace nowadays, the computational complexity of the learning algorithm is the decisive factor to assess the viability of a machine learning strategy, while the classic accounts of simplicity play a surrogate role. Some of the desirable features of computational simplicity derive from its reliance on the learning system concept, which integrates key aspects of machine learning that are ignored by the classic concepts. Moreover, computational simplicity is directly associated with energy efficiency. In particular, the question of whether the maximum possibly achievable predictive accuracy should be attained, no matter the economic cost of the associated energy consumption pattern, is considered. (shrink)

Advance care planning allows patients to articulate preferences for their medical treatment, lifestyle, and surrogate decision-makers in order to anticipate and mitigate their potential loss of decision-making capacity. Written advance directives are often emphasized in this regard. While these directives contain important information, there are several barriers to consider: veracity and accuracy of surrogate decision-makers in making choices consistent with the substituted judgement standard, state-to-state variability in regulations, literacy issues, lack of access to legal resources, lack of (...) understanding of medical options, and cultural disparities. Given these issues, it is vital to increase the use of patient and healthcare provider conversations as an advance care planning tool and to increase integration of such discourse into advance care planning policy as adjuncts and complements to written advance directives. This paper reviews current legislation about written advance directives and dissects how documentation of spoken interactions might be integrated and considered. We discuss specific institutional policy changes required to facilitate implementation. Finally, we explore the ethical issues surrounding the increased usage and recognition of clinician–patient conversations in advance care planning. (shrink)

Research involving adults who lack capacity to consent relies on proxy (or surrogate) decision making. Proxy decisions about participation are ethically complex, with a disparity between normative accounts and empirical evidence. Concerns about the accuracy of proxies’ decisions arise, in part, from the lack of an ethical framework which takes account of the complex and morally pluralistic world in which proxy decisions are situated. This qualitative study explored the experiences of family members who have acted as a research (...) proxy in order to develop an understanding of the ethical concepts involved, and the interactions between those concepts. Proxies described a complex process of respecting the wishes and preferences of the person they represented, whist integrating preferences with what they viewed as being in the interests of the person. They aimed to make a decision that was ‘best’ for the person and protected them from harm; they also aimed to make the ‘right’ decision, viewed as being authentic to the person’s values and life. Decisions were underpinned by the relationship between the person and their proxy, in which both trust and trustworthiness were key. Proxies’ decisions, based both on respect for the person and the need to protect their interests, arose out of their dual role as both proxy and carer. The findings raise questions about accounts which rely on existing normative assumptions with a focus on accuracy and discrepancy, and which fail to take account of the requirement for proxies to make authentic decisions that arise out of their caring obligations. (shrink)

BackgroundSevere brain injury is a leading cause of death and disability. Diagnosis and prognostication are difficult, and errors occur often. Novel neuroimaging methods can improve diagnostic and prognostic accuracy, especially in patients with prolonged disorders of consciousness (PDoC). Yet it is currently unknown how family caregivers understand this information, raising ethical concerns that disclosure of neuroimaging results could result in therapeutic misconception or false hope.MethodsTo examine these ethical concerns, we conducted semi-structured interviews with caregivers of patients with PDoC who (...) were enrolled in a concurrent neuroimaging research program designed to detect covert consciousness following severe brain injury. Caregivers held surrogate decision-making status for a patient. Interviews were conducted at two time points for each caregiver. The first interview occurred before the disclosure of neuroimaging results. The second occurred after disclosure. Descriptive analysis was applied to the data of four interview topics: (1) expectations for neuroimaging; (2) reactions to evidence of preserved cognition; (3) reactions to null results; and (4) understanding of the results and study.ResultsTwelve caregivers participated in the study; two caregivers shared surrogate decision-making status for one patient with PDoC. Twenty-one interviews were completed; one caregiver declined to participate in the post-disclosure interview. Three patients with PDoC associated with the study displayed evidence of covert consciousness. Overall, caregivers understood the neuroimaging research and results. Caregivers who received results of covert consciousness were generally pleased. However, there was some variation in expectations and reactions to these data and null results.ConclusionThis study, for the first time, reveals caregiver expectations for and reactions to neuroimaging evidence of covert consciousness in patients with PDoC. Caregivers understood the neuroimaging research and results, casting doubt on speculative ethical concerns regarding therapeutic misconception and false hope. However, disclosure of neuroimaging result could be improved. Pre-disclosure consultations might assist professionals in shaping caregiver expectations. Standardization of disclosure might also improve comprehension of the results. (shrink)

When a patient lacks sufficient capacity to make a certain treatment decision, whether because of deficits in their ability to make a judgement that reflects their values or to make a decision that reflects their judgement or both, the decision must be made by a surrogate. Often the best way to respect the patient’s autonomy, in such cases, is for the surrogate to make a ‘substituted’ judgement on behalf of the patient, which is the decision that best reflects (...) the patient’s values and identity-infused beliefs as they were when the patient last possessed capacity. It is by now well-known that there is troubling evidence that surrogates do only slightly better than chance at making accurate substituted judgements. The use of a patient preference predictor, an algorithm that predicts patient preferences based on characteristics like the patient’s age, gender, socioeconomic status and education level, could help. Rid and Wendler have done important work making a moral case for using the PPP.1 If it were shown to enhance accuracy, it is not at all obvious what objections there could be to its use. Yet several subtle criticisms of the PPP have emerged in the literature. In their feature article, Jardas, Wasserman and Wendler select six of the most prominent objections to the PPP in the literature and defend the PPP against them.2 Along the way they make significant contributions to broader issues concerning the proper uses of statistical evidence and limits on the kinds of preferences there can be reasons of autonomy to respect. Since I found the authors’ answers to the final two objections—that the PPP relies on naked statistical evidence and that it uses non-endorsed reasons—to be especially interesting and provocative, I will examine those answers and raise a few questions about …. (shrink)

In the philosophy of perception, representationalism is the view that all phenomenological differences among mental states are representational differences, in other words, differences in content. In this paper I defend an alternative view which I call external sortalism, inspired by traditional adverbialism, and according to which experiences are not essentially representational. The central idea is that the external world serves as a model for sorting, conceptualizing, and reasoning surrogatively about perceptual experience. On external sortalism, contents are construed as a kind (...) of gloss on experiences themselves. We can retain what is attractive about representationalism, namely, that perceptual experiences can be evaluated for accuracy, without problematic commitment to the idea that they bear a substantive, representational relation to external objects and properties and that this relation determines the phenomenal character of experience. (shrink)

This paper is divided in two parts. In part I, I argue against two attempts to naturalise the notion of scientific representation, by reducing it to isomorphism and similarity. I distinguish between the means and the constituents of representation, and I argue that isomorphism and similarity are common means of representation; but that they are not constituents of scientific representation. I look at the prospects for weakened versions of these theories, and I argue that only those that abandon the aim (...) to naturalise scientific representation are likely to be successful. In part II of the paper, I present a deflationary conception of scientific representation, which minimally characterises it by means of two necessary conditions: representation is essentially intentional and it has the capacity to allow surrogate reasoning and inference. I then defend this conception by showing that it successfully meets the objections and difficulties that make its competitors, such as isomorphism and similarity, untenable. In addition the inferential conception explains the success of various means of representation in their appropriate domains, and it sheds light on the truth and accuracy of scientific representations. (shrink)

Clinicians are often called upon to assess the capacity of a patient to appoint a healthcare agent. Although a consensus has emerged that the standard for such assessment should differ from that for capacity to render specific healthcare decisions, exactly what standard should be employed remains unsettled and differs by jurisdiction. The current models in use draw heavily upon analogous methods used in clinical assessment, such as the “four skills” approach. This essay proposes an alternative model that relies upon categorization (...) and sliding scale risk assessment that can be used to determine to how much scrutiny the proxy appointment should be subjected and how much certainty of accuracy should be required in order to maximize the patient’s autonomy and ensure that her underlying wishes are met. (shrink)

Richard Pettigrew offers an extended investigation into a particular way of justifying the rational principles that govern our credences. The main principles that he justifies are the central tenets of Bayesian epistemology, though many other related principles are discussed along the way. Pettigrew looks to decision theory in order to ground his argument. He treats an agent's credences as if they were a choice she makes between different options, gives an account of the purely epistemic utility enjoyed by different sets (...) of credences, and then appeals to the principles of decision theory to show that, when epistemic utility is measured in this way, the credences that violate the principles listed above are ruled out as irrational. The account of epistemic utility set out here is the veritist's: the sole fundamental source of epistemic utility for credences is their accuracy. Thus, Pettigrew conducts an investigation in the version of epistemic utility theory known as accuracy-first epistemology. (shrink)

A diagnosis of fetal abnormality presents parents with a difficult – even tragic – moral dilemma. Where this diagnosis is made in the context of surrogate motherhood there is an added difficulty, namely that it is not obvious who should be involved in making decisions about abortion, for the person who would normally have the right to decide – the pregnant woman – does not intend to raise the child. This raises the question: To what extent, if at all, (...) should the intended parents be involved in decision-making? In commercial surrogacy it is thought that as part of the contractual agreement the intended parents acquire the right to make this decision. By contrast, in altruistic surrogacy the pregnant woman retains the right to make these decisions, but the intended parents are free to decide not to adopt the child. We argue that both these strategies are morally unsound, and that the problems encountered serve to highlight more fundamental defects within the commercial and altruistic models, as well as in the legal and institutional frameworks that support them. We argue in favour of the professional model, which acknowledges the rights and responsibilities of both parties and provides a legal and institutional framework that supports good decision-making. In particular, the professional model acknowledges the surrogate's right to decide whether to undergo an abortion, and the intended parents' obligation to accept legal custody of the child. While not solving all the problems that arise in surrogacy, the model provides a framework that supports good decision-making. (shrink)

Two different programmes are in the business of explicating accuracy—the truthlikeness programme and the epistemic utility programme. Both assume that truth is the goal of inquiry, and that among inquiries that fall short of realizing the goal some get closer to it than others. Truthlikeness theorists have been searching for an account of the accuracy of propositions. Epistemic utility theorists have been searching for an account of the accuracy of credal states. Both assume we can make cognitive (...) progress in an inquiry even while falling short of the target. I show that the prospects for combining these two programmes are bleak. A core accuracy principle, proximity, that is universally embraced within the truthlikeness programme turns out to be incompatible with a central principle within the epistemic utility programme, namely propriety. 1Truthlikeness and Epistemic Utility 2Inquiries 3Accuracy for Propositions 4Proximity 5Accuracy for Credal States 6Propriety 7Proximity for Credal States 8Extensionality 9Admissible Weightings 10Propriety Violates Proximity 11Possible Responses 11.1Retreat to convexity 11.2Reject boundedness 11.3Reject additivity 12The Upshot. (shrink)

In Accuracy and the Laws of Credence Richard Pettigrew assumes a particular view of belief, which states that people don't have any other doxastic states besides credences. This is in tension with the popular position that people have both credences and outright beliefs. Pettigrew claims that such a dual view of belief is incompatible with the accuracy-first approach. I argue in this paper that it is not. This is good news for Pettigrew, since it broadens the appeal of (...) his framework. (shrink)

Surrogacy has long been discussed in reproductive medicine. In the Czech Republic, surrogacy is not legally regulated. Because of this legal vacuum, there are no official procedures or organizations that openly deal with surrogacy. Potential surrogate mothers and applicants do not have many options for obtaining or sharing information. The only source is the Internet. Online forums are a popular tool for gaining information and contacts regarding surrogacy. The goal of this research was to use qualitative research methods to (...) survey the most searched and discussed topics on Czech online discussion forum websites. We used discussions that we found on www.emimino.cz between 2009 and 2019. This article analyses the comments of the Internet forum discussants/participants, their involvement, knowledge of surrogacy, the information sought and their opinions. In particular, the participants discussed where to find a surrogate mother or how to become one. This article attempts to outline the discussions ordinary people have about surrogacy outside official expert forums. (shrink)

We argue that subjective Bayesians face a dilemma: they must offend against the spirit of their permissivism about rational credence or reject the principle that one should avoid accuracy dominance.

Given the standard dominance conditions used in accuracy theories for outright belief, epistemologists must invoke epistemic conservatism if they are to avoid licensing belief in both a proposition and its negation. Florian Steinberger (2019) charges the committed accuracy monist — the theorist who thinks that the only epistemic value is accuracy — with being unable to motivate this conservatism. I show that the accuracy monist can avoid Steinberger’s charge by moving to a subtly different set of (...) dominance conditions. Having done so, they no longer need to invoke conservatism. I briefly explore some ramifications of this shift. (shrink)

The computer revolution has had an enormous effect on all aspects of the practice of medicine, yet little thought has been given to the role of social media in identifying treatment choices for incompetent patients. We are currently living in the ?Internet age? and many people have integrated social media into all aspects of their lives. As use becomes more prevalent, and as users age, social media are more likely to be viewed as a source of information regarding medical care (...) preferences. This article explores the ethical and legal issues raised by the use of social media in surrogate decision making. (shrink)

In “A Nonpragmatic Vindication of Probabilism”, Jim Joyce argues that our credences should obey the axioms of the probability calculus by showing that, if they don't, there will be alternative credences that are guaranteed to be more accurate than ours. But it seems that accuracy is not the only goal of credences: there is also the goal of matching one's credences to one's evidence. I will consider four ways in which we might make this latter goal precise: on the (...) first, the norms to which this goal gives rise act as ‘side constraints’ on our choice of credences; on the second, matching credences to evidence is a goal that is weighed against accuracy to give the overall cognitive value of credences; on the third, as on the second, proximity to the evidential goal and proximity to the goal of accuracy are both sources of value, but this time they are incomparable; on the fourth, the evidential goal is not an independent goal at all, but rather a byproduct of the goal of accuracy. All but the fourth way of making the evidential goal precise are pluralist about credal virtue: there is the virtue of being accurate and there is the virtue of matching the evidence and neither reduces to the other. The fourth way is monist about credal virtue: there is just the virtue of being accurate. The pluralist positions lead to problems for Joyce's argument; the monist position avoids them. I endorse the latter. (shrink)

Credences, unlike full beliefs, can’t be true or false. So what makes credences more or less accurate? This chapter offers a new answer to this question: credences are accurate insofar as they license true educated guesses, and less accurate insofar as they license false educated guesses. This account is compatible with immodesty; : a rational agent will regard her own credences to be best for the purposes of making true educated guesses. The guessing account can also be used to justify (...) certain coherence constraints on rational credence, such as probabilism. The chapter concludes by discussing some advantages of the guessing account over rival accounts of accuracy. (shrink)

This chapter contains sections titled: Moral Arguments against and for Surrogate Motherhood Legal Remedies for Surrogate Motherhood Perspectives of Health‐care Practitioners on Surrogate Motherhood Perspectives of Society on Surrogate Motherhood Conclusion.

Recently, several epistemologists have defended an attractive principle of epistemic rationality, which we shall call Ur-Prior Conditionalization. In this essay, I ask whether we can justify this principle by appealing to the epistemic goal of accuracy. I argue that any such accuracy-based argument will be in tension with Evidence Externalism, i.e., the view that agent's evidence may entail non-trivial propositions about the external world. This is because any such argument will crucially require the assumption that, independently of all (...) empirical evidence, it is rational for an agent to be certain that her evidence will always include truths, and that she will always have perfect introspective access to her own evidence. This assumption is in tension with Evidence Externalism. I go on to suggest that even if we don't accept Evidence Externalism, the prospects for any accuracy-based justification for Ur-Prior Conditionalization are bleak. (shrink)

Philosophers such as Dan Brock believe that surrogates who make health care decisions on behalf of previously competent patients, in the absence of an advance directive, should make these decisions based upon a substituted judgment principle. Brock favours substituted judgment over a best interests standard. However, Edward Wierenga claims that the substituted judgment principle ought to be abandoned in favour of a best interests standard, because of an inherent problem with the substituted judgment principle. Wierenga's version of the substituted judgment (...) principle and his counterexample to the principle's successful interpretation of valid surrogate consent is presented. A new version of what is meant by the substituted judgment principle is advanced. The new version is not beset with the problems Wierenga initially ascribed to the substituted judgment principle. (shrink)

Expected accuracy arguments have been used by several authors (Leitgeb and Pettigrew, and Greaves and Wallace) to support the diachronic principle of conditionalization, in updates where there are only finitely many possible propositions to learn. I show that these arguments can be extended to infinite cases, giving an argument not just for conditionalization but also for principles known as ‘conglomerability’ and ‘reflection’. This shows that the expected accuracy approach is stronger than has been realized. I also argue that (...) we should be careful to distinguish diachronic update principles from related synchronic principles for conditional probability. (shrink)

Can we extend accuracy-based epistemic utility theory to imprecise credences? There's no obvious way of proceeding: some stipulations will be necessary for either (i) the notion of accuracy or (ii) the epistemic decision rule. With some prima facie plausible stipulations, imprecise credences are always required. With others, they’re always impermissible. Care is needed to reach the familiar evidential view of imprecise credence: that whether precise or imprecise credences are required depends on the character of one's evidence. I propose (...) an epistemic utility theoretic defense of a common view about how evidence places demands on imprecise credence: that your spread of credence should cover the range of chance hypotheses left open by your evidence. I argue that objections to the form of epistemic utility theoretic argument that I use will extend to the standard motivation for epistemically mandatory imprecise credences. (shrink)

Because it is often argued that surrogacy should not be treated as contractual, the question arises in which terms this practice might then be couched. In this article, I argue that a phenomenology of surrogacy centering on the notion of trust provides a description that is illuminating from the moral point of view. My thesis is that surrogacy establishes a complex and extended reproductive unit––the “surrogacy triad” consisting of the surrogate mother, the child, and the intending parents––whose constituents are (...) bound together by mutual trustful commitments. Even though a trust-based approach does not provide an ultimate answer to whether surrogacy should be sanctioned or prohibited, it allows for at least some practical suggestions. In particular, I will argue that, under certain conditions, surrogacy is tenable within familial or other significant relationships, and I will stress the necessity of acknowledging the new relationships and moral commitments that result from this practice. (shrink)

Accuracy‐first epistemology is an approach to formal epistemology which takes accuracy to be a measure of epistemic utility and attempts to vindicate norms of epistemic rationality by showing how conformity with them is beneficial. If accuracy‐first epistemology can actually vindicate any epistemic norms, it must adopt a plausible account of epistemic value. Any such account must avoid the epistemic version of Derek Parfit's “repugnant conclusion.” I argue that the only plausible way of doing so is to say (...) that accurate credences in certain propositions have no, or almost no, epistemic value. I prove that this is incompatible with standard accuracy‐first arguments for probabilism, and argue that there is no way for accuracy‐first epistemology to show that all credences of all agents should be coherent. (shrink)

I argue that bounded agents face a systematic accuracy-coherence tradeoff in cognition. Agents must choose whether to structure their cognition in ways likely to promote coherence or accuracy. I illustrate the accuracy-coherence tradeoff by showing how it arises out of at least two component tradeoffs: a coherence-complexity tradeoff between coherence and cognitive complexity, and a coherence-variety tradeoff between coherence and strategic variety. These tradeoffs give rise to an accuracy-coherence tradeoff because privileging coherence over complexity or strategic (...) variety often leads to a corresponding reduction in accuracy. I conclude with a discussion of two normative consequences for the study of bounded rationality: the importance of procedural rationality and the role of coherence in theories of bounded rationality. (shrink)

In the natural and social sciences, it is common to use toy models—extremely simple and highly idealized representations—to understand complex phenomena. Some of the simple surrogate models used to understand opaque machine learning (ML) models, such as rule lists and sparse decision trees, bear some resemblance to scientific toy models. They allow non-experts to understand how an opaque ML model works globally via a much simpler model that highlights the most relevant features of the input space and their effect (...) on the output. The obvious difference is that the common target of a toy and a full-scale model in the sciences is some phenomenon in the world, while the target of a surrogate model is another model. This essential difference makes toy surrogate models (TSMs) a new object of study for theories of understanding, one that is not easily accommodated under current analyses. This paper provides an account of what it means to understand an opaque ML model globally with the aid of such simple models. (shrink)

Chapter 19 of the Children’s Act No. 32 of 2005 regulates the practice of surrogate motherhood in South Africa and provides legal certainty regarding the rights of the children born as a result of surrogacy, including the rights of the different parties involved. Despite the clarity regarding the legal consequences of human reproduction by artificial fertilisation of women acting as surrogate mothers, some legal gaps and inconsistencies regarding certain medical and ethico-legal issues remain. The purpose of this article (...) is to critically examine selected provisions whose implementation is hampered by a lack of detail or clarity, compromising compliance by the different parties to the surrogate motherhood agreement. The article concludes with recommendations on how some of these issues may be addressed to provide for legal certainty and transparency. (shrink)

Accuracy arguments for the core tenets of Bayesian epistemology differ mainly in the conditions they place on the legitimate ways of measuring the inaccuracy of our credences. The best existing arguments rely on three conditions: Continuity, Additivity, and Strict Propriety. In this paper, I show how to strengthen the arguments based on these conditions by showing that the central mathematical theorem on which each depends goes through without assuming Additivity.

Probabilism says an agent is rational only if her credences are probabilistic. This paper is concerned with the so-called Accuracy Dominance Argument for Probabilism. This argument begins with the claim that the sole fundamental source of epistemic value for a credence is its accuracy. It then shows that, however we measure accuracy, any non-probabilistic credences are accuracy-dominated: that is, there are alternative credences that are guaranteed to be more accurate than them. It follows that non-probabilistic credences (...) are irrational. In this paper, I identify and explore a lacuna in this argument. I grant that, if the only doxastic attitudes are credal attitudes, the argument succeeds. But many philosophers say that, alongside credences, there are other doxastic attitudes, such as full beliefs. What's more, those philosophers typically claim, these other doxastic attitudes are closely connected to credences, either as a matter of necessity or normatively. Now, since full beliefs are also doxastic attitudes, it seems that, like credences, the sole source of epistemic value for them is their accuracy. Thus, if we wish to measure the epistemic value of an agent's total doxastic state, we must include not only the accuracy of her credences, but also the accuracy of her full beliefs. However, if this is the case, there is a problem for the Accuracy Dominance Argument for Probabilism. For all the argument says, there might be non-probabilistic credences such that there is no total doxastic state that accuracy-dominates the total doxastic state to which those credences belong. (shrink)

Unrepresented patients are individuals who lack decision makingcapacity and have no family or friends to make medical decisions for them. This population is growing in number in the United States, particularly within emergency and intensive care settings. While some bioethical discussion has taken place in response to the question of who ought to make decisions for these patients, the issue of how surrogate medical decisions ought to be made for this population remains unexplored. In this paper, we argue that (...) standard applications of surrogate decision making principles in health care are not well suited to many unrepresented patients with long-term mental health diagnosis. We argue that when applied to this population, the substituted judgment standard, designed to preserve patient preferences and values, may lead to the exclusion of their preferences. We argue further that the application of the best interest standard runs the risk of leading to harmful cases of overtreatment or undertreatment. We offer an alternative interpretation of the best interest principle that is better able to promote the well-being of unrepresented patients, especially for those who lack capacity because of mental disorders. This alternative is based on the practices and principles of harm reduction and includes three components: emphasis on considering the expressed preferences of unrepresented patients, a focus on reducing harm as well as the delivery of clinical benefits, and a recognition of the importance of promoting trust. (shrink)

In Speaking for the Dying: Life‐and‐Death Decisions in Intensive Care, Susan Shapiro attempts to penetrate and organize the chaotic communications between physicians and family members who are making medical decisions for people who have lost the capacity to make their own medical decisions. The work is based on observations undertaken by Shapiro and a coresearcher of one thousand encounters between physicians and the family members of two hundred patients too sick to participate. Their ethnographic work, which is both traditional and (...) innovative, leads to stunning findings. They reveal an inadequacy among surrogates that is undeniable, vast, and potentially tragic—if measured by the questionable standard of adhering to the patient's preferences. Further confirming research would be helpful, but what Shapiro has recognized already should shake the foundations of advance care planning. (shrink)