: In spite of recent political setbacks for the movement toward universal health insurance, considerable support remains for the idea. Among those supporting such plans, most assume that a universal insurance system, especially if it is a single-payer system, would offer a single list of basic covered services. This paper challenges that assumption and argues for the availability of multiple lists of services in a universal insurance system. The claim is made that multiple lists will be both (...) more efficient and more fair. Any single list will fund some services that are quite attractive to some people, but only marginally attractive to others. Thus any single-list plan will fund some services that produce only marginal benefit for the resources used. Moreover, since some people will hold values quite compatible with the single list and others will hold values leading to preferences for unfunded services, some people will get much more benefit from any single list than other people will. Fairness and efficiency require providing an entitlement to universal access to health insurance that could be purchased by typical consumers for a fixed price of perhaps $3500. By permitting everyone to pick their preferred list of services available at that price, each person will efficiently use his or her entitlement while getting more equal opportunity for benefits. (shrink)

Common sense and empirical evidence suggest that single-payer health insurance, combined with competitive private delivery, would be the most cost-effective way of achieving the major, widely accepted goals of health care reform. Among the current presidential candidates, Kucinich and Gravel have the most promising reform proposals, with Edwards’s and Obama’s as fall-backs.

: Although nothing could be less fashionable today than talk of comprehensive health care reform, the major problems of American health care have not gone away. Only a radical change in the way the U.S. finances health care--specifically, a single-payer system--will permit the achievement of universal coverage while keeping costs reasonably under control. Evidence from other countries, especially Canada, suggests the promise of this approach. In defending the single-payer approach, the author identifies several political and cultural (...) factors that make it difficult for Americans to obtain a clear view of this option. Finally, the author argues that much discussion of rationing is vitiated by bracketing more systemic questions to which the issue of rationing is inextricably linked. (shrink)

Abstract“Comprehensive Healthcare for America” is a largely single-payer reform proposal that, by applying the insights of behavioral economics, may be able to rally patients and clinicians sufficiently to overcome the opposition of politicians and vested interests to providing all Americans with less complicated and less costly access to needed healthcare.

Much has been written about medicine and the market in recent years. This book is the first to include an assessment of market influence in both developed and developing countries, and among the very few that have tried to evaluate the actual health and economic impact of market theory and practices in a wide range of national settings. Tracing the path that market practices have taken from Adam Smith in the eighteenth century into twenty-first-century health care, Daniel Callahan and Angela (...) A. Wasunna add a fresh dimension: they compare the different approaches taken in the market debate by health care economists, conservative market advocates, and liberal supporters of single-payer or government-regulated systems. In addition to laying out the market-versus-government struggle around the world -- from Canada and the United States to Western Europe, Latin America, and many African and Asian countries -- they assess the leading market practices, such as competition, physician incentives, and co-payments, for their economic and health efficacy to determine whether they work as advertised. This timely and necessary book engages new dimensions of a development that has urgent consequences for the delivery of health care worldwide. (shrink)

There are four basic models for health care systems: the private market insurance model, the national single-payer model, the national health service model, and the social insurance model. The social justice debate over health care usually focuses on the comparative efficiency and quality of competitive private market insurance and the universal coverage and equity of national health care systems. It is a mistake, however, to think that a universal right to health care services requires a single-payer, (...) government-run, national health care system. The social insurance model of Germany, France, Japan, and many other countries, deserves more attention, as it incorporates the strengths of both market models and national health care models. (shrink)

It is not too early to suggest that the attempts to place medical care in private hands (through group insurance arrangements) has not fulfilled its promise—or better, the promises that were made for it. Yet history has not been kind to plans to make government the single payer, and the laudable progress in medical technology has placed high-technology medical care beyond the reach of most privatebudgets. In this paper I suggest that the major problem of the U.S. health (...) care system as presently conceived is a failure of legitimacy,and I put forward a proposal that purports to solve that problem. The proposal is to localize health care, on the model of a public school system, on the argument that such localization will answer most of the questions of legitimacy at the core of the private insurance imbroglio, provide a brake for medical costs, while preserving our ability to take advantage of the most advanced medical interventions. I present some initial arguments for the proposal, but await its proof in the dialogue emerging as the present insurance system collapses. (shrink)

What balance of government and private institution activity might stand a reasonable chance of achieving universal access to basic health care in the United States? David De Grazia makes a strong case that single-payer national health insurance with managed competition in delivery is morally the preferred structure for universal access: it best achieves the combination of universal access, cost control, freedom of patient choice, and quality of care. If we account for the realities of American political and moral (...) culture, however, is this the model for reform that people seriously committed to actually achieving universal access should be pushing? (shrink)

American health care reformers face a number of ethical issues, including familiar debates over the merits of a single-payer system and publicly provided universal health insurance. No matter how these debates are resolved, a further ethical question must be addressed. Both universal coverage and a single-payer system are compatible with permitting some patients to pay more for faster, better, or more health care choices. Should the United States continue to have a two-tier health care system in (...) which wealth grants some patients access to medical services that others with the same needs cannot obtain? Critical evaluation of both principled objections to inequalities and practical objections to anticipated social and medical consequences of a two-tier health care system are needed. (shrink)

We live in the era of Facebook, Fitbit, and Skype. As such, it would be unreasonable to expect that the healthcare industry would not see the same kind of globalization as do our social spheres and consumer activities. Indeed, the explosion of information technology, the ease of transcontinental travel, and the emergence of a more globally aware citizenry allows for scientific collaboration that has had many positive effects on global health. However, the economic and structural disparities between systems of healthcare (...) delivery in the industrialized world and parts of the developing world have created a monster in the form of an international medical tourism industry that endangers the health and safety of citizens of the host country as well as visiting patients. Not only does the practice of medical tourism pose a practical danger to those in direct contact with the industry, but it brings up troubling philosophical problems centering on national responsibility and the commodification of healthcare, among other important issues. In the United States, the driving force behind international medical tourism is the exorbitant cost of healthcare, particularly for the uninsured but also for the underinsured and those who experience catastrophic medical expenses from chronic illness or sudden health crises. Not only have individuals begun to look outside the U.S. for surgical procedures and other expensive therapies, but employers have begun to toy with the idea of outsourcing the medical care of the employees they insure in order to cut costs. In other industrialized nations, the issues that underpin international medical tourism are related to healthcare rationing and reflect different shortcomings in the delivery of healthcare in those nations, such as the United Kingdom and Canada, that have single-payer systems. Yet the regulatory and philosophical implications for both patients and hosts of international healthcare are largely the same. The challenge of regulating international trade in medical care is obvious and becomes particularly acute when there are insurers and employers involved. Complicating matters further, medical care that takes place outside the country of origin of the patient is often brokered by “medical concierge services,” which, though quick to claim indemnity from any harm arising from substandard or inappropriate medical care, cannot be divorced from responsibility for the health outcomes of their clients. Agreements hashed out between concierge services and patients specify that any remedy for harm stemming from their medical care must be pursued within the confines of the law of the host country, but the practical implications of this are troublesome. How can a foreign patient—often without either linguistic or cultural competency in the host country—be expected to navigate the complexity of a foreign legal system, particularly one that may be far less developed than his home country? Furthermore, if insurance companies and employers are involved with such care, who pays for an adverse result or determines responsibility for harm that may befall the patient? Under which countries’ laws? If a patient travels to Singapore for sexual reassignment surgery or a cardiac valve repair, returns to the States and suffers complications, who pays for the restoration of her health? Beyond legal standards and judicial remedies for harm to patients seeking care on the international market, there is the question of what ethical standards and norms apply to such patients. What effect does it have on American patients, for example, to receive care within a system that does not emphasize autonomy and informed consent the way they are used to? Why should foreign physicians care about the cultural mores of their patients’ country of origin? Can they be expected to grasp cultural differences between American, Canadian, and British patients? The medical concierge might respond, “Well, buyer beware!” This is unreasonable: It is nearly impossible for any patient to accurately assess the various options, risks and benefits that go with a particular medical treatment, much less the patient who is attempting to do so on the international market. And the crass invocation of the doctrine of caveat emptor betrays a view of healthcare as a commodity that is naive and inappropriate. Paramount in my mind, however, are the practical implications for the care of the citizens of developing nations that host international patients and the broader philosophical issue of what the goals of the medical profession as a whole and each country’s individual healthcare system should be. While I understand the argument that international medical tourism creates great economic gains for developing nations, which can then be channeled toward the care of their citizenry as a whole, there is much reason to doubt that this “trickle-down” model of economics provides real benefits for underserved, whether in healthcare or other arenas. What is more likely is that, while lucrative international “medi-cities” may keep bright doctors in their home countries, it is also likely to lure them away from the institutions that serve the lion’s share of their countrymen. With the concentration of talented native doctors in private hospitals that serve citizens of the developed world, the population at large is left to obtain care at institutions that suffer “brain drain” from the flight of talented local staff to more prestigious, often “brand name,” institutions that give them more Western-like salaries while allowing them to practice in their countries of origin. The very fact that citizens of the wealthiest nations in the world are forced to go abroad for life-saving care speaks to an abdication of national responsibility on the part of their home countries. The provision of health care is one of the principal responsibilities of any nation and it is unacceptable that a nation with the strength and wealth of the United States would take advantage of the weaker political and economic situations of developing nations in order to shirk its responsibility to its fellow citizens. If we take care of our countrymen and take pride in an equitable system of healthcare delivery, there will be no need to shrug our shoulders and say “Buyer beware” to the patient who heads to the Philippines for heart surgery. (shrink)

The recent history of the Canadian healthcare system has been increasingly one of shortages. There are delays for services that impose risk and hardship, disparities between the accessibility of healthcare for rural versus urban populations, and a lack of adequate coverage for or access to prescription drugs, diagnostic services, and homecare. Add to these problems shortages of healthcare providers—in particular, physicians and nurses—and state-of-the-art equipment, and we can understand the universal agreement that the Canadian healthcare system must change. The only (...) question is how. Some argue for modifications within the basic framework of a one-tier single-payer system; others for more radical reform that will allow for infusions of money by expedients such as user fees, extra billing, or a full-blooded second tier where one can buy any healthcare one wants. a. (shrink)

With his Affordable Care Act decision, Chief Justice Roberts saved conservatives from themselves. A constitutional regime that prohibited a mandate for basic health insurance while permitting Medicare and the Veterans Health Administration, presumably on the basis of government taxing authority, would have been a conservative nightmare. These partial U.S. versions of single payer and national health service are permissible, but a coherent private health insurance market is not?! The surprising thing is not that the generally conservative Roberts had (...) the historical and logical sense to realize this, but that he was the only one of his conservative colleagues who did. It is not the only irony presented by promarket, conservative constitutionalism in this case. (shrink)

In The Ethics of Universal Health Insurance, Alex Rajczi shows how defenders of universal health insurance can address the ethical issues raised by these objections and make the moral case for an American universal health insurance system that improves on the gains made in the Affordable Care Act.

In response to rapidly rising health care costs in the United States, federal and state governments and private industry are instituting numerous and diverse cost-containment plans. As devices for coping with a scarcity of resources, such plans present serious challenges to physicians' traditional single-minded devotion to patient welfare. Those which contain costs by directly limiting medical options or by controlling physicians' daily clinical decisions can threaten the quality of medical care by allowing economic authorities to make essentially medical judgments. (...) In contrast, other plans coax compliance by arranging incentives, e.g., offering financial rewards for successful cost containment. While they allow for clinical freedom, these plans create conflicts between physicians' fiduciary obligations to their patients and the competing interests of the payers. Such conflicts arise as physicians try to work within governmental or corporate cost containment policies, and also as they attempt to streamline clinical efficiency. Throughout, issues of justice emerge as physicians seek to reconcile their own patients' claims upon limited common resources with others' equally legitimate claims. (shrink)

continent. 2.1 (2012): 6–21. The French philosopher and novelist Tristan Garcia was born in Toulouse in 1981. This makes him rather young to have written such an imaginative work of systematic philosophy as Forme et objet , 1 the latest entry in the MétaphysiqueS series at Presses universitaires de France. But this reference to Garcia’s youthfulness is not a form of condescension: by publishing a complete system of philosophy in the grand style, he has already done what none of us (...) in the older generation of speculative realists has done so far. His book is sophisticated, erudite, rigorous, imaginatively rich, and abundant in worldly wisdom– despite the author’s conclusion that wisdom does not exist. The quality and scope of Forme et objet took few observers by surprise, since Garcia has been treated as an emerging philosopher to watch across half a decade of Parisian oral tradition. But Garcia was not just the subject of rumor, being already well known to the French public as a writer of fiction. His debut novel, La meilleure part des hommes , 2 was awarded the 2008 Prix de Flore 3 and has already appeared in English as Hate: A Romance . 4 His follow-up novel, Mémoires de la jungle , 5 made clever use of a chimpanzee narrator. Nor was Garcia only published as a novelist before last November: his philosophical study L’Image 6 had already appeared when the author was just twenty-six, a year before he was crowned by the muses at the historic Café de Flore. And then in 2011, just months before the appearance of Forme et objet , Garcia published a widely distributed work entitled Nous, animaux et humains , 7 with its focus on Jeremy Bentham’s ideas about animals. Given this prolific and versatile track record, an optimistic scenario might envisage the young Garcia as one of those combined literary/philosophical talents who appear intermittently in France across the centuries: Jean-Paul Sartre is merely the most famous recent case. While more time is needed to see how Garcia will channel his impressive mental energies, Forme et objet displays such breadth of insight that its author has a good chance to emerge as one of the leading philosophers of his generation. If we accept Aristotle’s dictum that the peak mental age is fifty-one, then to read Garcia’s massive book is to gain some idea of what European philosophy might look like in the futuristic-sounding 2030’s. The present article is confined to Forme et objet . At 486 pages, the work is obviously daunting in size. Indeed, it is even longer than it sounds, given that many of its early sections are printed in a smaller typeface to designate them as supplemental commentary to the main flow of the argument. But while the length of the book reportedly led to delays in French publication, and will probably slow the inevitable appearance of an English translation, the length of the book should not deter interested readers– much of it results from Garcia’s teacherly writing style. Whereas Quentin Meillassoux’s prose displays an arctic economy of means, Garcia’s style is reminiscent of the repeated lessons of oral classroom proceedings. Rarely is the reader given fewer than three or four chances to master an idea before the author moves on to the next. In practice, the style feels welcoming rather than long-winded. Otherwise, the structure of Forme et objet is surprisingly simple. There is a useful Introduction of less than twenty pages. Then comes Book I: Formally , running to approximately 135 pages. Here Garcia outlines the most basic features of a thing “no matter what it is,” or n’importe quoi , an everyday phrase that Garcia shapes into a technical term. This part of the book feels at times like a more amiable version of Hegel’s Science of Logic , a parallel emphasized further by the threefold articulation of its theme: 1. Thing; 2. Thing and World; 3. Being and Understanding. This is followed by the much longer Book II: Objectively , totaling more than 300 pages. It contains sixteen essay-like meditations on specific kinds of objects—including time, animals, humans, history, gender, and death. Here each chapter rolls smoothly into the next, making this second part of the book feel more like a different work of Hegel: The Phenomenology of Spirit . But these are merely analogies. Garcia is no Hegelian, even if the book contains a few dialectical flourishes that seem to reflect his early enthusiasm for the Frankfurt School. Forme et objet ends with a six-page Coda, followed by the usual page of acknowledgments. In what follows, I will briefly summarize each of these four parts of the book before ending with some more general remarks. Before doing so, it will be useful to situate Garcia biographically (as much as I am able) and philosophically. Though Toulouse is his native city, his formative years were spent largely in Algeria, where his family has deep roots. During our sole private conversation, Garcia mentioned that his parents are professors of literature. 8 As a student of philosopher Garcia flourished so early that many of his current ideas date to his teenaged years: “There are sentences in Forme et objet that I wrote when I was seventeen,” he said in response to a question on that cold night on the Canal St.-Martin. I recalled that remark when reading his brilliant account, late in the book, of the central role of adolescence in contemporary culture. While many prodigies blow through their formal academic training without serious obstruction, Garcia’s student memories are rich in tales of isolation and struggle, though equally rich in gratitude for a half-dozen or so exceptional teachers who provided the intellectual space he needed: Meillassoux and Alain Badiou are simply two of the most prominent figures on that list. Though there are many points of agreement between Garcia’s philosophical position and my own, he not only reached his position years before reading my work, 9 he arrived along a rather different path: not through phenomenology, but via the Frankfurt School, which may be one of the reasons for his profound fascination with aesthetics. Garcia’s cultural background is as broad as one could wish: he is no less informed about punk rock and European football leagues than about the spiritualist roots of Bergson’s philosophy. Curious about everything and contemptuous towards nothing, Garcia can be expected to write insightfully on dozens of topics in the years to come. Given that his philosophy is so personally tantalizing in its agreements and disagreements with my own, and given the great internal richness of Forme et objet itself, the present review is no better than a first effort at coming to terms with the challenges posed by this minstrel from the rising generation. This is especially intriguing for older Generation X’ers like me, since confrontation with the younger generation is one of the many themes treated insightfully in Garcia’s book. 1. Introduction Garcia begins in defense of a so-called “flat ontology,” in which all things are equally things. While Roy Bhaskar 10 used this term pejoratively to refer to anti-realist philosophies that flatten everything onto an epistemic plane of human access, Manuel DeLanda 11 (an admirer of Bhaskar) reversed it into the positive principle that all realities are equally realities. Similar notions can be found in the “absistence” of Alexius Meinong, 12 the “irreduction” of Bruno Latour, 13 and my own critique 14 of the undermining/overmining pair. Also noteworthy is Levi Bryant’s use of the term “flat ontology” throughout The Democracy of Objects 15 and his earlier essay “The Ontic Principle.” 16 But for Garcia, flatness is only one face of the cosmos, and one that he ultimately declares to be rather impoverished. Even so, he always remains an advocate of a flat ontology. Insofar as everything is equally something, no matter what it is ( n’importe qui ), everything is equally a thing, equally solitary in its relation with world. This is why his book abounds in those long lists of random, ontologically equivalent entities that Ian Bogost has playfully termed “Latour Litanies.” 17 The first litany in Garcia’s book runs as follows: “We live in this world of things, where a cutting of acacia, a gene, a computer-generated image, a transplantable hand, a musical sample, a trademarked name, or a sexual service are comparable things.” (7) Yet Garcia is frankly dualistic; his flat ontology only lasts until page 159 and the end of Book I (entitled “Formally”), which deals entirely with things that are equally things. Thereafter Garcia turns his attention from things to objects, which are not flat in the least, but engage in hierarchical relations with one another. In agreement with both DeLanda and the speculative realists, Garcia proclaims that his book “proposes to put to the test a thought about things rather than a thought about our thought about things .” (8) Just as ducklings are “imprinted” (9) after hatching and treat the first creature they see as their mother, philosophers are imprinted by the idea with which they begin. Hence, philosophies that begin with human access will never truly find their way back to things. This makes Garcia rather suspicious of twentieth century philosophy, since “the twentieth century—to which in some way this work proposes to bid adieu—has been a period of theorizing modes of access to things rather than things...” (9) Among other possible benefits of the philosophy of things that Garcia proposes, it is fully able to account for thought as a special variant of things, while the reverse is not possible.(10) In Book I of Forme et objet , Garcia’s “things” are so flat, so de-determined, that he is forced to renounce some of the most basic features ascribed to things by most realists. As he tells us in his foreboding third footnote: “We will maintain that the solitude [of things] is less than unity, less than identity, and that it does not imply acceptance (any more than refusal) of the principle of non-contradiction.” (11) In a contemporary world cluttered with too many things, Garcia’s flat and formal plane provides us with some breathing room: “The formal plan of thought enables or re-enables us to cut short all accumulation—whether of knowing, experience, or action—by a simplicity, an impoverished surface...” (13) As Garcia says elsewhere in responding to a Deleuzian critic of the book, his starting point in flat ontology is designed to obstruct the claims of both analytic philosophy and Hegelianism: “Hence, this work seeks to protect each thing—real, imaginary, inconsistent, contradictory—both against Ockham’s Razor and against the Aufhebung or dialectical process.” 18 Yet contrary to the equalizing spirit of many flat ontologies, “we will add to our formal ontology of the equal, an objective ontology of the unequal.” (13) But initially, Garcia joins all flat ontologists in holding that everything is irreducible: “this irreducibility, which we will term the ‘chance’ of each thing... also marks the refusal of a positive thought that reduces things exclusively to natural things, or social things, or historical things, etc.” (15) This irreducible “chance” of a thing emerges as an important technical term in the book, always paired with its inverted brother, the “price to pay” ( prix à payer ). On pages 17-19, we find the only diagrams in the book. What they illustrate is that Garcia wishes to avoid two equally dangerous extremes. The first is the philosophy of substance, featuring the thing-in-itself as a mighty river fed by attributes as if by subordinate tributary streams. This model can be found in many of the classic thinkers of West and East alike. In it, “there is obviously a hierarchization between that which is dragged towards something other than itself, and this other which serves it as an ontological support while supporting its proper being.” (16) For Garcia, the second extreme worth avoiding is the philosophy of events: “One thus conceives trajectories of being, identified as events, facts, powers, intensities, or intentionality. These vectors of being come first, bearing and supporting being, displacing it, but without ever finding a stopping point, a buffer, an objective consistency.” (17) The first model gives us a thing too wrapped up in itself, too compact . This word “compact” (the French and the English are the same) is another technical term for Garcia. But if the “compact” model of things leads us to something more than things, the philosophy of events gives us less than things, by dissolving them into a play of vectors. Garcia’s alternative lies midway between these two extremes: Being enters the thing, being comes out of it. And a thing is nothing other than the difference between the enters and the being that comes out. Thus, the circuit of being is never halted. In the thing, there is never the thing-in-itself. And the thing is never in-itself, but outside of itself. Nonetheless, being is not eventally “pollinated” by vectors: it possesses an objecting halting-point... (19) This single idea is the key to Garcia’s book: the thing is neither a self-contained durable lump nor some sort of evental flux. Instead, the thing is the difference between its various components and its relations with its environment. Or stated differently: “the price to pay for this disposition is a circulation of being that systematically distinguishes two senses of things: that which is in the thing , and that in which the thing is , or that which encompasses it and that which it encompasses,” (19) translating comprendre here as “encompass.” 19 In a beautiful description of a piece of black slate, Garcia sums up the various minerals, qualities, and shapes that compose [ comprend ] it, and calls them “that which is in the thing,” (20) noting that this tells us nothing about “that in which [the slate] is”—namely, all the various situations in which the black slate can be found. Instead, the slate is the difference between these two: the most characteristic principle of Garcia’s philosophy. 2. Formally Book One of Forme et objet , “Formally,” is concerned with the formal equality of all things in a flat world. “Two questions mark the boundaries of reflection: of what is everything composed [ composé ], and: what do all things compose?” (27) Looking downward, we wish to know what everything is made of; looking upward, we want to know the ultimate result of the combination of all things. Here we must turn our attention to the thing n’importe quoi— no matter what it is. (30) Anything with finite qualities is obviously too specific to be relevant to global ontological questions. To an equal degree, something possessing all qualities (think of Whitehead’s God) 20 would not be n’importe quoi either, since it would still be too definite, even if incredibly vast. The same holds for contradictions, since these all differ from each other. The square circle, the non-white black white, and the non-city city are all too distinct to count as the thing no matter what it is. The n’importe quoi must be devoid of all specific qualities, including contradictory ones. In one of the more intriguing points in his book, so reminiscent of Meinong, Garcia proclaims that “the ‘no matter what it is’ is neither a reality nor an abstract construction, nor both of these at once; the ‘no matter what it is’ is simply the plane of equality of that which is real, that which is possible, that which is inexistent, that which is past, that which is impossible, that which is true, that which is false, that which is bad.”(39-40) Since everything has two faces, it would be a grievous mistake to focus on just one of them at the expense of the other, as physicalism or materialism do when reducing the world to minuscule physical underpinnings. For scientistic materialism, “it is either atoms, particles, or fields of force... which are the things.” (47-48) Moreover, “these more-than-things are accompanied by less-than-things: for example, ideas or facts of consciousness are determined by the state of matter and are not autonomous things, but manifestations reduced to secondary effects of material processes...” (48) On this point, Garcia’s position is in complete accord with my own critique of undermining and overmining. 21 Where we disagree is that Garcia is more deeply suspicious of the notion of substance, which I view as salvageable with a few needed changes, while Garcia sees this operation as hopeless: “A substance, in the history of philosophy, is the more-than-thing par excellence.” (51) Another agreement between our positions is visible when Garcia claims (correctly, in my opinion) “that it is vain to distinguish between things which are material and those which are not.” (52) Yet we also find an even more important disagreement, since for Garcia withdrawal cannot be the quality of a thing. Instead, the absence of a thing is simultaneous with it, embodied in all that is not it– the absence of the sculpture of a woman is to be found in the mold that appears at the same time as it, and thus withdrawal must be viewed as an “event” rather than as something pertaining to an object. For Garcia, nothing withdraws beyond access. Since we must distinguish between “that which is something” and “that which something is,” and since the former is identified with “no matter what it is is” and the latter with “ not no matter what it is,” we can say that “everything is thus a milieu, a fragile link between ‘no matter what it is’ and ‘ not no matter what it is.’” (62) And here we find Garcia’s critique of the thing-in-itself: “A thing is never defined en bloc . We can affirm that a thing is this or that, but that does not suffice. It is still necessary to state precisely that which is this thing .” (62) Stated differently, “something is not in itself : for that which is in the thing is not the thing, and that in which the thing is is not the thing.” (62) And here Garcia and I, facing the same evidence, draw opposite conclusions. For me, the fact that nothing can be identified with either its components or its concrete location means that the thing must be something in-itself distinct from both of these. Yet for Garcia, to be in-itself would mean to be identified with just one of these two extreme terms, and hence the thing can only be the difference between them. Garcia is equally suspicious of the classical tendency to view “unity” as a property of the thing, since in his eyes unity is too relational a property to belong to things. (65) While specific things are situated determinately with respect to other things, we are still speaking here about the thing no matter what it is, and this can be viewed only in terms of solitude, which all things share: a human being, a hand, or a chair or all equally things insofar as they are on their own , not insofar as they are one . (64) A thing is alone, and relates only to the one thing that is not another thing: world. In a striking parallel to my own argument for a partial revival of occasionalism, Garcia tells us that “the things communicate only by their solitude: it is because everything is equally on its own in the world that things can be together, enmeshed in one another.” (67) Alone in their solitude, things all relate to world, which serves as a mediator allowing them to become mixed up in one another. As we have seen, one reason that nothing can be in itself is because everything is in something else. For Garcia, “to be in something and to be something are equivalent.” (69) Stated more broadly, “being is thus the difference between the two aspects of each thing: that which is it, and that which it is.” (70) And even more vividly: “a thing is almost like a sack: there is that which one puts in the sack and that which remains outside the sack.” (70) But not quite like a sack, “since a thing is not a thin skin or film. Instead, a thing is comparable to a sack that is immaterial and without thickness: it is nothing other than the difference between that which is this thing and that which thing is, between content and container.” (71) Nothing can be in-itself because everything is two selves at once. For example, we cannot say that our self is defined by our consciousness: “Everything has a self because nothing is in itself. The self is not the quality of that which is related to itself (which is conscious, for example) or which thinks itself related to itself. Nonetheless, for an entity called ‘conscious’ to be related to itself, it is necessary that this very relation should be another thing than the self to which it is related.” (71) Consciousness cannot be the self, precisely because it is other than that of which it is conscious. Nothing is able to grasp itself. The self is “the function by which being and composition [ compréhension ] are mutually excluded...” (72) The self is “the point of shadow of everything that projects some light...” (72) The in-itself faces two opposite dangers: “For something to be in-itself is to be a self. Something which is a self flies out through one of its two sides... Stated differently, being in-itself is simply the possibility of a double failure.” (73) The in-itself can be termed compact : “There remains to us a means of thinking that which does not fully enter into the world, though without exiting from it. This means is what we call the compact.” (76) In a sense, the compact is the opposite of the world. For in the case of the world, everything enters it and it enters nothing; as for the compact, it enters the world (since it is something, after all) while nothing enters it. (77) The compact marks the presence of the impossible in the world. (78) It is not impossible, but possible only on the condition that it fails. (78) The time has come to speak of where a thing is located. “The sole condition of a thing is that of being in another thing than itself, and thus in another thing than something.” (78) A condition is “that which determines something, that which forms something, that in which something is.” (78) As for humans, “the condition of someone is his situation; my social condition is that which socially determines me, my place and my function...” (79) More generally, “to be conditioned is to find oneself reduced to that in which one is.” (79) Everything is conditioned, but nothing is reducible to this condition. To determine the condition of something is to determine in what it is. A thing is located in that which contradicts it, just as a statue exists in its mold, which is precisely that which it is not. Since the thing is finite and definite, its condition or form must be infinite and indefinite. That in which all things are is the world, which Garcia also terms “the whole.” (81) “To try to be in-itself is to attempt to remain outside the world. And indeed, to try to be in-itself is only a path of entry into the world.” (83) For Garcia, “the world is not the pre-existent container of the things it contains, a priori , nor the construction by the mind of a fictional ensemble of all things, a posteriori .” (85) Instead, the world is simultaneous with all things; the two always go together. The world cannot be a determinate world, such as the physical universe or mathematical space, since these are already too specific and limited. “Every determinate world, which is in fact a universe , is a ‘big thing’ [ grosse chose ]: it is a set, however vast, of composite things which itself embodies a thing.” (85) Every determinate world is really just a “big thing.” Stated differently, “it is nothing other than a balanced milieu between the things that compose it and the thing that it composes.” (85) We generally picture the world as a physical univer. (shrink)

Scholars of the classical American philosophical tradition have not written much about prayer, despite the fact that almost every single one of the major figures of this tradition acknowledged its significance. The gap in the literature is notable in the case of George Santayana, who discusses prayer in several of his major works. And of all the classical American philosophers, Santayana may have the most fully developed treatment of prayer, particularly as it relates to the problem of petitionary prayer. (...) Yet his account of payer has not received much attention. This is surprising since, on the one hand, many of Santayana’s other views on religion and spirituality have been widely commented on, and, on the other hand, prayer has been a prominent topic in philosophy of religion in recent decades. And it makes sense for scholars of the classical American tradition nowadays to consider Santayana’s views about prayer, at the least because this tradition concerns itself with the problems of ordinary people, and to most Americans–and even to some atheist Americans–prayer seems to matter a great deal. Santayana’s treatment of prayer can be organized into two phases. First, he offers a twofold case against the common view that petitionary prayer is materially efficacious–that is, the view that petitionary prayer can do something to affect whether God brings about a desired state of affairs that would not have otherwise obtained had the request for it not been made. (shrink)

Personality disorder symptomatology (PD-Sx) can result in personal distress and impaired interpersonal functioning, even in the absence of a clinical diagnosis, and is frequently comorbid with psychiatric disorders such as substance use, mood, and anxiety disorders; however, they often remain untreated, and are not taken into account in clinical studies. To investigate brain morphological correlates of PD-Sx, we measured subcortical volume and shape, and cortical thickness/surface area, based on structural magnetic resonance images. We investigated 37 subjects who reported PD-Sx exceeding (...) DSM-IV Axis-II screening thresholds, and 35 age, sex, and smoking status-matched control subjects. Subjects reporting PD-Sx were then grouped into symptom-based clusters: N = 20 into Cluster B (reporting Antisocial, Borderline, Histrionic, or Narcissistic PD-Sx) and N = 28 into Cluster C (reporting Obsessive–Compulsive, Avoidant, or Dependent PD-Sx); N = 11 subjects reported PD-Sx from both clusters, and none reported Cluster A (Paranoid, Schizoid, or Schizotypal) PD-Sx. Compared to control, Cluster C PD-Sx was associated with greater striatal surface area localized to the caudate tail, smaller ventral striatum volumes, and greater cortical thickness in right prefrontal cortex. Both Cluster B and C PD-Sx groups also showed trends toward greater posterior caudate volumes and orbitofrontal surface area anomalies, but these findings did not survive correction for multiple comparisons. The results point to morphological abnormalities that could contribute to Cluster C PD-Sx. In addition, the observations parallel those in substance use disorders, pointing to the importance of considering PD-Sx when interpreting findings in often-comorbid psychiatric disorders. (shrink)

Book reviewed in this article: Medicine and Culture: Varieties of Treatment in the United States, England, West Germany, and France. By Lynn Payer. Health Care Systems: Moral Conflicts in European and American Public Policy. Edited by Hans‐Martin Sass and Robert U. Massey.

The spatial organization of genomes is becoming increasingly understood. In mammals, where it is most investigated, this organization ties in with transcription, so an important research objective is to understand whether gene activity is a cause or a consequence of genome folding in space. In this regard, the phenomena of X‐chromosome inactivation and reactivation open a unique window of investigation because of the singularities of the inactive X chromosome. Here we focus on the cause–consequence nexus between genome conformation and transcription (...) and explain how recent results about the structural changes associated with inactivation and reactivation of the X chromosome shed light on this problem. (shrink)

Since 1990, the multinational public accounting firms have all adopted flexible work arrangement policies. In part, the firms are doing this to fulfill an ethical obligation in creating an appropriate professional environment for their employees. This study examines the effect of participation in a flexible work arrangement program on an individual''s professional success and anticipated turnover as perceived by the participant''s peers and superiors. Subjects from one Big Five accounting firm read a description of a manager and answered a series (...) of questions about the likelihood of the manager''s promotion to partner, voluntary and involuntary turnover, and desirability on a job. Gender and participation in a flexible work arrangement were manipulated in a 2×2 design. The results indicate that participation in a flexible work arrangement evoked significantly more pessimistic predictions on all of the dimensions. Gender did not have an effect on the likelihood ratings. Follow-up questions about the factors that enhance and hinder individuals career success in each work scenario indicated that the perceived ability to "juggle" and the ability to "pull one''s weight" potentially affects evaluations of what it takes to be a successful professional in the financial services environment. Implications for professional and ethics practice and research are also presented. (shrink)

Dans le titre un peu provocateur de ce livre, les lecteurs reconnaîtront sans peine un clin d’œil fait à la parabole du « fils prodigue » de l’évangile de Luc. D’emblée, l’auteure explique l’intérêt de ce récit biblique : alors que le fils dont il est question, revient à la maison, domaine privilégié des femmes, la parabole ne parle jamais d’elles. L’histoire de Luc ne concerne que des hommes. Pour Élisabeth Parmentier, ce silence est significatif de l’expérience des femmes dans (...) la « maison-É... (shrink)

J’ai rencontré Marie-Jeanne Bérère à Lyon en 1994. C’était une petite femme vive, à la parole claire et précise, avec un bel accent bourguignon. Elle avait accepté une interview, à son domicile lyonnais, le 23 mars 1995. Je souhaitais la revoir pour ce numéro de CLIO, Histoire, Femmes et Sociétés sur les Chrétiennes mais elle est décédée dans l’été 2000, à 73 ans, sans avoir eu le temps de rédiger ses mémoires. Son itinéraire de femme engagée dans l’Église catholique est (...) celui d’une chrétienn... (shrink)

Flexible work arrangements (FWAs) are widely offered in public accounting as a tool to retain valued professional staff. Previous research has shown that participants in FWAs are perceived to be less likely to succeed in their careers in public accounting than individuals in public accounting who do not participate in FWAs (Cohen and Single, 2001). Research has also documented an increasing backlash against family–friendly policies in the workplace as placing unfair burdens on individuals without children. Building directly on a (...) previous study in this journal (Cohen and Single, 2001), this study addresses the issue of whether the documented perceptions toward FWA participants are the result of electing to take part in the FWA or the result of bias against employees with children. The research questions are addressed in a 3 × 2 experimental setting in which we manipulate FWA participation, along with family status and gender of a hypothetical manager in a public accounting firm. Our findings indicate that FWA participants are viewed as less likely to advance and as less committed than individuals without children or individuals who had children but who were not taking part in a FWA. Male FWA participants are viewed as less likely to succeed than female FWA participants. This effect appears to arise from a perception that FWA participants are willing to make sacrifices in their careers to accommodate family needs and thus may not be as committed to making the sacrifices perceived as necessary to meet the rigorous demands of the public accounting environment. This raises the ethical question of what could be done to change the culture in public accounting to foster a substantive support system for individuals who want to balance a family and a career. (shrink)

Flexible work arrangements (FWAs) are widely offered in public accounting as a tool to retain valued professional staff. Previous research has shown that participants in FWAs are perceived to be less likely to succeed in their careers in public accounting than individuals in public accounting who do not participate in FWAs (Cohen and Single, 2001). Research has also documented an increasing backlash against family–friendly policies in the workplace as placing unfair burdens on individuals without children. Building directly on a (...) previous study in this journal (Cohen and Single, 2001), this study addresses the issue of whether the documented perceptions toward FWA participants are the result of electing to take part in the FWA or the result of bias against employees with children. The research questions are addressed in a 3 × 2 experimental setting in which we manipulate FWA participation, along with family status and gender of a hypothetical manager in a public accounting firm. Our findings indicate that FWA participants are viewed as less likely to advance and as less committed than individuals without children or individuals who had children but who were not taking part in a FWA. Male FWA participants are viewed as less likely to succeed than female FWA participants. This effect appears to arise from a perception that FWA participants are willing to make sacrifices in their careers to accommodate family needs and thus may not be as committed to making the sacrifices perceived as necessary to meet the rigorous demands of the public accounting environment. This raises the ethical question of what could be done to change the culture in public accounting to foster a substantive support system for individuals who want to balance a family and a career. (shrink)

Payers have shaped the healthcare system in the United States as fee-for-service has facilitated a care model that prioritizes volume over the sake of patient care. This worsens health disparities, especially in safety net facilities where ancillary social work is both necessary clinically and completely uncompensated. Using concepts from Iris Marion Young’s Responsibility for Justice, it can be concluded that payers have a moral responsibility for reimbursing social care to address historical injustices. In this article, I describe the ethical hazards (...) in paying for social care and propose a way to finance this through value-based payments. (shrink)

Logothetis, N.K.: Single units and conscious vision. Philosophical Transactions of the Royal Society of London Series B-Biological Sciences 353, 1801-1818 (1998) Abstract.

The presented study raises the issue of contribution payers in the field of social insurance, in particular based on the Covid-19 pandemic. Searching for ways of supporting was determined by the deterioration of the financial condition of entrepreneurs as payers of contributions. In 2020, there were no instruments or mechanisms to support entrepreneurs in a lockdown situation, which implied the need to build such tools and the legal environment for SMEs practically from the beginning. The Social Insurance Institution (ZUS) was (...) entrusted with the role of a stabilizer, consisting in servicing entrepreneurs as part of subsequent editions of the Anti-Crisis Shield. During the announcement of the COVID-19 pandemic, ZUS used the following forms of support for contribution payers: exemption from the obligation to pay contributions, postponement of the payment of contributions and payment of contributions in installments. The research question concerned the enforcement of the law and respect for the basic rights of entrepreneurs in the scope of the support used. In order to solve the research task legal interpretation were used in the work. The author’s considerations lead to the conclusion that forms of support used in connection with the Covid-19 pandemic turned out to be effective and may be used in the future in emergency situations. An important science contribution of the article results from the combination of the selected legal and economic aspects. (shrink)