Consensus, clinical decision making, and unsettled cases

The model of clinical ethics consultation (CEC) defended in the ASBH Core Competencies report has gained significant traction among scholars and healthcare providers. On this model, the aim of CEC is to facilitate deliberative reflection and thereby resolve conflicts and clarify value uncertainty by invoking and pursuing a process of consensus building. It is central to the model that the facilitated consensus falls within a range of allowable options, defined by societal values: prevailing legal requirements, widely endorsed organizational policies, and professional standards of practice and codes of conduct. Moreover, the model stipulates that ethics consultants must refrain from giving substantive recommendations regarding how parties to a moral disagreement in the clinic should evaluate their options. We argue that this model of CEC is incomplete, because it wrongly assumes that what counts as the proper set of allowable options among which the parties are to deliberate will itself always be clearly discernible. We illustrate this problem with a recent case on which one of us consulted-a neonate born with trisomy 18 (T18). We try to show that law, policy, and standards of practice reveal no clear answer to the question posed by the case: namely, whether forgoing gastrostomy tube feedings for a baby with T18 is allowable. We suggest there may be other kinds of cases in which it may simply be unsettled whether a given choice falls within the set of allowable options within which consensus is to be facilitated. What should an ethicist do when confronting such unsettled cases? We agree with the facilitation model that an ethicist should remain neutral among the allowable options, when it is clear what the allowable options are. But, in unsettled cases, the role of a consultant should be expanded to include a process of moral inquiry into what the allowable options should be. We end by raising the issue of whether this means an ethicist should share his or her own conclusions or views about the allowability of a given clinical option.     

"Facilitated consensus," "ethics facilitation," and unsettled cases

In "Consensus, Clinical Decision Making, and Unsettled Cases:' David M. Adams and William J.Winslade' make multiple references to both editions of the American Society of Bioethics and Humanities (ASBH) Core Competencies for Healthcare Ethics Consultation in their discussion of two assumptions that are supposed to be at the heart of the facilitated consensus model's inability to handle unsettled cases; that is, that: 1. Consultants "should maintain a kind of moral impartiality or neutrality throughout the process," "explicitly condemn[ing] anything resembling a substantive 'ethics' recommendation, and 2. "What counts as the proper set of allowable options among which the parties are to deliberate will itself always be clearly discernible' Herein, I argue that neither of these assumptions is required by ASBH's ethics facilitation approach. I then conclude by suggesting that, despite their fundamentally mistaken interpretation of the ASBH approach-perhaps even because of it-Adams and Winslade have made two important contributions to the ethics consultation literature.     

Taking responsibility for health in an epistemically polluted environment

Proposals for regulating or nudging healthy choices are controversial. Opponents often argue that individuals should take responsibility for their own health, rather than be paternalistically manipulated for their own good. In this paper, I argue that people can take responsibility for their own health only if they satisfy certain epistemic conditions, but we live in an epistemic environment in which these conditions are not satisfied. Satisfying the epistemic conditions for taking responsibility, I argue, requires regulation of this environment. I describe some proposals for such regulation and show that we cannot reject all regulation in the name of individual responsibility. We must either regulate individuals’ healthy choices or regulate the epistemic environment.     

Neglected Ends: Clinical Ethics Consultation and the Prospects for Closure

Clinical ethics consultations (CECs) are sometimes deemed complete at the moment when the consultants make a recommendation. In CECs that involve actual ethical conflict, this view of a consult's endpoint runs the risk of overemphasizing the conflict's resolution at the expense of the consult's process, which can have deleterious effects on the various parties in the conflict. This overly narrow focus on reaching a decision or recommendation in consults that involve profound moral disagreement can result in two types of adverse, lingering sequelae: moral distress or negative moral emotions. The problem, succinctly named, is that such consults have insufficient “closure” for patients, families, and providers. To promote closure, and avoid the ills of moral distress and the moral emotions, I argue that CECs need to prioritize assisted conversation between the different stakeholders in these conflicts, what is often referred to as “bioethics mediation.”     

Weakness and compulsion: the essential difference

This paper aims to defend the common-sense view that we exempt compulsive agents from responsibility to the extent that they are unable to choose what they do and hence they cannot control their actions by their choices. This view has been challenged in a seminal paper by Gary Watson, who claimed that akratic agents lack control in the same sense but they are responsible nonetheless. In the first part of the paper, I critically examine the arguments Watson advances for this claim first in his original paper and then in some more recent works. I conclude that his account is based on the widely held assumption that both compulsive behavior and weakness of the will must be understood as a direct result of some inner motivational conflict. In the second part, I argue for an alternative understanding of the difference between weakness and compulsion. My claim is that compulsion is a cognitive rather than a motivational deficiency, since the compulsive, unlike the weak-willed, does not desire to perform the action which she actually performs. Furthermore, I argue that compulsive agents cannot control their actions by their choices because they have a distorted view of their own actional abilities. In the final part of the paper, I discuss a consequence of this account to the conditional analysis of free will as a condition of responsibility.     

Libertarianism,the Rollback Argument,and the Objective Probability of Free Choices

It is widely assumed that candidates for free, undetermined choices must have objective probabilities prior to their performance. Indeed although this premise figures prominently in a widely discussed argument against libertarianism, few libertarians have called it into question. In this article, I will investigate whether libertarians ought to reject it. I will conclude that doing so should not be tempting to event‐causal libertarians or most agent‐causal ones, because the added costs outweigh the benefits.     

Idealism and illusions

According to the idealist, facts about phenomenal experience determine facts about the physical world. Any such view must account for illusions: cases where there is a discrepancy between the physical world and our experiences of it. In this article, I critique some recent idealist treatments of illusions before presenting my own preferred account. I then argue that, initial impressions notwithstanding, it is actually the realist who has difficulties properly accounting for illusions.     

Zombies and the Case of the Phenomenal Pickpocket

A prevailing view in contemporary philosophy of mind is that zombies are logically possible. I argue, via a thought experiment, that if this prevailing view is correct, then I could be transformed into a zombie. If I could be transformed into a zombie, then surprisingly, I am not certain that I am conscious. Regrettably, this is not just an idiosyncratic fact about my psychology; I think you are in the same position. This means that we must revise or replace some important positions in the philosophy of mind. We could embrace radical skepticism about our own consciousness, or maintain the complete and total infallibility of our beliefs about our own phenomenal experiences. I argue that we should actually reject the logical possibility of zombies.     

Unconfirmed peers and spinelessness

The Equal Weight View holds that, when we discover we disagree with an epistemic peer, we should give our peer’s judgment as much weight as our own. But how should we respond when we cannot tell whether those who disagree with us are our epistemic peers? I argue for a position I will call the Earn-a-Spine View. According to this view, parties to a disagreement can remain confident, at least in some situations, by finding justifiable reasons to think their opponents are less credible than themselves, even if those reasons are justifiable only because they lack information about their opponents.     

Which opinion should a clinical ethicist give: Personal viewpoint or professional consensus?

When clinical ethicists are called upon to give a recommendation regarding patient care, they may be faced with a dilemma of their own. If their own personal opinion is not widely shared, the ethicist will have three options. These include: (1) giving their own opinion; (2) giving the widely shared opinion; and (3) giving both opinions, leaving the physician to select which opinion to accept. The intentions of this article are to evaluate strengths and weaknesses of these three alternatives and to suggest that ethics consultants recognize and deal with this issue. Two cases are presented to explore the limitations of each option. The author suggests that when the views of ethics consultants differ from the consensus view, the consultant should give the consensus view, their own dissenting view and the arguments in support of each position.     

Other‐Centric Reasoning

This article considers question‐begging's opposite fallacy. Instead of relying on my beliefs for my premises when I should be using my adversary's beliefs, I rely on my adversary's beliefs when I should rely on my own. Just as question‐begging emerges from egocentrism, its opposite emerges from other‐centrism. Stepping into the other person's shoes is an effective strategy for understanding him. But you must return to your own shoes when forming your beliefs. Evidence is agent centered. Other‐centric reasoning is most striking when both parties partake simultaneously. We are then treated to the spectacle of each side using the other's premises to establish its conclusion. These remarkable debates arise regularly when there is open disagreement about whether a right‐conferring relationship has ended. Those who contend the relationship is abrogated will be tempted to stand on the rights persistently credited to them by their adversary.     

Paternalism and the Ill-Informed Agent

Most anti-paternalists claim that informed and competent self-regarding choices are protected by autonomy, while ill-informed or impaired self-regarding choices are not. Joel Feinberg, among many others, argues that we can in this way distinguish impermissible ??hard?? paternalism from permissible ??soft?? paternalism. I argue that this view confronts two related problems in its treatment of ill-informed decision-makers. First, it faces a dilemma when applied to decision-makers who are responsible for their ignorance: it either permits too much, or else too little, intervention to satisfy its proponents. Second, the most promising rationales in favor of the view ignore the distinction between an agent??s voluntarily bringing about some state of affairs, on the one hand, and an agent??s voluntarily assuming a risk, on the other. I conclude that a decision-maker??s ignorance is irrelevant to the permissibility of intervention on her behalf. If it is permissible to intervene in a given ill-informed choice, it would be permissible to intervene in an otherwise similar but informed choice, at least provided that intervention would produce similar benefits in both cases. This shows that we should sometimes accept straightforwardly paternalistic rationales.     

Bad Faith,Bad Behaviour,and Role Models

I argue that athletes should neither be taken as role models nor present themselves as such. Indeed, they should resist any attempt to take them as such on the grounds that seeing athletes (or other celebrities) as role models abrogates the existential and ethical responsibilities of both parties. Whether one takes on the role of being a model to others or whether one chooses to model one’s own behaviour on that of another, except in respect of the development of technical skill, one engages in bad faith and fails to act in an existentially ethical way. To this end, I consider the inclination to influence and admiration, as well as self-respect, agency, motivation, and envy. I argue that while celebrity sportspersons and similar others do not have duties that others do not have just by virtue of their notoriety alone, they may have situational responsibilities commensurate with their social reach. More importantly, however, since social influence is not a transformation of inert matter, there are also responsibilities belonging to their audiences, those who merely observe and those who choose to imitate     

Quietism and Cognitive Command

Crispin Wright has sought to establish the possibility of 'significant metaphysics' in the shape of a common metric with which to measure the realism or robustness of various discourses. One means by which to place discourses in the metric is via the 'cognitive command constraint'. Importantly, this constraint must be a priori . Richard Rorty has argued against this, that, given content is a function of standards of representationality, the a priori requirement cannot be satisfied. I show that this attack is inconsistent: to run his own argument Rorty must take recourse to a idealized view of identification of discourses which conflicts with his own basic premise about the determination of content. Hence Rorty's argument should not lead us to conclude that significant metaphysics is impossible.     

Rational Moral Ignorance

What should a person do when, through no fault of her own, she ends up believing a false moral theory? Some suggest that she should act against what the false theory recommends; others argue that she should follow her rationally held moral beliefs. While the former view better accords with intuitions about cases, the latter one seems to enjoy a critical advantage: It seems better able to render moral requirements ‘followable’ or ‘action-guiding.’ But this tempting thought proves difficult to justify. Indeed, whether it can be justified turns out to depend importantly on the rational status of epistemic akrasia. Furthermore, it can be argued, from premises all parties to the moral ignorance debate should accept, that rational epistemic akrasia is possible. If the argument proves successful, it follows that a person should sometimes act against her rationally held moral convictions.     

Reflection and Disagreement

How should you take into account the opinions of an advisor? When you completely defer to the advisor's judgment (the manner in which she responds to her evidence), then you should treat the advisor as a guru. Roughly, that means you should believe what you expect she would believe, if supplied with your extra evidence. When the advisor is your own future self, the resulting principle amounts to a version of the Reflection Principle—a version amended to handle cases of information loss. When you count an advisor as an epistemic peer, you should give her conclusions the same weight as your own. Denying that view—call it the “equal weight view”—leads to absurdity: the absurdity that you could reasonably come to believe yourself to be an epistemic superior to an advisor simply by noting cases of disagreement with her, and taking it that she made most of the mistakes. Accepting the view seems to lead to another absurdity: that one should suspend judgment about everything that one's smart and well‐informed friends disagree on, which means suspending judgment about almost everything interesting. But despite appearances, the equal weight view does not have this absurd consequence. Furthermore, the view can be generalized to handle cases involving not just epistemic peers, but also epistemic superiors and inferiors.     

FREEDOM AND WEAKNESS OF WILL

Can absolute freedom of will be defended by arguing that apparent cases of diminished freedom when we act out of passion are cases of weakness of will? Rogers Albritton thought so. What is intriguing about Albritton's view is that he thought when we act from desire we are making choices, yet our desires are not functioning as reasons for those choices. So our desires must be influencing our choices in some other unspecified way that does not diminish our freedom. I challenge the coherence of this position. My strategy is to examine the views of leading theorists of the will – Descartes, Aquinas and Reid – to argue that the only clear way in which passions can influence our choices so that we can accurately be described as weak‐willed and yet nevertheless free is that our passions influence our choices by providing reasons for them.     

Towards a Sociological turn in Contextualist Moral Philosophy

Contextualist moral philosophers criticise hands-off liberal theories of justice for abstracting from the cultural context in which people make choices. Will Kymlicka and Joseph Carens, for example, demonstrate that these theories are disadvantageous to cultural minorities who want to pursue their own way of life. I argue that Pierre Bourdieu's critique of moral reason radicalises contextualist moral philosophy by giving it a sociological turn. In Bourdieu's view it is not enough to provide marginalised groups or subgroups with equal access to public institutions and specific cultural rights—in some cases this may in fact be detrimental. He contends that scientists, politicians and other intellectuals have a duty to take seriously the social presuppositions of free deliberate choice and public opinion and to support cultural minorities with instruments to liberate themselves from their often precarious situation.     

An overview of malingering and deception in neuropsychiatric cases

Forensic practitioners must shoulder special responsibilities when evaluating over-stated pathology (e.g., malingering) as well as simulated adjustment. Such determinations may modify or even override other clinical findings. As a result, practitioners must be alert to their own misassumptions that may unintentionally bias their conclusions about response styles. Detection strategies for malingering—based on unlikely or markedly amplified presentations—are highlighted in this article. Given page constraints, assessment methods for feigning are succinctly presented with their applications to administrative, civil, and criminal referrals.