Search

Mexico is the country with the highest mortality due to ST-elevation acute myocardial infarction (STEMI), and the IMSS has therefore developed the protocol of care for emergency departments called Código Infarto (Infarction Code). In this article, aspects of translational medicine are discussed with a bioethical and comprehensive perspective.To analyze the Código Infarto protocol from the perspective of translational bioethics.A problem-centered approach was carried out through reflective equilibrium (or Rawls' method), as well as by applying the integral method for ethical discernment.The protocol of care for emergency services Código Infarto is governed by evidence-based medicine and value-based medicine; it is guided by a principle of integrity that considers six dimensions of quality for the care of patients with STEMI.The protocol overcomes some adverse social determinants that affect STEMI medical care, reduces mortality and global economic disease burden, and develops medicine of excellence with high social reach.México es el país con mayor mortalidad por infarto agudo de miocardio con elevación del segmento ST (IAM CEST), por lo que el Instituto Mexicano del Seguro Social desarrolló el protocolo de atención para los servicios de urgencias denominado Código Infarto. En este artículo se discuten aspectos de la medicina traslacional con una perspectiva bioética e integral.Analizar el protocolo Código Infarto desde la perspectiva de la bioética traslacional.Se realizó una aproximación centrada en el problema a través del equilibrio reflexivo, así como la aplicación del método integral para el discernimiento ético.El protocolo de atención para los servicios de urgencias Código Infarto se rige por la medicina basada en la evidencia y la medicina basada en valores; se orienta por el principio de integridad que considera las seis dimensiones de la calidad para la atención de pacientes con IAM CEST.El protocolo supera algunos determinantes sociales adversos que afectan la atención médica del IAM CEST, disminuye la mortalidad, la carga económica global de la enfermedad y desarrolla una medicina de excelencia de alto alcance social.

It is undeniable that people have beliefs about what actions are morally right. These beliefs play an important role in guiding moral action. Is it possible however to justify beliefs about what actions are morally right? How can beliefs of this sort be justified? Sinnott-Armstrong has advanced an epistemic regress argument against the justification of moral beliefs with the consequence that moral beliefs cannot be justified. This essay addresses the issue of the justification of moral beliefs to answer the question about how moral beliefs can be justified in response to Sinnott-Armstrong’s epistemic regress argument. It argues for the plausibility of Rawls’ reflective equilibrium as an adequate method of justification of moral beliefs. Three problems arise in the attempt to show that reflective equilibrium can adequately respond to Sinnott-Armstrong’s regress argument. These are vicious circularity, arbitrariness and epistemic moral disagreement. It is shown in this essay that these problems can be satisfactorily dealt with.

Background:Research Ethics Committees (RECs) or their equivalent review applications for prospective research with human participants. Reviewers use universally agreed principlesito make decisions about whether prospective health and social care research is ethical. Close attention to understanding how reviewers go about their decision-making work and consider principles in practice is limited.Objective:The study aimed to understand how reviewers made decisions in the contexts of meetings and to understand more about how reviewers approach their work. The purpose of this article is to draw on data and findings and to show how reflective equilibrium as a theoretical frame can (1) deepen understanding of ethics review and (2) permit a reflexive examination of the habitual processes of review.Design and participants:Methods captured the day-to-day work of the RECs. Seventeen applications were heard during eight observations. There were 12 formal interviews with reviewers (n = 12) and with researchers (n = 8) which are not reported on in this article.Ethical considerations:Organisational permission for the study was given by the National Research Ethics Service (NRES) whose functions became part of the Health Research Authority (HRA) during the study. The study was given favourable opinion by the University of Salford's REC (Reference HSCR11/17).Findings:Data were analysed using constructed grounded theory resulting in eight themes which revealed attention to procedure and engagement with applications. Reflective equilibrium was used as a qualitative frame to interpret themes distilling them into three processes at work in review: emotion and intuition; imagination and creative thinking; and intuition and trust.Discussion:Reviewers went back and forth between universal principles and considered these in the contexts of each application using the above processes.Conclusions:Reflective equilibrium offers a coherent and grounded account of review work. Reflexivity in training for reviewers is essential for improving practices. The challenges reflexivity presents can be assisted by using reflective equilibrium as a tool to illuminate tacit review processes.

The purpose of this study is to test tasks that participants will—in subsequent work—complete both individually and in small groups. For the subsequent work, we will need forced binary choice reasoning tasks and thought experiments that produce a roughly equal proportion of each response. So we developed a battery of forced choice items from the intelligence, philosophy, and psychology literature that have been relatively highly cited and have been replicated. The broad research questions are as follows. Which items produced the most equal response distributions? Does performance vary depending on whether reasoning items are presented before (vs. after) thought experiments? How familiar are participants with modified versions of classic reflection test questions and thought experiments? This preliminary experiment addresses this question by randomizing participants to one of two conditions. The reflection-first condition begins with a randomized battery of reflection test questions and proceeds to a randomized battery of thought experiments. The philosophy-first condition reverses this order. (See attached survey.)

Dual-process theories of the mind emphasize how reasoning is an interplay between intuitive and reflective thinking. This paper aims to understand how the two types of processing interact in the mo...

Is it morally justifiable to force non-consenting pregnant women to submit to caesarean surgery to save their fetus in distress? Even though proponents and opponents largely agree on the interests at stake, such as the health and life of the fetus and the respect for bodily integrity and autonomy of pregnant women, they disagree on which moral weight to attach to these interests. This is why disagreements about the justifiability of forced caesareans tend to be pervasive and intractable. To sidestep this deadlock, we will focus on conditions that give rise to the ‘caesarean dilemma’ in the first place, namely the conflict between inherent norms and values medical professionals are committed to by virtue of being a medical professional. Using the reflective equilibrium, we will test the opponents’ and proponents’ considered judgments about forced caesareans against the norms and values they—as medical professionals—are committed to and determine whether they are coherent. Subsequently we will identify the proponents’ incoherencies between the considered judgments and norms and values they are committed to and conclude that as long as these incoherencies are in place, forced caesareans are morally impermissible.

Reflective equilibrium (RE) has been criticized for various reasons ever since the publication of Rawls’A Theory of Justice. Recent empirical research into moral decision-making poses new challenges to RE because it questions the reliability of moral intuitions. This research might discredit moral intuitionism in general and RE in particular insofar as it ascribes epistemic value to moral intuitions. These findings suggest, for instance, that moral intuitions vary with cultural background, gender or framing. If it could be shown that all or certain kinds of moral intuitions are unreliable, this would diminish the plausibility of the claim that they provide good reasons to believe in the truth of their content, especially given the growing evidence that professional philosophers are just as biased and susceptible to distorting factors as lay people. In this paper I critically discuss three recent defenses of RE against this unreliable intuitions objection (UIO). Two of these defenses argue that the UIO misses its target, because RE does not depend on intuitions, or because the relevant considered judgments in RE are not intuitions. The third defense grants that RE depends on intuitions and that some Rawlsian considered judgments are intuitions. But it argues that the notion of considered judgments can be revised, and that wide reflective equilibrium (WRE) has the means to adopt the criticism because it can use information about unreliable intuitions and exclude those from further consideration. I argue that the first two defenses do not succeed. The third defense is the most promising one. However, I argue that this defense also fails. In this defense, RE is not a distinctive moral epistemic theory: different versions of RE would be conceivable, all of which are deeply problematic. I conclude with a discussion of the broader philosophical implications of the UIO, specifically whether or not accepting the UIO would warrant skepticism regarding moral knowledge.

To understand something involves some sort of commitment to a set of propositions comprising an account of the understood phenomenon. Some take this commitment to be a species of belief; others, such as Elgin and I, take it to be a kind of cognitive policy. This paper takes a step back from debates about the nature of understanding and asks when this commitment involved in understanding is epistemically appropriate, or ‘acceptable’ in Elgin’s terminology. In particular, appealing to lessons from the lottery and preface paradoxes, it is argued that this type of commitment is sometimes acceptable even when it would be rational to assign arbitrarily low probabilities to the relevant propositions. This strongly suggests that the relevant type of commitment is sometimes acceptable in the absence of epistemic justification for belief, which in turn implies that understanding does not require justification in the traditional sense. The paper goes on to develop a new probabilistic model of acceptability, based on the idea that the maximally informative accounts of the understood phenomenon should be optimally probable. Interestingly, this probabilistic model ends up being similar in important ways to Elgin’s proposal to analyze the acceptability of such commitments in terms of ‘reflective equilibrium’.

The method of reflective equilibrium starts with a set of initial judgments about some subject matter and refines that set to arrive at an improved philosophical worldview. However, the method faces two, trenchant objections. The Garbage-In, Garbage-Out Objection argues that reflective equilibrium fails because it has no principled reason to rely on some inputs to the method rather than others and putting garbage-in assures you of getting garbage-out. The Circularity Objection argues that reflective equilibrium fails because it has no principled, non-circular way of sorting whatever is put into the method. The moves required to avoid both objections are instructive. Reflective equilibrium requires a meta-justification, and we offer one that appeals to the epistemic goods that underwrite a view known as phenomenal conservatism. Reflective equilibrium calls on us to start with what seems most likely to be true and to alter that collection of judgments in the ways that seem most likely to get us to the truth. Proceeding in this way is epistemically defensible and unavoidable. Hence, reflective equilibrium is not just good, it’s phenomenal.

This chapter outlines the structure for a virtual reality (VR) ethical tool grounded in John Dewey’s concept of dramatic rehearsal. The culmination of ethical thinking on empathy, moral imagination and principlism is brought together with practical insights gained from the analysis of real-world examples of empathy-arousal virtual reality systems discussed in Chap. 5. The steps and sequence for a VR ethical tool are presented, and application to real-world practice is discussed through a vignette on medical ethics training on the issue of informed patient consent.

The Fifth World Congress on Family Law and Children’s Rights (“Halifax Resolutions” (2009) from http://www.lawrights.asn.au/index.php?option=com_content&view=article&id=76&Itemid=109) adopted a resolution endorsing a set of ethical guidelines for the management of infants and children with DSD (2009), based on the ethical principles developed by our group. In this chapter, we outline these principles and explain their basis. The principles are intended as an ethical foundation for treatment decisions for DSD, especially regarding type and timing of genital surgery for infants and young children. These principles were formulated by an analytic review of clinicians’ reasoning in particular cases, in relation to established principles of bioethics, in a process consistent with the Rawlsian concept of reflective equilibrium as the method for building ethical theory.

Empirical methods interact with moral philosophy in several ways. In this paper I remark the role of experience, as well as formative experience, in moral epistemology. I defend the thesis that abstract reasoning is not sufficient in morality. Experiences are needed for refined moral judgments. In particular, I focus on experience and formative experience through engagement with artworks. I endorse a form of art cognitivism, the thesis that we can learn through experiences of artworks, but here I remain neutral toward whether the cognitive value of artworks contributes to their artistic value. In my view, learning from artworks is not detached from abstract reasoning, but complementary to it. This is needed in order to reply to an objection directed at art cognitivism, one which appeals to the fact that the properties of artworks can improve our moral cognitive capacities, as well as reduce them. I reply to this objection by saying that although art is one resource of moral learning, it is not the only resource. This is why we must not passively endorse insights that are derived from experiences of artworks. We must critically analyse these by comparing them with other beliefs and experiences. Experiences of artworks are a source of moral learning, but insights that are derived from them must be reflective and critically examined. The model is a kind of reflective equilibrium, where various sources of learning interact and support, as well as check, each other for moral learning.

The practice of modern medical ethics is largely acute, episodic, fragmented, problem-focused, and institution-centered. Family medicine, in contrast, is built upon a relationship-based model of care that is accessible, comprehensive, continuous, contextual, community-focused and patient-centered. “Doing ethics” in the day-to-day practice of family medicine is therefore different from doing ethics in many other fields of medicine, emphasizing different strengths and exemplifying different values. For family physicians, medical ethics is more than just problem solving. It requires reconciling ethical concepts with modern medicine and asking the principal medical ethics question—What, all things considered, should happen in this situation?—at every clinical encounter over the course of the patient-doctor relationship. We assert that family medicine ethics is an integral part of family physicians’ day-to-day practice. We frame this approach with a four-step process modified from other ethical decision-making models: (1) Identify situational issues; (2) Identify involved stakeholders; (3) Gather objective and subjective data; and (4) Analyze issues and data to direct action and guide behavior. Next, we review several ethical theories commonly used for step four, highlighting the process of wide reflective equilibrium as a key integrative concept in family medicine. Finally, we suggest how to incorporate family medicine ethics in medical education and invite others to explore its use in teaching and practice.

There are scientific and technical challenges that must be addressed in developing systems that interact with humans and work along with other agents in complex, dynamic, and uncertain environments where ethical concerns may arise. In such systems relationships between users and autonomous components will be driven as much by issues such as trust, responsibility, and acceptability, as technical ones such as planning and coordination. This paper provides a comprehensive review and classification of existing methods in machine ethics, resulting in delineation of specific challenges and issues. To address the identified challenges, we introduce a method that leverages the method of reflective equilibrium and the multi-coherence theory as a unifying constraint satisfaction framework to simultaneously assess multiple ethical principles and manage ethical conflicts in a context-sensitive manner.

This article engages with debates concerning the moral worth of human beings with profound intellectual and multiple disabilities (PIMDs). Some argue that those with such disabilities are morally less valuable than so-called normal human beings, whereas others argue that all human beings have equal moral value and that, therefore, each group of humans ought to be treated with equal concern. We will argue in favor of a view that takes points from opposing camps in the debates about the moral worth of humans with such disabilities. Our position, roughly, is this: most humans with PIMDs are persons in the morally significant sense and, therefore, deserve moral consideration equal to that granted to so-called “normal” human beings. Some humans with PIMD may not be persons, but nevertheless deserve moral consideration equal to that of persons because they stand in a special relation to persons.

Vaccination is an explicit topic of the United Nations&rsquo, 2030 Agenda for Sustainable Development. The present article explores a new way of involving student teachers into the vaccination debate. To this aim, 273 students at a Swiss university for teacher education were invited to read a debate between a vaccination proponent and a vaccination opponent that had been published in a free local newspaper. Then, they were asked to judge five of the main arguments of each discussant and to take a (hypothetical) general decision in favor or against vaccination. This decision, the judgements, and students&rsquo, comments were investigated with a mixed method approach in order to better understand the students&rsquo, needs and to refine the new approach. It was found that the students eagerly took part in the intervention, but that they were very ambivalent concerning the arguments. They could be classified into three groups. Two groups, called the acceptors and the rejectors, supported the proponent and the opponent, respectively, and decided accordingly in favor or against vaccination. However, there remained a considerably large group that was called the hesitators. They were particularly ambivalent towards both types of argumentation, but, as structural equation modelling revealed, they eventually were more influenced by the arguments in favor than by those against vaccination. In their comments, these students wanted to know more about the prevented diseases, and they often referred to their personal experience but not to the experts&rsquo, arguments. It was concluded that this group would benefit most from the new type of intervention. A shared-decision approach, as is today prominently discussed in medicine, could improve its impact, and ways should be found to more seriously and consistently include empathetic understanding in pedagogical settings&mdash, for example, by adapting the three-step model from medicine or the reflective equilibrium approach from applied ethics.

Background Healthcare systems are increasingly struggling with resource constraints, given demographic changes, technological development, and citizen expectations. The aim of this article is to normatively analyze different suggestions regarding how publicly financed plastic surgery should be delineated in order to identify a well-considered, normative rationale. The scope of the article is to discuss general principles and not define specific conditions or domains of plastic surgery that should be treated within the publicly financed system. Methods This analysis uses a reflective equilibrium approach, according to which considered normative judgements in one area should be logically and argumentatively coherent with considered normative judgements and background theories at large within a system. Results and conclusions In exploring functional versus non-function conditions, we argue that it is difficult to find a principled reason for an absolute priority of functional conditions over non-functional conditions. Nevertheless, functional conditions are relatively easier to establish objectively, and surgical intervention has a clear causal effect on treating a functional condition. Considering non-functional conditions that require plastic surgery [i.e., those related to appearance or symptomatic conditions (not affecting function)], we argue that the patient needs to experience some degree of suffering (and not only a preference for plastic surgery), which must be ‘validated’ in some form by the healthcare system. This validation is required for both functional and non-functional conditions. Functional conditions are validated by distinguishing between statistically normal and abnormal functioning. Similarly, for non-functional conditions, statistical normality represents a potential method for distinguishing between what should and should not be publicly funded. However, we acknowledge that such a concept requires further development.

In this article, I argue that the neuroethics of cognitive enhancement can help us bridge the explanatory gap between metaethics and bioethics ( qua normative, applied ethics) and throw light on the classic gap between moral beliefs and neural correlates of brain processes. Insofar as it unveils the irreducibility of first-person propositional attitudes (esp. moral beliefs and judgments), neuroethics allows for justifying cosmetic, pharmacological interventions so as to bring about human enhancement, regardless of descriptive accounts of its neural correlates and independently of the cognitivist, noncognitivist or hybrid inputs of metanormative theories. Precisely because it cannot provide the ultimate grounds for any conservative, libertarian or liberal attitudes towards cognitive enhancement, neuroethics is better conceived in terms of a Rawlsian-like wide reflective equilibrium, procedurally and without any specific substantive commitment to any moral or comprehensive doctrine of sorts.

This chapter surveys three responses the problem of the criterion: particularists claim that beliefs can be justified without our knowing that their sources are trustworthy; methodists claim that methods can be trustworthy without our knowing that they reliably yield true beliefs; and beliefs and methods can be jointly justified by showing that they can accommodate one another in a reflective equilibrium. Each of these responses amounts to begging the question in response to the Agrippan argument, but this need not disqualify them from being effective responses to scepticism. However, the fact that these strategies also involve begging the question when used to justify an epistemic system does disqualify them from being effective responses to epistemic relativism.

In Fact, Fiction and Forecast, Nelson Goodman claims that the problem of justifying induction is not something over and above the problem of describing valid induction. Such claim seems to open up the possibility that the new riddle of induction could be addressed empirically. Discoveries about psychological preferences for projecting certain classes of objects could function as a criterion for determining which predicates are after all projectible. In this paper, I argue that Goodman’s claim must be construed within his project for constructional definitions, which is methodologically oriented by reflective equilibrium. The description of inductive practice is committed to the articulation of the extension of the class selected by the predicate ‘valid induction’. The mutual adjustment between theoretical considerations and inductive practice involved in the proposal of a definition of ‘valid induction’ must preserve that practice as much as possible, there is no way to get rid of entrenchment. Empirical discoveries about the psychological mechanism that underlies projections may help that adjustment but they cannot substitute the role played by the entrenchment of predicates.

When people must either save a greater number of people from a smaller harm or a smaller number from a greater harm, do their choices reflect a reasonable moral outlook? We pursue this question with the help of an experiment. In our experiment, two-fifths of subjects employ a similarity heuristic. When alternatives appear dissimilar in terms of the number saved but similar in terms of the magnitude of harm prevented, this heuristic mandates saving the greater number. In our experiment, this leads to choices that are inconsistent with all standard theories of justice. We argue that this demonstrates the untrustworthiness of distributive judgments in cases that elicit similarity-based choice.

Campbell, Ulrich, and Grady (2016) successfully argue that a broader conception of moral distress—as negative self-directed emotions stemming from one's perceived involvement in a morally undesirab...

In this paper, we examine different forms of altruism. We commence by analysing the ‘behavioural’ definition and, after clarifying its conditions for altruism, we argue that it is not in ‘reflective equilibrium’ with everyday linguistic usage of the term. We therefore consider a ‘psychological’ definition, which we likewise refine, and argue that it better reflects ordinary language use. Both behavioural and psychological approaches define altruism descriptively and thus fail to capture an important aspect of altruism, namely its normative component. Altruism, we argue, is a ‘thick concept’, i.e. one which embodies both positive and normative components. We discuss and compare various formulations of this normative component.

Reflective equilibrium is often credited with extending the idea of accounting for the data from its familiar home in the sciences to the realm of moral philosophy. But careful consideration of the main concepts of this idea—the data to be accounted for and the kind of accounting it is appropriate to expect of a moral theory—leads to a revised understanding of the “accounting for the data” perspective as it applies to the discipline of moral theory selection. This revised understanding is in tension with reflective equilibrium and actually provides more support for the alternative method of moral theory selection that has been termed ‘practical equilibrium’.

The metaphysics of necessity and possibility has flourished in the last half-century, but much less attention has been paid to the question of how we know what can be the case and what must be the case. Many friends of modal metaphysics and many enemies of modal metaphysics have agreed that while empirical discoveries can tell us what is the case, they cannot shed much light on what must be the case or on what non-actual possibilities there are. In this paper, in contrast, I discuss and defend naturalistic approaches to discovering the facts about necessity and possibility. After some remarks about what methodological naturalism in philosophy might amount to, I argue that naturalistic method in modal investigations may not need to be particularly revisionary of much of what is currently being done in modal investigation. I then discuss a number of respects in which a naturalistic orientation in modal investigation may improve on our current epistemic situation.

We describe a form of moral artificial intelligence that could be used to improve human moral decision-making. We call it the “artificial moral advisor” (AMA). The AMA would implement a quasi-relativistic version of the “ideal observer” famously described by Roderick Firth. We describe similarities and differences between the AMA and Firth’s ideal observer. Like Firth’s ideal observer, the AMA is disinterested, dispassionate, and consistent in its judgments. Unlike Firth’s observer, the AMA is non-absolutist, because it would take into account the human agent’s own principles and values. We argue that the AMA would respect and indeed enhance individuals’ moral autonomy, help individuals achieve wide and a narrow reflective equilibrium, make up for the limitations of human moral psychology in a way that takes conservatives’ objections to human bioenhancement seriously, and implement the positive functions of intuitions and emotions in human morality without their downsides, such as biases and prejudices.

This chapter offers a model of how to approach an ethical problem and produce an ethical argument, that is, make a well justified or sound recommendation in a case analysis, for an essay on a test or for a paper in a course. It also includes a model grading rubric which can be used by teachers new to teaching ethics to help them evaluate student essays or papers, and can also be shared with students to give them a better sense of how the teacher might evaluate their work. The chapter concludes with some advice to teachers on how to teach the subject if the teacher is not an ethicist by training.

The doctrine of transferred intent (or transferred “malice” in England) generally provides that if A attempts to harm B but, because of bad aim, misses and accidentally causes the same harm to befall C, A’s harmful intent vis-a-vis B is transferred to C, thus rendering A guilty of intentionally harming C. Commentators acknowledge the doctrine to be a legal fiction, but they differ regarding whether the fiction produces just results, some believing it does, others believing that A is guilty at most of attempting to harm B rather than intentionally harming C. Commentators who agree that the fiction produces just results nevertheless differ regarding whether the fiction should be retained or whether A’s intent to harm “a” person, in this case, B, is the only intent that signifies for crimes of intentional harm, regardless of whom A eventually harms. Doug Husak sought to achieve reflective equilibrium between intuition and theory regarding bad-aim cases by proposing in 1996 that A be punished for attempting to harm B (rather than for harming C) but sentenced as if he had harmed B. I once believed that Husak was correct. But I now have doubts, in part because Husak, along with others, cannot explain why the strength of people’s intuitions regarding A’s responsibility in bad-aim cases depends upon (1) C’s being a reasonably foreseeable victim, and (2) C’s being harmed by the same threat of force that A initially unleashed against B. I argue that one cannot achieve reflective equilibrium in bad-aim cases without inquiring into why resulting harm matters in criminal law, and that when one does, one discovers that just as people’s intuitions regarding whether intentional harms are proximate depend upon how resulting harms occur, so, too, people’s intuitions regarding whether an actor is guilty of intentional harm depend upon how resulting harm comes about.

This purpose of the study was to explore moral literacy and legal reasoning through educational leadership decision making. Participants in the study were students enrolled in a law and ethics course in an educational leadership graduate program. Each student drafted a personal code of ethics at the beginning of the course. Throughout the course, aspects of law, ethics and leadership were examined from a problem-based, case study approach offering students opportunities to examine school leadership decision making through legal and ethical lenses. At the end of the course, students wrote a reflection essay on the content studied, with a connection back to their personal codes and the relationship that those codes have to their legal knowledge, moral reasoning, and professional decision making in leadership. Respondents’ essays reflected each legal theme covered in the course, bringing ethical leadership to the study and practice of law. In addition, the essays illuminated ideas of reflective equilibrium and situational appreciation, both of which speak not only to the students’ personal codes of ethics but also to the approaches that the students bring to professional decision making. Educational leaders bring their personal ethics to the professional decisions they make and, as a result, to the defenses of those decisions. In the end, the questions asked and answered by the statutes, regulations, and cases covered in the course are not merely legal. They are also moral. And the issues raised speak not merely to legal compliance; they speak to leadership.

This is the second of 2 companion articles in this issue. The first article explored the clinical and ethical implications of new emphases in physical therapy codes of conduct reflecting the growing evidence regarding the importance of social determinants of health, epidemiological trends for health service delivery, and the enhanced participation of physical therapists in shaping health care reform in a number of international contexts. The first article was theoretically oriented and proposed that a re-thinking of ethical frameworks expressed in codes of ethics could both inform and underpin practical strategies for working in primary health care. A review of the ethical principle of "justice", which, arguably, remains the least consensually understood and developed principle in the ethics literature of physical therapy, was provided, and a more recent perspective-the capability approach to justice-was discussed. The current article proposes a clinical and ethical decision-making framework, the ethical reasoning bridge (ER bridge), which can be used to assist physical therapy practitioners to: (1) understand and implement the capability approach to justice at a clinical level; (2) reflect on and evaluate both the fairness and influence of beliefs, perspectives, and context affecting health and disability through a process of "wide reflective equilibrium" and assist patients to do this as well; and (3) nurture the development of moral agency, in partnership with patients, through a transformative learning process manifest in a mutual "crossing" and "re-crossing" of the ER bridge. It is proposed that the development and exercise of moral agency represent an enacted justice that is the result of a shared reasoning and learning experience on the part of both therapists and patients. Refereed/Peer-reviewed

Anti-theory is a multi-faceted critique of moral theory which, it appears, is undergoing something of reassessment. In a recent paper Hamalainen discusses the relevance of an anti-theoretical perspective for the activity of applied ethics. This paper explores her view of anti-theory. In particular I examine its relevance for understanding the formal guidance on pandemic flu planning issues by the Department of Health (DoH) in the UK and some subsequent discussions around triage and reverse triage decisions which may be considered by both Primary and Secondary Care Trusts (PCTs and SCTs) (On the division between Primary and Secondary Care Trusts in the UK National Health Service see: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhsstructure.aspx [Accessed August 2010]). in setting their own policies and which may face clinicians in the eventuality of a pandemic. Following Hamalainen in contrasting reflective equilibrium with her anti-theory inspired suggestion of an instrumental approach to moral theory in practice I demonstrate how this understanding complements the diversity of our intuitive moral judgements. Consequentially I suggest that this anti-theoretical instrumental approach is in greater accord with the conditions under which such policy planning and decision making is, or will be, made. Furthermore, on the grounds of keeping open the ethical dimensions of medical practice in conditions of uncertainty, i.e. during a pandemic, I suggest that the anti-theoretical instrumental perspective is, ethically, the preferable approach to producing such policies and guidelines.

In ethics, the use of empirical data has become more and more popular, leading to a distinct form of applied ethics, namely empirical ethics. This 'empirical turn' is especially visible in bioethics. There are various ways of combining empirical research and ethical reflection. In this paper we discuss the use of empirical data in a special form of Reflective Equilibrium (RE), namely the Network Model with Third Person Moral Experiences. In this model, the empirical data consist of the moral experiences of people in a practice. Although inclusion of these moral experiences in this specific model of RE can be well defended, their use in the application of the model still raises important questions. What precisely are moral experiences? How to determine relevance of experiences, in other words: should there be a selection of the moral experiences that are eventually used in the RE? How much weight should the empirical data have in the RE? And the key question: can the use of RE by empirical ethicists really produce answers to practical moral questions? In this paper we start to answer the above questions by giving examples taken from our research project on understanding the norm of informed consent in the field of pediatric oncology. We especially emphasize that incorporation of empirical data in a network model can reduce the risk of self-justification and bias and can increase the credibility of the RE reached.

We consider the current debate between bioconservatives and their chief opponents--whom we dub bioliberals--about the moral acceptability of human enhancement and the policy implications of moral debates about enhancement. We argue that this debate has reached an impasse, largely because bioconservatives hold that we should honour intuitions about the special value of being human, even if we cannot identify reasons to ground those intuitions. We argue that although intuitions are often a reliable guide to belief and action, there are circumstances in which they are not reliable. Intuitions--including intuitions about enhancement--are subject to various cognitive biases rendering them unreliable in some circumstances. We argue that many bioconservative intuitions about enhancement are examples of such unreliable intuitions. Given this, it is unrealistic of bioconservatives to expect others to rely on their unexamined intuitions. Furthermore, refusing to engage in debates about the reasons and values that underpin their intuitions about enhancement will have the effect of making bioconservative voices less relevant in policy debates about enhancement than they would otherwise be.

In the moral realm, our deontic judgments are usually (always?) binary. An act (or omission) is either morally forbidden or morally permissible.1 Yet the determination of an act's deontic status frequently turns on the existence of properties that are matters of degree. In what follows I shall give several examples of binary moral judgments that turn on scalar properties, and I shall claim that these examples should puzzle us. How can the existence of a property to a specific degree demarcate a boundary between an act's being morally forbidden and its not being morally forbidden? Why aren't our moral judgments of acts scalar in the way that the properties on which those judgments are based are scalar, so that acts, like states of affairs, can be morally better or worse rather than right or wrong? I conceive of this inquiry as operating primarily within the realm of normative theory. Presumably it will give aid and comfort to consequentialists, who have no trouble mapping their binary categories onto scalar properties. For example, a straightforward act utilitarian, for whom one act out of all possible acts is morally required (and hence permissible) and all others morally forbidden, can, in theory at least, provide an answer to every one of the puzzles I raise. And, in theory, so can all other types of act and rule consequentialists. They will find nothing of interest here beyond embarrassment for their deontological adversaries. The deontologists, however, must meet the challenges of these puzzles. And for them, the puzzles may raise not just normative questions, but questions of moral epistemology and moral ontology. Just how do we know that the act consequentialist's way of, say, trading off lives against lives is wrong? For example, do we merely intuit that taking one innocent, uninvolved person's life to save two others is wrong? Can our method of reflective equilibrium work if we have no theory by which to rationalize our intuitions? And what things in the world make it true, if it is true, that one may not make the act consequentialist's tradeoff? I do not provide any answers to these questions any more than I provide answers to the normative ones. But they surely lurk in the background.

Living kidney donation provides a promising opportunity in situations where the scarcity of cadaveric kidneys is widely acknowledged. While many patients and their relatives are willing to accept its benefits, others are concerned about living kidney programs; they appear to feel pressured into accepting living kidney transplantations as the only proper option for them. As we studied the attitudes and views of patients and their relatives, we considered just how actively health care professionals should encourage living donation. We argue that active interference in peoples’ personal lives is justified - if not obligatory. First, we address the ambiguous ideals of non-directivity and value neutrality in counselling. We describe the main pitfalls implied in these concepts, and conclude that these concepts cannot account for the complex reality of living donation and transplantation. We depict what is required instead as truthful information and context-relative counselling. We then consider professional interference into personal belief systems. We argue that individual convictions are not necessarily strong, stable, or deep. They may be flawed in many ways. In order to justify interference in peoples’ personal lives, it is crucial to understand the structure of these convictions. Evidence suggests that both patients and their relatives have attitudes towards living kidney donation that are often open to change and, accordingly, can be influenced. We show how ethical theories can account for this reality and can help us to discern between justified and unjustified interference. We refer to Stephen Toulmin’s model of the structure of logical argument, the Rawlsian model of reflective equilibrium, and Thomas Nagel’s representation of the particularistic position.

Although drugs that enhance the cognition of ‘healthy’ individuals (e.g. methylphenidate and modafinil) have received attention from ethicists and philosophers, little research has focused on the concrete opportunities they present for particular groups in society. Recent policy discussion has gone as far as suggesting there may be a moral obligation for individuals in high-risk professions (e.g. surgeons, pilots) to take enhancers. This chapter outlines a theoretical framework and methodology for investigating the claims that some professionals: (a) might have a responsibility to enhance and (b) might acquire more responsibilities once enhanced. Our methodology is interdisciplinary — as we examine normative hypotheses alongside psychological data and legal precedent — and practice-oriented—as we ultimately aim to make recommendations for policy and the professionals within its remit. Philosophical analysis exposes the conceptual and normative questions involved in a discussion of enhancement in professional contexts, offering and refining definitions of concepts (capacity, responsibility) and theory about their relationship. Psychological inquiry uses surveys and experimental methods to collect data from lay people and professionals on attitudes and responsibility attributions associated with enhancement. Legal analysis examines the conditions under which professional duties to enhance might emerge and how the law might impose or limit liability.

Some people have thought that there is a power of intuition by which we have a priori knowledge of self-evident moral truths. Bernard Williams in Ethics and the Limits of Philosophy writes of this view: This model of intuition in ethics has been demolished by a succession of critics, and the ruins of it that remain above ground are not impressive enough to invite much history of what happened to it.1

Bioethical research has tended to focus on theoretical discussion of the principles on which the analysis of ethical issues in biomedicine should be based. But this discussion often seems remote from biomedical practice where researchers and physicians confront ethical problems. On the other hand, published empirical research on the ethical reasoning of health care professionals offer only descriptions of how physicians and nurses actually reason ethically. The question remains whether these descriptions have any normative implications for nurses and physicians? In this article, we illustrate an approach that integrates empirical research into the formulation of normative ethical principles using the moral-philosophical method of Wide Reflective Equilibrium (WRE). The research method discussed in this article was developed in connection with the project ‘Bioethics in Theory and Practice’. The purpose of this project is to investigate ethical reasoning in biomedical practice in Denmark empirically. In this article, we take the research method as our point of departure, but we exclusively discuss the theoretical framework of the method, not its empirical results. We argue that the descriptive phenomenological hermeneutical method developed by Lindseth and Norberg (2004) and Pedersen (1999) can be combined with the theory of WRE to arrive at a decision procedure and thus a foundation for the formulation of normative ethical principles. This could provide health care professionals and biomedical researchers with normative principles about how to analyse, reason and act in ethically difficult situations in their practice. We also show how to use existing bioethical principles as inspiration for interpreting the empirical findings of qualitative studies. This may help researchers design their own empirical studies in the field of ethics.

This article argues that, suitably modified, the method of reflective equilibrium is a plausible way of selecting moral principles. The appropriate conception of the method is wide and radical, admitting consideration of a full range of moral principles and arguments, and requiring the enquiring individual to consider others' views and undergo experiences that may offset any formative biases. The individual is not bound by his initial considered judgments, and may revise his view in any way whatsoever. It is appropriate to describe the method as a balance between coherentism and fallibilist foundationalism. With these points in mind, various criticisms, including the claims that considered judgments are not initially credible and are shaped by prejudice, and that the method itself fails to determine principle selection, are challenged.

This paper outlines a new approach to the epistemology of normative beliefs, based on a version of the claim that ‘the intentional is normative.’ This approach incorporates an account of where our ‘normative intuitions’ come from, and of why it is essential to these intuitions that they have a certain weak connection to the truth. This account allows that these intuitions may be fallible, but it also seeks to explain why it is rational for us to rely on these intuitions in forming normative beliefs—although it is also rational for us to try to correct for these intuitions’ fallibility by revising our normative beliefs in such a way as to approach what Rawls called ‘reflective equilibrium’.

Ethical theories and theories of the person constrain each other, in that a proposition about the person may be a reason for or against an ethical proposition, and conversely. An important class of such propositions about the person concern the boundaries of the person. These boundaries enclose a person's defining properties, which constitute his identity. A person's identity may partly determine and partly be determined by his ethical judgments. An equilibrium between one's identity and one's ethical judgments is the counterpart, at the personal level, of the philosophical ideal of reflective equilibrium between a theory of the person and an ethical theory.

In my recent article, I addressed the question of whether a potential categorical exclusion of decisionally impaired patients from non-therapeutic medical research would be inaccordance with the Principle of Justice as Fairness. I came to the conclusion that a categorical exclusion of decisionally impaired persons from relevant research projects may collide with Rawls’s understanding of Justice as Fairness. Derek Bell has criticized my paper by denying that it is legitimate to apply Rawls to this bioethical problem. In my restatement I try to show that an extrapolation of John Rawls’s thought to such bioethical cases is possible, because Rawls himself has written that his orientation towards decisionally non-impaired persons is an idealized situation that allows extrapolations. In a second part I try to show that Bell hasroughly misunderstood my concept of “presumed consent” which I make a prerequisite for the legitimisation of research on decisionally impaired persons. In using advance consent as a proposal for resolving the problem, Bell has indirectly confirmed my approach because he is using a similar construct of consent, which operates with similar hypotheses and probabilities of error. I see here no categorical difference between Bell’s conclusion and my discussion. Thus, Bell’s reply does not represent a refutation of my thoughts, but rather it is a para phrased confirmation of my central theses. I conclude by showing the relevance of Rawls, pointing out that the discussion between Bell and me illustrates how Rawls’s concept of reflective equilibrium is an appropriate approach to finding a solution to this bioethical problem.

The rationality paradox centers on the observation that people are highly intelligent, yet show evidence of errors and biases in their thinking when measured against normative standards. Elqayam and Evans' (2011) reject normative standards in the psychological study of thinking, reasoning and deciding in favor of a 'value-free' descriptive approach to studying high-level cognition. In reviewing Elqayam and Evans' (2011) position, we defend an alternative to descriptivism in the form of 'soft normativism,' which allows for normative evaluations alongside the pursuit of descriptive research goals. We propose that normative theories have considerable value provided that researchers: (1) are alert to the philosophical quagmire of strong relativism; (2) are mindful of the biases that can arise from utilizing normative benchmarks; and (3) engage in a focused analysis of the processing approach adopted by individual reasoners. We address the controversial 'is-ought' inference in this context and appeal to a 'bridging solution' to this contested inference that is based on the concept of 'informal reflective equilibrium.' Furthermore, we draw on Elqayam and Evans' (2011) recognition of a role for normative benchmarks in research programs that are devised to enhance reasoning performance and we argue that such Meliorist research programs have a valuable reciprocal relationship with descriptivist accounts of reasoning. In sum, we believe that descriptions of reasoning processes are fundamentally enriched by evaluations of reasoning quality, and argue that if such standards are discarded altogether then our explanations and descriptions of reasoning processes are severely undermined.