Mary Jean Walker

Alcohol use causes significant harms and is extensively regulated by governments, but alcohol-related questions are under-explored in public health ethics. To inform future work in this area, I conducted interviews with key informants from alcohol research and policy work in Australia. Thematic analysis of interviews identified a range of ethical issues that can be categorized under six themes: ethical issues in alcohol research; ethical issues raised by judgements about alcohol use; ethical issues raised by alcohol policies; ethical issues in policy processes; ethical questions about policy aims; and ethical issues in how alcohol problems are defined. The study provides direction for future research on problems that are underexplored in the ethics literature. These include problems arising from the influence of industry in alcohol research and policy, the question of how to develop research and policy without generating stigma, and social justice issues connected to alcohol-related stereotypes and judgements.

Criminal courts increasingly treat intoxication as an aggravating rather than a mitigating factor in sentencing. This shift, seen in Australian law and other jurisdictions, raises the prospect of unjust outcomes. We examine this trend through the lens of desert‐based justifications for punishment, setting aside questions of deterrence and public safety. We first argue that intoxication can impair key capacities required for responsibility, suggesting that it should sometimes mitigate blame. We then examine two counter‐arguments. The first takes responsibility to stem from the expression of character (attributability) while the second traces responsibility for intoxicated wrongdoing to an earlier decision to become intoxicated (the tracing principle). We argue that these arguments can only justify treating intoxication as non‐mitigating in specific cases. Drawing on this analysis, we identify conditions under which intoxication might legitimately aggravate culpability, but again find that these conditions are met in only a subset of cases. We conclude that sentencing guidelines which treat intoxication as generally aggravating are likely to increase sentences in many cases where punishment is otherwise appropriate or should even be reduced, leading to systematic injustice in sentencing decisions.

Debate about whether or not addiction is a disease has been central to practice and policy responses. In this paper, we aim to move that debate forward by understanding why the disease status of addiction is so unclear and contested, and draw on pragmatic considerations to suggest a partial resolution. To do this, we apply the vague cluster view of ‘disease’. This view is pragmatic since it allows appeal to the practical implications of considering a condition to be a disease in justifying the classification, for particular purposes. After explaining the view, we apply it to addiction to show that whether or not addiction has the typical features of a disease is unclear due to the vagueness and ambiguity of these features. We then examine pragmatic considerations often deemed relevant to deciding addiction’s disease status to see if these can suggest precisification. Pragmatic disease accounts are potentially problematic in that pathologising addiction simultaneously has both positive and negative effects, and it can be difficult to maintain different precisifications across contexts. Nonetheless we argue that the vague cluster approach circumscribes some ways of conceptualising addiction as disease, namely those that conceptualise disease as solely physiological dysfunction. It thus prompts a pragmatic shift to a broader understanding of addiction that partially resolves the negative consequences of disease designation. The discussion suggests that disagreements over whether addiction is a disease are primarily normative and semantic, rather than being disagreements over facts.

An influential group of authors writing in philosophy of mind defend what has become known as the “extended mind”. The extended mind thesis (EMT) states that cognition is not confined to the brain or the body but extends into the environment. A cognitive process can include objects such as notebooks, electronic devices, or beads on an abacus. Where the objects involved in cognitive processes meet certain criteria, they can be considered part of a person’s ‘extended mind’. In this paper we develop an analogous argument for an ‘extended body thesis’ (EBT). EBT claims that bodily processes are not confined within the skin but extend into the environment. A bodily process can include objects such as machines that support respiration, circulation, mobility, or manipulation of objects. Where the objects involved in bodily processes meet certain criteria, they can be considered parts of a person’s ‘extended body’. This is a counterintuitive conclusion about bodies, with difficult practical and ethical implications. We suggest that proponents of the extended mind thesis need to either explain why arguments for EMT are valid, but the analogous argument for EBT are invalid, or bite the bullet and admit that bodies as well as minds are extended. Those who choose the latter option owe us an account of how we should relate to each other as entities who are both mentally and physically “in the world” with all the radical possibilities for entanglements that implies.

Philosophy of medicine is thought of today as a distinct discipline with its own set of concerns. This title focuses on all major aspects of the philosophy of medicine and the attempts of philosophers, bioethicists, and physicians to address its unique set of problems and questions. It deals with the various metaphysical, ethical and practical problems and questions facing modern medicine such as human nature and mind; reductionism and holism; causation and etiology; notions of disease, health, illness and disability; ageing, death and suicide; medical theory and models; social determinants of health and the role of factors such as technology and evidence-based medicine in providing valid diagnostic and therapeutic knowledge.

“Classic,” serotonergic psychedelic drugs such as LSD and psilocybin are the objects of renewed attention in science and psychiatry. A recent spate of research has produced evidence that psychedelics might be safe and effective adjuncts to the treatment of mood and addictive disorders, agents of positive psychological change in healthy subjects, and valuable tools for studying the neural mechanisms of perception and cognition. This chapter surveys three philosophical debates that have arisen in response to this “renaissance” of psychedelic research. The first concerns the mechanisms of psychedelic-assisted psychotherapy (“psychedelic therapy”): How, exactly, does psychedelic administration in controlled conditions cause lasting psychological benefits? The second concerns the implications of psychedelic research for the philosophy of mind: Does psychedelic evidence show that there can be conscious mental states lacking all forms of self-consciousness? The third concerns the epistemic status of the psychedelic state: Is it possible that certain kinds of knowledge, or other epistemic benefits, could be gained by undergoing a psychedelic experience?

Advances in prosthetic design should benefit people with limb difference. But empirical evidence demonstrates a lack of uptake of prosthetics among those with limb difference, including of advanced designs. Non-use is often framed as a problem of prosthetic design or a user’s response to prosthetics. Few studies investigate user experience and preferences, and those that do tend to address satisfaction or dissatisfaction with functional aspects of particular designs. This results in limited data to improve designs and, we argue, this is pragmatically and ethically problematic. This paper presents results of a survey we conducted in 2017 with people with upper limb difference in Australia. The survey sought to further knowledge about preferences surrounding prosthetics and understanding of how preferences relate to user experience, perspective, and context. Survey responses demonstrated variety in the uptake, use and type of prosthetic—and that use of, preferences about, and impacts of prosthetics rely not just on design factors but on various contextual factors bearing on identity and social understandings of disability and prosthetic use. From these results, we argue that non-use of prosthetics could be usefully reframed as an issue of understanding how prosthetics can best support users’ autonomy. This supports the claim that there is a need to incorporate user engagement into design processes for prosthetic limbs, though further work is needed on methods for doing so.

This paper examines potential ethical and legal issues arising during the research, develop- ment and clinical use of a proposed strategy in personalized medicine (PM): using human induced pluripotent stem cell (iPSC)-derived tissue cultures as predictive models of individ- ual patients to inform treatment decisions. We focus on epilepsy treatment as a likely early application of this strategy, for which early-stage stage research is underway. In relation to the research process, we examine issues associated with biological samples; data; health; vulnerable populations; neural organoids; and what level of accuracy justifies using the iPSC-derived neural tissue system. In relation to clinical use, we examine potential uses in pre-natal screening, and effects on clinical decision-making. Although our focus is providing recommendations for researchers developing work in this area, we identify the novel issue of deciding on an acceptable accuracy level for the system. We also emphasize an issue thus far neglected in the ethics of PM: PM tends to represent treatment decisions as though they should be directed solely by biomedical information, but this in itself could be detri- mental to best personalizing treatment decisions in the clinic.

Artificial devices that functionally replace internal organs are likely to be more common in the future. They are becoming more and more technologically feasible, increases in chronic diseases that can compromise various organs are anticipated, and donor organs will remain necessarily limited. More people in the future may have bodies that are partly nonorganic. How might artificial organs affect how we experience and conceptualize our bodies and how we understand the relation of the body to the experiencing, acting subject, or self? Here, I focus on artificial heart devices (AHDs), including total artificial hearts (TAHs) and ventricular assist devices (VADs). While other devices, such as pacemakers and implantable cardiac defibrillators, assist the heart, I focus on devices that replace rather than assist organic function. AHDs, I argue, may have two opposing effects. On the one hand, having an AHD could alter experience, seemingly confirming that selves are shaped by the specifics of embodiment. On the other hand, AHDs are likely to encourage people to regard bodies as machines that are separable from the self. AHDs thus both confirm and undermine a body-self dualism. People with these devices may come to regard their bodies as machinelike even while having an artificial part alters their subjective experience.

Positive claims about narrative approaches to healthcare suggest they could have many benefits, including supporting person-centred healthcare (PCH). Narrative approaches have also been criticised, however, on both theoretical and practical grounds. In this paper we draw on epistemological work on narrative and knowledge to develop a conception of narrative that responds to these concerns. We make a case for understanding narratives as accounts of events in which the way each event is described as influenced by the ways other events in the narrative are described. This view of narratives recognises that they can contribute knowledge of different kinds of connections between events: not just causal, and not just of patient’s perspectives. Additionally, narratives can add further epistemic value by suggesting potentially useful lines of inquiry. We take narrative approaches to healthcare to include clinicians considering both patients’ informational offerings and their own professional understandings as narratives. On this understanding, our account is able to overcome the major theoretical and practical criticisms that have been levelled against the use of narrative approaches in healthcare, and can help to explain why and how narrative approaches are consistent with PCH.

Recently, concerns have been raised about the phenomenon of 'overdiagnosis', the diagnosis of a condition that is not causing harm, and will not come to cause harm. Along with practical, ethical, and scientific questions, overdiagnosis raises questions about our concept of disease. In this paper, we analyse overdiagnosis as an epistemic problem and show how it challenges many existing accounts of disease. In particular, it raises questions about conceptual links drawn between disease and dysfunction, harm, and risk. We argue that "disease" should be considered a vague concept with a nonclassical structure. On this view, overdiagnosed cases are 'borderline' cases of disease, falling in the zone between cases that are clearly disease, and cases that are clearly not disease. We then develop a précising definition of disease designed to provide practical help in preventing and limiting overdiagnosis. We argue that for this purpose, we can define disease as dysfunction that has a significant risk of causing severe harm to the patient.

The ethical debate about neurotechnologies—including both drugs and implanted devices—has been largely framed around the questions of whether and when these technologies could damage or promote authenticity. Patients can experience changes in mood, behavior, emotion, or preferences—seemingly, changes in character or personality. Some describe such changes by saying they feel like different people; that they have become either more or less themselves; or that they feel as though some of their moods, behaviors, emotions or preferences are not their own. These kinds of statements are used to describe both changes that a drug or device is...

Advances in prosthetic design should benefit people with limb difference. But empirical evidence demonstrates a lack of uptake of prosthetics among those with limb difference, including of advanced designs. Non-use is often framed as a problem of prosthetic design or a user’s response to prosthetics. Few studies investigate user experience and preferences, and those that do tend to address satisfaction or dissatisfaction with functional aspects of particular designs. This results in limited data to improve designs and, we argue, this is pragmatically and ethically problematic. This paper presents results of a survey we conducted in 2017 with people with upper limb difference in Australia. The survey sought to further knowledge about preferences surrounding prosthetics and understanding of how preferences relate to user experience, perspective, and context. Survey responses demonstrated variety in the uptake, use and type of prosthetic—and that use of, preferences about, and impacts of prosthetics rely not just on design factors but on various contextual factors bearing on identity and social understandings of disability and prosthetic use. From these results, we argue that non-use of prosthetics could be usefully reframed as an issue of understanding how prosthetics can best support users’ autonomy. This supports the claim that there is a need to incorporate user engagement into design processes for prosthetic limbs, though further work is needed on methods for doing so.

The literature of Twelve Step groups such as Alcoholics Anonymous contains apparently contradictory implications regarding powerlessness and personal responsibility. In this essay I examine the treatment of these concepts in Twelve Step literature and their implications for the self-conception of people in these programs. In the first section, I examine the literature to demonstrate that addicts are presented as powerless over, yet responsible for, their addictive behaviors. In the second section, I outline two potential ways people in Twelve Step programs might reconcile this contradiction within their self-conception, but I argue that neither is satisfactory. In the third section, I draw on Paul Ricoeur's theory of narrative identity to develop an account of how someone ni a Twelve Step group could coherently understand herself as both powerless and responsible.

Surgery is an important part of contemporary health care, but currently much of surgery lacks a strong evidence base. Uptake of evidence-based medicine (EBM) methods within surgical research and among practitioners has been slow compared with other areas of medicine. Although this is often viewed as arising from practical and cultural barriers, it also reflects a lack of epistemic fit between EBM research methods and surgical practice. In this paper we discuss some epistemic challenges in surgery relating to this lack of fit, and investigate how resources from feminist epistemology can help to characterize them. We point to ways in which these epistemic challenges may be addressed by gathering and disseminating evidence about what works in surgery using methods that are contextual, pluralistic, and sensitive to hierarchies

Recently, concerns have been raised about the phenomenon of ‘overdiagnosis’, the diagnosis of a condition that is not causing harm, and will not come to cause harm. Along with practical, ethical, and scientific questions, overdiagnosis raises questions about our concept of disease. In this paper, we analyse overdiagnosis as an epistemic problem and show how it challenges many existing accounts of disease. In particular, it raises ques- tions about conceptual links drawn between disease and dysfunction, harm, and risk. We argue that ‘disease’ should be considered a vague concept with a non-classical structure. On this view, overdiagnosed cases are ‘borderline’ cases of disease, falling in the zone between cases that are clearly disease, and cases that are clearly not disease. We then develop a pre ́cising definition of disease designed to provide practical help in preventing and limiting overdiagnosis. We argue that for this purpose, we can define disease as dysfunction that has a significant risk of causing severe harm to the patient.

Personalised medicine has been discussed as a medical paradigm shift that will improve health while reducing inefficiency and waste. At the same time, it raises new practical, regulatory, and ethical challenges. In this paper, we examine PM strategies epistemologically in order to develop capacities to address these challenges, focusing on a recently proposed strategy for developing patient-specific models from induced pluripotent stem cells so as to make individualised treatment predictions. We compare this strategy to two main PM strategies—stratified medicine and computational models. Drawing on epistemological work in the philosophy of medicine, we explain why these two methods, while powerful, are neither truly personalised nor, epistemologically speaking, novel strategies. Both are forms of correlational black box. We then argue that the iPSC models would count as a new kind of black box. They would not rely entirely on mechanistic knowledge, and they would utilise correlational evidence in a different way from other strategies—a way that would enable personalised predictions. In arguing that the iPSC models would present a novel method of gaining evidence for clinical practice, we provide an epistemic analysis that can help to inform the practical, regulatory, and ethical challenges of developing an iPSC system.

Technological advances are making devices that functionally replace body parts—artificial organs and limbs—more widely used, and more capable of providing patients with lives that are close to “normal.” Some of the ethical issues this is likely to raise relate to how such prostheses are conceptualized. Prostheses are ambiguous between being inanimate objects and sharing in the status of human bodies—which already have an ambiguous status, as both objects and subjects. At the same time, the possibility of replacing body parts with artificial objects puts pressure on the normative status typically accorded to human bodies, seemingly confirming that body parts are replaceable objects. The paper argues that bodies’ normative status relies on the relation of a body to a person and shows that persons could have similar relations to prostheses. This suggests that in approaching ethical issues surrounding prostheses, it is appropriate to regard them as more like body parts than like objects.

Programs of drug testing welfare recipients are increasingly common in US states and have been considered elsewhere. Though often intensely debated, such programs are complicated to evaluate because their aims are ambiguous – aims like saving money may be in tension with aims like referring people to treatment. We assess such programs using a proportionality approach, which requires that for ethical acceptability a practice must be: reasonably likely to meet its aims, sufficiently important in purpose as to outweigh harms incurred, and lower in costs than feasible alternatives. In the light of empirical findings, we argue that the programs fail the three requirements. Pursuing recreational drug users is not important in the light of costs incurred, while dependent users who may require referral are usually identifiable without testing and typically need a broader approach than one focussing on drugs. Drug testing of welfare recipients is therefore not ethically acceptable policy.

In this paper, we examine recent critiques of the debate about defining disease, which claim that its use of conceptual analysis embeds the problematic assumption that the concept is classically structured. These critiques suggest, instead, developing plural stipulative definitions. Although we substantially agree with these critiques, we resist their implication that no general definition of “disease” is possible. We offer an alternative, inductive argument that disease cannot be classically defined and that the best explanation for this is that the concept is structured as a cluster. We further argue that we do not need to reject the possibility of defining the general concept “disease” to legitimate developing stipulative definitions of disease that are relative to particular purposes. A cluster definition of disease is compatible with contextually motivated definitions, which may be considered précisifications of the more general cluster concept.

‘Contract cheating’ has recently emerged as a form of academic dishonesty. It involves students contracting out their coursework to writers in order to submit the purchased assignments as their own work, usually via the internet. This form of cheating involves epistemic and ethical problems that are continuous with older forms of cheating, but which it also casts in a new form. It is a concern to educators because it is very difficult to detect, because it is arguably more fraudulent than some other forms of plagiarism, and because it appears to be connected to a range of systemic problems within modern higher education. This paper provides an overview of the information and literature thus far available on the topic, including its definition, the problems it involves, its causal factors, and the ways in which educators might respond. We argue that while contract cheating is a concern, some of the suggested responses are themselves problematic, and that best practice responses to the issue should avoid moral panic and remain focussed on supporting honest students and good academic practice

Vaccine refusal occurs for a variety of reasons. In this article we examine vaccine refusals that are made on conscientious grounds; that is, for religious, moral, or philosophical reasons. We focus on two questions: first, whether people should be entitled to conscientiously object to vaccination against contagious diseases ; second, if so, to what constraints or requirements should conscientious objection to vaccination be subject. To address these questions, we consider an analogy between CO to vaccination and CO to military service. We argue that conscientious objectors to vaccination should make an appropriate contribution to society in lieu of being vaccinated. The contribution to be made will depend on the severity of the relevant disease, its morbidity, and also the likelihood that vaccine refusal will lead to harm. In particular, the contribution required will depend on whether the rate of CO in a given population threatens herd immunity to the disease in question: for severe or highly contagious diseases, if the population rate of CO becomes high enough to threaten herd immunity, the requirements for CO could become so onerous that CO, though in principle permissible, would be de facto impermissible.

In this paper I seek to clarify the role of narrative in personal unity. Examining the narrative self-constitution view developed by Marya Schechtman, I use a case of radical personal change to identify a tension in the account. The tension arises because a narrative can be regarded either to capture a continuing agent with a loosely coherent, consistent self-conception – or to unify over change and inconsistency. Two possible ways of responding, by distinguishing senses of identity or distinguishing identity and autonomy, are examined, but I argue that neither precisely maps this tension. I then develop a distinction between two ways in which narrative can unify: through “bottom-up” processes related to the connection between agency and self-conception; and “top-down” processes related to self-interpretative activity. The account provides ways to resolve some criticisms of narrative theories of identity, in particular in better accounting for the role of repudiated characteristics in narrative identity.

Designing and manufacturing medical devices for specific patients is becoming increasingly feasible with developments in 3D printing and 3D imaging software. This raises the question of how patient-specific devices can be evaluated, since our ‘gold standard’ method for evaluation, the randomised controlled trial, requires that an intervention is standardised across a number of individuals in an experimental group. I distinguish several senses of patient-specific device, and focus the discussion on understanding the problem of variations between instances of an intervention for RCT evaluation. I argue that, despite initial appearances, it is theoretically possible to use RCTs to evaluate some patient-specific medical devices. However, the argument reveals significant difficulties for ensuring the validity of such trials, with implications for how we should think about methods of evidence gathering and regulatory approaches for these technologies.

Evidence in medicine can come from more or less trustworthy sources and be produced by more or less reliable methods, and its interpretation can be disputed. As such, it can be unclear when disagreements in medicine result from different, but reasonable, interpretations of the available evidence and when they result from unreasonable refusals to consider legitimate evidence. In this article, we seek to show how assessments of the relevance and implications of evidence are typically affected by factors beyond that evidence itself, such as our beliefs about the credibility of the speaker or source of the evidence. In evaluating evidence, there is thus a need for reflective awareness about why we accept or dismiss particular claims