Max F. Kramer

Services dedicated to clinical ethics consultation (CEC) have rapidly proliferated through American hospital systems. One concern about this notable rate of growth is the possibility that practice has outstripped theory. In particular, it is controversial whether clinical ethicists should offer substantive recommendations as part of their practice. This article addresses the status, legitimacy, and authority of such recommendations, proceeding from the idea that they are to be treated as advisory. Taking this idea seriously and developing it through recent philosophical work on advising helps to defuse challenges to CEC as a profession and promotes a conception of CEC as a collaborative activity with a clear distribution of responsibility between ethicist and stakeholders. Moreover, moral norms for advising that exist in abstraction from particular knowledge domains can help to substantiate and clarify professional norms for CEC practice, including the loci of moral responsibility for patient outcomes, the relationship to patient advocacy, and the norm against functioning as the “ethics police.”

This Case Study describes a patient with oliguric kidney failure who denied his need for hemodialysis even when experiencing symptoms of volume overload. Although any adequate analysis of the case will address a hotly debated issue in clinical ethics, namely, whether denying a diagnosis or prognosis renders a patient incapable of medical decision-making, the focus of this article is elsewhere. Specifically, I raise the concern that no matter which answer we provide to the prior question, the circumstances in which it arises constitute a form of second-order injustice when patient disbelief is a result of justified distrust of medical providers.

Distressing emotions and emotions that impede social functioning are standard components of psychiatric disorders, but the presence of a pathology requires underlying psychological dysfunction in addition. This article argues that, given a commitment to a popular philosophical picture of emotions (and moods), affective dysfunction should be understood in terms of the normative concept of fittingness. Therefore, an individual should be understood to be affectively disordered only if their emotional responses are systematically unfitting. This view gains support from some quarters; notably, the DSM-V-TR diagnostic criteria for Major Depressive Disorder exhibits an inchoate appreciation of the importance of (un)fittingness to psychiatric disorder, and debates about the pathological status of prolonged grief are naturally interpreted as debates about the fittingness of that attitude. Taking a synoptic perspective, accounting for fittingness can help to establish the limits of psychiatric practice and avoid potential disciplinary injustices.

This Case Study describes a patient with oliguric kidney failure who denied his need for hemodialysis even when experiencing symptoms of volume overload. Although any adequate analysis of the case will address a hotly debated issue in clinical ethics, namely, whether denying a diagnosis or prognosis renders a patient incapable of medical decision-making, the focus of this article is elsewhere. Specifically, I raise the concern that no matter which answer we provide to the prior question, the circumstances in which it arises constitute a form of second-order injustice when patient disbelief is a result of justified distrust of medical providers.

Philosophers and psychiatrists have independently turned their attention to a specific question about grief, namely, how long it should last. They come to surprisingly different conclusions: for philosophers, there always exists a reason for grief; for psychiatrists, prolonged grief constitutes a mental disorder. Where to go from here? One starting point is the common experience in grief of having "lost a part of oneself," known in the literature as 'identity disruption.' If this idea is developed in the context of Nada Gligorov's recent work on identity crisis, it provides a way of pinning down the crux of the interdisciplinary disagreement. However, it is not enough to resolve it—determining exactly how long one should grieve will require careful weighing of ethical, epistemic, and practical reasons.

(Runner-up, Royal Institute of Philosophy 2020 Philosophy Essay Prize) Technological developments have led to the digitization of certain sectors of the economy, and this has many authors looking ahead to the prospects of a post-work society. While it is valuable to theorize about this possibility, it is also important to take note of the present state of work. For better or worse, it is what we are currently stuck with, and as the COVID-19 pandemic has ensured, much of that work is now taking place online. Though a ‘return to normalcy’ is on the horizon, part of that normalcy involves online work, which is itself a significant change in the lives of many workers. Here I develop an account of work on which work is teleologically structured. This gives the result that working is something we can fail at doing, even when we try, and we can also be unsure of whether we’ve succeeded or failed. The shift of certain work from in-person to online modes generates a persistent uncertainty for workers in affected professions. Because our ability to work is something we typically value, this uncertainty has significant negative consequences for a worker’s self-conception. Indeed, it is analogous to disorders of agency and generates a kind of alienation.

Many theorists have defended the claim that collective entities can attain genuine agential status. If collectives can be agents, this opens up a further question: can they be conscious? That is, is there something that it is like to be them? Eric Schwitzgebel argues that yes, collective entities, may well be significantly conscious. Others, including Kammerer, Tononi and Koch, and List reject the claim. List does so on the basis of Tononi’s Integrated Information Theory of consciousness. I argue here that List’s rejection is too quick, and that groups can, at least in principle, display the kind of informational integration we might think is necessary for consciousness. However, group consciousness will likely differ substantially from the individual experiences that give rise to it. This requires the defender of group consciousness to face up to a similar combination problem as the panpsychist.