New Blackfriars, Volume 103, Issue 1107, Page 607-621, September 2022.

There has recently been a resurgence of philosophical and scientific interest in the foundations of self-consciousness, with particular focus on its altered, anomalous forms. This paper looks at the altered forms of self-awareness in Depersonalization Disorder (DPD), a condition in which people feel detached from their self, their body and the world (Derealisation). Building upon the phenomenological distinction between reflective and pre-reflective self-consciousness, we argue that DPD may alter thetransparencyof basic embodied forms of pre-reflective self-consciousness, as well as the capacity (...) to flexibly modulate and switch between the reflective and pre-reflective facets of self-awareness. Empirical evidence will be invoked in support of the idea that impaired processing of bodily signals is characteristic of the condition. We provide first-hand subjective reports describing the experience of self-detachment or fracture between an observing and an observed self. This split is compared with similar self-detachment phenomena reported in certain Buddhist-derived meditative practices. We suggest that these alterations and changes may reveal the underlying and tacit transparency that characterises the embodied and basic pre-reflective forms of self-consciousness, in the same way that a crack in a transparent glass may indicate the presence of an unnoticed window. (shrink)

The National Institute for Health and Care Excellence, the UK’s main healthcare priority-setting body, recently reaffirmed a longstanding claim that in recommending technologies to the National Health Service it cannot apply the ‘rule of rescue’. This paper explores this claim by identifying key characteristics of the rule and establishing to what extent these are also features of NICE’s approach to evaluating ultra-orphan drugs through its highly specialised technologies programme. It argues that although NICE in all likelihood does not act because (...) of the rule in prioritising these drugs, its actions in relation to HSTs are nevertheless in accordance with the rule and are not explained by the full articulation of any alternative set of rationales. That is, though NICE implies that its approach to HSTs is not motivated by the rule of rescue, it is not explicit about what else might justify this approach given NICE’s general concern with overall population need and value for money. As such, given NICE’s reliance on notions of procedural justice and its commitment to making the reasons for its priority-setting decisions public, the paper concludes that NICE’s claim to reject the rule is unhelpful and that NICE does not currently meet its own definition of a fair and transparent decision-maker. (shrink)

_Imagination_ is an outstanding contribution to a notoriously elusive and confusing subject. It skillfully interrelates problems in philosophy, the history of ideas and literary theory and criticism, tracing the evolution of the concept of imagination from Hume and Kant in the eighteenth century to Ryle, Sartre and Wittgenstein in the twentieth. She strongly belies that the cultivation of imagination should be the chief aim of education and one of her objectives in writing the book has been to put forward reasons (...) why this is so. Purely philosophical treatment of the concept is shown to be related to its use in the work of Coleridge and Wordsworth, who she considers to be the creators of a new kind of awareness with more than literary implications. The purpose of her historical account is to suggest that the role of imagination in our perception and thought is more pervasive than may at first sight appear, and that the thread she traces is an important link joining apparently different areas of our experience. She argues that imagination is an essential element in both our awareness of the world and our attaching of value to it. (shrink)

The UK’s National Institute for Health and Care Excellence is responsible for conducting health technology assessment on behalf of the National Health Service. In seeking to justify its recommendations to the NHS about which technologies to fund, NICE claims to adopt two complementary ethical frameworks, one procedural—accountability for reasonableness —and one substantive—an ‘ethics of opportunity costs’ that rests primarily on the notion of allocative efficiency. This study is the first to empirically examine normative changes to NICE’s approach and to analyse (...) whether these enhance or diminish the fairness of its decision-making, as judged against these frameworks. It finds that increasing formalisation of NICE’s approach and a weakening of the burden of proof laid on technologies undergoing HTA have together undermined its commitment to EOC. This implies a loss of allocative efficiency and a shift in the balance of how the interests of different NHS users are served, in favour of those who benefit directly from NICE’s recommendations. These changes also weaken NICE’s commitment to AfR by diminishing the publicity of its decision-making and by encouraging the adoption of rationales that cannot easily be shown to meet the relevance condition. This signals a need for either substantial reform of NICE’s approach, or more accurate communication of the ethical reasoning on which it is based. The study also highlights the need for further empirical work to explore the impact of these policy changes on NICE’s practice of HTA and to better understand how and why they have come about. (shrink)

Healthcare priority-setting institutions have good reason to want to demonstrate that their decisions are morally justified—and those who contribute to and use the health service have good reason to hope for the same. However, finding a moral basis on which to evaluate healthcare priority-setting is difficult. Substantive approaches are vulnerable to reasonable disagreement about the appropriate grounds for allocating resources, while procedural approaches may be indeterminate and insufficient to ensure a just distribution. In this paper, we set out a complementary, (...) coherence-based approach to the evaluation of healthcare priority-setting. Drawing on Rawls, we argue that an institutional priority-setter’s claim to moral justification can be assessed, in part, based on the extent to which its many normative commitments are mutually supportive and free from dissonance; that is, on the ability to establish narrow reflective equilibrium across the normative content of a priority-setter’s policy and practice. While we do not suggest that the establishment of such equilibrium is sufficient for moral justification, we argue that failure to do so might—like the proverbial canary in the coalmine—act as a generalised warning that something is awry. We offer a theoretical argument in support of this view and briefly outline a practical method for systematically examining coherence across priority-setting policy and practice. (shrink)

The National Institute for Health and Care Excellence (NICE) is the UK’s primary healthcare priority-setting body, responsible for advising the National Health Service in England on which technologies to fund and which to reject. Until recently, the normative approach underlying this advice was described in a 2008 document entitled ‘Social value judgements: Principles for the development of NICE guidance’ (SVJ). In January 2020, however, NICE replaced SVJ with a new articulation of its guiding principles. Given the significant evolution of NICE’s (...) methods between 2008 and 2020, this study examines whether this new document (‘Principles’) offers a transparent account of NICE’s current normative approach. It finds that it does not, deriving much of its content directly from SVJ and failing to fully acknowledge or explain how and why NICE’s approach has since changed. In particular, Principles is found to offer a largely procedural account of NICE decision-making, despite evidence of the increasing reliance of NICE’s methods on substantive decision-rules and ‘modifiers’ that cannot be justified in purely procedural terms. Thus, while Principles tells NICE’s stakeholders much about how the organisation goes about the process of decision-making, it tells them little about the substantive grounds on which its decisions are now based. It is therefore argued that Principles does not offer a transparent account of NICE’s normative approach (either alone, or alongside other documents) and that, given NICE’s reliance on transparency as a requirement of procedural justice, NICE does not in this respect satisfy its own specification of a just decision-maker. (shrink)

Background As the UK’s main healthcare priority-setter, the National Institute for Health and Care Excellence (NICE) has good reason to want to demonstrate that its decisions are morally justified. In doing so, it has tended to rely on the moral plausibility of its principle of cost-effectiveness and the assertion that it has adopted a fair procedure. But neither approach provides wholly satisfactory grounds for morally defending NICE’s decisions. In this study we adopt a complementary approach, based on the proposition that (...) a priority-setter's claim to moral justification can be assessed, in part, based on the coherence of its approach and that the reliability of any such claim is undermined by the presence of dissonance within its moral system. This study is the first to empirically assess the coherence of NICE’s formal approach and in doing so to generate evidence-based conclusions about the extent to which this approach is morally justified. Methods The study is grounded in the theory, methods and standards of empirical bioethics. Twenty NICE policy documents were coded to identify and classify the normative commitments contained within NICE technology appraisal policy as of 31 December 2021. Coherence was systematically assessed by attempting to bring these commitments into narrow reflective equilibrium (NRE) and by identifying sources of dissonance. Findings Much of NICE policy rests on coherent values that provide a strong foundation for morally justified decision-making. However, NICE’s formal approach also contains several instances of dissonance which undermine coherence and prevent NRE from being fully established. Dissonance arises primarily from four sources: i) NICE’s specification of the principle of cost-effectiveness; ii) its approach to prioritising the needs of particular groups; iii) its conception of reasonableness in the context of uncertainty, and iv) its concern for innovation as an independent value. Conclusion At the time of analysis, the level of coherence across NICE policy provides reason to question the extent to which its formal approach to technology appraisal is morally justified. Some thoughts are offered on why, given these findings, NICE has been able to maintain its legitimacy as a healthcare priority-setter and on what could be done to enhance coherence. (shrink)

The latter half of the eighteenth century saw radical changes in the way nature - both external and human nature - was perceived. It is these new perceptions, these new images of the 'the natural' that this book examines: new appreciations of the 'sublime' wildness of landscape; new revelations by the life sciences of natural creative fecundity; new assertions of the innocence of 'natural man', as illustrated by the noble savage, the contented peasant, the happy family; a new sense of (...) harmony between man and nature, reflected in changing moral, psychological, economic, and religious attitudes. Professor Charlton concentrates on French examples, for in France the contrast between old and new views was particularly vivid; but there are also numerous comparisons with England and other European countries, making this a major study in the cultural history of Europe at an especially crucial time for the formation of many of our modem assumptions about man and nature. (shrink)

One rationale policy-makers sometimes give for declining to fund a service or intervention is on the grounds that it would be ‘unaffordable’, which is to say, that the total cost of providing the service or intervention for all eligible recipients would exceed the budget limit. But does the mere fact that a service or intervention is unaffordable present a reason not to fund it? Thus far, the philosophical literature has remained largely silent on this issue. However, in this article, we (...) consider this kind of thinking in depth. Albeit with certain important caveats, we argue that the use of affordability criteria in matters of public financing commits what Parfit might have called a ‘mistake in moral mathematics’. First, it fails to abide by what we term a principle of ‘non-perfectionism’ in moral action: the mere fact that it is practically impossible for you to do all the good that you have reason to do does not present a reason not to do whatever good you can do. And second, when used as a means of arbitrating between which services to fund, affordability criteria can lead to a kind of ‘numerical discrimination’. Various attendant issues around fairness and lotteries are also discussed. (shrink)

Systems Theory analyses the world in terms of communications and divides the natural world into environment and systems. Systems are characterised by their high density of communications and tend to become more complex and efficient with time, usually by means of increased specialisation and coordination of functions. Management is an organisational sub-system which models all necessary aspects of organisational activity such that this model may be used for monitoring, prediction and planning of the organisation as a whole. The function of (...) a specific management system depends on its history of selection by interactions with the environment (which includes other systems). The main function of a management system will be a consequence of the most powerful and sustained selection pressure it has experienced. Systems Theory implies a management science which is quantitative and comparative. It is quantitative because it is based upon the measurement and mapping of communications as the basis of analysis; it is comparative because evaluations relate to specific variables measured in a specific spatio-temporal context and subjected to analytic processes of constrained complexity. Selection processes are broadly responsible for the dominance of management in contemporary Western societies. The complexity of management systems will probably continue to increase for as long as the efficiency-enhancing potential of complexity outweighs its increased transaction costs. (shrink)

First published in 1970. What is a work of art? What is the status of things in pictures and books? How are we to distinguish and ascertain the meaning of a literary work at various levels? This book is intended both to introduce the reader to classic philosophical accounts of art and beauty, and to bring out the significance for aesthetics of recent developments in philosophy.

BackgroundIn the Canadian Alliance for Healthy Hearts and Minds (CAHHM) cohort, participants underwent magnetic resonance imaging (MRI) of the brain, heart, and abdomen, that generated incidental findings (IFs). The approach to managing these unexpected results remain a complex issue. Our objectives were to describe the CAHHM policy for the management of IFs, to understand the impact of disclosing IFs to healthy research participants, and to reflect on the ethical obligations of researchers in future MRI studies.MethodsBetween 2013 and 2019, 8252 participants (...) (mean age 58 ± 9 years, 54% women) were recruited with a follow-up questionnaire administered to 909 participants (40% response rate) at 1-year. The CAHHM policy followed a restricted approach, whereby routine feedback on IFs was not provided. Only IFs of severe structural abnormalities were reported.ResultsSevere structural abnormalities occurred in 8.3% (95% confidence interval 7.7–8.9%) of participants, with the highest proportions found in the brain (4.2%) and abdomen (3.1%). The majority of participants (97%) informed of an IF reported no change in quality of life, with 3% of participants reporting that the knowledge of an IF negatively impacted their quality of life. Furthermore, 50% reported increased stress in learning about an IF, and in 95%, the discovery of an IF did not adversely impact his/her life insurance policy. Most participants (90%) would enrol in the study again and perceived the MRI scan to be beneficial, regardless of whether they were informed of IFs. While the implications of a restricted approach to IF management was perceived to be mostly positive, a degree of diagnostic misconception was present amongst participants, indicating the importance of a more thorough consent process to support participant autonomy.ConclusionThe management of IFs from research MRI scans remain a challenging issue, as participants may experience stress and a reduced quality of life when IFs are disclosed. The restricted approach to IF management in CAHHM demonstrated a fair fulfillment of the overarching ethical principles of respect for autonomy, concern for wellbeing, and justice. The approach outlined in the CAHHM policy may serve as a framework for future research studies.Clinical trial registrationhttps://clinicaltrials.gov/ct2/show/nct02220582. (shrink)

On a wide range of measures and across cultures and societies, women tend to be more religious than men. Religious beliefs are associated with evolved social-cognitive mechanisms such as agency detection and theory-of-mind. Women perform better on most of these components of social cognition, suggesting an underlying psychological explanation for these sex differences. The Existential Orientation Scale was developed to extend the measurement of religion to include non-religious beliefs. Factor analysis extracted two dimensions: religious orientation and science acceptance. This new (...) scale was used to investigate the hypothesis that the dimensions of empathizing, a measure of social cognition, and systemizing can explain the sex differences in religious orientation. The sex differences in both religious orientation and science acceptance disappeared when empathizing and systemizing were entered. This indicates that underlying dimensions of individual differences can explain existential orientation better than being male or female. (shrink)

Historians of French politics, art, philosophy and literature have long known the tensions and fascinations of Louis XV's reign, the 1750s in particular. David Charlton's study comprehensively re-examines this period, from Rameau to Gluck and elucidates the long-term issues surrounding opera. Taking Rousseau's Le Devin du Village as one narrative centrepiece, Charlton investigates this opera's origins and influences in the 1740s and goes on to use past and present research to create a new structural model that explains the elements of (...) reform in Gluck's tragédies for Paris. Charlton's book opens many new perspectives on the musical practices and politics of the period, including the Querelle des Bouffons. It gives the first detailed account of intermezzi and opere buffe performed by Eustachio Bambini's troupe at the Paris Opéra from August 1752 to February 1754 and discusses Rameau's comedies Platée and Les Paladins and their origins. (shrink)