Thanks to everyone who contacted me about the malware on this site. While I am (or was) the last writer remaining, I do not control the site and have been able to nothing about the issue.

I do continue to post my essays on my own malware free site, aphilosopher.drmcl.com.

Mike LaBossiere

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On February 14th, 2018 seventeen people were murdered during a school shooting. As per the well-established script: the media focused on the weapon used, the right offered “thoughts and prayers” while insisting that this was not the time to talk about gun violence, and the left called for more gun control. As other have pointed out many times, this script will also play out in the usual way—the attention of the nation will drift away, children will be buried by their parents and nothing will really be done. This cycle will repeat with the next school shooting. And the next. As a country, we are getting it wrong in many ways.

One way we get it wrong, which is a fault of the media and the left, is to obsess on the specific weapon used in the latest school shooting. In this case, like many other cases, the weapon was an AR-15. The media always seems to ask why the weapon is used in shootings; the easy and obvious answer is that it shows up at mass shootings for the same reason that McDonald wrappers and bags end up alongside the roads I run. That is, both are very popular. There is also the fact that the AR-15 is an ideal weapon for engaging a crowd—it has a large magazine capacity, it is lethal and is easy to shoot. But, the AR-15 is not unique in those traits. There are many other assault rifles (as they are called) that are similar. For example, the AK-47 and its clones are also effective weapons of this type; but they are the Arby’s of assault weapons. That is, less popular. There is also the fact that non-assault weapons are just as lethal (or more so) than the assault rifles. They just tend to have smaller magazines. This shows one of the problems with the obsession with the AR-15—there are other weapons that would do the same.

Another problem with obsessing about the specific weapon is that it allows an easy red herring counter. A red herring is when one diverts attention from the original issue to another issue. When, for example, a reporter starts pressing a congressman about the AR-15, they can easily switch the discussion from gun violence to a discussion about the AR-15, thus getting away from the real issue. The solution is, obviously enough, is to get over the obsession with the specific weapon and focus instead on the issue of gun violence in general. Which leads to another way we get it wrong.

School shootings are horrific, but they are not the way most victims of gun violence die. In general, homicides are at record low levels (although we are still a world leader in homicides). Most gun-related deaths are suicides and the assault rifle is not the most commonly used weapon in most gun deaths. School shootings and mass shootings do get the attention of the media and the nation, but this seems to enable us to ignore the steady flow of gun-related deaths that do not grab the headlines. This is not to say that mass shootings are not a serious problem, nor that we should not act in response to them. But, the gun violence problem in America goes far beyond mass shootings. It is, ironically, a quiet problem that does not get the spotlight of the media. As such, even less is done about the broader problem than is done about mass shootings. And, to be honest, little or nothing is done about mass shootings.

While there are proposals from the left for gun control, the right usually advocates having a “good guy with a gun”, addressing mental illness, and fortifying places such as schools. There seems to be little evidence that the “good guy with a gun” will solve the problem of mass shootings; but this is largely due to the fact that there is so little good data about gun violence. While mental illness is clearly a problem and seriously addressing mental illness would be a broad social good, it seems unlikely that the vague proposals being offered would really do anything. America essentially abandoned the mentally ill during the Reagan era, an approach that has persisted to this day. The right does not seem to be serious about putting in the social services needed to address mental illness; they merely bring it up in response to mass shootings to distract people from gun control. The left, while expressing concern, also has done little—we have massive problems in this country that are simply festering away. Also, people with mental illnesses are more likely to be victims than perpetrators, so addressing mental health in a way that focuses on mass shooters would not address the much broader problem.

The proposals to create “Fortress Academia” might seem appealing, but there is the obvious problem with cost: public schools tend to be chronically underfunded and it is not clear where the money needed for such fortification would come from. There is also the fact that turning schools intro fortresses seems fundamentally wrong and is, perhaps, a red herring to distract people from the actual causes of the problem. To use an analogy, it is like addressing the opioid epidemic by telling people to get better home security to prevent addicts from breaking in to steal things to sell to buy drugs. This is not to say that school safety is a bad idea, just that turning our schools into forts does not seem to be the best approach.

I know that it will not be that long before I am writing about another mass shooting; people will move on to other things, as they always do, and the malign neglect of the problem will persist.

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While Logan Paul has posted YouTube videos of rather awful behavior, his channel is still operating as of this writing. Paul’s latest video adventure involved tasering a dead rat, leading Penny Arcade to raise the moral question of the ethics of dead rat tasering as well as the morality of YouTube continuing to tolerate the presence of Paul’s videos.

Since YouTube is in the business of making money, it makes sense for it to monetize whatever legal product will make money, regardless of how awful it is. Since our civilization tolerates the sale of tobacco and opioids (with a prescription), it is rather hard to condemn the “selling” of what Paul creates. After all, there are clear doubts about the harms of viewing a video of a dead rat riding the lightning. While much could be said about the ethics of allowing these videos to remain up (since YouTube is a private company, it has no requirement to honor the 1st Amendment), I will turn to Penny Arcade’s inquiry into the tasering of a dead rat. Obviously, this discussion will take place within the context of Kant’s ethical theory.

Kant makes it clear that animals are means rather than ends—they have no moral status of their own. Rational beings, in contrast, are ends. For Kant, this distinction rests on the fact that rational beings can chose to follow the moral law. Animals, lacking reason, cannot do this. Since animals are means and not ends, Kant claims that we have no direct duties to animals. They are classified in with the other “objects of our inclinations” that derive value from the value we give them. While one might dispute Kant’s view about the ability of living animals to follow the moral law, one can see clearly and distinctly that a dead rat cannot do this. It is, after all, dead. An ex-rat.

Despite this view, Kant argues that we should treat animals well. However, he does so while also trying to avoid ascribing animals themselves any moral status. While Kant is not willing to accept that we have any direct duties to animals, he “smuggles” in duties to them indirectly. As he puts it, our duties towards animals are indirect duties towards humans. To make his case for this, he employs an argument from analogy: if a human doing X would obligate us to that human, then an animal doing X would also create an analogous moral obligation. For example, a human who has long and faithfully served another person should not simply be abandoned or put to death when he has grown old. Likewise, a dog who has served faithfully and well should not be cast aside in his old age.

While this would seem to create an obligation to the dog, Kant uses philosophical sleight of hand: the dog cannot judge (that is, the dog is not rational) so, as Kant sees it, the dog cannot be wronged. So, then, why would it be wrong to shoot the dog?

Kant’s answer seems to be rather consequentialist in character: he argues that if a person acts in inhumane ways towards animals (shooting the dog, for example) then his humanity will likely be damaged. Since, as Kant sees it, humans do have a duty to show humanity to other humans, shooting the dog would be wrong. This would not be because the dog was wronged but because humanity would be wronged by the shooter damaging his humanity through such a cruel act. In support of this, Kant discusses how people develop cruelty: they often begin with animals and then work up to harming human beings.

Kant goes beyond merely enjoining us to not be cruel to animals and encourages kindness. He even praises Leibniz’ gentleness towards a mere worm. Of course, he encourages this because those who are kind to animals will develop more humane feelings towards humans. So, roughly put, animals are essentially practice for us: how we treat them is training for how we will treat human beings. But what about dead animals, like the rat Paul tasered?

A dead animal clearly and obviously lacks any meaningful moral status of their own. While animal right advocates tend to argue that living animals think and feel, even they would agree that a dead animal does not feel or think. As such, a dead animal lacks all the qualities that might give them a moral status of their own. Oddly enough, given Kant’s view of living animals, a dead animal would seem to be on par with a living one. After all, living animals are also mere objects and have no moral status of their own.

Of course, the same is also true of rocks and dirt. Yet Kant would never argue that we should treat rocks well. Perhaps this would also apply to dead animals, such as the rat Paul tasered. That is, perhaps it makes no sense to talk about good or bad relative to dead animals. Thus, the issue is whether dead animals are more like live animals or rocks.

A case can be made for not abusing dead animals. If Kant’s argument has some merit, then the key concern about how non-rational beings are treated is how such treatment affects the behavior of the person engaging in said behavior. So, for example, if being cruel to a living rat could damage a person’s humanity, then he should (as Kant sees it) not be cruel to the living rat.  This should also extend to dead animals. For example, if being cruel to a dead rat would damage a person’s humanity, then he should not act in that way. If being kind to the dead rat, such as giving it a burial, would make a person more inclined to be kind to other rational beings, then the person should be kind to the corpse.

While some might think to mock the idea of treating dead animals well, it is well worth noting that Kant’s reasoning would also apply to dead humans. A dead human is no longer a rational being—the corpse is but a thing. However, abusing the corpse of a human could damage a person’s humanity and make them more inclined to harm living humans. As such, while human corpses have no moral status of their own, it would be wrong to abuse them.

While the impact of abusing a human corpse would probably be greater than abusing the corpse of an animal, it would be odd to think that most decent people would be able to abuse animal corpses and suffer no ill consequences to their character. As such, the question raised by Penny Arcade can be answered: tasering a dead rat is morally wrong.

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While analogies, like cars, always break down in the end, they can be useful discussion devices. While on a run, I was thinking about my recent injury-induced lack of racing trophies and this topic kept blending in with that of the division of goods in a competitive capitalist society. This lead to an obvious analogy between road races and capitalism.

Both racing and capitalism involve competition and this generates winners and losers. Winners are, of course, supposed to be rewarded for the victories while losers are expected to reflect on their defeat and try harder next time. When planning a road race or managing capitalism, those in charge must address the nature and division of the rewards for the competition. In the case of a road race, this requires the race director to work out the prizes and decide such things as whether there will be age group awards and, if so, how deep the awards will go. In the case of capitalism, those in charge decide how the laws and polices will divide up the rewards.

While there are many ways to approach the division of the rewards, there are two broad approaches. One is to have a top-heavy reward system that yields the rewards to a few winners. In the case of a road race, this will typically involve all the prizes going to the top three runners or even just the first-place finisher. In the case of capitalism, this will typically involve most of the rewards going to the very top winners with the leftovers divided up among the many losers.

Another approach, broadly speaking, is to spread the rewards more broadly among a larger base of winners. For example, many races have age group awards in addition to the overall awards. Most races also have male and female groups as well, which further divides the prizes of victory. In the case of capitalism, this approach would give less to the top winners and divide more among the lesser winners. For example, under such an approach successful small businesses and successful middle and lower class individuals would get more of the rewards. This would, of course, mean less for those at the top of the pyramid, such as the biggest corporations and the individual billionaires.

One argument often advanced in favor of the top-heavy systems of capitalism is to contend that a broader division of the rewards would be some sort of socialism that would destroy competition. But, this is not the case. A broader reward system would still be competitive capitalism, it would just have a broader division of the rewards. Returning to the race analogy, a race that has a broader division of prizes is no less a race than one that offers prizes only to the first-place finishers. Competition remains, the difference is that there will be more winners and fewer losers.

It could, of course, still be argued that having a broader division of rewards would reduce competition and make things worse. In the case of a race, the idea is that runners would think “why should I train or race as hard as before to try to win the whole race when I can now get a prize for being third in my age group?” In the case of capitalism, people would presumably say “why should I work as hard as before to try to be the biggest winner when I can now get decent rewards for just being moderately successful?”

While I will not claim that no one thinks that way, most runners still train hard and race hard regardless of what sort of division of prizes the race offers. The same would seem to hold true of capitalism—people would still work hard and compete even when there was no massive prize for a few and little for everyone else. In fact, people who know they have little or no chance at the biggest prize would presumably compete somewhat harder if they knew that there was a broader division of the rewards and their efforts could pay off with prizes. Also, in the case of capitalism, people already work hard for small prizes when they know they have no chance of ever getting the biggest prize. As such, unless they are delusional or irrational they are not motivated by having a top-heavy reward system. Survival provides an adequate motivation.

At this point, one might want to bring up the example of races that have participation awards—that everyone gets a medal just for showing up. The economic analog would be a form of socialism or communism in which everyone gets the same reward regardless of effort. This, many would argue, would be terrible and unfair.

In the case of races, runners still compete even if everyone gets the same prize (be it the same medal or nothing at all). Because, of course, many people just love to compete for the sake of competition or for reasons that have nothing to do with prizes. It would hardly be a stretch to think that this view also extends into the economic realm—especially since there are people, such as open source developers and community volunteers, who work hard for no prizes. But, there is certainly a reasonable case to be made that people need to win prizes to be really motivated to do anything.

I must admit that while I will still run hard in such a race, I still have a love for competing for prizes. As such, I prefer races that offer competition-based rewards. I am, however, grudgingly tolerant of participation medals—after all, someone who shows up and does the whole race has accomplished something meaningful even if they did not win. Naturally enough, a race can have both participation medals and prizes for winning. In the case of an economy, this would be a competitive system that offered better rewards to the winners, but also provided those who are actively participating in the economy with at least minimal reward. One area in which this analogy breaks down is that the economy has people who cannot participate (the very old, the very young, the ill and so on) and it would be a far more serious matter for these people to get nothing than it is for people who do not finish the race to not get their participation medals.

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In an earlier essay, I considered the various evil Dungeons & Dragons alignments in the context of institutions. In that essay, I took the view that lawful evil people are the most dangerous of all because they aim to institutionalize evil. However, a case can be made that the lawful evil approach is better than that of the other evil alignments. Making a case for this involves appealing to the work of Thomas Hobbes.

In the Leviathan, Hobbes argues that the state of nature would be a war of all against all, a state perhaps best described as chaotic evil at worst and chaotic neutral at best. However, his description of people makes most of them seem to be neutral evil (utterly selfish, with no concern for others). He regarded the chaos of the state of nature as the worst and his solution was, roughly put, for people to accept a sovereign to rule over them and impose order. This would transform the chaotic evil of the state of nature into the lawful evil of the state of civilization. In D&D, lawful evil is defined in this way:

A lawful evil villain methodically takes what he wants within the limits of his code of conduct without regard for whom it hurts. He cares about tradition, loyalty, and order but not about freedom, dignity, or life. He plays by the rules but without mercy or compassion. He is comfortable in a hierarchy and would like to rule, but is willing to serve. He condemns others not according to their actions but according to race, religion, homeland, or social rank. He is loath to break laws or promises.

This reluctance comes partly from his nature and partly because he depends on order to protect himself from those who oppose him on moral grounds. Some lawful evil villains have particular taboos, such as not killing in cold blood (but having underlings do it) or not letting children come to harm (if it can be helped). They imagine that these compunctions put them above unprincipled villains.

This description shows that lawful evil types have the qualities needed to maintain civilization and hold off the state of nature. The lawful evil persons respect for tradition, loyalty and order lead them to value the institutions of the state and they will seek to protect and preserve them. They might even be willing to tolerate some goodness in these institutions, provided that the goodness contributes to order.

Interestingly, a principled lawful evil person would be loath to harm or attack an institution even if doing so was personally advantageous. For example, a lawful evil ruler being investigated for a crime would do much to avoid being punished but would be very reluctant to harm or weaken the institutions of law enforcement. This is because a lawful evil person lacks the shallow selflessness of the neutral evil person and cares, in their own evil way, about the preservation of society and its institutions. As such, the lawful evil person can act in a principled way and could even sacrifice themselves for others, and thus they could be mistaken for being good people.

While a lawful evil person would not be good, they could be rightly said to have virtues.  Kant, in his Fundamental Principles of the Metaphysics of Morals, makes this point:

Moderation in the affections and passions, self-control, and calm deliberation are not only good in many respects, but even seem to constitute part of the intrinsic worth of the person; but they, are far from deserving to be called good without qualification, although they have been so unconditionally praised by the ancients. For without the principles of a good will, they may become extremely bad; and the coolness of a villain not only makes him far more dangerous, but also directly makes him more abominable in our eyes than he would have been without it.

While Kant regards evil combined with virtue to be perhaps the very worst, the lawful evil villain, as noted above, operates within limits that puts them above the worst villains—the chaotic evil and neutral evil types. While lawful evil types lack, in Kantian terms, the good will, they could be said to have the lawful will. That is, while they do not will the good, they do will the law. While this would certainly not satisfy Kant, it would be quite enough for Hobbes. For him, what gets humans out of the chaos of the state of nature is not goodness or love or others, but self-interest and an acceptance of order. Roughly put, enough people are willing to shift their alignments from chaotic or neutral evil to lawful evil to allow society to form. Maintaining that society requires that enough people remain lawful, even if they are lawful evil. As such, good people who value society and order can find allies in their lawful evil fellows, although this alliance can presumably never be more than one of convenience. This is because while good and lawful evil people share a common desire to oppose chaotic evil and neutral evil types, they still have an irreconcilable moral difference regarding good and evil.

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As noted in an earlier essay, the Trump administration plans to modify the Health and Human Services (HHS) civil rights office to protect health care workers who have moral or religious objections to performing certain medical procedures or treating certain patients.  In that essay I addressed the general moral issue of  whether health workers have the moral right to refuse certain services. I now turn to the general issue of whether they have the moral right to refuse to treat certain patients (or clients) based on the identity of the patients (or clients). The legal matter, of course, is something for the courts to settle.

As noted in the earlier essay, a person does not surrender their moral rights or conscience when they enter a profession. As such, it should not simply be assumed that a health care worker cannot refuse to treat a person because of the worker’s values. But, of course, it should also not be assumed that the moral or religious values of a health care worker grant them the right to refuse treatment based on the identity of the patient.

One moral argument for the right to refuse treatment because of the patient’s identity is based on the general right to refuse to provide a good or service. A key freedom, one might argue, is this freedom from compulsion. For example, an author has every right to determine who they will and will not write for.

Another moral argument for the right to refuse is a general one about the right to not be forced to interact with people whom one regards as evil or at least immoral. This can also be augmented by contending that serving the needs of an immoral person is to engage in an immoral action, if only by association. For example, a Jewish painter has every right to refuse to paint a mural for Nazis.

While these arguments have considerable appeal, especially in cases in which the refusal is directed at the sorts of people one dislikes, it is important to consider the implications of a right of refusal based on values. One obvious implication is that such a right could warrant a health care worker to refuse to treat you if they regarded you as immoral. In general terms, moral rights need to be assessed by applying a moral method I call reversing the situation. Parents and others often employ this method informally by asking questions such as “how would you feel if someone did that to you?”

Somewhat more formally, this method is based on the Golden Rule: “do unto others as you would have them do unto you.” Assuming this rule is correct, if a person is unwilling to abide by his own principles when the situation is reversed, then it is reasonable to question those principles. In the case at hand, while a person might be fine with the right to refuse services to those they dislike because of their values, they would presumably not be fine with it if the situation were reversed.

An obvious objection is that reversing the situation would, strictly speaking, only apply to health workers themselves. Fortunately, there is a modified version of this method that would apply to everyone. In this method one test of a moral right, principle or rule is for a person to replace the proposed target of the right, principle or rule with themselves or a group (or groups) they belong to. For example, a Christian who thinks it is morally fine to refuse services to transgender people based on religious freedom should consider their thoughts on atheists refusing services to Christians based on religious freedom. Naturally, a person could insist that the right, rule or principle should only be applied to those they do not like—but if anyone can take this out, then it would seem everyone could as well, thus the objection would fail.

One reasonable reply to this method is to point out that there are clear exceptions to its application. For example, while most Christians are fine with convicted murders being locked up, it does that follow that they are wrong about this because they would not want to be locked up for being Christians. In such cases, which also applies to reversing the situation, it can be argued that there is a morally relevant difference between the two people or groups that justifies the difference in treatment. For example, convicted murders generally deserve to be punished for being murders while Christians obviously do not merit punishment just for being Christians. As such, when considering the moral right of health care workers to refuse services based on the identity of the patient (or client) the possibility of relevant differences must be given due consideration.

The obvious problem with relevant difference considerations is that people will tend to think there is a relevant difference between themselves and those they want to apply the right of refusal. For example, a person who is a social justice warrior might regard a member of the alt-right as an evil racist and see this as a relevant difference that warrants refusing service to such a person. One solution is to appeal to an objective moral judge—but this creates the obvious problem of finding such a person. Another solution is for the person to take special pains to be objective—but this is rather difficult and especially so in cases in which objectivity is often most needed.

A final relevant consideration is the fact that while entering a profession does not strip a person of their conscience or moral agency, it often imposes professional ethics on the person that supersede their own values within the professional context. For example, lawyers must accept a professional ethics that requires them to keep certain secrets their client might have (the most obvious being when they did the crime) even when doing so might violate their personal ethics. As another example, lawyers (especially public defenders) are expected to defend their clients even if they find their clients morally awful. As a third example, as a professor I (in general) cannot insist that a student be removed from my class by appealing to my religious or moral values regarding the identity of the student. As a professor, I am obligated to teach anyone enrolled in my class, if they do not engage in behavior that would warrant their removal (such as assaulting other students). Health care workers generally fall under professional ethics as well and these typically include requirements to render care to people regardless of what the worker things of the morality of the person. For example, a doctor does not have the right to refuse to perform surgery on someone just because they committed adultery, are a compulsive liar, have engaged in shady and even illegal business practices or expressed their proclivity to grab people by a certain part of their anatomy. This is not to say that there cannot be exceptions, but professional medical ethics would seem to forbid refusing service just because of the moral judgment by the service provider of the patient (or client). This, obviously enough, is distinct from refusing services because a patient or client has engaged in behavior that warrants refusal, such as attacking the service provider.

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The government shutdown of January, 2018 led to the usual efforts to place blame. The Republicans assert that the Democrats are in the wrong—if only they would put the interest of America ahead of their unpatriotic devotion to the illegals eager to remain or cross in search of handouts, then there would be no problem. The Democrats blame the Republicans, presenting their own narrative of the evils of the Republicans. Sorting out the responsibility in such matters can be rather problematic; especially since everyone typically contributes to the problem.

It is, of course, tempting to be cynical about the matter and embrace the narrative that each side is simply maneuvering to maximize the chances that its members will be re-elected in the next cycle. To truly cynical eyes, the Democrats are trying to win the votes of the brown people. The Republicans are struggling to win the votes of the white people who are terrified of the brown people. This view, I hope, does a disservice to both sides. But, the problem remains of sorting out the responsibility.

One factor that makes objectively assessing responsibility in this matter is in-group bias. This is a cognitive bias that influences people to see members of their group as better than those outside the group. As such, people who identify with a political party will see their party as better and the other party as worse. So, in the eyes of most Democrats, the Republicans are to blame—they seem to be in the wrong because Democrats see other Democrats as better. The same sort of bias holds for Republicans—they will tend to see the Democrats as being in the wrong.

This bias can also fuel a full fallacy, which is sometimes called the group think fallacy. This fallacy occurs when a person infers that their group is right or better simply because it is their group. The mistake is, of course, that the fact that a group is one’s own does not entail that it is right, good or better. Naturally, many people have the sense to realize that openly asserting that their side is right because it is their side is not a good argument. As such, they tend to advance reasons in favor of the position they already hold, seeking evidence that confirms the conclusion they have drawn from the in-group fallacy and that conforms to their in-group bias.

The psychological commitment people have to their groups can lead to distorting the evidence and, not surprisingly, to making use of other fallacies in “defense” of their position. As such, a Democrat reading this is most likely certain that the Republicans are to blame, while a Republican reading this is probably sure that this trouble is all the fault of the Democrats.

Even if people were willing and able to push through the in-group bias and resist the lure of the group think fallacy, there would still be a challenge in assigning responsibility. One reason for this is the matter of value. In the case at hand, a key question is whether it is worth shutting down the government to try to get what one wants (or to deny the other people what they want). Both the Democrats and Republicans have agreed that it is worth doing so—the Democrats refused to go along with the Republicans and the Republicans refused to cooperate with the Democrats. This leaves the question of whether one of them has it right. This, of course, leads to the debate over values and both sides can sincerely believe that they are in the right. This leads to the classic question of whether such values are objective or subjective. If they are objective, at least one side is in the wrong. If values are subjective, then they could both be in the right, albeit meaningless so. After all, if everyone is right, then right means nothing.

As far as who I blame, my inclination is to place most of it on Trump. Both the Democrats and the Republicans worked together on a compromise, but Trump rejected it and seems to be engaged in yet another twitter tantrum. But, of course, my perception is shaded by my biases.

 

 

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The Trump administration plans to modify the Health and Human Services (HHS) civil rights office to protect health care workers who have moral or religious objections to performing certain medical procedures or treating certain patients. As should be expected, the focus of concern is mainly on abortion and transgender patients. Two of the general moral issues raised by this situation are whether health workers have the moral right to refuse certain services and whether they have the right to refuse to treat certain patients based on the identity of the patients.

While some might, perhaps while thinking of abortion rights, automatically conclude that health care workers have no moral right to refuse services, this would be far to hasty. After all, entering a profession does not entail that a person surrenders their moral rights or conscience. To think otherwise would be to embrace the discredited notion that just following orders or just doing one’s job provides a blanket moral excuse for one’s professional actions. As such, since health care workers are morally accountable for their actions, they also retain the moral agency and freedom needed to ground that accountability.

But, this moral coin has another side—entering a profession, especially in the field of health, also comes with moral and professional responsibilities. These responsibilities can, like all responsibilities, can justly impose burdens. For example, doctors are not permitted to instantly abandon patients they dislike or because they want to move to a better paying position. As such, ethics of a health worker refusing to perform a procedure based on their moral or religious views requires that each procedure be reviewed to determine whether it is one that a health care worker can justly refuse or one that is a justly imposed burden.

To illustrate, consider a doctor who is asked to keep prisoners conscious and alive during torture performed by agents of the state. Most doctors, like most people, would have moral objections to being involved in torture. However, there is the question of whether this would be something they should be morally expected to do as part of their profession. On the face of it, since the purpose of the medical profession is to heal and alleviate suffering (a professional ethics that goes back to the origin of western medicine) this is not something that a doctor is obligated to do even in the face of moral objections. In fact, the ethics of the profession would dictate against engaging in this behavior.

Now, imagine a health care worker who has sincere religious or moral beliefs that when a person can no longer sustain their life on their own, they must be released to God. As such, the worker refuses to engage in procedures that violate their principles, such as keeping a patient on life support. While this could be a sincerely held belief, it seems to run counter to the ethics of the profession. As such, such a health care worker would seem to not have the right to refuse such services.

One could even imagine very extreme cases—after all there is no requirement to prove that sincerely held religious belief is true, one must only be convincing in one’s alleged sincerity. For example, imagine a health care worker who has a sincere religious belief that a patient must prove themselves worthy in the eyes of God by surviving with only the most basic care; anything beyond that is an affront to God’s will: the patient will survive if God wants them to and humans should not interfere with this. Obviously enough, such workers’ views would not be accepted as justifying their actions—they should seek another profession if they cannot do their jobs.

Turning back to services like abortion and gender transition, the issue would be whether these are more like asking a medical worker to participate in torture or more like expecting a medical worker to provide normal medical services. As should be expected, this is a central point of the dispute. Those who oppose abortion will make the moral argument that performing abortion is as bad or worse than abetting torture—it does, after all, involve killing a living entity. Those who are pro-choice will contend that it is a medical procedure like any other. I must admit that I do not have a compelling argument to change any minds on this matter.

In the case of gender transition, there can be no appeal to concerns about killing. Rather, a person must appeal to the view that people should not modify their sex and should simply accept what they were born with. This seems to be more like my imaginary case of a health care worker who believes that people must prove themselves worthy in the eyes of God than like the torture case, especially if someone takes the view that God wants people to stick with their original sex. That said, it could be argued that such modifications are wrong in the same way that non-restorative cosmetic surgery is wrong—after all, both aim to allow a person to be as they envision themselves to be. I do not, however, want to claim that the transitional process is as trivial as a face lift. Once again, I do not think I have a compelling argument here that will change any minds.

While I do not think I will change minds about abortion and such, I do think that the matter of moral objections needs to be given due consideration. It is easy to simply embrace one’s unreflecting views without considering the possibility of error. In my next essay I’ll turn to the issue of whether health workers have the moral right to refuse services based on the identity of the patient, such as their being transgender or Christian.

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Dungeons & Dragons (D&D) introduced the alignment system to the gaming world. This system, though regarded by many players as restrictive and artificial, offered a degree of guidance on how to play good, evil, lawful, chaotic and neutral characters. This system has also proven useful in the real world, allowing gaming nerds like me to quickly categorize actions and people. This system is also rather useful for mapping the current political landscape of America.

A key component of any society is its institutions. In the United States these institutions include the systems that constitute the government such as Congress, the Environmental Protection Agency, the Supreme Court and the Federal Bureau of Investigation. These institutions are used to maintain (or impose, if you prefer) order. While it is tempting to mistake order for goodness, D&D makes a clear distinction between lawful and good—a distinction long recognized by philosophers. In the D&D alignment system, creatures can be lawful (as opposed to chaotic or neutral) but also evil at the same time. Good creatures can be chaotic or neutral; thus rejecting the constraints of law and order.  Evil creatures that are not lawful also have the option to be chaotic or neutral. While chaotic good and neutral good creatures will support (or at least not harm) good institutions of order and law, evil creatures that are not lawful are generally willing to harm evil institutions of order and law—as will be seen, they care not for order.

The alignment most vehemently opposed to order and institutions of order is chaotic evil. Chaotic Evil is defined this way:

A chaotic evil character does whatever his greed, hatred, and lust for destruction drive him to do. He is hot-tempered, vicious, arbitrarily violent, and unpredictable. If he is simply out for whatever he can get, he is ruthless and brutal. If he is committed to the spread of evil and chaos, he is even worse. Thankfully, his plans are haphazard, and any groups he joins or forms are poorly organized. Typically, chaotic evil people can be made to work together only by force, and their leader lasts only as long as he can thwart attempts to topple or assassinate him.

In the real world, chaotic evil types are generally involved with institutions from the outside and this is typically an adversarial role. For example, a person who is actively chaotic evil will tend to run afoul of law enforcement. Chaotic evil types can be useful to institutions—for example, terrorist groups find this sort of person useful as a suicide bomber or cannon fodder. If a chaotic evil person holds power in an institution, either or both will tend to fare poorly—such types tend to either destroy or be destroyed by the forces of order. Be they good or evil.

Neutral evil beings can operate within institutions far better than chaotic evil types. Neutral evil is defined this way

A neutral evil villain does whatever she can get away with. She is out for herself, pure and simple. She sheds no tears for those she kills, whether for profit, sport, or convenience. She has no love of order and holds no illusion that following laws, traditions, or codes would make her any better or more noble. On the other hand, she doesn’t have the restless nature or love of conflict that a chaotic evil villain has.

While chaotic evil types can be like wild beasts assailing order or beastly idiots within the china shop of society, neutral evil types tend to be like parasites within a host. While institutions sensibly regard neutral evil types as a dangerous enemy, neutral evil people often find institutions very useful as means to their own selfish ends. For example, a neutral evil person who secured a political office would use it to enrich themselves at the expense of the institution and the people they are supposed to serve. Sensible neutral evil types are careful to not kill their host—at least for as long as they need it. They can even seem to serve order by exposing or destroying other neutral evil people. But this is also from selfishness-they do not value order for its own sake, they merely dislike having competition.

As should be surmised from the name, lawful evil creatures favor institutions of order and law. D&D defines lawful evil this way:

 A lawful evil villain methodically takes what he wants within the limits of his code of conduct without regard for whom it hurts. He cares about tradition, loyalty, and order but not about freedom, dignity, or life. He plays by the rules but without mercy or compassion. He is comfortable in a hierarchy and would like to rule, but is willing to serve. He condemns others not according to their actions but according to race, religion, homeland, or social rank. He is loath to break laws or promises.

This reluctance comes partly from his nature and partly because he depends on order to protect himself from those who oppose him on moral grounds. Some lawful evil villains have particular taboos, such as not killing in cold blood (but having underlings do it) or not letting children come to harm (if it can be helped). They imagine that these compunctions put them above unprincipled villains.

In the real world, lawful evil people find happy homes in institutions. In some cases, they make up most of the leaders of the institution and rely on non-evil, but lawful, followers to implement their evil. In fiction, the Empire of Star Wars is a paradigm case of lawful evil. In the real world, Nazi Germany is often presented as a paradigm of lawful evil. While these examples are clear cases of evil, most governments tend to have strong lawful evil components. For example, the legal acceptance and state enforcement of slavery in the United States was a paradigm case of lawful evil.

Lawful evil people, as the description suggests, can appear to be good people—or at least to have virtues. For example, a lawful person in the real world might work for law enforcement and be a paradigm of loyalty, a respecter of tradition and a stickler for rules as they systematically oppress people of a certain ethnicity or religion within their society. They are a paragon of law, but not of goodness.

Both Plato and Kant were aware of this sort of problem—the danger of a person with only some of the virtues, or in Kant’s terms, lacking a good will. Plato warned of the clever rogue: “Did you never observe the narrow intelligence flashing from the keen eye of a clever rogue‑how eager he is, how clearly his paltry soul sees the way to his end; he is the reverse of blind, but his keen eye‑sight is forced into the service of evil, and he is mischievous in proportion to his cleverness?” Kant, in his Fundamental Principles of the Metaphysics of Morals, raises a similar point:

Moderation in the affections and passions, self-control, and calm deliberation are not only good in many respects, but even seem to constitute part of the intrinsic worth of the person; but they, are far from deserving to be called good without qualification, although they have been so unconditionally praised by the ancients. For without the principles of a good will, they may become extremely bad; and the coolness of a villain not only makes him far more dangerous, but also directly makes him more abominable in our eyes than he would have been without it.

The paragon of lawful evil is just this sort of person and the most dangerous villain of all, for they are not content with mere selfishness nor are they merely bringers of chaos. Rather they forge institutions of evil or corrupt existing institutions. This allows for systematic, large scale evil that is easily perceived by good—even by the lawful evil themselves.

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One aspect of Obamacare was the expansion of Medicaid in states that agreed to accept this expansion. Some states, such as my adopted state of Florida, declined the expansion. This provided researchers with an opportunity to study the effects of accepting or rejecting the expansion.

One study, conducted by <a href=”https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2017.0976″>researchers at the University of Colorado Anschutz Medical Campus</a>, found that hospitals in states that expanded Medicaid were six times less likely to close than hospitals in states that declined the expansion. Hospitals in rural areas, which tend to rely more heavily on Medicaid and generally have less income relative to urban hospitals, were the hardest hit.

These results are hardly surprising. Hospitals are required by the <a href=”https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/”>1986 Emergency Medial Treatment and Labor Act</a>(EMTALA) “to ensure public access to emergency services regardless of ability to pay.” As such, unlike other businesses, they cannot turn away people who cannot pay for the services they provide. While Medicaid payments to hospitals are notoriously low, some payment is better than no payment. Because of this, hospitals in states that expanded Medicaid are less likely to need to provide unpaid services and this makes it more likely that they can remain profitable and stay open.

It is, of course, reasonable to consider alternative explanations. After all, mere correlation is not causation and it would be fallacious post hoc reasoning (to infer that because A happened after B, B must have caused A) to simply conclude that Medicaid is the cause. The states that expanded Medicaid might differ in other ways from states that did not—for example, they might have more robust economies or larger percentages of privately ensured patients. That said, the study does seem to support the connection between Medicaid and hospitals remaining open.

One moral and practical concern about hospital closings is that people who need care will be less able to receive it. While it would be hyperbole to claim that hospital closings would leave people in the area with no care, it does reduce their access to care. This is especially of concern in rural areas that already have few hospitals. While people can, of course, travel to get medical care, increased travel times would reduce the likelihood that people will seek care and would also impact outcomes. For example, rapid treatment is critical for stroke victims. Even if patients still have access to a local hospital, hospital closures will increase the time patients need to wait for treatment and this can have a negative impact on medical outcomes.

While health care does not operate within a free market of informed consumers and competitive prices, the closing of hospitals can result in increased costs for medical care. After all, the scarcer a commodity is, the more people tend to charge for it. Since medical care is already extremely expensive, an increase in costs would be even more of a burden on patients, especially those that are not affluent.

Because of the negative impact of not expanding Medicaid, states that have not expanded it should do so. This will decrease hospital closures and thus have a generally positive impact. From a moral standpoint, this would be the right thing to do—assuming that the state has an obligation to the well-being of its citizens.

One obvious counter to this view is to argue against such an obligation. This position is often taken by conservatives who favor limited government and oppose entitlements. There is also the obvious market-based argument here (although medical care is clearly not operating as a free market). The gist of this argument is that medical services are a business and that if a business cannot stay open on its own, then the state has no obligation to intervene. As such, Medicaid should not be expanded to address this problem: if the hospitals cannot stay open on their own, then the market should close them.

The easy and obvious reply to this is that, as noted above, the law requires hospitals to provide medical services even when patients cannot pay. By imposing this restriction, the state has taken a strong role in the market. Since the state imposes this requirement on hospitals, it seems reasonable that the state should take steps to offset this burden—in this case, by expanding Medicaid.

Alternatively, EMTALA could be repealed and hospitals could operate like other businesses in terms of being able to refuse services for those who cannot pay. In this case, there would not be a need to expand Medicaid to assist hospitals in remaining open—they would not lose money providing services to those who cannot pay. But, there would be a high cost in terms of sickness and death among those unable to afford medical care. There is also the possibility that even without the burden of EMTALA hospitals would still be more likely to close without a Medicaid expansion. After all, while hospitals would not be losing money on patients who cannot pay, they would also not have the financial benefit of the Medicaid expansion. As such, their closure rate would presumably be higher than hospitals in states that have expanded Medicaid.

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