Jason Turner

Surveying Freedom: Folk Intuitions about free will and moral responsibility

Philosophers working in the nascent field of ‘experimental philosophy’ have begun using methods borrowed from psychology to collect data about folk intuitions concerning debates ranging from action theory to ethics to epistemology. In this paper we present the results of our attempts to apply this approach to the free will debate, in which philosophers on opposing sides claim that their view best accounts for and accords with folk intuitions. After discussing the motivation for such research, we describe our methodology of surveying peoples prephilosophical judgments about the freedom and responsibility of agents in deterministic scenarios. In two studies, we found that a majority of participants judged that such agents act of their own free will and are morally responsible for their actions. We then discuss the philosophical implications of our results as well as various difficulties inherent in such research.

Logic and Ontological Pluralism

Ontological pluralism is the doctrine that there are different ways or modes of being. In contemporary guise, it is the doctrine that a logically perspicuous description of reality will use multiple quantifiers which cannot be thought of as ranging over a single domain. Although thought defeated for some time, recent defenses have shown a number of arguments against the view unsound. However, another worry looms: that despite looking like an attractive alternative, ontological pluralism is really no different than its counterpart, ontological monism. In this paper, after explaining the worry in detail, I argue that considerations dealing with the nature of the logic ontological pluralists ought to endorse, coupled with an attractive philosophical thesis about the relationship between logic and metaphysics, show this worry to be unfounded.

When payment systems collide: the effect of hospitalization on anemia in renal dialysis patients.

Background:Different types of providers often face differing financial incentives for providing similar types of care. This may have implications for payment systems that target improvements in care requiring multiple types of providers. Objectives:The objective of this study was to determine how hospitalization influences the anemia of Medicare patients with chronic renal failure, where anemia is treated under a prospective payment system during hospitalizations and under a fee-for-service system during outpatient renal dialysis. Methods:We examined the effects of time in hospital and reason for hospitalization on levels of anemia among 87,263 Medicare renal dialysis patients with a hospital stay of 3 days or more during 2004. Medicare claims were used to measure changes in hematocrit between the month before and the month after hospital discharge, and to classify admissions with a high risk of anemia. Multilevel models were used to study variation in outcomes across providers. Results:Longer time in the hospital was associated with worsening anemia. As expected, larger declines in hematocrit occurred following admissions for conditions or procedures with a high risk of anemia. However, we observed a similar effect of time in the hospital for admissions both with and without a high risk of anemia. There were relatively large differences in anemia outcomes across both individual hospitals and physicians. Conclusions:Hospitalization-related anemia increases the need for care by outpatient renal dialysis providers. Efforts to improve care through payment system design are more likely to be successful if financial incentives are aligned across care settings.

Existence and Many-One Identity

C endorses the doctrine of Composition as Identity, which holds that a composite object is (plurally) identical to its many parts, and entails that one object can be (plurally) identical to several others. In this dialogue, N argues that many-one identity, and thus composition as identity, is conceptually confused. In particular, N claims it violates two conceptual truths: that existence facts fix identity facts, and that identity is no addition to being. In response to pressure from C, N considers several candidate interpretations of the first slogan. Each interpretation imagines God issuing a divine existential decree that counts as ‘fixing the existence facts’, and then considers what questions about identity are left open by it. N eventually hits on an appealing interpretation of the slogan that C can neither undermine nor accommodate, and uses it to interpret the second slogan as well.

The Incompatibility of Free Will and Naturalism

The Consequence Argument is a staple in the defence of libertarianism, the view that free will is incompatible with determinism and that humans have free will. It is often thought that libertarianism is consistent with a certain naturalistic view of the world—that is, even if libertarians are right, free will can be had without metaphysical commitments beyond those provided by our best (indeterministic) physics. In this paper, I argue that libertarians who endorse the Consequence Argument are forced to reject this naturalistic worldview. The Consequence Argument has a sister argument—I call it the Supervenience Argument—which cannot be rejected without threatening either the Consequence Argument or the naturalistic worldview in question.

A Decomposition of Hospital Profitability An Application of DuPont Analysis to the US Market

Objectives: This paper evaluates the drivers of profitability for a large sample of U.S. hospitals. Following a methodology frequently used by financial analysts, we use a DuPont analysis as a framework to evaluate the quality of earnings. By decomposing returns on equity (ROE) into profit margin, total asset turnover, and capital structure, the DuPont analysis reveals what drives overall profitability. Methods: Profit margin, the efficiency with which services are rendered (total asset turnover), and capital structure is calculated for 3,255 U.S. hospitals between 2007 and 2012 using data from the Centers for Medicare & Medicaid Services’ Healthcare Cost Report Information System (CMS Form 2552). The sample is then stratified by ownership, size, system affiliation, teaching status, critical access designation, and urban or non-urban location. Those hospital characteristics and interaction terms are then regressed (OLS) against the ROE and the respective DuPont components. Sensitivity to regression methodology is also investigated using a seemingly unrelated regression. Results: When the sample is stratified by hospital characteristics, the results indicate investor-owned hospitals have higher profit margins, higher efficiency, and are substantially more leveraged. Hospitals in systems are found to have higher ROE, margins, and efficiency but are associated with less leverage. In addition, a number of important and significant interactions between teaching status, ownership, location, critical access designation, and inclusion in a system are documented. Many of the significant relationships, most notably not-for-profit ownership, lose significance or are predominately associated with one interaction effect when interaction terms are introduced as explanatory variables. Results are not sensitive to the alternative methodology. Conclusion: The results of the DuPont analysis suggest that although there appears to be convergence in the behavior of NFP and IO hospitals, significant financial differences remain depending on their respective hospital characteristics. Those differences are tempered or exacerbated by location, size, teaching status, system affiliation, and critical access designation. With the exception of cost-based reimbursement for critical access hospitals, emerging payment systems are placing additional financial pressures on hospitals. The financial pressures being applied treat hospitals as a monolithic category and, given the delicate and often negative ROE for many hospitals, the long-term stability of the healthcare facility infrastructure may be negatively impacted.

A Longitudinal Analysis of the Association Between Living Arrangements and Health Among Older Adults in China

This article used the nationally representative Chinese Longitudinal Healthy Longevity Survey to explore the associations between living arrangements and health among older adults. Living arrangements were stratified into six categories. Health was measured by self-rated health, activities of daily living (ADL) disability, and cognitive impairment. Random-effects ordered probit regressions were applied. The results indicated that coresidence had a positive effect on self-rated health compared with living alone. After introducing psychological well-being, the health differences observed in living with a spouse and living with both spouse and children were not significant. Participants with each of the living arrangement were more likely to have a higher rate of cognitive impairment and ADL disability than those living alone. Living arrangements were associated with older adults’ health. Psychological well-being was a key factor in this association, which may result from living with a spouse, and could contribute to the self-rated health of older adults.

What Should We Expect? A Comparison of the Community Benefit and Projected Government Support of Maryland Hospitals.

Designation as a tax-exempt, not-for-profit entity carries with it specific tax benefits. In exchange for tax exemptions, not-for-profit entities are expected to provide benefits to their communities. To evaluate whether hospitals provide community benefits (CBs) equivalent to the financial subsidies and advantages extended to them, tax liabilities and financial support were projected for all Maryland acute care hospitals between 2010 and 2012 and in the aggregate over the 3 years of this study. A comparison was then made between the provision of CBs and the financial support that governments provide to the hospitals. The results indicate that hospitals provide significantly and substantially more CBs than the material financial support they receive. Even after modeling changes in CB activities and the associated tax liabilities that may result from transitioning to taxable status, the benefits that hospitals provide to the communities they serve continue to exceed the potential government tax revenues.

What’s So Bad About Second-Order Logic?

Second-order logic is generally thought problematic by the philosophical populace. Philosophers of mathematics and logic may have sophisticated reasons for rejecting second-order logic, but ask the average philosopher-on-the-street what’s wrong with second-order logic and they will probably mumble something about Quine, ontological commitment, and set theory in sheep’s clothing. In this paper, I try to get more precise about exactly what might be behind these mumblings. I offer four potential arguments against second-order logic and consider several lines of response to each. Two arguments target the coherence of second-order quantification generally, and stem from concerns about ontological commitment. The other two target the expressive power of ‘full’ (as opposed to ‘Henkin’) second-order logic, and give content to the concern that second-order logic is in fact “set theory in sheep’s clothing”. My aim is to understand the dialectic, not take sides; still, second-order logic comes through looking more promising than we might have initially thought.

Is There a Relationship Between Value-Based Purchasing and Hospital Profitability? An Exploratory Study of Missouri Hospitals

Recent US legislation is attempting to transition inpatient Medicare payments to a value-based purchasing (VBP) program. The VBP program is a pay-for-performance (P4P) system that incentivizes hospitals to improve patient satisfaction, health outcomes, and adherence to clinical protocols while simultaneously holding down costs. Our study evaluates (1) the impact of financial performance on the VBP adjustments and (2) whether there is a correlation between the VBP adjustment and the financial performance of Missouri hospitals that opted into the program. While upward and downward adjustments to the inpatient base rate may be related to hospital financial performance, prior financial performance may also be related to the adjustments. Financial health may allow facilities to invest and position the hospital for favorable future P4P adjustments. The results of our analysis indicate the VBP adjustment to the inpatient base rate is very small (±0.18%), clustered around zero, and is not correlated with financial performance. We also find that financial performance and improvement in the years prior to the adjustment are not related to the VBP adjustment or its respective components. This suggests that CMS is avoiding penalizing less profitable facilities, but the adjustment is also so small and tightly clustered around zero that it is failing to provide an adequate incentive to hospitals. The costs of improving patient satisfaction, clinical process adherence, health care outcomes, and efficiency above that of peers coupled with the growing number of metrics being used to calculate the VBP adjustments call into question the financial incentives of the hospital VBP program.