Autonomy in Applied Ethics

Population obesity and associated morbidities pose significant public health and economic burdens in the United Kingdom, United States, and globally. As a response, public health initiatives often seek to change individuals’ unhealthy behavior, with the dual aims of improving their health and conserving health care resources. One such initiative—taxes on sugar‐sweetened beverages (SSB)—has sparked considerable ethical debate. Prominent in the debate are arguments seeking to demonstrate the supposed impermissibility of SSB taxes and similar policies on the grounds that they interfere (...) with individuals’ freedom and autonomy. Commentators have often assumed that a policy intended to restrict or change private individuals’ consumption behavior will necessarily curtail freedom and, as a corollary, will undermine individuals’ autonomy with respect to their consumption choices. Yet this assumption involves a conceptual mistake. To address the misunderstanding, it’s necessary to attend to the differences between negative liberty, freedom of options, and autonomy. Ultimately, concerns about negative liberty, freedom, and autonomy do not provide strong grounds for opposing SSB taxes. (shrink)

The aim of this paper is to evaluate the reflective equilibrium between the acknowledgment of the right to end one’s life and the Rawlsian idea of freedom. This article evaluates the possibility of a self-destructive exercise of freedom. It is asserted that this kind of exercise is inconsistent with the highest order interest in freedom. Allowing the self-destructive practice of freedom jeopardizes the Rawlsian foundation of the priority of liberty, a crucial aspect of the justice as fairness. || -/- El (...) presente artículo tiene como objetivo evaluar el equilibrio reflexivo entre el reconocimiento al derecho a disponer de la propia vida y la idea rawlsiana de libertad. Se considera la posibilidad de llevar a cabo un ejercicio autodestructivo de la libertad. Se defiende que este tipo de ejercicios son contrarios al interés de orden supremo en ejercer la libertad. Permitir la práctica autodestructiva de la libertad pone en riesgo la fundamentación rawlsiana de la prioridad de la libertad, un elemento central de la justice as fairness. (shrink)

Autonomy has been central to moral and political philosophy for millenia, and has been positioned as a critical aspect of both justice and wellbeing. Research in psychology supports this position, providing empirical evidence that autonomy is critical to motivation, personal growth and psychological wellness. Responsible AI will require an understanding of, and ability to effectively design for, human autonomy (rather than just machine autonomy) if it is to genuinely benefit humanity. Yet the effects on human autonomy of digital experiences are (...) neither straightforward nor consistent, and are complicated by commercial interests and tensions around compulsive overuse. This multi-layered reality requires an analysis that is itself multidimensional and that takes into account human experience at various levels of resolution. We borrow from HCI and psychological research to apply a model (“METUX”) that identifies six distinct spheres of technology experience. We demonstrate the value of the model for understanding human autonomy in a technology ethics context at multiple levels by applying it to the real-world case study of an AI-enhanced video recommender system. In the process we argue for the following three claims: 1) There are autonomy-related consequences to algorithms representing the interests of third parties, and they are not impartial and rational extensions of the self, as is often perceived; 2) Designing for autonomy is an ethical imperative critical to the future design of responsible AI; and 3) Autonomy-support must be analysed from at least six spheres of experience in order to approriately capture contradictory and downstream effects. (shrink)

When agents insert technological systems into their decision-making processes, they can obscure moral responsibility for the results. This can give rise to a distinct moral wrong, which we call “agency laundering.” At root, agency laundering involves obfuscating one’s moral responsibility by enlisting a technology or process to take some action and letting it forestall others from demanding an account for bad outcomes that result. We argue that the concept of agency laundering helps in understanding important moral problems in a number (...) of recent cases involving automated, or algorithmic, decision-systems. We apply our conception of agency laundering to a series of examples, including Facebook’s automated advertising suggestions, Uber’s driver interfaces, algorithmic evaluation of K-12 teachers, and risk assessment in criminal sentencing. We distinguish agency laundering from several other critiques of information technology, including the so-called “responsibility gap,” “bias laundering,” and masking. (shrink)

Respect for autonomy is a central moral principle in bioethics. The concept of autonomy can be construed in various ways. Under the non-ideal conceptualization proposed by Beauchamp and Childress, everyday choices of generally competent persons are autonomous to the extent that they are intentional and are made with understanding and without controlling influences. It is sometimes suggested that authenticity is important to personal autonomy, so that inauthenticity prevents otherwise autonomous persons from making autonomous decisions. Building from Beauchamp and Childress’s theory, (...) this article develops a non-ideal authenticity-based conceptualization of personal autonomy. Factors that indicate inauthentic decision-making are explicated, and the full concept is defended from three expected objections. The theory is then tested on a paradigm case which has concerned theorists and practitioners for some time, namely the possible inauthenticity of anorexia nervosa patients’ decision-making. It is concluded that the theory seems to be fruitful in analyses of the degree of autonomy of patients’ decision-making, and that it succeeds in providing reliable action-guidance in practical contexts. (shrink)

The notion of authenticity, i.e., being “genuine,” “real,” or “true to oneself,” is sometimes held as critical to a person’s autonomy, so that inauthenticity prevents the person from making autonomous decisions or leading an autonomous life. It has been pointed out that authenticity is difficult to observe in others. Therefore, judgments of inauthenticity have been found inadequate to underpin paternalistic interventions, among other things. This article delineates what justifies judgments of inauthenticity. It is argued that for persons who wish to (...) live according to the prevailing social and moral standards and desires that are seriously undesirable according to those standards, it is justified to judge that a desire is inauthentic to the extent that it is due to causal factors that are alien to the person and to the extent that it deviates from the person’s practical identity. The article contributes to a tradition of thinking about authenticity which is known mainly from Frankfurt and Dworkin, and bridges the gap between theoretical ideals of authenticity and real authenticity-related problems in practical biomedical settings. (shrink)

It is sometimes argued that autonomous decision-making requires that the decision-maker’s desires are authentic, i.e., “genuine,” “truly her own,” “not out of character,” or similar. In this article, it is argued that a method to reliably determine the authenticity (or inauthenticity) of a desire cannot be developed. A taxonomy of characteristics displayed by different theories of authenticity is introduced and applied to evaluate such theories categorically, in contrast to the prior approach of treating them individually. The conclusion is drawn that, (...) in practice, the authenticity of desires cannot be reliably determined. It is suggested that authenticity should therefore not be employed in informed consent practices in healthcare. (shrink)

According to one influential view, requirements to elicit consent for medical interventions and other interactions gain their rationale from the respect we owe to each other as autonomous, or self-governing, rational agents. Yet the popular presumption that consent has a central role to play in legitimate intervention extends beyond the domain of cases where autonomous agency is present to cases where far from fully autonomous agents make choices that, as likely as not, are going to be against their own best (...) interest. The question how we should understand the rationale for eliciting consent in this range of ‘non-ideal’ cases is comparatively ill understood. In this paper, I explore the prospects of accounting for consent requirements in such ‘non-ideal’ cases by appealing to a set of agency-based interests; including an interest in playing a meaningful part in joint decisions affecting ourselves and others. (shrink)

This article addresses two areas of continuing controversy about consent in clinical research: the question of when consent to low risk research is necessary, and the question of when consent to research is valid. The article identifies a number of considerations relevant to determining whether consent is necessary, chief of which is whether the study would involve subjects in ways that would (otherwise) infringe their rights. When consent is necessary, there is a further question of under what conditions consent is (...) valid or successful in waiving a right. The most influential account of validity conditions is non-moralized, in the sense that the conditions make no essential reference to whether the researcher soliciting consent has obtained it in a way that wrongs the subject. The article examines the implications of this account, and compares it with recent accounts that moralize some of the validity conditions. -/- . (shrink)

Despite the acknowledgement of the moral significance of consent there is still much work to be done in determining which specific sexual encounters count as unproblematically consensual. This paper focuses on the impact of deception. It takes up the specific case of deception about one’s self. It may seem obvious that one ought not to lie to a sexual partner about who one is, but determining which features of oneself are most relevant to the consent of one’s partner, as well (...) as the lies which it follows would be impermissible to tell, is complicated. It is argued here that deception about one’s morally valenced character traits, those we think of as virtues and vices, are particularly problematic. This is true regardless of whether knowing the truth about those traits would have made a difference to one’s partner’s consent. Attention is then drawn to a range of types of lies that one ought not to tell. (shrink)

Shared Decision Making (‘SDM’) is one of the most significant developments in Western health care practices in recent years. Whereas traditional models of care operate on the basis of the physician as the primary medical decision maker, SDM requires patients to be supported to consider options in order to achieve informed preferences by mutually sharing the best available evidence. According to its proponents, SDM is the right way to interpret the clinician-patient relationship because it fulfils the ethical imperative of respecting (...) patient autonomy. However, there is no consensus about how decisions in SDM contexts relate to the principle of respect for autonomy. In response, I demonstrate that in order to make decisions about what treatment they will or will not receive, patients will be required to meet different conditions depending on the approach proponents of SDM take to understanding personal autonomy. Due to the fact that different conceptions of autonomy yield different obligations, I argue that if physicians and patients satisfied all the conditions described in standard accounts of SDM, then SDM would undermine patient autonomy. (shrink)

Davis called for “extreme caution” in the use of non-invasive brain stimulation to treat neurological disorders in children, due to gaps in scientific knowledge. We are sympathetic to his position. However, we must also address the ethical implications of applying this technology to minors. Compensatory trade-offs associated with NIBS present a challenge to its use in children, insofar as these trade-offs have the effect of limiting the child’s future options. The distinction between treatment and enhancement has some normative force here. (...) As the intervention moves away from being a treatment toward being an enhancement—and thus toward a more uncertain weighing of the benefits, risks, and costs—considerations of the child’s best interests diminish, and the need to protect the child’s autonomy looms larger. NIBS for enhancement involving trade-offs should therefore be delayed, if possible, until the child reaches a state of maturity and can make an informed, personal decision. NIBS for treatment, by contrast, is permissible insofar as it can be shown to be at least as safe and effective as currently approved treatments, which are themselves justified on a best interests standard. (shrink)

Five arguments are presented in favour of the proposal that people who opt in as organ donors should receive a tax break. These arguments appeal to welfare, autonomy, fairness, distributive justice and self-ownership, respectively. Eight worries about the proposal are considered in this paper. These objections focus upon no-effect and counter-productiveness, the Titmuss concern about social meaning, exploitation of the poor, commodification, inequality and unequal status, the notion that there are better alternatives, unacceptable expense, and concerns about the veto of (...) relatives. The paper argues that none of the objections to the proposal is very telling. (shrink)

A key point of feminist moral philosophy is that social and political conditions continue to work against women’s ability to flourish as moral agents. By pointing to how violence against women undermines both autonomy and integrity I uncover a significant means through which women are undermined in society. My focus is on violence against women as a pervasive, inescapable social condition that women can counter through self-defence training.

Our position is that the threat and experience of violence that sex workers face is a crucial issue to address and should be considered in debates concerning the legalization of prostitution because even in countries where prostitution is legalized, prostitutes continue to experience violence. Our focus is to show that violence is crucially important to address because both the experience and the fear of physical, sexual or psychological harm erodes women ’s capacity to choose and act autonomously. We shall argue, (...) then, that despite differences between inside and outside prostitution, all women in prostitution suffer unacceptable levels of violence ; hence, we conclude that all forms of prostitution continue to be morally problematic. (shrink)

Many of us took pride in never feeling violent, never hitting. We had not thought deeply about our relationships to inflicting physical pain. Some of us expressed terror and awe when confronted with physical strength on the part of others. For us, the healing process included the need to learn how to use physical force constructively, to remove the terror—the dread. —bell hooks, Talking Back: Thinking Feminist, Thinking Black.

According to many of its proponents, shared decision making ("SDM") is the right way to interpret the clinician-patient relationship because it respects patient autonomy in decision-making contexts. In particular, medical ethicists have claimed that SDM respects a patient's relational autonomy understood as a capacity that depends upon, and can only be sustained by, interpersonal relationships as well as broader health care and social conditions. This paper challenges that claim. By considering two primary approaches to relational autonomy, this paper argues that (...) standard accounts of SDM actually undermine patient autonomy. It also provides an overview of the obligations generated by the principle of respect for relational autonomy that have not been captured in standard accounts of SDM and which are necessary to ensure consistency between clinical practice and respect for patient autonomy. (shrink)

This chapter argues that rather than viewing transparency as a right, we should regard it as a finite resource whose allocation involves tradeoffs. It then argues that those tradeoffs should be resolved by using a multi-principle approach to distributive justice. The relevant principles include maximizing welfare, maximizing autonomy, and giving priority to the worst off. Finally, it examines some of the implications for law of recognizing the tradeoffs presented by transparency proposals.

Neste artigo defendo a tese de que o direito de não saber é independente do direito à privacidade. Há duas diferenças fundamentais entre esses dois direitos que os tornam independentes: (1) a direção da informação do direito de não saber é oposta a do direito à privacidade e (2) o âmbito do direito de não saber é maior do que o do direito à privacidade. Pretendo clarificar essas diferenças e fazer algumas qualificações sobre o direito de não saber, tal como (...) os requisitos para o seu exercício e os limites desse direito. Apesar de o foco da análise não ser sobre um direito jurídico de não saber, ela traz implicações relevantes para o tratamento jurídico tanto do direito de não saber, quanto para o direito à privacidade. (shrink)

The 'critical turn' in tourism studies is defined as a research perspective that explores social transfor- mation in and through tourism by facing the negative impact of strategic-instrumental rationality on this activity. This work explores the features of discourse ethics that may normatively support tourism transformation, a gap that has not been thoroughly discussed in tourism research. For this purpose, the study combines the use of critical and ethical theory with an analysis of discourse ethics in tourism literature to demonstrate (...) that the use of Habermasian discourse ethics needs to be complemented with the Apelian approach. Through these steps the work reveals the theoretical bases of discourse ethics to discuss whether understandings between stakeholders guided by strategic-instrumental rationality can be reached not only in the political sphere —Habermas—, but also in the ethical field —Apel. (shrink)

In The Great Endarkenment, Elijah Millgram argues that the hyper-specialization of expert domains has led to an intellectual crisis. Each field of human knowledge has its own specialized jargon, knowledge, and form of reasoning, and each is mutually incomprehensible to the next. Furthermore, says Millgram, modern scientific practical arguments are draped across many fields. Thus, there is no person in a position to assess the success of such a practical argument for themselves. This arrangement virtually guarantees that mistakes will accrue (...) whenever we engage in cross-field practical reasoning. Furthermore, Millgram argues, hyper-specialization makes intellectual autonomy extremely difficult. Our only hope is to provide better translations between the fields, in order to achieve intellectual transparency. I argue against Millgram’s pessimistic conclusion about intellectual autonomy, and against his suggested solution of translation. Instead, I take his analysis to reveal that there are actually several very distinct forms intellectual autonomy that are significantly in tension. One familiar kind is direct autonomy, where we seek to understand arguments and reasons for ourselves. Another kind is delegational autonomy, where we seek to find others to invest with our intellectual trust when we cannot understand. A third is management autonomy, where we seek to encapsulate fields, in order to manage their overall structure and connectivity. Intellectual transparency will help us achieve direct autonomy, but many intellectual circumstances require that we exercise delegational and management autonomy. However, these latter forms of autonomy require us to give up on transparency. (shrink)

According to what Douglas calls ‘the consent requirement’, neuro-correctives can only permissibly be provided with the valid consent of the offender who will undergo the intervention. Some of those who endorse the consent requirement have claimed that even though the requirement prohibits the imposition of mandatory neurocorrectives on criminal offenders, it may yet be permissible to offer offenders the opportunity to consent to undergoing such an intervention, in return for a reduction to their penal sentence. I call this the neurocorrective (...) offer. In this chapter I consider the coercion-based objection to the neurocorrective offer, which claims that offenders cannot provide valid consent to undergoing a neurocorrective on the basis of this offer because it is inherently coercive. Having outlined early formulations of this argument, I point out that there are in fact two different versions of this objection, which appeal to different understandings of the concepts of coercion, consent and voluntariness. (shrink)

A prominent objection to non-cognitive moral bio-enhancements is that they would compromise the recipient’s ‘freedom to fall’. I begin by discussing some ambiguities in this objection, before outlining an Aristotelian reading of it. I suggest that this reading may help to forestall Persson and Savulescu’s ‘God-Machine’ criticism; however, I suggest that the objection still faces the problem of explaining why the value of moral conformity is insufficient to outweigh the value of the freedom to fall itself. I also question whether (...) the objection is compatible with Neil Levy’s parity principle. Accordingly, I go on to consider an alternative relational freedom-based objection to NCMBEs that aims to explain the fundamental moral importance of the freedom that NCMBEs would violate. I argue that although this strategy might allow the critic of NCMBEs to bypass a powerful criticism of Harris’ objection, it also weakens the freedom-based objection’s compatibility with the parity principle. (shrink)

Deep brain stimulation has been of considerable interest to bioethicists, in large part because of the effects that the intervention can occasionally have on central features of the recipient’s personality. These effects raise questions regarding the philosophical concept of authenticity. In this article, we expand on our earlier work on the concept of authenticity in the context of deep brain stimulation by developing a diachronic, value-based account of authenticity. Our account draws on both existentialist and essentialist approaches to authenticity, and (...) Laura Waddell Ekstrom’s coherentist approach to personal autonomy. In developing our account, we respond to Sven Nyholm and Elizabeth O’Neill’s synchronic approach to authenticity, and explain how the diachronic approach we defend can have practical utility, contrary to Alexandre Erler and Tony Hope’s criticism of autonomy-based approaches to authenticity. Having drawn a distinction between the authenticity of an individual’s traits and the authenticity of that person’s values, we consider how our conception of authenticity applies to the context of anorexia nervosa in comparison to other prominent accounts of authenticity. We conclude with some reflections on the prudential value of authenticity, and by highlighting how the language of authenticity can be invoked to justify covert forms of paternalism that run contrary to the value of individuality that seems to be at the heart of authenticity. (shrink)

In December 2013, the Nonhuman Rights Project (NhRP) filed a petition for a common law writ of habeas corpus in the New York State Supreme Court on behalf of Tommy, a chimpanzee living alone in a cage in a shed in rural New York (Barlow, 2017). Under animal welfare laws, Tommy’s owners, the Laverys, were doing nothing illegal by keeping him in those conditions. Nonetheless, the NhRP argued that given the cognitive, social, and emotional capacities of chimpanzees, Tommy’s confinement constituted (...) a profound wrong that demanded remedy by the courts. Soon thereafter, the NhRP filed habeas corpus petitions on behalf of Kiko, another chimpanzee housed alone in Niagara Falls, and Hercules and Leo, two chimpanzees held in research facilities at Stony Brook University. Thus began the legal struggle to move these chimpanzees from captivity to a sanctuary, an effort that has led the NhRP to argue in multiple courts before multiple judges. The central point of contention has been whether Tommy, Kiko, Hercules, and Leo have legal rights. To date, no judge has been willing to issue a writ of habeas corpus on their behalf. Such a ruling would mean that these chimpanzees have rights that confinement might violate. Instead, the judges have argued that chimpanzees cannot be bearers of legal rights because they are not, and cannot be persons. In this book we argue that chimpanzees are persons because they are autonomous. (shrink)

According to the common view, conscientious objection is grounded in autonomy or in ‘freedom of conscience’ and is tolerated out of respect for the objector's autonomy. Emphasising freedom of conscience or autonomy as a central concept within the issue of conscientious objection implies that the conscientious objector should have an independent choice among alternative beliefs, positions or values. In this paper it is argued that: (a) it is not true that the typical conscientious objector has such a choice when they (...) decide to act upon their conscience and (b) it is not true that the typical conscientious objector exercises autonomy when developing or acquiring their conscience. Therefore, with regard to tolerating conscientious objection, we should apply the concept of autonomy with caution, as tolerating conscientious objection does not reflect respect for the conscientious objector’s right to choose but rather acknowledges their lack of real ability to choose their conscience and to refrain from acting upon their conscience. This has both normative and analytical implications for the treatment of conscientious objectors. (shrink)

We propose a multi-step evaluation schema designed to help procurement agencies and others to examine the ethical dimensions of autonomous systems to be applied in the security sector, including autonomous weapons systems.

IN her work on the distinction between freedom and voluntariness, Serena Olsaretti suggests the following definition of voluntary action: an action is voluntary if it is not non-voluntary, and non-voluntary if it is performed because there are no acceptable alternatives, where ‘acceptable’ means conforming to some objective standard (which Olsaretti suggests might be well-being). Olsaretti suggests that ascriptions of responsibility are underwritten by judgments of voluntariness, rather than freedom. Also, Olsaretti notes that a concern for voluntary choice might be grounded (...) in respect for autonomy. So, two important questions in political philosophy – when an agent is responsible for her actions and what we must do if we want agents to live autonomous lives – hang upon whether Olsaretti's account of voluntariness is correct once it has been developed in detail. This article is a contribution to that development. I show that well-informedness about our options is crucial to whether we act voluntarily or not, and I argue that we should restrict the scope of what we consider relevantly unacceptable to include only things which involve serious prudential harm. Inevitably there are some questions left unanswered, but what follows indicates what I take to be the strongest form of Olsaretti's theory, and one which can play the role described for it above. (shrink)

The notion of respect for autonomy dominates bioethical discussion, though what qualifies precisely as autonomous action is notoriously elusive. In recent decades, the notion of autonomy in medical contexts has often been defined in opposition to the notion of autonomy favoured by theoretical philosophers. Where many contemporary theoretical accounts of autonomy place emphasis on a condition of “authenticity”, the special relation a desire must have to the self, bioethicists often regard such a focus as irrelevant to the concerns of medical (...) ethics, and too stringent for use in practical contexts. I argue, however, that the very condition of authenticity that forms a focus in theoretical philosophy is also essential to autonomy and competence in medical ethics. After tracing the contours of contemporary authenticity-based theories of autonomy, I consider and respond to objections against the incorporation of a notion of authenticity into accounts of autonomy designed for use in medical contexts. By looking at the typical problems that arise when making judgments concerning autonomy or competence in a medical setting, I reveal the need for a condition of authenticity—as a means of protecting choices, particularly high-stakes choices, from being restricted or overridden on the basis of intersubjective disagreement. I then turn to the treatment of false and contestable beliefs, arguing that it is only through reference to authenticity that we can make important distinctions in this domain. Finally, I consider a potential problem with my proposed approach; its ability to deal with anorexic and depressive desires. (shrink)

The concept of food sovereignty is becoming an element of everyday parlance in development politics and food justice advocacy. Yet to successfully achieve food sovereignty, the demands within this movement have to be compatible with the way people are pursuing consumer sovereignty, and vice versa. The aim of this article is to examine the different sets of demands that the two ideals of sovereignty bring about, analyze in how far these different demands can stand in constructive relations with each other (...) and explain why consumers have to adjust their food choices to seasonal production variability to promote food sovereignty and so secure future autonomy. (shrink)

Jurgen Habermas has argued that carrying out pre-natal germline enhancements would be inimical to the future child's autonomy. In this article, I suggest that many of the objections that have been made against Habermas' arguments by liberals in the enhancement debate misconstrue his claims. To explain why, I begin by explaining how Habermas' view of personal autonomy confers particular importance to the agent's embodiment and social environment. In view of this, I explain that it is possible to draw two arguments (...) against germline enhancements from Habermas' thought. I call these arguments ‘the argument from negative freedom’ and ‘the argument from natality’. Although I argue that many of the common liberal objections to Habermas are not applicable when his arguments are properly understood, I go on to suggest ways in which supporters of enhancement might appropriately respond to Habermas' arguments. (shrink)

Respect for autonomy and beneficence are frequently regarded as the two essential principles of medical ethics, and the potential for these two principles to come into conflict is often emphasised as a fundamental problem. On the one hand, we have the value of beneficence, the driving force of medicine, which demands that medical professionals act to protect or promote the wellbeing of patients or research subjects. On the other, we have a principle of respect for autonomy, which demands that we (...) respect the self-regarding decisions of individuals. As well as routinely coming into opposition with the demands of beneficence in medicine, the principle of respect for autonomy in medical ethics is often seen as providing protection against beneficial coercion (i.e. paternalism) in medicine. However, these two values are not as straightforwardly opposed as they may appear on the surface. In fact, the way that we understand autonomy can lead us to implicitly sanction a great deal of paternalistic action, or can smuggle in paternalistic elements under the guise of respect for autonomy. -/- This paper is dedicated to outlining three ways in which the principle of respect for autonomy, depending on how we understand the concept of autonomy, can sanction or smuggle in paternalistic elements. As the specific relationship between respect for autonomy and beneficence will depend on how we conceive of autonomy, I begin by outlining two dominant conceptions of autonomy, both of which have great influence in medical ethics. I then turn to the three ways in which how we understand or employ autonomy can increase or support paternalism: firstly, when we equate respect for autonomy with respect for persons; secondly, when our judgements about what qualifies as an autonomous action contain intersubjective elements; and thirdly, when we expect autonomy to play an instrumental role, that is, when we expect people, when they are acting autonomously, to act in a way that promotes or protects their own wellbeing. I then provide a proposal for how we might work to avoid this. I will suggest that it may be impossible to fully separate paternalistic elements out from judgements about autonomy. Instead, we are better off looking at why we are motivated to use judgements about autonomy as a means of restricting the actions of patients or research subjects. I will argue that this is a result of discomfort about speaking directly about our beneficent motivations in medical ethics. Perhaps we can reduce the incentive to smuggle in these beneficent motivations under the guise of autonomy by talking directly about beneficent motivations in medicine. This will also force us to recognise paternalistic motivations in medicine when they appear, and to justify paternalism where it occurs. (shrink)

BACKGROUND: Little is known about how hospitalized patients share decisions with physicians. METHODS: We conducted an observational study of patient-doctor communication on an inpatient medicine service among 18 hospitalized patients and 9 physicians. A research assistant (RA) approached newly hospitalized patients and their physicians before morning rounds and obtained consent. The RA audio recorded morning rounds, and then separately interviewed both patient and physician. Coding was done using integrated analysis. RESULTS: Most patients were white (61%) and half were female. Most (...) physicians were male (66%) and of Southeast Asian descent (66%). All physicians explained the plan of care to the patients; most believed that their patient understood. However, many patients did not. Physicians rarely asked the patient for their opinion. In all those cases, the decision had been made previously by the doctors. No decisions were made with the patient. Patients sometimes disagreed. CONCLUSIONS: Shared decision-making may not be the norm in hospital care. Although physicians do explain treatment plans, many hospitalized patients do not understand enough to share in decisions. When patients do assert their opinion, it can result in conflict. PRACTICE IMPLICATIONS: Some hospitalized patients are interested in discussing treatment. Improving hospital communication can foster patient autonomy. (shrink)

Many people feel that respecting a person’s autonomy is not sufficiently important to obligate us to stay out of their affairs in all cases; but the ground for interference may often turn out to be a hunch that the agent cannot really be competent, or cannot really know what her decision implies; for if she were both of these things, surely she would not make such a foolish decision. This paper suggests a justification of paternalism that does not rely on (...) such appeals. I argue that in cases where an agent will undergo a significant alteration in their evaluative outlook – ‘evaluative shift’ – three central, persuasive objections to paternalism lose their force, and offer a prima facie case for paternalism in some of these cases. I then suggest that we can extend this argument to some cases where evaluative alteration is not predictable, but where the risk and harm are both significant. In such cases, paternalism may be justified. (shrink)

A commentary on “Models of Consent to Return of Incidental Findings in Genomic Research” by Paul S. Appelbaum, Erik Parens, Cameron R. Waldman, Robert Klitzman, Abby Fyer, Josue Martinez, W. Nicholson Price II, and Wendy K. Chung, in the July-August 2014 issue, http://www.thehastingscenter.org/Publications/HCR/Detail.aspx?id=6964.

Kant’s deontological ethics, along with Aristotle’s virtue ethics and Mill’s utilitarian ethics, is often identified as one of the three primary moral options between which individuals can choose. Given the importance of Kant’s moral philosophy, it is surprising and disappointing how little has been written on his important contributions to moral education. Kant argues for a catechistic approach to moral education. By memorizing a series of moral questions and answers, an individual learns the basic principles of morality in the same (...) way that Martin Luther believed an individual should learn the tenets of Christianity. The difficulty, however, is that this approach appears to violate a central tenet of Kantian morality: virtuous acts must be performed out of respect for the moral law itself, not due to habituation. This paper demonstrates Kant’s significant contribution to moral education by showing how a catechistic moral education establishes the foundation necessary for autonomous action. (shrink)

I argue that political liberals should not support the monopoly of a single educational approach in state sponsored schools. Instead, they should allow reasonable citizens latitude to choose the worldview in which their own children are educated. I begin by defending a particular conception of political liberalism, and its associated requirement of public reason, against the received interpretation. I argue that the values of respect and civic friendship that motivate the public reason requirement do not support the common demand that (...) citizens “bracket” their comprehensive commitments in politics. Rather, citizens should seek to enact policies the justification of which is compatible with the truth of their fellow reasonable citizens’ worldviews. Next I argue that no single educational approach can meet this standard of justification. Many believe that state sponsored education in a pluralist, liberal society ought to present multiple worldviews in a neutral way. I argue that this aspiration is unrealizable, and no other educational model will plausibly meet the justificatory demand. Finally, I address two objections to my favored alternative: that it may allow for the inculcation of disrespect, and that it violates children’s autonomy. Against the first, I claim that political liberals have no grounds for thinking that reasonable citizens will seek to inculcate disrespect. Finally, I argue that there is no conception of autonomy that can sustain the second. (shrink)

The literature acknowledges a distinction between immoral, amoral and moral management. This paper makes a case for the employee (at any level) as a moral agent, even though the paper begins by highlighting a body of evidence which suggests that individual moral agency is sacrificed at work and is compromised in deference to other pressures. This leads to a discussion about the notion of discretion and an examination of a separate, contrary body of literature which indicates that some individuals in (...) corporations may use their discretion to behave in a socially entrepreneurial manner. My underlying assumption is that CSR isn’t solely driven by economics and that it may also be championed as a result of a personal morality, inspired by employees’ own socially oriented personal values. A conceptual framework is put forward and it is suggested that individuals may be categorized as Active or Frustrated Corporate Social Entrepreneurs; Conformists or Apathetics, distinguished by their individualistic or collectivist personal values. In a discussion of the nature of values, this paper highlights how values may act as drivers of our behavior and pays particular attention to the values of the entrepreneur, thereby linking the existing debate on moral agency with the field of corporate social responsibility. (shrink)

MacKay and Robinson (2016) claim that some legal procedures that regulate organ donations (VAC, opt-in, opt-out) bypass people's rational capacities and thus are “potentially morally worse than MAC”, which only employs a very mild form of coercion. We provide a critique of their argumentation and defend the opposite thesis: MAC is potentially morally worse than the three other options.

Advocates of political liberalism hold it as a superior alternative to perfectionism on the grounds that it avoids superfluous and/or controversial claims in favor of a maximally-inclusive approach undergirded by a "free-standing" justification for the ideology. These assertions prove difficult to defend: political interpretations of liberalism tend to be implicitly ethnocentric; they often rely upon a number of controversial, and even empirically falsified, assumptions about rationality--and in many ways prove more parochial than their perfectionist cousins. It is possible to reform (...) political liberalism to address these challenges, but generally at the expense of the supposed normative force and universality of the liberal project. However, this para-liberal approach is much better in keeping with contemporary findings in sociology, psychology and cognitive science--and can much more effectively accommodate the illiberal challenge. (shrink)

Although advance directives are widely believed to be a key way to safeguard the autonomy of incompetent medical patients, significant questions exist about their moral authority. The main philosophical concern involves cases in which an incompetent patient no longer possesses the desires on which her advance directive was based. The question is, does that entail that prior expressions of medical choices are no longer morally binding? I believe that the answer is “yes.” I argue that a patient’s autonomy is not (...) respected by honoring the desires she used to have but no longer does. I also consider and reject the view that honoring an advance directive that reflects the patient’s previous values must be in that patient’s best interests. If that is correct, then advance directives in the kind of case at issue are not morally binding. (shrink)

Techniques from behavioral economics—nudges—may help physicians increase pediatric vaccine compliance, but critics have objected that nudges can undermine autonomy. Since autonomy is a centrally important value in healthcare decision-making contexts, it counts against pediatric vaccination nudges if they undermine parental autonomy. Advocates for healthcare nudges have resisted the charge that nudges undermine autonomy, and the recent bioethics literature illustrates the current intractability of this debate. This article rejects a principle to which parties on both sides of this debate sometimes seem (...) committed: that nudges are morally permissible only if they are consistent with autonomy. Instead, I argue that, at least in the case of pediatric vaccination, some autonomy-undermining nudges may be morally justified. This is because parental autonomy in pediatric decision-making is not as morally valuable as the autonomy of adult patients, and because the interests of both the vaccinated child and other members of the community can sometimes be weighty enough to justify autonomy-infringing pediatric vaccination nudges. This article concludes with a set of worries about the effect of pediatric vaccination nudges on parent-physician relationships, and it calls on the American Academy of Pediatrics to draw on scientific and bioethics research to develop guidelines for the use of nudges in pediatric practice and, in particular, for the use of pediatric vaccination nudges. (shrink)

It is crucial for indigenous people living in the Arctic to harvest animals by hunting in a traditional manner, as is the case with such peoples in other parts of the world. Given the nutritional, economic, and cultural importance of hunting for aboriginal people, it seems reasonable to say that they have the moral right to hunt animals. On the other hand, non-aboriginal people are occasionally prohibited from hunting a particular species of animal in many societies. The question then arises: (...) why can aboriginal people, unlike other citizens, have special hunting rights? If indigenous people are to have the right to hunt a particular species that other citizens are denied, then it presents a significant challenge to philosophers to explore the moral grounds that justify such a special right. This exploration is the subject of the current paper. (shrink)

This paper aims to provide a clarification of the long debate on whether enhancement will or will not diminish authenticity. It focuses particularly on accounts provided by Carl Elliott and David DeGrazia. Three clarifications will be presented here. First, most discussants only criticise Elliott’s identity argument and neglect that his conservative position in the use of enhancement can be understood as a concern over social coercion. Second, Elliott’s and DeGrazia’s views can, not only co-exist, but even converge together as an (...) autonomy based theory of authenticity. Third, the current account of autonomy provided by DeGrazia fails to address the importance of rationality and the ability of self-correction, which, as a result impedes the theory to provide a fully developed account for authenticity. In conclusion, a satisfactory account of authenticity cannot focus only on identity or subjective preference. (shrink)