Informed Consent in Medicine

We discuss the role of prior authorization (PA) in supporting patient-centered care (PCC) by directing health system resources and thus the ability to better meet the needs of individual patients. We begin with an account of PCC as a standard that should be aimed for in patient care. In order to achieve widespread PCC, appropriate resource management is essential in a healthcare system. This brings us to PA, and we present an idealized view of PA in order to argue how (...) at its best, it can contribute to the provision of PCC. PA is a means of cost saving and as such it has mixed success. The example of the US demonstrates how implementation of PA has increased health inequalities whereas best practice has the potential to reduce them. In contrast, systems of universal coverage, like those in Europe, may use the cost savings of PA to better address individuals' care and PCC. The conclusion we offer therefore is an optimistic one, pointing towards areas of supportive overlap between PCC and PA where usually the incongruities are most evident. (shrink)

Despite the lack of evidence for their effectiveness, the use of physical restraints for patients is widespread. The best ethical justification for restraining patients is that it prevents them from harming themselves. We argue that even if the empirical evidence supported their effectiveness in achieving this aim, their use would nevertheless be unethical, so long as well known exceptions to informed consent fail to apply. Specifically, we argue that ethically justifiable restraint use demands certain necessary and sufficient conditions. These conditions (...) are that the physician obtain informed consent for their application, that their application be medically appropriate, and that restraints be the least liberty-restricting way of achieving the intended benefit. It is a further question whether their application is ever medically appropriate, given the dearth of evidence for their effectiveness. (shrink)

Deep Brain Stimulation is currently being investigated as an experimental treatment for patients suffering from treatment-refractory AN, with an increasing number of case reports and small-scale trials published. Although still at an exploratory and experimental stage, initial results have been promising. Despite the risks associated with an invasive neurosurgical procedure and the long-term implantation of a foreign body, DBS has a number of advantageous features for patients with SE-AN. Stimulation can be fine-tuned to the specific needs of the particular patient, (...) is relatively reversible, and the technique also allows for the crucial issue of investigating and comparing the effects of different neural targets. However, at a time when DBS is emerging as a promising investigational treatment modality for AN, lesioning procedures in psychiatry are having a renaissance. Of concern it has been argued that the two kinds of interventions should instead be understood as rivaling, yet “mutually enriching paradigms” despite the fact that lesioning the brain is irreversible and there is no evidence base for an effective target in AN. We argue that lesioning procedures in AN are unethical at this stage of knowledge and seriously problematic for this patient group, for whom self-control is particularly central to wellbeing. They pose a greater risk of major harms that cannot justify ethical equipoise, despite the apparent superiority in reduced short term surgical harms and lower cost. (shrink)

Under the current Mental Health Act of England and Wales, it is lawful to perform deep brain stimulation in the absence of consent and independent approval. We argue against the Care Quality Commission's preferred strategy of addressing this problematic issue, and offer recommendations for deep brain stimulation-specific provisions in a revised Mental Health Act.

contents -/- i. short review: The Intern -/- ii. the confusion of Chinatown -/- iii. we'll remember water, in Theology -/- iv. Respironics versus ResMed -/- v. i'd bet my life, my home and happiness -/- vi. hypothetic as a deaththreat -/- vii. the Mad Max deity -/- viii. they'd kill my rat, not heal him .

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)

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 this paper, I argue that deceptive placebo use can be morally permissible, on the grounds that the deception involved in the prescription of deceptive placebos can differ in kind to the sorts of deception that undermine personal autonomy. In order to argue this, I shall first delineate two accounts of why deception is inimical to autonomy. On these accounts, deception is understood to be inimical to the deceived agent’s autonomy because it either involves subjugating the deceived agent’s will to (...) another’s authority or because it precludes the agent from acting effectively in pursuit of their ends. I shall argue that providing an agent with false beliefs is not inimical to their autonomy if they are only able to effectively pursue their autonomously chosen ends by virtue of holding those particular false beliefs. Finally, I show that deceptive placebo use need only involve this latter sort of deception. (shrink)

Mitochondrial replacement therapy requires oocytes of women whose mitochondrial DNA will be transmitted to resultant children. These techniques are scientifically, ethically and socially controversial; it is likely that some women who donate their oocytes for general in vitro fertilisation usage would nevertheless oppose their genetic material being used in MRT. The possibility of oocytes being used in MRT is therefore relevant to oocyte donation and should be included in the consent process when applicable. In present circumstances, specific consent should be (...) obtained. However, once MRT becomes more routine, such consent could be incorporated into the general consent process for oocyte donation. The reported lack of proper consent for MRT from the oocyte donor in the first baby born via the technique is an ethical failing and should be corrected in any future practice of MRT. (shrink)

A properly programmed artificially intelligent agent may eventually have one duty, the duty to satisfice expected welfare. We explain this claim and defend it against objections.

In this issue, Elizabeth Shaw and Gulzaar Barn offer a number of replies to my arguments in ‘Criminal Rehabilitation Through Medical Intervention: Moral Liability and the Right to Bodily Integrity’, Journal of Ethics. In this article I respond to some of their criticisms.

It is widely accepted among medical ethicists that competence is a necessary condition for informed consent. In this view, if a patient is incompetent to make a particular treatment decision, the decision must be based on an advance directive or made by a substitute decision-maker on behalf of the patient. We call this the competence model. According to a recent report of the United Nations (UN) High Commissioner for Human Rights, article 12 of the UN Convention on the Rights of (...) Persons with Disabilities (CRPD) presents a wholesale rejection of the competence model. The High Commissioner here adopts the interpretation of article 12 proposed by the Committee on the Rights of Persons with Disabilities. On this interpretation, CRPD article 12 renders it impermissible to deny persons with mental disabilities the right to make treatment decisions on the basis of impaired decision-making capacity and demands the replacement of all regimes of substitute decision-making by supported decision-making. In this paper, we explicate six adverse consequences of CRPD article 12 for persons with mental disabilities and propose an alternative way forward. The proposed model combines the strengths of the competence model and supported decision-making. (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)

A common critique of nudges is that they reduce someone's of choices or elicit behavior through means other than rational persuasion. In this paper, I argue against this form of critique. I argue that, if there is anything distinctively worrisome about nudges from the standpoint of morality, it is is their tendency to hide the amount of social control that they embody, undermining democratic governance by making it more difficult for members of a political community to detect the social architect’s (...) pulling of the strings. This concern is particularly salient as to choices where it is important for people to directly engage with a certain set of values, “big personal decisions” (to use a simplifying phrase). Many healthcare decisions are exactly these kinds of choices. (shrink)

While several tests and strategies are recommended for colorectal cancer (CRC) screening, studies suggest that primary care providers often recommend colonoscopy without providing information about its risks or alternatives. These observations raise concerns about the quality of informed consent for screening colonoscopy.

Patients should not always receive hard data about the risks and benefits of a medical intervention. That information should always be available to patients who expressly ask for it, but it should be part of standard disclosure only sometimes, and only for some patients. And even then, we need to think about how to offer it.

Some experts have argued that patients should routinely be told the specific magnitude and absolute probability of potential risks and benefits of screening tests. This position is motivated by the idea that framing risk information in ways that are less precise violates the ethical principle of respect for autonomy and its application in informed consent or shared decisionmaking. In this Perspective, we consider a number of problems with this view that have not been adequately addressed. The most important challenges stem (...) from the danger that patients will misunderstand the information or have irrational responses to it. Any initiative in this area should take such factors into account and should consider carefully how to apply the ethical principles of respect for autonomy and beneficence. (shrink)

Despite being assailed for decades by disability activists and disability studies scholars spanning the humanities and social sciences, the medical model of disability—which conceptualizes disability as an individual tragedy or misfortune due to genetic or environmental insult—still today structures many cases of patient–practitioner communication. Synthesizing and recasting work done across critical disability studies and philosophy of disability, I argue that the reason the medical model of disability remains so gallingly entrenched is due to what I call the “ableist conflation” of (...) disability with pain and suffering. In an effort to better equip healthcare practitioners and those invested in health communication to challenge disability stigma, discrimination, and oppression, I lay out the logic of the ableist conflation and interrogate examples of its use. I argue that insofar as the semiosis of pain and suffering is structured by the lived experience of unwelcome bodily transition or variation, experiences of pain inform the ableist conflation by preemptively tying such variability and its attendant disequilibrium to disability. I conclude by discussing how philosophy of disability and critical disability studies might better inform health communication concerning disability, offering a number of conceptual distinctions toward that end. (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)

A high level of confidence in the identity of individuals is required to let them die as ordered by an advance directive. Thus, if we are animalists, then we should lack the confidence required to apply lethal advance directives to the cheerfully demented, or so I argue. In short, there is consensus among animalists that the best way to avoid serious objections to their account is to adopt an ontology that denies the existence of brains, hands, tables, chairs, iced-tea, and (...) lemonade. The adoption of such an ontology reduces the justificatory force of commonsense, which is key in arguing that we are animals and that we persist as long as we are biologically alive. With this loss of justification comes the loss of a high level of confidence that Quinn-pre-dementia’s lethal advanced directive applies to Quinn-post-dementia, via identity. If we do not have a high level of confidence that Quinn-pre-dementia’s advanced directive applies to Quinn-post- dementia, then it is not enough (on its own) to let Quinn-post-dementia die. (shrink)

In this paper we analyze the non-coercive ways in which researchers can use knowledge about the decision-making tendencies of potential participants in order to motivate them to consent to research enrollment. We identify which modes of influence preserve respect for participants’ autonomy and which disrespect autonomy, and apply the umbrella term of manipulation to the latter. We then apply our analysis to a series of cases adapted from the experiences of clinical researchers in order to develop a framework for thinking (...) through the ethics of manipulating people into research participation. All manipulation disrespects autonomy and is therefore pro tanto wrong. However, only deceptive manipulation invalidates the consent that results from it. Use of the other forms of manipulation can be permissible, but only if the outcome of using manipulation is sufficiently good and if the research cannot be carried out using ethically preferable means to obtain consent. (shrink)

This article first describes a dilemma for liberalism: On the one hand restricting their own options is an important means for groups of people to shape their lives. On the other hand, group members are typically divided over whether or not to accept option-restricting solutions or policies. Should we restrict the options of all members of a group even though some consent and some do not? This dilemma is particularly relevant to public health policy, which typically target groups of people (...) with no possibility for individuals to opt out. The article then goes on to propose and discuss a series of aggregation rules for individual into group consent. Consideration of a number of scenarios shows that such rules cannot be formulated only in terms of fractions of consenters and non-consenters, but must incorporate their motives and how much they stand to win or lose. This raises further questions, including what is the appropriate impact of altruistic consenters and non-consenters, what should be the impact of costs and benefits and whether these should be understood as gross or net. All these issues are dealt with in a liberal, anti-paternalistic spirit, in order to explore whether group consent can contribute to the justification of option-restricting public health policy. (shrink)

This is an early volume from a much respected psychedelic psychotherapist. He has written several other books since this one but until recently none of his books were on Amazon and still you can only find a German edition and a Spanish one (from 1993) but no English one (except a couple used copies). This is sad since these drugs have enormous therapeutic potential but afaik government suppression still prevents their use. The most interesting and readable parts are the case (...) histories of drug therapy, especially his own-e.g., on pages 114, 166 and 178. Though a very advanced therapist compared to many, he is far from finished with his intellectual growing up and clings to his psychoanalytic background even though he often mentions its extreme shortcomings. The often painfully awkward text is full of insights from his own therapeutic voyages and those of his patients interspersed with psychoanalytic nonsense. Part of the awkwardness may be due to bad translation from the German but the lack of a rational spiritual framework is a major problem (as with most therapy-or most life for that matter) that he only occasionally seems to recognize. He also sometimes veers off into the ozone-e.g., after many pages of sensible dialog he can opine that varicose veins and cancer are a result of the splitting of a psychosis (p99)! He quotes Zen and Sufi stories, Krishnamurti and Al Ghazali and even Castenada (seemingly unaware of his exposure as a fraud 20 years ago!), yet he seems oblivious to the fact that meditation is the most powerful therapy there is and to the presence around him in his own country and all over the globe of the most diverse and effective therapeutic community that has ever existed-that of the students of the great Indian mystic (ie, psychotherapist) Osho. What a great pity! He could have learned so much and advanced his therapy so far. But like most people he deliberately or unconsciously avoids anything which might wake him up too much. It's possible however that he just avoids mentioning Osho as he's radical enough to trigger the control templates in the monkey brain and enlightenment has the power to change one's whole life and not just put a bandaid on as other therapies usually do. Widmer refers repeatedly to the great LSD therapy pioneer Stanislav Grof, whose writings are one of the first that the interested reader may want to consult. Also, anyone who has a serious interest in psychedelic therapy should read Myron Stolaroff´s " The Secret Chief "-an account of the most remarkable clandestine therapist of this type of all time. It tells the story of the late Leo Zeff, who helped thousands to find themselves with the skilled and varied use of a wide variety of psychedelics. As the book is hard to find you may wish to read the info on Zeff on the web. In addition the clinical chapters in the excellent Ecstasy:the complete guide by J. Holland(2001) and her web page www.drholland.com (and elsewhere on the net) provide a broad framework and guide to therapy that is lacking here. A lovely book to add to any drug or therapy library, if you can find it. -/- Those wishing a comprehensive up to date framework for human behavior from the modern two systems view may consult my article The Logical Structure of Philosophy, Psychology, Mind and Language as Revealed in Wittgenstein and Searle 59p(2016). For all my articles on Wittgenstein and Searle see my e-book ‘The Logical Structure of Philosophy, Psychology, Mind and Language in Wittgenstein and Searle 367p (2016). Those interested in all my writings in their most recent versions may consult my e-book Philosophy, Human Nature and the Collapse of Civilization - Articles and Reviews 2006-2016 662p (2016). -/- All of my papers and books have now been published in revised versions both in ebooks and in printed books. -/- Talking Monkeys: Philosophy, Psychology, Science, Religion and Politics on a Doomed Planet - Articles and Reviews 2006-2017 (2017) https://www.amazon.com/dp/B071HVC7YP. -/- The Logical Structure of Philosophy, Psychology, Mind and Language in Ludwig Wittgenstein and John Searle--Articles and Reviews 2006-2016 (2017) https://www.amazon.com/dp/B071P1RP1B. -/- Suicidal Utopian Delusions in the 21st century: Philosophy, Human Nature and the Collapse of Civilization - Articles and Reviews 2006-2017 (2017) https://www.amazon.com/dp/B0711R5LGX -/- . (shrink)

Recent developments in neuroscience have inspired proposals to perform deep brain stimulation on psychopathic detainees. We contend that these proposals cannot meet important ethical requirements that hold for both medical research and therapy. After providing a rough overview of key aspects of psychopathy and the prospects of tackling this condition via deep brain stimulation, we proceed to an ethical assessment of such measures, referring closely to the distinctive features of psychopathic personality, particularly the absence of subjective suffering and a lack (...) of moral motivation. Scrutiny of these factors reveals that two essential bioethical criteria, individual medical benefit and voluntary informed consent, cannot be met in performing neurosurgical experiments or treatments on psychopathic inmates. (shrink)

We argue that charging people to participate in research is likely to undermine the fundamental ethical bases of clinical research, especially the principles of social value, scientific validity, and fair subject selection.

Some early phase clinical studies of candidate HIV cure and remission interventions appear to have adverse medical risk–benefit ratios for participants. Why, then, do people participate? And is it ethically permissible to allow them to participate? Recent work in decision theory sheds light on both of these questions, by casting doubt on the idea that rational individuals prefer choices that maximise expected utility, and therefore by casting doubt on the idea that researchers have an ethical obligation not to enrol participants (...) in studies with high risk–benefit ratios. This work supports the view that researchers should instead defer to the considered preferences of the participants themselves. This essay briefly explains this recent work, and then explores its application to these two questions in more detail. (shrink)

The paper attempts to set a guideline to contemporary common morality debate. The author points out what he sees as two common problems that occur in the field of comparative cultural studies related to a common morality debate. The first problem is that the advocates and opponents of common morality, consciously or unconsciously, define the moral terms in question in a way that their respective meanings would naturally lead to the outcomes that each party desires. The second problem is that (...) the examples each party chooses as the empirical evidences may not be as simple and clear-cut as the researchers think they are, mainly because the situational contexts where the examples are located between two different cultures vastly differ. To prevent these mistakes, the author emphasizes that we should pay attention to a subtle distinction between "thick" and "thin" construed from the levels of "theoretical status" and of "material content". With the conceptual distinctions in mind, the author shows how different cultures (i.e., Western individualist society and East Asian neo-Confucian society) see the moral principles like autonomy and beneficence in different lexical orders. (shrink)

In this peer commentary on L. Syd M. Johnson’s “Inference and Inductive Risk in Disorders of Consciousness,” I argue for the necessity of disability education as an integral component of decision-making processes concerning patients with DOC and, mutatis mutandis, all patients with disabilities. The sole qualification Johnson places on such decision-making is that stakeholders are educated about and “understand the uncertainties of diagnosis and prognosis.” Drawing upon research in philosophy of disability, social epistemology, and health psychology, I argue that this (...) educational qualification is insufficient to address systemic ableism and other forms of epistemic bias in quality of life judgments. (shrink)

Henry Richardson has recently published the first book ever devoted to ancillary care obligations, which roughly concern what medical researchers are morally required to provide to participants beyond what safety requires. In it Richardson notes that he has presented the ‘only fully elaborated view out there’ on this topic, which he calls the ‘partial-entrustment model’. In this article, I provide a new theory of ancillary care obligations, one that is grounded on ideals of communion salient in the African philosophical tradition (...) and is intended to rival and surpass Richardson’s model, which is a function of Western considerations of autonomy. I argue that the relational approach of the former has several virtues in comparison to the basic individualism of the latter. (shrink)

Since the Supreme Court upheld the partial birth abortion ban in 2007, more U.S. abortion providers have begun performing intraamniotic digoxin injections prior to uterine dilation and evacuations. These injections can cause medical harm to abortion patients. Our objective is to perform an in-depth bioethical analysis of this procedure, which is performed mainly for the provider’s legal benefit despite potential medical consequences for the patient.

The current ethical and regulatory framework for research is often charged with burdening investigators and impeding socially valuable research. To address these concerns, a growing number of research ethicists argue that informed consent should be adapted to the risks of research participation. This would require less rigorous consent standards in low-risk research than in high-risk research. However, the current discussion is restricted to cases of research in which the risks of research participation are outweighed by the potential clinical benefits for (...) the individual research participant. Furthermore, current proposals do not address the worry that risk-adapted informed consent may result in enrolling participants into research without their autonomous authorization. In this paper, we show how the standard view of informed consent – consent as autonomous authorization – can be adapted to risk even when the research does not have a favourable risk-benefit profile for the participant. Our argument has two important implications: first, it implies that current and proposed consent standards are not adequately calibrated to risk and, second, that consent standards also need to be adapted to factors other than risk. (shrink)

Euthanasia and assisted suicide have proved to be very contentious topics in medical ethics. Some ethicists are particularly concerned that allowing physicians to carry out these procedures will undermine their professional obligations and threaten the very goals of medicine. However, I maintain that the fundamental goals of medicine not only do not preclude the practice of euthanasia and assisted suicide by physicians, but can in fact be seen to support these practices in some instances. I look at two influential views (...) of the goals of medicine, one based on the broad guiding principles of autonomy, beneficence and nonmaleficence, and the other focusing on several more concrete aims, concluding that both approaches can be seen to support euthanasia and assisted suicide. I then turn to the popular concern that allowing physicians to carry out euthanasia and assisted suicide will lead to widespread abuse. I argue that the possibility for abuse can be minimised if we make the patient's autonomous consent an essential requirement of the practice. (shrink)

Most regulations and guidelines require that potential research participants be told a great deal of information during the consent process. Many of these documents, and most of the scholars who consider the consent process, assume that all this information must be disclosed because it must all be understood. However, a wide range of studies surveying apparently competent participants in clinical trials around the world show that many do not understand key aspects of what they have been told. The standard view (...) of the conditions for valid consent therefore implies that these people have failed to give valid consent to research participation. In this paper we argue that the standard view is false. The primary function of the requirement that researchers disclose information about a study is the avoidance of illegitimate control over someone’s consent decision, which is a form of fraud.We derive the content and manner of appropriate disclosure by analysing the ways in which the manipulation of information can invalidate consent. Our analysis shows that the informational requirements for valid consent are conceptually distinct and thus unlikely to have identical contents. This implies that consent can be valid when not everything that ought to be disclosed by the person asking for consent is understood by the person who proffers it. (shrink)

In a recent discussion, Walter Glannon discusses a number of ways we might try to minimize harm to patients who experience intraoperative awareness. In this response I direct attention to a possibility that deserves further attention. It might be that a kind of psychological intervention – namely, informing patients of the possibility of intraoperative awareness and of what to expect in such a case – would constitute a unique way to respect patient autonomy, as well as minimize the harm that (...) typically follows intraoperative awareness events. (shrink)

In 2012, a German court ruled that religious circumcision of male minors constitutes criminal bodily assault. Muslim and Jewish groups responded with outrage, with some commentators pegging the ruling to Islamophobic and anti-Semitic motivations. In doing so, these commentators failed to engage with any of the legal and ethical arguments actually given by the court in its landmark decision. In this brief commentary, I argue that a firm distinction must be drawn between criticisms of religious practices that stem from irrational (...) prejudice and bigoted attitudes and those that are grounded in sound moral reasoning. Given that ritual circumcision is a pre-Enlightenment custom that elevates the inclinations of the community over the rights of the individual, it is hardly surprising that a growing number of post-Enlightenment philosophers and legal scholars are taking an ethical stand against it. As the “circumcision debate” continues, parties on all sides of the issue must remember to reason through the relevant considerations with care and respect. (shrink)

Addressing the question in the form of Kant’s maxim, this paper moves on to a more controversial topic in biomedical ethics, physician-assisted suicide. However, my conclusion is tentative, and what is worse, negative: I partially approve suicide. It does not imply a moral hazard. The situation is opposite: in the present times, terminal patients seriously wish it. I, as an author, put an emphasis on this very respect. Now suicide is, for certain circles, nothing but justice. The arguments of thinkers (...) who approve suicide are also cited from this angle. (shrink)

The American Journal of Bioethics, Volume 12, Issue 3, Page 35-36, March 2012.

I distinguish between 'hard nudges' and 'soft nudges', arguing that it is possible to show that the latter can be compatible with informed consent - as Cohen has recently suggested; but that the real challenge is the compatibility of the former. Hard nudges are the more effective nudges because they work on less than conscious mechanisms such as those underlying our habits: whether those influences - which are often beyond the subject's awareness - can be reconciled with informed consent in (...) health care is the more challenging question. I suggest two directions for possible answers: on the one hand, looking at the growing empirical literature on mindless judgement and behaviour; and on the other hand considering a more diversified conception of consent, which I sketch. (shrink)

Decisional capacity evaluations (DCEs) occur in clinical settings where it is unclear whether a consumer of medical services has the capacity to make an informed decision about the relevant medical options. DCEs are localized interventions, not the global loss of competence, that assign a surrogate decision maker to make the decision on behalf of the medical consumer. We maintain that one important necessary condition for a DCE to be morally justified, in cases of medical necessity, is that the health care (...) consumer under evaluation is incapable of expressing a preference for a certain outcome. (shrink)

This paper explores the claim that someone can reasonably consider themselves to be under a duty to respect the autonomy of a person who does not have the capacities normally associated with substantial self-governance.