Phenomenology gives rise to certain ontological considerations that have far-reaching implications for standard conceptions of patient autonomy in medical ethics, and, as a result, the obligations of and to patients in clinical decision-making contexts. One such consideration is the phenomenological reduction in classical phenomenology, a core feature of which is the characterisation of our primary experiences as immediately and inherently meaningful. This paper builds on and extends the analyses of the phenomenological reduction in the works of Husserl, Heidegger, and Merleau-Ponty (...) in order to identify and explain its implications for our current understanding of the principle of respect for patient autonomy and the norms of clinical decision making. (shrink)

Transhumanism is a challenging movement that invites us to rethink what defines humanity, including what we value and regret the most about our existence. Vulnerability is a key concept that require thorough philosophical scrutiny concerning transhumanist proposals. Vulnerability can refer to a universal condition of human life or, rather, to the specific exposure to certain harms due to particular situations. Even if we are all vulnerable in the first sense, there are also different sources and levels of vulnerability depending on (...) concrete social circumstances. Recently, Michael Hauskeller argued about a fundamental incompatibility between transhumanism and vulnerability. He understands vulnerability as an existential category, linked to woundability and mortality. This idea is akin to ontological vulnerability, but it does not notice some important features of social vulnerability. On the other side, transhumanism is a complex and non-homogeneous movement. Here we distinguish between a strong and a weak version of transhumanism. We will propose that the salience of vulnerability is only diminished in the radical one, while a moderate version can reconcile vulnerability with human enhancement. Thus, vulnerability, a concept that has recently gained much importance as an anthropological category in contemporary ethics, is not necessarily at odds with any transhumanist project. (shrink)

Trust is critical for social life, and yet it is alarmingly fragile. It is easily damaged and difficult to repair. Philosophers studying trust have often noted that basic kind of trust needs to be in place in order for social life to be possible. Although philosophers have suggested that basic trust must exist, they have not tried to describe in explicit terms what this basic trust looks like, or how it comes to be. In this article I will identify and (...) describe a basic form of trust that I call recognition trust. It is a latent expectation we have in others to respect our moral status as persons. By conceptualizing recognition trust, I can explain why trust is not just a useful tool for social cooperation: having our personhood recognized is necessary for living a minimally decent human life, and trust is a necessary element of recognition. First, I motivate the need for conceptualizing a basic form of trust by looking at cases of moral injury and our inherent vulnerability. Such injuries involve the betrayal of an expectation we have in others to recognize us as persons with moral status. Second, I dig deeper into this basic human need of recognition that is thwarted in moral injuries. I argue that fulfilling this basic need requires a particular kind of trust that others will not morally injure us. Third, I give shape to recognition trust by describing its core features, showing why it is a candidate for basic trust. Finally, I defend my concept of recognition trust against a pair of objections. (shrink)

ABSTRACT This paper examines the question of whether recognition relations are based on trust. Theorists of recognition have acknowledged the ways in which recognition relations make us vulnerable to others but have largely neglected the underlying ‘webs of trust’ in which such relations are embedded. In this paper, I consider the ways in which the theories of recognition developed by Jürgen Habermas and Axel Honneth, not only point to our mutual vulnerability but also implicitly rely upon mutual relations of trust. (...) The paper first offers a novel examination of the relation between recognition, vulnerability and trust in Habermas’ account of communicative action with the aim of arguing that such a consideration helps to elucidate important features of recognition. My claim is that a consideration of the dynamics of recognition and vulnerability in language-use, leads to an acknowledgment of the forms of trust that not only underpin communicative action, but recognition more generally. I conclude by considering the elements that are underplayed in Habermas’ account by turning to an examination of Axel Honneth’s alternative affective theory of recognition, specifically considering the interrelation between vulnerability and recognition. In doing so, I also turn to a consideration of the kind of trust that must be assumed in Honneth’s account of mutual recognition and point to a recognitive notion of trust. (shrink)

Demands for improved access to innovative therapies have prompted a discourse that claims patients have rights to access treatments that may be of benefit, even if evidence that demonstrates safety and efficacy is lacking. This rights-based discourse is grounded in accounts of autonomy and assertions claiming that the state ought to not interfere with the free choices of patients and clinical decision-making. In this essay, we scrutinise these arguments to defend the ethical and legal permissibility of interference in contexts where (...) the uncertainty of benefit and potential for harm creates vulnerabilities that undermine patient capacity for self-determination. In support of this argument, we draw on two theoretical approaches to explore the limits of autonomy in innovative contexts and analyse the legal bases of the rights-based discourse. We then apply this analysis to the case example of stem cell transplantation as an innovative treatment for multiple sclerosis. (shrink)

Like being able to drive a car, being autonomous is a socially attributed, claimed, and contested status. Normative debates about criteria for autonomy (and what autonomy entitles one to) are best understood, not as debates about what autonomy, at core, really is, but rather as debates about the relative merits of various possible packages of thresholds, entitlements, regulations, values, and institutions. Within different “regimes” of autonomy, different criteria for (degrees of) autonomy become authoritative. Neoliberal, solidaristic, and perfectionist regimes entail conflicting (...) understandings of what gets you autonomy and what autonomy gets you—for example, in relation to policies regarding physician-assisted suicide or financial support for senior citizens. In light of this, justifying a particular understanding of autonomy is inseparable from the task of arguing for the context-specific merits of a regime of autonomy as a whole and in relation to other ethical and political commitments. (shrink)

When people argue, they are vulnerable to unwanted and costly changes in their beliefs. This vulnerability motivates the position that belief involuntarism makes argument inherently adversarial, as well as the development of alternatives to adversarial argumentation such as “invitational rhetoric”. The emphasis on involuntary belief change in such accounts, in our perspective, neglects three dimensions of arguing: the diversity of arguer intentions, audience agency, and the benefits of belief change. The complex impact of arguments on both audiences and arguers involves (...) vulnerabilities related to various forces of argument, not just the intellectual force of premise-conclusion complexes. Shifting emphasis from adversariality to vulnerability, we propose a more holistic understanding of argument, in which vulnerability reveals various sources of strength and opportunity in addition to risk. (shrink)

In this paper I present a critical analysis of the English law relating to the safeguarding of vulnerable adults, in particular how the law impacts on the sexual lives of adult women with mental disabilities. I consider the discourses of vulnerability that surround the different legal regimes and whether the emerging theoretical vulnerability literature can assist in developing more nuanced legal responses. I argue that the inherent jurisdiction and Care Act 2014 provide an opportunity to move away from the focus (...) on inherent features of vulnerability such as mental disability towards a more nuanced, situational and embodied account of what it means to safeguard ‘vulnerable adults’. This has the potential to be developed in England through the new legal framework of the Care Act and can be achieved through targeting interventions against the situational causes of vulnerability, for example the perpetrators of sexual violence. (shrink)

Technical advances in genome editing methods raise the question how autonomy should figure in theological ethical debates about genetic enhancements. Thinking primarily of the parents’ reproductive autonomy, several secular and theological thinkers argue parents should be allowed to ‘enhance’ an embryo genetically. Jürgen Habermas’s critique of enhancements in the name of the child’s autonomy, meanwhile, has been met with a critique of autonomy in theology. This article argues that theological views about God’s relationship to the creature provide strong theological grounds (...) for a new appropriation of autonomy. A liberal maximisation of individual choice is to be viewed critically, but more recent discourses on relational autonomy see certain forms of vulnerability contribute to a communal understanding of autonomy. This view dovetails with Habermas’s argument, according to which enhancements create too strong a temptation towards overly directive parenting—less in modifying an embryo than in the ensuing relationship to the child. (shrink)

The High Court continues to exercise its inherent jurisdiction to make declarations about interventions into the lives of situationally vulnerable adults with mental capacity. In light of protective responses of health care providers and the courts to decision-making situations involving capacitous vulnerable adults, this paper has two aims. The first is diagnostic. The second is normative. The first aim is to identify the harms to a capacitous vulnerable adult’s autonomy that arise on the basis of the characterisation of situational vulnerability (...) and autonomy as fundamentally opposed concepts or the failure to adequately acknowledge the conceptual relationship between them at common law. The second part of this aim is to draw upon developments in analytic feminist philosophy to illustrate how standard approaches to autonomy are ill-equipped to capture the autonomy issues of capacitous vulnerable adults when their decisions regarding care and treatment are at stake. The second (normative) aim is to develop an account of self-authorised, intersubjective autonomy on the basis of analytic feminist insights into the relational practices of recognition. This account not only attempts to capture the autonomy of capacitous vulnerable adults and account for the necessary harms to their autonomy that arise from standard common law responses to their situational vulnerability, it is also predicated on the distinctions between mental capacity, the satisfaction of conditions for informed consent and the exercise of autonomy, meaning that it is better placed to fulfil the primary aim of the inherent jurisdiction – to facilitate the autonomy of vulnerable adults with capacity. (shrink)

This article investigates how human life is conceptualized in the design and use of digital assistants and how this conceptualization feeds back into the life really lived. It suggests that a specific way of conceptualizing human life — namely as a set of tasks to be optimized — is responsible for the much-criticized information hunger of these digital assistants. The data collection of digital assistants raises not just several issues of privacy, but also the potential for improving people’s degree of (...) self-determination, because the optimization model of daily activity is genuinely suited to a certain mode of self-determination, namely the explicit and reflective setting, pursuing, and monitoring of goals. Furthermore, optimization systems’ need for generation and analysis of data overcomes one of the core weaknesses in human capacities for self-determination, namely problems with objective and quantitative self-assessment. It will be argued that critiques according to which digital assistants threaten to reduce their users’ autonomy tend to ignore that the risks to autonomy are derivative to potential gains in autonomy. These critiques are based on an overemphasis of a success conception of autonomy. Counter to this conception, being autonomous does not require a choice environment that exclusively supports a person’s “true” preferences, but the opportunity to engage with external influences, supportive as well as adverse. In conclusion, it will be argued that ethical evaluations of digital assistants should consider potential gains as well as potential risks for autonomy caused by the use of digital assistants. (shrink)

In recent years, several studies have advocated the need to expand the concept of patient autonomy beyond the capacity to deliberate and make decisions regarding a specific medical intervention or treatment (decision-making or decisional autonomy). Arguing along the same lines, this paper proposes a multidimensional concept of patient autonomy (decisional, executive, functional, informative and narrative) and argues that determining the specific aspect of autonomy affected is the first step towards protecting or promoting (and respecting) patient autonomy. These different manifestations of (...) autonomy are not mutually dependent; there may be patients who have problems in one dimension, while at the same time being fully autonomous in others. Nevertheless, a close interaction has been observed between the various dimensions and indeed, a phenomenological analysis shows that damage to or a reduction in one aspect of people’s capacity for self-government generally affects other aspects of their autonomy, which in turn disrupts their identity and the way in which they see themselves and are seen by others. In this paper, I shall examine some of these interactions and show how they may lie at the heart of the problem of poor treatment adherence (where adherence is defined as being the extent to which a patient’s behavior over time coincides with the recommendations made by and agreed with their health professional). One example given is that of psoriasis, a chronic skin disease with a very poor adherence record. In Spain, it is calculated that 85% of patients diagnosed with mild to moderate psoriasis fail to comply properly with their treatment, and figures from other parts of the world are similar. Although there are many possible causes for non-adherence among psoriasis patients, assessing their decisional, executive and narrative capacities and taking appropriate action based on the results may help increase adherence rates. (shrink)

Kantian moral concepts concerning respect for human dignity have played a central role in articulating ethical guidelines for medical practice and research, and for articulating some central positions within bioethical debates more generally. The most common of these Kantian moral concepts is the obligation to respect the dignity of patients and of human research subjects as autonomous, self-determining individuals. This article describes Kant’s conceptual distinction between dignity and autonomy as values, and draws on the work of several contemporary Kantian philosophers (...) who employ the distinction to make sense of some common moral intuitions, feelings, and norms. Drawing on this work, the article argues that the conceptual distinction between dignity and autonomy as values is indispensable in the context of considering our obligations to those who are dependent and vulnerable. (shrink)

Recently debates about the worth of “ideal theory” have directed attention to the functions that an account of a perfectly just society can serve. One function is that of “reconciliation”: learning that a seemingly undesirable feature of the social world would exist even in the perfectly just society can show us the value that it has in the present as well. John Rawls has emphasized reconciliation as among the roles of political philosophy. For instance, Rawls claims that his theory of (...) justice can reconcile us to the pluralism of liberal democracies. In this essay, I argue that Rawls’s political theory also can reconcile the inhabitants of liberal democratic societies to the fact that such societies may be cognitively confusing on account of their complexity. Then I contend that Rawls’s work offers valuable theoretical resources for analysing a society’s transparency or lack thereof. (shrink)

Mobile health applications (‘health apps’) that promise the user to help her with some aspect of her health are very popular: for-profit apps such as MyFitnessPal, Fitbit, or Headspace have tens of millions of users each. For-profit health apps are designed and run as optimization systems. One would expect that these health apps aim to optimize the health of the user, but in reality they aim to optimize user engagement and, in effect, conversion. This is problematic, I argue, because digital (...) health environments that aim to optimize user engagement risk being manipulative. To develop this argument, I first provide a brief analysis of the underlying business models and the resulting designs of the digital environments provided by popular for-profit health apps. In a second step, I present a concept of manipulation that can help analyze digital environments such as health apps. In the last part of the article, I use my concept of manipulation to analyze the manipulative potential of for-profit health apps. Although for-profit health can certainly empower their users, the conditions for empowerment also largely overlap with the conditions for manipulation. As a result, we should be cautious when embracing the empowerment discourse surrounding health apps. An additional aim of this article is to contribute to the rapidly growing literature on digital choice architectures and the ethics of influencing behavior through such choice architectures. I take health apps to be a paradigmatic example of digital choice architectures that give rise to ethical questions, so my analysis of the manipulative potential of health apps can also inform the larger literature on digital choice architectures. (shrink)

This article aims to contribute to literature on the conceptualisation of ‘vulnerability’ and its use by neo-liberal welfare regimes to demean, stigmatize and responsibilize welfare recipients. Several conceptions of ‘vulnerability’ will be explored and utilised in the context of welfare reforms that purport to regulate social security recipients as highly risky ‘vulnerable’ subjects. However, as this article will make clear, ‘vulnerability’ is a somewhat slippery concept and one susceptible to abuse by powerful interests intent on increasing coercive surveillance, discipline and (...) disentitlement for those designated as ‘vulnerable’. Legislation enacted ostensibly to address the ‘vulnerability’ of welfare recipients can foster intensive regulation and it must be asked who benefits most from such arrangements and the rhetoric that supports them. (shrink)