En los sectores políticos democráticos liberales, el principio del respeto a la autonomía es ampliamente aceptado —en teoría, si no siempre en la práctica— como un valor moral cardinal que debería guiar tanto la deliberación política, la política pública y las prácticas, como nuestras actitudes respecto a nuestros conciudadanos. En términos simples, respetar la autonomía es respetar los intereses de cada persona de vivir su vida según su propia concepción del bien. En la base del requisito normativo de respetar la (...) autonomía de otro está la presunción de que la autonomía confiere autoridad normativa sobre la propia vida; la autoridad para tomar decisiones de importancia práctica para la propia vida, por razones propias, cualesquiera que sean. Se asume que las personas autónomas tienen la capacidad, el derecho y la responsabilidad de ejercer esta autoridad, incluso si no siempre lo hacen sabiamente. (shrink)

The concept of paternalism is intricately tied to the concept of autonomy. It is commonly assumed that when paternalistic interventions are wrong, they are wrong because they impede individuals’ autonomy. Our aim in this paper is to show that the recent shift towards conceiving of autonomy relationally highlights a separate conceptual space for a nonpaternalistic kind of interpersonal intervention termed maternalism. We argue that maternalism makes a twofold contribution to the debate over the ethics of interpersonal action and decision-making. Descriptively, (...) it captures common experiences that, while not unusual in everyday life, are largely absent from the present discussion. Normatively, it describes a type of intervention with justification conditions distinct from the standard framework of paternalism. We explicate these contributions by describing six key differences between maternalism and paternalism, and conclude by anticipating and responding to potential objections. (shrink)

We argue that contemporary psychiatry adopts a defensive strategy vis-à-vis various external sources of pressure. We will identify two of these sources – the plea for individual autonomy and the idea of Managed Care – and explain how they have promoted a strict biomedical conception of disease. The demand for objectivity, however, does not take into account the complexity of mental illness. It ignores that the psychiatrist’s profession is essentially characterized by fragility: fluctuating between scientific reduction and the irreducible complexity (...) of reality. Therefore, the psychiatrist is not in need of hard and fast rules, but of judgment. At the end, we suggest that philosophy could inject some healthy uncertainty within psychiatry in order to restore its fragile identity. Our examples are drawn from the Dutch situation but we are confident that they apply to other countries as well. (shrink)

The value of applied philosophy is often taken to consist in its contribution to our understanding of practical issues with which applied philosophy engages and in its contribution to their satisfactory resolution. This chapter examines the relationship between the nature of applied philosophy and its value. It regards the value of applied philosophy as dependent both on its philosophical quality and on its contribution to the understanding and (potential) resolution of practical issues with which it engages. These dual points of (...) reference are difficult simultaneously to fulfill and arguably sometimes in tension with one another. The chapter takes issue with the idea that the value of applied philosophy consists, or ought to consist, in its direct impact on actual policy or practice. (shrink)

Next SectionFollowing the influential Gifford and Reith lectures by Onora O’Neill, this paper explores further the paradigm of individual autonomy which has been so dominant in bioethics until recently and concurs that it is an aberrant application and that conceptions of individual autonomy cannot provide a sufficient and convincing starting point for ethics within medical practice. We suggest that revision of the operational definition of patient autonomy is required for the twenty first century. We follow O’Neill in recommending a principled (...) version of patient autonomy, which for us involves the provision of sufficient and understandable information and space for patients, who have the capacity to make a settled choice about medical interventions on themselves, to do so responsibly in a manner considerate to others. We test it against the patient–doctor relationship in which each fully respects the autonomy of the other based on an unspoken covenant and bilateral trust between the doctor and patient. Indeed we consider that the dominance of the individual autonomy paradigm harmed that relationship. Although it seems to eliminate any residue of medical paternalism we suggest that it has tended to replace it with an equally (or possibly even more) unacceptable bioethical paternalism. In addition it may, for example, lead some doctors to consider mistakenly that unthinking acquiescence to a requested intervention against their clinical judgement is honouring “patient autonomy” when it is, in fact, abrogation of their duty as doctors. (shrink)

A prima facie analysis suggests that there are essentially two, mutually exclusive, ways in which risk arising from engineering design can be managed: by imposing external constraints on engineers or by engendering their feelings of responsibility and respect their autonomy. The author discusses the advantages and disadvantages of both approaches. However, he then shows that this opposition is a false one and that there is no simple relation between regulation and autonomy. Furthermore, the author argues that the most pressing need (...) is not more or less regulation but the further development of moral imagination. The enhancement of moral imagination can help engineers to discern the moral relevance of design problems, to create new design options, and to envisage the possible outcomes of their designs. The author suggests a dual program of developing regulatory frameworks that support engineers’ autonomy and responsibility simultaneously with efforts to promote their moral imagination. He describes how some existing institutional changes have started off in this direction and proposes empirical research to take this further. (shrink)

Over the past decades, mood enhancement effects of various drugs and neuromodulation technologies have been proclaimed. If one day highly effective methods for significantly altering and elevating one’s mood are available, it is conceivable that the demand for them will be considerable. One urgent concern will then be what role physicians should play in providing such services. The concern can be extended from literature on controversial demands for aesthetic surgery. According to Margaret Little, physicians should be aware that certain aesthetic (...) enhancement requests reflect immoral social norms and ideals. By granting such requests, she argues, doctors render themselves complicit to a collective ‘evil’. In this paper, we wish to question the extent to which physicians, psychiatrists and/or neurosurgeons should play a role as ‘moral gatekeepers’ in dealing with suspect demands and norms underlying potential desires to alter one’s mood or character. We investigate and discuss the nature and limits of physician responsibilities in reference to various hypothetical and intuitively problematic mood enhancement requests. (shrink)

Key ideas in the work of Michel Foucault are explored and applied to the organized pursuit of knowledge in higher education. His association of power and knowledge accounts for deeply rooted practices in higher education that would need to be mediated or overcome for there to be a revolution in inquiry to occur, such as the one advanced by Nicholas Maxwell. Foucault’s concepts of disciplinary power and bio-power, and how they act to manage the behavior of free citizens, are described. (...) These concepts are then applied to free inquiry, to show how the activity of individual inquirers is managed and how critical inquiry is controlled. The management of inquiry involving four norms, two of them intrinsic to inquiry and the other two extrinsic, is explained. The potential of Foucault’s concept of discursive formations is introduced as a means of reconceiving inquiry to overcome these impediments to a revolution in inquiry. (shrink)

The recent ruling from England on the case of M is one of very few worldwide to consider whether life-sustaining treatment, in the form of clinically assisted nutrition and hydration, should continue to be provided to a patient in a minimally conscious state. Formally concerned with the English law pertaining to precedent autonomy (specifically advance decision-making) and the best interests of the incapacitated patient, the judgment issued in M's case implicitly engages with three different accounts of the value of human (...) life, which respectively emphasise its self-determined, intrinsic and instrumental value. The judge appeared to be most persuaded by the intrinsic value of life and he concluded that treatment ought to continue. Assessing whether his approach or conclusion were ethically appropriate involves significant substantive and evidential questions regarding where the burden of proof should lie and what standard of proof should be required when decisions are to be made about the fates of patients inhabiting ‘twilight worlds’. (shrink)

Autonomy is a concept that holds much appeal to social and legal philosophers. Within a medical context, it is often argued that it should be afforded supremacy over other concepts and interests. When respect for autonomy merely requires non-intervention, an adult’s right to refuse treatment is held at law to be absolute. This apparently simple statement of principle does not hold true in practice. This is in part because an individual must be found to be competent to make a valid (...) refusal of consent to medical treatment, and capacity to decide is not an absolute concept. But further to this, I argue that there are three relevant understandings of autonomy within our society, and each can demand in differing cases that different courses of action be followed. Judges, perhaps inadvertently, have been able to take advantage of the equivocal nature of the concept to come tacitly to decisions that reflect their own moral judgments of patients or decisions made in particular cases. The result is the inconsistent application of principle. I ask whether this is an unforeseen outcome or if it reflects a wilful disregard for equal treatment in favour of silent moral judgments in legal cases. Whatever the cause, I suggest that once this practice is seen to occur, acceptable justification of it in some cases is difficult to find. (shrink)

Discovering obligations that are ascribed to them by others is potentially an important element in the development of the moral imagination of engineers. Moral imagination cannot reasonably be developed by contemplating oneself and one’s task alone: there must be some element of discovering the expectations of people one could put at risk. In practice it may be impossible to meet ascribed obligations if they are completely general and allow no exceptions — for example if they demand an unlimited duty to (...) avoid harm. But they can still serve to modify engineers’ prior ethics, for example by limiting a purely utilitarian approach to deciding who should bear risk and how much risk they should bear. Ascribed obligations can also give engineers insight into the public reaction to risks that arise from engineered systems, and the consequent expectations that the public have about how much protection is desirable and where the responsibility for this protection lies. This article analyses the case for taking ascribed obligations seriously, and reviews some of the obligations that have been ascribed in the aftermath of recent engineering failures. It also proposes ways in which ascribed obligations could be used in engineers’ moral development. (shrink)