In recent years, neuroscience has been a particularly prolific discipline stimulating many innovative treatment approaches in medicine. However, when it comes to the brain, new techniques of intervention do not always meet with a positive public response, in spite of promising therapeutic benefits. The reason for this caution clearly is the brain’s special importance as “organ of the mind”. As such it is widely held to be the origin of mankind’s unique position among living beings. Likewise, on the level of (...) the individual human being, the brain is considered the material substrate of those traits that in combination render each person unique. In view of this preeminent significance of the brain, it is understandable that, in general, interventions into the brain are considered a delicate issue and that new techniques of intervention are scrutinised with particular care. However, in doing so it is important not to go to the opposite extreme and shy away from promising new therapeutic approaches for debilitating disorders of the brain. With respect to the new techniques of brain intervention a broad interdisciplinary perspective is required to discern irrational fear from justified concern. Hence, the Europäische Akademie established a project group consisting, on the one hand, of experts from different fields of medicine who have got first-hand experience of applying the techniques at issue and, on the other hand, of philosophers and a legal expert. The task of this team was to review the state of the art with respect to each single technique of intervening in the brain, to indicate future developments, and to address the ethical and legal issues common to all of them. The project’s outcome is the book at hand. (shrink)

What grounds my experience of my body as my own? The body that one experiences is always one’s own, but it does not follow that one always experiences it as one’s own. One might even feel that a body part does not belong to oneself despite feeling sensations in it, like in asomatognosia. The article aims at understanding the link between bodily sensations and the sense of ownership by investigating the role played by the body schema.

The term body integrity identity disorder (BIID) describes the extremely rare phenomenon of persons who desire the amputation of one or more healthy limbs or who desire a paralysis. Some of these persons mutilate themselves; others ask surgeons for an amputation or for the transection of their spinal cord. Psychologists and physicians explain this phenomenon in quite different ways; but a successful psychotherapeutic or pharmaceutical therapy is not known. Lobbies of persons suffering from BIID explain the desire for amputation in (...) analogy to the desire of transsexuals for surgical sex reassignment. Medical ethicists discuss the controversy about elective amputations of healthy limbs: on the one hand the principle of autonomy is used to deduce the right for body modifications; on the other hand the autonomy of BIID patients is doubted. Neurological results suggest that BIID is a brain disorder producing a disruption of the body image, for which parallels for stroke patients are known. If BIID were a neuropsychological disturbance, which includes missing insight into the illness and a specific lack of autonomy, then amputations would be contraindicated and must be evaluated as bodily injuries of mentally disordered patients. Instead of only curing the symptom, a causal therapy should be developed to integrate the alien limb into the body image. (shrink)

We argue against Thomson’s view that abortion is permissible even if fetuses have high moral status. Against this, we argue that, because many mothers are morally responsible for their pregnancies, they have a special obligation to assist. Finally, we address an objection according to which many mothers whose pregnancies are not a product of rape are not morally responsible to a sufficient degree, and so an obligation to assist is not generated. This objection assumes that the force of the mother’s (...) right to bodily integrity is not diminished if she is insufficiently morally responsible. We challenge this assumption. Our complete thesis is as follows: If a mother is morally responsible to a sufficient degree, she acquires an obligation to assist. If she is not, the force of her right to bodily integrity may be reduced. (shrink)

Recent criticisms of medicine converge on fundamental questions about the aim of medicine. The main task of this paper is to propose an account of the aim of medicine. Discussing and rejecting the initially plausible proposal according to which medicine is pathocentric, the paper presents and defends the Autonomy Thesis, which holds that medicine is not pathocentric, but sanocentric, aiming to promote health with the final aim to enhance autonomy. The paper closes by considering the objection that the Autonomy Thesis (...) is overly permissive and allows many highly controversial procedures as legitimate parts of medicine. (shrink)

Most people who defend physician-assisted death (PAD) endorse the Joint View, which holds that two conditions—autonomy and welfare—must be satisfied for PAD to be justified. In this paper, we defend an Autonomy Only view. We argue that the welfare condition is either otiose on the most plausible account of the autonomy condition, or else is implausibly restrictive, particularly once we account for the broad range of reasons patients cite for desiring PAD, such as “tired of life” cases. Moreover, many of (...) the common objections to an Autonomy Only view fail once we understand the extent of the autonomy condition’s requirements—in particular, the importance of one’s values for autonomous choices. If our view is correct, then the scope of permissible PAD is broader than is currently accepted in both the philosophical literature and the law, and therefore poses an important challenge to this widely accepted view on justified PAD. (shrink)

In this paper, we offer a new account of disability. According to our account, some state of a person's biology or psychology is a disability if that state makes it more likely that a person's life will get worse, in terms of his or her own wellbeing, in a given set of social and environmental circumstances. Unlike the medical model of disability, our welfarist approach does not tie disability to deviation from normal species’ functioning, nor does it understand disability in (...) essentialist terms. Like the social model of disability, the welfarist approach sees disability as a harmful state that results from the interaction between a person's biology and psychology and his or her surrounding environment. However, unlike the social model, it denies that the harm associated with disability is entirely due to social prejudice or injustice. In this paper, we outline and clarify the welfarist approach, answer common objections and illustrate its usefulness in addressing a range of difficult ethical questions involving disability. (shrink)

In this article, we present an analysis of bodily integrity in hand transplants from a phenomenological narrative perspective, while drawing on two contrasting case stories. We consider bodily integrity as the subjective bodily experience of wholeness which, instead of referring to actual bodily intactness, involves a positive identification with one’s physical body. Bodily mutilations, such as the loss of a hand, may severely affect one’s bodily integrity. A possible restoration of one’s experience of wholeness requires a process of re-identification. Medical (...) interventions, such as a hand transplant, may improve the possibility of a successful re-identification. However, since the experience of wholeness does not refer simply to physical intactness or impairment, the choice for medical intervention should not be based merely upon the degree of physical mutilation. It should also be based upon the degree to which a person fails in re-identifying with his or her mutilated body. We argue that a normalizing operation is only ethically justifiable if the intervention enables the person to be the body he or she has. (shrink)

Body integrity identity disorder (BIID), previously called apotemnophilia, is an extremely rare condition where sufferers desire the amputation of a healthy limb because of distress associated with its presence. This paper reviews the medical and philosophical literature on BIID. It proposes an evidenced based and ethically informed approach to its management. Amputation of a healthy limb is an ethically defensible treatment option in BIID and should be offered in some circumstances, but only after clarification of the diagnosis and consideration of (...) other treatment options. (shrink)

In this paper, we argue that promoting patient values is a legitimate goal of medicine. Our view offers a justification for certain current practices, including birth control and living organ donation, that are widely accepted but do not fit neatly within the most common extant accounts of the goals of medicine. Moreover, we argue that recognising value promotion as a goal of medicine will expand the scope of medical practice by including some procedures that are sometimes rejected as being outside (...) the scope of acceptable medical practice, such as certain forms of physician-assisted death. We then rebut some common and possible objections to this view. Our aim is not to argue that other accounts are mistaken—except when they argue for a single goal that does not include patient values—but rather to show that value promotion should play a more central role in discussions about the goals of medicine. (shrink)

Most people have a clear sense of what they mean by disability, and have little trouble identifying conditions they consider disabling. Yet providing a clear and consistent definition of disability is far from straightforward. Standardly, disability is understood as the restriction in our abilities to perform tasks, as a result of an impairment of normal physical or cognitive human functioning. However, which inabilities matter? We are all restricted by our bodies, and are all incapable of performing some tasks, but most (...) of these inabilities are not considered disabilities. If, then, we are to avoid the category of disability becoming overly broad—and thus politically and practically useless—we need some way of picking out the specific inabilities that are disabling. I argue that our answer should be informed by an account of the opportunities individuals are entitled to be able to perform as a matter of justice. Thus, to be disabled is to have these opportunities restricted, and not to deviate from the species norm or lack any ability that might improve our well-being. (shrink)

Medical ethics would be better if people were taught to think more clearly about well-being or the concept of what is good for a person. Yet for a variety of reasons, bioethicists have generally paid little attention to this concept. Here, I argue, first, that focusing on general theories of welfare is not useful for practical medical ethics. I argue, second, for what I call the “theory-without-theories approach” to welfare in practical contexts. The first element of this approach is a (...) focus on examining important and relatively uncontroversial constituents of welfare as opposed to general theories. The second key element is a framework for thinking about choice in relation to welfare, a framework I refer to as “the mild objectivity framework.” I conclude with illustrations of the way in which the “theory without theories approach” can improve thinking in medicine. (shrink)

The principle of autonomy is widely recognized to be of utmost importance in bioethics; however, we argue that this principle is often misapplied when one fails to distinguish two different contexts in medicine. When a particular patient is offered treatment options, she has the ultimate say in whether to proceed with any of those treatments. However, when deciding whether a particular intervention should be regarded as a form of medical treatment in the first place, it is the medical community who (...) has the ultimate say. Some argue that particular interventions should be allowed by virtue of the fact that they are autonomously requested. But making such an argument fails to distinguish between these two contexts and misapplies the principle of autonomy, ultimately having the potential to instigate problematic changes in the practice of medicine. (shrink)

Are bodily self-ascriptions immune to error through misidentification? According to the Inside mode view, one cannot be mistaken about whose body part it is when experiencing them from the inside. Here I shall consider two possible objections to bodily immunity. On the one hand, I shall briefly envisage two cases of misidentification: somatoparaphrenia and the Rubber Hand illusion. I shall show that none of them challenges the immunity principle. On the other hand, I shall highlight a more serious issue for (...) bodily immunity, namely, the multimodal nature of bodily self-knowledge. Very few bodily self-ascriptions are based on grounds that are purely or exclusively from the inside. I shall evaluate the consequences of multimodality for bodily immunity. (shrink)

The prelims comprise: Introduction Controversial Choices Kinds of Normative Reasons for Action Limits on Respect for Autonomy Children and Controversial Choice Controversial Choices and the Duty to Strive Toward Perfection and Full Autonomy Acknowledgments Notes References.

Patients with the controversial diagnosis of body integrity identity disorder report an emotional discomfort with having a body part that they feel should not be there. This discomfort is so strong that it interferes with routine functioning and, in a majority of cases, BIID patients are motivated to seek amputation of the limb. Although patient requests to receive the best available treatment are generally respected, BIID demands for amputation, at present, are not. However, what little has been said in the (...) ethics literature on the subject tends to favour doing so in cases of BIID. The general argument is that BIID demands should be respected, first, because of the importance that is already placed on respecting autonomy in medical decision-making contexts and second, because of the potential harm of not providing amputation coupled with the fact that no alternative means of relieving suffering exists. The defence of the right to self-demanded amputation is thus typically supported by the use of analogies with other unproblematical cases in order to show that the denial of BIID patient demands is inconsistent with conventional medical norms and practices. This paper criticises the appropriateness of the particular analogies that are thought to shed light on the allegedly unproblematical nature of BIID demands and argues that a proper understanding of the respect for autonomy in the medical decision-making context prohibits agreeing to BIID demands for amputation. (shrink)

Individuals with body integrity identity disorder seek to address a non-delusional incongruity between their body image and their physical embodiment, sometimes via the surgical amputation of healthy body parts. Opponents to the provision of therapeutic healthy-limb amputation in cases of BIID make appeals to the envisioned harms that such an intervention would cause, harms such as the creation of a lifelong physical disability where none existed before. However, this concept of harm is often based on a normative biomedical model of (...) health and disability, a model which conflates amputation with impairment, and impairment with a disability. This article challenges the prima facie harms assumed to be inherent in limb amputation and argues in favour of a potential treatment option for those with BIID. To do this, it employs the social model of disability as a means to separate the concept of impairment and disability and thereby separate the acute and chronic harms of the practice of therapeutic healthy-limb amputation. It will then argue that provided sufficient measures are put in place to ensure that those with atypical bodily constructions are not disadvantaged, the chronic harms of elective amputation would cease to be. (shrink)

It is widely agreed that living kidney donation is permitted but living kidney sales are not. Call this the Received View. One way to support the Received View is to appeal to a particular understanding of the conditions under which living kidney transplantation is permissible. It is often claimed that donors must act altruistically, without the expectation of payment and for the sake of another. Call this the Altruism Requirement. On the conventional interpretation, the Altruism Requirement is a moral fact. (...) It states a legitimate constraint on permissible transplantation and is accepted on the basis of cogent argument. The present paper offers an alternative interpretation. I suggest the Altruism Requirement is a moral fiction—a kind of motivated falsehood. It is false that transplantation requires altruism. But the Requirement serves a purpose. Accepting it allows kidney donation but not kidney sale. It, in short, rationalizes the Received View. (shrink)

Abstract: What grounds the experience of our body as our own? Can we rationally doubt that this is our own body when we feel sensations in it? This article shows how recent empirical evidence can shed light on issues on the body and the self, such as the grounds of the sense of body ownership and the immunity to error through misidentification of bodily self-ascriptions. In particular, it discusses how bodily illusions (e.g., the Rubber Hand Illusion), bodily disruptions (e.g., somatoparaphrenia), (...) and the multimodal nature of bodily self-knowledge challenge a classic view of ownership and immunity that puts bodily sensations at its core. (shrink)

Pain is unpleasant. It is something that one avoids as much as possible. One might then claim that one wants to avoid pain because one cares about one's body. On this view, individuals who do not experience pain as unpleasant and to be avoided, like patients with pain asymbolia, do not care about their body. This conception of pain has been recently defended by Bain [2014] and Klein [forthcoming]. In their view, one needs to care about one's body for pain (...) to have motivational force. But does one need to care about one's body qua one's own? Or does one merely need to care about the body that happens to be one's own? In this paper, I will consider various interpretations of the notion of bodily care, in light of a series of pathological cases in which patients report pain in a body part that they do not experience as their own. These cases are problematic if one adopts a first-personal interpretation of bodily care, according to which pain requires one to care about what is represented as one's own body. Th.. (shrink)

Apotemnophilia, a disorder that blurs the distinction between neurology and psychiatry, is characterized by the intense and longstanding desire for amputation of a speci¢c limb. Here we present evidence from two individuals suggestive that this condition, long thought to be entirely psychological in origin, actually has a neurological basis. We found heightened skin conductance response..

Beneficence and respect for autonomy are two of the most fundamental moral duties in general and in bioethics in particular. Beyond the usual questions of how to resolve conflicts between these duties in particular cases, there are more general questions about the possible forms of the interactions between them. Only recognition of the full spectrum of possible interactions will ensure optimal moral deliberation when duties potentially conflict. This paper has two simultaneous objectives. The first is to suggest a typological scheme (...) of all possible modes of interaction; these will be classified under the “discrete,” “semi-discrete,” and “non-discrete” categories, according to whether the meaning and/or forms of expression of each duty are treated as independent from or rather as constrained by the other. The second objective is to show that all logical possibilities of interaction indeed have real expressions in medical ethics, to provide clear illustrations of each, and in particular to stress those that have usually escaped recognition. (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)

This article discusses the acquisition of a physical impairment/disability through voluntary body modification, or transability. From the perspectives of critical genealogy and feminist intersectional analysis, the article considers the ability and cis*/trans* axes in order to question the boundaries between trans and transabled experience and examines two assumptions impeding the conceptualization of their placement on the same continuum: 1) trans studies assumes an able-bodied trans identity and able-bodied trans subject of analysis; and 2) disability studies assumes a cis* disabled identity. (...) The perception of transsexuality and transability as mutually exclusive phenomena results from a nonintersectional analysis of transsexuality as an issue of sex/gender, but not of ability, and of transability as an issue of ability, but not of sex/gender. Difficulty recognizing continuities between these phenomena thus stems from an ableist interpretation of sex/gender and a cisnormative* interpretation of ability. This article aims to: 1) enrich intersectional analysis in trans and disability studies and transability scholarship; 2) complicate disability studies, in which disabilities are often presumed to be “involuntary,” and encourage the decentering of a cis* subject; 3) encourage trans studies to decenter an able-bodied subject; and 4) advocate for increased dialogue and the creation of alliances between trans and disability studies and movements. (shrink)

In this paper, I explore the meaning of bodily integrity in disfiguring breast cancer. Bodily integrity is a normative principle precisely because it does not simply refer to actual physical or functional intactness. It rather indicates what should be regarded and respected as inviolable in vulnerable and damageable bodies. I will argue that this normative inviolability or wholeness can be based upon a person's embodied experience of wholeness. This phenomenological stance differs from the liberal view that identifies respect for integrity (...) with respect for autonomy (resulting in an invalidation of bodily integrity's proper normative meaning), as well as from the view that bodily integrity is based upon ideologies of wholeness (which runs the risk of being disadvantageous to women). I propose that bodily integrity involves a process of identification between the experience of one's body as “Leib” and the experience of one's body as “Körper.” If identification fails or is not possible, one's integrity is threatened. This idea of bodily integrity can support breast cancer patients and survivors in making decisions about possible corrective interventions. To implement this idea in oncology care, empirical-phenomenological research needs to establish how breast cancer patients express their embodied self-experiences. (shrink)

This paper explores the impact that developments in the field of neuroprosthetics will have on the ethical viability of healthy limb amputation, specifically in cases of Body Integrity Identity Dis...

This paper presents the foundation upon which the contemporary knowledge of body integrity dysphoria (BID) is built. According to the World Health Organisation’s International Classification of Diseases, 11th edition (ICD-11), the main feature of BID is an intense and persistent desire to become physically disabled in a significant way. Three putative aetiologies that are considered to explain the insurgence of the condition are discussed: neurological, psychological and postmodern theories. The concept of bodily representation within the medical context is highlighted, with (...) the concept of dysphoria, which was brought to the fore with the introduction of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), and the ICD-11. Contemporary issues of “justice” are addressed to identify ethically relevant distinctions between BID and sex reassignment surgery. It is argued that there is no ethically relevant difference between the BID actor’s desire for invasive surgical intervention and the wish of gender dysphoric individuals to undergo sex reassignment surgery procedures. Some BID actors self-mutilate, and this presents medical professionals with difficult choices regarding whether or not to intervene in order to satisfy the BID patient’s desire. Both abstention and intervention may lead to severe ethical complications for doctors and patients despite the positive outcomes in terms of quality of life for BID individuals who manage to undergo such procedures. (shrink)

In this article, I argue that persons suffering from Body Integrity Identity Disorder (BIID) can give informed consent to surgical measures designed to treat this disorder. This is true even if the surgery seems radical or irrational to most people. The decision to have surgery made by a BIID patient is not necessarily coerced, incompetent or uninformed. If surgery for BIID is offered, there should certainly be a screening process in place to insure informed consent. It is beyond the scope (...) of this work, however, to define all the conditions that should be placed on the availability of surgery. However, I argue, given the similarities between BIID and gender dysphoria and the success of such gatekeeping measures for the surgical treatment of gender dysphoria, it is reasonable that similar conditions be in place for BIID. Once other treatment options are tried and gatekeeping measures satisfied, A BIID patient can give informed consent to radical surgery. (shrink)

Opponents of the provision of therapeutic, healthy limb amputation in Body Integrity Identity Disorder cases argue that such surgeries stand in contrast to the goal of medical practice – that of health restoration and maintenance. This paper refutes such a conclusion via an appeal to the nuanced and reflective model of health proposed by Georges Canguilhem. The paper examines the conceptual entanglement of the statistically common with the normatively desirable, arguing that a healthy body can take multiple forms, including that (...) of an amputee, provided that such a form enables the continuing ability to initiate new norms of existence. It concludes that the practice of healthy limb amputation in cases of Body Integrity Identity Disorder is not only compatible with the goal of medicine but is potentially the only method of achieving this goal in the face of a complex and often mischaracterized disorder. (shrink)

Mental capacity and autonomy are often understood to be normatively neutral? the only values or other norms they may presuppose are those the assessed person does or would accept. We show how mental disorder threatens normatively neutral accounts of autonomy. These accounts produce false positives, particularly in the case of disorders (such as depression, anorexia nervosa and schizophrenia) that affect evaluative abilities. Two normatively neutral strategies for handling autonomy-undermining disorder are explored and rejected: a blanket exclusion of mental disorder, and (...) functional tests requiring consistency, expression of identity, reflective non-alienation or lack of compulsion. Finally, we suggest ways in which substantivist alternatives to neutrality can be made more promising through increased transparency, democratic contestability of conditions for capacity and autonomy, and a historically sensitive caution concerning restrictions of liberty. (shrink)

Interventions are medically necessary when they are vital in achieving the goal of medicine. However, with varying perspectives comes varying views on what interventions are (un)necessary and, thus, what potential treatment options are available for those suffering from the myriad of conditions, pathologies and disorders afflicting humanity. Medical necessity's teleological nature is perhaps best illustrated in cases where there is debate over using contentious medical interventions as a last resort. For example, whether it is appropriate for those suffering from body (...) integrity dysphoria to receive healthy limb amputations. This paper explores how one's perception of medicine's goal underpins whether interventions are necessary or unnecessary, using the controversial topic of therapeutic amputation as an example. By contrasting ‘classical’ amputations with their more contentious counterparts, it highlights how the idea of medical necessity influences and restrains clinical decision-making. The paper starts by giving an account of body integrity dysphoria, focusing on the debate concerning elective amputation's justifiability. It then introduces Georges Canguilhem's vitalist theory of health, paying particular attention to his emphasis on adaptability. Then, this paper uses his theory as a lens through which to evaluate the appropriateness of therapeutic amputation as a medically necessary procedure. Ultimately, the paper highlights how the label of medical necessity is withheld from potential therapeutic interventions because they fail to conform to pre-established ideas of medicine's purpose and that by doing so, potential harm befalls those who are left with no effective treatments and must look for solutions in the non-clinical world. (shrink)

ABSTRACT In this paper, I discuss several arguments against non‐therapeutic mutilation. Interventions into bodily integrity, which do not serve a therapeutic purpose and are not regarded as aesthetically acceptable by the majority, e.g. tongue splitting, branding and flesh stapling, are now practised, but, however, are still seen as a kind of ‘aberration’ that ought not to be allowed. I reject several arguments for a possible ban on these body modifications. I find the common pathologisation of body modifications, Kant's argument of (...) duties to oneself and the objection from irrationality all wanting. In conclusion, I see no convincing support for prohibition of voluntary mutilations. (shrink)

Phenomenology provides a method for disability theorists to describe embodied subjectivity lacking within the social model of disability. Within the literature on body integrity identity disorder (BIID), dominant narratives of disability are influential, individual bodies are considered in isolation, and experiences of disabled people are omitted. Research on BIID tends to incorporate an individualist ontology. In this article, I argue that Merleau-Ponty's conceptualization of “being in the world,” which recognizes subjectivity as embodied and intersubjective, provides a better starting point for (...) research describing the experiences of those with BIID and amputees. (shrink)

Recently, the discussion regarding the physicians’ “Right of Conscience” has been on the rise. This issue is often confined to the “reproductive health” arena within the political context. The recent dispute of the Bush-Obama administrations regarding the legal protections of health workers who refuse to provide care that violates their personal beliefs is an example of the political aspects of this dispute. The involvement of the political system automatically shifts the discussion regarding physicians’ ROC into the narrow area of “reproductive (...) health laws.” Indeed, the immediate association that comes to mind when thinking about the practical implications of this dispute is related to the reproductive health arena. This is partly because of the historical context of the first “conscience clauses,” initially enacted by Congress and state legislatures in the mid-1970s; in fact, most of these clauses provided specific exemptions for abortion and few exempted sterilization as well. (shrink)

In this paper, I discuss several arguments against non‐therapeutic mutilation. Interventions into bodily integrity, which do not serve a therapeutic purpose and are not regarded as aesthetically acceptable by the majority, e.g. tongue splitting, branding and flesh stapling, are now practised, but, however, are still seen as a kind of ‘aberration’ that ought not to be allowed. I reject several arguments for a possible ban on these body modifications. I find the common pathologisation of body modifications, Kant's argument of duties (...) to oneself and the objection from irrationality all wanting. In conclusion, I see no convincing support for prohibition of voluntary mutilations. (shrink)

The Bad-Difference View of disability says, roughly, that disability makes one worse off. The Mere-Difference View of disability says, roughly, that it doesn’t. In recent work, Barnes – a MDV proponent – offers a detailed exposition of the MDV. No BDV proponent has done the same. While many thinkers make it clear that they endorse a BDV, they don’t carefully articulate their view. In this paper, I clarify the nature of the BDV. I argue that its best interpretation is probabilistic (...) and comparative: it is the view that a person is likely to be, all things considered, worse off with a disability than without. As such, Barnes – who criticises the version of the BDV that disability by itself, intrinsically or automatically makes a person worse off – misses an opportunity to attack the most plausible and relevant version of the BDV, and the best version remains unchallenged. (shrink)

In light of the variety of uses of the term autonomy in recent bioethics literature, in this paper, I suggest that competence, not being as contested, is better placed to play the anti-paternalistic role currently assigned to autonomy. The demonstration of competence, I will argue, can provide individuals with robust spheres of non-interference in which they can pursue their lives in accordance with their own values. This protection from paternalism is achieved by granting individuals rights to non-interference upon demonstration of (...) competence. In this paper, I present a risk-sensitive account of competence as a means of grounding rights to non-interference. On a risk-sensitive account of competence individuals demonstrate their competence by exercising three capacities to the extent necessary to meet a threshold determined by the riskiness of the decision. These three capacities are the capacity to acquire knowledge, use instrumental rationality, and form and revise a life plan. (shrink)

Moral agential neuroenhancement can transform us into better people. However, critics of MB raise four central objections to MANEs use: It destroys moral freedom; it kills one moral agent and replaces them with another, better agent; it carries significant risk of infection and illness; it benefits society but not the enhanced person; and it’s wrong to experiment on nonconsenting persons. Herein, I defend MANE’s use for prisoners of war fighting unjustly. First, the permissibility of killing unjust combatants entails that, in (...) cases where MANE is equally or more likely as termination to reduce moral recidivism in unjust combatants, then MANE is morally justified. Second, the relevant infections and illnesses caused by MANE are less bad than death, so MANE leaves unjust POWs better off than the alternative. Third, just as incarceration is often permissible despite benefitting society but not the incarcerated, the same holds for unjust POWs. Fourth, we should accept a broader construal of “benefit” that includes moral benefits. Thus, 3 and 4 are false when applied to unjust POWs. Fifth, medical experimentation likely to help nonconsenting persons is sometimes permissible. Because MANE is likely to help unjust POWs irrespective of their consent or lack thereof, its use is permissible. Sixth, basic principles of proper medical care support the use of MANE on unjust POWs as pro tanto morally obligatory. I conclude that militaries should therefore begin to employ MANE for unjust POWs. (shrink)

Technological measures meant to change sexual orientation are, we have argued elsewhere, deeply alarming, even and indeed especially if they are safe and effective. Here we point out that this in part because they produce a distinctive kind of ‘clinical collective action problem’, a sort of dilemma for individual clinicians and researchers: a treatment which evidently relieves the suffering of particular patients, but in the process contributes to a practice that substantially worsens the conditions that produce this suffering in the (...) first place. We argue that the role obligations of clinicians to relieve the suffering of their patients put them in a poor position to solve this problem, though they can take measures to avoid complicity in the harms that would result from widespread use of individually safe and effective reorientation biotechnology. But in the end the medical community as a whole still seems obligated to provide these measures, if they become technologically feasible. Medical researchers are in a better position to prevent the harms that would result if reorientation techniques were safe, effective and widely available. We argue that the harms attendant on the development of safe and effective re-orientation techniques give researchers reason to avoid ‘applied‘ research aimed at developing these techniques, and to be careful in the conduct of basic orientation research which might be applied in this way. (shrink)

Body integrity identity disorder (BIID), formerly also known as apotemnophilia, is characterized by a desire for amputation of a healthy limb and is claimed to straddle or to even blur the boundary between psychiatry and neurology. The neurological line of approach, however, is a recent one, and is accompanied or preceded by psychodynamical, behavioural, philosophical, and psychiatric approaches and hypotheses. Next to its confusing history in which the disorder itself has no fixed identity and could not be classified under a (...) specific discipline, its sexual component has been an issue of unclarity and controversy, and its assessment a criterion for distinguishing BIID from apotemnophilia, a paraphilia. Scholars referring to the lived body—a phenomenon primarily discussed in the phenomenological tradition in philosophy—seem willing to exclude the sexual component as inessential, whereas other authors notice important similarities with gender identity disorder or transsexualism, and thus precisely focus attention on the sexual component. This contribution outlines the history of BIID highlighting the vicissitudes of its sexual component, and questions the justification for distinguishing BIID from apotemnophilia and thus for omitting the sexual component as essential. Second, we explain a hardly discussed concept from Maurice Merleau-Ponty’s Phenomenology of Perception (1945a), the sexual schema, and investigate how the sexual schema could function in interaction with the body image in an interpretation of BIID which starts from the lived body while giving the sexual component its due. (shrink)

Some 14 years ago, I published an article in which I identified a prime site for bioethicists to ply their trade: medical responses to requests for hormonal and surgical interventions aimed at facilitating transgendered people’s transition to their desired genders. Deep issues about the impact of biotechnologies and health care practices on central aspects of our conceptual system, I argued, were raised by how doctors understood and responded to people seeking medical assistance in changing their gender, and there were obviously (...) significant issues of regulation involved as well. Yet mainstream bioethics was conspicuous by its relative absence from the discussion. Here, I return to the matter and find that, while the conceptual issues are just as profound and their connection to health care practice and policy just as intimate, even as transgender issues have become much more socially visible, bioethical engagement with gender reassignment has increased only slightly. I set the little movement that has occurred against the backdrop of the situation as I saw it in 1998 and conclude, once again, by trying to make the bait for bioethicists inviting. (shrink)

Physicians are expected to engage patients as partners in identifying the possible benefits and harms associated with treatment options and selecting from among medically appropriate treatment options, rather than simply dictating what treatments patients will and will not receive. This collaborative model reflects the recognition that citizens in multicultural societies have diverse values and are likely to have different views about whether the possible benefits of a medical intervention outweigh the possible harms. However, there are circumstances in which the collaborative (...) process breaks down due to irresolvable disagreement. Especially challenging are cases in which patients are expected to die if they do not receive a treatment and either the patients or their surrogates insist on the treatment despite the physician's belief that providing it is ill advised. The source of disagreement is often differing appraisals of the risks and potential benefits. In such cases, physicians generally judge that there is insufficient likelihood or magnitude of benefit to justify the burdens or expense of treatment, while patients or surrogates believe that the small chance of preventing the patient's death is sufficient to justify the costs and potential burdens to the patient.There is a perception that surgeons enjoy considerable discretion in deciding when the risks of a procedure outweigh the expected benefits. An important contrast can be drawn between surgeons and intensivists—physicians who specialize in the medical management of critically ill patients. We will argue that there are good reasons for subjecting the decisions of both surgeons and intensivists to some oversight. We begin by showing that, for many cases, major professional society guidelines for intensivists recommend oversight via a procedural mechanism rather than unilateral decision‐making by individual clinicians. Next, we present reasons for adopting a procedural approach to dispute resolution, and we argue that these reasons apply to situations in which intensivists believe that patients or surrogates are requesting inappropriate life support as well as to many disagreements between surgeons and surrogates. Finally, we present and respond to several objections. (shrink)

This paper explores early Australasian philosophy in some detail. Two approaches have dominated Western philosophy in Australia: idealism and materialism. Idealism was prevalent between the 1880s and the 1930s, but dissipated thereafter. Idealism in Australia often reflected Kantian themes, but it also reflected the revival of interest in Hegel through the work of ‘absolute idealists’ such as T. H. Green, F. H. Bradley, and Henry Jones. A number of the early New Zealand philosophers were also educated in the idealist tradition (...) and were influential in their communities, but produced relatively little. In Australia, materialism gained prominence through the work of John Anderson, who arrived in Australia in 1927, and continues to be influential. John Anderson had been a student of Henry Jones, who might therefore be said to have influenced both main strands of Australian philosophical thought. (shrink)

Body integrity identity disorder is a very rare condition in which people experience long-standing anguish because there is a mismatch between their bodies and their internal image of how their bodies should be. Most typically, these people are deeply distressed by the presence of what they openly acknowledge as a perfectly normal leg. Some with the condition request that their limb be amputated. 1 We and others have argued that such requests should be acceded to in carefully selected patients.1–4 Consistent (...) with this view, a group at the University of Sydney is developing a programme to better understand and treat BIID and to offer amputation if appropriate. In a recent paper, Patrone argues that such amputations should be prohibited.5 He suggests that authors supporting amputation in BIID depend on analogies with more familiar conditions and then claim that the ‘the desires, choices and requests of BIID patients should be held to exactly the same standards and treated with exactly the same respect as the desires, choices and requests of any more conventional patient’.5 He believes that these analogies are invalid and that therefore the arguments for amputation are invalid.Patrone concentrates a great deal upon whether a decision to have a particular medical intervention is to be regarded as ‘rational’. Unfortunately, he makes no attempt to define what he …. (shrink)

If Australasian philosophers constitute the kind of group to which a collective identity or broadly shared self-image can plausibly be ascribed, the celebrated history of Australian materialism rightly lies close to its heart. Jack Smart’s chapter in this volume, along with an outstanding series of briefer essays in A Companion to Philosophy in Australia and New Zealand (Forrest 2010; Gold 2010; Koksvik 2010; Lycan 2010; Matthews 2010; Nagasawa 2010; Opie 2010; Stoljar 2010a), effectively describe the naturalistic realism of Australian philosophy (...) of mind. In occasional semi-serious psychogeographic speculation, this long-standing and strongly-felt intellectual attitude has been traced back to the influences of our light, land, or lifestyle (Devitt 1996, x; compare comments by Chalmers and O’Brien in Mitchell, 2006). Australasian work in philosophy of mind and cognition has become more diverse in the last 40 years, but is almost all still marked, in one way or another, by the history of these debates on materialism. (shrink)

Rita Charon says that narrative medicine is about honoring stories of illness. In a system where physicians and patients can often feel as though they are reduced to numbers, narrative medicine is a plea to take the narratives of illness seriously. But what does it mean to honor a story? In this essay, I use the framework of narrative medicine to offer narrative reflections on the concept of honor inspired by on three definitions, including respect, moral rightness, and high regard. (...) I explain how each definition illustrates an aspect of honor and its role as an ethical virtue in narrative medicine. (shrink)