A lively topic of debate in decision theory over recent years concerns our understanding of the different risk attitudes exhibited by decision makers. There is ample evidence that risk-averse and risk-seeking behaviours are widespread, and a growing consensus that such behaviour is rationally permissible. In the context of clinical medicine, this matter is complicated by the fact that healthcare professionals must often make choices for the benefit of their patients, but the norms of rational choice are conventionally grounded in a (...) decision maker’s own desires, beliefs and actions. The presence of both doctor and patient raises the question of whose risk attitude matters for the choice at hand and what to do when these diverge. Must doctors make risky choices when treating risk-seeking patients? Ought they to be risk averse in general when choosing on behalf of others? In this paper, I will argue that healthcare professionals ought to adopt a deferential approach, whereby it is the risk attitude of the patient that matters in medical decision making. I will show how familiar arguments for widely held anti-paternalistic views about medicine can be straightforwardly extended to include not only patients’ evaluations of possible health states, but also their attitudes to risk. However, I will also show that this deferential view needs further refinement: patients’ higher-order attitudes towards their risk attitudes must be considered in order to avoid some counterexamples and to accommodate different views about what sort of attitudes risk attitudes actually are. (shrink)

A growing number of decision theorists have, in recent years, defended the view that rationality is permissive under risk: Different rational agents may be more or less risk-averse or risk-inclined. This can result in them making different choices under risk even if they value outcomes in exactly the same way. One pressing question that arises once we grant such permissiveness is what attitude to risk we should implement when choosing on behalf of other people. Are we permitted to implement any (...) of the rationally permissible risk attitudes, is there some specific risk attitude that is required when choosing for others, or are we required to defer to the risk attitudes of the people on whose behalf we are choosing? This article elaborates on this question, explains its wider practical and theoretical significance, provides an overview of existing answers, and explores how to go about providing a more systematic account of how to choose on behalf of others in risky contexts. (shrink)

I evaluate two contractualist approaches to the ethics of risk: mutual constraint and the probabilistic, ex ante approach. After explaining how these approaches address problems in earlier interpretations of contractualism, I object that they fail to respond to diverse risk preferences in populations. Some people could reasonably reject the risk thresholds associated with these approaches. A strategy for addressing this objection is considering individual risk preferences, similar to those Buchak discusses concerning expected-utility approaches to risk. I defend the risk-preferences-adjusted contractualist (...) approach, which calculates a population’s average risk preference and permits risk thresholds below that preference, only. (shrink)

Are some risks to study participants too much, no matter how valuable the study is for society? This article answers in the negative.

Consent processes for clinical trials involving HIV prevention research have generated considerable debate globally over the past three decades. HIV cure/eradication research is scientifically more complex and consequently, consent processes for clinical trials in this field are likely to pose a significant challenge. Given that research efforts are now moving toward HIV eradication, stakeholder engagement to inform appropriate ethics oversight of such research is timely. This study sought to establish the perspectives of a wide range of stakeholders in HIV treatment (...) and research to inform consent processes for cure research. In total, 68 South African stakeholders participated in two qualitative research modalities. In-depth interviews were conducted with a purposive sample of 42 individuals - audiotaped with consent. Twenty-six stakeholders participated in three focus group discussions. Thematic analysis of transcribed IDIs and FGDs was conducted. The majority of respondents indicated that there could be unique challenges in HIV cure research requiring special attention. In particular, given the complexity of cure science, translation of concepts into lay language would be critical for potential participants to adequately appreciate risks and benefits in early phase research with experimental interventions. Furthermore, to aid understanding of risks and benefits against a background of desperation for a cure, specially trained facilitators would be required to assist with a psychological assessment prior to consent to avoid curative misconceptions. Long-term participant engagement to assess durability of a cure would mean that the consent process would be prolonged, necessitating annual re-consent. Building trust to maintain such long-term relationships would be critical to retain study participants. Unique consent requirements for cure research in South Africa would include significant efforts to maximise understanding of trial procedures, risks and the need for long-term follow-up. However, the psychological dimension of cure must not be underestimated. Beyond an understanding of cure science, the emotional impact of HIV cure advances the discourse from cure to healing. Consequently, the consent process for cure research would need to be enhanced to include psychological support and counselling. This has several important implications for research ethics review requirements for consent in HIV cure research. (shrink)

This response to Gail Henderson et al argues that they were right that interviewees’ appraisals of cure study participation should inform protocol review decisions, but wrong to take these appraisals at face value.

Though antiretroviral therapy is the standard of care for people living with HIV, its treatment limitations, burdens, stigma and costs lead to continued interest in HIV cure research. Early-phase cure trials, particularly those that include analytic treatment interruption, involve uncertain and potentially high risk, with minimal chance of clinical benefit. Some question whether such trials should be offered, given the risk/benefit imbalance, and whether those who choose to participate are acting rationally. We address these questions through a longitudinal decision-making study (...) nested in a Thai acute HIV research cohort. In-depth interviews revealed central themes about decisions to join. Participants felt they possessed an important identity as members of the acute cohort, viewing their bodies as uniquely suited to both testing and potentially benefiting from HIV cure approaches. While acknowledging risks of ATI, most perceived they were given an opportunity to interrupt treatment, to test their own bodies and increase normalcy in a safe, highly monitored circumstance. They were motivated by potential benefits to themselves, the investigators and larger acute cohort, and others with HIV. They believed their own trial experiences and being able to give back to the community were sufficient to offset participation risks. These decisions were driven by the specific circumstances experienced by our participants. Judging risk/benefit ratios without appreciating these lived experiences can lead to false determinations of irrational decision- making. While this does not minimise vital oversight considerations about risk reduction and protection from harm, it argues for inclusion of a more participant-centered approach. (shrink)

When our choice affects some other person and the outcome is unknown, it has been argued that we should defer to their risk attitude, if known, or else default to use of a risk‐avoidant risk function. This, in turn, has been claimed to require the use of a risk‐avoidant risk function when making decisions that primarily affect future people, and to decrease the desirability of efforts to prevent human extinction, owing to the significant risks associated with continued human survival. I (...) raise objections to the claim that respect for others' risk attitudes requires risk‐avoidance when choosing for future generations. In particular, I argue that there is no known principle of interpersonal aggregation that yields acceptable results in variable population contexts and is consistent with a plausible ideal of respect for others' risk attitudes in fixed population cases. (shrink)

To counter the pandemic caused by severe acute respiratory syndrome coronavirus 2, some have proposed accelerating SARS-CoV-2 vaccine development through controlled human infection trials. These trials would involve the deliberate exposure of relatively few young, healthy volunteers to SARS-CoV-2. We defend this proposal against the charge that there is still too much uncertainty surrounding the risks of COVID-19 to responsibly run such a trial.

Until very recently, normative theorizing in ethics was frequently conducted without even mentioning uncertainty. Just a few years ago, Sven Ove Hansson described this state of affairs with the slogan: “Ethics still lives in a Newtonian world.” In the new Oxford Handbook of Philosophy and Probability, David McCarthy writes that “mainstream moral philosophy has not been much concerned with probability,” understanding probability as “the best-known tool for thinking about uncertainty.” This special predilection for certainty in ethics was surprising since most (...) decisions or evaluations are made both by individuals and policy-makers through the fog of a widely understood uncertainty that includes risk, ignorance, indeterminacy. Therefore, the main task of this special issue is to encourage philosophers to rethink the standard paradigm in ethics by redirecting discussions about ethical questions to problems involving different kinds of uncertainty when an individual or a policy maker does not have access to or knowledge about. (shrink)