This article critically examines the development and consensus outputs of the Concussion in Sport Group. We examine the six Consensus Statements between 2001 and 2023 to explore the challenges that the presence of contextual forces pose to the development of effective and ethically justifiable medical guidelines to manage situations involving brain-injured athletes. First, we discuss the implicit and explicit ethical framework and goals underlining the statements. Secondly, drawing on a relational account of athlete choice, we expound on the limitations of (...) the framework, concentrating on those resulting from a simplified understanding of athlete autonomy. Thirdly, we conclude by proposing a series of recommendations to improve concussion management protocols: (1) adopting a broader understanding of autonomy built upon relational accounts, beyond just the healthcare professional-athlete relationship; (2) further minimizing conflicts of interest that increase athletes’ vulnerability and hinder decision-making ability; (3) enhancing healthcare professional training to allow better adjustment of treatment plans to athletes’ contexts; and (4) promoting research on sociocultural elements affecting athletes’ vulnerability and autonomy. (shrink)

Patients in need of palliative care are often described as vulnerable. Being vulnerable can sometimes be interpreted as the opposite of being autonomous, if an autonomous person is seen as an independent, self-sufficient person who forms decisions independently of others. Such a dichotomous view can create a situation where one has experiences of vulnerability that cannot be reconciled with the central ethical principle of autonomy. The article presents a feminist ethical perspective on the conceptualisation of vulnerability in the context of (...) palliative care. It does so through the lens of the concepts of inherent and pathogenic vulnerability from the taxonomy on vulnerability suggested by Mackenzie et al. To differentiate between forms of vulnerability, is important since even though vulnerability can be regarded as a shared life condition it can be the product of practices creating harm to the patient. The article also presents an analysis of how vulnerability can be included in the interpretation of the ethical principle of autonomy, in order to be relevant in palliative care where vulnerability is salient, namely, as relational autonomy. Furthermore, two practical implications for nursing practice are suggested. Firstly, to acknowledge vulnerability as a shared life condition one needs training in order to neither be overwhelmed by one’s own vulnerability, nor become invulnerable when facing vulnerability in others. Secondly, to foster relational autonomy includes navigating between the patient exercising their autonomy within a framework of relations, and shielding the patient from paternalistic practices. Nurses could be particularly suited for this role, which includes creating an environment which is open and supportive; navigating between patient, family and staff; seeing and acknowledging the complex situation in which patient autonomy is actually played out; and promoting patient autonomy. (shrink)

The development of personal technologies has recently shifted from devices that seek to capture user attention to those that aim to improve user well-being. Digital wellness technologies use the same attractive qualities of other persuasive apps to motivate users towards behaviors that are personally and socially valuable, such as exercise, wealth-management, and meaningful communication. While these aims are certainly an improvement over the market-driven motivations of earlier technologies, they retain their predecessors’ focus on influencing user behavior as a primary metric (...) of success. Digital wellness technologies are still persuasive technologies, and they do not evade concerns over whether their influence on users is ethically justified. In this paper, we describe several ethical frameworks with which to assess the justification of digital wellness technologies’ influence on users. We propose that while some technologies help users to complete tasks and satisfy immediate preferences, other technologies encourage users to reflect on the values underlying their habits and teach them to evaluate their lives’ competing demands. While the former approach to digital wellness technology is not unethical, we propose that the latter approach is more likely to lead to skillful user engagement with technology. (shrink)

In Moral Case Deliberation, healthcare professionals discuss ethically difficult patient situations in their daily practice. There is a lack of knowledge regarding the content of MCD and there is a need to shed light on this ethical reflection in the midst of clinical practice. Thus, the aim of the study was to describe the content of healthcare professionals’ moral reasoning during MCD. The design was qualitative and descriptive, and data consisted of 22 audio-recorded inter-professional MCDs, analysed with content analysis. The (...) moral reasoning centred on how to strike the balance between personal convictions about what constitutes good care, and the perceived dissonant care preferences held by the patient. The healthcare professionals deliberated about good care in relation to demands considered to be unrealistic, justifications for influencing the patient, the incapacitated patient’s nebulous interests, and coping with the conflict between using coercion to achieve good while protecting human dignity. Furthermore, as a basis for the reasoning, the healthcare professionals reflected on how to establish a responsible relationship with the vulnerable person. This comprised acknowledging the patient as a susceptible human being, protecting dignity and integrity, defining their own moral responsibility, and having patience to give the patient and family time to come to terms with illness and declining health. The profound struggle to respect the patient’s autonomy in clinical practice can be understood through the concept of relational autonomy, to try to secure both patients’ influence and at the same time take responsibility for their needs as vulnerable humans. (shrink)

Many political philosophers argue that interference (or vulnerability to interference) threatens a person’s agency. And they cast political freedom in opposition to interpersonal threats to agency, as non-interference (or non-subjection). I argue that this approach relies on an inapt model of agency, crucial aspects of which emerge from our relationships with other people. Such relationships involve complex patterns of vulnerability and subjection, essential to our constitution as particular kinds of agents: as owners of property, as members of families, and as (...) participants in a market for labor. We should construct a conception of freedom that targets the structures of our interpersonal relations, and the kinds of agents these relations make us. Such a conception respects the interpersonal foundations of human agency. It also allows us to draw morally significant connections between diverse species of unfreedom—between, for instance, localized domination and structural oppression. (shrink)

According to rational will views of paternalism, the wrongmaking feature of paternalism is that paternalists disregard or fail to respect the rational will of the paternalized, in effect substituting their own presumably superior judgments about what ends the paternalized ought to pursue or how they ought to pursue them. Here I defend a version of the rational will view appealing to three rational powers that constitute rational agency, which I call recognition, discrimination, and satisfaction. By appealing to these powers, my (...) version of the rational will view can rank the wrongfulness of paternalistic acts in terms of the extent to which such acts (a) amount to supplanting the paternalized individual’s identity as a rational agent with that of the paternalist, and (b) the degree of mistrust the paternalistic act shows in the paternalized individual’s rational agency. My rational powers account thus provides a more complete account of why paternalism is a powerful, but not decisive or absolute, objection to an act or policy. My rational powers account also provides powerful explanations of why rational suasion deflects charges of paternalism; why consenting to intercessions in one’s rational agency negates paternalism; why we ordinarily believe that strong paternalism is more objectionable than weak paternalism; and why we ordinarily believe that hard paternalism is more objectionable than soft paternalism. (shrink)

Respect for patient autonomy is paramount in resolving ethical tensions in end-of-life care. The concept of relational autonomy has contributed to this debate; however, scholars often use this concept in a fragmented manner. This leads to partial answers on ascertaining patients’ true wishes, meaningfully engaging patients’ significant others, balancing interests among patients and significant others, and determining clinicians’ obligations to change patients’ unconventional convictions to enhance patient autonomy. A satisfactory solution based on relational autonomy must incorporate patients’ competence (apart from (...) decisional capacity), authenticity (their true desires or beliefs) and the involvement level of their significant others. To that end, we argue that John Christman’s procedural approach to relational autonomy provides critical insights, such as the diachronic or socio-historical personhood, sustained critical reflection and his recent explication of the nature of asymmetrical relationships and helpful interlocutors. This study reviews Christman’s account, proposes minor modifications and advocates for an integrated three-dimensional model for medical decision-making. Clarifying the relationship among the three elements promotes an ethical framework with a coherent understanding of relational autonomy. This model not only provides a descriptive and normative framework for end-of-life care practice but also reconsiders the nature of the clinician–patient relationship and its normative implications. We further present a case study to illustrate the merits of our proposed model. Altogether, our proposal will help navigate complex medical decision-making, foster trust and negotiate shared values between patients and their significant others, particularly in end-of-life care. (shrink)

Background Older patients in emergency care often have complex needs and may have limited ability to make their voices heard. Hence, there are ethical challenges for healthcare professionals in establishing a trustful relationship to determine the patient’s preferences and then decide and act based on these preferences. With this comes further challenges regarding how the patient’s autonomy can be protected and promoted. Aim To describe nurses’ experiences of dealing with older patients’ autonomy when cared for in emergency departments (EDs). Research (...) design This study adopted reflective lifeworld theory and a phenomenological design. Participants and research context A total of 13 open-ended interviews were performed with nurses working at two EDs in Sweden. Ethical considerations The study was reviewed by the Ethical Advisory Board in South East Sweden and conducted according to the Declaration of Helsinki. All participants gave consent. Findings Nurses’ experiences of dealing with older patients’ autonomy in EDs are characterized by moving in a conflicting uphill struggle, indicating obscure thoughts on how patient autonomy can be protected in an ethically challenging context. The phenomenon is further described with its meaning constituents: ‘Being hampered by prioritization under stress’, ‘Balancing paternalism and patient autonomy’, ‘Making decisions without consent in the patient’s best interests’ and ‘Being trapped by notions of legitimate care needs’. Conclusion Stressful work conditions and lacking organizational strategies in EDs contribute to nurses maintaining unjustified paternalistic care, regardless of the patient’s ability and medical condition, and questioning who has legitimacy for participating in decisions about care. The nurses’ protection and promotion of older patients’ autonomy is dependent on the opportunity, ability and willingness to create a patient relationship where the patient’s voice and preferences are valued as important. Consequently, strategies are needed to improve patient autonomy in EDs based on the idea of ‘relational autonomy’. (shrink)

Reproductive genetic carrier screening is increasingly being offered more widely, including to people with no family history or otherwise elevated chance of having a baby with a genetic condition. There are valid reasons to reject a prevention-focused public health ethics approach to such screening programs. Rejecting the prevention paradigm in this context has led to an emphasis on more individually-focused values of freedom of choice and fostering reproductive autonomy in RCS. We argue, however, that population-wide RCS has sufficient features in (...) common with other public health screening programs that it becomes important also to attend to its public health implications. Not doing so constitutes a failure to address the social conditions that significantly affect people’s capacity to exercise their reproductive autonomy. We discuss how a public health ethics approach to RCS is broader in focus than prevention. We also show that additional values inherent to ethical public health—such as equity and solidarity—are essential to underpin and inform the aims and implementation of reproductive carrier screening programs. (shrink)

Volume 20, Issue 8, August 2020, Page 85-87.

Volume 20, Issue 8, August 2020, Page 83-85.

There is an urge to introduce high technology and robotics in care settings. Assisted living (AL) is the fastest growing form of older adults’ long-term care. Resident autonomy has become the watchword for good care. This article sheds light on the potential effects of care robotics on the sense of autonomy of older people in AL. Three aspects of the residents’ sense of autonomy are of particular interest: (a) interaction-based sense of autonomy, (b) coping-based sense of autonomy, and (c) potential-based (...) sense of autonomy. Ethnographical data on resident autonomy in an AL facility and existing literature on care robots are utilized in studying what kind of assurances different types of robots would provide to maintain the sense of autonomy in AL. Robots could strengthen the different types of sense of autonomy in multiple ways. Different types of robots could widen the residents’ space of daily movements, sustain their capacities, and help them maintain and even create future expectations. Robots may strengthen the sense of autonomy of older persons in AL; however, they may simultaneously pose a threat. Multi-professional discussions are needed on whether robots are welcomed in care, and if they are, how, for whom, and in what areas. (shrink)

This paper presents a reconceptualization of autonomy as the iterative realization of one’s capacity for “effective self-definition,” that is, possessing a sense of clarity and coherence in “who I am,” and exercising the decisional and volitional ownership over my life that this engenders. This process is “Relational,” wherein people’s interpersonal interactions have a deep and pervasive influence on their ability to recognize and exercise their autonomous capacities. This Relational understanding of autonomy is contextualized within the field of addiction rehabilitative practice. (...) Addiction is a pathology that progressively and insidiously undermines autonomy – producing a number of negative consequences that present themselves along a “continuum of pervasiveness.” In order to most fully foster rehabilitation, therapeutic alliances should to be attentive to facilitating autonomy’s dialogical antecedents. Here, interpersonal recognition can help clients to more fully recognize their own autonomous resources – enabling them to embark on their rehabilitative journey and achieve broader autonomous living. This paper concludes by proposing ways that practitioners can manifest their recognition of their clients’ autonomy within the therapeutic encounter. (shrink)

The nature and role of the patient in biomedicine comprise issues central to bioethical inquiry. Given its developmental history grounded firmly in a backlash against 20th-century cases of egregious human subjects abuse, contemporary medical bioethics has come to rely on a fundamental assumption: the unit of care is the autonomous self-directing patient. In this article we examine first the structure of the feminist social critique of autonomy. Then we show that a parallel argument can be made against relational autonomy as (...) well, demonstrating how this second concept of autonomy fails to take sufficiently into account an array of biological determinants, particularly those from microbial biology. Finally, in light of this biological critique, we question whether or to what extent any relevant and meaningful view of autonomy can be recovered in the contemporary landscape of bioethics. (shrink)

Autonomy is a core value that is deeply entrenched in the moral, legal, and political practices of many societies. The development and deployment of artificial intelligence (AI) have raised new questions about AI’s impacts on human autonomy. However, systematic assessments of these impacts are still rare and often held on a case-by-case basis. In this article, I provide a conceptual framework that both ties together seemingly disjoint issues about human autonomy, as well as highlights differences between them. In the first (...) part, I distinguish between distinct concerns that are currently addressed under the umbrella term ‘human autonomy’. In particular, I show how differentiating between autonomy-as-authenticity and autonomy-as-agency helps us to pinpoint separate challenges from AI deployment. Some of these challenges are already well-known (e.g. online manipulation or limitation of freedom), whereas others have received much less attention (e.g. adaptive preference formation). In the second part, I address the different roles AI systems can assume in the context of autonomy. In particular, I differentiate between AI systems taking on agential roles and AI systems being used as tools. I conclude that while there is no ‘silver bullet’ to address concerns about human autonomy, considering its various dimensions can help us to systematically address the associated risks. (shrink)

Recent criticism of the role of respect for autonomy in bioethics has focused on that principle's status as ‘dogma’ or ‘ideology’. I suggest that lying beneath many applications of respect for autonomy in medical ethics are some influential dogmas — propositions accepted, not as explicit premises or as a consequence of reasoned argument, but simply because moral problems are so frequently framed in such terms. Furthermore, I will argue that rejecting these dogmas is vital to secure and protect an autonomy (...) worthy of respect. The concept of autonomy that is widely applied in clinical ethics emphasises decision-making competence, at the expense of considering the authenticity of those decisions. Respect for such autonomy is interpreted in largely synchronic and individual terms — concerned with the isolated decisions of individual agents — and thus neglects the diachronic and social dimensions of many moral dilemmas arising in the health care context. I will examine how these unwritten rules lead to an impoverished understanding of respect and a systematic neglect in bioethics of certain kinds of ethical consideration, and draw on insights from feminist and communitarian work on autonomy to sketch an alternative approach to understanding respect, modelled on the norms of respectful conversation — a respect that is firstly concerned with engaging with the another as a potential giver and bearer or reasons, and working with them to promote both individual and social flourishing. (shrink)

What is the moral value of formal democratic decision-making? Egalitarian accounts of democracy provide a powerful answer to this question. They present formal democratic procedures as a way for a society of equals to arrive at collective decisions in a transparent and mutually acceptable manner. More specifically, such procedures ensure and publicly affirm that all members of a political community, in their capacity as autonomous actors, are treated as equals who are able and have a right to participate in collective (...) decision-making. Recently, a number of authors have raised what I describe as the ‘no impact’ objection. This objection focuses on the egalitarian emphasis on autonomy to cast doubt on the moral value of formal democratic procedures. It holds that individual participation in formal democratic decision-making has no impact on the eventual result, and therefore cannot be understood as an exercise in autonomy. Consequently, the ‘no impact’ objection claims that the moral value of formal democracy cannot be explained with reference to an egalitarian ideal of ‘rule by the people’. In this article, I refute this objection by complementing an egalitarian account of democracy with an account of basic autonomy. (shrink)

Advances in psychology and neuroscience have elucidated the social aspects of human agency, leading to a broad shift in our thinking about fundamental concepts such as autonomy and responsibility. Here, we address a critical aspect of this inquiry by investigating how people consider the socio-relational nature of their own agency, particularly the influence of others on their perceived control over their decisions and actions. Specifically, in a series of studies using contrastive vignettes, we examine public attitudes about when external influences (...) on everyday decisions are perceived as " undue " – that is, as undermining the control conditions for these decisions to be considered autonomous – vs. when they are perceived as appropriate and even supportive of autonomous decision-making. We found that the influence of preauthorized agents – individuals and institutions with whom we share a worldview – was judged to be less undue than non-preauthorized agents, even after controlling for the familiarity of the agent. These effects persisted irrespective of the extent to which respondents identified as communitarian or individualistic, and were consistent across two distinct scenarios. We also found that external influences that were rational were perceived as less undue than those that were arational. Our study opens new avenues of inquiry into the " folk conception " of autonomy, and we discuss the implications of our findings for the ethics of public policies designed to influence decisions and for information sharing in social networks. (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)

Given that many people with disabilities have been excluded from political deliberation and subjected to infantilizing and degrading treatment from others, many members of the disability rights movement are understandably critical of policies and practices that speak on behalf of people with disabilities and presume to know what is really in their best interest. Yet, this analysis argues that a general principle of anti-paternalism is not desirable for disability politics. In particular, people with cognitive disabilities are sometimes unable to make (...) important decisions by themselves, and may require assistance from family members or more cognitively able and verbally fluent citizens to make their political voices and choices heard. Drawing from John Locke and Alasdair MacIntyre, this article reconsiders the relationship between paternalism and autonomy, suggesting that autonomous decisionmaking and expression are best thought of as collaborative processes undertaken between people with a range of capacities. (shrink)