Personal Information Management Systems (PIMS) aim to facilitate the sharing of personal information and protect privacy. Efforts to enhance privacy management, aligned with established privacy policies, have led to guidelines for integrating transparent notices and meaningful choices within these systems. Although discussions have revolved around the design of privacy-friendly systems that comply with legal requirements, there has been relatively limited philosophical discourse on incorporating the value of privacy into these systems. Exploring the connection between privacy and personal autonomy illuminates the (...) instrumental value of privacy and highlights the importance of intentionally embedding the value of privacy into these systems. To translate the value of privacy into concrete design requirements, this study constructs a values hierarchy consisting of values, norms, and design requirements. After analyzing the relationships between privacy and autonomy and identifying norms, the design requirements translated from the norms associated with the components of personal autonomy are specified at the lowest layer. These requirements include a design to prevent unauthorized access and dark patterns and to provide effective and efficient notices and choices. The findings contribute to expanding the requirements for designing the aspect of privacy as a legal requirement to incorporate the value of privacy into systems. (shrink)

In African philosophical literature, and especially in Afro-communitarianism, there are discussions about the value of the relationship an individual has with her respective community. By community, reference is made to the metaphysical holistic view of community which includes all beings in nature. But since the article deals with gender, which is a social construction, most of the arguments appeal to a narrower version of community, that of human beings. Therefore, discussions about “value” refer to the value that is given to (...) the relationship that surpasses any individual value, and it applies or appeals to human beings. One implication of this understanding and the prioritisation of the relationship is that identity is something that is conferred by this sort of relationship. In this article, we argue that this way of understanding “identity” from an Afro-communitarian world view has something to offer in understanding or conceptualising gender(ed) identity(ies). The assumption is that gender identity will be understood as socially conferred and most importantly, one that takes community as essential. (shrink)

Feminists debate whether women can autonomously embrace their own subordination. Some argue that it is the process of identifying with desires and values that matters; others, that it is the content of the desires and values that matters. In this paper, I introduce a novel class of cases of ‘thwarted autonomy,’ in which women pursue autonomy but in ways that reinforce gendered subordination, and draw on these cases to develop an expressivist view of women’s autonomy. On this view, agents must (...) embody desires and values in the social world if they are to achieve self-understanding, such that the social world mediates the relation-to-self. Oppressive meanings and norms can channel this expressive activity in ways that violate women’s physical integrity and involve self-abnegation that is incompatible with autonomy. (shrink)

The increasing popularity of artificial cognitive enhancements raises the issue of their impact on the agent’s personal autonomy, and issues pertaining to how the latter is to be secured. The extended mind thesis implies that mental states responsible for autonomous action can be partly constituted by the workings of cognitive artifacts themselves, and the question then arises of whether this commits one to embracing an extended agent thesis. My answer is negative. After briefly presenting the main accounts on the conditions (...) for autonomous agency, and analyzing how the latter can be protected from threats posed by the use of cognitive artifacts, I argue that autonomous agency is essentially tied to conscious experience and intentionality, which in turn can only be attributed to the human part of any extended cognitive system. I present both theoretical (conceptual) and practical arguments against recognizing the entire extended system, composed of one human and an artifact, as an autonomous agent. (shrink)

Much stalking consists in behavior which would normally be permissible; indeed, many stalking behaviors are protected liberties. How, then, does the stalker wrong the victim? I consider and reject different answers as failing to identify the essential wrong of stalking: stalking perpetuates gender oppression; it threatens or coerces, disrespects autonomy, or violates privacy. I argue that the stalker forces a personal relationship on the target and that our interest in being able to refuse such relationships is strong enough to ground (...) a right. It is a benefit if my account changes the standards of which intimacy-seeking behaviors we consider permissible. (shrink)

Recommender Systems (RecSys) have been around since the early days of the Internet, helping users navigate the vast ocean of information and the increasingly available options that have been available for us ever since. The range of tasks for which one could use a RecSys is expanding as the technical capabilities grow, with the disruption of Machine Learning representing a tipping point in this domain, as in many others. However, the increase of the technical capabilities of AI-powered RecSys did not (...) come with a thorough consideration of their ethical implications and, despite being a well-established technical domain, the potential impacts of RecSys on their users are still under-assessed. This paper aims at filling this gap in regards to one of the main impacts of RecSys: personal autonomy. We first describe how technology can affect human values and a suitable methodology to identify these effects and mitigate potential harms: Value Sensitive Design (VSD). We use VSD to carry out a conceptual investigation of personal autonomy in the context of a generic RecSys and draw on a nuanced account of procedural autonomy to focus on two components: competence and authenticity. We provide the results of our inquiry as a value hierarchy and apply it to the design of a speculative RecSys as an example. (shrink)

“Bodily autonomy” has received significant attention in bioethics, medical ethics, and medical law in terms of the general inviolability of a patient’s bodily sovereignty and the rights of patients to make choices (e.g., reproductive choices) that concern their own body. However, the role of the body in terms of how it can or does contribute to a patient’s capacity for, or exercises of their autonomy in clinical decision-making situations has not been explicitly addressed. The approach to autonomy in this paper (...) is aligned with traditional theories that conceive autonomy in terms of an individual’s capacities for, and exercises of rational reflection. However, at the same time, this paper extends these accounts by arguing that autonomy is, in part, embodied. Specifically, by drawing on phenomenological conceptions of the experience of autonomy, we argue that, in principle, the body is a necessary component of the capacity for autonomy. Secondly, through the presentation of two different cases, we highlight ways in which a patient’s body can contribute to the autonomy of treatment choices. Ultimately, we hope to encourage others to explore additional conditions under which a concept of embodied autonomy should be employed in medical decision making, how its underlying principles might be operationalised in clinical situations, and its consequences for approaches to patient autonomy in healthcare practice, policy, and law. (shrink)

The necessity of consent is widely justified on the basis of the principle of respect for autonomy. Also, it is widely believed that shared decision making (SDM) is the practical device to seek patients’ consent for medical treatment. In this essay, I argue that SDM, while necessary, is insufficient for consent; because, in the paradigm of evidence-based medicine, SDM is contingent upon other practices to identify appropriate treatments that form the subjects of SDM. Indeed, case law emphasises normative decision-making practices (...) that precede SDM. Furthermore, case law supplies a nuanced understanding of SDM, which includes not only exchange of information but also attention to human vulnerability that persists despite formal retention of decision-making capacity. In addition, the law marks out a space in which people with capacity are absolutely entitled to self-determination. Thus, a four-step framework of decision making can be induced from legal doctrine. This legal framework corresponds to a construct of respect for autonomy that draws upon feminist theory. Feminist scholars have objected to the focus on individuals in traditional theories of autonomy; instead, they insist that people have to be considered in the context of their social influences and relationships. Feminists separate out four ideas of autonomy, and these ideas can be used to construct a four-layered model of respect for autonomy, in which each layer corresponds sequentially to a step in the legal framework of decision making. This model of respect for autonomy provides both conceptual clarity and theoretically robust justification for doctors’ various obligations in decision-making practices for consent. (shrink)

Individualistic traditions of autonomy have long been critiqued by feminists for their atomistic and asocial presentation of human agents. Relational approaches to autonomy were developed as an alternative to these views. Relational accounts generally capture a more socially informed picture of human agents, and aim to differentiate between social phenomena that are conducive to our agency versus those that pose a hindrance to our agency. In this article, I explore the various relational conceptualizations of autonomy profferred to date. I critically (...) review some of the ongoing internal disputes within the relational autonomy literature, and conclude the article by taking stock of the value of relational autonomy despite these unresolved debates. (shrink)

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

In the debates regarding the ethics of human organoid biobanking, the locus of donor autonomy has been identified in processes of consent. The problem is that, by focusing on consent, biobanking processes preclude adequate engagement with donor autonomy because they are unable to adequately recognise or respond to factors that determine authentic choice. This is particularly problematic in biobanking contexts associated with organoid research or the clinical application of organoids because, given the probability of unforeseen and varying purposes for which (...) a donor’s organoids could be employed and given the different ways in which a donor can relate to her biospecimens, a donor can value her organoids differently in different contexts and her reasons for autonomously permitting use of her cells and tissues in one case may not support an autonomous decision in another. In response, this paper has three aims: firstly, to make the case for why organoid biobanks ought to respect donor autonomy conceived as authentic choice; secondly, to explore the autonomy-respecting limits of established and widely prevalent models of biobank consent; and thirdly, to propose certain conditions that organoid biobanks ought to support or facilitate in order to respect donor autonomy. (shrink)

This chapter will explore the dynamics of power underpinning ethical issues within smart cities via a new paradigm derived from Systems Theory. The smart city is an expression of technology as a socio-technical system. The vision of the smart city contains a deep fusion of many different technical systems into a single integrated “ambient intelligence”. ETICA Project, 2010, p. 102). Citizens of the smart city will not experience a succession of different technologies, but a single intelligent and responsive environment through (...) which they move. Analysis of such an environment requires a framework which transcends traditional ontologically-based models in order to accommodate this deep fusion. This chapter will outline a framework based on Latour’s Actor-Network Theory and Luhmann’s treatment of society as an autopoetic system. We shall use this framework to map the influence of relevant factors on ethical issues, irrespective of their composition or type. For example, under this treatment, both human praxis and technical design can be viewed as comparable tools of domination. This chapter will provide a framework for the analysis of relations between any elements of the smart city, ranging from top-level urban management processes down to individual device operations. While we will illustrate the use of this schema through examination of ethical issues arising from power dynamics within the smart city, it is intended that this example will demonstrate the wider utility of the model in general. (shrink)

An increasingly popular solution to the anti-scientific climate rising on social media platforms has been the appeal to more critical thinking from the user's side. In this paper, we zoom in on the ideal of critical thinking and unpack it in order to see, specifically, whether it can provide enough epistemic agency so that users endowed with it can break free from enclosed communities on social media (so called epistemic bubbles). We criticise some assumptions embedded in the ideal of critical (...) thinking online and, instead, we propose that a better way to understand the virtuous behaviour at hand is as critical engagement, namely a mutual cultivation of critical skills among the members of an epistemic bubble. This mutual cultivation allows members within an epistemic bubble (in contrast, as we will show, with the authority-based models of epistemic echo chambers) to become more autonomous critical thinkers by cultivating self-trust. We use the model of relational autonomy as well as resources from work on epistemic self-trust and epistemic interdependence to develop an explanatory framework, which in turn may ground rules for identifying and creating virtuous epistemic bubbles within the environments of social media platforms. (shrink)

Social robots are robots that can interact socially with humans. As social robots and the artificial intelligence that powers them becomes more advanced, they will likely take on more social and work roles. This has many important ethical implications. In this paper, we focus on one of the most central of these, the impacts that social robots can have on human autonomy. We argue that, due to their physical presence and social capacities, there is a strong potential for social robots (...) to enhance human autonomy as well as several ways they can inhibit and disrespect it. We argue that social robots could improve human autonomy by helping us to achieve more valuable ends, make more authentic choices, and improve our autonomy competencies. We also argue that social robots have the potential to harm human autonomy by instead leading us to achieve fewer valuable ends ourselves, make less authentic choices, decrease our autonomy competencies, make our autonomy more vulnerable, and disrespect our autonomy. Whether the impacts of social robots on human autonomy are positive or negative overall will depend on the design, regulation, and use we make of social robots in the future. (shrink)

As the use of nudges by governmental agencies becomes more common, the need for normative guidelines regarding the processes by which decisions about the implementation of specific nudges are taken becomes more acute. In order to find a justified set of such guidelines one must meet several theoretical challenges to Libertarian Paternalism that arise at the foundational level. In this paper, I identify three central challenges to Libertarian Paternalism, and suggest that Susan Hurley's political philosophy as presented in her Natural (...) Reasons (1989) can be viewed as offering powerful responses to them. (shrink)

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

This article asks how people come to interpret themselves and others as autonomous given their multiple dependencies. We draw on a cross-case comparison of ethnographic studies with two populations for whom autonomy is both central and problematic: elderly patients in post-acute care, and young adults with disabilities in an independent living program. Analyzing the institutional efforts to make their clients “as independent as possible,” we find that staff members at each organization formulate autonomy as a temporal project through an ongoing (...) calibration of open futures, ideal pasts, and situational competence. Constantly adjusting and fine-tuning where in time autonomy “really” is, workers arrange present dependence so that the contours of the future remain open for their clients. In other words, they make use of temporal markers to produce recognizable autonomous subjects whose dependencies are momentary. Theorizing this temporal project enables us to see more clearly how all of us engage in the constant business of “doing” autonomy, and to better understand the role of institutions in producing autonomous selves. (shrink)

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

This article argues that supported decision making is ideal for people with dynamic cognitive and functional impairments that place them at the margins of autonomy. First, we argue that guardianship and similar surrogate decision-making frameworks may be inappropriate for people with dynamic impairments. Second, we provide a conceptual foundation for supported decision making for individuals with dynamic impairments, which integrates the social model of disability with relational accounts of autonomy. Third, we propose a three-step model that specifies the necessary conditions (...) of supported decision making: identifying domains for support; identifying kinds of supports; and reaching a mutually acceptable and formal agreement. Finally, we identify a series of challenges for supported decision making, provide preliminary responses, and highlight avenues for future bioethics research. (shrink)

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)

Gerald Dworkin provides an insightful starting point for determining acceptable paternalism through his commitment to protecting our future autonomy and health from lasting damage. Dworkin grounds his argument in an appeal to inherent goods, which this paper argues is best considered as a commitment to human flourishing. However, socialconnectedness is also fundamental to human flourishing and an important consideration when determining the just limits of paternalistic drug controls, a point missing from Dworkin’ essay. For British philosopher Thomas Hill Green, regulation (...) of alcohol sales emerged from the social ideal. Green argued that policy interventions, including restricted opening hours and locations, improved the conditions for humans to flourish. Green offers a compelling political vision but fails to account for the fact pleasure is also an inherent good. He focused excessively on our social nature, excluding our more pleasure-seeking and egoistic characteristics. In contrast, a more realistic and complete vision of human flourishing can be found in an amended version of Gerald’s Dworkin’s arguments. In conclusion, this paper argues drug policy makers should remain committed to the harm principle as applied to criminal law whereby a person should never be criminalized for self-harm. Such a limit on paternalistic interventions is deemed necessary when eudaimonia is the end of government action. In practical terms, this means that the criminalization of drug use, as opposed to drug production, is always unjust. (shrink)

Relational autonomy theorists attempt to accommodate social embeddedness within a conception of autonomy. These attempts are conceptually messy, at best, and category errors, at worst. Rejecting the liberal conception of autonomy due to feminist concerns is more helpfully answered by the neorepublican notion of freedom as nondomination. The conception of freedom as nondomination captures the values that motivate the relational turn in moral and political theory and does so in a conceptually neater way than attempting to accommodate those concerns in (...) our accounts of autonomy. (shrink)

In the debates regarding the ethics of human enhancement, proponents have found it difficult to refute the concern, voiced by certain bioconservatives, that cognitive enhancement violates the autonomy of the enhanced. However, G. Owen Schaefer, Guy Kahane and Julian Savulescu have attempted not only to avoid autonomy-based bioconservative objections, but to argue that cognition-enhancing biomedical interventions can actually enhance autonomy. In response, this paper has two aims: firstly, to explore the limits of their argument; secondly, and more importantly, to develop (...) a more complete understanding of autonomy and its relation to cognitive enhancement. By drawing a distinction between the capacity for autonomy and the exercise and achievement of autonomy and by exploring the possible effects of cognitive enhancement on both competence and authenticity conditions for autonomy, the paper identifies and explains which dimensions of autonomy can and cannot, in principle, be enhanced via direct cognitive interventions. This allows us to draw conclusions regarding the limits of cognitive enhancement as a means for enhancing autonomy. (shrink)

Feminist socially constitutive conceptions of autonomy make the presence of idealized social conditions necessary for autonomy. I argue that such conceptions cannot, when applied under nonideal conditions, play two key feminist theoretical roles for autonomy: the roles of anti-oppressive character ideal and paternalism-limiting concept. Instead, they prescribe action that reinforces oppression. Treated as character ideals, socially constitutive conceptions of autonomy ask agents living under nonideal ones to engage in self-harm or self-subordination. Moreover, conceptions of autonomy that make idealized social conditions (...) a requirement of autonomy yield the conclusion that oppressed agents are appropriate objects of paternalism. (shrink)

The starting point regarding consent has to be that it is both extremely important, and that it is often suspicious. In this article, the author tries to make sense of both of these claims, from a largely liberal perspective, tying consent, predictably, to the value of autonomy and distinguishing between autonomy as sovereignty and autonomy as nonalienation. The author then discusses adaptive preferences, claiming that they suffer from a rationality flaw but that it's not clear that this flaw matters morally (...) or politically. What matters is whether they suffer from an autonomy flaw. To answer this question, the author develops an account of autonomy failure, according to which a preference is nonautonomous if an injustice played an appropriate role in its causal history. The author then discusses the moral implications—and in an initial way, the political ones as well—of proclaiming a preference, or consent based on it, nonautonomous in this way. (shrink)

Personal autonomy is often lauded as a key value in contemporary Western bioethics. Though the claim that there is an important relationship between autonomy and rationality is often treated as uncontroversial in this sphere, there is also considerable disagreement about how we should cash out the relationship. In particular, it is unclear whether a rationalist view of autonomy can be compatible with legal judgments that enshrine a patient's right to refuse medical treatment, regardless of whether the reasons underpinning the choice (...) are known and rational, or indeed whether they even exist. Jonathan Pugh brings recent philosophical work on the nature of rationality to bear on the question of how we should understand personal autonomy in contemporary bioethics. In doing so, he develops a new framework for thinking about the concept of autonomy, one that is grounded in an understanding of the different roles that rational beliefs and rational desires have to play in it. Pugh's account allows for a deeper understanding of d the relationship between our freedom to act and our capacity to decide autonomously. His rationalist perspective is contrasted with other prominent accounts of autonomy in bioethics, and the revisionary implications it has for practical questions in biomedicine are also outlined. (shrink)

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

Part I of the dissertation examines the cognitive aspects of autonomy. The central question concerns what kind of cognitive capacity autonomy is. It will be argued that the concept of autonomy is best understood in terms of a metacognitive capacity of the individual. It is argued that metacognition has two components: procedural reflexivity and metarepresentation. Metarepresentation in turn can be divided into inferential reflexivity and other-attributiveness. These two components are essential for autonomy. Particular emphasis is put on procedural reflexivity. Further, (...) since the essential function of metacognition is control, it is argued that the concept of autonomy, understood as a metacognitive capacity, can be interpreted in terms of control. Issues arising from empirical data from neuroscience on functional, as well as impaired, metacognition, and on undermined autonomy, are dealt with. It is argued that autonomy cannot be determined with respect to subjective conditions. Neurological impairments, like Anton’s Syndrome, dementia, and thought insertion in schizophrenia, are put forward in support of this claim. To determine autonomy we require external conditions. In order to determine whether an individual is autonomous, both the metacognitive status of the individual and the external setting must be considered, since they are in interplay and consequently influence each other. In Part II, the analysis put forward in Part I is applied to Swedish healthcare. It is argued that the distinction between autonomy as a right and as a capacity must be explicit in order to understand what autonomy means and to deal with it effectively in healthcare practice. A discussion about whether or not the patient’s right to autonomy sometimes tends to be over-emphasized in healthcare is put forward. Special emphasis is placed on psychitaric issues such as deinstitutionalization and participation. Following the closure of the mental hospitals, deinstitutionalization and community-based care have become central topics in psychiatry. At the same time, the implementation of such care can be demanding for patients suffering from a persistent mental disorder. In part II it is also suggested that the metacognitive account of the concept of autonomy might help clarify the criteria governing coercive care. Finally, some suggestions concerning developments and improvements in Swedish healthcare, especially in psychiatry, where the concept of autonomy is important but problematic, are put forward. (shrink)

Self‐care, or self‐management, is presented in healthcare policy as a precursor to patient empowerment and improved patient outcomes. Alternatively, critiques of the self‐care agenda suggest that it represents an over‐reliance on individual autonomy and responsibility, without adequate support, whereby ‘self‐care’ is potentially unachievable and becomes ‘care left undone’. In this sense, self‐care contributes to a blame culture where ill‐health is attributed to personal behaviours or lack thereof. Furthermore, self‐care may represent a covert form of rationing, as the fiscal means to (...) enable effective self‐care and supplement, or replace, self‐care capacities, is not provided. This paper explores these arguments through a contemporary ethical analysis of the self‐care agenda. The terms self‐care and self‐management are used interchangeably throughout whereby self‐management is understood as a point in the wider self‐care continuum. (shrink)

In this article, we sketch how theoretical neuroethics can clarify the concept of autonomy. We hope that this can both serve as a model for the conceptual clarification of other components of PIAAAS and contribute to the development of the empirical measures that Gilbert and colleagues [1] propose.

When and why do socially constructed norms—including the laws of the land, norms of etiquette, and informal customs—generate moral obligations? I argue that the answer lies in the duty to respect others, specifically to give them what I call “agency respect.” This is the kind of respect that people are owed in light of how they exercise their agency. My central thesis is this: To the extent that (i) existing norms are underpinned by people’s commitments as agents and (ii) they (...) do not conflict with morality, they place moral demands on us on agency-respect grounds. This view of the moral force of socially constructed norms, I suggest, is superior to views that deny the moral force of such norms, and it elegantly explains certain instances of wrongdoing that would otherwise remain unaccounted for. (shrink)

Journal of Social Philosophy, EarlyView.

Bioethicists, medical professionals and lawyers who support Posthumous Assisted Reproduction as an ethical procedure in the case of the deceased’s spouse often oppose it in the case of the deceased’s parents. In addition, supporters of PAR usually rely on an individualistic version of liberalism, thus focusing on a personal rather than relational approach to autonomy. This article proposes an alternative and comprehensive theoretical framework for the practice of PAR, based on the concepts of solidarity and relational autonomy. By analyzing empirical (...) data on people’s attitudes towards PAR, we reveal an important distinction between the deceased’s wish and the deceased’s consent. In addition, we show that in the majority of cases individuals report that the well-being of their relatives is paramount once they are dead. This finding, as will be demonstrated in the article, is not fully in line with Tremellen and Savulescu’s position who allow PAR in the case of the deceased’s spouse but not in the case of his parents. We also suggest that a relational autonomy perspective can be used to evaluate the choices and actions of the deceased, and to justify the requests for PAR by his spouse or parents. Furthermore, the discussion leads us to analyze both Sandel’s account of solidarity and the more recent account of Prainsack and Buyx. We conclude that PAR can be considered as a solidarity-based practice, both at the familial and societal level, an aspect that should be given more emphasis in the discourse surrounding PAR. (shrink)

Shared Decision Making (‘SDM’) is one of the most significant developments in Western health care practices in recent years. Whereas traditional models of care operate on the basis of the physician as the primary medical decision maker, SDM requires patients to be supported to consider options in order to achieve informed preferences by mutually sharing the best available evidence. According to its proponents, SDM is the right way to interpret the clinician-patient relationship because it fulfils the ethical imperative of respecting (...) patient autonomy. However, there is no consensus about how decisions in SDM contexts relate to the principle of respect for autonomy. In response, I demonstrate that in order to make decisions about what treatment they will or will not receive, patients will be required to meet different conditions depending on the approach proponents of SDM take to understanding personal autonomy. Due to the fact that different conceptions of autonomy yield different obligations, I argue that if physicians and patients satisfied all the conditions described in standard accounts of SDM, then SDM would undermine patient autonomy. (shrink)

Advance care planning is a process that encourages people to identify their values, to reflect upon the meanings and consequences of serious illness, to define goals and preferences for future medical treatment and care, and to discuss these goals with family and health-care providers. Advance care planning is especially important for those who are chronically ill, as patients and their families face a variety of complex healthcare decisions. Participating in advance care planning has been associated with improved outcomes; yet, despite (...) over 25 years of public awareness campaigns, research, and interventions developed to increase participation, advance care planning completion rates for people with chronic illnesses are no different than those in the general public (approximately 25%).Advance care planning has traditionally used an individualistic approach to autonomy, which puts forward an understanding of agents as independent, rational and self-interested persons. Because this individualistic approach has been largely unsuccessful in improving advance care planning uptake, a re-examination of the philosophical underpinnings of this practice and an exploration of alternative frameworks is warranted. In offering this exploration, we briefly outline two current perspectives on autonomy: the individualistic view and the relational view as articulated by feminist philosophers. Using a critical examination of the theoretical and empirical work on this topic, we argue that the individualistic view of autonomy does not sufficiently capture the relational and social complexities of the decision-making process of advance care planning. To offer a counterpoint, we examine the relational view of autonomy and suggest that this perspective is better aligned with the process of advance care planning. Specifically, we demonstrate that a relational model of autonomy is well suited to exploring advance care planning for four main reasons: (1) it recognizes the importance of relationships, (2) it reflects the fluctuating nature of autonomy in chronic illness, (3) it recognizes vulnerability, and (4) it is consonant with empirical work examining the advance care planning process. (shrink)

According to many of its proponents, shared decision making ("SDM") is the right way to interpret the clinician-patient relationship because it respects patient autonomy in decision-making contexts. In particular, medical ethicists have claimed that SDM respects a patient's relational autonomy understood as a capacity that depends upon, and can only be sustained by, interpersonal relationships as well as broader health care and social conditions. This paper challenges that claim. By considering two primary approaches to relational autonomy, this paper argues that (...) standard accounts of SDM actually undermine patient autonomy. It also provides an overview of the obligations generated by the principle of respect for relational autonomy that have not been captured in standard accounts of SDM and which are necessary to ensure consistency between clinical practice and respect for patient autonomy. (shrink)

Self‐management is often presented as a panacea for chronic disease care. It plays an important role at the policy level and increasingly guides the delivery of health care services. Self‐management approaches to care are founded on traditional individualistic views of autonomy in which the patient is understood as being independent, rational, self‐interested, and self‐governing. This conceptualization of autonomy has been challenged, particularly by feminist scholars. In this paper I review predominant critiques of self‐management and the traditional individualistic view of autonomy. (...) I propose that a relational approach to autonomy, which is premised on social embeddedness and attends to social, political, and material conditions, is a more sound conception of autonomy capable of taking into consideration the complexities of illness experiences. I suggest that integrating a relational perspective of autonomy into self‐management will be valuable in guiding its progression and elaborate ways in which self‐management research and practice could benefit from incorporating a relational approach to autonomy. (shrink)

Affectively uncomfortable concern, anxiety, indecisionand disputation over ‘right’ action are among the expressions of moral tension associated with ethical dilemmas. Moral tension is generated and experienced by people. While ethical principles, rules and situations must be worked through in any dilemma, each occurs against a backdrop of people who enact them and stand much to gain or lose depending on how they are applied and resolved. This paper attempts to develop a taxonomy of moral tension based on its intrapersonal and (...) interpersonal sources and expressions. The proposed ‘ethics of incongruity’ outlines ways in which values, actions and needs can find themselves mismatched in morally relevant ways between patients and their clinicians, their own psychologies and their societies. Patient–clinician incongruities may manifest as discord, value misalignment and deception. Patient–patient incongruities may manifest as incapacity, akrasia and self-deception. Patient–society incongruities may manifest as disenfranchisement, disaffiliation and disregard. Brief explanations of the incongruities in this scheme are provided, as are suggestions on working within them. Using concepts from moral philosophy when applicable, these suggestions may either ease direct resolution of problems arising from the incongruities, or make sense of the moral tension that arises from the human context of the ethical dilemma at hand. This presentation of content and resolution methods for the EOI is no doubt incomplete. Hopefully, refinement of this preliminary proposal will follow, particularly from clinicians, as the ones who, along with their patients, experience medical ethics in directly tension-inducing ways. (shrink)

This paper challenges the view that contentment leads to personal freedom and autonomy and argues for a relational and exercise concept of de facto freedom in the Zhuangzi 莊子. I first review influential interpretations of freedom in the Zhuangzi that equate freedom with contentment and nonfrustration, starting with Guo Xiang's 郭象 (d. 312 CE). By putting these interpretations in dialog with contemporary social philosophy (Christman, Meyers, Pettit, Elster, and Khader), I reflect on the two seminal problems of the psychologizing causal (...) and procedural approaches that allow the interpretation of freedom as contentment: the “happy slave” problem and the “sour grapes” problem. Proving this account of freedom inadequate, I argue for a different interpretation of freedom in the Zhuangzi that resembles a weakly substantive and constitutive account of freedom and autonomy in modern‐day social philosophy terms, such as Marina Oshana's. The theory of freedom that I analyze in the Zhuangzi, however, helps us correct the risk of material determinism of the constitutive account, offering a description of relational freedom and autonomy as constituted by socio‐material conditions but not determined by them. (shrink)

Problems arise when applying the current procedural conceptualization of decision-making capacity to paediatric healthcare: Its emphasis on content-neutrality and rational cognition as well as its implicit assumption that capacity is an ability that resides within a person jeopardizes children’s position in decision-making. The purpose of the paper is to challenge this dominant account of capacity and provide an alternative for how capacity should be understood in paediatric care. First, the influence of developmental psychologist Jean Piaget upon the notion of capacity (...) is discussed, followed by an examination of Vygostky’s contextualist view on children’s development, which emphasizes social interactions and learning for decision-making capacity. In drawing parallels between autonomy and capacity, substantive approaches to relational autonomy are presented that underline the importance of the content of a decision. The authors then provide a relational reconceptualization of capacity that leads the focus away from the individual to include important social others such as parents and physicians. Within this new approach, the outcome of adults’ decision-making processes is accepted as a guiding factor for a good decision for the child. If the child makes a choice that is not approved by adults, the new conceptualization emphasizes mutual exchange and engagement by both parties. (shrink)

El enfoque de las capacidades ha estado principalmente asociado al liberalismo, ya que sus figuras fundacionales, Sen y Nussbaum, se han declarado explícitamente parte de esa corriente de pensamiento. Sin embargo, puede afirmarse que algunas de las características de dicho enfoque podrían encontrar su mejor formulación, proyección y desarrollo fuera del liberalismo. A partir de sus conceptos constitutivos de reconocimiento, intersubjetividad y alta sensibilidad a la vulnerabilidad, la justicia social crítica se presenta como un espacio normativo más apropiado para el (...) desarrollo y la proyección del enfoque de las capacidades. Esta tesis es ilustrada a través de dos importantes discusiones normativas, la primera de ellas es la que tiene por tema a la métrica de justicia y la segunda es la que hace a la forma de entender la democracia, la ciudadanía y la razón pública. A partir de la interpretación de estos conceptos es que se justifica que la justicia social crítica es un mejor marco normativo para el enfoque de las capacidades que el liberalismo. (shrink)

The extent to which English law remedies injury to autonomy as a stand-alone actionable damage in negligence is disputed. In this article I argue that the remedy available is not only partial and inconsistent but also gendered and discriminatory against women. I first situate the argument within the broader feminist critique of tort law as failing to appropriately remedy gendered harms, and of law more broadly as undervaluing women’s interest in reproductive autonomy. I then show by reference to English remedies (...) law’s first principles how imposed motherhood cases—Rees v Darlington and its predecessor McFarlane v Tayside Health Board—result in gender injustice when compared with other autonomy cases such as Chester v Afshar and Yearworth v North Bristol NHS Trust: A minor gender-neutral ITA is better remedied than the significant gendered harm of imposing motherhood on the claimant; men’s reproductive autonomy is protected to a greater extent than women’s; women’s reproductive autonomy is protected by an exceptional, derisory award. Worst of all, courts refuse to recognise imposed motherhood as detriment; and the deemed, mansplained, nonpecuniary joys of motherhood are used to offset pecuniary upkeep costs, forcing the claimant into a position she sought to avoid and thus further undermining her autonomy. The recent Singaporean case ACB v Thomson Medical Pte Ltd, awarding compensation for undermining the claimant’s genetic affinity in an IVF wrong-sperm-mix-up demonstrates some improvement in comparison to English law, and some shared gender injustices in the context of reproductive autonomy. ACB’s analysis is oblivious to the nature of reproductive autonomy harm as gendered; and prioritises the father’s interest in having genetic affinity with the baby over a woman’s interest in not having motherhood imposed upon her. (shrink)

As in other areas of medical practice, relatives accompany patients to genetic consultations. However, unlike in other areas, the consultations may be relevant to the relatives’ health because they may be at risk of developing the same genetic condition as the patient. The presence of relatives in genetic consultation may affect the decision‐making process and it raises questions about the perception of patient autonomy and the way it is practiced in genetics. However, these issues have not been examined in previous (...) empirical studies. This article aims to fill this gap by reporting findings from a qualitative study with clinicians working in the area of inherited breast cancer. The findings indicate that family presence has an impact on the patient's decisions to undergo genetic testing and preventative operations when she is diagnosed as a carrier. The findings further indicate that, unlike in other areas of medical practice, blood relatives who are present in consultations are perceived by clinicians as patients or potential patients, and this in turn increases their involvement in discussions in the consultation room. Finally, the findings indicate that in genetics, a relational approach to autonomy is applied. Decisions are made in a social context, where the relatives’ views are heard and taken into account. The findings suggest that the conventional bioethical approach to autonomy, which perceives the decision‐making unit as comprising a clinician and an individual patient, is challenged in genetics. The findings thus suggest that bioethicists, lawyers and policy‐makers should consider whether this individualistic approach is still valid and applicable. (shrink)

The notion of authenticity, i.e., being “genuine,” “real,” or “true to oneself,” is sometimes held as critical to a person’s autonomy, so that inauthenticity prevents the person from making autonomous decisions or leading an autonomous life. It has been pointed out that authenticity is difficult to observe in others. Therefore, judgments of inauthenticity have been found inadequate to underpin paternalistic interventions, among other things. This article delineates what justifies judgments of inauthenticity. It is argued that for persons who wish to (...) live according to the prevailing social and moral standards and desires that are seriously undesirable according to those standards, it is justified to judge that a desire is inauthentic to the extent that it is due to causal factors that are alien to the person and to the extent that it deviates from the person’s practical identity. The article contributes to a tradition of thinking about authenticity which is known mainly from Frankfurt and Dworkin, and bridges the gap between theoretical ideals of authenticity and real authenticity-related problems in practical biomedical settings. (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)

In the 1980s and 1990s, a series of attempts were made to put into U.S. law a civil rights ordinance that would make it possible to sue the makers and distributors of pornography for doing so (under certain conditions). One defence of such legislation has come to be called "the free speech argument against pornography." Philosophers Rae Langton, Jennifer Hornsby and Caroline West have supposed that this defence of the legislation can function as a liberal defence of the legislation: in (...) particular, a defence of the legislation based on the value of women's liberty. This would be somewhat unexpected given MacKinnon's own antipathy toward liberalism. In this paper, I argue that the free speech argument against pornography cannot be used as a liberal defence of the ordinances. The legislation is, to some extent, self-defeating insofar as it understood in terms acceptable to a fairly standard kind of liberal. This becomes apparent when we consider the value pornography can have for women, which we can see if we consider what female makers, distributors and consumers of pornography have to say about why they make, distribute and consume it. (shrink)

The dominant, individualistic understanding of autonomy that features in clinical practice and research is underpinned by the idea that people are, in their ideal form, independent, self-interested and rational gain-maximising decision-makers. In recent decades, this paradigm has been challenged from various disciplinary and intellectual directions. Proponents of ‘relational autonomy’ in particular have argued that people’s identities, needs, interests – and indeed autonomy – are always also shaped by their relations to others. Yet, despite the pronounced and nuanced critique directed at (...) an individualistic understanding of autonomy, this critique has had very little effect on ethical and legal instruments in clinical practice and research so far. In this article, we use four case studies to explore to what extent, if at all, relational autonomy can provide solutions to ethical and practical problems in clinical practice and research. We conclude that certain forms of relational autonomy can have a tangibl... (shrink)

Fair skin is often regarded as a beauty ideal in many parts of the world. Genetic selection for non-disease traits may allow reproducers to select fair skin for the purposes of beauty, and may be justified under various procreative principles. In this paper I assess the ethics of genetic selection for fair skin as a beauty feature. In particular, I explore the discriminatory aspects and demands of such selection. Using race and colour hierarchies that many would find objectionable, I argue (...) that selection for beauty that is underpinned by such hierarchies is not a trivial selection. Given this, I claim that we should not make such selections. (shrink)