Questions about the nature of self and self-consciousness are closely aligned with questions about the nature of autonomy. These concepts have deep roots in traditional philosophical discussions that concern metaphysics, epistemology and ethics. They also have direct relevance to practical considerations about informed consent in medical contexts. In this paper, with reference to understanding specific side effects of deep brain stimulation treatment in cases of, for example, Parkinson’s Disease, Obsessive Compulsive Disorder, and Major Depressive Disorder, I’ll argue that it is (...) best to frame discussions of informed consent in terms of relational autonomy and a pattern theory of self. (shrink)

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)

According to relational views of autonomy, some social relations or forms of dependence are necessary for autonomous agency. Recent relational theorists have primarily focused on autonomy of action or practical autonomy, and the result has been a shift away from individualistic conceptions of autonomy in the practical realm. Despite these trends, individualistic conceptions are still the default when it comes to autonomy of belief or intellectual autonomy. In this paper, I argue for a relational account of intellectual autonomy. Specifically, I (...) claim that intellectual autonomy requires a sense of one’s standing as an equal member of the epistemic community. (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)

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)

In a recent paper, Braun argued for an autonomy-based approach to assisted suicide as a way to avoid the expressivist objection to assisted dying laws. In this paper, I will argue that an autonomy-based approach actually extends the expressivist objection to assisted dying because it is not possible for one agent to assist another in pursuit of a goal without expressing that it would be good for that goal to come about. Braun argued that assisted dying should be viewed purely (...) as an individual’s autonomous action, but this requires the assistance of the medical professional to be understood as that of a non-moral automaton, such as a suicide booth. Instead, it will be argued that a beneficent motivation to promote human flourishing provides moral reasons for both non-interference in the actions, for example, suicide, of competent agents and for considering whether assisting another agent with their goal will promote their flourishing. (shrink)

Advances in neuroscience are changing how mental health issues such as addiction are understood and addressed as a brain disease. Although a brain disease model legitimizes addiction as a medical condition, it promotes neuro-essentialist thinking and categorical ideas of responsibility and free choice, and undermines the complexity involved in its emergence. We propose a “biopsychosocial systems” model where psychosocial factors complement and interact with neurogenetics. A systems approach addresses the complexity of addiction and approaches free choice and moral responsibility within (...) the biological, lived experience and sociohistorical context of the individual. We examine heroin-assisted treatment as an applied case example within our framework. We conclude with a discussion of the model and its implications for drug policy, research, addiction health care systems and delivery, and treatment of substance use problems. (shrink)

In this paper I ask what implicit attitudes tell us about our freedom. I analyze the relation between the literature on implicit attitudes and an important subcategory of theories of free will—self-disclosure accounts. If one is committed to such a theory, I suggest one may have to move to a more social conceptualization of the capacity for freedom. I will work out this argument in five sections. In the first section, I discuss the specific theories of free will that are (...) central to this paper. In the second section, I will show that implicit-bias research raises questions about people’s capacities to exercise free will. In the third section, I will consider how an individual may overcome these failures and argue that the individual ability for self-regulation is significantly limited. One could stop here and conclude that free will is a limited capacity. But I argue that this conclusion would be too hastily drawn. I will instead continue to ask what would be required for free will. By discussing how failures of free will are due to social structures and may be therefore repaired by changing social structures in section 4, I will arrive at an alternative conclusion about the capacity for free will in section 5. (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)

There appears to be a conflict between global bioethical principles and the local understanding and application of these principles, but this conflict has misleadingly been characterized through the east–west dichotomy. This dichotomy portrays bioethical principles as western and as alien to non-western cultures. In this paper, I present reasons to reject the east–west dichotomy. Using the discussion around the principle of informed consent as an example, I propose that while bioethical values are common, bioethical governance must display a certain flexibility (...) akin to Aristotle’s metaphor about the Lesbian rule. Such flexibility combined with a deeper understanding of the lived experiences of bioethical subjects might lead to the purging of tensions between global and local, giving us Glocal Bioethics. (shrink)

Questions of individuality are traditionally predicated upon recognizing discrete entities whose behavior can be measured and whose value and agency can be meaningfully ascribed. We consider a series of challenges to the metaphysical concept of individuality as the ground of the self. We argue that an ecological conception of individuality renders ascriptions of autonomy to selves highly improbable. We find conceptual resources in the work of environmental philosopher Arne Naess, whose distinction between shallow and deep responses helps us rethink the (...) notion of individuality and, thus, assess whether the conceptual and normative coherence of human autonomy could, at least partially, be salvaged. (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)

Being autonomous depends on the kind of relations we enjoy in the different domains of our lives, but the impact of decision-making and the power exercise that takes place in the political sphere, makes political relations crucial to our development and enjoyment of autonomy. This dissertation develops a novel view of political participation by interrogating its connection to our personal autonomy. According to this view, our political relations are partially constitutive of our personal autonomy, which in other words means there (...) is a political aspect of our autonomy. The kind of political relations we should hold to fully enjoy our autonomy is what I call Relations of Mutual Recognition. It is the mutual recognition of each agent’s autonomous standing—translated into a proper distribution of political power— that will face dominating political relations. The basis for that domination comes from our democracies’ power imbalances that condition influence over political decision-making to each individual’s economic, social or cultural standing. Consequently, there are political conditions for our autonomy to thrive. Relations of Mutual Recognition require two main conditions: non-domination and control. I take these two neo-republican ideals and redefine them to shape what a proper distribution of political power amounts to. Political participation comes in precisely to identify a way to challenge power imbalances. Therefore, my definition of political participation, which I call Collective Self-Government, requires a particular sort of implementation. Accordingly, I suggest a deliberative and inclusive arrangement that involves direct and innovative forms of decision-making, and more importantly, grants relevant shares of authority to all actors, i.e., common citizens, legislators, technocrats, etcetera. This project could rightly belong to both a relational approach to autonomy and be labelled as a version of deliberative democracy. However, relational accounts focus on our social relations, whilst I claim that we cannot be “less” or non-autonomous in the political sphere and still enjoy an autonomous life. Likewise, the participatory focus—in the sense of inclusion of all actors—of this proposal more accurately turn it into either a participatory version of deliberative democracy or a deliberative version of participatory democracy. (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)