Adaptation to illness, and its relevance for distribution in health care, has been the subject of vigorous debate. In this paper I examine an aspect of this discussion that seems so far to have been overlooked: that some illnesses are difficult, or even impossible, to adapt to. This matters because adaptation reduces suffering. Illness severity is a priority setting criterion in several countries. When considering severity, we are interested in the extent to which an illness makes a person worse-off. I (...) argue that no plausible theory of well-being can disregard suffering when determining to what extent someone is worse-off in terms of health. We should accept, all else equal, that adapting to an illness makes the illness less severe by reducing suffering. Accepting a pluralist theory of well-being allows us to accept my argument, while still making room for the possibility that adaptation is sometimes, all things considered, bad. Finally, I argue that we should conceptualize adaptability as a feature of illness, and thereby account for adaptation on a group level for the purposes of priority setting. (shrink)

A prominent objection to non-cognitive moral bio-enhancements is that they would compromise the recipient’s ‘freedom to fall’. I begin by discussing some ambiguities in this objection, before outlining an Aristotelian reading of it. I suggest that this reading may help to forestall Persson and Savulescu’s ‘God-Machine’ criticism; however, I suggest that the objection still faces the problem of explaining why the value of moral conformity is insufficient to outweigh the value of the freedom to fall itself. I also question whether (...) the objection is compatible with Neil Levy’s parity principle. Accordingly, I go on to consider an alternative relational freedom-based objection to NCMBEs that aims to explain the fundamental moral importance of the freedom that NCMBEs would violate. I argue that although this strategy might allow the critic of NCMBEs to bypass a powerful criticism of Harris’ objection, it also weakens the freedom-based objection’s compatibility with the parity principle. (shrink)

Recent articles published in this journal have highlighted the shortcomings of individualistic approaches to health promotion, and the potential contributions of relational analyses of autonomy to public health ethics. I argue that the latter helps to elucidate the former, by showing that an inadequate analysis of autonomy leads to misassignment of both forward-looking and backward-looking responsibility for health outcomes. Health promotion programmes predicated on such inadequate analyses are then ineffective, because they assign responsibility to agents whose social environment inhibits their (...) ability to act on such responsibilities; inequitable, because the social barriers to autonomous agency display a socio-economic gradient; and stigmatizing, because they license blaming of individuals for their own poor health without taking into account how reasonable it is to hold these individuals responsible, given the social barriers to autonomy they face. I further sketch how incorporating a relational understanding of autonomy could help to produce health promotion programmes that do not succumb to these difficulties, while avoiding coercive paternalism, exploring potential applications in ecological approaches to health promotion. (shrink)

The principle of respect for autonomy in clinical ethics is frequently linked to bioethics’ neglect of community-level ethical considerations. I argue that the latter is not an inevitable consequence of the former; rather, that neglect results from a common interpretation of respect for autonomy in solely synchronic and individual terms. A relational understanding of autonomy reveals the way in which respect inescapably involves diachronic and social dimensions. When these are acknowledged, the association between respect for autonomy and liberal individualism is (...) weakened. Such respect has more in common with communitarian approaches, and it need not conflict with the incorporation of collective-level values into ethical deliberation. (shrink)

Felicitas Kraemer draws on the experiences of patients undergoing deep-brain stimulation to propose two distinct and potentially conflicting principles of respect: for an individual's autonomy , and for their authenticity. I argue instead that, according to commonly-invoked justifications of respect for autonomy, authenticity is itself in part constitutive of an analysis of autonomy worthy of respect; Kraemer's argument thus highlights the shortcomings of practical applications of respect for autonomy that emphasise competence while neglecting other important dimensions of autonomy such as (...) authenticity, since it shows that competence alone cannot be interpreted as a reliable indicator of an individual's capacity for exercising autonomy. I draw from relational accounts to suggest how respect for a more expansive conception of autonomy might be interpreted for individuals undergoing DBS and in general. (shrink)

Feminists have long been aware of the pathology and the dangers of what are now termed “adaptive preferences.” Adaptive preferences are preferences formed in unconscious response to oppression. Thinkers from each wave of feminism continue to confront the problem of women's internalization of their own oppression, that is, the problem of women forming their preferences within the confining and deforming space that patriarchy provides. All preferences are, in fact, formed in response to a limited set of options, but not all (...) preferences are unconscious, pathological responses to oppression. Feminist theory therefore requires a method for distinguishing all preferences from adaptive or deformed preferences. Social contract theory provides such a tool. Social contract theory models autonomous preference-acquisition and retention at both the external level of causation and the internal level of justification. In doing so, social contract theory exposes preferences that do not meet those standards, acting as both a conceptual test that identifies adaptive preferences and as a practical tool for personal and social clarification. A social contract approach helps persons and societies to identify and to confront preferences rooted in unconscious response to oppression. (shrink)

One widespread argument against the efficacy of subjective well-being as a measure of well-being is the adaptation problem as formulated by Sen and Nussbaum: the phenomenon that people may adapt to deprivation and find satisfaction or happiness in objectively bad circumstances. It is not generally noticed that there are two distinct arguments for why the phenomenon of adaptation is a problem for subjective well-being as a measure of well-being. The Axiological Adaptation Argument is a counter-example to theories of well-being that (...) rely on mental states. The Epistemic Adaptation Argument illustrates that levels of happiness or satisfaction cannot be measured well when people have adapted. I argue that the most serious threat to subjective well-being measures is not the Axiological Argument, but the Epistemic Argument. I reflect on the implications the epistemic problem has for the empirical literature in general, and for research on the phenomenon of adaptation in particular. (shrink)

This article looks at how and why addiction should be understood as a ‘sociorelational’ disorder, and what this implies on a policy level in terms of the treatment and prevention of addiction. In light of scientific research, we argue that the neurobiological changes that underlie addiction are heavily influenced by sociorelational processes. We thereby advocate for a conceptual approach in which autonomy in addiction is a sociorelational concept, and social environments are considered autonomy undermining or autonomy promoting. We then discuss (...) the various implications this should have on policies. (shrink)

When are we morally obligated as a society to help the homeless, and is coercive interference justified when help is not asked for, even refused? To answer this question, we propose a comprehensive taxonomy of different types of homelessness and argue that different levels of autonomy allow for interventions with varying degrees of pressure to accept help. There are only two categories, however, where paternalism proper is allowed, be it heavily qualified. The first case is the homeless person with severely (...) diminished autonomy as a result of mental illness, and the second case is the homeless person who runs a risk of serious and imminent harm to self. In the first case, namely, that of soft paternalism, we argue that coercive intervention in the case of a refusal to accept help should be focused on the provision of housing that meets basic needs—needs that we outline in the article. In the case of imminent and severe harm to self, the case of hard paternalism, we argue that forced intervention can only be allowed if it is temporary and local, namely focused on getting someone out of harm’s way. (shrink)

Although the problem of adaptiveness plays an important motivating role in her work on human capabilities, Martha Nussbaum never gives a clear account of the controversial concept of adaptive preferences on which she relies. In this paper, I aim both to reconstruct the most plausible account of the concept that may be attributed to Nussbaum and to provide a critical appraisal of that account. Although her broader work on the capabilities approach moves progressively towards political liberalism as time passes, I (...) aim to show that her account of adaptive preferences continues to maintain her earlier commitment to perfectionism about the good. I then distinguish between two obligatory kinds of respect for persons, which I call, respectively, primary and secondary recognition respect. This distinction allows us to see that her perfectionist account of adaptive preferences allows her to show persons primary but not secondary recognition respect. Ultimately, I claim that an acceptable account of adaptive prefer.. (shrink)

Accounts of adaptive preferences are of two kinds: well-being accounts fully theorized for their own sake and political accounts theorized to facilitate the political project of reducing oppression and marginalization. Given their practical role, the latter are often less fully theorized, and are therefore less robust to theoretical criticism. In this paper, I first draw on well-being accounts to identify the well-theorized elements that political accounts should want to adopt in order to strengthen their project and avoid common criticisms. Second, (...) I appeal to the political project to show the shortcomings of the well-being accounts on which I draw. (shrink)

In healthcare ethics there is a discussion regarding whether autonomy of personal preferences, what sometimes is referred to as authenticity, is necessary for autonomous decision-making. It has been argued that patients’ decisions that lack sufficient authenticity could be deemed as non-autonomous and be justifiably overruled by healthcare staff. The present paper discusses this issue in relation certain psychiatric disorders. It takes its starting point in recent qualitative studies of the experiences and thoughts of patients’ with anorexia nervosa where issues related (...) to authenticity seem particularly relevant. The paper examines different interpretations of authenticity relevant for autonomy and concludes that the concept, as it has been elaborated in recent debate, is highly problematic to use as a criterion for autonomous decision-making in healthcare. (shrink)

Neo-Kantian philosophers see accountability as a key property of autonomy, or of social freedom more broadly. Autonomy, among those theorists, is, I contend, implicitly co-conceived with responsibility, producing a quasi-juridical conception of autonomy and a limiting notion of freedom. This article criticizes the connecting of freedom with accountability on a number of grounds. First, various conceptions of autonomy not only operate without a notion of accountability, but, in fact, would be impaired by an accountability requirement. Second, the neo-Kantians are unable (...) to defend the freedom enhancing properties that are supposedly brought about by the giving of reasons for one’s beliefs and actions. Third, the project of accountability is indifferent to personal outlooks, not because it takes a holistic perspective, but because of its interest in social convergence. (shrink)

The most discussed puzzle about weakness of will (WoW) is how it is possible: how can a person freely and intentionally perform actions that she judges she ought not perform, or that she has resolved not to perform? In this paper, we are concerned with a much less discussed puzzle about WoW?how is overcoming it possible? We explain some of the ways in which previously weak-willed agents manage to overcome their weakness. Some of these are relatively straightforward?as agents learn of (...) the real costs of weakness, or as those costs mount dramatically, they can become strongly motivated to do what they already judged best. But other cases are more difficult to explain: sometimes, agents with a long history of forming and then weakly abandoning resolutions manage to stick to their guns. We argue that these cases can be explained by combining George Ainslie's model of agents as multiple preference orderings competing in game theoretic interactions along with the insights of evolutionary game theory. This can explain the puzzling cases where agents suddenly adopt successful strategies for avoiding weak-willed behavior, especially where agents gain no new information about themselves or the consequences of their actions. (shrink)

One of humans’ distinctive cognitive abilities is that they develop an array of capacities through an enculturation process. In “Cognition as a Social Skill,” Sally points to one of the dangers associated with enculturation: ideological oppression. To conceptualize how such oppression takes root, Haslanager appeals to notions of mindshaping and social coordination, whereby people participate in oppressive social practices unthinkingly or even willingly. Arguably, an appeal to mindshaping provides a new kind of argument, grounded in philosophy of mind, which supports (...) the claims that feminist and anti-racist want to defend. However, some theorists worry that Haslanger’s account does not shed much light on how individuals could exert their agency to resist oppression. I argue that enactivist conceptions of mindshaping and habit can help us to make sense of the power of social influences and how they have the potential to both enable and undermine cognition and agency. This moves us toward increased understanding of the workings of social oppression—distinguishing between constructive and enabling forms of heteronomy, and overdetermining and pernicious modes that lead to atrophied moral cognition and a narrowing of the field of affordances. (shrink)

Subjectivism about well-being holds that an object contributes to one's well-being to the extent that one has a pro-attitude toward this object under certain conditions. Most subjectivists have contended that these conditions should be ideal. One reason in favor of this idea is that when people adapt their pro-attitudes to situations of oppression, the levels of well-being they may attain is diminished. Nevertheless, I first argue that appealing to idealized conditions of autonomy or any other condition to erase or replace (...) adaptive pro-attitudes is mistaken. Second, I show that the most natural version of subjectivism that does not appeal to any such idealizing condition can explain why the well-being of people having adaptive pro-attitudes should not be restricted to the fulfillment of these pro-attitudes. In sum, the existence of adaptive preferences does not militate in favor of the introduction of conditions of idealization but against it. (shrink)

The author reviews various conceptions of autonomy to show that humans are actually not autonomous, strictly speaking. He argues for a need to rethink the personal autonomy approaches to HIV testing in sub-Saharan Africa (SSA) countries. HIV/AIDS has remained a leading cause of disease burden in SSA. It is important to bring this disease burden under control, especially given the availability of current effective antiretroviral regimens in low- and middle-income countries. In most SSA countries the ethic or value of personal (...) autonomy or self-determination is promoted as primary in HIV testing decision-making. SSA policymakers have an ontological and moral duty to adopt HIV testing policies that reflect human and medical realities, relationships, local contexts, and respect human rights for both individuals and others who are affected by HIV in society. Without rethinking the value of autonomy in HIV testing decision-making, the article cautions that attainment of the Sustainable Development Goal (SDG) 3 and the UNAIDS fast-track strategy that explicitly call to end the epidemic by 2030 will not be feasible for SSA. (shrink)

On the face of it, self-censorship is profoundly subversive of democracy, particularly in its talk-centric forms, and undermines the culture of openness and publicity on which it relies. This paper has two purposes. The first is to develop a conception of self-censorship that allows us to capture what is distinctive about the concept from a political perspective and which allows us to understand the democratic anxiety about self-censorship: if it is not obvious that biting our tongues is always wrong, we (...) need a fuller account of the moral sensibility that finds it so troubling and this is elaborated here. The second is to develop an argument to the effect that this sensibility should not have the last, or only, word, but instead that self-censorship should be viewed as an ‘ordinary vice’ of democratic societies. The grounds for tolerating it rest on the democratic values that critics believe it threatens. (shrink)

This article proposes a way to disambiguate the evaluative states currently identified as “adaptive preferences” in development literature. It provides a brief analysis of Serene Khader's Deliberative Perfectionist Approach, and demonstrates that distinguishing between adaptive states has important implications for the theory and practice of development intervention. Although I support Khader's general approach and consider my project to be complementary, I argue that the term preferences be replaced with four distinct terms: beliefs, choices, desires, and values. Distinguishing among adaptive states (...) can serve to prevent inappropriate intervention and appreciate the costs of transforming inappropriate adaptations. I argue that adaptive values are especially problematic, given how central a person's values are to their sense of meaning and self. Attempts to transform adaptive values are likely to produce internal conflict, resulting in psychological distress and diminished agency. Furthermore, some values preclude deliberation and comparison given their communal status as infinitely valuable. To deliberate about sacred values is to violate them. The emotional and psychological damage that may result from value transformation is thus likely to be extensive, and must be taken into account when determining whether, and what type of, intervention is justified. (shrink)

There is little agreement among moral and political philosophers when it comes to determining what it is that makes adaptive preferences problematic. The large number of competing explanations offered by philosophers illustrates the absence of any consensus. The most prominent versions of these explanations have recently come under attack by Dale Dorsey, who argues that adaptive preferences are a red herring: the problematic nature of adaptive preferences is not explained by the fact of adaptation but by an appeal to some (...) other normative consideration. In this article I offer an account of adaptive preferences that both accommodates the thought that only some of our adaptive preferences are problematic and responds to the skeptical challenge pressed by Dorsey. I argue that some adaptive preferences are prima facie irrational as they exhibit a peculiar error in reasoning where individuals change the semantic content of the reasons underpinning the new preference. (shrink)

ABSTRACT:Current literature in moral and political philosophy is rife with discussion of adaptive preferences. This is no accident: while preferences are generally thought to play an important role in a number of normative domains, adaptive preferences seem exceptions to this general rule—they seem problematic in a way that preference-respecting theories of these domains cannot adequately capture. Thus, adaptive preferences are often taken to be theoretically explanatory: a reason for adjusting our theories of the relevant normative domains. However, as I shall (...) argue here, the relentless focus on the phenomenon of preference adaptation is a mistake. While I do not take a stand on whether typical examples of adaptive preferences are or are not problematic, I argue here that if they are problematic, it cannot be because they are adaptive. (shrink)

Miller, Truog, and Brock have recently argued that the “dead donor rule,” the requirement that donors be determined to be dead before vital organs are procured for transplantation, cannot withstand ethical scrutiny. In their view, the dead donor rule is inconsistent with existing life-saving practices of organ transplantation, lacks a cogent ethical rationale, and is not necessary for maintenance of public trust in organ transplantation. In this paper, the second of these claims will be evaluated. (The first and third are (...) not addressed.) The claim that the dead donor rule lacks a cogent ethical rationale will be shown to be an expression of the contemporary rejection of the moral significance of the traditional distinction between killing and allowing to die. The moral significance of this traditional distinction, and the associated norm that doctors should not kill their patients, will be defended, and this critique of it shown to be unsuccessful. (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)

This paper clarifies the usage of Albert Hirschman’s categories of market behaviour as of exit and voice in debates about workplace democracy by taking seriously his critique of the neoclassical analysis of competition. Pro-market liberals are generally hostile to the idea of workplace democracy and tend to favour top-down hierarchies as a way of organising labour. This hostility is generally inspired by the neoclassical analysis of exploitation and efficiency, which leads them to defend distributions achieved through exit-based competitive equilibria. Following (...) Hirschman, I propose to consider a hypothetical alternative: a democratic equilibrium, reached through the use of voice. I show that it would present the same appealing characteristics than its competitive counterpart while also accounting for the non-ideal conditions in which markets operate. Support for free markets should entail support for workplace democracy minimally understood as a strengthening of voice. (shrink)

In this chapter, I articulate the structure of a general concept of autonomy and then reply to possible objections with reference to Ulysses arrangements in psychiatry. The line of argument is as follows. Firstly, I examine three alternative conceptions of autonomy: value-neutral, value-laden, and relational. Secondly, I identify two paradigm cases of autonomy and offer a sketch of its concept as opposed to the closely related freedom of action and intentional agency. Finally, I explain away the autonomy paradox, to which (...) the previously identified pair of paradigm cases seems to give rise in the context of mental disorder. By addressing this paradox, we learn two valuable lessons. The first is about the relationships between the three conceptions of autonomy above. The second is about the relationship between autonomy and mental disorder. (shrink)

This thesis explores the relationship between the capability approach to justice and liberal philosophy. I argue that the most compelling articulation of the capability approach—one given by Martha Nussbaum—suffers from an unattractive kind of inconsistency. On the one hand, Nussbaum is committed to formulating a robust account of a dignified human life which can give rise to a range of individual entitlements which ought to be guaranteed to all individuals. On the other hand, Nussbaum is committed to political liberalism which (...) requires state institutions to uphold strict neutrality between a variety of reasonable conceptions of the good. Nussbaum’s first commitment results in the formulation of a list of ten central human capabilities. However, I argue that the content and justification of this list cannot be successfully established in a way that is consistent with Nussbaum’s second commitment. Therefore, in this thesis, I propose a novel capability approach: a two-step approach which consists of two principles arranged in lexical priority. First, governments have a moral obligation to secure individuals with a meta-capability of autonomy. That is to say, governments must provide the conditions which are conducive to individuals exercising a range of agentic competencies which are constitutive of autonomous judgement. Second, governments have a moral obligation to provide opportunities for individuals to exercise this meta-capability in six domains of well-being: health, politics, knowledge, relationships, self-expression, and work. I argue that exercising autonomous choice in the pursuit of welfare is necessary for a good life, regardless of the specific choices individuals eventually make, and even if they choose to forgo some supposedly valuable choices altogether. My proposal has two striking features which set it apart from other articulations of the capability approach. First, my proposal is comprehensive in that it relies on a particular view about what is a valuable way of life. In my view, a way of life is valuable if it is pursued autonomously, that is to say, if it involves an individual exercising a set of agentic competencies and standing in appropriate relations with other people. And second, by virtue of being based in this particular comprehensive claim, my account of justice is anti-perfectionist. That is to say, my proposal does not aim to compel people to make valuable choices. Rather, it aims to equip people with the means to live the kind of life they find valuable and worth living. I then apply this capability approach to the domain of education, and I argue it can be useful in formulating an ambitious and transformative approach to education. In particular, I develop a program of civic education aimed at responding to the problems associated with disinformation and ‘post-truth’ trends in politics. (shrink)

Many economists and social theorists hypothesize that most societies could soon face a ‘post-work’ future, one in which employment and productive labor have a dramatically reduced place in human affairs. Given the centrality of employment to individual identity and its pivotal role as the primary provider of economic and other goods, transitioning to a ‘post-work’ future could prove traumatic and disorienting to many. Policymakers are thus likely to face the difficult choice of the extent to which they ought to satisfy (...) individual citizens’ desires to work in a socioeconomic environment in which work is in permanent decline. Here I argue that policymakers confronting a post-work economy should discount, or at least consider problematic, the desire to work because it is very likely that this desire is an adaptive preference. An adaptive preference is a preference for some state of affairs within a limited set of options formed under unjust conditions. The widespread desire for work has been formed under unjust labor conditions to which individuals are compelled to submit in order to meet material and ethical needs. Furthermore, the prevalence of the ‘work dogma’ in contemporary societies precludes nearly all individuals from seeing alternatives to work as live options. (shrink)