Physicians generally recommend that patients resuscitated with naloxone after opioid overdose stay in the emergency department for a period of observation in order to prevent harm from delayed sequelae of opioid toxicity. Patients frequently refuse this period of observation despiteenefit to risk. Healthcare providers are thus confronted with the challenge of how best to protect the patient’s interests while also respecting autonomy, including assessing whether the patient is making an autonomous choice to refuse care. Previous studies have shown that physicians (...) have widely divergent approaches to navigating these conflicts. This paper reviews what is known about the effects of opioid use disorder on decision-making, and argues that some subset of these refusals are non-autonomous choices, even when patients appear to have decision making capacity. This conclusion has several implications for how physicians assess and respond to patients refusing medical recommendations after naloxone resuscitation. (shrink)

In recent years, several studies have advocated the need to expand the concept of patient autonomy beyond the capacity to deliberate and make decisions regarding a specific medical intervention or treatment (decision-making or decisional autonomy). Arguing along the same lines, this paper proposes a multidimensional concept of patient autonomy (decisional, executive, functional, informative and narrative) and argues that determining the specific aspect of autonomy affected is the first step towards protecting or promoting (and respecting) patient autonomy. These different manifestations of (...) autonomy are not mutually dependent; there may be patients who have problems in one dimension, while at the same time being fully autonomous in others. Nevertheless, a close interaction has been observed between the various dimensions and indeed, a phenomenological analysis shows that damage to or a reduction in one aspect of people’s capacity for self-government generally affects other aspects of their autonomy, which in turn disrupts their identity and the way in which they see themselves and are seen by others. In this paper, I shall examine some of these interactions and show how they may lie at the heart of the problem of poor treatment adherence (where adherence is defined as being the extent to which a patient’s behavior over time coincides with the recommendations made by and agreed with their health professional). One example given is that of psoriasis, a chronic skin disease with a very poor adherence record. In Spain, it is calculated that 85% of patients diagnosed with mild to moderate psoriasis fail to comply properly with their treatment, and figures from other parts of the world are similar. Although there are many possible causes for non-adherence among psoriasis patients, assessing their decisional, executive and narrative capacities and taking appropriate action based on the results may help increase adherence rates. (shrink)

This essay lays the groundwork for a novel conception of autonomy that may be called “effective autonomy”—a conception designed to be genuinely action guiding in bioethics. As empirical psychology research on the heuristics and biases approach shows, decision making commonly fails to correspond to people’s desires because of the biases arising from bounded cognition. People who are classified as autonomous on contemporary philosophical accounts may fail to be effectively autonomous because their decisions are uncoupled from their autonomous desires. Accordingly, continuing (...) attempts to value patient autonomy must go beyond existing philosophical conceptions of autonomy to consider the background conditions of human decision making. (shrink)

The aim of this article is to explore the impact of commercial marketing on personal autonomy. Several philosophers argue that marketing conflicts with ideals of autonomy or, at best, is neutral to these ideals. After qualifying our concept of marketing and introducing the distinctions between (i) divergent and convergent marketing and (ii) being autonomous and acting autonomously, we demonstrate the heretofore unnoticed positive impact of marketing on autonomy. Specifically, we argue that (i) convergent marketing has a significant potential to reinforce (...) autonomous action and (ii) divergent marketing has a significant potential to reinforce the state of being autonomous. (shrink)

The use of tanning beds has been identified as being among the most significant causes of melanoma and non-melanoma skin cancer. Accordingly, the activity is properly seen as one that involves profound harm to self. The article examines paternalistic reasons for restricting sunbed usage. We argue that both so-called soft and hard paternalistic arguments support prohibiting the use of sunbeds. We make the following three arguments: an argument from oppressive patterns of socialization suggesting that the autonomous nature of the conduct (...) in question is questionable; an argument from so-called evaluative delusions in which individuals attach incorrect weights to some of their values; a strictly hard paternalistic argument appealing to the harm in itself pertaining to the use of sunbeds. (shrink)

Like being able to drive a car, being autonomous is a socially attributed, claimed, and contested status. Normative debates about criteria for autonomy (and what autonomy entitles one to) are best understood, not as debates about what autonomy, at core, really is, but rather as debates about the relative merits of various possible packages of thresholds, entitlements, regulations, values, and institutions. Within different “regimes” of autonomy, different criteria for (degrees of) autonomy become authoritative. Neoliberal, solidaristic, and perfectionist regimes entail conflicting (...) understandings of what gets you autonomy and what autonomy gets you—for example, in relation to policies regarding physician-assisted suicide or financial support for senior citizens. In light of this, justifying a particular understanding of autonomy is inseparable from the task of arguing for the context-specific merits of a regime of autonomy as a whole and in relation to other ethical and political commitments. (shrink)

The spectacular progress in assisted reproduction technology that has been witnessed for the past thirty years resulted in emerging new ethical dilemmas as well as the revision of some perennial ones. The paper aims at a feminist approach to oocyte and spare embryo donation for research. First, referring to different concepts of autonomy and informed consent, we discuss whether the decision to donate oocyte/embryo can truly be an autonomous choice of a female patient. Secondly, we argue the commonly adopted language (...) of gift is misleading and that calling for altruism could put female patients at risk of exploitation. Finally, we point out that the presence of gender stereotypes in the procreative area casts doubt whether even a more robust notion of informed consent manages to overcome this risk. (shrink)

In this essay I critique two influential accounts of rational autonomy in common schooling that conceive liberalism as an ideal form of life, and I offer an alternative approach to democratic education that views liberal theory as concerned with coexistence among rival ways of living. This view places moral agency, not rational autonomy, at the heart of schooling in liberal societies—a moral agency grounded in initiation into dynamic traditions that enable self-definition and are accompanied by exposure to life-paths other than (...) one’s own. This alternative challenges the tendency in large diverse democracies (such as those of the US and the UK) to prefer common to particularistic schools, thereby placing many types of faith and secular schools on a more equal footing and providing moral justification for education in the national cultures of small liberal republics (such as Denmark, Israel and Lithuania) that maintain special relationships to particular groups while acknowledging the rights of all citizens. I call this approach the pedagogy of difference. (shrink)

Common-sense holds that morality requirespeople who know that they are infected with theHuman Immunodeficiency Virus (HIV) to disclosethis fact to their sexual partners. But manygay men who are HIV-positive do not disclose,and AIDS Service Organizations (ASOs) promotepublic-health policies based on safer sex byall, rather than disclosure by those who knowthat they are infected. The paper shows thatthe common-sense view follows from a minimalsexual morality based on consent. ASOs'seeming rejection of the view follows fromtheir need to take seriously widespreadweakness of will (...) in the realm of sexuality. The author argues that gay men take themselvesto follow the common sense view, but hold thatthe possibility of a partner's HIV infection isbackground information that need not bedisclosed for sexual consent. This suggestionis criticized. The paper concludes with aconsideration of HIV disclosure and sexualethics outside of the gay community and oflegal restrictions on the sexuality of theHIV-positive. (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)

It is sometimes argued that autonomous decision-making requires that the decision-maker’s desires are authentic, i.e., “genuine,” “truly her own,” “not out of character,” or similar. In this article, it is argued that a method to reliably determine the authenticity (or inauthenticity) of a desire cannot be developed. A taxonomy of characteristics displayed by different theories of authenticity is introduced and applied to evaluate such theories categorically, in contrast to the prior approach of treating them individually. The conclusion is drawn that, (...) in practice, the authenticity of desires cannot be reliably determined. It is suggested that authenticity should therefore not be employed in informed consent practices in healthcare. (shrink)

Respect for autonomy is a central moral principle in bioethics. The concept of autonomy can be construed in various ways. Under the non-ideal conceptualization proposed by Beauchamp and Childress, everyday choices of generally competent persons are autonomous to the extent that they are intentional and are made with understanding and without controlling influences. It is sometimes suggested that authenticity is important to personal autonomy, so that inauthenticity prevents otherwise autonomous persons from making autonomous decisions. Building from Beauchamp and Childress’s theory, (...) this article develops a non-ideal authenticity-based conceptualization of personal autonomy. Factors that indicate inauthentic decision-making are explicated, and the full concept is defended from three expected objections. The theory is then tested on a paradigm case which has concerned theorists and practitioners for some time, namely the possible inauthenticity of anorexia nervosa patients’ decision-making. It is concluded that the theory seems to be fruitful in analyses of the degree of autonomy of patients’ decision-making, and that it succeeds in providing reliable action-guidance in practical contexts. (shrink)

ABSTRACT I have two main theses. The first is that the inference from accepting an educational aim, especially an ideal aim such as self-realization or critical thinking, to a conclusion as to the content or structure of a curriculum is fallacious. The first thesis should not be controversial. But even if so, the aims-curricula fallacy is readily committed, and that calls for explanation. My second thesis is that the aims–curricula fallacy is often committed because the possibilities for realizing educational aims (...) through indirect methods or learning is ignored. (shrink)

Respect for autonomy is a central moral principle in bioethics. It is sometimes argued that authenticity, i.e., being “real,” “genuine,” “true to oneself,” or similar, is crucial to a person’s autonomy. Patients sometimes make what appears to be inauthentic decisions, such as when anorexia nervosa patients refuse treatment to avoid gaining weight, despite that the risk of harm is very high. If such decisions are inauthentic, and therefore non-autonomous, it may be the case they should be overridden for paternalist reasons. (...) However, it is not clear what justifies the judgment that someone or something is inauthentic. This article discusses one recent theory of what justifies judgments of inauthenticity. It is argued that the theory is seriously limited, as it only provides guidance in three out of nine identified cases. There are at least six authenticity-related problems to be solved, and autonomy theorists thus have reason to engage with the topic of authenticity in practical biomedicine. (shrink)

In a recent article in this journal, Rolf Ahlzén treats a moral problem related to physician-assisted suicide and the notion of authenticity. The problem is whether considerations of a patient’s “true self” should be included in judgments of PAS. In this short commentary, it is argued that Ahlzén neglects to attend to central contributions to the philosophy of authenticity, provides an internally inconsistent theory thereof, and conflates crucial distinctions in the debate.

In this open access book, Timothy Aylsworth and Clinton Castro draw on the deep well of Kantian ethics to argue that we have moral duties, both to ourselves and to others, to protect our autonomy from the threat posed by the problematic use of technology. The problematic use of technologies like smartphones threatens our autonomy in a variety of ways, and critics have only begun to appreciate the vast scope of this problem. In the last decade, we have seen a (...) flurry of books making “self-help” arguments about how we could live happier, more fulfilling lives if we were less addicted to our phones. But none of these authors see this issue as one involving a moral duty to protect our autonomy. (shrink)

The central insights of Philip Pettit’s republican account of liberty are that (1) freedom consists in the absence of domination and (2) non-domination is not reducible to what is commonly called ‘negative liberty’. Recently, however, Matthew Kramer and Ian Carter have questioned whether the harms identified by Pettit under the banner of domination are not equally well accounted for by what they call the ‘pure negative’ view. In this article, first I argue that Pettit’s response to their criticism is problematic (...) insofar as it produces the following dilemma: either Pettit must concede that domination which one regards as consistent with one’s own best interests does not limit one’s freedom or he must embrace the implication that one can be forced to be free, a result he explici tly wants to avoid. Second, I argue that, despite the inadequacy of Pettit’s response, he is ultimately right in thinking that domination and negative liberty are sometimes compatible. My central contention, then, is that neither Pettit’s non-domination view nor Carter and Kramer’s pure negative view are able to account for the loss of liberty one suffers under conditions of domination. (shrink)

Our primary focus is on analysis of the concept of voluntariness, with a secondary focus on the implications of our analysis for the concept and the requirements of voluntary informed consent. We propose that two necessary and jointly sufficient conditions must be satisfied for an action to be voluntary: intentionality, and substantial freedom from controlling influences. We reject authenticity as a necessary condition of voluntary action, and we note that constraining situations may or may not undermine voluntariness, depending on the (...) circumstances and the psychological capacities of agents. We compare and evaluate several accounts of voluntariness and argue that our view, unlike other treatments in bioethics, is not a value-laden theory. We also discuss the empirical assessment of individuals? perceptions of the degrees of noncontrol and self-control. We propose use of a particular Decision Making Control Instrument. Empirical research using this instrument can provide data that will help establish appropriate policies and procedures for obtaining voluntary consent to research. (shrink)

Kants Kritik der praktischen Vernunft (1788) steht zu Unrecht oft im Schatten der Kritik der reinen Vernunft und der Grundlegung zur Metaphysik der Sitten. Tatsächlich sind die Grundelemente der Kantischen Moralphilosophie im Gegensatz zu vielen Thesen der ersten Kritik bis heute weitgehend anerkannt, und erst der Nachweis der zweiten Kritik, dass Freiheit wirklich ist, macht "den Schlussstein von dem ganzen Gebäude eines Systems der reinen, selbst der spekulativen Vernunft aus". Entlang der Stichworte reiner Wille, gesetzgebende Form der Maxime, transzendentale Freiheit, (...) Autonomie und Faktum der Vernunft zeigt Kant in der "Analytik", dass reine Vernunft "für sich" praktisch sein, nämlich den Willen bestimmen kann. Die "Dialektik" sichert den Ideen von der Existenz Gottes und der Unsterblichkeit der Seele objektive Realität und untersucht das Verhältnis von theoretischer und praktischer Vernunft. Die "Methodenlehre" schließlich skizziert eine Theorie moralischer Erziehung, die für den heutigen Ethikunterricht noch aktuell ist. Die zwölf Beiträge dieses kooperativen Kommentars, der anlässlich des 300. Jubiläums Immanuel Kants in einer 3., überarbeiteten Auflage erscheint, rekonstruieren die Argumente eines Schlüsseltextes der Moralphilosophie und prüfen die sachliche Überzeugungskraft. Mit Beiträgen von: Karl Ameriks, Reinhard Brandt, Eckart Förster, Otfried Höffe Allen W. Wood Christoph Horn, G. Felicitas Munzel, Onora O'Neill Annemarie Pieper, Friedo Ricken, Nico Scarano. (shrink)

This paper offers a critique of the “democratic state of education” proposed by Amy Gutmann in her influential book Democratic Education. In the democratic state of education, educational authority is shared among the state, parents and educational professionals; and educational objectives are geared toward equipping future citizens to participate in what Gutmann calls “conscious social reproduction”—the collective shaping of the future of society through democratic deliberation. Although I agree with some of Gutmann’s broad recommendations for civic education, I have misgivings (...) about the centrality that she gives to conscious social reproduction in her theory of education. I argue that in focusing so intently on the facilitation of conscious social reproduction, Gutmann’s theory makes insufficient room for the basic interests of individual children, and in particular, their prospective interest in autonomy. Gutmann’s considered position on sex education policy—specifically, her willingness to allow local communities to deny their children access to sex education—exemplifies the shortcomings of her theory. Ultimately, her democratic state of education fails to acknowledge the fundamental moral importance of individual flourishing, and the contribution that education can and should make to it. (shrink)

While it is intuitive to many that oppressive socialization undermines autonomy in virtue of its ability to shape the desires and values of the oppressed, it’s difficult to provide a plausible account of autonomy that can explain when and why socialization is autonomy undermining. I provide such an account, arguing that self-respect is a necessary condition for autonomous choice and that oppressive socialization functions in part by undermining the self-respect of the oppressed. On my account, our choices lack autonomy to (...) the degree that they are motivated by a failure to respect ourselves as beings whose plans and desires matter as much as anyone else’s; whose capacity for rational deliberation and practical reasoning are valuable; and whose particularities and interests contribute to our value. This theory of personal autonomy is able to account for the lack of autonomy in a wide range of cases, for example, a cult member being brainwashed by a cult leader, or a wife being subservient to her husband. I defend this account against objections which claim that it is disrespectful to the oppressed to claim that their autonomy is undermined by their oppression, and in the final chapter, I expand my theory to explain not only what our minds must be like for us to be autonomous, but also what the world outside of us must be like. (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)

According to a number of influential views in penal theory, 1 one of the primary goals of the criminal justice system is to rehabilitate offenders. Rehabilitativemeasures are commonly included as a part of a criminal sentence. For example, in some jurisdictions judges may order violent offenders to attend anger management classes or to undergo cognitive behavioural therapy as a part of their sentences. In a limited number of cases, neurointerventions — interventions that exert a direct biological effect on the brain (...) — have been used as aids to rehabilitation, typically being imposed as part of criminal sentences, separate treatment orders, or conditions of parole. Examples of such interventions include medications intended to attenuate addictive desires in substance-abusing offenders and agents intended to suppress libido in sex offenders.This chapter reviews some of the ethical issues raised by the use of neurointerventions as aids to rehabilitation. (shrink)

Philosophical tradition demands rational reflection as a condition for genuine moral acts. But the grounds for that requirement are untenable, and when the requirement is dropped morality comes into clearer view as a naturally developing phenomenon that is not confined to human beings and does not require higher-level rational reflective processes. Rational consideration of rules and duties can enhance and extend moral behavior, but rationality is not necessary for morality and (contrary to the Kantian tradition represented by Thomas Nagel) morality (...) cannot transcend its biological roots. Recognizing this helps forge a complementary rather than competitive relation between feminist care-based ethics and rationalistic duty-based ethics. (shrink)

Offering the first developed account of political liberal education, this book combines a thorough analysis of the theoretical groundwork of political liberal education with application-oriented approaches to contemporary educational challenges. Following in depth engagement with the shortcomings of Rawls’ theory and addressing some key objections to neutrality-based restrictions in education, the volume moves on to provide an insightful discussion of topics such as same-sex relations in sex-education, the position of migrant children and the rights of religious parents to determine the (...) education of their children. This book outlines a political liberal account of education which provides a useful contribution to the current debates about liberalism and education in a way unprecedented in the literature on political liberalism so far. It is of interest to anyone working at the intersection of political philosophy and philosophy of education as well as for scholars with a broader interest in how liberalism can respond to the challenges of value pluralism. (shrink)

The books’ goal is to answer the question: Do the weaknesses of value-free economics imply the need for a paradigm shift? The author synthesizes criticisms from different perspectives (descriptive and methodological). Special attention is paid to choices over time, because in this area value-free economics has the most problems. In that context, the enriched concept of multiple self is proposed and investigated. However, it is not enough to present the criticisms towards value-free economics. For scientists, a bad paradigm is better (...) than no paradigm. Therefore, the author considers whether value-based economics with normative approaches such as economics of happiness, capability approach, libertarian paternalism, and the concept of multiple self can be the alternative paradigm for value-free economics. This book is essential reading to everyone interested in the current state of economics as a discipline. (shrink)

Is it possible to construct a machine that can act of its own accord? There are a number of skeptical arguments which conclude that autonomous machine agency is impossible. Yet if autonomous machine agency is impossible, then serious doubt is cast on the possibility of autonomous human action, at least on the widely held assumption that some form of materialism is true. The purpose of this dissertation is to show that autonomous machine agency is possible, thereby showing that the autonomy (...) of human action is compatible with materialism. ;I proceed as follows. Chapter 1 casts the problem of autonomous machine agency. Chapter 2 sets out the skeptic's case against autonomous machine agency by canvassing arguments against the possibility of machine agency and arguments against the possibility of autonomous machine agency. Chapter 3 begins work on a theory of autonomous machine agency by developing and defending axioms of a theory of agency from thought experiments and examples. Chapter 4 expands the theory of agency to a theory of autonomous agency by adding axioms of autonomy. ;The axioms of autonomous agency contain the primitive terms 'belief', 'desire', and 'deliberation', which require further explication if the theory is to be of any use in arguing for the possibility of autonomous machine agency. Chapters 5 and 6 take up this challenge by developing mathematically tractable axioms of deliberation, belief, and desire. ;Chapter 7 completes the theory by developing axioms of mechanism derived from the substantial literature in the foundations of computer science. Chapter 8 employs the resulting theory of autonomous machine agency to show just how the functional prerequisites of autonomous agency can in principle be met by machines, thereby demonstrating the possibility of autonomous machine agency. ;Chapter 9 serves as a cautionary postscript. In spite of having shown that autonomous machine agency is possible, the implications are not always happy for current efforts in artificial intelligence or current philosophical theories of autonomous human agency. Nevertheless, the argument for autonomous machine agency suggests several research programs at the nexus of Philosophy of Mind and Artificial Intelligence. (shrink)

This paper aims to provide autonomy-based reasons in favour of limitarianism. Limitarianism affirms it is of primary moral importance that no one gets too much. The paper challenges the standard assumption that having more material resources always increases autonomy. It expounds five mechanisms through which having too much material wealth might undermine autonomy. If these hypotheses are true, a theory of justice guided by a concern for autonomy will support a limitarian distribution of wealth. Finally, the paper discusses two issues (...) autonomy-based limitarianism would raise. First, insofar as coercion invades autonomy, do autonomy-based reasons legitimate coercive measures to secure a limitarian distribution of wealth? Second, is a limitarian ethos consistent with the incentive to produce enough wealth to secure distributive justice? (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.

In the age of artificial intelligence, the common interest in human autonomy is experiencing a revival. Autonomy has formerly and mostly been investigated from a theoretical scientific perspective, in which scholars from various disciplines have linked autonomy with the concepts of dignity, independence from others, morality, self-awareness, and unconventionality. In a series of three semi-qualitative, preregistered online studies, we investigated laypersons' understanding of autonomy with a bottom-up procedure to find out how far lay intuition is consistent with scientific theory. First, (...) in Study 1, participants provided us with at least three and up to 10 examples of autonomous behaviors, for a total of 807 meaningful examples. With the help of blinded research assistants, we sorted the obtained examples into categories, from which we generated 34 representative items for the following studies. Next, in Study 2, we asked a new sample of participants to rate the degree of autonomy reflected in each of these 34 items. Last, we presented the five highest-rated and the five lowest-rated items to the participants of Study 3, whom we asked to evaluate how strongly they represented the components of autonomy: dignity, independence from others, morality, self-awareness, and unconventionality. We identified that dignity, independence from others, morality, and self-awareness significantly distinguished between high- and low-autonomy items, implying that high autonomy items were rated higher on dignity, independence from others, morality, and self-awareness than low autonomy items, but unconventionality did not. Our findings contribute to both our understanding of autonomous behaviors and connecting lay intuition with scientific theory. (shrink)

The aims of this paper are to: (1) identify the best framework for comprehending multidimensional impact of deep brain stimulation on the self; (2) identify weaknesses of this framework; (3) propose refinements to it; (4) in pursuing (3), show why and how this framework should be extended with additional moral aspects and demonstrate their interrelations; (5) define how moral aspects relate to the framework; (6) show the potential consequences of including moral aspects on evaluating DBS’s impact on patients’ selves. Regarding (...) (1), I argue that the pattern theory of self can be regarded as such a framework. In realizing (2) and (3), I indicate that most relevant issues concerning PTS that require resolutions are ontological issues, including the persistence question, the “specificity problem”, and finding lacking relevant aspects of the self. In realizing (4), I identify aspects of the self not included in PTS which are desperately needed to investigate the full range of potentially relevant DBS-induced changes—authenticity, autonomy, and responsibility, and conclude that how we define authenticity will have implications for our concept of autonomy, which in turn will determine how we think about responsibility. Concerning (5), I discuss a complex relation between moral aspects and PTS—on one hand, they serve as the lens through which a particular self-pattern can be evaluated; on the other, they are, themselves, products of dynamical interactions of various self-aspects. Finally, I discuss (6), demonstrating novel way of understanding the effects of DBS on patients’ selves. (shrink)

IntroductionExtended decision -making through the use of proxy decision -makers has been enshrined in a range of International Codes, Professional Guidance and Statute,For example, the UK Mental Capacity Act section 9.1; The General Medical Council ; the US National Guardianship Association ; Nuffield Council on Bioethics ; CIOMS-WHO section 6. Court cases such as Re Quinlan in the US have also contributed to establishing the groundings for the legal status of the proxy, albeit in terms of who might be suitable (...) as a proxy in cases where there was no clear appointment of them by a still competent individual. and is now widely seen as a useful means through which we can exercise control over decisions that affect our lives when we have lost capacity to make these decisions for ourselves.I will here limit myself to discussion of proxy consent for adults appointed prior to the loss of competence by the person they are acting as proxy for. The issue of p. (shrink)

ZusammenfassungEs ist ein Standard-Verfahren der Medizinethik, auf die Möglichkeit des Missbrauchs solcher Instrumente hinzuweisen, die im lege-artis-Gebrauch legitim sein können. Ein etabliertes Instrument der medizinischen Praxis sind paternalistische Handlungen, die bei geringer Reichweite individueller Entscheidungskompetenz, etwa bei Minderjährigen, verantwortliches Handeln absichern sollen. In der bisherigen Debatte wird Paternalismus als Problem eines ungerechtfertigten oder übermäßigen Gebrauchs diskutiert. Bislang erscheint in der medizinethischen Paternalismus-Debatte das Problem des scheinbaren Paternalismus zu wenig reflektiert. Auch die Thematik der sexualisierten Gewalt gegen Minderjährige im medizinischen Setting (...) ist bisher wenig beachtet worden. Für diese spezifische Form der Gewalt gibt es verschiedene Ermöglichungsbedingungen. Eine wichtige liegt in der Akzeptanz paternalistischer Handlungen im medizinischen Kontext. Denn ein scheinbarer Paternalismus im Zusammenhang mit sexualisierter Gewalt gegen Minderjährige profitiert von der Praxis des passageren Übergehens des aktuellen Willens eines Kindes. Der prominente Fall Larry Nassars, der als Teamarzt der US-Kunstturnerinnen in hunderten Fällen junge Patientinnen sexualisierter Gewalt ausgesetzt hat, macht auf die Möglichkeit sexualisierter Gewalt durch medizinisches Personal aufmerksam. Geht es in der Paternalismus-Debatte um die Frage, in welchen Zusammenhängen Paternalismus problematisch oder unproblematisch ist, so trägt diese Studie den Problemaspekt der Täuschung im Zusammenhang mit sexualisierter Gewalt bei. Sie leistet damit einerseits einen Beitrag zur Thematisierung sexualisierter Gewalt im klinischen Kontext, und sie trägt zum anderen zur medizinethischen Diskussion des Paternalismus bei, die nicht von der Möglichkeit des Schein-Paternalismus absehen sollte. Unter Schein-Paternalismus oder fingiertem Paternalismus wird hier eine Haltung und Praxis verstanden, die in der Gestalt eines Paternalismus eigene Interessen des Agierenden zum Schaden der in Abhängigkeit befindlichen Person verfolgt und Fürsorgepflichten ignoriert. Denn die kindliche Gewöhnung an die Unterordnung des eigenen Willens und Körpers im asymmetrischen klinischen Kontext kann dazu genutzt werden, fingierten Paternalismus zu etablieren. Die Rede vom Schein-Paternalismus soll dabei aber nicht darüber hinwegtäuschen, dass die Grenzziehung zwischen Paternalismus und Nicht-Paternalismus in der Praxis ebenso komplex ist wie diejenige zwischen körperlich-asexueller und körperlich-sexueller Gewalt. Ein präzises und transparentes lege-artis-Modell des Paternalismus soll hier als Basis für die Prävention sexualisierter Gewalt im klinischen Kontext diskutiert werden. Methodisch basiert diese Arbeit auf einer Auswertung der interdisziplinären Fachliteratur zur sexualisierten Gewalt im klinischen Kontext und zum Paternalismus. Es folgt dann eine Zusammenfügung der so gewonnenen Erkenntnisse, sodass am Ende eine komplexere Aussage AB über das Verhältnis von sexualisierter Gewalt und Schein-Paternalismus steht. (shrink)

It is seemingly bad for animals to have their desires modified in at least some cases, for instance where brainwashing or neurological manipulation takes place. In humans, many argue that such modification interferes with our positive liberty or undermines our autonomy but this explanation is inapplicable in the case of animals as they lack the capacity for autonomy in the relevant sense. As such, the standard view has been that, despite any intuitions to the contrary, the modification of animals’ desires (...) is not harmful (at least not in itself). In this article, I offer a different perspective on this issue, laying the foundations of a novel argument in defence of the view that animals _can_ be harmed by desire modification directly. I suggest that the modification of an animal’s desires (under certain circumstances) is harmful for that animal because it undermines their agency. (shrink)

The notion of respect for autonomy dominates bioethical discussion, though what qualifies precisely as autonomous action is notoriously elusive. In recent decades, the notion of autonomy in medical contexts has often been defined in opposition to the notion of autonomy favoured by theoretical philosophers. Where many contemporary theoretical accounts of autonomy place emphasis on a condition of “authenticity”, the special relation a desire must have to the self, bioethicists often regard such a focus as irrelevant to the concerns of medical (...) ethics, and too stringent for use in practical contexts. I argue, however, that the very condition of authenticity that forms a focus in theoretical philosophy is also essential to autonomy and competence in medical ethics. After tracing the contours of contemporary authenticity-based theories of autonomy, I consider and respond to objections against the incorporation of a notion of authenticity into accounts of autonomy designed for use in medical contexts. By looking at the typical problems that arise when making judgments concerning autonomy or competence in a medical setting, I reveal the need for a condition of authenticity—as a means of protecting choices, particularly high-stakes choices, from being restricted or overridden on the basis of intersubjective disagreement. I then turn to the treatment of false and contestable beliefs, arguing that it is only through reference to authenticity that we can make important distinctions in this domain. Finally, I consider a potential problem with my proposed approach; its ability to deal with anorexic and depressive desires. (shrink)

In accordance with a recent statement released by the World Health Organization, the Canadian province of Ontario is moving to ban payment for plasma donation. This is partially based on contentions that remuneration for blood and blood products undermines autonomy and personal dignity. This paper is dedicated to evaluating this claim. I suggest that traditional autonomy-based arguments against commodification of human body parts and substances are less compelling in the context of plasma donation in Canada, but that there is another (...) autonomy-based objection to paid plasma donation that has not received sufficient attention. Namely, the stigma that surrounds exchanging plasma for payment makes it difficult to make an autonomous decision to engage in this activity. I suggest that this problem can be overcome in one of two ways; by banning payment for plasma, or by reducing the stigma surrounding this practice. I provide an indication of how we might work to achieve the latter, contending that this possibility should be taken seriously, due to the difficulties in achieving a sufficient supply of plasma without remuneration. (shrink)

She was intensely sympathetic. She was immensely charming. She excelled in the difficult arts of family life. She sacrificed herself daily. If there was chicken, she took the leg, if there was a draught, she sat in it—in short, she was so constituted that she never had a mind or wish of her own, but preferred to sympathise always with the minds and wishes of others. — Virginia Woolf (1979, 59).

John Christman has argued that constitutively relational accounts of autonomy, as defended by some feminist theorists, are problematically perfectionist about the human good. I argue that autonomy is constitutively relational, but not in a way that implies perfectionism: autonomy depends on a dialogical disposition to hold oneself answerable to external, critical perspectives on one's action-guiding commitments. This type of relationality carries no substantive value commitments, yet it does answer to core feminist concerns about autonomy.

It is plausible to think that part of what it is to be an autonomous agent is to adequately respond to important changes in one’s circumstances. The agent who has set her own course in life, but is unable to recognize and respond appropriately when evidence arises indicating the need to reconsider and perhaps adjust her plan, lacks an important form of personal autonomy. However, this “evidence-responsiveness” aspect of autonomy has not yet been adequately analyzed. Most autonomy theorists ignore it (...) altogether and the few who have addressed it have failed to give a satisfactory account. In this paper, I first examine an evidence-responsiveness condition proposed by Arneson. I argue there that while Arneson’s condition provides a valuable framework in which to examine evidence-responsiveness, there are several crucial issues that it either fails to address at all or else fails to adequately resolve. That condition is therefore in need of further elaboration and refinement. I then examine a recent article in this journal by Blöser, Schöpf, and Willaschek which develops an account of autonomy that I argue can usefully be understood as employing and elaborating upon the general framework offered by Arneson. I argue that while the elaboration Blöser and her co-authors provide Arneson’s condition is instructive, it is inadequate in several important ways which indicate the form a more satisfactory evidence-responsiveness condition will take. I go on to develop such a condition and conclude by highlighting the advantages to be gained by including that condition in a complete theory of autonomy. (shrink)

In some places consumption of alcohol raises serious public health issues. One recent proposal for addressing these issues has been to set a minimum price at which a unit of alcohol can be sold. In this paper I argue that such a policy, while it may have substantial health benefits, is ethically problematic. This is primarily because it unfairly places considerable burdens on those already most disadvantaged in society. In addition, such policies are poorly targeted if our concern is with (...) preventing the harms drinkers pose to other people. (shrink)

It is relatively uncontroversial that some public health policies are paternalistic. Furthermore, that they are paternalistic is often taken to show that they are morally wrong. In this article I challenge this position. The article starts by arguing that given standard definitions of paternalism it is unclear why such policies count as paternalistic. Whilst it might appear that they impose restrictions on what individuals can, or cannot, do for their own good, this is not the case. The reason for this (...) is that whilst public health policies focus on achieving benefits at a population or group level, the imposition is made at the level of the individual. If we are to retain the idea that such policies are paternalistic we must characterize them in such a way that both the benefit and imposition are at the same level: either that of the individual or that of the group. I argue that in many cases moving to the group level is the only plausible option. However, if we move to the group level, the features that make a policy paternalistic will not, unlike in those cases where paternalism is targeted at an individual, make the policy morally wrong. (shrink)

Schiller says that “it is only through beauty that man makes his way to freedom.” Here I attempt to defend a claim in the same spirit as Schiller’s but by different means. My thesis is that a person’s autonomous agency depends on their adopting an aesthetic identity. To act, we need to don contingent features of agency, things that structure our practical thought and explain what we do in very general terms but are neither universal nor necessary features of agency (...) as such. Without these things, the question of what to do for any individual would be underdetermined. The problem is that adopting such a contingent form of agency amounts to a restriction on what we can do, and so it is a prima facie threat to our autonomy. I will argue that one way, and indeed the only way, of meeting this challenge lies in aesthetic experience. Granting our capacity for aesthetic pleasure the authority to determine the particularities of our agency is compatible with autonomy because doing so means identifying with one’s capacity for pleasure in free and creative activity. Doing this allows us to be both particular sorts of agents and creatures regulated by the universalizing demands of reason. (shrink)

The widespread practices of data collection by third-party actors pose challenges to children’s and adolescents’ privacy when they navigate digital environments. Given that the informed-consent par...

Background A topic of great concern in bioethics is the medical research conducted in poor countries sponsored by wealthy nations. Western drug companies increasingly view Latin America as a proper place for clinical research trials. The region combines a large population, modern medical facilities, and low per capita incomes. Participants from developing countries may have little or non alternative means of treatment other than that offered through clinical trials. Therefore, the provision of a valid informed consent is important. Methods To (...) gain insight about some aspects of the informed consent procedure in a major cancer centre in Mexico, we conducted a three-step evaluation process: 1) a ten point multiple choice survey questionnaires, was used to explore some aspects of the patients' experiences during the informed consent process, 2) researchers' knowledge about specific aspects of the informed consent was evaluated in this study using survey questionnaires; and 3) the comprehensibility, readability and number of pages of the consent forms were analysed. The socioeconomic and educational level of the patients, were also considered. Results were reported using a numerical scale. Results Thirty five patients, 20 doctors, and 10 individuals working at the hospital agreed to participate in the study. Eighty three percent of the patients in the study were classified as living in poverty; education level was poor or non existent, and 31% of the patients were illiterate. The consent forms were difficult to understand according to 49% of the patients, most doctors agreed that the forms were not comprehensible to the patients. The average length of the IC documents analysed was 14 pages, and the readability average score was equivalent to 8TH Grade. Conclusion The results presented in this work describe some relevant characteristics of the population seen at public health care institutions in Mexico. Poverty, limited or no education, and the complexity of the information provided to the patients may question the validity of the informed consent procedure in this group of patients. (shrink)

It is plausible that what possible courses of action patients may legitimately expect their physicians to take is ultimately determined by what medicine as a profession is supposed to do and, consequently, that we can determine the moral acceptability of voluntary euthanasia and physician-assisted suicide on the basis of identifying the proper goals of medicine. This article examines the main ways of defining the proper goals of medicine found in the recent bioethics literature and argues that they cannot provide a (...) clear answer to the question of whether or not voluntary euthanasia and physician-assisted suicide are morally acceptable. It is suggested that to find a plausible answer to this question and to complete the task of defining the proper goals of medicine, we must determine what is the best philosophical theory about the nature of prudential value. (shrink)

It has been argued that voluntary euthanasia (VE) and physician-assisted suicide (PAS) are morally wrong. Yet, a gravely suffering patient might insist that he has a moral right to the procedures even if they were morally wrong. There are also philosophers who maintain that an agent can have a moral right to do something that is morally wrong. In this article, I assess the view that a suffering patient can have a moral right to VE and PAS despite the moral (...) wrongness of the procedures in light of the main argument for a moral right to do wrong found in recent philosophical literature. I maintain that the argument does not provide adequate support for such a right to VE and PAS. (shrink)