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)

ZusammenfassungDie Bestimmung der Einwilligungsfähigkeit von Patienten beinhaltet weitreichende ethische und rechtliche Implikationen. Ausreichende Klärung des Begriffs ist daher unerlässlich. Solche Bemühungen gelten vorwiegend der Definition von Kriterien hinsichtlich relevanter mentaler Fähigkeiten. Grundlegendere Aspekte werden kaum explizit besprochen, so die Frage, ob Einwilligungsfähigkeit eher eine inhärente Fähigkeit oder ein ethisches Urteil bezeichnet. Zentral bei dieser Unterscheidung ist der Stellenwert ethischer Überlegungen die Zulässigkeit fürsorglicher Bevormundung betreffend. Geht man von einer inhärenten Fähigkeit aus, schließen solche Überlegungen an die Beurteilung von Einwilligungsfähigkeit an. (...) Im Fall eines Urteils sind diese konstitutiv für das Verständnis und die Bestimmung von Einwilligungsfähigkeit. Obwohl Einwilligungsfähigkeit idealerweise als inhärente Fähigkeit gedacht wird, weist die tatsächliche Herangehensweise eher in die Richtung, sie als ethisches Urteil zu verstehen. Diese verschiedenen Tendenzen sind für konzeptuelle Kontroversen hinsichtlich des Stellenwerts risiko-relativer Beurteilungen verantwortlich. Des Weiteren muss sich die Bestimmung von Einwilligungsfähigkeit – konzipiert man sie als ethisches Urteil – nicht rigide an einer bestimmten Definition des Begriffs der Autonomiefähigkeit orientieren und vermag so mit dessen definitorischen Unklarheiten besser umzugehen. (shrink)

This paper explores how the norms of belief relate to the norms of action. The discussion centres on addressing a challenge from positive illusions stating that the demands we face as believers aiming at the truth and the demands we face as agents aiming at success often pull in opposite directions. In response to this challenge, it is argued that the pursuits of aiming at the truth and aiming at success are fully compatible and mutually reinforcing. More specifically, the link (...) between the two takes the form of a two-way connection. In addition to succeeding in virtue of getting it right, it is normatively appropriate to get it right in virtue of succeeding. This two-way connection thesis is supported by a wide scope reading of how the truth norm of belief may be satisfied. On this reading, believing p is permissible both as a result of settling the question of whether p in light of the available evidence and as a result of engaging a believer’s agency in making it the case that p. (shrink)

Although employed throughout health-related rhetoric and research today, prevention it is an ambiguous and complicated category when applied to mental and behavioral health. It is analyzed here, along with four ethical issues arising when public health preventative methods and goals involve mental health: age of intervention; resource priorities between prevention and treatment; substantive issues in preventive pedagogies and trade-offs framed by differences of approach. Illustrations include some of the most widespread and ambitious recent preventive models: those aiming to avert subsequent (...) mood disorders of depression and anxiety; those that would curb self-harming behavior, and efforts to anticipate and avoid or delay psychosis. To suppose that public mental health can be entirely modeled on other public health programs is mistaken. Instead, it must proceed with awareness of the particular features typifying many mental disorders. These include features of the disorders themselves; the preliminary nature of scientific knowledge about them; the contested applicability of traditional disease models to them; the dearth of established research data available about preventive interventions currently in place or proposed; and the effects of stigma and discrimination on any such interventions. (shrink)

Human rights theory generally conceptualizes freedom of thought, conscience, religion, and belief as well as freedom of opinion and expression, as offering absolute protection in what is called the forum internum. At a minimum, this is taken to mean the right to maintain thoughts in one’s own mind, whatever they may be and independently of how others may feel about them. However, if we adopt this stance, it seems to imply that there exists an absolute right to hold psychotic delusions. (...) This article takes the position that this conclusion is ethically problematic from the perspective of psychiatric treatment and the rights of persons with psychosis. The article reflects on this particular challenge and sets forth an understanding of freedom in the forum internum that might apply to situations where for various reasons it is not, necessarily accurate to maintain that persons have an absolute right to their own thoughts. For the purpose of proposing such an understanding, the article engages with current debates within human rights theory and political philosophy and analyzes discussions about psychotic delusions and the way in which involuntary treatment is justified. Based on this analysis, this article in turn conceptualizes freedom in the forum internum as ‘negative liberty’, ‘authenticity’, and ‘capability’. This article suggests that when forum internum is redefined as encompassing a right to certain internal capabilities, the right remains meaningful for persons with psychotic delusions as well. (shrink)