One recurring criticism of the best interests standard concerns its vagueness, and thus the inadequate guidance it offers to care providers. The lack of an agreed definition of ‘best interests’, together with the fact that several suggested considerations adopted in legislation or professional guidelines for doctors do not obviously apply across different groups of persons, result in decisions being made in murky waters. In response, bioethicists have attempted to specify the best interests standard, to reduce the indeterminacy surrounding medical decisions. (...) In this paper, we discuss the bioethicists’ response in relation to the state's possible role in clarifying the best interests standard. We identify and characterise two clarificatory strategies employed by bioethicists —elaborative and enumerative—and argue that the state should adopt the latter. Beyond the practical difficulties of the former strategy, a state adoption of it would inevitably be prejudicial in a pluralistic society. Given the gravity of best interests decisions, and the delicate task of respecting citizens with different understandings of best interests, only the enumerative strategy is viable. We argue that this does not commit the state to silence in providing guidance to and supporting healthcare providers, nor does it facilitate the abuse of the vulnerable. Finally, we address two methodological worries about adopting this approach at the state level. The adoption of the enumerative strategy is not defeatist in attitude, nor does it eventually collapse into (a form of) the elaborative strategy. (shrink)

This paper argues that we can see our lives as a snapshot happening now or as a moving picture extending across time. These dual ways of seeing our lives inform how we conceive of the problem of age group justice. A snapshot view sees age group justice as an interpersonal problem between distinct age groups. A moving picture view sees age group justice as a first-person problem of prudential choice. This paper explores these different ways of thinking about age group (...) justice and illustrates them using a principle of respect for human dignity, understood in terms of reasonable support for floor level central human capabilities at each stage of life. I argue that different frames are suitable for different kinds of decisions, and each provides a true, but partial, picture of aging and age group justice. (shrink)

Definition of the problemThe medical-ethical principle of beneficence is directed towards the well-being of patients. In clinical practice, the focus is often on the relief of pain, the elimination of symptoms and the restoration of bodily functioning. However, the significance of these health-related aspects for the overall well-being of patients also depends on individual values, desires, and life plans.ArgumentationAn overemphasis on the subjective perspective of patients on their well-being would admittedly lead to a strong substantial convergence of the two medical-ethical (...) principles of beneficence and respect for autonomy. In addition, it would not be compatible with some of the guiding principles of the medical profession. A mere objective perspective on patient well-being conversely carries the danger of imposing values on individual patients that they do not share. Consequently, actions that are intended to benefit patients instead harm them.ConclusionThrough a more detailed analysis of the relationship between health-related and overall well-being, this paper shows that health is only a relative value in our overall well-being. Basic health-related goods like a sound cardiovascular system or fully functioning lungs have special standing because they are seen as valuable independently of individual preferences and life plans, which means they are of objective value. (shrink)

Medical ethics would be better if people were taught to think more clearly about well-being or the concept of what is good for a person. Yet for a variety of reasons, bioethicists have generally paid little attention to this concept. Here, I argue, first, that focusing on general theories of welfare is not useful for practical medical ethics. I argue, second, for what I call the “theory-without-theories approach” to welfare in practical contexts. The first element of this approach is a (...) focus on examining important and relatively uncontroversial constituents of welfare as opposed to general theories. The second key element is a framework for thinking about choice in relation to welfare, a framework I refer to as “the mild objectivity framework.” I conclude with illustrations of the way in which the “theory without theories approach” can improve thinking in medicine. (shrink)

Mackenzie Graham has made an important contribution to the literature on decisionmaking for patients with disorders of consciousness. He argues, and I agree, that decisions for unresponsive patients who are known to retain some degree of covert awareness ought to focus on current interests, since such patients likely retain the kinds of mental capacities that in ordinary life command our current respect and attention. If he is right, then it is not appropriate to make decisions for such patients by appealing (...) to the values they had in the past, either the values expressed in an advance directive or the values recalled by a surrogate. There are two things I wish to add to the discussion. My first point is somewhat critical, for although I agree with his general conclusion about how, ideally, such decisions should be approached, I remain skeptical about whether his conclusion offers decisionmakers real practical help. The problem with these cases is that the evidence we have about the nature of the patient’s current interests is minimal or nonexistent. However—and this is important—Graham’s conclusion will be extremely relevant if in the future, our ability to communicate with such patients improves, as I hope it will. This leads to my second point. Graham’s conclusion illustrates a more general problem with our standard framework for decisionmaking for previously competent patients, a problem that has not been adequately recognized. So, in what follows, I explain the problem I see and offer some brief thoughts about solutions. (shrink)

Patients in the vegetative state are wholly unaware of themselves, or their surroundings. However, a minority of patients diagnosed as vegetative are actually aware. What is the well-being of these patients? How are their lives going, for them? It has been argued that on a reasonable conception of well-being, these patients are faring so poorly that it may be in their best interests not to continue existing. I argue against this claim. Standard conceptions of well-being do not clearly support the (...) conclusion that these patients would be better off having life-sustaining treatment withdrawn, and in fact, it may be possible for these patients to retain a passable level of well-being. I suggest that further research into the subjective experiences of these patients will allow us to better promote their well-being. (shrink)

In recent times, there has been a surge of interest in, and enthusiasm for, contextualist views about prudential discourse — thought and talk about what has prudential value or contributes to someone’s well-being. In this paper I examine and reject two cases for radical forms of prudential contextualism, proposed by Anna Alexandrova and Steve Campbell. Alexandrova holds that the semantic content of terms like ‘well-being’ and ‘doing well’ varies across contexts. Campbell proposes that there are plural prudential concepts at play (...) in prudential discourse (and in philosophical reflection upon such discourse) and that we find evidence of this in the conflicting commitments of prudential discourse. ​The negative aim of the paper is to show that Alexandrova and Campbell have not given us a good case for ambitious forms of contextualism about prudential discourse. The positive aim of the paper is to provide alternative, aspectualist, explanations of the features of prudential discourse that their discussions highlight. (shrink)

advanced directivesend-of-life decisionsharming the deadposthumous reproductiontransplant ethics.

In Memory of Ed PellegrinoEuthanasia in Belgium is not limited to terminally ill patients. It may be applied to patients with chronic degenerative diseases. Currently, people in Belgium wish to make it possible to euthanize incompetent patients who suffer from dementia. This article explains the Belgian law and then explores arguments for and against euthanasia of patients with dementia. It probes the dementia paradox by elucidating Dworkin’s distinction between critical and experiential interests, arguing that at the end-of-life this distinction is (...) not clearcut. It argues against euthanasia for patients with dementia, for respecting patients’ humanity and for providing them with more care, compassion, and good doctoring. (shrink)

It seems better to have a life that begins poorly and ends well than a life that begins well and ends poorly. One possible explanation is that the very shape of a life can be good or bad for us. If so, this raises a tough question: when can the shape of our lives be good or bad for us? In this essay, I present and critique an argument that the shape of a life is a non-synchronic prudential value—that is, (...) something that can be good or bad for us in a way that is not good or bad for us at any particular time. After distinguishing two interpretations of ‘the shape of a life’, I argue that the first type of shape can be good or bad for us at particular moments while the other cannot be good or bad for us at all. This suggests that the shape of a life gives us no reason to posit non-synchronic prudential values. (shrink)

This paper revisits Ronald Dworkin’s influential position that a person’s advance directive for future health care and medical treatment retains its moral authority beyond the onset of dementia, even when respecting this authority involves foreshortening the life of someone who is happy and content and who no longer remembers or identifies with instructions included within the advance directive. The analysis distils a eudaimonist perspective from Dworkin’s argument and traces variations of this perspective in further arguments for the moral authority of (...) advance directives by other authors. It then critiques a feature of the eudaimonist perspectives within these arguments—namely, the position that dementia has a retroactive negative impact on what a person has previously valued—and challenges the commonly held assumption underlying them that a person’s life and well-being have relatively low value beyond the onset of dementia. Although advance directives have moral authority as a means of guiding one’s future health care, accounts that dismiss the value of the lives and well-being of people living with dementia should be questioned to the extent that such accounts are used to support the moral authority of advance directives stipulating measures to foreshorten individuals’ lives. (shrink)

There are two main ways of understanding the function of surrogate decision making in a legal context: the Best Interests Standard and the Substituted Judgment Standard. First, we will argue that the Best Interests Standard is difficult to apply to unconscious patients. Application is difficult regardless of whether they have ever been conscious. Second, we will argue that if we accept the least problematic explanation of how unconscious patients can have interests, we are also obliged to accept that the Substituted (...) Judgment Standard can be coherently applied to patients who have never been conscious at the same extent as the Best Interests Standard. We then argue that acknowledging this result is important in order to show patients respect. (shrink)

There are roughly two philosophical literatures on “happiness,” each corresponding to a different sense of the term. One uses ‘happiness’ as a value term, roughly synonymous with well-being or flourishing. The other body of work uses the word as a purely descriptive psychological term, akin to ‘depression’ or ‘tranquility’. An important project in the philosophy of happiness is simply getting clear on what various writers are talking about: what are the important meanings of the term and how do they connect? (...) While the “well-being” sense of happiness receives significant attention in the contemporary literature on well-being, the psychological notion is undergoing a revival as a major focus of philosophical inquiry, following on recent developments in the science of happiness. This entry focuses on the psychological sense of happiness (for the well-being notion, see the entry on well-being). The main accounts of happiness in this sense are hedonism, the life satisfaction theory, and the emotional state theory. Leaving verbal questions behind, we find that happiness in the psychological sense has always been an important concern of philosophers. Yet the significance of happiness for a good life has been hotly disputed in recent decades. Further questions of contemporary interest concern the relation between the philosophy and science of happiness, as well as the role of happiness in social and political decision-making. (shrink)

The connections between medicine and well-being are myriad. This paper focuses on the place of well-being in clinical medicine. It is here that different views of well-being, and their connection to concepts like “autonomy” and “authenticity”, both illuminate and are illuminated by looking closely at the kinds of interactions that routinely take place between clinicians, patients, and family members. -/- In the first part of the paper, I explore the place of well-being in a paradigmatic clinical encounter, one where a (...) competent patient interacts with a clinician. The main question here is how, or even whether, the pursuit of patient well-being – however we construe it – figures into a paradigmatic clinical encounter. In the second part of the paper, I consider what I will call a marginal clinical encounter – one where the patient is, as Agnieska Jaworska (1999) puts it, at the “margins of agency” – to theorize about the nature of well-being and to show how different theories of well-being can have dramatic consequences for clinical decision-making. (shrink)