In Ecological Thinking, Lorraine Code argues that advocacy “often makes knowledge possible” and without it “certain kinds of knowing are impossible.” By acknowledging the value of subjectivity and testimony in knowledge creation, I argue that ecological thinking serves as an appropriate framework for engagement with individuals who are living with mental illnesses. Contrasted with the dominant Anglo-American epistemologies that involve excessive degrees of mastery and control (with the tendency to silence the voices of Others), I argue that ecological thinking facilitates (...) healthy advocacy practices precisely because of its inclusivity and receptivity towards different perspectives in knowledge creation. (shrink)

Journal of Social Philosophy, EarlyView.

Background Advance healthcare decision-making presumes that a prior treatment preference expressed with sufficient mental capacity (“T1 preference”) should trump a contrary preference expressed after significant cognitive decline (“T2 preference”). This assumption is much debated in normative bioethics, but little is known about lay judgments in this domain. This study investigated participants’ judgments about which preference should be followed, and whether these judgments differed depending on a first-person (deciding for one’s future self) versus third-person (deciding for a friend or stranger) perspective. (...) -/- Methods A vignette-based survey was conducted (N = 1445 US Americans; gender-balanced sample), in a 3 (relationship: self, best friend, stranger) × 2 (T1 preference: treat, do not treat) × 2 (T2 contrary preference: ambiguous, unambiguous) design. -/- Results Participants were more likely to defer to the incapacitated T2 preference of a third-party, while being more likely to insist on following their own T1 capacitated preference. Further, participants were more likely to conclude that others with substantial cognitive decline were still their “true selves,” which correlated with increased deference to their T2 preferences. -/- Conclusions These findings add to the growing evidence that lay intuitions concerning the ethical entitlement to have decisions respected are not only a function of cognition, as would be expected under many traditional bioethical accounts, but also depend on the relationship of the decision to the decision-maker’s true self. (shrink)

In this dissertation I develop a philosophical theory of scapegoating that explains the role of blame-shifting and guilt avoidance in the endurance of oppression. I argue that scapegoating masks and justifies oppression by shifting unwarranted blame onto marginalized groups and away from systems of oppression and those who benefit from them, such that people in dominant positions are less inclined to notice or challenge its workings. I first identify a gap in our understanding of oppression, namely how oppression endures despite (...) widespread formal commitments to principles of equality and justice. I argue that prominent theories of oppression do not place enough weight on the question of how oppression is justified and concealed from us through blame-shifting, in ways that enable its persistence without our explicit approval of its systems. Scapegoating, a concept as old as the Bible, offers potential insight into the means through which we shift blame and avoid responsibility. However, my survey of the genealogy of scapegoating shows that existing conceptualizations of scapegoating are limited in their scope and cannot be applied to explain the endurance of oppression. I propose an ameliorative theory of scapegoating that accounts for deficiencies in prevailing theories of both oppression and scapegoating. Distinct from interpersonal theories and psychologistic analyses of scapegoating, my theory characterizes scapegoating according to its social function in oppression, thereby explaining structural dimensions that are not already captured by other accounts.With the motivation and ingredients in place, I develop my theory of scapegoating as made up of three sub-mechanisms: essentialization of marginalized groups as blameworthy, collective interest in protection against a threat, and social exclusion of the blamed. These sub-mechanisms work together to construct certain groups as scapegoats and encourage us to treat them accordingly through various structural and interpersonal means. I argue that scapegoating has important implications for the formation of social identities; namely, scapegoating constructs social identities in an oppressive arrangement that is largely hidden from us but informs our social and affective relations. By constructing some identities as essentially blameworthy and threatening, dominantly situated identity groups are encouraged to internalize a protected status, act together in defense of their status, and maintain systems of oppressive exclusion. Finally, I elaborate the epistemic dimensions of my theory of scapegoating to argue that scapegoating functions within our social imaginaries and structural epistemic practices. In particular, I focus on the ways that ignorance functions to maintain the scapegoat mechanism, and how scapegoating helps insulate structural forms of ignorance. I end by considering the potential for resistance to scapegoating. (shrink)

The ethical philosophy of Emmanuel Levinas is typically associated with a punishing conception of responsibility rather than freedom. In this chapter, our aim is to explore Levinas’s often overlooked theory of freedom. Specifically, we compare Levinas’s account of freedom to the Kantian (and Fichtean) idea of freedom as autonomy and the Hegelian idea of freedom as relational. Based on these comparisons, we suggest that Levinas offers a distinctive conception of freedom—“finite freedom.” In contrast to Kantian autonomy, finite freedom constitutively involves (...) standing in certain social relations with others. And in contrast to Hegelian relational freedom, the social relations involved in finite freedom are not defined by mutual recognition, but by feelings of separation and even antagonism. Along the way, we promote a reading Levinas’s Totality and Infinity as a Hegel-style story of Bildung (development), and show how, on Levinas’s view, freedom can develop or mature in the life of the individual. (shrink)

Phenomenology gives rise to certain ontological considerations that have far-reaching implications for standard conceptions of patient autonomy in medical ethics, and, as a result, the obligations of and to patients in clinical decision-making contexts. One such consideration is the phenomenological reduction in classical phenomenology, a core feature of which is the characterisation of our primary experiences as immediately and inherently meaningful. This paper builds on and extends the analyses of the phenomenological reduction in the works of Husserl, Heidegger, and Merleau-Ponty (...) in order to identify and explain its implications for our current understanding of the principle of respect for patient autonomy and the norms of clinical decision making. (shrink)

According to the High Court in England and Wales, the primary purpose of legal interventions into the lives of vulnerable adults with mental capacity should be to allow the individuals concerned to regain their autonomy of decision making. However, recent cases of clinical decision making involving capacitous vulnerable adults have shown that, when it comes to medical law, medical ethics and clinical practice, vulnerability is typically conceived as opposed to autonomy. The first aim of this paper is to detail the (...) problems that arise when the courts and health care practitioners respond to the vulnerability of capacitous adults on the basis of such an opposition. It will be shown that not only does the common law approach to vulnerability fail to adequately capture the autonomy of capacitous vulnerable adults, the conception of vulnerability and autonomy in oppositional terms leads to objectionably paternalistic health care responses that undermine the autonomy of vulnerable patients as well as clinical and legal interventions that violate their autonomy. In response, the second aim of this paper is to show that the concepts of autonomy and vulnerability are necessarily entwined and, on that basis, the focus should be on promoting the autonomy of capacitous vulnerable adults where possible. In order to make this case, the paper explains the limitations of standard approaches to the autonomy of vulnerable adults and, in their place, offers a conception of legitimate, self-authorised autonomy that is fundamentally dependent on intersubjective practices of recognition. (shrink)

In the debates regarding the ethics of human enhancement, proponents have found it difficult to refute the concern, voiced by certain bioconservatives, that cognitive enhancement violates the autonomy of the enhanced. However, G. Owen Schaefer, Guy Kahane and Julian Savulescu have attempted not only to avoid autonomy-based bioconservative objections, but to argue that cognition-enhancing biomedical interventions can actually enhance autonomy. In response, this paper has two aims: firstly, to explore the limits of their argument; secondly, and more importantly, to develop (...) a more complete understanding of autonomy and its relation to cognitive enhancement. By drawing a distinction between the capacity for autonomy and the exercise and achievement of autonomy and by exploring the possible effects of cognitive enhancement on both competence and authenticity conditions for autonomy, the paper identifies and explains which dimensions of autonomy can and cannot, in principle, be enhanced via direct cognitive interventions. This allows us to draw conclusions regarding the limits of cognitive enhancement as a means for enhancing autonomy. (shrink)

The concept of paternalism is intricately tied to the concept of autonomy. It is commonly assumed that when paternalistic interventions are wrong, they are wrong because they impede individuals’ autonomy. Our aim in this paper is to show that the recent shift towards conceiving of autonomy relationally highlights a separate conceptual space for a nonpaternalistic kind of interpersonal intervention termed maternalism. We argue that maternalism makes a twofold contribution to the debate over the ethics of interpersonal action and decision-making. Descriptively, (...) it captures common experiences that, while not unusual in everyday life, are largely absent from the present discussion. Normatively, it describes a type of intervention with justification conditions distinct from the standard framework of paternalism. We explicate these contributions by describing six key differences between maternalism and paternalism, and conclude by anticipating and responding to potential objections. (shrink)

This paper aims to critique the phenomenon of advanced patient autonomy and choice in healthcare within the specific context of self-testing devices. A growing number of self-testing medical devices are currently available for home use. The premise underpinning many of these devices is that they assist individuals to be more autonomous in the assessment and management of their health. Increased patient autonomy is assumed to be a good thing. We take issue with this assumption and argue that self-testing provides a (...) specific example how increased patient autonomy and choice within healthcare might not best serve the patient population. We propose that current interpretations of autonomy in healthcare are based on negative accounts of liberty to the detriment of a more relational understanding. We also propose that Kantian philosophy is often applied to the healthcare arena in an inappropriate manner. We draw on the philosophical literature and examples from the self-testing process to support these claims. We conclude by offering an alternative account of autonomy based on the interrelated concepts of relationality, care and responsibility. (shrink)

When women become perpetrators of suicide bombing, their agency – their ability to act upon and affect the world – is often denied. There are a number of reasons for this and one this thesis considers is that – as females – they are not expected to be violent. Accordingly, such women are judged to be coerced or incompetent, and so unable to rule themselves sufficiently as agents. Models of autonomy propose various frameworks for assessing whether acts or persons are (...) self-governing, and the relational approach in particular has garnered much support recently. However, some aspects of the relational account remain under-theorised, including how autonomy might be measured. In this thesis, I aim to bring these two elements together by examining whether an extension of the relational model may offer a way in which to estimate the autonomy of the bombers in a more nuanced fashion. I make two claims. First, that the relational conception of the agent and autonomy ‘fits’ the bombers. Second, that my spectrum view, which is rooted in the relational approach, maps the bomber’s autonomy approximately but in detail. As such, my spectrum view is a befitting notion of autonomy and allows a graded and comparative representation of the bomber’s autonomy. (shrink)

Incidental findings and secondary findings, being results that are unrelated to the diagnostic question, are the subject of an important debate in the practice of clinical genomic medicine. Arguments for reporting these results or not doing so typically relate to the principles of autonomy, non-maleficence and beneficence. However, these principles frequently conflict and are insufficient by themselves to come to a conclusion. This study investigates empirically how ethical principles are considered when actually reporting IFs or SFs and how value conflicts (...) are weighed. A qualitative focus group study has been undertaken, including a multidisciplinary group of professionals from Belgian centres for medical genetics. The data were analysed thematically. All eight Belgian centres participated in this study. Ethical values were frequently referred to for disclosure policies on IFs and SFs. Participants invoked respect for patient autonomy to support the disclosure of IFs and opt-out options for IFs and SFs, non-maleficence for the professional delineation of reportable IFs and opt-out options for IFs and SFs and beneficence for the mandatory reporting of actionable IFs, the delineation of reportable IFs and a current decline of actively pursued SFs. Professional assumptions about patients’ genetic literacy were an important factor in the weighing of values. In line with the traditional bioethical discourse, the mandatory reporting of actionable IFs might be interpreted as a “technological, soft paternalism”. Restricting patients’ choices might be acceptable, but then its motives should be valid and its beneficent outcomes highly plausible. Hence, the presuppositions of technological, soft paternalism - patients’ inability to make informed decisions, normative rationality, the efficacy of beneficent outcomes and the delineated spectrum of beneficence - should be approached critically. Moreover, distributive justice should be considered an important value in the delineation of the current scope of the ethical debate on IFs and SFs. This study of guiding values may stimulate the debate on the ethical grounds for a solid policy on IFs and SFs internationally. (shrink)

Ageism within the context of care has attracted increasing attention in recent years. Similarly, autonomy has developed into a prominent concept within health care law and ethics. This paper explores the way that ageism, understood as a set of negative attitudes about old age or older people, may impact on an older person’s ability to make maximally autonomous decisions within health care. In particular, by appealing to feminist constructions of autonomy as relational, I will argue that the key to establishing (...) this link is the concept of self-relations such as self-trust, self-worth and self-esteem. This paper aims to demonstrate how these may be impacted by the internalisation of negative attitudes associated with old age and care. In light of this, any legal or policy response must be sensitive to and flexible enough to deal with the way in which ageism impacts autonomy. (shrink)

In this paper, following the taxonomy developed by Mackenzie, Rogers and Dodds of different sources and states of vulnerability, I claim that wild animals are inherently and situationally vulnerable. This is because they can experience suffering as a response to certain internal and external states and have a high exposure to, and a low capacity to cope with, harmful natural processes. From this it follows that we have a moral obligation to support and assist individuals who are occurrently vulnerable and (...) to reduce the risk of dispositional vulnerabilities becoming occurrent in the future, by endorsing some form of what I call ‘environmental enhancement’. Finally, I pay critical attention to how to prevent interventions aimed at ameliorating vulnerability from paradoxically generating pathogenic vulnerabilities. (shrink)

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

Clinical assessments of mental capacity have long been guided by four basic cognitive criteria (understanding, appreciation, ability to reason, communication of decision), distilled directly from widespread legal precedent in common law cases of informed consent and refusal. This article will challenge the sufficiency of these legal criteria at the bedside on the assertion that clinicians and bioethicists who evaluate decisional capacity face questions far deeper than the mere presence or absence of a patient’s informed consent. It will then present an (...) additional standard beyond the existing cognitive criteria – to be called the Narrative Coherence Standard – that may begin to bridge the gap between the existing legal standards and higher-order bioethical priorities. This standard will be treated with a philosophical argument for its use, as well as a detailed exploration of its technical components and conceptual underpinnings. (shrink)