A governing principle in medical ethics is respect for patient autonomy. This principle is commonly drawn upon in order to argue for the permissibility of assisted dying. In this paper I explore the proper role that respect for patient autonomy should play in this context. I argue that the role of autonomy is not to identify a patient’s best interests, but instead to act as a side-constraint on action. The surprising conclusion of the paper is that whether or not it (...) is in the best interests for the patient to die is a morally objective matter. This allows for the possibility that it can be in the best interests of the patient to die even if she autonomously considers it to be in her best interest to continue living. I argue that concerns about ‘mandatory’ euthanasia can be met when patient autonomy is respected as a side-constraint on action. Ultimately, this means that assisted dying is permissible, not because the autonomous patient views her suffering to be unbearable, but because it is in her objective best interests and she permitted it via her consent. (shrink)

In this chapter, I consider the idea that physician-assisted death might come into question in the cases of psychiatric patients who are incapable of making autonomous choices about ending their lives. I maintain that the main arguments for physician-assisted death found in recent medical ethical literature support physician-assisted death in some of those cases. After assessing several possible criticisms of what I have argued, I conclude that the idea that physicianassisted death can be acceptable in some cases of psychiatric patients (...) who lack autonomy ought to be taken into account in assessing the moral and legal acceptability of physician-assisted death. (shrink)

Should people suffering from untreatable psychiatric conditions be eligible for physician-assisted death? This is possible in Belgium and the Netherlands, where PAD for psychiatric conditions is permitted, though rare, so long as the criteria of due care are met. Those opposed to all instances of PAD point to Belgium and the Netherlands as a dark warning that once PAD is legalized, restricting it will prove impossible because safeguards, such as the requirement that a patient be terminally ill, will inevitably be (...) eroded or discarded. However, some supporters respond that limiting PAD to those suffering from terminal illness, or physical illnesses generally, is arbitrary and illogical. In addition, precisely because such patients are not terminally ill, their suffering may last for years, even the rest of their lives. Finally, severe depression may not be treatable. If PAD is justifiable under some conditions—as I shall assume in this article—then why wouldn't it be justifiable for these patients? Why shouldn't psychiatrists who have nothing else to offer their suffering patients be able to help them to die, if that is what they want? (shrink)

Over the past decade there has been a trend within adapted physical activity (APA) to question the hegemony of the medical understanding of disability. This debate has consequences for professional practice, which some argue should be regarded as a learning situation with a pedagogical orientation. The concept of evidence-based practice and research has spread from its origin in medicine to other allied health fields and education. In this article I discuss the limitations of applying evidence-based practice to a pedagogical approach (...) to APA. More specifically, I use the Aristotelian notion phronesis to show that professional practice of APA is essentially characterized by an indeterminacy that cannot be eradicated through the technological thinking inherent in evidence-based practice. (shrink)

Two clusters of essays in this issue of The Journal of Medicine and Philosophy provide a critical gaze through which to explore central moral, phenomenological, ontological, and political concerns regarding human moral agency and personal responsibility. The first cluster challenges common assumptions in bioethics regarding the voluntariness of human actions. The second set turns the debate towards morally responsible choice within the requirements of distributive justice. The force of their collective analysis leaves us with a well-founded basis critically to approach (...) any account of bioethics or health policy that is insufficiently attentive to the central challenges of human freedom and responsible free choice. (shrink)

ObjectivesThe end of life is an ethically challenging time requiring complex decision-making. This study describes ethical frameworks among physician trainees, explores how these frameworks manifest and relates these frameworks to experiences delivering end-of-life care.DesignWe conducted semistructured in-depth exploratory qualitative interviews with physician trainees about experiences of end-of-life care and moral distress. We analysed the interviews using thematic analysis.SettingAcademic teaching hospitals in the United States and United Kingdom.ParticipantsWe interviewed 30 physician trainees. We purposefully sampled across three domains we expected to be (...) associated with individual ethics in order to elicit a diversity of ethical and experiential perspectives.ResultsSome trainees subscribed to a best interest ethical framework, characterised by offering recommendations consistent with the patient’s goals and values, presenting only medically appropriate choices and supporting shared decision-making between the patient/family and medical team. Others endorsed an autonomy framework, characterised by presenting all technologically feasible choices, refraining from offering recommendations and prioritising the voice of patient/family as the decision-maker.ConclusionsThis study describes how physician trainees conceptualise their roles as being rooted in an autonomy or best interest framework. Physician trainees have limited clinical experience and decision-making autonomy and may have ethical frameworks that are dynamic and potentially highly influenced by experiences providing end-of-life care. A better understanding of how individual physicians’ ethical frameworks influences the care they give provides opportunities to improve patient communication and advance the role of shared decision-making to ensure goal-aligned end-of-life care. (shrink)

This paper considers proposals for developing ‘co-productive’ medical partnerships, within the UK National Health Service (NHS), concentrating in particular on the potential problem involved in combining professional and lay conceptions of health. Much of the literature that advocates the introduction of co-productive healthcare partnerships assumes that medical professionals and patients share, or can easily come to share, a common set of beliefs about what is valuable with regard to health interventions and outcomes. However, a substantial literature documents the contestability of (...) the concept of health, particular across professional and lay divides. We suggest that this potential disagreement ought to be taken seriously, and suggest that the prospect of a co-productive NHS in which patients and professionals act in partnership is threatened by the existence of unresolved epistemic differences. We suggest that part of the solution may lie in re-framing this potential disagreement in the terms provided by Engel’s bio-psycho-social account of health, and demonstrate how support for this account can be grounded upon a critical realist foundation. What we call a ‘stratified conception of health’ reveals the potential complementarity between health beliefs which may have at first seemed to be essentially contradictory. We consider some of the practical implications this idea has for conceiving and creating co-productive medical partnerships. (shrink)

This article considers the ethical dimensions of attempts to ‘personalise’ health and social care services in the UK. Personalisation is identified as closely related to efforts to introduce elements of neoliberal marketisation into public service provision, particularly through the introduction of consumer choice for services users. We consider two areas of ethical concern surrounding personalisation: its contribution to social justice agendas and the enhancement of service users’ autonomy. While personalisation in general, and consumer choice in particular, has been presented as (...) positively contributing to both social justice and autonomy, we critically revaluate these claims. We draw on the work of Nancy Fraser and relational theories of autonomy to highlight the ethical complexities of personalisation and the potentially negative effects that the extension of consumer choice may have on promoting social justice and supporting substantive forms of autonomy. We suggest that understanding and negotiating these complexities imposes ethical constraints on the ways in which, and extent to which, health and social care services can be defensibly personalised. (shrink)