Part I of the dissertation examines the cognitive aspects of autonomy. The central question concerns what kind of cognitive capacity autonomy is. It will be argued that the concept of autonomy is best understood in terms of a metacognitive capacity of the individual. It is argued that metacognition has two components: procedural reflexivity and metarepresentation. Metarepresentation in turn can be divided into inferential reflexivity and other-attributiveness. These two components are essential for autonomy. Particular emphasis is put on procedural reflexivity. Further, (...) since the essential function of metacognition is control, it is argued that the concept of autonomy, understood as a metacognitive capacity, can be interpreted in terms of control. Issues arising from empirical data from neuroscience on functional, as well as impaired, metacognition, and on undermined autonomy, are dealt with. It is argued that autonomy cannot be determined with respect to subjective conditions. Neurological impairments, like Anton’s Syndrome, dementia, and thought insertion in schizophrenia, are put forward in support of this claim. To determine autonomy we require external conditions. In order to determine whether an individual is autonomous, both the metacognitive status of the individual and the external setting must be considered, since they are in interplay and consequently influence each other. In Part II, the analysis put forward in Part I is applied to Swedish healthcare. It is argued that the distinction between autonomy as a right and as a capacity must be explicit in order to understand what autonomy means and to deal with it effectively in healthcare practice. A discussion about whether or not the patient’s right to autonomy sometimes tends to be over-emphasized in healthcare is put forward. Special emphasis is placed on psychitaric issues such as deinstitutionalization and participation. Following the closure of the mental hospitals, deinstitutionalization and community-based care have become central topics in psychiatry. At the same time, the implementation of such care can be demanding for patients suffering from a persistent mental disorder. In part II it is also suggested that the metacognitive account of the concept of autonomy might help clarify the criteria governing coercive care. Finally, some suggestions concerning developments and improvements in Swedish healthcare, especially in psychiatry, where the concept of autonomy is important but problematic, are put forward. (shrink)

*As mentioned in Peter Coy's NYT essay "When Being Good Is Just a Matter of Being Lucky" (2023) -/- ----- -/- How is the problem of free will related to the problem of moral luck? In this essay, I answer that question and outline a new solution to the paradox of moral luck, the source-paradox solution. This solution both explains why the paradox arises and why moral luck does not exist. To make my case, I highlight a few key connections (...) between the paradox of moral luck and two related problems, namely the problem of free will and determinism and the paradox of self-creation. Piecing together intuitions, arguments, and insights from recent work on each of these three problems, I argue that the type of control necessary for moral responsibility can only be had by someone who is a genuine source of his own actions, but the relevant notion of sourcehood admits no coherent characterization. If our commonsense view of moral responsibility is incoherent, it is unsurprising that our commitment to the existence of morally responsible agents commits us to some paradoxical things—e.g. to both the existence and impossibility of moral luck. For more information about this article, please write to gmail account: kristin.mickelson.42. (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)

In light of the variety of uses of the term autonomy in recent bioethics literature, in this paper, I suggest that competence, not being as contested, is better placed to play the anti-paternalistic role currently assigned to autonomy. The demonstration of competence, I will argue, can provide individuals with robust spheres of non-interference in which they can pursue their lives in accordance with their own values. This protection from paternalism is achieved by granting individuals rights to non-interference upon demonstration of (...) competence. In this paper, I present a risk-sensitive account of competence as a means of grounding rights to non-interference. On a risk-sensitive account of competence individuals demonstrate their competence by exercising three capacities to the extent necessary to meet a threshold determined by the riskiness of the decision. These three capacities are the capacity to acquire knowledge, use instrumental rationality, and form and revise a life plan. (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)

It is commonly assumed that to educate means to control or guide a person’s acting and development. On the other hand, it is often presupposed that the addressees of education must be seen as being endowed with free will. The question raised in this paper is whether these two assumptions are compatible. It might seem that if the learner is free in her will, she cannot be educated; however, if she is successfully educated, then it is doubtful whether she can (...) be seen as free. Inspired by the current philosophical debate on the compatibility of free will and determinism, this paper spells out two versions of this dilemma. The first version relies on the idea that to be free means being the causal source of one’s actions. The second formulation refers to the notion of freedom as the ability to act otherwise than the way one actually acts. The solution to the dilemma that is developed in this paper, however, uses a third concept of free will—to be free means being able to act on reasons. (shrink)

Given the ubiquity and centrality of social and relational influences to the human experience, our conception of self-governance must adequately account for these external influences. The inclusion of socio-historical, externalist considerations into more traditional internalist accounts of autonomy has been an important feature of the debate over personal autonomy in recent years. But the relevant socio-temporal dynamics of autonomy are not only historical in nature. There are also important, and under-examined, future-oriented questions about how we retain autonomy while incorporating new (...) values into the existing set that guides our interaction with the world. In this paper, we examine these questions from two complementary perspectives: philosophy and neuroscience. After contextualizing the philosophical debate, we show the importance to theories of autonomous agency of the capacity to appropriately adapt our values and beliefs, in light of relevant experiences and evidence, to changing circumstances. We present a plausible philosophical account of this process, which we claim is generally applicable to theories about the nature of autonomy, both internalist and externalist alike. We then evaluate this account by providing a model for how the incorporation of values might occur in the brain; one that is inspired by recent theoretical and empirical advances in our understanding of the neural processes by which our beliefs are updated by new information. Finally, we synthesize these two perspectives and discuss how the neurobiology might inform the philosophical discussion. (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)

Philosophy & Social Criticism, Ahead of Print. An ongoing debate between ‘procedural’ and ‘substantive’ theorists of personal autonomy addresses the following question: should agents have the final say on their own autonomy or should the objective circumstances in which agents live take prevalence when assessing their autonomy? Proceduralists favour the first strategy and substantive theorists restrict more explicitly the conditions under which autonomy is possible. I focus on forms of heteronomy which derive from oppressive circumstances and accept that substantive theorists (...) are correct in contending that forms of oppression common in contemporary liberal societies tend to increase heteronomy; and the heteronomy which derives from social oppression tends to fly below the radar of procedural accounts. Still, I argue that a revised procedural strategy could limit these forms of heteronomy as long as it avoids the injunctions to ‘authenticity’ common in procedural models. I proceed by reconstructing John Christman’s model which, I argue, constitutes the most promising procedural account to assess autonomy under oppression. Christman’s theory, however, needs to be reinforced to ensure self-problematisation in light of a social perspective. I show that the latter is necessary to experience the forms of alienation which are markers of heteronomy according to Christman. (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)

One of the most pervasive criticisms of nudges has been the claim that they violate, undermine or decrease people’s autonomy. This claim, however, is seldom backed up by an explicit and detailed conception of autonomy. In this paper, we aim to do three things. First, we want to clear up some conceptual confusion by distinguishing the different conceptions used by Cass Sunstein and his critics in order to get clear on how they conceive of autonomy. Second, we want to add (...) to the existing discussion by distinguishing between ‘autonomy’ as the ability to set your own ends and ‘autocracy’ as the ability to actually realize those ends. This will allow for a more careful ethical evaluation of specific nudge interventions. Third, we will introduce the idea of ‘perimeters of autonomy’ in an attempt to provide a realistic account of personal autonomy and we will argue that it can alleviate most of the worries about nudging being autonomy-undermining. (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)

In this paper I propose and develop a social account of global autonomy. On this view, a person is autonomous simply to the extent to which it is difficult for others to subject her to their wills. I argue that many properties commonly thought necessary for autonomy are in fact properties that tend to increase an agent’s immunity to such interpersonal subjection, and that the proposed account is therefore capable of providing theoretical unity to many of the otherwise heterogeneous requirements (...) of autonomy familiar from recent discussions. Specifically, I discuss three such requirements: (i) possession of legally protected status, (ii) a sense of one’s own self-worth, and (iii) a capacity for critical reflection. I argue that the proposed account is not only theoretically satisfying but also yields a rich and attractive conception of autonomy. (shrink)

In this article I argue that it does not make sense – either empirically or normatively – to speak of ‘authentic’ cultures. All we need when talking about cultures is a relatively weak concept that still carries enough normative weight to function as the meaningful background of a person’s identity, autonomy and good life. Discussing the authentic culture, I refer to the debates around the German Leitkultur as well as the Dutch populist movement as examples. However, I am interested not (...) only in the concept of the authenticity of a culture but also in the concept of the authenticity of persons: if an ‘authentic culture’ is not feasible, does this have repercussions on the concept of the autonomy and authenticity of persons? In suggesting that this might be the case, I argue that persons can be autonomous without always being fully authentic. (shrink)

Recent studies in psychosocial oncology that seek to address the social, psychological, emotional, spiritual, quality of life, and functional impacts of cancer, report positive findings for meaning-making interventions designed to help cancer patients cope with their illness experience. These interventions are successful in decreasing depression among cancer patients and increasing life satisfaction, self-esteem, coping, physical functioning, and optimism. Yet, despite these positive findings meaning-making interventions and, more generally psychosocial care, are not well integrated into hospital or healthcare organization routine cancer (...) patient care.This thesis explores practical, theoretical, and bioethical barriers to integrating psychosocial care, focusing primarily on the latter considerations. I will argue that meaning-making interventions fall within the bounds of healthcare professionals’ capacities and duty to care, more to the point, as necessary for quality cancer patient care. The bioethical principle of respect for autonomy, when reconsidered from a feminist standpoint, morally requires the intervention’s inclusion in routine care. (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.

Ethical evaluation of deep brain stimulation as a treatment for Parkinson’s disease is complicated by results that can be described as involving changes in the patient’s identity. The risk of becoming another person following surgery is alarming for patients, caregivers and clinicians alike. It is one of the most urgent conceptual and ethical problems facing deep brain stimulation in Parkinson’s disease at this time. In our paper we take issue with this problem on two accounts. First, we elucidate what is (...) meant by “becoming another person” from a conceptual point of view. After critically discussing two broad approaches we concentrate on the notion of “individual identity” which centers on the idea of “core attitudes”. Subsequently we discuss several approaches to determine what distinguishes core attitudes from those that are more peripheral. We argue for a “foundational-function model” highlighting the importance of specific dependency relations between these attitudes. Our second aim is to comment on the possibility to empirically measure changes in individual identity and argue that many of the instruments now commonly used in selecting and monitoring DBS-patients are inappropriate for this purpose. Future research in this area is advised combining a conceptual and an empirical approach as a basis of sound ethical appraisal. (shrink)

In this paper, I question the view that liberal perfectionism and neutrality are mutually exclusive doctrines. I do so by criticizing two claims made by Jonathan Quong. First, I object to his claim that comprehensive anti-perfectionism is incoherent. Second, I criticize his claim that liberal perfectionism cannot avoid a paternalist stance. I argue that Quong’s substantive assumptions about personal autonomy undermine both of his arguments. I use the discussion of Quong to argue that the standard assumption in liberal theory about (...) mutual exclusivity of liberal perfectionism and neutrality needs to be reconsidered, and I show why the argument about the convergence of perfectionism and neutrality makes conceptual sense. (shrink)

Philosophy & Social Criticism, Ahead of Print. An ongoing debate between ‘procedural’ and ‘substantive’ theorists of personal autonomy addresses the following question: should agents have the final say on their own autonomy or should the objective circumstances in which agents live take prevalence when assessing their autonomy? Proceduralists favour the first strategy and substantive theorists restrict more explicitly the conditions under which autonomy is possible. I focus on forms of heteronomy which derive from oppressive circumstances and accept that substantive theorists (...) are correct in contending that forms of oppression common in contemporary liberal societies tend to increase heteronomy; and the heteronomy which derives from social oppression tends to fly below the radar of procedural accounts. Still, I argue that a revised procedural strategy could limit these forms of heteronomy as long as it avoids the injunctions to ‘authenticity’ common in procedural models. I proceed by reconstructing John Christman’s model which, I argue, constitutes the most promising procedural account to assess autonomy under oppression. Christman’s theory, however, needs to be reinforced to ensure self-problematisation in light of a social perspective. I show that the latter is necessary to experience the forms of alienation which are markers of heteronomy according to Christman. (shrink)

An ongoing debate between ‘procedural’ and ‘substantive’ theorists of personal autonomy addresses the following question: should agents have the final say on their own autonomy or should the objective circumstances in which agents live take prevalence when assessing their autonomy? Proceduralists favour the first strategy and substantive theorists restrict more explicitly the conditions under which autonomy is possible. I focus on forms of heteronomy which derive from oppressive circumstances and accept that substantive theorists are correct in contending that (i) forms (...) of oppression common in contemporary liberal societies (e.g. gender or racial oppression) tend to increase heteronomy; and (ii) the heteronomy which derives from social oppression tends to fly below the radar of procedural accounts. Still, I argue that a revised procedural strategy could limit these forms of heteronomy as long as it avoids the injunctions to ‘authenticity’ common in procedural models. I proceed by reconstructing John Christman’s model which, I argue, constitutes the most promising procedural account to assess autonomy under oppression. Christman’s theory, however, needs to be reinforced to ensure self-problematisation in light of a social perspective. I show that the latter is necessary to experience the forms of alienation which are markers of heteronomy according to Christman. (shrink)

‘Undermatched’ is the name education researchers have given to the surprisingly large number of students who attend post-secondary institutions which are less selective than their academic credentials would permit, or who simply fail to even apply for college when they are qualified to do so. At first, this might seem like an obviously bad trend, especially as rates of undermatching are much higher among students from low-income backgrounds. This article argues, however, that individual cases of undermatching are sometimes morally acceptable (...) when the choice is made autonomously. Some readers will have trouble calling this situation just, as it is one in which a disadvantaged person has decided on a course of action which will likely perpetuate this disadvantage. To address this, the article considers alternate ways in which we might distinguish between autonomous and non-autonomous choices in undermatching cases. The article concludes with some indications about how this analysis should affect future theory and policy intended to protect against unjust undermatching. (shrink)

In “How the Neuroscience of Decision Making Informs Our Conception of Autonomy,” Gidon Felsen and Peter Reiner (2011) argue that decisions typically regarded as rational and autonomous are in fact...

An ongoing debate between ‘procedural’ and ‘substantive’ theorists of personal autonomy addresses the following question: should agents have the final say on their own autonomy or should the objective circumstances in which agents live take prevalence when assessing their autonomy? Proceduralists favour the first strategy and substantive theorists restrict more explicitly the conditions under which autonomy is possible. I focus on forms of heteronomy which derive from oppressive circumstances and accept that substantive theorists are correct in contending that (i) forms (...) of oppression common in contemporary liberal societies (e.g. gender or racial oppression) tend to increase heteronomy; and (ii) the heteronomy which derives from social oppression tends to fly below the radar of procedural accounts. Still, I argue that a revised procedural strategy could limit these forms of heteronomy as long as it avoids the injunctions to ‘authenticity’ common in procedural models. I proceed by reconstructing John Christman’s model which, I argue, constitutes the most promising procedural account to assess autonomy under oppression. Christman’s theory, however, needs to be reinforced to ensure self-problematisation in light of a social perspective. I show that the latter is necessary to experience the forms of alienation which are markers of heteronomy according to Christman. (shrink)