With increased frequency, reproductive technologies are placing prospective parents in the position of choosing whether to bring a disabled child into the world. The most well-known objection to the act of “selecting against disability” is known as the Expressivist Argument. The argument claims that such acts express a negative or disrespectful message about disabled people and that one has a moral reason to avoid sending such messages. We have two primary aims in this essay. The first is to critically examine (...) the standard Expressivist Argument, which we analyze in terms of the expression of ableist attitudes. We distinguish three interpretations of the argument and argue that each version faces serious objections. Our second aim is to articulate two closely related arguments that also pertain to expressed ableist attitudes. The Expressive Harms Argument maintains that there is a moral reason to avoid actions that give rise to the perception of ableist attitudes in cases where this is likely to have negative consequences for disabled people. The Ableist Motivation Argument speaks against selecting against disability in cases where one would be motivated by ableist attitudes. While these two arguments face various objections, we seek to establish that they are more promising than the most natural interpretations of the Expressivist Argument. (shrink)

Typical philosophical discussions of physician-assisted death have focused on whether the practice can be permissible. We address a different question: assuming that pad can be morally permissible, how far does that permission extend? We will argue that granting requests for pad may be permissible even when the pad recipient can no longer speak for themselves. In particular, we argue against the ‘competency requirement’ that constrains pad-eligibility to presently-competent patients in most countries that have legalized pad. We think pad on terminally (...) ill, incapacitated patients can be morally permissible in cases where advance directives or suitable surrogate decision-makers are available, and should be legally permissible in such cases as well. We argue that this view should be accepted on pain of inconsistency: by allowing surrogate decision-makers to request withdrawal of life-sustaining care on behalf of patients and by allowing patients to request pad, we rule out any plausible justification for imposing a competency requirement on pad. (shrink)

There are increasing calls for rejecting the ‘dead donor’ rule and permitting ‘organ donation euthanasia’ in organ transplantation. I argue that the fundamental problem with this proposal is that it would bestow more worth on the organs than the donor who has them. What is at stake is the basis of human equality, which, I argue, should be based on an ineliminable dignity that each of us has in virtue of having a rational nature. To allow mortal harvesting would be (...) to make our worth contingent upon variable quality of life of judgments that can only be based on properties that come in degrees. Thus, rejecting the ‘dead donor’ rule comes at the expense of our egalitarian principles with respect to the value each individual human life has in relation to the protections against killing. (shrink)

One criticism of medical aid in dying (MAID) is the expressivist objection: MAID is morally wrong because it expresses judgments about disabilities or persons with disabilities, that are offensive, disrespectful, or discriminatory. The expressivist objection can be made at the level of individual patients, medical providers, or the state. The expressivist objection originated with selective abortion, and responses to it in that context typically claim either that selective abortion does not express specific judgments about disabilities, or that any judgments expressed (...) are not offensive. This response is inadequate: MAID often does express negative judgments about disabilities, which could reasonably be seen as offensive. But, does this offensiveness make MAID wrong? Drawing on Joel Feinberg’s account of offense, I argue that it is unlikely that the offensiveness of the judgments expressed by individuals who seek MAID or through the state’s legalization of MAID is enough to make it morally impermissible. (shrink)

The purpose of this paper is to identify a kind of discrimination that has hitherto gone unrecognised. ‘Terminalism’ is discrimination against the dying, or treating the terminally ill worse than they would expect to be treated if they were not dying. I provide four examples from healthcare settings of this kind of discrimination: hospice eligibility requirements, allocation protocols for scarce medical resources, right to try laws and right to die laws. I conclude by offering some reflections on why discrimination against (...) the dying has been hard to identify, how it differs from ageism and ableism, and its significance for end-of-life care. (shrink)

Epidemics, the medical historian Charles Rosenberg argued, typically have four Acts, as in a play. In Act I, which he termed ‘Progressive revelation’, ‘merchants’, ‘municipal authorities’ and ‘the complacency of ordinary men and women’, alike are reluctant to acknowledge an epidemic because of its threat to their ‘economic and institutional interests’ and to ‘their accustomed way of doing things’: gradually however, ‘inexorably accumulating deaths and sicknesses’ bring ‘ultimate, if unwilling, recognition’. In Act II, ‘Managing randomness’, ‘collective agreement’ is sought on (...) an ‘explanatory framework’ to manage the epidemic’s ‘dismaying arbitrariness’. Such frameworks, in previous centuries mainly religious, are now more ‘secular and mechanistic’, but again also moral and social: explanation for example of the ‘differential susceptibility of particular individuals’ is sought in terms of ‘risk-enhancing behaviour’ and ‘style of life’, but also of environmental and social factors, such as ‘residence and occupation’, providing ‘a vehicle for social criticism as well as a rationale for social control’. In Act III, ‘Negotiating public response’, pressure is generated for ‘decisive and visible community response’, often taking the form of ‘collective rites integrating cognitive and emotional elements’. Such rites, including not only ‘the imposition of a quarantine’ and ‘procedures to cleanse and disinfect’, but also religious, or now more often moral or social rituals, afford ‘the reassurance of familiar frames of explanation and logically consequent policies that provide both meaning and the promise of efficacy’. Finally, In Act IV, ‘Subsidence and retrospection’, ‘incidence of the disease gradually declines’, and questions are raised ‘for retrospective moral judgement’ about ‘what “lasting impact” particular incidents have had and what “lessons” have been learnt. Have the dead died in vain? Has a heedless society reverted to its accustomed ways of doing things as soon as denial became once more a …. (shrink)

In this original and interesting article,1 Phil Reed argues that the objections launched against expressivism at the beginning of life do not apply to expressivism at the end of life. Moreover, he claims that the expressivist argument adds to and substantiates the arguments against physician-assisted suicide and euthanasia (PAS/E). In this commentary, I will 1. Briefly examine whether the comparison between expressivism at the beginning and at the end holds. 2. Scrutinise whether there is a trickle down-effect of expressivism at (...) the end of life on other arguments against PAS/E. 3. Examine one version of the expressivist argument that is not discussed by Reed both at the beginning and at the end of life. Although Phil Reed certainly advances the expressivist debate, it is not clear that the objections to the expressivist argument are so different at the end compared with the beginning of life or that this adds to and substantiates the arguments against physician assisted suicide and euthanasia. Moreover, it is not obvious that the traditional objections to the expressivist argument, for example, that there is no message, no sender, and no receiver, have such a strong bite – neither at the beginning nor at the end of life. Biotechnologies are normative in many ways. We implement them normatively to obtain certain goals. At the same time, they facilitate certain actions and establish practices which form our norms and values, either intended or unintended. In either case, we need to pay attention to them, as …. (shrink)

The Japanese government and medical professionals have negative attitudes toward the provision of prenatal testing and related information due to social concern regarding discrimination against persons with disabilities. However, with the rapid increase in the number of non-invasive prenatal tests, particularly at non-certificated medical facilities, in response to the growing demand from pregnant women, the Japanese government and medical professional associations have enacted radical changes marking an active commitment to the provision of information on these services. While a major justification (...) for these policy changes is to ensure respect for reproductive autonomy and women’s self-determination, they may reinforce the concern regarding discrimination. This article investigated the argument that these new policies may reinforce discrimination and examined three objections to this argument. The results revealed that the recent policy changes, particularly for specific fetal traits, may imply a negative belief about people living with the same traits. Consequently, fundamental institutional changes are necessary. (shrink)

According to the expressivist objection, laws that only allow assisted dying for those suffering from certain medical conditions express the judgement that their lives are not worth living. I have recently argued that an autonomy-based approach that legally allows assisted suicide for all who make an autonomous request is a way to avoid the expressivist objection. In response to this, Thomas Donaldson has argued that rather than avoiding the expressivist objection, an autonomy-based approach extends this objection. According to Donaldson, this (...) is because helping a person achieve a goal requires endorsement of that goal. In this reply, I show that Donaldson misunderstands the target of the expressivist objection: it is not aimed at an individual’s attitude towards another person’s death but rather at a legal regulation. Moreover, helping someone end their life does not necessarily require endorsing this goal—instead, respect for a person’s autonomous choice can be another reason for providing assisted suicide. Donaldson also assumes that the autonomy-based approach requires doctors to accept autonomous requests for assisted dying. Yet, this approach merely makes it legal for individuals (not necessarily only doctors) to provide assisted suicide to autonomous persons but does not require anyone to do so. (shrink)

Death can be good— I’ll tell you how. Just have it come Decades from now.1 Full disclosure: The above poem expresses my outlook, and I have trouble empathising with people who want to die. But that does not make me unable to evaluate objections to the expressivist argument against PAS. Reed sets forth the expressivist argument as follows: ‘[W]hen we allow PAS for individuals who are terminally ill or facing some severe disease or disability, we send a message of disrespect (...) to all individuals who face such adversities in that we imply that they are inferior or their lives are not worth living (or at least less worth living than they otherwise would be) precisely insofar as they are diseased or disabled’.2 The passage of mine that Reed quotes, however, was not intended to set forth an expressivist view. Rather than saying the double standard of selective legalisation ‘send[s] a message of disrespect’,3 it says this double standard in fact involves a systematic devaluation of some people’s lives. I will argue that there are conditions under which this double standard does send a message of disrespect, but first I want to disassociate myself from the expressivist formulations of Coleman and Keown that …. (shrink)