Toleration is one of the fundamental principles that inform the design of a democratic and liberal society. Unfortunately, its adoption seems inconsistent with the adoption of paternalistically benevolent policies, which represent a valuable mechanism to improve individuals’ well-being. In this paper, I refer to this tension as the dilemma of toleration. The dilemma is not new. It arises when an agent A would like to be tolerant and respectful towards another agent B’s choices but, at the same time, A is (...) altruistically concerned that a particular course of action would harm, or at least not improve, B’s well-being, so A would also like to be helpful and seeks to ensure that B does not pursue such course of action, for B’s sake and even against B’s consent. In the article, I clarify the specific nature of the dilemma and show that several forms of paternalism, including those based on ethics by design and structural nudging, may not be suitable to resolve it. I then argue that one form of paternalism, based on pro-ethical design, can be compatible with toleration and hence with the respect for B’s choices, by operating only at the informational and not at the structural level of a choice architecture. This provides a successful resolution of the dilemma, showing that tolerant paternalism is not an oxymoron but a viable approach to the design of a democratic and liberal society. (shrink)

:Contemporary global governance is organized around an odd pairing: care and control. On the one hand, much of global governance is designed to reduce human suffering and improve human flourishing, with the important caveat that individuals should be allowed to decide for themselves how they want to live their lives. On the other hand, these global practices of care are also entangled with acts of control. Peacebuilding, public health, emergency aid, human rights, and development are expressions of this tension between (...) care and control. There is a concept that captures this tension: paternalism. Drawing on our moral intuitions, I argue that paternalism is the attempt by one actor to substitute his judgment for another actor's on the grounds that such an imposition will improve the welfare of the target actor. After discussing and defending this definition, I note how our unease with paternalism seems to grow as we scale up from the interpersonal to the international, which I argue owes to the evaporation of community and equality. After exploring the implications of this definition and distinguishing it from other forms of intervention, I consider how different elements of paternalism combine to generate different configurations. Specifically, I point to five dimensions that are most relevant for examining the paternalism found in contemporary global and humanitarian governance: the tools used to restrict another actor’s liberty ; the scope of the interference ; the purpose of the intervention ; the source of the paternalizer’s confidence ; and the mechanisms of accountability. These different elements often correlate historically, suggestive of two ideal types of global paternalism: strong and weak. Contemporary global and humanitarian governance is largely the weak variety: force is severely proscribed, interference is relatively restricted, the paternalizer’s confidence has epistemic roots, and accountability to local populations remains a noble but rarely practiced goal. I further speculate that a major reason for this difference is the effects of liberalism and rationalization. I use this taxonomy to suggest how two different global efforts to improve the lives of those peoples living in what were perceived to be unstable and illiberal territories — the civilizing missions of the nineteenth century and the peacebuilding operations of the post-Cold War period — exhibited different kinds of paternalism. I conclude by reflecting on the ethics of international paternalism. (shrink)

Legal restrictions of the right to self-determination increasingly pretend to be compatible with the liberal concept of autonomy: they act upon a ‘soft’ or autonomy-orientated paternalistic rationale. Conventional liberal critique of paternalism turns out to be insensitive to the intricate normative problems following from ‘soft’ or ‘libertarian’ paternalism. In fact, these autonomy-oriented forms of paternalism could actually be even more problematic and may infringe liberty rights even more intensely than hard paternalistic regulation. This paper contributes to the systematic differentiation of (...) soft and hard paternalism by discussing the (legal) concept of autonomy and elaborates the moral and legal limits of autonomy-orientated paternalism. (shrink)

Most anti-paternalists claim that informed and competent self-regarding choices are protected by autonomy, while ill-informed or impaired self-regarding choices are not. Joel Feinberg, among many others, argues that we can in this way distinguish impermissible “hard” paternalism from permissible “soft” paternalism. I argue that this view confronts two related problems in its treatment of ill-informed decision-makers. First, it faces a dilemma when applied to decision-makers who are responsible for their ignorance: it either permits too much, or else too little, intervention (...) to satisfy its proponents. Second, the most promising rationales in favor of the view ignore the distinction between an agent’s voluntarily bringing about some state of affairs, on the one hand, and an agent’s voluntarily assuming a risk, on the other. I conclude that a decision-maker’s ignorance is irrelevant to the permissibility of intervention on her behalf. If it is permissible to intervene in a given ill-informed choice, it would be permissible to intervene in an otherwise similar but informed choice, at least provided that intervention would produce similar benefits in both cases. This shows that we should sometimes accept straightforwardly paternalistic rationales. (shrink)

This article investigates the hitherto under-examined relations between affirmative action, paternalism and respect. We provide three main arguments. First, we argue that affirmative action initiatives are typically paternalistic and thus disrespectful towards those intended beneficiaries who oppose the initiatives in question. Second, we argue that not introducing affirmative action can also be disrespectful towards these potential beneficiaries because such inaction involves a failure to adequately recognize their moral worth. Third, we argue that the paternalistic disrespect involved in affirmative action is (...) alleviated when the potential beneficiaries’ preferences against such initiatives are adaptive. We conclude that although there is a relevant sense in which paternalistic affirmative action is disrespectful, it may well be more disrespectful not to pursue such policies. (shrink)

Un nouveau type de paternalisme s’est développé ces dix dernières années sous l’impulsion de travaux innovateurs de certains économistes comportementaux. Ce nouveau type de paternalisme, que j’appelle ici paternalisme comportemental, s’est popularisé grâce à la théorie du « coup de pouce » de Richard Thaler et Cass Sunstein et remet en question l’idée selon laquelle le paternalisme serait inacceptable dans nos sociétés. L’objet de cet article est d’évaluer sa légitimité morale sans, néanmoins, se limiter à son supposé libertarianisme. Les résultats (...) de mon investigation peuvent se résumer ainsi : bien que le paternalisme comportemental soit généralement reconnu pour son caractère libéral, il ne satisfait pas en fait les conditions de ce que Joel Feinberg nomme le « paternalisme mou ». Néanmoins, il possède des qualités morales sous-estimées par ses partisans. Il résiste d’abord très bien à la critique égalitariste d’Elizabeth Anderson. A la différence des formes traditionnelles de paternalisme, le paternalisme comportemental n’est pas dégradant et n’est pas ostracisant. Le paternalisme comportemental, enfin, peut se targuer d’être véritablement altruiste, à la condition, cependant, d’abandonner les hypothèses principales de Sunstein et Thaler. Classification JEL : A12, D64, I18, I31, K32. (shrink)

In this paper, I argue that a definition of paternalism must meet certain methodological constraints. Given the failings of descriptivist and normatively charged definitions of paternalism, I argue that we have good reason to pursue a normatively neutral definition. Archard's 1990 definition is one such account. It is for this reason that I return to Archard's account with a critical eye. I argue that Archard's account is extensionally inadequate, failing to capture some cases which are clear instances of paternalism. I (...) refine each of his three conditions, ultimately providing an improved definition of paternalistic interference. This revised definition meets specific methodological constraints, offering a definition that is both neutral between anti- and pro-paternalistic intuitions, but that also explains why paternalism is normatively significant. Specifically, this definition captures the conflict between interfering with an individual's choices and treating the individual benevolently, without making paternalism permissible or impermissible by definition. (shrink)

Wherever a government or state is concerned with the welfare of its citizens, there will probably also exist policies which compel the individual citizen to undertake or abstain from activities which affect that citizen alone. The set of theories behind such policies is collectively known as ‘paternalism’. It is not hard to understand why this term has developed strong pejorative overtones. Policies of this type appear to offend a fundamental tenet of liberal societies: namely, that the individual is best placed (...) to know what is in his or her interests. Paternalistic policies imply, and are concerned with correcting, failures of precisely this kind of judgement. And yet, at the same time, there is a popular consensus that compelling people to wear a seat belt when driving a car is a reasonable restriction of personal liberty. Paternalism may be difficult to accept in principle, but it is equally difficult to avoid in practice. Not surprisingly, the literature reveals a long heritage of debate in a wide range of academic disciplines. This debate reveals a failure to make progress in two areas in particular. First, analyses of paternalism often confuse policies which are actually concerned with correcting failures of market exchange — in particular, those concerned with insufficient or imperfect information — with those which are genuinely paternalistic. One objective of this paper will be to clarify the difference between these two kinds of policy. (shrink)

Can a preference-based conception of welfare accommodate changes in people's preferences? I argue that the fact that people care about which preferences they have, and the fact that people can change their preferences about which preferences it is good for them to have, together undermine the case for accepting a preference-satisfaction conception of welfare.

This article takes a critical look at the classic couplet of theories on the justification of rights, namely, the choice theory and the interest or benefit theory, where the two are understood to be in conflict. The argument is made that this couplet is best replaced with a new one, namely, a sophisticated rendering of the benefit theory coupled with the autonomy theory, such that any conflict is resolved. The latter two theories take different cases in justifying the attribution of (...) rights: The autonomy theory is concerned with justifying the attribution of rights to adult, rational, and competent subjects, arguing that this attribution requires a sufficiently autonomous claim by such subjects, while the benefit theory seeks to justify the attribution of rights to subjects who lack any of these three properties, meaning that they cannot be considered adult, rational, or competent. (shrink)

This essay defends duty-sensitive self-ownership, a view about the special authority people have over their bodies that is designed to capture what is attractive about self-ownership theories without the implausible stringency usually associated with them.

Beneficence and respect for autonomy are two of the most fundamental moral duties in general and in bioethics in particular. Beyond the usual questions of how to resolve conflicts between these duties in particular cases, there are more general questions about the possible forms of the interactions between them. Only recognition of the full spectrum of possible interactions will ensure optimal moral deliberation when duties potentially conflict. This paper has two simultaneous objectives. The first is to suggest a typological scheme (...) of all possible modes of interaction; these will be classified under the “discrete,” “semi-discrete,” and “non-discrete” categories, according to whether the meaning and/or forms of expression of each duty are treated as independent from or rather as constrained by the other. The second objective is to show that all logical possibilities of interaction indeed have real expressions in medical ethics, to provide clear illustrations of each, and in particular to stress those that have usually escaped recognition. (shrink)

In this paper, we explore the issue of the elimination of sports, or elements of sports, that present a high risk of brain injury. In particular, we critically examine two elements of Angelo Corlett’s and Pam Sailors’ arguments for the prohibition of football and Nicholas Dixon’s claim for the reformation of boxing to eliminate blows to the head based on the empirical assumption of an essential or causal connection between brain injuries incurred in football and the development of a degenerative (...) brain disease known as chronic traumatic encephalopathy ; and John Stuart Mill’s rejection of consensual domination. We present four arguments to contest the validity of Corlett, Dixon’s and Sailor’s positions. Specifically, we argue that certain autonomy-based arguments undermine paternalist arguments for reform; the nature of the goods people pursue in their lives might justify their foregoing future autonomy; Mill’s argument against consensual domination draws on ambiguous and arbitrary distinctions; the lack of consensus and empirical evidence regarding CTE arising from brain injuries in sport underdetermines calls for reform. We conclude that these proposals for reforming or eliminating sports with high risks of brain injuries are not well founded. (shrink)

This paper scrutinizes the tension between individuals’ rights and paternalism. I will argue that no normative account that includes rights of individuals can justify hard paternalism since the infringement of a right can only be justified with the right or interest of another person, which is never the case in hard paternalism. Justifications of hard paternalistic actions generally include a deviation from the very idea of having rights. The paper first introduces Tom Beauchamp as the most famous contemporary hard paternalist (...) by outlining his moral theory (principlism) and showing why it, as it stands, has to allow for hard paternalism. Secondly, the paper focuses on the notion of rights within principlism. I will employ traditional theories of rights to make sense of rights in principlism. Unfortunately, this attempt fails. In the third part, then, I claim that rights can only be limited with reference to the rights or interests of others. This structure is the very point of rights, it is their bite. I will argue for this claim and show its implications. The most important implication is that not only principlism, but every normative theory that includes rights of individuals, has to abolish hard paternalism. (shrink)

Ordinary Language Philosophy has largely fallen out of favour, and with it the belief in the primary importance of analyses of ordinary language for philosophical purposes. Still, in their various endeavours, philosophers not only from analytic but also from other backgrounds refer to the use and meaning of terms of interest in ordinary parlance. In doing so, they most commonly appeal to their own linguistic intuitions. Often, the appeal to individual intuitions is supplemented by reference to dictionaries. In recent times, (...) Internet search engine queries for expressions of interest have become quite popular. Apparently, philosophers attempt to surpass the limits of their own linguistic intuitions by appealing to experts or to factual uses of language. I argue that this attempt is commendable but that its execution is wanting. Instead of appealing to dictionaries or Internet queries, philosophers should employ computer-based linguistic corpora in order to confirm or falsify hypotheses about the factual use of language. This approach also has some advantages over methods employed by experimental philosophers. If the importance of ordinary language is stressed, the use of linguistic corpora is hardly avoidable. (shrink)

Though much has been written about when paternalistic intervention is justified, and about how it is justified, much less has been written about who may do the intervening. This is a substantial lacuna in our understanding of the nature of justified paternalism. By examining the question of who it is that may most appropriately interfere with the course of our decision-making, we can learn something useful both about paternalism and about the nature of friendship.In this essay I will argue that (...) friendship and paternalistic intervention are linked. Friendship of the close, intimate variety that I will be discussing is in part constituted by the fact that one friend is morally justified in interfering with the other’s decisions. Intimate friendship involves a partial meshing of identities. This meshing of identities manifests itself in part by the liberties that one friend takes in guiding the life of the other. Paternalistic intervention between friends can thus be justified because it expresses the union of the friends, and because it preserves that union. (shrink)

Patients who are incompetent need a surrogate decision maker to make treatment decisons on their behalf. One of the main ethical questions that arise in this context is what standard ought to govern such decision making. According to the Substituted Judgment Standard, a surrogate ought to make the decision that the patient would have made, had he or she been competent. Although this standard has sometimes been criticized on the grounds of being difficult to apply, it has found wide appeal, (...) since it it is alleged to protect incompetent patients? right to autonomy. The main purpose of the thesis is to evaluate SJS, from a conceptual and ethical perspective. It argues that the traditional formulation of SJS is seriously incomplete, and discusses alternative ways of completing it. Moreover, it questions the received view on how SJS should be morally justified, by offering arguments against the view that decision making in accordance with this standard extends the patient's opportunities for self-determination. Instead it suggests a virtue-ethical approach according to which the moral point of SJS-based decision making is not to protect the patient's interests, but to express respect for person. The thesis also critically assesses empirical studies according to which surrogates often fail to correctly predict patients? actual treatment preferences. It is shown that such results cannot, for a number of reasons, support the conclusion drawn that surrogates are ill-equipped to make decisions that comply with SJS. (shrink)

Some writers suggest that corporations should act in ways which reflect a broad concern for the well-being of others, as opposed to a more narrow (Libertarian) conception of responsibility. But this Broad View of moral responsibility puts us on a collision course with our considered intuitions about paternalistic acts. This paper discusses several aspects of this issue: the neutrality of the Standard View of Paternalism, the nature of the defenses of paternalistic interventions allowed by the Standard View of Paternalism and (...) their reliance on consent; and the sort of position on paternalism the Board View would have to endorse in order to justify the benevolence-motivated orientation required by its conception of moral responsibility.The conclusion is that unless we are prepared to take a different, non-standard view of paternalism the Board View of corporate moral responsibility will be untenable. (shrink)

Philosophers disagree about what precisely makes an act paternalistic, and about whether, when, and why paternalistic acts are morally objectionable. Despite these disagreements, it might seem uncontroversial to think that it is permissible to paternalize children. When paternalism seems morally objectionable, that is usually because an adult has been treated in a way that seems appropriate only for children. But, we might think, there can be nothing morally objectionable about treating children as children. In this paper, however, I argue that (...) there are limits to how we may permissibly paternalize children. I begin in Section 1 by describing and endorsing Jonathan Quong’s account of paternalism, which defines paternalistic acts as those that involve particular kinds of judgments that the paternalizer makes about the capacities of the paternalizee. In Section 2, I identify a distinction between two kinds of paternalism: ‘compensatory’ paternalism, and ‘non-compensatory’ paternalism. In Section 3, I argue that compensatory paternalism is usually permissible in the case of children. In section 4, I argue that non-compensatory paternalism is much harder to justify than compensatory paternalism, and because of this, it is sometimes impermissible even when directed at children. (shrink)

Das von Cass Sunstein und Richard Thaler ausgearbeitete Projekt eines Libertären Paternalismus stellt fraglos einen der zurzeit meistdiskutierten neopaternalistischen Theorieentwürfe dar. Als hybride Mischung zwischen Theorieprogramm, politischer Bewegung und praxis- und anwendungsorientiertem Policy-Manual, das zuweilen Züge eines populären philosophischen Lebensratgebers trägt, hat Libertärer Paternalismus viel Zuspruch, aber auch heftige Kritik auf sich gezogen, die in diesem Aufsatz auf ihre Plausibilität geprüft werden. Zu diesem Zweck geben die Autoren zunächst einen kurzen Überblick über Ausgangspunkte, Leitorientierungen und Problemvorgaben des Theorie- und Politikprogramms (...) des Libertären Paternalismus. In einem zweiten Schritt werden zentrale Konzepte und Unterscheidungen des libertär paternalistischen Rationales vorgestellt und problematisiert. Daran anschließend werden drei der prominentesten Kritikpunkte an Libertärem Paternalismus auf den Prüfstand gestellt. Hierzu gehören der Manipulationseinwand, Kritiken, die sich auf grundlegende Rechtfertigungsprobleme des Libertären Paternalismus beziehen, und Einwände, die auf langfristige negative Folgen des Nudging verweisen. (shrink)

Incentives are typically conceived as a form of trade, and so voluntariness appears to be the only ethical concern. As a consequence, incentives are often considered ethically superior to regulations because they are voluntary rather than coercive. But incentives can also be viewed as one way to get others to do what they otherwise would not; that is, as a form of power. When incentives are viewed in this light, many ethical questions arise in addition to voluntariness: What are the (...) responsibilities of the powerful in using incentives? Can incentives be manipulative or exploitative, even if people are free to refuse them? Like all other forms of power, incentives can be abused. This paper develops criteria for distinguishing their legitimate from their illegitimate uses, viz. legitimacy of purpose, voluntariness, and effect on character. The criteria are then applied to three cases: plea bargaining, recruiting medical research subjects, and motivating children to learn. Thinking of incentives in terms of.. (shrink)

During the last two decades a broad and intensive discussion has taken place in the field of medical ethics. Especially in the English-speaking countries, “Biomedical Ethics” have developed as a part of secular, philosophical moral theory. Two ethical problems in organ transplantation – living organ donation and organ allocation – illustrate that this transition reflects both the complex ethical questions raised by rapid changes in the biological sciences and in health care, and the fact that traditional Hippocratic ethics have proven (...) to be inadequate in several respects. (shrink)

Labeling of food consumption is related to food safety, food quality, environmental, safety, and social concerns. Future politics of food will be based on a redefinition of commodity food consumption as an expression of citizenship. “Citizen-consumers” realize that they could use their buying power in order to develop a new terrain of social agency and political action. It takes for granted kinds of moral selfhood in which human responsibility is bound into human agency based on knowledge and recognition. This requires (...) new kinds of food labeling practices. Existing research on consumer’s preferences often fails to recognize the full complexity of the motivations and intentions through which the identity of the moral self is built up in relation to food consumption practices. For citizens, not only food production practices matter but also the impact of what we eat on who we are and the ecological foot print of our food stuff. Two major drivers for this are the idea that we ourselves have to take care of our own bodies (“We are what we eat”) and that we are responsible for Planet Earth. Since both obesity and climate change have become major public concerns, also governments develop an increasing interest in defining how citizens ought to behave as consumers and how retailers and producers should facilitate such responsible behavior. Since they are supposed to defend the “bonum commune,” e.g., the public health of their citizens and a sound common future for all, a new consensus on “appropriate” consumption choices has to be found, balancing beneficence and autonomy. (shrink)

Labeling of food consumption is related to food safety, food quality, environmental, safety, and social concerns. Future politics of food will be based on a redefinition of commodity food consumption as an expression of citizenship. “Citizen-consumers” realize that they could use their buying power in order to develop a new terrain of social agency and political action. It takes for granted kinds of moral selfhood in which human responsibility is bound into human agency based on knowledge and recognition. This requires (...) new kinds of food labeling practices. Existing research on consumer’s preferences often fails to recognize the full complexity of the motivations and intentions through which the identity of the moral self is built up in relation to food consumption practices. For citizens, not only food production practices matter but also the impact of what we eat on who we are and the ecological foot print of our food stuff. Two major drivers for this are the idea that we ourselves have to take care of our own bodies (“We are what we eat”) and that we are responsible for Planet Earth. Since both obesity and climate change have become major public concerns, also governments develop an increasing interest in defining how citizens ought to behave as consumers and how retailers and producers should facilitate such responsible behavior. Since they are supposed to defend the “bonum commune,” e.g., the public health of their citizens and a sound common future for all, a new consensus on “appropriate” consumption choices has to be found, balancing beneficence and autonomy. (shrink)

In patient centred care, shared decision making is a central feature and widely referred to as a norm for patient centred medical consultation. However, it is far from clear how to distinguish SDM from standard models and ideals for medical decision making, such as paternalism and patient choice, and e.g., whether paternalism and patient choice can involve a greater degree of the sort of sharing involved in SDM and still retain their essential features. In the article, different versions of SDM (...) are explored, versions compatible with paternalism and patient choice as well as versions that go beyond these traditional decision making models. Whenever SDM is discussed or introduced it is of importance to be clear over which of these different versions are being pursued, since they connect to basic values and ideals of health care in different ways. It is further argued that we have reason to pursue versions of SDM involving, what is called, a high level dynamics in medical decision-making. This leaves four alternative models to choose between depending on how we balance between the values of patient best interest, patient autonomy, and an effective decision in terms of patient compliance or adherence: Shared Rational Deliberative Patient Choice, Shared Rational Deliberative Paternalism, Shared Rational Deliberative Joint Decision, and Professionally Driven Best Interest Compromise. In relation to these models it is argued that we ideally should use the Shared Rational Deliberative Joint Decision model. However, when the patient and professional fail to reach consensus we will have reason to pursue the Professionally Driven Best Interest Compromise model since this will best harmonise between the different values at stake: patient best interest, patient autonomy, patient adherence and a continued care relationship. (shrink)

Our decision-making is often subject to framing effects: alternative but equally informative descriptions of the same options elicit different choices. When a decision-maker is vulnerable to framing, she may consent under one description of the act, which suggests that she has waived her right, yet be disposed to dissent under an equally informative description of the act, which suggests that she has not waived her right. I argue that in such a case the decision-maker’s consent is simply irrelevant to the (...) permissibility of proceeding. I then consider two alternative views. According to the first, people susceptible to framing are able to give valid consent so long as they are sufficiently informed. This suggestion, I argue, maintains an overly narrow focus on mere quantity of information to the exclusion of other choice-affecting factors. A second response, which appeals to hypothetical consent, is likewise of little use in resolving the moral problem posed by framing effects. I conclude that if susceptibility to framing undermines the validity of consent, we may have good reason to reconsider whether consent has the rights-waiving function commonly attributed to it. (shrink)

The use of tanning beds has been identified as being among the most significant causes of melanoma and non-melanoma skin cancer. Accordingly, the activity is properly seen as one that involves profound harm to self. The article examines paternalistic reasons for restricting sunbed usage. We argue that both so-called soft and hard paternalistic arguments support prohibiting the use of sunbeds. We make the following three arguments: an argument from oppressive patterns of socialization suggesting that the autonomous nature of the conduct (...) in question is questionable; an argument from so-called evaluative delusions in which individuals attach incorrect weights to some of their values; a strictly hard paternalistic argument appealing to the harm in itself pertaining to the use of sunbeds. (shrink)

In this article I assess the ability of motivational accounts of paternalism to respond to a particular challenge: can its proponents adequately explain the source of the distinctive form of disrespect that animates this view? In particular I examine the recent argument put forward by Jonathan Quong that we can explain the presumptive wrong of paternalism by relying on a Rawlsian account of moral status. I challenge the plausibility of Quong's argument, claiming that although this approach can provide a clear (...) response to the explanatory challenge, it is only successful in doing so when it relies on the strength of its rival: the argument from personal autonomy. In doing so I illustrate that such responses are conceptually dependent on an account of respect for persons, and thus much of the relevant controversy is actually disagreement over how we respect other individuals. (shrink)

Our goal in this chapter is to draw on empirical work about preference formation and welfare to propose a distinctive form of paternalism, libertarian in spirit, one that should be acceptable to those who are firmly committed to freedom of choice on grounds of either autonomy or welfare. Indeed, we urge that a kind of ‘libertarian paternalism’ provides a basis for both understanding and rethinking many social practices, including those that deal with worker welfare, consumer protection, and the family.

What is the foundation of consent in the criminal law? Classically liberal commentators have offered at least three distinct theories. J.S. Mill contends we value consent because individuals are the best judges of their own interests. Joel Feinberg argues an individual’s consent matters because she has a right to autonomy based on her intrinsic sovereignty over her own life. Joseph Raz also focuses on autonomy, but argues that society values autonomy as a constituent element of individual well-being, which it is (...) the state’s duty to promote. The criminal law’s approach to the problem of non-contemporaneous consent—prospective consent and retrospective consent—casts a unique light on the differences among these three justifications. Peter Westen claims neither Mill’s nor Feinberg’s justifications for consent fully explains how non-contemporaneous consent is treated in the criminal law. Specifically, Mill’s “self-interest” conception explains the criminal law’s limited recognition of prospective consent, but cannot explain its total rejection of retrospective consent. Conversely, Feinberg’s “sovereign autonomy” conception explains why the criminal law rejects retrospective consent, but cannot explain why the law recognizes irrevocable prospective consent only in limited circumstances. I resolve this dilemma by explaining that Raz’s “autonomy is good” conception is consistent with both the criminal law’s limited recognition of irrevocable prospective consent and its total rejection of retrospective consent. This suggests the existing criminal law embodies Raz’s theory that it is the duty of the state to promote morality, in particular the moral good of individual well-being through living autonomously. In contrast, the criminal law’s treatment of consent would have to be modified if it were to reflect Mill’s “self-interest” conception, or Feinberg’s “sovereign autonomy” conception. (shrink)

In the face of mounting criticism against advance directives, we describe how a novel, computer-based decision aid addresses some of these important concerns. This decision aid, Making Your Wishes Known: Planning Your Medical Future , translates an individual's values and goals into a meaningful advance directive that explicitly reflects their healthcare wishes and outlines a plan for how they wish to be treated. It does this by (1) educating users about advance care planning; (2) helping individuals identify, clarify, and prioritize (...) factors that influence their decision-making about future medical conditions; (3) explaining common end-of-life medical conditions and life-sustaining treatment; (4) helping users articulate a coherent set of wishes with regard to advance care planning—in the form of an advance directive readily interpretable by physicians; and (5) helping individuals both choose a spokesperson, and prepare to engage family, friends, and health care providers in discussions about advance care planning. (shrink)

The notion of a non-renounceable right is an integral part of recent liberal reconciliatory attempts to justify apparently paternalistic policies, such as compulsory insurance or providing people with certain goods irrespective of their subjective preferences, non-paternalistically. However, non-renounceable rights cannot be justified non-paternalistically. A critical scrutiny of the liberal reconciliatory arguments in question reveals this and points towards a plausible paternalist justification of the policies in question.

Life saving or life sustaining treatment may not be instigated in the clinical setting when such treatment is deemed to be futile and therefore not in the patient’s best interests. The concept of futility, however, is related to many assumptions about quality and quantity of life, and may be relied upon in a manner that is ethically unjustifiable. It is argued that the concept of futility will remain of limited practical use in making decisions based on the best interests principle (...) because it places such high demands on the individual responsible for decision making. This article provides a critical analysis of futility (in the context of the best interests decision-making principle), and proposes an ethically defensible notion of futility. (shrink)

NThere are many problems with Levi and Green’s (2010) suggestion that a computer-based decision aid will overcome the major objections to advance directives (ADs). We focus on just two here. First, we argue that the key assumption underlying Levi and Green’s paper, that autonomy always ought to take priority over other values, is false. Second, we argue that the paper misses the point of the most telling objections to the use of ADs: they lack the relevant moral authority to determine (...) treatments. It is not that they are merely subject to a set of contingent problems related to capturing the wishes of individuals or being open to misinterpretation by others.We conclude that the plug should be pulled on Levi and Green’s computer-based proposal. (shrink)

Distributive egalitarians believe that distributive justice is to be explained by the idea of distributive equality (DE) and that DE is of intrinsic value. The socio-relational critique argues that distributive egalitarianism does not account for the “true” value of equality, which rather lies in the idea of “equality as a substantive social value” (ESV). This paper examines the socio-relational critique and argues that it fails because – contrary to what the critique presupposes –, first, ESV is not conceptually distinct from (...) DE, and second, the idea of ESV cannot serve as a “foundation” or “root” of distributive egalitarianism. (shrink)

Advance directives for psychiatric care are the subject of debate in a number of Western societies. By using psychiatric advance directives , it would be possible for mentally ill persons who are competent and with their disease in remission, and who want timely intervention in case of future mental crisis, to give prior authorisation to treatment at a later time when they are incompetent, have become non-compliant, and are refusing care. Thus the devastating consequences of recurrent psychosis could be minimised.Ulysses (...) contracts raise a number of ethical questions. In this article the central issues of concern and debate are discussed from a narrative perspective. Ulysses contracts are viewed as elements of an ongoing narrative in which patient and doctor try to make sense of and get a hold on the recurrent crises inherent in the patient's psychiatric condition. (shrink)

A ‘Ulysses arrangement’ (UA) is an agreement where a patient may arrange for psychiatric treatment or non-treatment to occur at a later stage when she expects to change her mind. In this article, I focus on ‘competence-insensitive’ UAs, which raise the question of the permissibility of overriding the patient’s subsequent decisionally competent change of mind on the authority of the patient’s own prior agreement. In “The Ethical Justification for Ulysses Arrangements”, I consider sceptical and supportive arguments concerning competence-insensitive UAs, and (...) argue that there are compelling reasons to give such UAs serious consideration. In “Decisional Competence and Legal Capacity in UAs”, I examine the nature of decisional competence and legal capacity as they arise in UAs, an issue neglected by previous research. Using the distinctions which emerge, I then identify the legal structure of a competence-insensitive UA in terms of the types of legal capacity it embodies and go on to explain how types of legal capacity might be shared between the patient and a trusted other to offer support to the patient in the creation and implementation of a competence-insensitive UA. This is significant because it suggests possibilities for building patient support mechanisms into models of legal UAs, which has not addressed in the literature to date. Drawing on this, in “Using Insights from the Competence/Capacity Distinction to Enhance Patient Support in UAs”, I offer two possible models to operationalize competence-insensitive UAs in law that allow for varying degrees of patient support through the involvement of a trusted other. Finally, I outline some potential obstacles implementing these models would face and highlight areas for further research. (shrink)

Nudges have gained popularity as a behavioral change tool that aims to facilitate the selection of the sensible choice option by altering the way choice options are presented. Although nudges are designed to facilitate these choices without interfering with people’s prior preferences, both the relation between individuals’ prior preferences and nudge effectiveness, as well as the notion that nudges ‘facilitate’ decision-making have received little empirical scrutiny. Two studies examine the hypothesis that a social proof nudge is particularly effective when people (...) have no clear prior preference, either because people are indifferent (in a colour-categorization task; Study 1, N = 255) or because people experience a choice conflict (making shopping decisions about meat products; Study 2, N = 97). Both studies employed a social proof nudge to steer participants’ choices. The potential facilitating effect of the nudge was tested using a mouse-tracker paradigm that implicitly assessed experienced uncertainty during decision-making. Results showed that the nudge was effective in steering participants’ decisions; the facilitation effect (i.e., reduced uncertainty regarding the decision) was only observed for conflicting preferences, but not under indifference. A better understanding of when and how nudges can influence individuals’ behavior may help in deciding whether nudges are an appropriate policy tool for changing particular undesirable behavior. (shrink)

New Zealand is one of two OECD countries in the world where direct-to-consumer advertising of prescription medicine (DTCA-PM) is permitted. Increase in such activity in recent years has resulted in a disproportionate increase in dispensary volume of heavily advertised medicines. Concern for the potential harm to healthcare consumers and the public healthcare system has prompted the medical profession to call for a ban on DTCA-PM as the best way of protecting the public interest. Such blanket prohibition however also interferes with (...) the public’s right of access to information. This paper will examine if banning DTCA-PM would constitute a justified form of paternalism in the context of today’s New Zealand. (shrink)

Is there anything special about the ethical problems of intracerebral stem-cell transplantation and other forms of cell or tissue transplantation in the brain that provides neuroethics with a distinctive normative profile, setting it apart from other branches of medical ethics? This is examined with reference to some of the ethical problems associated with interventions in the brain such as potential changes in personal identity and potential changes in personality. It is argued that these problems are not sufficiently specific to justify (...) the autonomy of neuroethics as a separate discipline and can be handled by the established principles of medical ethics. The paper concludes with a constructive proposal how to deal with interventions in the brain for which the patient is unable to give valid ex-ante consent. (shrink)