The authors use the term “principlism” to refer to the practice of using “principles” to replace both moral theory and particular moral rules and ideals in dealing with the moral problems that arise in medical practice. The authors argue that these “principles” do not function as claimed, and that their use is misleading both practically and theoretically. The “principles” are in fact not guides to action, but rather they are merely names for a collection of sometimes superficially related matters for (...) consideration when dealing with a moral problem. The “principles” lack any systematic relationship to each other, and they often conflict with each other. These conflicts are unresolvable, since there is no unified moral theory from which they are all derived. For comparison the authors sketch the advantages of using a unified moral theory. (shrink)

This article summarizes some of the results of the BIOMED II project “Basic Ethical Principles in European Bioethics and Biolaw” connected to a research project of the Danish Research Councils “Bioethics and Law”. The BIOMED project was based on cooperation between 22 partners in most EU countries. The aim of the project was to identify the ethical principles of respect for autonomy, dignity, integrity and vulnerability as four important ideas or values for a European bioethics and biolaw. The research concluded (...) that the basic ethical principles cannot be understood as universal everlasting ideas or transcendental truths but they rather function reflective guidelines and important values in European culture. The method of the research was conceptual, philosophical analysis of the cultural background of the four values or normative ideas that people use and find important in their existence. Moreover, this was combined with analysis of empirical legal material and policy documents. Also, a number of qualitative interviews with relevant experts were carried out. Another important result of the BIOMED project was the partner's Policy Proposals to the European Commission, the Barcelona Declaration, unique as a philosophical and political agreement between experts in bioethics and biolaw from many different countries. The Policy Proposals are reprinted here at the end of the article. (shrink)

Importance.--Expression.--Understanding.--Perspective.--Forms of process.--Civilized universe.--Nature lifeless.--Nature alive.--The aim of philosophy.

This collection of original essays explores the social and relational dimensions of individual autonomy. Rejecting the feminist charge that autonomy is inherently masculinist, the contributors draw on feminist critiques of autonomy to challenge and enrich contemporary philosophical debates about agency, identity, and moral responsibility. The essays analyze the complex ways in which oppression can impair an agent's capacity for autonomy, and investigate connections, neglected by standard accounts, between autonomy and other aspects of the agent, including self-conception, self-worth, memory, and the (...) imagination. (shrink)

Key ethical challenges for healthcare workers arising from the COVID-19 pandemic are identified: isolation and social distancing, duty of care and fair access to treatment. The paper argues for a relational approach to ethics which includes solidarity, relational autonomy, duty, equity, trust and reciprocity as core values. The needs of the poor and socially disadvantaged are highlighted. Relational autonomy and solidarity are explored in relation to isolation and social distancing. Reciprocity is discussed with reference to healthcare workers’ duty of care (...) and its limits. Priority setting and access to treatment raise ethical issues of utility and equity. Difficult ethical dilemmas around triage, do not resuscitate decisions, and withholding and withdrawing treatment are discussed in the light of recently published guidelines. The paper concludes with the hope for a wider discussion of relational ethics and a glimpse of a future after the pandemic has subsided. (shrink)

BackgroundRespect for autonomy is a key concept in contemporary bioethics and end-of-life ethics in particular. Despite this status, an individualistic interpretation of autonomy is being challenged from the perspective of different theoretical traditions. Many authors claim that the principle of respect for autonomy needs to be reconceptualised starting from a relational viewpoint. Along these lines, the notion of relational autonomy is attracting increasing attention in medical ethics. Yet, others argue that relational autonomy needs further clarification in order to be adequately (...) operationalised for medical practice. To this end, we examined the meaning, foundations, and uses of relational autonomy in the specific literature of end-of-life care ethics.MethodsUsing PRESS and PRISMA procedures, we conducted a systematic review of argument-based ethics publications in 8 major databases of biomedical, philosophy, and theology literature that focused on relational autonomy in end-of-life care. Full articles were screened. All included articles were critically appraised, and a synthesis was produced.ResultsFifty publications met our inclusion criteria. Twenty-eight articles were published in the last 5 years; publications were originating from 18 different countries. Results are organized according to: (a) an individualistic interpretation of autonomy; (b) critiques of this individualistic interpretation of autonomy; (c) relational autonomy as theoretically conceptualised; (d) relational autonomy as applied to clinical practice and moral judgment in end-of-life situations.ConclusionsThree main conclusions were reached. First, literature on relational autonomy tends to be more a ‘reaction against’ an individualistic interpretation of autonomy rather than be a positive concept itself. Dichotomic thinking can be overcome by a deeper development of the philosophical foundations of autonomy. Second, relational autonomy is a rich and complex concept, formulated in complementary ways from different philosophical sources. New dialogue among traditionally divergent standpoints will clarify the meaning. Third, our analysis stresses the need for dialogical developments in decision making in end-of-life situations. Integration of these three elements will likely lead to a clearer conceptualisation of relational autonomy in end-of-life care ethics. This should in turn lead to better decision-making in real-life situations. (shrink)

Volume 19, Issue 11, November 2019, Page 9-12.

Why has autonomy been a leading idea in philosophical writing on bioethics, and why has trust been marginal? In this important book, Onora O'Neill suggests that the conceptions of individual autonomy so widely relied on in bioethics are philosophically and ethically inadequate, and that they undermine rather than support relations of trust. She shows how Kant's non-individualistic view of autonomy provides a stronger basis for an approach to medicine, science and biotechnology, and does not marginalize untrustworthiness, while also explaining why (...) trustworthy individuals and institutions are often undeservingly mistrusted. Her arguments are illustrated with issues raised by practices such as the use of genetic information by the police or insurers, research using human tissues, uses of new reproductive technologies, and media practices for reporting on medicine, science and technology. Autonomy and Trust in Bioethics will appeal to a wide range of readers in ethics, bioethics and related disciplines. (shrink)

2014 Reprint of 1945 Edition. Full facsimile of the original edition, not reproduced with Optical Recognition Software. The first part deals with Greek cosmology and is the longest, the most elaborate and, on the whole, the liveliest part of a book which never deviates into dullness. The dominant thought in Greek cosmology, Collingwood holds, was the microcosm-macrocosm analogy, nature being the substance of something ensouled where "soul" meant the self-moving. Part II is "The Renaissance View of Nature." Collingwood describes the (...) rise and decline of the deists' view of Nature as a machine designed by the Great Contriver who, having turned it out, watches it go. Part III, "The Modern View of Nature," deals with very recent or contemporary philosophy and science, discerning in it a radical evolutionism first in biology and later in cosmology. Remains to this day a classic text in the history of ideas. (shrink)

This important new book develops a new concept of autonomy. The notion of autonomy has emerged as central to contemporary moral and political philosophy, particularly in the area of applied ethics. professor Dworkin examines the nature and value of autonomy and uses the concept to analyse various practical moral issues such as proxy consent in the medical context, paternalism, and entrapment by law enforcement officials.

John Christman has argued that constitutively relational accounts of autonomy, as defended by some feminist theorists, are problematically perfectionist about the human good. I argue that autonomy is constitutively relational, but not in a way that implies perfectionism: autonomy depends on a dialogical disposition to hold oneself answerable to external, critical perspectives on one's action-guiding commitments. This type of relationality carries no substantive value commitments, yet it does answer to core feminist concerns about autonomy.

How do human beings become human? This question lies behind the so-called human sciences. But these disciplines are scattered among many different departments and hold up a cracked mirror to humankind. This is why, in the view of Paul Ricoeur, we need to develop a philosophical anthropology, one that has a much older history but still offers many untapped resources. This appeal to a specifically philosophical approach to questions regarding what it was to be human did not stop Ricoeur from (...) entering into dialogue with other disciplines and approaches, such as psychoanalysis, history, sociology, anthropology, linguistics and the philosophy of language, in order to offer an up-to-date reflection on what he saw as the fundamental issues. For there is clearly not a simple, single answer to the question what is it to be human? Ricoeur therefore takes up the complexity of this question in terms of the tensions he sees between the voluntary and the involuntary, acting and suffering, autonomy and vulnerability, capacity and fragility, and identity and otherness. The texts brought together in this volume provide an overall view of the development of Ricoeurs philosophical thinking on the question of what it is to be human, from his early 1939 lecture on Attention to his remarks on receiving the Kluge Prize in 2004, a few months before his death. (shrink)

This collection of new essays examines philosophical issues at the intersection of feminism and autonomy studies. Are autonomy and independence useful goals for women and subordinate persons? Is autonomy possible in contexts of social subordination? Is the pursuit of desires that issue from patriarchal norms consistent with autonomous agency? How do emotions and caring relate to autonomous deliberation? Contributors to this collection answer these questions and others, advancing central debates in autonomy theory by examining basic components, normative commitments, and applications (...) of conceptions of autonomy. Several chapters look at the conditions necessary for autonomous agency and at the role that values and norms -- such as independence, equality, inclusivity, self-respect, care and femininity -- play in feminist theories of autonomy. Whereas some contributing authors focus on dimensions of autonomy that are internal to the mind -- such as deliberative reflection, desires, cares, emotions, self-identities and feelings of self-worth -- several authors address social conditions and practices that support or stifle autonomous agency, often answering questions of practical import. These include such questions as: What type of gender socialization best supports autonomous agency and feminist goals? When does adapting to severely oppressive circumstances, such as those in human trafficking, turn into a loss of autonomy? How are ideals of autonomy affected by capitalism? and How do conceptions of autonomy inform issues in bioethics, such as end-of-life decisions, or rights to bodily self-determination? (shrink)

Most recent accounts of personal autonomy acknowledge that the social environment a person lives in, and the personal relationships she entertains, have some impact on her autonomy. Two kinds of conceptualizing social conditions are traditionally distinguished in this regard: Causally relational accounts hold that certain relationships and social environments play a causal role for the development and on-going exercise of autonomy. Constitutively relational accounts, by contrast, claim that autonomy is at least partly constituted by a person’s social environment or standing. (...) The central aim of this paper is to raise the question how causally and constitutively relational approaches relate to the fact that we exercise our autonomy over time. I argue that once the temporal scope of autonomy is opened up, we need not only to think differently about the social dimension of autonomy. We also need to reconsider the very distinction between causally and constitutively relational accounts, because it is itself a synchronic (and not a diachronic) distinction. (shrink)

The justification for advance directives is grounded in the notion that they extend patient autonomy into future states of incompetency through patient participation in decision making about end-of-life care. Four objections challenge the necessity and sufficiency of individual autonomy, perceived to be a defining feature of liberal philosophical theory, as a basis of advance care planning. These objections are that the liberal concept of autonomy (i) implies a misconception of the individual self, (ii) entails the denial of values of social (...) justice, (iii) does not account for justifiable acts of paternalism, and (iv) does not account for the importance of personal relationships in the advance care planning process. The last objection is especially pertinent in light of recent empirical research highlighting the importance of personal relationships in advance care planning. This article examines these four objections to autonomy, and the liberal theoretical framework with which it is associated, in order to re-evaluate the philosophical basis of advance care planning. We argue that liberal autonomy (i) is not a misconceived concept as critics assume, (ii) does not entail the denial of values of social justice, (iii) can account for justifiable acts of paternalism, though it (iv) is not the best account of the value of personal relationships that arise in advance care planning. In conclusion, we suggest that liberalism is a necessary component of a theoretical framework for advance care planning but that it needs to be supplemented with theories that focus explicitly on the significance of personal relationships. (shrink)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

Some philosophers have criticized the use of psychopharmaceuticals on the grounds that even if these drugs enhance the person using them, they threaten their authenticity. Others have replied by pointing out that the conception of authenticity upon which this argument rests is contestable; on a rival conception, psychopharmaceuticals might be used to enhance our authenticity. Since, however, it is difficult to decide between these competing conceptions of authenticity, the debate seems to end in a stalemate. I suggest that we need (...) not resolve this debate to end the stalemate. New technologies which alter the self can be understood within the framework of the first conception of authenticity, I suggest, not as threatening the authentic self, but rather as bringing the outward appearance of the self into line with its deepest essence. Since psychopharmaceutical use can plausibly be understood on this model, it can be seen as enhancing our authenticity on either conception. (shrink)

Principle-based formulations of bioethical theory have recently come under increasing scrutiny, particularly insofar as they give prominence to personal autonomy. This essay critiques the dominant conceptualization of autonomy and urges an alternative formulation freed from the individualistic assumptions that pervade the prevailing framework. Drawing on feminist perspectives, I discuss the need for a vision of patient autonomy that joins relational experiences to individuality and acknowledges the influence of patterns of power and authority on the exercise of patient agency. Deficiencies in (...) the current models of science and social relations guiding medical practice are analyzed, particularly (1) the tendency to disregard the patients self-knowledge and (2) failure to recognize limitations on the generalizability of medical knowledge. Models of social relations such as mothering and friendship are explored to advance a conception of autonomy better suited to the practical activities of medicine. In conclusion, I consider how acknowledgement of the specificity and complexity of social relations can contribute to reconfiguration of other principles comprising the standard framework of bioethics, particularly beneficence, justice, and equality. (shrink)

Family members do not have an official position in the practice of euthanasia and physician assisted suicide in the Netherlands according to statutory regulations and related guidelines. However, recent empirical findings on the influence of family members on EAS decision-making raise practical and ethical questions. Therefore, the aim of this review is to explore how family members are involved in the Dutch practice of EAS according to empirical research, and to map out themes that could serve as a starting point (...) for further empirical and ethical inquiry. A systematic mixed studies review was performed. The databases Pubmed, Embase, PsycInfo, and Emcare were searched to identify empirical studies describing any aspect of the involvement of family members before, during and after EAS in the Netherlands from 1980 till 2018. Thematic analysis was chosen as method to synthesize the quantitative and qualitative studies. Sixty-six studies were identified. Only 14 studies had family members themselves as study participants. Four themes emerged from the thematic analysis. 1) Family-related reasons to request EAS. 2) Roles and responsibilities of family members during EAS decision-making and performance. 3) Families’ experiences and grief after EAS. 4) Family and ‘the good euthanasia death’ according to Dutch physicians. Family members seem to be active participants in EAS decision-making, which goes hand in hand with ambivalent feelings and experiences. Considerations about family members and the social context appear to be very important for patients and physicians when they request or grant a request for EAS. Although further empirical research is needed to assess the depth and generalizability of the results, this review provides a new perspective on EAS decision-making and challenges the Dutch ethical-legal framework of EAS. Euthanasia decision-making is typically framed in the patient-physician dyad, while a patient-physician-family triad seems more appropriate to describe what happens in clinical practice. This perspective raises questions about the interpretation of autonomy, the origins of suffering underlying requests for EAS, and the responsibilities of physicians during EAS decision-making. (shrink)

BackgroundRespect for autonomy is a paramount principle in end-of-life ethics. Nevertheless, empirical studies show that decision-making, exclusively focused on the individual exercise of autonomy fails to align well with patients’ preferences at the end of life. The need for a more contextualized approach that meets real-life complexities experienced in end-of-life practices has been repeatedly advocated. In this regard, the notion of ‘relational autonomy’ may be a suitable alternative approach. Relational autonomy has even been advanced as a foundational notion of palliative (...) care, shared decision-making, and advance-care planning. However, relational autonomy in end-of-life care is far from being clearly conceptualized or practically operationalized.Main bodyHere, we develop a relational account of autonomy in end-of-life care, one based on a dialogue between lived reality and conceptual thinking. We first show that the complexities of autonomy as experienced by patients and caregivers in end-of-life practices are inadequately acknowledged. Second, we critically reflect on how engaging a notion of relational autonomy can be an adequate answer to addressing these complexities. Our proposal brings into dialogue different ethical perspectives and incorporates multidimensional, socially embedded, scalar, and temporal aspects of relational theories of autonomy. We start our reflection with a case in end-of-life care, which we use as an illustration throughout our analysis.ConclusionThis article develops a relational account of autonomy, which responds to major shortcomings uncovered in the mainstream interpretation of this principle and which can be applied to end-of-life care practices. (shrink)

The dominant, individualistic understanding of autonomy that features in clinical practice and research is underpinned by the idea that people are, in their ideal form, independent, self-interested and rational gain-maximising decision-makers. In recent decades, this paradigm has been challenged from various disciplinary and intellectual directions. Proponents of ‘relational autonomy’ in particular have argued that people’s identities, needs, interests – and indeed autonomy – are always also shaped by their relations to others. Yet, despite the pronounced and nuanced critique directed at (...) an individualistic understanding of autonomy, this critique has had very little effect on ethical and legal instruments in clinical practice and research so far. In this article, we use four case studies to explore to what extent, if at all, relational autonomy can provide solutions to ethical and practical problems in clinical practice and research. We conclude that certain forms of relational autonomy can have a tangibl... (shrink)

This article reflects on the work of feminist bioethicists over the past ten years, reviewing how effective feminists have been in using relational theory to reorient bioethics and where we hope it will go from here. Feminist bioethicists have made significant achievements using relational theory to shape the notion of autonomy, bringing to light the relevance of patients' social circumstances and where they are situated within systems of privilege and oppression. But there is much work to be done to reorient (...) bioethics so that it is capable of addressing some current public health challenges. We argue that relational theory holds promise for beginning this work. (shrink)

This article traces the way autonomy has become a recognised value in health care in France. In a country that based its social fundamentals on the very idea of solidarity for many years, autonomy has long been considered a foreign ‘Anglo-American principle’. Taking the example of the end-of-life debate, the article shows, however, how the use of the French term ‘accompagnement’ allowed autonomy to be redefined and to be associated with the concept of solidarity. Exploring the arguments used over the (...) past 25 years in professional guidelines, parliamentary reports, ethics committee reports, and legal texts, the authors describe the shift that took place in public and legal discourses on end-of-life care. The analysis demonstrates how the scope of autonomy has been limited by other social values, such as the protection of the dying person, in order to become an accepted social value in its own right. The example of the French end-of-life debate shows that depending on how the concept of autonomy is adapted and applied in a specific context, it can be compatible with the idea of solidarity. Such compatibility has been challenged previously in the international bioethics debate. By demonstrating the possibility of combining autonomy and solidarity, this article makes an important contribution to the international bioethics debate and to the dialogue between countries that are often perceived as significantly different. (shrink)

As given, the case presents at least two questions for the ethics consultant to explore: to what extent should Declan’s parent, Karesha, be involved in his health care decisions, and why is...

History's judgment on the success of bioethics will not depend solely on the conceptual creativity and innovation in the field at the level of ethical and political theory, but this intellectual work is not insignificant. One important new development is what I shall refer to as the relational turn in bioethics. This development represents a renewed emphasis on the ideographic approach, which interprets the meaning of right and wrong in human actions as they are inscribed in social and cultural practices (...) and in structures of lived meaning and interdependence; in an ideographic approach, the task of bioethics is to bring practice into theory, not the other way around. The relational turn in bioethics may profoundly affect the critical questions that the field asks and the ethical guidance it offers society, politics, and policy. The relational turn provides a way of correcting the excessive atomism of many individualistic perspectives that have been, and continue to be, influential in bioethics. Nonetheless, I would argue that most of the work reflecting the relational turn remains distinctively liberal in its respect for the ethical significance of the human individual. It moves away from individualism, but not from the value of individuality.In this review essay, I shall focus on how the relational turn has manifested itself in work on core concepts in bioethics, especially liberty and autonomy. Following a general review, I conclude with a brief consideration of two important recent books in this area: Jennifer Nedelsky's Law's Relations and Rachel Haliburton's Autonomy and the Situated Self. (shrink)

COVID-19 has truly affected most of the world over the past many months, perhaps more than any other event in recent history. In the wake of this pandemic are patients, family members, and various types of care providers, all of whom share different levels of moral distress. Moral conflict occurs in disputes when individuals or groups have differences over, or are unable to translate to each other, deeply held beliefs, knowledge, and values. Such conflicts can seriously affect healthcare providers and (...) cause distress during disastrous situations such as pandemics when medical and human resources are stretched to the point of exhaustion. In the current pandemic, most hospitals and healthcare institutions in the United States have not allowed visitors to come to the hospitals to see their family or loved ones, even when the patient is dying. The moral conflict and moral distress among care providers when they see their patients dying alone can be unbearable and lead to ongoing grief and sadness. This paper will explore the concepts of moral distress and conflict among hospital staff and how a system-wide provider wellness programme can make a difference in healing and health. (shrink)

Volume 20, Issue 7, July 2020, Page 9-12.

The realities of long‐term care call for a refurbished, concrete concept of autonomy that systematically attends to the history and development of persons and takes account of the experiences of daily living.

Advance Care Planning was introduced as a means of empowering individuals to make informed decisions regarding their health and end-of-life care. It is a way for individuals to contemplate their own personal values and to exercise autonomy. However, there is reason to believe that ACP may not be widely taken up and when adopted, may not be applied as intended. The ethical challenges facing ACP need careful study. This essay focuses on two problematic ethical aspects of ACP: 1. a strict (...) adherence to procedural formalism, 2. an over-emphasis on individualistic autonomy, which can lead to hindrances in its implementation. These may explain both the low uptake as well as its ineffectiveness. ACP should not be a compliance exercise and implementers will need to think hard about when and how to implement ACP, given cultural and perceptual sensitivities. By discussing the concept of “narrativism” and “relational autonomy”, we provide an avenue for solving the dilemmas faced and present a scenario that is closer to the ideal of what the ACP framework hopes to achieve. This would include patient preference as well as best interest and family values. An increased uptake of ACP will be a useful health service delivery indicator, but this [End Page 53] would also entail developing a more morally mindful and just society in a broader sense. (shrink)