Book reviewed in this article: Protecting The Vulnerable: A Reanalysis of Our Social Responsibilities. By Robert E. Goodin. Chicago: University of Chicago Press.

According to bioethics orthodoxy, the question, “What would the patient choose?” is a question about the patient's autonomy. is at stake. In fact, what underpins the moral force of that question is a value different from either autonomy or best interests. This is the value of doing things in a way that is authentic to the person.

In pursuit of the dream that patients' exercise of autonomy could extend beyond their span of competence, living wills have passed from controversy to conventional wisdom, to widely promoted policy. But the policy has not produced results, and should be abandoned.

Prevailing ethical thinking about informed consent to clinical research is characterized by theoretical confidence and practical disquiet. On the one hand, bioethicists are confident that informed consent is a fundamental norm. And, for the most part, they are confident that what makes consent to research valid is that it constitutes an autonomous authorization by the research participant. On the other hand, bioethicists are uneasy about the quality of consent in practice. One major source of this disquiet is substantial evidence of (...) the “therapeutic misconception”—the tendency of patient-subjects in clinical trials to confuse participating in research with receiving personalized medical care. This .. (shrink)

When patients cannot make their own treatment decisions, surrogates typically step in to do it for them. Surrogate decision‐making is far from ideal, of course, as the surrogate may not know what the patient prefers or what best promotes her interests. One way to improve it would be to arm surrogates with information about what patients in similar circumstances tend to prefer, allowing them to make empirically grounded predictions about what their patient would want.

According to bioethics orthodoxy, the question, “What would the patient choose?” is a question about the patient's autonomy. is at stake. In fact, what underpins the moral force of that question is a value different from either autonomy or best interests. This is the value of doing things in a way that is authentic to the person.

A 78 year old married woman with progressive Alzheimer's disease was admitted to a local hospital with pneumonia and other medical problems. She recognized no one and had been incontinent for about a year. Despite aggressive treatment, the pneumonia failed to resolve and it seemed increasingly likely that this admission was to be for terminal care. The patient's husband (who had been taking care of her in their home) began requesting that the doctors be less aggressive in her treatment and, (...) as the days wore on, he became more and more insistent that they scale back their aggressive care. The physicians were reluctant to do so, due to the small but real chance that the patient could survive to discharge. But her husband was her only remaining family, so he was the logical proxy decisionmaker. Multiple conferences ensued, and finally a conference with a social worker revealed that the husband had recently proposed marriage to the couple's housekeeper and she had accepted. (shrink)

Being concerned with representation, this book is about an idea, a concept, a word. It is primarily a conceptual analysis, not a historical study of the way in which representative government has evolved, nor yet an empirical investigation of the behavior of contemporary representatives or the expectations voters have about them. Yet, although the book is about a word, it is not about mere words, not merely about words. For the social philosopher, for the social scientist, words are not "mere"; (...) they are the tools of his trade and a vital part of his subject matter. Since human beings are not merely political animals but also language-using animals, their behavior is shaped by their ideas. What they do and how they do it depends upon how they see themselves and their world, and this in turn depends upon the concepts through which they see. Learning what "representation" means and learning how to represent are intimately connected. But even beyond this, the social theorist sees the world through a network of concepts. Our words define and delimit our world in important ways, and this is particularly true of the world of human and social things. For a zoologist may capture a rare specimen and simply observe it; but who can capture an instance of representation (or of power, or of interest)? Such things, too, can be observed, but the observation always presupposes at least a rudimentary conception of what representation (or power, or interest) is, what counts as representation, where it leaves off and some other phenomenon begins. Questions about what representation is, or is like, are not fully separable from the question of what "representation" means. This book approaches the former questions by way of the latter. (shrink)

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

This essay investigates the structure of fiduciary obligations, specifically the obligation of loyalty. Fiduciary obligations differ from promissory obligations with respect to the possibility of “accidental compliance.” Promissory obligations can be satisfied through behavior that conforms to a promise, even if that behavior is done for inappropriate reasons. By contrast, fiduciary loyalty necessarily has an intentional dimension, one that prevents satisfaction through accidental compliance. The intentional dimension of fiduciary loyalty is best described by what we call the “shaping” account. This (...) account both explains the conscientiousness that loyalty demands and improves on other accounts of the intentional dimension of loyalty. Our analysis challenges two of the most prominent ways of conceptualizing fiduciary obligations. “Contractarianism” configures fiduciary obligations as a species of contractual duties. The view that we call “proscriptivism” reduces fiduciary obligations to the juridical prohibitions that apply to fiduciaries. Neither of these approaches is satisfactory, because each neglects the intentional dimension of fiduciary loyalty. (shrink)

We regularly wield powers that, upon close scrutiny, appear remarkably magical. By sheer exercise of will, we bring into existence things that have never existed before. With but a nod, we effect the disappearance of things that have long served as barriers to the actions of others. And, by mere resolve, we generate things that pose significant obstacles to others' exercise of liberty. What is the nature of these things that we create and destroy by our mere decision to do (...) so? The answer: the rights and obligations of others. And by what seemingly magical means do we alter these rights and obligations? By making promises and issuing or revoking consent When we make promises, we generate obligations for ourselves, and when we give consent, we create rights for others. Since the rights and obligations that are affected by means of promising and consenting largely define the boundaries of permissible action, our exercise of these seemingly magical powers can significantly affect the lives and liberties of others. (shrink)