The power of new medical technologies, the cultural authority of physicians, and the gendered power dynamics of many patient-physician relationships can all inhibit women's reproductive freedom. Often these factors interfere with women's ability to trust themselves to choose and act in ways that are consistent with their own goals and values. In this book Carolyn McLeod introduces to the reproductive ethics literature the idea that in reproductive health care women's self-trust can be undermined in ways that threaten their autonomy. Understanding (...) the importance of self-trust for autonomy, McLeod argues, is crucial to understanding the limits on women's reproductive freedom. -/- McLeod brings feminist insights in philosophical moral psychology to reproductive ethics, and to health-care ethics more broadly. She identifies the social environments in which self-trust is formed and encouraged. She also shows how women's experiences of reproductive health care can enrich our understanding of self-trust and autonomy as philosophical concepts. The book's theoretical components are grounded in women's concrete experiences. The cases discussed, which involve miscarriage, infertility treatment, and prenatal diagnosis, show that what many women feel toward themselves in reproductive contexts is analogous to what we feel toward others when we trust or distrust them. -/- McLeod also discusses what health-care providers can do to minimize the barriers to women's self-trust in reproductive health care, and why they have a duty to do so as part of their larger duty to respect patient autonomy. (shrink)

To be autonomous is to be a law to oneself; autonomous agents are self-governing agents. Most of us want to be autonomous because we want to be accountable for what we do, and because it seems that if we are not the ones calling the shots, then we cannot be accountable. More importantly, perhaps, the value of autonomy is tied to the value of self-integration. We don't want to be alien to, or at war with, ourselves; and it seems that (...) when our intentions are not under our own control, we suffer from self-alienation. What conditions must be satisfied in order to ensure that we govern ourselves when we act? Philosophers have offered a wide range of competing answers to this question. (shrink)

One of liberalism’s core commitments is to safeguarding individuals’ autonomy. And a central aspect of liberal social justice is the commitment to protecting the vulnerable. Taken together, and combined with an understanding of autonomy as an acquired set of capacities to lead one’s own life, these commitments suggest that liberal societies should be especially concerned to address vulnerabilities of individuals regarding the development and maintenance of their autonomy. In this chapter, we develop an account of what it would mean for (...) a society to take seriously the obligation to reduce individuals’ autonomy-related vulnerabilities to an acceptable minimum. In particular, we argue that standard liberal accounts underestimate the scope of this obligation because they fail to appreciate various threats to autonomy. (shrink)

Shared Decision Making (‘SDM’) is one of the most significant developments in Western health care practices in recent years. Whereas traditional models of care operate on the basis of the physician as the primary medical decision maker, SDM requires patients to be supported to consider options in order to achieve informed preferences by mutually sharing the best available evidence. According to its proponents, SDM is the right way to interpret the clinician-patient relationship because it fulfils the ethical imperative of respecting (...) patient autonomy. However, there is no consensus about how decisions in SDM contexts relate to the principle of respect for autonomy. In response, I demonstrate that in order to make decisions about what treatment they will or will not receive, patients will be required to meet different conditions depending on the approach proponents of SDM take to understanding personal autonomy. Due to the fact that different conceptions of autonomy yield different obligations, I argue that if physicians and patients satisfied all the conditions described in standard accounts of SDM, then SDM would undermine patient autonomy. (shrink)

The idea that deep brain stimulation (DBS) induces changes to personality, identity, agency, authenticity, autonomy and self (PIAAAS) is so deeply entrenched within neuroethics discourses that it has become an unchallenged narrative. In this article, we critically assess evidence about putative effects of DBS on PIAAAS. We conducted a literature review of more than 1535 articles to investigate the prevalence of scientific evidence regarding these potential DBS-induced changes. While we observed an increase in the number of publications in theoretical neuroethics (...) that mention putative DBS-induced changes to patients’ postoperative PIAAAS, we found a critical lack of primary empirical studies corroborating these claims. Our findings strongly suggest that the theoretical neuroethics debate on putative effects of DBS relies on very limited empirical evidence and is, instead, reliant on unsubstantiated speculative assumptions probablyin lieuof robust evidence. As such, this may reflect the likelihood of a speculative neuroethics bubble that may need to be deflated. Nevertheless, despite the low number of first-hand primary studies and large number of marginal and single case reports, potential postoperative DBS changes experienced by patients remain a critical ethical concern. We recommend further empirical research in order to enhance theoretical neuroethics work in the area. In particular, we call for the development of better instruments capable of capturing potential postoperative variations of PIAAAS. (shrink)

In this chapter, we introduce the notion of “moral neuroenhancement,” offering a novel definition as well as spelling out three conditions under which we expect that such neuroenhancement would be most likely to be permissible (or even desirable). Furthermore, we draw a distinction between first-order moral capacities, which we suggest are less promising targets for neurointervention, and second-order moral capacities, which we suggest are more promising. We conclude by discussing concerns that moral neuroenhancement might restrict freedom or otherwise “misfire,” and (...) argue that these concerns are not as damning as they may seem at first. (shrink)

Recent legal developments challenge how valid the concept of mental capacity is in determining whether individuals with impairments can make decisions about their care and treatment. Kong defends a concept of mental capacity but argues that such assessments must consider how relationships and dialogue can enable or disable the decision-making abilities of these individuals. This is thoroughly investigated using an interdisciplinary approach that combines philosophy and legal analysis of the law in England and Wales, the European Court of Human Rights, (...) and the United Nations Convention on the Rights of Persons with Disabilities. By exploring key concepts underlying mental capacity, the investigation concludes that both primary relationships and capacity assessments themselves must display key competencies to ensure that autonomy skills are promoted and encouraged. This ultimately provides scope for justifiable interventions into disabling relationships and articulates the dialogical practices that help better situate, interpret, and understand the choices and actions of individuals with impairments. (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.

The enhancement debate in neuroscience and biomedical ethics tends to focus on the augmentation of certain capacities or functions: memory, learning, attention, and the like. Typically, the point of contention is whether these augmentative enhancements should be considered permissible for individuals with no particular “medical” disadvantage along any of the dimensions of interest. Less frequently addressed in the literature, however, is the fact that sometimes the _diminishment_ of a capacity or function, under the right set of circumstances, could plausibly contribute (...) to an individual's overall well-being: more is not always better, and sometimes less is more. Such cases may be especially likely, we suggest, when trade-offs in our modern environment have shifted since the environment of evolutionary adaptation. In this article, we introduce the notion of “diminishment as enhancement” and go on to defend a _welfarist_ conception of enhancement. We show how this conception resolves a number of definitional ambiguities in the enhancement literature, and we suggest that it can provide a useful framework for thinking about the use of emerging neurotechnologies to promote human flourishing. (shrink)

Recently there has been some discussion concerning a particular type of enhancement, namely ‘moral enhancement’. However, there is no consensus on what precisely constitutes moral enhancement, and as a result the concept is used and defined in a wide variety of ways. In this article, we develop a clarificatory taxonomy of these definitions and we identify the criteria that are used to delineate the concept. We think that the current definitions can be distinguished from each other by the criteria used (...) for determining whether an intervention is indeed moral enhancement. For example, some definitions are broad and include moral enhancement by any means, while other definitions focus only on moral enhancement by means of specific types of intervention. Moreover, for some definitions it suffices for an intervention to be aimed or intended to morally enhance a person, while other definitions only refer to ‘moral enhancement’ in relation to interventions that are actually effective. For all these differences in definitions we discuss some of their implications. This shows that definitions are significantly less descriptive and more normative than they are regularly portrayed to be. We therefore hope that the taxonomy developed in this paper and the comments on the implications for the normative debate of the variety of definitions will provide conceptual clarity in a complex and highly interesting debate. (shrink)

Vigorous debate over the moral propriety of cognitive enhancement exists, but the views of the public have been largely absent from the discussion. To address this gap in our knowledge, four experiments were carried out with contrastive vignettes in order to obtain quantitative data on public attitudes towards cognitive enhancement. The data collected suggest that the public is sensitive to and capable of understanding the four cardinal concerns identified by neuroethicists, and tend to cautiously accept cognitive enhancement even as they (...) recognize its potential perils. The public is biopolitically moderate, endorses both meritocratic principles and the intrinsic value of hard work, and appears to be sensitive to the salient moral issues raised in the debate. Taken together, these data suggest that public attitudes toward enhancement are sufficiently sophisticated to merit inclusion in policy deliberations, especially if we seek to align public sentiment and policy. (shrink)

Some have objected to human enhancement on the grounds that it violates the autonomy of the enhanced. These objections, however, overlook the interesting possibility that autonomy itself could be enhanced. How, exactly, to enhance autonomy is a difficult problem due to the numerous and diverse accounts of autonomy in the literature. Existing accounts of autonomy enhancement rely on narrow and controversial conceptions of autonomy. However, we identify one feature of autonomy common to many mainstream accounts: reasoning ability. Autonomy can then (...) be enhanced by improving people’s reasoning ability, in particular through cognitive enhancement; given how valuable autonomy is usually taken to be, this gives us extra reason to pursue such cognitive enhancements. Moreover, autonomy-based objections will be especially weak against such enhancements. As we will argue, those who are worried that enhancements will inhibit people’s autonomy should actually embrace those enhancements that will improve autonomy. (shrink)

Self-trust is a necessary condition of personal autonomy and self-respect. Self-trust involves a positive sense of the motivations and competence of the trusted person; a willingness to depend on him or her; and an acceptance of vulnerability. It does not preclude trust in others. A person may be rightly said to have too much self-trust; however core self-trust is essential for functioning as an autonomous human being.

Our aim is to expand the regulative ideal governing consent. We argue that consent should not only be informed but also based on rational beliefs. We argue that holding true beliefs promotes autonomy. Information is important insofar as it helps a person to hold the relevant true beliefs. But in order to hold the relevant true beliefs, competent people must also think rationally. Insofar as information is important, rational deliberation is important. Just as physicians should aim to provide relevant information (...) regarding the medical procedures prior to patients consenting to have those procedures, they should also assist patients to think more rationally. We distinguish between rational choice/action and rational belief. While autonomous choice need not necessarily be rational, it should be based on rational belief. The implication for the doctrine of informed consent and the practice of medicine is that, if physicians are to respect patient autonomy and help patients to choose and act more rationally, not only must they provide information, but they should care more about the theoretical rationality of their patients. They should not abandon their patients to irrationality. They should help their patients to deliberate more effectively and to care more about thinking rationally. We illustrate these arguments in the context of Jehovah's Witnesses refusing life-saving blood transfusions. Insofar as Jehovah's Witnesses should be informed of the consequences of their actions, they should also deliberate rationally about these consequences. (shrink)

There is preliminary evidence, from case reports and investigational studies, to suggest that Deep Brain Stimulation could be used to treat some patients with Anorexia Nervosa. Although this research is at an early stage, the invasive nature of the intervention and the vulnerability of the potential patients are such that anticipatory ethical analysis is warranted. In this paper, we first show how different treatment mechanisms raise different philosophical and ethical questions. We distinguish three potential mechanisms alluded to in the neuroscientific (...) literature, relating to desire, control, and emotion, respectively. We explain why the precise nature of the mechanism has important implications for the patient’s autonomy and personal identity. In the second part of the paper, we consider practical dimensions of offering DBS to patients with AN in certain cases. We first discuss some limited circumstances where the mere offering of the intervention might be perceived as exerting a degree of coercive pressure that could serve to undermine the validity of the patient’s consent. Finally, we consider the implications of potential effects of DBS for the authenticity of the patient’s choice to continue using stimulation to ameliorate their condition. (shrink)

Relational conceptions of autonomy attempt to take into account the social aspects of autonomous agency. Those views that incorporate not merely causally, but constitutively necessary relational conditions, incorporate a condition that has the form: A necessary condition for autonomous agency is that the agent stands in social relations S. I argue that any account that incorporates such a condition cannot play one of autonomy’s key normative roles: identifying those agents who ought to be protected from paternalistic intervention. I argue, against (...) objections from Oshana, that there are good reasons for maintaining the notion of autonomy in this role, and thus that such relational conceptions should not be accepted. This rejection goes beyond that from John Christman, which holds only for those relational conditions which are value-laden. (shrink)