Mele endeavors to analyze autonomy, understood as an actual condition of self-governance, in two stages. An account of ideally self-controlled agents is developed first. This account is then supplemented with features sufficient for individual autonomy.

This book follows hard upon Korsgaard's The Sources of Normativity. Both present the author's influential version of a Kantian theory of normative ethics and metaethics. Whereas The Sources of Normativity was a systematic investigation of "normativity" written as a single unit, the present volume is a collection of previously published papers, some of them already well known and much discussed, dating between 1983 and 1993. By the nature of the case, one might expect less thematic unity in this book than (...) in the other one, but the present book is a deeper and more wide ranging presentation of the author's views. Korsgaard's historical focus in The Sources of Normativity is less on Kant and more on the British moralists. Creating the Kingdom of Ends deals quite explicitly with the interpretation of Kant's moral philosophy. The papers in this book contain, in my judgment, the heart of Korsgaard's work: a variety of fresh and illuminating insights into Kant's moral theory and its relation to contemporary ethical theory which have helped to reshape the image of Kant's ethics and to refocus the issues dealt with in current moral philosophy. Or to make claims less grand but of more immediate relevance to this review, there is no question that some of the papers in this book have helped to reshape both the present writer's image of Kant's ethics and his conception of the way questions of ethical theory should be addressed. I hope below to say something both about where I think Korsgaard has gotten these matters right, and where I find her position either unclear or dubious. (shrink)

An updated and extended second edition supporting the findings of its well-known predecessor which claimed that courts employ common-sense notions of causation in determining legal responsibility.

Nomy Arpaly rejects the model of rationality used by most ethicists and action theorists. Both observation and psychology indicate that people act rationally without deliberation, and act irrationally with deliberation. By questioning the notion that our own minds are comprehensible to us--and therefore questioning much of the current work of action theorists and ethicists--Arpaly attempts to develop a more realistic conception of moral agency.

Whether it is fair to use personal responsibility of patients for their own health as a rationing criterion in healthcare is a controversial matter. A host of difficulties are associated with the concept of personal responsibility in the field of medicine. These include, in particular, theoretical considerations of justice and such practical issues as multiple causal factors in medicine and freedom of health behaviour. In the article, personal responsibility is evaluated from the perspective of several theories of justice. It is (...) argued that in a healthcare system based on both equality of opportunity and solidarity, responsible health behaviour can—in principle—be justifiably expected. While the practical problems associated with personal responsibility are important, they do not warrant the common knee-jerk refusal to think more deeply about responsibility for health as a means of allocating healthcare resources. In conclusion, the possibility of introducing personal responsibility as a fair rationing criterion is briefly sketched. (shrink)

Although the responsibility for health debate has intensified in several ways between Norman Daniels’ 1985 Just healthcare and Just health: meeting health needs fairly of 2008, comparatively little space is dedicated to the issue in Just health, and Daniels notes repeatedly that his account “says nothing about personal responsibility for health”. Daniels considers health responsibility mainly in a particular luck-egalitarian version which he rejects because of its potentially unfeasible, penalising and inhumane character. But I show that he nonetheless acknowledges and (...) endorses explicitly other dimensions of health responsibility. I develop a wider, more nuanced and less punitive concept of health responsibility, which expands Daniels’ brief consideration and is compatible with the overall approach set out in Just health. In its application to preventative medicine and health promotion in particular, the concept is suited to support and complement the notion that “health is special”, which is central in Just health. The concept of health responsibility as co-responsibility specifies the subjects and objects of health responsibilities. It permits the attribution of responsibility without blame and disconnects the question of assigning responsibility from decisions about entitlement to treatment or different status in prioritisation decisions. This approach secures conceptual plausibility and clarity of the concept of health responsibility, is of use in policy making, and can help reduce political tensions. (shrink)

The distribution of scarce healthcare resources is an increasingly important issue due to factors such as expensive ‘high tech’ medicine, longer life expectancies and the rising prevalence of chronic illness. Furthermore, in the current healthcare context lifestyle-related factors such as high blood pressure, tobacco use and obesity are believed to contribute significantly to the global burden of disease. As such, this paper focuses on an ongoing debate in the academic literature regarding the role of responsibility for illness in healthcare resource (...) allocation: should patients with self-caused illness receive lower priority in access to healthcare resources? This paper critically describes the lower priority debate's 12 key arguments and maps out their relationships. This analysis reveals that most arguments have been refuted and that the debate has stalled and remains unresolved. In conclusion, we suggest progression could be achieved by inviting multidisciplinary input from a range of stakeholders for the development of evidence-based critical evaluations of existing arguments and the development of novel arguments, including the outstanding rebuttals. (shrink)

This dissertation addresses the question of whether act-utilitarianism (AU) can provide practical action-guidance. Traditionally, when approaching this question, utilitarians invoke the distinction between criteria of rightness and methods of decision-making. The utilitarian criterion of rightness states, roughly, that an action is right if and only if there is nothing else that the agent can do that has a better outcome. However, this criterion needs to be supplemented, it is said, with some description of a strategy that allows an agent to (...) reach decisions that approximate the utilitarian idea – a method of decision-making. The main question in the essay is if any such method can indeed be justified on the basis of AU. I argue that the justification of a method of decision-making depends on the extent to which it has two different features: practicability and validity. Roughly a method of decision-making is practicable if an agent trying to adhere to the method will succeed in doing so. A method of decision-making is valid if adhering to the method makes the agent approximate the overall goal of AU. I then proceed by examining whether it is possible to justify a belief to the effect that any of the various candidates of methods of decision-making that have been proposed in the literature have these features. My main conclusion is negative. No proposed method of decision-making can be shown to satisfy these desiderata to a sufficient degree. In the final chapter the implications of this conclusion are examined. Does this mean that we cannot justify a belief in AU? Does it mean that AU is false? My conclusion is that whether or not this shows that AU is false depends on what meta-ethical view is the most plausible one. I also present a tentative way of justifying a belief in AU. (shrink)

In patient-centred care, shared decision-making is advocated as the preferred form of medical decision-making. Shared decision-making is supported with reference to patient autonomy without abandoning the patient or giving up the possibility of influencing how the patient is benefited. It is, however, not transparent how shared decision-making is related to autonomy and, in effect, what support autonomy can give shared decision-making. In the article, different forms of shared decision-making are analysed in relation to five different aspects of autonomy: (1) self-realisation; (...) (2) preference satisfaction; (3) self-direction; (4) binary autonomy of the person; (5) gradual autonomy of the person. It is argued that both individually and jointly these aspects will support the models called shared rational deliberative patient choice and joint decision as the preferred versions from an autonomy perspective. Acknowledging that both of these models may fail, the professionally driven best interest compromise model is held out as a satisfactory second-best choice. (shrink)

Mele's ultimate purpose in this book is to help readers think more clearly about free will. He identifies and makes vivid the most important conceptual obstacles to justified belief in the existence of free will and meets them head on. Mele clarifies the central issues in the philosophical debate about free will and moral responsibility, criticizes various influential contemporary theories about free will, and develops two overlapping conceptions of free will--one for readers who are convinced that free will is incompatible (...) with determinism (incompatibilists), and the other for readers who are convinced of the opposite (compatibilists). Luck poses problems for all believers in free will, and Mele offers novel solutions to those problems--one for incompatibilist believers in free will and the other for compatibilists. An early chapter of this empirically well-informed book clearly explains influential neuroscientific studies of free will and debunks some extravagant interpretations of the data. Other featured topics include abilities and alternative possibilities, control and decision-making, the bearing of manipulation on free will, and the development of human infants into free agents. Mele's theory offers an original perspective on an important problem and will garner the attention of anyone interested in the debate on free will. (shrink)

On the whole, we continue to believe firmly both that we have free will and that we are morally responsible for what we do. Here, the author argues that there is a fundamental sense in which there is no such thing as free will or true moral responsibility (as ordinarily understood). Devoting the main body of his book to an attempt to explain why we continue to believe as we do, Strawson examines various aspects of the "cognitive phenomenology" of freedom--the (...) nature, causes, and consequences of our deep commitment to belief in freedom. (shrink)

Essays discuss reason, self-control, self-definition, time, cause and effect, accidents, and responsibility, and explain why people want free will.

Health, Luck, and Justice is the first attempt to systematically apply luck egalitarianism to the just distribution of health and health care.

Most of the discussion in bioethics and health policy concerning social responsibility for health has focused on society’s obligation to provide access to healthcare. While ensuring access to healthcare is an important social responsibility, societies can promote health in many other ways, such as through sanitation, pollution control, food and drug safety, health education, disease surveillance, urban planning and occupational health. Greater attention should be paid to strategies for health promotion other than access to healthcare, such as environmental and public (...) health and health research.Lifestyle plays a major role in most of the illnesses in industrialised nations.1 Six of the 10 leading factors contributing to the global burden of disease are lifestyle related: unsafe sex, high blood pressure, tobacco use, alcohol use, high cholesterol and obesity.2 Lifestyle-related illnesses also contribute to the rising costs of healthcare. Spending on healthcare accounts for about 16% of the gross domestic product in the USA, or US$1.9 trillion.3 Although smoking has declined steadily there since the 1960s, smoking-related medical expenses are still about US$75.5 billion per year.4 Obesity, which has been climbing in the past two decades, accounts for about US$75 billion in healthcare costs there each year.5 Alcoholism and drug addiction in the USA account for annual healthcare costs of about US$22.5 billion and US$12 billion, respectively.6,7 Federal government spending on healthcare relating to HIV/AIDS is over US$13 billion per year.8Given the well-documented relationship between lifestyle, disease burden and healthcare costs, it makes economic and medical sense to hold individuals morally responsible for their health-related choices. While this view has a great deal of intuitive appeal, it also faces numerous objections.9–12 First, holding individuals entirely responsible for their own health conflicts with medicine’s obligation to treat the sick and society’s obligation …. (shrink)

This is a wide-ranging defense of a distinctive version of hedonistic act utilitarianism. It is plainly written, forthright, and stimulating. Also, it is replete with disputable assertions and arguments. I shall pursue one issue here, after sketching the project of each substantial chapter.

Many argue that our reasons to value choice do not depend on our having libertarian free will.The paper argues against this view. One reason to value choice is that it is constitutive of a life of self-determination. If choices are determined, however, they can be predicted and brought about by others; and if choices are randomly indeterministic, they can be mimicked. In either case, the importance of choice to self-determination is challenged. Thus, it is only as long as our choices (...) are free in a libertarian manner that the importance of choice as a means to self-determination makes full sense. (shrink)

John Fischer and Mark Ravizza defend in this book a painstakingly constructed analysis of what they take to be a core condition of moral responsibility: the notion of guidance control. The volume usefully collects in one place ideas and arguments the authors have previously published in singly or jointly authored works on this and related topics, as well as various refinements to those views and some suggestive discussions that aim to show how their account of guidance control might fit into (...) a more comprehensive account of moral responsibility. (shrink)

All health care systems face problems of justice and efficiency related to setting priorities for allocating a limited pool of resources to a population. Because many of the central issues are the same in all systems, the United States and other countries can learn from the successes and failures of countries that have explicitly addressed the question of health care priorities. We review explicit priority setting efforts in Norway, Sweden, Israel, the Netherlands, Denmark, New Zealand, the United Kingdom and the (...) state of Oregon in the US. The approaches used can be divided into those centered on outlining principles versus those that define practices. In order to establish the main lessons from their experiences we consider the process each country used, criteria to judge the success of these efforts, which approaches seem to have met these criteria, and using their successes and failures as a guide, how to proceed in setting priorities. We demonstrate that there is little evidence that establishment of a values framework for priority setting has had any effect on health policy, nor is there evidence that priority setting exercises have led to the envisaged ideal of an open and participatory public involvement in decision making. (shrink)

In a health service with limited resources we must make decisions about who to treat first. In this paper I develop a version of the restoration argument according to which those whose need for resources is a consequence of their voluntary choices should receive lower priority when it comes to health care. I then consider three possible problems for this argument based on those that have been raised against other theories of this type: that we don't know in a particular (...) case that the illness is self-inflicted, that it seems that all illness is self-inflicted in the sense used in my argument, and finally that this type of approach incorporates an unacceptable moralising element if it is to avoid giving those like fire-fighters a lower priority for treatment. I argue that the position outlined here has the resources to respond to each of these objections. (shrink)

While promoting population health has been the classic goal of public health practice and policy, in recent decades, new objectives in terms of autonomy and equality have been introduced. These different goals are analysed, and it is demonstrated how they may conflict severly in several ways, leaving serious unclarities both regarding the normative issue of what goal should be pursued by public health, what that implies in practical terms, and the descriptive issue of what goal that actually is pursued in (...) different contexts. A basic conflict of perspective is handled by integrating the ideas of public health striving for health-related autonomy and equality, resulting in a prioritarian oriented population approach to health-related autonomy. This integrated goal is demonstrated to constrain itself in several ways attractive from the point of view of the classic goal, but several serious problems remain. For this reason, a model where all of the three goals are integrated into one coherent structure where they can be assigned varying degrees of importance relative to the level of population health is described. It is argued that this model avoids the problems set out earlier, and is actually normatively preferable to the classic goal alone. It is furthermore argued that the model may be employed as a useful tool for descriptive ethics, as well as a vehicle for international harmonisation of public health policies. A number of practical implications regarding, e.g., the importance of respecting autonomy and the allocation of public health resources are noted, as are a battery of questions for further research. (shrink)