This paper argues that we should replace the common classification of theories of welfare into the categories of hedonism, desire theories, and objective list theories. The tripartite classification is objectionable because it is unduly narrow and it is confusing: it excludes theories of welfare that are worthy of discussion, and it obscures important distinctions. In its place, the paper proposes two independent classifications corresponding to a distinction emphasised by Roger Crisp: a four-category classification of enumerative theories (about which items constitute (...) welfare), and a four-category classification of explanatory theories (about why these items constitute welfare). (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)

It is a commonplace that ‘autonomy’ has several different senses in contemporary moral and political discussion. The term’s original meaning was political: a right assumed by states to administer their own affairs. It was not until the nineteenth century that ‘autonomy’ came (in English) to refer also to the conduct of individuals, and even then there were, as now, different meanings.1 Odd as it may seem from our perspective, one that was in play from the beginning was Kant’s notion of (...) “autonomy of the will,”2 as Kant defined it, “the property of the will by which it is a law to itself independently of any property of the objects of volition” (4:440).3That’s a mouthful, to say the least. And interpreting.. (shrink)

According to the principle of patient autonomy, patients have the right to be self-determining in decisions about their own medical care, which includes the right to refuse treatment. However, a treatment refusal may legitimately be overridden in cases where the decision is judged to be incompetent. It has recently been proposed that in assessments of competence, attention should be paid to the evaluative judgments that guide patients' treatment decisions.In this paper I examine this claim in light of theories of practical (...) rationality, focusing on the difficult case of an anorexic person who is judged to be competent and refuses treatment, thereby putting themselves at risk of serious harm. I argue that the standard criteria for competence assess whether a treatment decision satisfies the goals of practical decision-making, and that this same criterion can be applied to a patient's decision-guiding commitments. As a consequence I propose that a particular understanding of practical rationality offers a theoretical framework for justifying involuntary treatment in the anorexia case. (shrink)

Although some healthcare professionals have the legal right to conscientiously object to authorise or perform certain lawful medical services, they have an associated duty to provide the patient with enough information to seek out another professional willing to authorise or provide the service (the ‘duty to refer’). Does the duty to refer morally undermine the professional's conscientious objection (CO)? I narrow my discussion to the National Health Service in Britain, and the case of a general practitioner (GP) being asked by (...) a pregnant woman to authorise an abortion. I will be careful not to enter the debate about whether abortion should be legalised, or the debate about whether CO should be permitted—I will take both as given. I defend the objecting GP's duty to refer against those I call the ‘conscience absolutists’, who would claim that if a state is serious enough in permitting the GP's objection in the first place (as is the UK), then it has to recognise the right to withhold any information about abortion. (shrink)

Adaptive preference formation is the unconscious altering of our preferences in light of the options we have available. Jon Elster has argued that this is bad because it undermines our autonomy. I agree, but think that Elster's explanation of why is lacking. So, I draw on a richer account of autonomy to give the following answer. Preferences formed through adaptation are characterized by covert influence (that is, explanations of which an agent herself is necessarily unaware), and covert influence undermines our (...) autonomy because it undermines the extent to which an agent's preferences are ones that she has decided upon for herself. This answer fills the lacuna in Elster's argument. It also allows us to draw a principled distinction between adaptive preference formation and the closely related phenomenon of character planning. (shrink)

The duty to procure informed consent (IC) from patients before any significant intervention is among the pillars of medical and research ethics. The provision by the doctor of relevant information about treatment and free decision-making by the patient are essential elements of IC. The paper presents cases of IC where the free decision about treatment is not causally related to the information provided, and claims that such cases pose a difficulty parallel to that presented by the Gettier Problem in epistemology. (...) In analogy to the original problem with the concept of knowledge, these Gettier-type cases show an indeterminacy in the concept of IC: we either need to add some explicit additional condition of causal connection between information and consent, or else we should understand the concept in a new way—specifically, since the practice of autonomy necessarily involves some consideration of the relevant information, we must understand free consent in a way that no longer refers to patient autonomy. (shrink)

Libertarian paternalism's notion of “nudging” refers to steering individual decision making so as to make choosers better off without breaching their free choice. If successful, this may offer an ideal synthesis between the duty to respect patient autonomy and that of beneficence, which at times favors paternalistic influence. A growing body of literature attempts to assess the merits of nudging in health care. However, this literature deals almost exclusively with health policy, while the question of the potential benefit of nudging (...) for the practice of informed consent has escaped systematic analysis. This article focuses on this question. While it concedes that nudging could amount to improper exploitation of cognitive weaknesses, it defends the practice of nudging in a wide range of other conditions. The conclusion is that, when ethically legitimate, nudging offers an important new paradigm for informed consent, with a special potential to overcome the classical dilemma between paternalistic beneficence and respect for autonomy. (shrink)

It is a common assumption that lack of autonomy is incompatible with decisional capacity and mental health. However, there are two general conceptions of autonomy, one value-neutral and the other value-laden, which imply different notions of mental health. I argue that the value-neutral notion of autonomy is independently inadequate and that it also provides an inadequate foundation for judging whether someone is decisionally incapable or mentally disordered. I propose an alternative, value-laden account which posits ten capabilities required for basic human (...) functioning. I then defend this account against objections and highlight its practical utility in designing optimal treatment. (shrink)

Virtually any appraisal of a person’s welfare, integrity, or moral status, as well as the moral and political theories built on such appraisals, will rely crucially on the presumption that her preferences and values are in some important sense her own. In particular, the nature and value of political freedom is intimately connected with the presupposition that actions one is left free to do flow from desires and values that are truly an expression of the ‘self-government’ of the agent. However, (...) we all know that no person is self-made in the sense of being a fully formed and intact ‘will’ blossoming out of nowhere. Our values and preferences are explained by essential reference to a variety of influences that have come to bear on our development throughout our personal histories. What is needed, then, is to establish an account of self-determination or autonomy that would help determine just when and if the values and preferences we find ourselves with deserve the centrality that moral and political theories place on them. (shrink)

What makes a choice hard? I discuss and criticize three common answers and then make a proposal of my own. Paradigmatic hard choices are not hard because of our ignorance, the incommensurability of values, or the incomparability of the alternatives. They are hard because the alternatives are on a par; they are comparable, but one is not better than the other, and yet nor are they equally good. So understood, hard choices open up a new way of thinking about what (...) it is to be a rational agent. (shrink)

In what sense are persons equal, such that it is appropriate to treat them as equals? This difficult question has been strangely neglected by political philosophers. A plausible answer can be found by adopting a particular interpretation of the idea of respect. Central to this interpretation is the thought that in order to respect persons we need to treat them as ‘opaque', paying attention only to their outward features as agents. This proposed basis of equality has important implications for the (...) currency of egalitarian justice, ruling out a number of the equalizanda favored by contemporary egalitarians. (shrink)

In a recent article in this journal, John Bishop argues in defence of conceiving of Christian faith as a ‘doxastic venture’. That is, he defends the claim that, in exercising faith, agents believe beyond ‘what can be established rationally on the basis of evidence and argument’. Careful examination reveals that Bishop fails adequately to show that faith in the face of inadequate epistemic reasons for believing is, or can even be, a uniquely doxastic venture. I argue that faith is best (...) conceived of as a sub-doxastic venture that involves pragmatically assuming that God exists. (shrink)

There is concern that the use of neuroenhancements to alter character traits undermines consumer's authenticity. But the meaning, scope and value of authenticity remain vague. However, the majority of contemporary autonomy accounts ground individual autonomy on a notion of authenticity. So if neuroenhancements diminish an agent's authenticity, they may undermine his autonomy. This paper clarifies the relation between autonomy, authenticity and possible threats by neuroenhancements. We present six neuroenhancement scenarios and analyse how autonomy accounts evaluate them. Some cases are considered (...) differently by criminal courts; we demonstrate where academic autonomy theories and legal reasoning diverge and ascertain whether courts should reconsider their concept of autonomy. We argue that authenticity is not an appropriate condition for autonomy and that new enhancement technologies pose no unique threats to personal autonomy. (shrink)

This article references the following linked citations. If you are trying to access articles from an off-campus location, you may be required to first logon via your library web site to access JSTOR. Please visit your library's website or contact a librarian to learn about options for remote access to JSTOR.

The prelims comprise: References Additional Reading.

It is common, in current literature on the topic at hand, to distinguish two kinds of reasons for action: justificatory reasons, which answer questions about what we ought to do, and explanatory reasons, which explain what we actually do. Internalism is a thesis about justificatory reasons—that is, the kind of reasons we are in search of when we deliberate about what to do or advise others about what they ought to do. Of course, since internalism traces justificatory reasons to the (...) subjective motivations of those to whom the reasons apply, and since these motivations play a central role in explaining actions, the doctrine implies that there is a close relation—perhaps even a relation of identity—between justificatory and explanatory reasons. Still, the main proponents of internalism have presented it, in the first instance, as a thesis about justificatory reasons. What I hope to show is that internalism cannot be accepted as a limitation on justificatory reasons because it cannot coherently be accepted in the course of first-person deliberation; and it ought not to be accepted when offering advice. To think otherwise, I will argue, is to reverse the ‘direction of gaze’ appropriate to deliberation, mistaking the psychological states that shape our view of justificatory reasons for the justificatory reasons they bring into view. The upshot of this reversal is to make justification far too easy to come by, and to render it obscure what we are doing when we pause to consider whether we really have the reasons that we are disposed to think we have. (shrink)

We are purposive agents; but we—adult humans in a broadly modern world—are more than that. We are reflective about our motivation. We form prior plans and policies that organize our activity over time. And we see ourselves as agents who persist over time and who begin, develop, and then complete temporally extended activities and projects. Any reasonably complete theory of human action will need in some way to advert to this trio of features—to our reflectiveness, our planfulness, and our conception (...) of our agency as temporally extended. These are, further, features that have great significance for the kinds of lives we can live. For these two reasons I will say that these are among the core features of human agency. A theory of human action needs to say what these core features consist in and how they are related to each other. And such a theory needs also to clarify the relation between these core features of our agency and the possibility that we are fully embedded in an event causal order. (shrink)

I [try] to understand identification by appeal to phenomena of deciding to treat, and of treating, a desire of one's as reason-giving in one's practical reasoning, planning, and action. Is identification, so understood, "fundamental," as Frankfurt says, "to any philosophy of mind and of action"? Well, we have seen reason to include in our model of intentional agency such phenomena of deciding to treat, and of treating, certain of one's desires as reason-giving. Identification, at bottom, consists in such phenomena — (...) or so I have proposed. Given that such phenomena are important in our practical lives, we may agree with Frankfurt that identification is, in this sense, "fundamental.". (shrink)

Positions on the ethics of human enhancement technologies can be (crudely) characterized as ranging from transhumanism to bioconservatism. Transhumanists believe that human enhancement technologies should be made widely available, that individuals should have broad discretion over which of these technologies to apply to themselves, and that parents should normally have the right to choose enhancements for their children-to-be. Bioconservatives (whose ranks include such diverse writers as Leon Kass, Francis Fukuyama, George Annas, Wesley Smith, Jeremy Rifkin, and Bill McKibben) are generally (...) opposed to the use of technology to modify human nature. A central idea in bioconservativism is that human enhancement technologies will undermine our human dignity. To forestall a slide down the slippery slope towards an ultimately debased ‘posthuman’ state, bioconservatives often argue for broad bans on otherwise promising human enhancements. This paper distinguishes two common fears about the posthuman and argues for the importance of a concept of dignity that is inclusive enough to also apply to many possible posthuman beings. Recognizing the possibility of posthuman dignity undercuts an important objection against human enhancement and removes a distortive double standard from our field of moral vision. (shrink)

Philosophers and psychologists have been attracted to two differing accounts of addictive motivation. In this paper, we investigate these two accounts and challenge their mutual claim that addictions compromise a person’s self-control. First, we identify some incompatibilities between this claim of reduced self-control and the available evidence from various disciplines. A critical assessment of the evidence weakens the empirical argument for reduced autonomy. Second, we identify sources of unwarranted normative bias in the popular theories of addiction that introduce systematic errors (...) in interpreting the evidence. By eliminating these errors, we are able to generate a minimal, but correct account, of addiction that presumes addicts to be autonomous in their addictive behavior, absent further evidence to the contrary. Finally, we explore some of the implications of this minimal, correct view. (shrink)

This article challenges Jennifer Jackson's recent defence of doctors' rights to deceive patients. Jackson maintains there is a general moral difference between lying and intentional deception: while doctors have a prima facie duty not to lie, there is no such obligation to avoid deception. This paper argues 1) that an examination of cases shows that lying and deception are often morally equivalent, and 2) that Jackson's position is premised on a species of moral functionalism that misconstrues the nature of moral (...) obligation. Against Jackson, it is argued that both lying and intentional deception are wrong where they infringe a patient's right to autonomy or his/her right to be treated with dignity. These rights represent 'deontological constraints' on action, defining what we must not do whatever the functional value of the consequences. Medical ethics must recognise such constraints if it is to contribute to the moral integrity of medical practice. (shrink)

Belief is a central focus of inquiry in the philosophy of religion and indeed in the field of religion itself. No one conception of belief is central in all these cases, and sometimes the term 'belief' is used where 'faith' or 'acceptance' would better express what is intended. This paper sketches the major concepts in the philosophy of religion that are expressed by these three terms. In doing so, it distinguishes propositional belief (belief that) from both objectual belief (believing something (...) to have a property) and, more importantly, belief in (a trusting attitude that is illustrated by at least many paradigm cases of belief in God). Faith is shown to have a similar complexity, and even propositional faith divides into importantly different categories. Acceptance differs from both belief and faith in that at least one kind of acceptance is behavioral in a way neither of the other two elements is. Acceptance of a proposition, it is argued, does not entail believing it, nor does believing entail acceptance in any distinctive sense of the latter term. In characterizing these three notions (and related ones), the paper provides some basic materials important both for understanding a person's religious position and for appraising its rationality. The nature of religious faith and some of the conditions for its rationality, including some deriving from elements of an ethics of belief, are explored in some detail. (shrink)

In 1993 the Law Lords upheld the original conviction of five men under the 1861 Offences Against the Person Act for participating in sado-masochistic practices. Although the five men were fully consenting adults, the Law Lords held that consent did not constitute a defence to acts of violence within a sado-masochistic context. This paper examines the judgements in this case and argues that sado-masochistic practices are no different from the known exceptions cited by the court to the idea that consent (...) is no defence to violence (sport, parental chastisement and surgery). It also argues that if we can make sense of rape as a non-consensual, violent act, expressed through sex, then we can make sense of sado-masochism as a consensual sexual act, expressed through violence. (shrink)

Charles Foster and Jonathan Herring are to be congratulated on their useful presentation of the roles played by concepts of personhood and identity in English medical law.1 However, I fear that the project they have undertaken here is misconceived. It is an interesting and important misconception, which is widely shared in the literature on medical law and ethics; but a misconception it remains. The problem is this. What we call ‘the Law’ is in fact a complex assemblage of institutions, rules, (...) accredited persons, practices and systems. What it is not is a self-sufficient, integrated and self-interpreting system of doctrine. As such it does not have a clear structure which we can excavate and the idea that we can find concepts which explain and unify that structure at some deep level is thus quixotic. To approach ‘the Law’ in that way is to pursue a chimaera. We should instead think of ‘the Law’ as Wittgenstein taught us to approach a language.2 We can find concepts through investigation of language in practical use, but the …. (shrink)

Charles Foster and Jonathan Herring are to be congratulated on their useful presentation of the roles played by concepts of personhood and identity in English medical law. 1 However, I fear that the project they have undertaken here is misconceived. It is an interesting and important misconception, which is widely shared in the literature on medical law and ethics; but a misconception it remains. The problem is this. What we call ‘the Law’ is in fact a complex assemblage of institutions, (...) rules, accredited persons, practices and systems. What it is not is a self-sufficient, integrated and self-interpreting system of doctrine. As such it does not have a clear structure which we can excavate and the idea that we can find concepts which explain and unify that structure at some deep level is thus quixotic. To approach ‘the Law’ in that way is to pursue a chimaera. We should instead... (shrink)

Individuals with major depression may benefit from psychiatric treatment, yet they may refuse such treatment, sometimes because of their depression. Hence the question is raised whether such individuals are competent to refuse psychiatric treatment. The standard notion of competence to consent to treatment, which refers to expression of choice, understanding of medical information, appreciation of the personal relevance of this information, and logical reasoning, may be insufficient to address this question. This is so because major depression may not impair these (...) four abilities while it may disrupt coherence of personal preferences by changing them. Such change may be evaluated by comparing the treatment preferences of the individual during the depression to his or her treatment preferences during normal periods. If these preferences are consistent, they should be respected. If they are not consistent, or past treatment preferences that were arrived at competently cannot be established, treatment refusal may have to be overridden or ignored so as to alleviate the depression and then determine the competent treatment decision of the individual. Further study of the relation between depression and competence to refuse or consent to psychiatric treatment is required. (shrink)

Using the example of an unconsented mouth swab I criticise the view that an action of this kind taken in itself is wrongful in respect of its being a violation of autonomy. This is so much inasmuch as autonomy merits respect only with regard to ‘critical life choices’. I consider the view that such an action is nevertheless harmful or risks serious harm. I also respond to two possible suggestions: that the action is of a kind that violates autonomy; and, (...) that the class of such actions violates autonomy. I suggest that the action is wrongful in as much as it is a bodily trespass. I consider, and criticise, two ways of understanding how morally I stand to my own body: as owner and as sovereign. In respect of the latter I consider Arthur Ripstein's recent defence of a sovereignty principle. Finally I criticise an attempt by Joel Feinberg to explain bodily trespass in terms of personal autonomy. (shrink)

It is my view that one essential difference between persons and other creatures is to be found in the structure of a person's will. Besides wanting and choosing and being moved to do this or that, men may also want to have certain desires and motives. They are capable of wanting to be different, in their preferences and purposes, from what they are. Many animals appear to have the capacity for what I shall call "first-order desires" or "desires of the (...) first order," which are simply desires to do or not to do one thing or another. No animal other than man, however, appears to have the capacity for reflective self-evaluation that is manifested in the formation of second-order desires. (shrink)

Our primary focus is on analysis of the concept of voluntariness, with a secondary focus on the implications of our analysis for the concept and the requirements of voluntary informed consent. We propose that two necessary and jointly sufficient conditions must be satisfied for an action to be voluntary: intentionality, and substantial freedom from controlling influences. We reject authenticity as a necessary condition of voluntary action, and we note that constraining situations may or may not undermine voluntariness, depending on the (...) circumstances and the psychological capacities of agents. We compare and evaluate several accounts of voluntariness and argue that our view, unlike other treatments in bioethics, is not a value-laden theory. We also discuss the empirical assessment of individuals? perceptions of the degrees of noncontrol and self-control. We propose use of a particular Decision Making Control Instrument. Empirical research using this instrument can provide data that will help establish appropriate policies and procedures for obtaining voluntary consent to research. (shrink)

What happens when someone acts? A familiar answer goes like this. There is something that the agent wants, and there is an action that he believes conducive to its attainment. His desire for the end, and his belief in the action as a means, justify taking the action, and they jointly cause an intention to take it, which in turn causes the corresponding movements of the agent's body. I think that the standard story is flawed in several respects. The flaw (...) that will concern me in this paper is that the story fails to include an agent-or, more precisely, fails to cast the agent in his proper role. (shrink)

This essay challenges the widely accepted principle that a person is morally responsible for what he has done only if he could have done otherwise. The author considers situations in which there are sufficient conditions for a certain choice or action to be performed by someone, So that it is impossible for the person to choose or to do otherwise, But in which these conditions do not in any way bring it about that the person chooses or acts as he (...) does. In such situations the person may well be morally responsible for what he chooses or does despite his inability to choose or to do otherwise. Finally the author considers certain suggestions for revising the principle he rejects or for replacing it with a principle of an altogether different kind. (shrink)

This chapter discusses some concerns regarding the effects of enhancement technologies on autonomy and authenticity, insofar as authenticity relates to autonomy. As a preliminary, it describes how enhancement and autonomy should be understood in this context along with some examples of enhancement. The chapter moves on to explain why enhancement can promote autonomy. Three types of concerns regarding the effect of enhancement technologies on autonomy are raised: (i) that medical technologies should not be used to enhance autonomy, since this is (...) not the proper use of such technologies; (ii) that some enhancement technologies are inimical to our authenticity; and (iii) that the widespread use of some enhancement technologies have negative overall consequences on people's autonomy. Different kinds of enhancements typically arouse different kinds of concerns as regards autonomy. These include cognitive, mood, physical, and aesthetic enhancement. (shrink)