Patients with the controversial diagnosis of body integrity identity disorder report an emotional discomfort with having a body part that they feel should not be there. This discomfort is so strong that it interferes with routine functioning and, in a majority of cases, BIID patients are motivated to seek amputation of the limb. Although patient requests to receive the best available treatment are generally respected, BIID demands for amputation, at present, are not. However, what little has been said in the (...) ethics literature on the subject tends to favour doing so in cases of BIID. The general argument is that BIID demands should be respected, first, because of the importance that is already placed on respecting autonomy in medical decision-making contexts and second, because of the potential harm of not providing amputation coupled with the fact that no alternative means of relieving suffering exists. The defence of the right to self-demanded amputation is thus typically supported by the use of analogies with other unproblematical cases in order to show that the denial of BIID patient demands is inconsistent with conventional medical norms and practices. This paper criticises the appropriateness of the particular analogies that are thought to shed light on the allegedly unproblematical nature of BIID demands and argues that a proper understanding of the respect for autonomy in the medical decision-making context prohibits agreeing to BIID demands for amputation. (shrink)

The illusion that Kant respects persons comes from ascribing contemporary meanings to purely technical terms within his second formulation of the categorical imperative, “[A]ct so that you treat humanity, whether in your own person or in that of another, always as an end and never as a means only”. When we realize that “humanity” means rational nature and “person” means the supersensible self (homo noumenon), we find that we are to respect, not human selves in all their diversity (homo phaenomenon), (...) but rational selves in all their sameness, in their unvarying conformity to the universal principles of pure practical reason. Contemporary individualism gets no support from Kant. (shrink)

S. 39: "My project in this paper is to develop the initial distinction which I have drawn between recognition and appraisal respect into a more detailed and specific account of each. These accounts will not merely be of intrinsic interest. Ultimately I will use them to illuminate the puzzles with which this paper began and to understand the idea of self-respect." 42 " Thus, insofar as respect within such a pursuit will depend on an appraisal of the participant from the (...) perspective of whatever standards are held to be appropriate to the pursuit, such respect will depend on a judgement to which excellences of character are thought relevant. Note that exactly what aspect of the person's character is thought to be relevant in this instance is his recognition respect (or lack of it) for the standards of the pursuit." 44 "This attitude fails of being appraisal respect in that my having it toward the person is conditional on those traits being such as to make him server a particular purpose that I happen to have" 44 - 45 "To sum up: Appraisal respect is an attitude of positibe appraisal of a person either judged as a person or as engaged in some more specific pursuit. In the first case, the appropriate grounds are features of the person's character: dispositions to act for particular reasons or a higher-level disposition to act for the best reasons. In the second case, though features of character do not exhaust the appropriate grounds for appraisal respect, some such character traits will be relevant (recognition respect for the standards of a particular pursuit). Also, the other features which constitute the appoprate excellences of the pursuit must be related to traits of character in the way specified. In both cases, the positive appraisal of the person, and of his traits, must be categorical. It cannot depend on the fact that the person, because of his traits, serves an interest or purpose of one's own." 45 "To have recognition respect for someone as a person is to give appropriate weight to the fact that he or she is a person by being willing to constrain one's behaviour in ways required by that fact." 45 "This is rather different from having an attitude of appraisal respect for someone as a person. The latter is a positive appraisal oif an individual made with regard ti those features which are excellences of persons. As such, it is not owed to everone, for it may or may not be merited. When it is, what is merited is just the positive appraisal itself." 47 "Second, the only beings who are approriate objects of appraisal respect are those who are capable of acting for reasons and hence capable of conceiving of various facts as meriting more or less consideration in deliberation.". (shrink)

This discussion paper addresses Ian Wilks’ defence of the risk‐related standard of competence that appears in Bioethics 11. Wilks there argues that the puzzle posed by Mark Wicclair in Bioethics 5 against Dan Brock's argument in favour of a risk‐related standard of competence — namely that Brock’s argument allows for situations of asymmetrical competence — is not a genuine problem for a risk‐related standard of competence. To show this, Wilks presents what he believes to be two examples of real situations (...) in which asymmetrical competence arises. I argue that insofar as Wilks equivocates two senses of competence in his examples — namely, competence to perform a task and competence in performing a task — Wilks is unable to illustrate the existence of real situations of asymmetrical competence. By examining the way in which Wilks equivocates two senses of competence in his examples, and by applying the results of this examination to the problem of patient competency within the medical field, I argue that not only does Wilks fail to show that situations of asymmetrical competence exist, but he is also unable to provide a foundation for understating how the risk‐related standard of competence can strike a balance between an individual’s autonomy and benevolent intervention. I thus conclude that insofar as Wilks fails to answer the objections raised by Wicclair and others against the risk‐related standard of competence, the risk‐related standard of competence continues to be undermined by the problem of asymmetrical competence. (shrink)

In this paper I discuss the view that the appropriate concept of competence is a decision‐relative one: that a person may be competent to make one decision but not another. The argument that I present is that neither of the two competing theories supporting the decision‐relative approach, internalism and externalism, can provide a coherent explanation of why a person’s competence should be thought to be relative to a particular decision. On the one hand, internalism, which regards competence as exhaustively a (...) matter of the person’s understanding, fails to identify the specific skills or content that would warrant linking a specific decision with competence, and thus cannot provide an account of decision‐relative that parallels task‐relative. On the other hand, externalism, which regards competence as a matter of the person’s understanding in relation to external elements such as risk, cannot adequately defend why a person’s competence to make a decision should ‘track’ the level of probable harm that results from the decision. (shrink)

In 1997, a Scottish surgeon by the name of Robert Smith was approached by a man with an unusual request: he wanted his apparently healthy lower left leg amputated. Although details about the case are sketchy, the would-be amputee appears to have desired the amputation on the grounds that his left foot wasn’t part of him – it felt alien. After consultation with psychiatrists, Smith performed the amputation. Two and a half years later, the patient reported that his life had (...) been transformed for the better by the operation [1]. A second patient was also reported as having been satisfied with his amputation [2]. (shrink)

In the subsequent pages, I want to develop a distinction between wanting and valuing which will enable the familiar view of freedom to make sense of the notion of an unfree action. The contention will be that, in the case of actions that are unfree, the agent is unable to get what he most wants, or values, and this inability is due to his own "motivational system." In this case the obstruction to the action that he most wants to do (...) is his own will. It is in this respect that the action is unfree: the agent is obstructed in and by the very performance of the action. (shrink)

Edmund Gettier is Professor Emeritus at the University of Massachusetts, Amherst. This short piece, published in 1963, seemed to many decisively to refute an otherwise attractive analysis of knowledge. It stimulated a renewed effort, still ongoing, to clarify exactly what knowledge comprises.

Russian translation of Gettier E. L. Is Justified True Belief Knowledge? // Analysis, vol. 23, 1963. Translated by Lev Lamberov with kind permission of the author.

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.

This is the first volume in which an account of personal autonomy is developed that both captures the contours of this concept as it is used in social philosophy and bioethics, and is theoretically grounded in, and a part of, contemporary autonomy theory. James Stacey Taylor’s account is unique as it is explicitly a political one, recognizing that the attribution of autonomy to agents is dependent in part on their relationships with others and not merely upon their own mental states. (...) The volume is distinctive in its examples, which touch on the ethics of using inducements to encourage persons to participate in medical research, the ethical issues associated with the use of antibiotics, and the ethical basis for both patient confidentiality and informed consent. (shrink)

The rare phenomenon in which a person desires amputation of a healthy limb, now often termed body integrity identity disorder, raises central questions for biomedical ethics. Standard bioethical discussions of surgical intervention in such cases fail to address the meaning of bodily integrity, which is intrinsic to a theological understanding of the goodness of the body. However, moral theological responses are liable to assume that such interventions necessarily represent an implicitly docetic manipulation of the body. Through detailed attention to the (...) ethics of mutilation and of surgery for psychiatric disorders, this article explores the theological and ethical significance of the body for human identity. (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)

Dr Baumgarten analyses three possible justifications for doctors to decide that a patient is 'incompetent' to make or participate in medical decisions affecting him, and points out the difficulties of each. He argues that the degree to which a patient relinquishes control over decision-making which affects him will vary in different circumstances and should be explicitly agreed in the initial doctor-patient contract, rather as it often is when a client employs a professional to invest money on his behalf.

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)

The prelims comprise: Introduction Controversial Choices Kinds of Normative Reasons for Action Limits on Respect for Autonomy Children and Controversial Choice Controversial Choices and the Duty to Strive Toward Perfection and Full Autonomy Acknowledgments Notes References.

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.

"A very good book indeed: there is scarcely an issue anyone has thought to raise about the topic which Childress fails to treat with sensitivity and good judgement....Future discussions of paternalism in health care will have to come to terms with the contentions of this book, which must be reckoned the best existing treatment of its subject."--Ethics. "A clear, scholarly and balanced analysis....This is a book I can recommend to physicians, ethicists, students of both fields, and to those most affected--the (...) patients themselves."--Edmund D. Pellegrino, John Carroll Professor of Medicine and Medical Humanities, Georgetown University Medical Center. (shrink)

Body integrity identity disorder (BIID), previously called apotemnophilia, is an extremely rare condition where sufferers desire the amputation of a healthy limb because of distress associated with its presence. This paper reviews the medical and philosophical literature on BIID. It proposes an evidenced based and ethically informed approach to its management. Amputation of a healthy limb is an ethically defensible treatment option in BIID and should be offered in some circumstances, but only after clarification of the diagnosis and consideration of (...) other treatment options. (shrink)

ABSTRACT In this paper, I discuss several arguments against non‐therapeutic mutilation. Interventions into bodily integrity, which do not serve a therapeutic purpose and are not regarded as aesthetically acceptable by the majority, e.g. tongue splitting, branding and flesh stapling, are now practised, but, however, are still seen as a kind of ‘aberration’ that ought not to be allowed. I reject several arguments for a possible ban on these body modifications. I find the common pathologisation of body modifications, Kant's argument of (...) duties to oneself and the objection from irrationality all wanting. In conclusion, I see no convincing support for prohibition of voluntary mutilations. (shrink)

I argue that despite it being said often that the concept of personal autonomy is important for grounding moral responsibility and in applied ethics, a certain type of theories of autonomy and identification, descended from the work of Harry Frankfurt starting 1971, are not relevant in an obvious way to either moral responsibility or applied ethics.

In this paper, I discuss several arguments against non‐therapeutic mutilation. Interventions into bodily integrity, which do not serve a therapeutic purpose and are not regarded as aesthetically acceptable by the majority, e.g. tongue splitting, branding and flesh stapling, are now practised, but, however, are still seen as a kind of ‘aberration’ that ought not to be allowed. I reject several arguments for a possible ban on these body modifications. I find the common pathologisation of body modifications, Kant's argument of duties (...) to oneself and the objection from irrationality all wanting. In conclusion, I see no convincing support for prohibition of voluntary mutilations. (shrink)

Controversy swept the U.K. in January of 2000 over public disclosure of the fact that a Scottish surgeon named Robert Smith had amputated the limbs of two able-bodied individuals who reportedly suffered from a condition known as apotemnophilia. The patients, both of whom had sought and consented to the surgery, claimed they had desperately desired for years to live as amputees and had been unable, despite considerable efforts, to reconcile themselves psychologically to living with the bodies with which they were (...) born. Both surgeries were successful, and both patients, who had undergone psychiatric evaluation prior to the amputations, subsequently reported having no regrets. In the wake of a wave of sensationalistic stories in the media, the hospital at which the surgeries had been performed, the Falkirk and District Royal Infirmary, banned any future surgeries of the kind. Outraged local politicians promptly announced their intention to pass laws banning the procedure outright. One member of Scottish Parliament declared the surgery obscene and asserted that the whole thing is repugnant and legislation needs to be brought in now to outlaw this. (shrink)

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.