If one values freedom, what sort of regime of property should one favor: libertarianism, socialism, or something else again? Debate on this topic has been hampered by a failure to distinguish freedom and liberty, which are both of great value, but can come into conflict. Furthermore there are many similar concepts—distinct from both liberty and freedom, yet each representing something we rightly value—which may also come into conflict with each other and with freedom and liberty. Consequently the question posed above (...) has no easy answer. (shrink)

The right to refuse medical intervention is well established, but it remains unclear how best to respect and exercise this right in life support. Contemporary ethical guidelines for critical care give ambiguous advice, largely because they focus on the moral equivalence of withdrawing and withholding care without confronting the very real differences regarding who is aware and informed of intervention options and how patient values are communicated and enacted. In withholding care, doctors typically withhold information about interventions judged too futile (...) to offer. They thus retain greater decision-making burden and face weaker obligations to secure consent from patients or proxies. In withdrawing care, there is a clearer imperative for the doctor to include patients in decisions, share information and secure consent, even when continued life support is deemed futile. How decisions to withhold and withdraw life support differ ethically in their implications for positive versus negative interpretations of patient autonomy, imperatives for consent, definitions of futility and the subjective evaluation of benefits and burdens of life support in critical care settings are explored. Professional reflection is required to respond to trends favouring a more positive interpretation of patient autonomy in the context of life support decisions in critical care. Both the bioethics and critical care communities should investigate the possibilities and limits of growing pressure for doctors to disclose their reasoning or seek patient consent when decisions to withhold life support are made. (shrink)

Smoking is disproportionately common among the disadvantaged, both within many countries and globally; the burden associated with smoking is, therefore, borne to a great extent by the disadvantaged. In this paper, I argue that this should be regarded as a problem of social justice. Even though smokers do, in a sense, ‘choose’ to smoke, the extent to which these choices can legitimise the resulting inequalities is limited by the unequal circumstances in which they are made. An analysis of the empirical (...) literature reveals a variety of factors—such as targeted advertising, unequal dissemination of information about the health risks of smoking and inequalities in smoking norms—that make the disadvantaged more likely to become smokers and less likely to quit successfully. The paper then considers a range of common tobacco control policies from the perspective of social justice. The social justice perspective developed here poses a challenge for policy-makers: on the one hand, social justice concerns strengthen the case for tobacco control policies because such policies disproportionately benefit the health of the disadvantaged. At the same time, however, we must be particularly sensitive to any harms associated with such policies because such burdens, too, will fall largely on the disadvantaged. (shrink)

The recent debates about the nature of social freedom, understood in a broadly negative way, have generated three main views of the topic: these represent freedom respectively as non-limitation, non-interference and non-domination. The participants in these debates often go different ways, however, because they address different topics under common names, not because they hold different intuitions on common topics. Social freedom is sometimes understood as option-freedom, sometimes as agency-freedom and the different directions taken by the theories can often be explained (...) by their addressing freedom in one sense, then in another. The non-limitation approach focuses primarily on option-freedom, the non-domination approach on agencyfreedom, whereas the representation of freedom as non-interference seems to spring from a failure to resolve the focus decisively on one target or another. (shrink)

Suppose that we develop a medically safe and affordable means of enhancing human intelligence. For concreteness, we shall assume that the technology is genetic engineering (either somatic or germ line), although the argument we will present does not depend on the technological implementation. For simplicity, we shall speak of enhancing “intelligence” or “cognitive capacity,” but we do not presuppose that intelligence is best conceived of as a unitary attribute. Our considerations could be applied to specific cognitive abilities such as verbal (...) fluency, memory, abstract reasoning, social intelligence, spatial cognition, numerical ability, or musical talent. It will emerge that the form of argument that we use can be applied much more generally to help assess other kinds of enhancement technologies as well as other kinds of reform. However, to give a detailed illustration of how the argument form works, we will focus on the prospect of cognitive enhancement. (shrink)

"Political Ideas in the Twentieth Century", Historical Inevitability", "Two Concepts of Liberty", "John Stuart Mill and the Ends of Life". These four essays deal with the various aspects of individual liberty, including the distinction between positive and negative liberty and the necessity of rejecting determinism if we wish to keep hold of the notions of human responsibility and freedom.

In their recently published book Nudge (2008) Richard H. Thaler and Cass R. Sunstein (T&S) defend a position labelled as ‘libertarian paternalism’. Their thinking appeals to both the right and the left of the political spectrum, as evidenced by the bedfellows they keep on either side of the Atlantic. In the US, they have advised Barack Obama, while, in the UK, they were welcomed with open arms by the David Cameron's camp (Chakrabortty 2008). I will consider the following questions. What (...) is Nudge? How is it different from social advertisement? Does Nudge induce genuine preference change? Does Nudge build moral character? Is there a moral difference between the use of Nudge as opposed to subliminal images to reach policy objectives? And what are the moral constraints on Nudge? (shrink)

Too often, we as individuals do things that harm us, that seriously interfere with our being able to live in the way that we want. We eat food that makes us obese, that promotes diabetes, heart failure and other serious illness, while at the same time, we want to live long and healthy lives. Too many of us smoke cigarettes, even while acknowledging we wish we had never begun. We behave in ways that undercut our ability to reach some of (...) our most valued goals, despite education and despite incentives to choose the right thing. What should be done?If I were to try to harm someone else in a way that alters his future seriously and perhaps irrevocably for the worse, I would be stopped. When it comes to hurting myself, though, we have a common belief that it is wrong to interfere, even if I foresee that I will very much regret what I have done, often when it is too late to fix what I have let happen. I think this makes no sense. If it is permissible, even obligatory, to stop me when I do something that seriously interferes with someone else's chances of achieving the life he wants, I think …. (shrink)

The introduction (about 6,000 words) to _The Cambridge Companion to Utilitarianism_, in three sections: utilitarianism’s place in recent and contemporary moral philosophy (including the opinions of critics such as Rawls and Scanlon), a brief history of the view (again, including the opinions of critics, such as Marx and Nietzsche), and an overview of the chapters of the book.

Since Mill's seminal work On Liberty, philosophers and political theorists have accepted that we should respect the decisions of individual agents when those decisions affect no one other than themselves. Indeed, to respect autonomy is often understood to be the chief way to bear witness to the intrinsic value of persons. In this book, Sarah Conly rejects the idea of autonomy as inviolable. Drawing on sources from behavioural economics and social psychology, she argues that we are so often irrational in (...) making our decisions that our autonomous choices often undercut the achievement of our own goals. Thus in many cases it would advance our goals more effectively if government were to prevent us from acting in accordance with our decisions. Her argument challenges widely held views of moral agency, democratic values and the public/private distinction, and will interest readers in ethics, political philosophy, political theory and philosophy of law. (shrink)

In recent years, ‘nudge’ theory has gained increasing attention for the design of population-wide health interventions. The concept of nudge puts a label on efficacious influences that preserve freedom of choice without engaging the influencees’ deliberative capacities. Given disagreements over what it takes genuinely to preserve freedom of choice, the question is whether health influences relying on automatic cognitive processes may preserve freedom of choice in a sufficiently robust sense to be serviceable for the moral evaluation of actions and policies. (...) In this article, I offer an argument to this effect, explicating preservation of freedom of choice in terms of choice-set preservation and noncontrol. I also briefly explore the healthcare contexts in which nudges may have priority over more controlling influences. (shrink)

In his provocative book Matthew Kramer offers a systematic theory of freedom that challenges most of the other major contemporary treatments of the topic.

Muddles can be instructive. The clarifying confusion to be examined in this paper is Isaiah Berlin's intelligent vacillation on the issue of whether or not the extent of a person's freedom depends on his desires. Is the amount of freedom an agent possesses determined solely by his objective circumstances or is it also partly a function of his subjective tastes and preferences? In clarifying this question I shall suggest that Berlin has trouble answering it because he almost perceives that interpersonal (...) cardinal measurement of freedom, if possible at all, is possible only on a subjective basis. Yet as Berlin eloquently reminds us measuring freedom according to a subjective metric generates paradox. Whether commonsense ideas of freedom are consistent and reasonable is not purely an academic issue, for we do often make political judgments to the effect that one or another policy, or a movement to one or another form of society, can be expected to reduce or enlarge human freedom. If freedom is not measurable these judgments are merely hortatory. (shrink)

It is often said that one person or society is `freer' than another, or that people have a right to equal freedom, or that freedom should be increased or even maximized. Such quantitative claims about freedom are of great importance to us, forming an essential part of our political discourse and theorizing. Yet their meaning has been surprisingly neglected by political philosophers until now. Ian Carter provides the first systematic account of the nature and importance of our judgements about degrees (...) of freedom. He begins with an analysis of the normative assumptions behind the claim that individuals are entitled to a measure of freedom, and then goes on to ask whether it is indeed conceptually possible to measure freedom. Adopting a coherentist approach, the author argues for a conception of freedom that not only reflects commonly held intuitions about who is freer than who but is also compatible with a liberal or freedom-based theory of justice. (shrink)

Freedom, in Philip Pettit's provocative analysis, requires more than just being let alone. In Just Freedom, a succinct articulation of the republican philosophy for which he is renowned, Pettit builds a theory of universal freedom as nondomination. Seen through this lens, even societies that consider themselves free may find their political arrangements lacking. Do those arrangements protect people's liberties equally? Are they subject to the equally shared control of those they protect? Do they allow the different peoples of the world (...) to live in equal freedom? With elegant, user-friendly tests of freedom--the eyeball test, the tough luck test, and the straight talk test--Pettit addresses these questions, laying out essential yardsticks for policymakers and concerned citizens alike. An invitation to join in a program that would better articulate and realize justice in our social, democratic, and international lives, Just Freedom offers readers an essential starting place for the world's thorniest problems. (shrink)

Ethical analyses, professional guidelines and legal decisions support the equivalence thesis for life-sustaining treatment: if it is ethical to withhold treatment, it would be ethical to withdraw the same treatment. In this paper we explore reasons why the majority of medical professionals disagree with the conclusions of ethical analysis. Resource allocation is considered by clinicians to be a legitimate reason to withhold but not to withdraw intensive care treatment. We analyse five arguments in favour of non-equivalence, and find only relatively (...) weak reasons to restrict rationing to withholding treatment. On the contrary, resource allocation provides a strong argument in favour of equivalence: non-equivalence causes preventable death in critically ill patients. We outline two proposals for increasing equivalence in practice: (1) reduction of the mortality threshold for treatment withdrawal, (2) time-limited trials of intensive care. These strategies would help to move practice towards more rational treatment limitation decisions. (shrink)

We consider the role of preferences in the assessment of an agent's freedom, visualized as the opportunity for choice. After discussing several possible intuitive approaches to the problem, we explore an approach based on the notion of preference orderings that a reasonable person may possibly have. Using different sets of axioms, we characterize the rules for ranking opportunity sets in terms of freedom. We also show that certain axioms for ranking opportunity sets are incompatible.

Many medical ethicists accept the thesis that there is no moral difference between withholding and withdrawing life-sustaining therapy. In this paper, we offer an interesting counterexample which shows that this thesis is not always true. Withholding is distinguished from withdrawing by the simple fact that therapy must have already been initiated in order to speak coherently about withdrawal. Provided that there is a genuine need and that therapy is biomedically effective, the historical fact that therapy has been initiated entails a (...) claim to continue therapy that cannot be attributed to patients who have not yet received therapy. This intrinsic difference between withholding and withdrawing therapy is of moral importance. In many instances, patients will waive this claim. But when one considers withdrawing therapy from one patient to help another in a setting of scarce resources, this intrinsic moral difference comes into sharp focus. In an era of shrinking medical resources, this difference cannot be ignored. (shrink)

Policymakers, employers, insurance companies, researchers, and health care providers have developed an increasing interest in using principles from behavioral economics and psychology to persuade people to change their health-related behaviors, lifestyles, and habits. In this article, we examine how principles from behavioral economics and psychology are being used to nudge people (the public, patients, or health care providers) toward particular decisions or behaviors related to health or health care, and we identify the ethically relevant dimensions that should be considered for (...) the utilization of each principle. (shrink)