This essay argues that nonlinguistic animals qualify not just for externalist notions of rationality (maximizing biological fitness or utility), but also for internal ones. They can act for reasons in several senses: their behaviour is subject to intentional explanations, they can act in the light of reasonsprovided that the latter are conceived as objective facts rather than subjective mental statesand they can deliberate. Finally, even if they could not, it would still be misguided to maintain that animals are capable only (...) of (mechanical) behaviour, not of (intentional) action. (shrink)

The various jurisdictions worldwide that now legally permit assisted suicide (or voluntary euthanasia) vary concerning the medical conditions needed to be legally eligible for assisted suicide. Some jurisdictions require that an individual be suffering from an unbearable and futile medical condition that cannot be alleviated. Others require that individuals must be suffering from a terminal illness that will result in death within a specified timeframe, such as six months. -/- Popular and academic discourse about assisted suicide paradigmatically focuses on individuals (...) with ‘physical,’ i.e., non-psychiatric medical conditions, such as cancer or AIDS. Here I defend analyses of the notions of unbearable suffering, futility, and terminality that imply that, regardless of which of these medical conditions is invoked, at least some individuals with severe and persistent psychiatric illnesses satisfy these conditions and ought to be classified as legally eligible for assisted suicide. The legal and moral case for a right to assisted suicide is therefore not in principle weaker for the severely psychiatrically disordered than for those with ‘typical’ terminal or futile medical conditions. (shrink)

In this paper I propose and develop a social account of global autonomy. On this view, a person is autonomous simply to the extent to which it is difficult for others to subject her to their wills. I argue that many properties commonly thought necessary for autonomy are in fact properties that tend to increase an agent’s immunity to such interpersonal subjection, and that the proposed account is therefore capable of providing theoretical unity to many of the otherwise heterogeneous requirements (...) of autonomy familiar from recent discussions. Specifically, I discuss three such requirements: (i) possession of legally protected status, (ii) a sense of one’s own self-worth, and (iii) a capacity for critical reflection. I argue that the proposed account is not only theoretically satisfying but also yields a rich and attractive conception of autonomy. (shrink)

Recent neuroscientific evidence brings into question the conclusion that all aspects of consciousness are gone in patients who have descended into a persistent vegetative state (PVS). Here we summarize the evidence from human brain imaging as well as neurological damage in animals and humans suggesting that some form of consciousness can survive brain damage that commonly causes PVS. We also raise the issue that neuroscientific evidence indicates that raw emotional feelings (primary-process affects) can exist without any cognitive awareness of those (...) feelings. Likewise, the basic brain mechanisms for thirst and hunger exist in brain regions typically not damaged by PVS. If affective feelings can exist without cognitive awareness of those feelings, then it is possible that the instinctual emotional actions and pain "reflexes" often exhibited by PVS patients may indicate some level of mentality remaining in PVS patients. Indeed, it is possible such raw affective feelings are intensified when PVS patients are removed from life-supports. They may still experience a variety of primary-process affective states that could constitute forms of suffering. If so, withdrawal of life-support may violate the principle of nonmaleficence and be tantamount to inflicting inadvertent "cruel and unusual punishment" on patients whose potential distress, during the process of dying, needs to be considered in ethical decision-making about how such individuals should be treated, especially when their lives are ended by termination of life-supports. Medical wisdom may dictate the use of more rapid pharmacological forms of euthanasia that minimize distress than the de facto euthanasia of life-support termination that may lead to excruciating feelings of pure thirst and other negative affective feelings in the absence of any reflective awareness. (shrink)

In their account of passive euthanasia, Garrard and Wilkinson present arguments that might lead one to overlook significant moral differences between killing and letting die. To kill is not the same as to let die. Similarly, there are significant differences between active and passive euthanasia. Our moral duties differ with regard to them. We are, in general, obliged to refrain from killing each and everyone. We do not have a similar obligation to try to prevent each and everyone from dying. (...) In any case, to be morally obliged to persist in trying to prevent their deaths would be different from being morally obliged to refrain from killing all other people even if we had both obligations. (shrink)

The President's Council on Bioethics has recently released a report supportive of the continued use of brain death as a criterion for human death. The Council's conclusions were based on a conception of life that stressed external work as the fundamental marker of organismic life. With respect to human life, it is spontaneous respiration in particular that indicates an ability to interact with the external environment, and so indicates the presence of life. Conversely, irreversible apnoea marks an inability to carry (...) out the necessary work of life, an inability which the Council considers an indicator of death. This conception has been conceived to circumvent criticisms of the previous model of loss of somatic integration, a model the Council admits that, in the presence of evidence of continuing functional integration in brain dead patients, was looking less than convincing. Nevertheless, by focusing on external work and ignoring the more essential work of integrative unity, the Council's conception of the nature of life is untenable, and of no assistance in supporting a relation of equivalence between the concepts of brain death and death. Consequently, the Council's conclusions do little to advance the definition of death debate, a potentially intractable debate that may necessitate the investigation of alternate ethical justifications for organ harvesting. (shrink)

In this provocative book, a professor of philosophy examines the arguments for and against euthanasia, analyzes specific case studies, including those of Baby Jane Doe and Barney Clark, and offers an alternate theory on the morality of euthanasia. Various traditional distinctions--between "human" and "non-human," intentional and nonintentional, killing and "letting die"--are taken into account to determine whether euthanasia is permissible or not. Rachels presents a systematic argument against the traditional view, defending an alternative position based on the belief that there (...) is a profound difference between having a life and merely being alive. (shrink)

This book is the most comprehensive treatment available of one of the most urgent - and yet in some respects most neglected - problems in bioethics: decision-making for incompetents. Part I develops a general theory for making treatment and care decisions for patients who are not competent to decide for themselves. It provides an in-depth analysis of competence, articulates and defends a coherent set of principles to specify suitable surrogate decisionmakers and to guide their choices, examines the value of advance (...) directives, and investigates the role that considerations of cost ought to play in decisions concerning incompetents. Part II applies this theoretical framework to the distinctive problems of three important classes of individuals, many of whom are incompetent: minors, the elderly and psychiatric patients. The authors' approach combines a probing analysis of fundamental issues in ethical theory with a sensitive awareness of the concrete realities of health care institutions and the highly personal and individual character of difficult practical problems. Its broad scope will appeal to health professionals, moral philosophers and lawyers alike. (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.

Margaret Pabst Battin has established a reputation as one of the top philosophers working in bioethics today. This work is a sequel to Battin's 1994 volume The Least Worst Death. The last ten years have seen fast-moving developments in end-of-life issues, from the legalization of physician-assisted suicide in Oregon and the Netherlands, to a furor over proposed restrictions of scheduled drugs used for causing death, and the development of "NuTech" methods of assistance in dying. Battin's new collection covers a remarkably (...) wide range of end-of-life topics, including suicide prevention, AIDS, suicide bombing, serpent-handling and other religious practices that pose a risk of death, genetic prognostication, suicide in old age, global justice and the "duty to die." It also examines suicide, physician-assisted suicide, and euthanasia in both American and international contexts. As with the earlier volume, these new essays are theoretically adroit but draw richly from historical sources, fictional techniques, and ample factual material. (shrink)

Literature on the mental capacities and cognitive mechanisms of the great apes has been silent about whether they can act autonomously. This paper provides a philosophical theory of autonomy supported by psychological studies of the cognitive mechanisms that underlie chimpanzee behavior to argue that chimpanzees can act autonomously even though their psychological mechanisms differ from those of humans. Chimpanzees satisfy the two basic conditions of autonomy: (1) liberty (the absence of controlling influences) and (2) agency (self-initiated intentional action), each of (...) which is specified here in terms of conditions of understanding, intention, and self-control. In this account, chimpanzees make knowledge-based choices reflecting a richly information-based and socially sophisticated understanding of the world. Finally, two major theories of autonomy (Kantian theory and two-level theory) are rejected as too narrow to adequately address these issues, necessitating the modifications made in the present approach. (shrink)

Suicide is devastating. It is an assault on our ideas of what living is about. In Contemplating Suicide Gavin Fairbairn takes fresh look at suicidal self harm. His view is distinctive in not emphasising external facts: the presence or absence of a corpse, along with evidence that the person who has become a corpse, intended to do so. It emphasises the intentions that the person had in acting, rather than the consequences that follow from those actions. Much of the book (...) is devoted to an attempt to construct a natural history of suicidal self harm and to examine some of the ethical issues that it raises. Fairbairn sets his philosophical reflections against a background of practical experience in the caring professions and uses a storytelling approach in offering a critique of the current language of self harm along with some new ways of thinking. Among other things he offers cogent reasons for abandoning the mindless use of terms such as attempted suicide and parasuicide , and introduces a number of new terms including cosmic roulette , which he uses to describe a family of human acts in which people gamble with their lives. By elaborating a richer model of suicidal self harm than most philosophers and most practitioners of caring professions currently inhabit, Fairbairn has contributed to the development of understanding in this area. Among other things a richer model and vocabulary may reduce the likelihood that those who come into contact with suicidal self harm, will believe that familiarity with the physical facts of the matter - the actions of the suicider and the presence or absence of a corpse - is always sufficient to justify a definite conclusion about the nature of the self harming act. (shrink)

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)

Suicide is devastating. It is an assault on our ideas of what living is about. In Contemplating Suicide Gavin Fairbairn takes fresh look at suicidal self harm. His view is distinctive in not emphasising external facts: the presence or absence of a corpse, along with evidence that the person who has become a corpse, intended to do so. It emphasises the intentions that the person had in acting, rather than the consequences that follow from those actions. Much of the book (...) is devoted to an attempt to construct a natural history of suicidal self harm and to examine some of the ethical issues that it raises. Fairbairn sets his philosophical reflections against a background of practical experience in the caring professions and uses a storytelling approach in offering a critique of the current language of self harm along with some new ways of thinking. Among other things he offers cogent reasons for abandoning the mindless use of terms such as attempted suicide and parasuicide , and introduces a number of new terms including cosmic roulette , which he uses to describe a family of human acts in which people gamble with their lives. By elaborating a richer model of suicidal self harm than most philosophers and most practitioners of caring professions currently inhabit, Fairbairn has contributed to the development of understanding in this area. Among other things a richer model and vocabulary may reduce the likelihood that those who come into contact with suicidal self harm, will believe that familiarity with the physical facts of the matter - the actions of the suicider and the presence or absence of a corpse - is always sufficient to justify a definite conclusion about the nature of the self harming act. (shrink)

What factors should be taken into account when attributing criminal responsibility to perpetrators of severe crimes? We discuss the Breivik case, and the considerations which led to holding Breivik accountable for his criminal acts. We put some pressure on the view that experiencing certain psychiatric symptoms or receiving a certain psychiatric diagnosis is sufficient to establish criminal insanity. We also argue that the presence of delusional beliefs, often regarded as a key factor in determining responsibility, is neither necessary nor sufficient (...) for criminal insanity. (shrink)

This paper examines the recent prominent view in medical ethics that withdrawing life-sustaining treatment is an act of killing. I trace this view to the rejection of the traditional claim that withdrawing LST is an omission rather than an act. Although that traditional claim is not as problematic as this recent prominent view suggests, my main claim is that even if we accepted that withdrawing LST should be classified as an act rather than as an omission, it could still be (...) classified as letting die rather than killing. Even though omissions are contrasted with acts, letting die need not be, for one can let die by means of acts. The remainder of the paper is devoted to establishing this claim and addresses certain objections to it. (shrink)

Suicide prevention is a National Health Service priority in the United Kingdom. People with mental illness are seen to represent one of the most vulnerable groups for suicide and recent British Government policy has focused on prevention and management of perceived risk. This approach to suicide prevention is constructed under a biomedical model of psychiatry, which maintains that suicidal persons suffer from some form of disease or irrational drive towards self-destruction. Many react to the idea of self-inflicted death with instinctive (...) revulsion, which has prevented serious discussion of the concept of rational suicide, particularly in relation to those with schizophrenia. The idea that there may be circumstances in which suicide can be viewed as rational is discussed within the biomedical approach to ethics and wider literature primarily in relation to physical disease, terminal states and chronic pain. It is not deemed a viable choice for those who are considered ‘non-autonomous’ due to the controlling forces of mental illness. I propose that suicide is not a consequence of mental illness per se, and that it may be seen as a rational response to a realistic perspective on the course and consequences of living with schizophrenia. The denial of dialogue about the validity of suicidal ideation for people with schizophrenia has led to negative consequences for people with serious mental illness in terms of justice and recognition of person-hood. (shrink)

In the article the concept of natural death as used in end-of-life decision contexts is explored. Reviewing some recent empirical studies on end-of-life decision-making, it is argued that the concept of natural death should not be used as an action-guiding concept in end-of-life decisions both for being too imprecise and descriptively open in its current use but mainly since it appears to be superfluous to the kind of considerations that are really at stake in these situations. Considerations in terms of (...) the quality of life cost of the intervention in relation to the quality and length of life benefits of the same intervention. In referring to the concept of natural death we risk to blur these considerations and end up in difficult distinctions between what is a natural and non- or un-natural death, a distinction which it is argued is of no real moral interest. (shrink)

Most of us are more or less dissatisfied with some aspect of our present self and want to change it to a better future self. This makes us divided beings. The beliefs, emotions, and motives of our present self prompt us to act in one way and our desired future and better self often prompts us to act in another way. This makes us ambivalent. One of the shibboleths of the present age is that the key to overcoming our ambivalence (...) is to cultivate autonomy. This Kantian ideal is defended, developed, and somewhat revised by Christine Korsgaard, who constructs an ideal theory of self-constitution. This theory is untenable. Its very nature makes it incapable of addressing the concrete problems ambivalence presents to us in our very different individual circumstances. It unreasonably claims that either we meet arbitrary, unrealistic, and mind-bogglingly complex requirements, or disqualify ourselves from being rational and moral agents. And it optimistically assumes that by becoming more autonomous, we become more rational and moral, rather than merely continue to act in the ways we have been acting before. The failure of this latest ideal theory does not show that there is something wrong with autonomy. It shows that the extravagant claims Korsgaard makes for autonomy are groundless. The way to cope with our ambivalence is not to follow a theory, but to think better and harder about what we – individuals in individual circumstances – are, and want to be. (shrink)

In this article I defend a new definition of what it is to commit suicide:(D) A commits suicide by performing an act x if and only if A intends that he or she kill himself or herself by performing x (under the description ‘I kill myself’), and this intention is fully satisfied.The definition has some surprising implications: various real-life examples often referred to as ‘suicides’ (e.g. ‘suicide bombers’) may well turn out not to be suicides after all.1.

Recent writers on negligence and culpable ignorance have argued that there are two kinds of culpable ignorance: tracing cases, in which the agent’s ignorance traces back to some culpable act or omission of hers in the past that led to the current act, which therefore arguably inherits the culpability of that earlier failure; and non-tracing cases, in which there is no such earlier failure, so the agent’s current state of ignorance must be culpable in its own right. An unusual but (...) intriguing justification for blaming agents in non-tracing cases is provided by Attributionism, which holds that we are as blameworthy for our non-voluntary emotional reactions, spontaneous attitudes, and the ensuing patterns of awareness as we are for our voluntary actions. The Attributionist explanation for why some non-tracing cases involve culpability is an appealing one, even though it has limited scope. After providing a deeper account of why we should take the Attributionist position seriously, I use recent psychological research to argue for a new account of the conditions under which agents are culpable for straightforward instances of blameworthy acts. That account is extended to blameworthiness for non-voluntary responses. I conclude that even when the agent’s failure to notice arises from a nonvoluntary objectionable attitude, very few such cases are ones in which Attributionism implies that the agent is blameworthy for her act. (shrink)

Surveys in different countries (e.g. the UK, Belgium and The Netherlands) show a marked recent increase in the incidence of continuous deep sedation at the end of life (CDS). Several hypotheses can be formulated to explain the increasing performance of this practice. In this paper we focus on what we call the ‘natural death’ hypothesis, i.e. the hypothesis that acceptance of CDS has spread rapidly because death after CDS can be perceived as a ‘natural’ death by medical practitioners, patients' relatives (...) and patients.We attempt to show that the label ‘natural’ cannot be unproblematically applied to the nature of this end-of-life practice. We argue that the labeling of death following CDS as ‘natural’ death is related to a complex set of mechanisms which facilitate the use of this practice. However, our criticism does not preclude the view that CDS may be clinically and ethically justified in many cases. (shrink)

In this essay, we present three case studies which suggest that sometimes we are better off supporting a so–called irrational suicide, and that emotional or psychological distress – even if medically controllable – might justify a suicide. We underscore how complicated these decisions are and how murky a physician's moral role can be. We advocate a more individualized route to end–of–life care, eschewing well–meaning, principled, generalizations in favor of a highly contextualized, patient–centered, approach. We conclude that our Western traditions of (...) promoting reasoned behavior and life themselves may at times be counter–productive. (shrink)

A large part of the debate around the right to refuse life-prolonging treatment of anorexia nervosa sufferers centers on the issue of competence. Whether or not the anorexic should be allowed to refuse life-saving treatment does not depend solely or primarily on competence. It also depends on whether the anorexic’s suffering is bearable or tractable, and on the degree of involvement of the family in the therapeutic process. Anorexics could be competent to refuse lifesaving treatment (Giordano 2008). However, the anorexic’s (...) refusal of life-saving treatment should not be respected purely because it is a competent decision. In fact, anorexia has two characteristics that weaken the strength of the principle .. (shrink)

In contemplating any life and death moral dilemma, one is often struck by the possible importance of two distinctions; the distinction between killing and “letting die”, and the distinction between an intentional killing and an action aimed at some other outcome that causes death as a foreseen but unintended “side-effect”. Many feel intuitively that these distinctions are morally significant, but attempts to explain why this might be so have been unconvincing. In this paper, I explore the problem from an explicitly (...) consequentialist point of view. I first review and endorse the arguments that the distinctions cannot be drawn with perfect clarity, and that they do not have the kind of fundamental significance required to defend an absolute prohibition on killing. I go on to argue that the distinctions are nonetheless important. A complete consequentialist account of morality must include a consideration of our need and ability to construct and follow rules; our instincts about these rules; and the consequences that might follow if the agent breaks a good general rule, particularly if this involves acting contrary to moral instinct. With this perspective, I suggest that the distinctions between killing and letting die and between intending and foreseeing do have moral relevance, especially for those involved in the care of the sick and dying. (shrink)

Conventional medical ethics and the law draw a bright line distinguishing the permitted practice of withdrawing life-sustaining treatment from the forbidden practice of active euthanasia by means of a lethal injection. When clinicians justifiably withdraw life-sustaining treatment, they allow patients to die but do not cause, intend, or have moral responsibility for, the patient's death. In contrast, physicians unjustifiably kill patients whenever they intentionally administer a lethal dose of medication. We argue that the differential moral assessment of these two practices (...) is based on a series of moral fictions – motivated false beliefs that erroneously characterize withdrawing life-sustaining treatment in order to bring accepted end-of-life practices in line with the prevailing moral norm that doctors must never kill patients. When these moral fictions are exposed, it becomes apparent that conventional medical ethics relating to end-of-life decisions is radically mistaken. (shrink)

This paper presents a way of classifying different forms of naturalness and unnaturalness. Three main forms of (un)naturalness are found as the following: history- based (un)naturalness, property-based (un)naturalness and relation-based (un)naturalness. Numerous subforms (and some subforms of the subforms) of each are presented. The subforms differ with respect to the entities that are found (un)natural, with respect to their all-inclusiveness, and whether (un)naturalness is seen as all-or-nothing affair, or a continuous gradient. This kind of conceptual analysis is needed, first, because (...) discussion concerning (un)naturalness is common in current bioethics and environmental ethics, and second, because the terms natural and unnatural are highly ambiguous. Thus, the lack of an exact definition of the type of (un)naturalness may lead into equivocation, other forms of bad argumentation, or at least vagueness. (shrink)

Death concept, death definition, death criterion and death test pluralism has been described by some as a problematic approach. Others have claimed it to be a promising way forward within modern pluralistic societies. This article describes the New Jersey Death Definition Law and the Japanese Transplantation Law. Both of these laws allow for more than one death concept within a single legal system. The article discusses a philosophical basis for these laws starting from John Rawls' understanding of comprehensive doctrines, reasonable (...) pluralism and overlapping consensus. It argues for the view that a certain legal pluralism in areas of disputed metaphysical, philosophical and/or religious questions should be allowed, as long as the disputed questions concern the individual and the resulting policy, law or acts based on the policy/law, do not harm the lives of other individuals to an intolerable extent. However, while this death concept, death definition, death criterion and death test pluralism solves some problems, it creates others. (shrink)

ABSTRACTThere are a number of arguments that purport to show, in general terms, that there is no difference between killing and letting die. These are used to justify active euthanasia on the basis of the reasons given for allowing patients to die. I argue that the general and abstract arguments fail to take account of the complex and particular situations which are found in the care of those with terminal illness. When in such situations, there are perceptions and intuitions available (...) that do not easily find propositional form but lead most of those whose practice is in the care of the dying to resist active euthanasia. I make a plea for their intuitions to be heeded above the sterile voice of abstract premises and arguments by examining the completeness of the outline form of the pro‐euthanasia argument. In doing so, I make use of Nussbaum's discussion of moral perception and general claims to be found in the literature of moral particularism. (shrink)

This is a comprehensive resource of original essays by leading thinkers exploring the newly emerging inter-disciplinary field of the philosophy of psychiatry. The contributors aim to define this exciting field and to highlight the philosophical assumptions and issues that underlie psychiatric theory and practice, the category of mental disorder, and rationales for its social, clinical and legal treatment. As a branch of medicine and a healing practice, psychiatry relies on presuppositions that are deeply and unavoidably philosophical. Conceptions of rationality, personhood (...) and autonomy frame our understanding and treatment of mental disorder. Philosophical questions of evidence, reality, truth, science, and values give meaning to each of the social institutions and practices concerned with mental health care. The psyche, the mind and its relation to the body, subjectivity and consciousness, personal identity and character, thought, will, memory, and emotions are equally the stuff of traditional philosophical inquiry and of the psychiatric enterprise. A new research field--the philosophy of psychiatry--began to form during the last two decades of the twentieth century. Prompted by a growing recognition that philosophical ideas underlie many aspects of clinical practice, psychiatric theorizing and research, mental health policy, and the economics and politics of mental health care, academic philosophers, practitioners, and philosophically trained psychiatrists have begun a series of vital, cross-disciplinary exchanges. This volume provides a sampling of the research yield of those exchanges. Leading thinkers in this area, including clinicians, philosophers, psychologists, and interdisciplinary teams, provide original discussions that are not only expository and critical, but also a reflection of their authors' distinctive and often powerful and imaginative viewpoints and theories. All the discussions break new theoretical ground. As befits such an interdisciplinary effort, they are methodologically eclectic, and varied and divergent in their assumptions and conclusions; together, they comprise a significant new exploration, definition, and mapping of the philosophical aspects of psychiatric theory and practice. (shrink)

ABSTRACT There are a number of arguments that purport to show, in general terms, that there is no difference between killing and letting die. These are used to justify active euthanasia on the basis of the reasons given for allowing patients to die. I argue that the general and abstract arguments fail to take account of the complex and particular situations which are found in the care of those with terminal illness. When in such situations, there are perceptions and intuitions (...) available that do not easily find propositional form but lead most of those whose practice is in the care of the dying to resist active euthanasia. I make a plea for their intuitions to be heeded above the sterile voice of abstract premises and arguments by examining the completeness of the outline form of the pro‐euthanasia argument. In doing so, I make use of Nussbaum's discussion of moral perception and general claims to be found in the literature of moral particularism. (shrink)