Decision-making Capacity matters to whether a patient’s decision should determine her treatment. But why it matters in this way isn’t clear. The standard story is that dmc matters because autonomy matters. And this is thought to justify dmc as a gatekeeper for autonomy – whereby autonomy concerns arise if but only if a patient has dmc. But appeals to autonomy invoke two distinct concerns: concern for authenticity – concern that a choice is consistent with an individual’s commitments; (...) and concern for sovereignty – concern that an individual exercises control over that which is hers to control. Here, I argue, neither concern can alone explain why dmc matters. Instead, dmc matters because it indicates a harmony between the two concerns – the demands of each concern are more likely to agree if a patient has dmc. This vindicates the standard story, but also makes clear that dmc is an inappropriate gatekeeper for autonomy. (shrink)

Decision-making capacity (DMC) plays an important role in clinical practice—determining, on the basis of a patient’s decisional abilities, whether they are entitled to make their own medical decisions or whether a surrogate must be secured to participate in decisions on their behalf. As a result, it’s critical that we get things right—that our conceptual framework be well-suited to the task of helping practitioners systematically sort through the relevant ethical considerations in a way that reliably and transparently delivers correct (...) verdicts about who should and should not have the authority to make their own medical decisions. Unfortunately, however, the standard approach to DMC does not get things right. It is of virtually no help in identifying and clarifying the relevant ethical considerations. And, embedded in the prevailing anti-paternalist paradigm, DMC assessments obfuscate and distort the underlying ethical justification for granting or withholding decisional authority. Here, we describe the core commitments of the standard approach to DMC and then highlight three problems with it. We then argue that these problems are significant enough that they call for more than merely tinkering and fine tuning—variations of the standard approach cannot adequately address them. Instead, we should ditch DMC. (shrink)

There is wide consensus among bioethicists about the importance of autonomy when determining whether or not a patient has the right to refuse life-saving treatment (LST). In this context, autonomy has typically been understood in terms of the patient’s ability to make an informed decision. According to the traditional view, decision-making capacity (DMC) is seen as both necessary and sufficient for the right to refuse LST. Recently, this view has been challenged by those who think that considerations (...) of authenticity and putative counterexamples should lead us to revise the traditional account. In this paper, we respond to these revisionist arguments, and we defend the traditional view according to which we have autonomy-based reasons to respect a patient’s decision to refuse LST if and only if she has DMC. (shrink)

This article is about the information relevant to decision-making capacity in refusal of life-prolonging medical treatment cases. We examine the degree to which the phenomenology of the options available to the agent—what the relevant states of affairs will feel like for them—forms part of the capacity-relevant information in the law of England and Wales, and how this informational basis varies across adolescent and adult medical treatment cases. We identify an important doctrinal phenomenon. In the leading authorities, the courts (...) appear to count the first-personal phenomenology of the available options among the information that adolescents seeking to refuse life-prolonging treatment must understand and appreciate in order to possess capacity; adults are not held to this (higher) standard. We evaluate this differential treatment in light of philosophical work on transformative choice—decisions involving options whose sensory character, and effect on our values and preferences, are grasped only through experience itself. (shrink)

Any ethical inquiry into addiction research is faced with the preliminary challenge that the term “addiction” is itself a matter of scientific and ethical controversy. Accordingly, the chapter begins with a brief history of the term “addiction.” The chapter then turns to ethical issues surrounding consent and decision-making capacity viewed from the perspective of the current opioid epidemic. One concern is the neglect of the cyclical nature of addiction and the implications of this for the validity of current (...) psychometric instruments used to evaluate decision-making capacity in addiction. Another is the apparent discrepancy—possibly an ethical double standard—in the manner in which society and addiction researchers view the mental capacity and vulnerability of individuals who suffer from severe addiction. On the whole, the main ethical concern of the chapter is the puzzling lack of clinical research on decision-making capacity in research on addiction. (shrink)

The dominant approach to assessing decision-making capacity in medicine focuses on determining the extent to which individuals possess certain core cognitive abilities. Critics have argued that this model delivers the wrong verdict in certain cases where patient values that are the product of mental disorder or disordered affective states undermine decision-making without undermining cognition. I argue for a re-conceptualization of what it is to possess the capacity to make medical treatment decisions. It is, I argue, the (...) ability to track one’s own personal interests at least as well as most people can. Using this idea, I demonstrate that it is possible to craft a solution for the problem cases—one that neither alters existing criteria in dangerous ways (e.g. does not open the door to various kinds of abuse) nor violates the spirit of widely accepted ethical constraints on decision-making assessment. (shrink)

Jennifer Hawkins (2024) offers two cases that challenge traditional accounts of decision-making capacity, according to which respect for a medical decision turns on an individual’s cognitive capacities at the time the decision is made (Hawkins 2024; Appelbaum and Grisso 1988). In each of her described cases (involving anorexia nervosa and grief, respectively), a patient makes a decision that—although instrumentally rational at the time—does not reflect the patient’s longer-term values due to being in a particular psychological (...) state. Importantly, this state does not impair the patient’s cognition, but rather predisposes them to make a decision that conflicts with their own broader values, beliefs, or desires. (shrink)

Whether anorexic patients should be able to refuse treatment when this potentially has a fatal outcome is a vexed topic. A recent proposal for a new category of ‘terminal anorexia’ suggests criteria when a move to palliative care or even physician assisted suicide might be justified. I argue that this proposed diagnosis presents a false sense of certainty of the illness trajectory by conceptualizing anorexia in analogy with physical disorders and stressing the effects of starvation. Furthermore, this conceptualization is in (...) conflict with the claim that individuals who meet the diagnostic criteria for terminal anorexia have decision making capacity. It should therefore be rejected. (shrink)

For people with Bipolar Affective Disorder, a self-binding (advance) directive (SBD), by which they commit themselves to treatment during future episodes of mania, even if unwilling, can seem the most rational way to deal with an imperfect predicament. Knowing that mania will almost certainly cause enormous damage to themselves, their preferred solution may well be to allow trusted others to enforce treatment and constraint, traumatic though this may be. No adequate provision exists for drafting a truly effective SBD and efforts (...) to establish such provision are hampered by very valid, but also paralysing ethical, clinical and legal concerns. Effectively, the autonomy and rights of people with bipolar are being 'protected' through being denied an opportunity to protect themselves. From a standpoint firmly rooted in the clinical context and experience of mania, this article argues that an SBD, based on a patient-centred evaluation of capacity to make treatment decisions (DMC-T) and grounded within the clinician-patient relationship, could represent a legitimate and ethically coherent form of self-determination. After setting out background information on fluctuating capacity, mania and advance directives, this article proposes a framework for constructing such an SBD, and considers common objections, possible solutions and suggestions for future research. (shrink)

According to many of its proponents, shared decision making ("SDM") is the right way to interpret the clinician-patient relationship because it respects patient autonomy in decision-making contexts. In particular, medical ethicists have claimed that SDM respects a patient's relational autonomy understood as a capacity that depends upon, and can only be sustained by, interpersonal relationships as well as broader health care and social conditions. This paper challenges that claim. By considering two primary approaches to relational autonomy, (...) this paper argues that standard accounts of SDM actually undermine patient autonomy. It also provides an overview of the obligations generated by the principle of respect for relational autonomy that have not been captured in standard accounts of SDM and which are necessary to ensure consistency between clinical practice and respect for patient autonomy. (shrink)

Shared Decision Making (‘SDM’) is one of the most significant developments in Western health care practices in recent years. Whereas traditional models of care operate on the basis of the physician as the primary medical decision maker, SDM requires patients to be supported to consider options in order to achieve informed preferences by mutually sharing the best available evidence. According to its proponents, SDM is the right way to interpret the clinician-patient relationship because it fulfils the ethical (...) imperative of respecting patient autonomy. However, there is no consensus about how decisions in SDM contexts relate to the principle of respect for autonomy. In response, I demonstrate that in order to make decisions about what treatment they will or will not receive, patients will be required to meet different conditions depending on the approach proponents of SDM take to understanding personal autonomy. Due to the fact that different conceptions of autonomy yield different obligations, I argue that if physicians and patients satisfied all the conditions described in standard accounts of SDM, then SDM would undermine patient autonomy. (shrink)

A crucial question in relation to support designed to enable the legal capacity of people with mental disabilities concerns when support constitutes undue influence. This article addresses this question in order to facilitate the development of law and policy in England and Wales, by providing a normative analysis of the different approaches to undue influence across decisions about property, contracts, health, finances, and accommodation. These are all potential contexts for supporting legal capacity, and, in doing so, the article compares approaches (...) to undue influence that are rarely considered together. -/- Drawing on the UN Convention on the Rights of Persons with Disabilities, third sector and public body documents, and law in England and Wales, the analysis identifies six models that conceptualise undue influence in terms of: modes of influence; an overborne will; an inference from the situation; an overborne will understood as a mental incapacity; an overborne will in connection with vulnerability; and impaired discursive control. This final approach is a novel proposal for understanding undue influence. The analysis highlights key policy-relevant issues that distinguish the models, and generates a deliberative framework for navigating them, with the ‘overborne will’, ‘inference-based’, and ‘discursive control’ models identified as potentially fitting for the support context. (shrink)

What does it mean to respect autonomy and encourage meaningful consent to treatment in the case of patients who have dementia or are otherwise incompetent? This question has been thrown into sharp relief by the Law Lords' decision in R.v Bournewood Community and Mental Health NHS Trust, ex parte L.

The scientific understanding of cognition and consciousness is currently hampered by the lack of rigorous and universally accepted definitions that permit comparative studies. This paper proposes new functional and un- ambiguous definitions for cognition and consciousness in order to provide clearly defined boundaries within which general theories of cognition and consciousness may be developed. The proposed definitions are built upon the construction and manipulation of reality representation, decision making and learning and are scoped in terms of an underlying (...) logical structure. It is argued that the presentation of reality also necessitates the concept of ab- sence and the capacity to perform transitive inference. Explicit predictions relating to these new definitions, along with possible ways to test them, are also described and discussed. (shrink)

The Substituted Judgment Standard for surrogate decision-making dictates that a surrogate, when making medical decisions on behalf of an incapacitated patient, ought to make the decision that the patient would have made if the patient had decisional capacity. Despite its intuitive appeal, however, SJS has been the target of a variety of criticisms. Most objections to SJS appeal to epistemic difficulties involved in determining what a patient would have decided in a given case. In this article, (...) I offer an alternative standard for surrogate decision-making that avoids these difficulties. I then offer an account of its theoretical underpinnings which shows that it preserves the central moral justification for SJS, namely, respect for patient autonomy. (shrink)

In the recent literature on episodic memory, there has been increasing recognition of the need to provide an account of its adaptive function. In this context, it is sometimes argued that episodic memory is critical for certain forms of decision making about the future. We criticize existing accounts that try to give episodic memory a role in decision making, before giving a novel such account of our own. This turns on the thought of a link between (...) episodic memory and the emotion of regret. We discuss how both experienced and anticipated regret can have a distinctive influence on decision making, and argue that the ability to recollect past events in episodic memory underpins the capacity to engage in the sophisticated types of mental time travel recruited in experiencing and anticipating regret. (shrink)

An important philosophical issue in the study of addiction is what difference the fact that a person is addicted makes to attributions of autonomy (and responsibility) to their drug-oriented behavior. In spite of accumulating evidence suggesting the role of emotional dysregulation in understanding addiction, it has received surprisingly little attention in the debate about this issue. I claim that, as a result, an important aspect of the autonomy impairment of many addicted individuals has been largely overlooked. A widely shared assumption (...) in the philosophical literature is that for addiction to impair a person’s autonomy it has to make them (in some sense) take drugs against their will. So-called “willing addicts” are therefore usually seen as exempted from the autonomy impairment believed to characterize “unwilling addicts”, the latter being those who ‘truly want’ to stop using drugs but find their attempts repeatedly derailed by failures of self-control. In this article, I argue that the association between addiction and emotional dysregulation shows why this assumption is false. Emotional dysregulation is not only consistent with the possibility that many addicts take drugs ‘willingly’, it supports the hypothesis that they use drugs because they truly want to. The article proposes an explanation for why emotional dysregulation should nevertheless be seen as an aspect of their loss of control and an important reason why they have impaired autonomy. I end by exploring some implications of this account for addict’s decision-making capacity when they are prescribed the drugs to which they are addicted. -/- . (shrink)

Local participation is always beneficial for sustainable action and environmental problems resulting from urban implementation due to the failure of social and institutional change necessary for a successful transformation of rural life to urban life ahead of the rapid movement of the population. Despite good legal practice and comprehensive guidelines, evidence suggests that Environmental Impact Assessment (EIA) or more broadly Environmental, Social and Health Impact Assessment (ESHIA) have not yet been found satisfactory in Nigeria, as the current system amounts to (...) duplication of efforts and cost. However, ESHIA has been developed and integrated to help manage project activities, facilities, and operations sustainably, so that both economic and ecological profits are accrued (sustainable development) or ensure that any development project does not result in excessive deterioration of and/or the irreversible adverse effect on any component of the environment – a recite for sustainable development. A literature review was done by using a variety of search engines including Research Gate, Google Scholar, Academia, Mendeley, SSRN search strategy to retrieve research publications, “grey literature” and expert working group reports. The thrust of this study is to evaluate the potential benefits of ESHIA as a tool for sustainable environmental development. The evaluation and implementation of EIA are one of the strengths of these tools. Indeed, EIA is the first and foremost management tool employed to help mitigate adverse, potential, and associated impacts of proposed major developments in our environment. EIA is a regulatory requirement that is efficiently used to improve performance, project design, enhancing decision-making, and facilitating policy programs in a sustainable environment. An evaluation of the EIA systems reveals several weaknesses of the EIA system. These include the inadequate capacity of EIA approval authorities, deficiencies in screening and scoping, poor EIA quality, insufficient public participation, and weak monitoring, and erratic government policies. Overall, most EIA study rarely meets the objectives of being a project planning tool to contribute to achieving sustainable development and mitigate the impact of the development project. The study recommends some directions for the future to ensure that entire content of the EIA are religiously implemented, review the existing EIA act, increase the expertise of EIA consultants, create a liaison office with an international organisation and with sister agency, ESHIA must enjoy Improved budgetary provision, time latitude, spatial contexts and methodological improvements for outcome measures to achieve results that are relevant to sustainable development by improving project design, enhancing decision making and facilitating policy programs. (shrink)

Charland's article suggests that we need to think more about whether decision-making capacity is impaired in severe addiction, working from the idea that drug dealers rely on this understanding of addiction to draw in their clients. Charland argues that it is possible to make a choice without being in control (to make decisions without having decision-making capacity). I argue in support of Charland's ideas by examining the reasons supporting a medical model of addiction and its importance. (...) (For Charland's article and the full set of commentaries, please see the Research Gate link). (shrink)

Most adult persons with anorexia satisfy the existing criteria widely used to assess decision-making capacity, meaning that incapacity typically cannot be used to justify coercive intervention. After rejecting two other approaches to justification, Professor Radden concludes that it is most likely not possible to justify coercive medical intervention for persons with anorexia in liberal terms, though she leaves it open whether some other framework might succeed. I shall assume here that the standard approach to assessing decisionmaking capacity is (...) adequate.1 The question then is whether we can justify—within a liberal framework—coercive intervention with the decision of a competent... (shrink)

A key objective of the law in the assessment of decision-making capacity in clinical settings is to allow clinicians and judges to avoid making value judgements about the reasons that patients use to refuse treatment. This paper advances two lines of argument in respect of this objective. The first is that authorities cannot rationally avoid significant evaluative judgements in the assessment of a patient’s own assessment of the facts of their case. Assessing reasoning is unavoidably value-laden. Yet (...) the underlying motivation behind clinicians’ and the law’s value-neutral aims, ie, the avoidance of undue paternalism, is worth preserving. That being so, the second line of argument will try to show that that underlying motivation is better served in a limited range of cases by embedding a ‘reversibility standard’ in the assessment process so that the patient can, if they wish, and in due course, bring about the consequences that they were prevented from realising as a result of a determination of incapacity. (shrink)

Mackenzie Graham has made an important contribution to the literature on decisionmaking for patients with disorders of consciousness. He argues, and I agree, that decisions for unresponsive patients who are known to retain some degree of covert awareness ought to focus on current interests, since such patients likely retain the kinds of mental capacities that in ordinary life command our current respect and attention. If he is right, then it is not appropriate to make decisions for such patients by appealing (...) to the values they had in the past, either the values expressed in an advance directive or the values recalled by a surrogate. There are two things I wish to add to the discussion. My first point is somewhat critical, for although I agree with his general conclusion about how, ideally, such decisions should be approached, I remain skeptical about whether his conclusion offers decisionmakers real practical help. The problem with these cases is that the evidence we have about the nature of the patient’s current interests is minimal or nonexistent. However—and this is important—Graham’s conclusion will be extremely relevant if in the future, our ability to communicate with such patients improves, as I hope it will. This leads to my second point. Graham’s conclusion illustrates a more general problem with our standard framework for decisionmaking for previously competent patients, a problem that has not been adequately recognized. So, in what follows, I explain the problem I see and offer some brief thoughts about solutions. (shrink)

This article advances two views on the role of evaluative judgment in clinical assessments of decision-making capacity. The first is that it is rationally impossible for such assessments to exclude judgments of the values a patient uses to motivate their decision-making. Predictably, and second, attempting to exclude such judgments sometimes yields outcomes that contain intractable dilemmas that harm patients. These arguments count against the prevailing model of assessment in common law countries—the four abilities model—which is often (...) incorrectly advertised as being value-neutral in respect of patient decision-making both by its proponents and in statute. A straightforward evaluative model of capacity assessment which wears its values on its sleeves and is biased against what are called ‘serious prudential mistakes’ avoids these rational and practical problems. (shrink)

The chapter traces the history of psychiatric ethics with a focus on the emergence of autonomy and how assumptions and thresholds surrounding informed consent and decision-making capacity have changed over the centuries. Innovators like Philippe PInel and William Tuke are featured in this account of how the 'mad' and the abuses of the 'domestication paradigm' of madness eventually gave way to more humanitarian approaches of treating the 'mad', like moral treatment. The chapter closes with a brief reflection regarding (...) the limits of autonomy and the decline of paternalism in psychiatric ethics. (shrink)

It is widely accepted among medical ethicists that competence is a necessary condition for informed consent. In this view, if a patient is incompetent to make a particular treatment decision, the decision must be based on an advance directive or made by a substitute decision-maker on behalf of the patient. We call this the competence model. According to a recent report of the United Nations (UN) High Commissioner for Human Rights, article 12 of the UN Convention on (...) the Rights of Persons with Disabilities (CRPD) presents a wholesale rejection of the competence model. The High Commissioner here adopts the interpretation of article 12 proposed by the Committee on the Rights of Persons with Disabilities. On this interpretation, CRPD article 12 renders it impermissible to deny persons with mental disabilities the right to make treatment decisions on the basis of impaired decision-making capacity and demands the replacement of all regimes of substitute decision-making by supported decision-making. In this paper, we explicate six adverse consequences of CRPD article 12 for persons with mental disabilities and propose an alternative way forward. The proposed model combines the strengths of the competence model and supported decision-making. (shrink)

This article draws upon the civic republican tradition to offer new conceptual resources for the normative assessment of mental capacity law. The republican conception of liberty as non-domination is used to identify ways in which such laws generate arbitrary power that can underpin relationships of servility and insecurity. It also shows how non-domination provides a basis for critiquing legal tests of decision-making that rely upon ‘diagnostic’ rather than ‘functional’ criteria. In response, two main civic republican strategies are recommended (...) for securing freedom in the context of the legal regulation of psychological disability: self-authorisation techniques and participatory shaping of power. The result is a series of proposals for the reform of decisional capacity law, including a transition towards purely functional assessment of decisional capacity, surer legal footing for advanced care planning, and greater control over the design and administration of decision-making capacity laws by those with psychological disabilities. (shrink)

It is usually appropriate for adults to make significant decisions, such as about what kinds of medical treatment to undergo, for themselves. But sometimes impairments are suffered - either temporary or permanent - which render an individual unable to make such decisions. The Mental Capacity Act 2005 sets out the conditions under which it is appropriate to regard an individual as lacking the capacity to make a particular decision (and when provisions should be made for a decision on (...) their behalf). -/- To what extent does having capacity require the endorsement of certain values? Drawing on Owens et al (2009), I assess the extent to which understanding relevant information and weighing it in coming to a decision requires certain evaluative commitments. With reference to literature on anorexia nervosa and decisions informed by religious beliefs, I argue that it is difficult to avoid the conclusion that the conditions for capacity are value-laden, and that if this is so it is important to open discussion about which patterns of distorted valuing undermine capacity, and why. (shrink)

The conventional wisdom about advance care planning holds that the normative force of my prior wishes is simply that they are mine. It is their connection to me that matters. This paper challenges conventional thinking. I propose that the normative force of prior wishes does not depend exclusively on personal identity. Instead, it sometimes depends on a special relationship that exists between a prior, capacitated person and a now incapacitated person. I consider what normative guidance governs persons who stand in (...) a special relationship, and contrast these with the standard model of respect for autonomy. My conclusion is that advance care planning for individuals who have lost decision-making capacity should incorporate the virtues of prudence and integrity, even when one and the same person ceases to exist, and respect for personal autonomy is no longer relevant. (shrink)

“Bodily autonomy” has received significant attention in bioethics, medical ethics, and medical law in terms of the general inviolability of a patient’s bodily sovereignty and the rights of patients to make choices (e.g., reproductive choices) that concern their own body. However, the role of the body in terms of how it can or does contribute to a patient’s capacity for, or exercises of their autonomy in clinical decision-making situations has not been explicitly addressed. The approach to autonomy in (...) this paper is aligned with traditional theories that conceive autonomy in terms of an individual’s capacities for, and exercises of rational reflection. However, at the same time, this paper extends these accounts by arguing that autonomy is, in part, embodied. Specifically, by drawing on phenomenological conceptions of the experience of autonomy, we argue that, in principle, the body is a necessary component of the capacity for autonomy. Secondly, through the presentation of two different cases, we highlight ways in which a patient’s body can contribute to the autonomy of treatment choices. Ultimately, we hope to encourage others to explore additional conditions under which a concept of embodied autonomy should be employed in medical decision making, how its underlying principles might be operationalised in clinical situations, and its consequences for approaches to patient autonomy in healthcare practice, policy, and law. (shrink)

In this article, we focus on the definition and application of the sliding scale of capacity. We show that the current interpretations of the sliding scale confound distinct features of the medical decision, such as its urgency, its severity, or its complexity, that do not always covary.We propose that the threshold for assessing capacity should be adjusted based solely on the cognitive complexity of the decision at hand. We further suggest that the complexity of a decision should (...) be identified based on a patient’s particular cognitive deficits. We utilize the current research on the types of deficits that characterize amnestic dementias and examine which types of medical decisions might be most complex for patients with that type of dementia. We conclude that applying the sliding scale based on individualized judgments of cognitive complexity will improve accuracy of assessment of capacity and enable capable patients to participate in medical decision making. (shrink)

It is increasingly acknowledged that creativity cannot be fully understood without considering the setting where it takes place. Building on this premise, we use the concepts of niche construction, scaffolding, coupling, and functional integration to expound on the environmentally situated nature of painters’ studio work. Our analysis shows studios to be multi-resource niches that are customized by artists to support various capacities, states, and actions crucial to painting. When at work in these personalized spaces, painters do not need to rely (...) solely on their “inner” powers of imagination, memory, decision making, and technique to execute their paintings. Instead, with the help of carefully selected resources, they can offload elements of creative mentation and action onto the studio niche and enact different forms of a creative agency. To put more flesh on these ideas, we examine how painters use existing artworks, memory aids, and music to scaffold the creative process. Overall, our analysis illuminates underexamined aspects of environmentally situated creativity and demonstrates the broader utility of the applied concepts for future creativity research. (shrink)

Aryeh Goldberg compellingly argues for a Narrative Coherence Standard (NCS) to bolster existing methods of assessing patients' mental capacity. But his account fails to distinguish between the cognitive abilities of children and adults; consequently, worries may be raised about the scope of the NCS, in particular when we consider child patients. In this article, I argue the NCS cannot plausibly apply to children. Since children's self-conception does not arrive fully formed — but rather is a product of both incomplete cognitive (...) development and socializing factors — I claim children may not possess a sufficiently intimate knowledge of self, and therefore a sufficiently coherent sense of self, as Goldberg demands. Therefore, we should either revise the NCS to accommodate children, adopt an incremental view of consent, or revert to the relevant form of the MacArthur competence criteria to establish children’s capacity to consent. (shrink)

The goal of achieving Universal Health Coverage (UHC) can generally be realized only in stages. Moreover, resource, capacity and political constraints mean governments often face difficult trade-offs on the path to UHC. In a 2014 report, Making fair choices on the path to UHC, the WHO Consultative Group on Equity and Universal Health Coverage articulated principles for making such trade-offs in an equitable manner. We present three case studies which illustrate how these principles can guide practical decision- (...) class='Hi'>making. These case studies show how progressive realization of the right to health can be effectively guided by priority-setting principles, including generating the greatest total health gain, priority for the worse off, and financial risk protection. They also demonstrate the value of a fair and accountable process of priority setting. (shrink)

According to the High Court in England and Wales, the primary purpose of legal interventions into the lives of vulnerable adults with mental capacity should be to allow the individuals concerned to regain their autonomy of decision making. However, recent cases of clinical decision making involving capacitous vulnerable adults have shown that, when it comes to medical law, medical ethics and clinical practice, vulnerability is typically conceived as opposed to autonomy. The first aim of this paper (...) is to detail the problems that arise when the courts and health care practitioners respond to the vulnerability of capacitous adults on the basis of such an opposition. It will be shown that not only does the common law approach to vulnerability fail to adequately capture the autonomy of capacitous vulnerable adults, the conception of vulnerability and autonomy in oppositional terms leads to objectionably paternalistic health care responses that undermine the autonomy of vulnerable patients as well as clinical and legal interventions that violate their autonomy. In response, the second aim of this paper is to show that the concepts of autonomy and vulnerability are necessarily entwined and, on that basis, the focus should be on promoting the autonomy of capacitous vulnerable adults where possible. In order to make this case, the paper explains the limitations of standard approaches to the autonomy of vulnerable adults and, in their place, offers a conception of legitimate, self-authorised autonomy that is fundamentally dependent on intersubjective practices of recognition. (shrink)

With the increasing degrees A.I.s and machines are applied across different social contexts, the need for implementing ethics in A.I.s is pressing. In this paper, we argue for a pluralist hybrid model for the implementation of moral A.I.s. We first survey current approaches to moral A.I.s and their inherent limitations. Then we propose the pluralist hybrid approach and show how these limitations of moral A.I.s can be partly alleviated by the pluralist hybrid approach. The core ethical decision-making capacity (...) of an A.I. based on the pluralist hybrid approach consists of two systems. The first is a deterministic algorithm system that incorporates different moral rules for making explicit moral decisions. The second is a machine learning system that calculates the value of the variables required by the application of moral principles. The pluralist hybrid system is better than the existing proposals as (i) it better addresses the moral disagreement problem of the top-down approach by including different moral principles, while (ii) it reduces the opacity of ethical decision-making compared with a bottom-up system by implementing explicit moral principles for moral decision making. (shrink)

In this article, we describe a project in which philosophy, in combination with methods drawn from mental modeling, was used to structure dialogue among stakeholders in a region-scale climate adaptation process. The case study we discuss synthesizes the Toolbox dialogue method, a philosophically grounded approach to enhancing communication and collaboration in complex research and practice, with a mental modeling approach rooted in risk analysis, assessment, and communication to structure conversations among non-academic stakeholders who have a common interest in planning for (...) a sustainable future. We begin by describing the background of this project, including details about climate resiliency efforts in West Michigan and the Toolbox dialogue method, which was extended in this project from academic research into community organization involving the West Michigan Climate Resiliency Framework Initiative. This extension involved application of several methods, which are the focus of the Methods section. We then present and discuss preliminary results that suggest the potential for philosophical dialogue to enhance mutual understanding in complex community initiatives that focus on sustainable responses to climate change. Overall, the article supplies a detailed, instructive example of how philosophy can support policy-relevant decision-making processes at the community level. (shrink)

Consent governs innumerable everyday social interactions, including sex, medical exams, the use of property, and economic transactions. Yet little is known about how ordinary people reason about the validity of consent. Across the domains of sex, medicine, and police entry, Study 1 showed that when agents lack autonomous decision-making capacities, participants are less likely to view their consent as valid; however, failing to exercise this capacity and deciding in a nonautonomous way did not reduce consent judgments. Study 2 (...) found that specific and concrete incapacities reduced judgments of valid consent, but failing to exercise these specific capacities did not, even when the consenter makes an irrational and inauthentic decision. Finally, Study 3 showed that the effect of autonomy on judgments of valid consent carries important downstream consequences for moral reasoning about the rights and obligations of third parties, even when the consented-to action is morally wrong. Overall, these findings suggest that laypeople embrace a normative, domain-general concept of valid consent that depends consistently on the possession of autonomous capacities, but not on the exercise of these capacities. Autonomous decisions and autonomous capacities thus play divergent roles in moral reasoning about consent interactions: while the former appears relevant for assessing the wrongfulness of consented-to acts, the latter plays a role in whether consent is regarded as authoritative and therefore as transforming moral rights. (shrink)

Adolescents are routinely treated differently to adults, even when they possess similar capacities. In this article, we explore the justification for one case of differential treatment of adolescents. We attempt to make philosophical sense of the concurrent consents doctrine in law: adolescents found to have decision-making capacity have the power to consent to—and thereby, all else being equal, permit—their own medical treatment, but they lack the power always to refuse treatment and so render it impermissible. Other parties, that (...) is, individuals who exercise parental responsibility or a court, retain the authority to consent on an adolescent’s behalf. We explore four defences of the doctrine. We reject two attempts to defend the asymmetry in the power to consent to and refuse medical treatment by reference to transitional paternalism. We then consider and reject a stage of life justification. Finally, we articulate a justification based on the distinctiveness of adolescent well-being. (shrink)

Humankind is facing many existential global problems that require international and transgenerational efforts to be solved. Preparing our next generation with sufficient knowledge and skills to deal with such problems is imperative. Fortunately, the digital environment provides foundational conditions for children’s and adolescents’ exploration and self-learning, which might help them cultivate the necessary knowledge and skills for future survival. We conducted the Bayesian Mindsponge Framework (BMF) analytics on a dataset of 2069 students from 54 Vietnamese elementary, secondary, and high schools (...) to test this presumption. The results showed that students with higher digital literacy are more curious and have better knowledge regarding global issues (i.e., climate change, disease, overpopulation, aging, etc.). Students’ curiosity also mediates the relationship between digital literacy and global issues knowledge. Based on these findings, we argue that digital explorative space is essential for digital natives’ education for survival, individually (i.e., for future employment requirements) and socially (i.e., for making informed decisions and creating innovations that can be helpful to society). Children’s and adolescents’ exposure to digital explorative space should be promoted to improve their digital literacy rather than prohibition. During the exploration, emotional intelligence is critical in mitigating existential risks, or threats, to digital natives to navigate and overcome chaotic processes occurring in unchartered waters in the virtual world. (shrink)

In this article, I argue that depression and suicide are natural kinds insofar as they are classes of abnormal behavior underwritten by sets of stable biological mechanisms. In particular, depression and suicide are neurobiological kinds characterized by disturbances in serotonin functioning that affect various brain areas (i.e., the amygdala, anterior cingulate, prefrontal cortex, and hippocampus). The significance of this argument is that the natural (biological) basis of depression and suicide allows for reliable projectable inferences (i.e., predictions) to be made about (...) individual members of a kind. In the context of assisted suicide, inferences about the decision-making capacity of depressed individuals seeking physician-assisted suicide are of special interest. I examine evidence that depression can hamper the decision-making capacity of individuals seeking assisted suicide and discuss some implications. (shrink)

Advocates of physician-assisted suicide often argue that, although the provision of PAS is morally permissible for persons with terminal, somatic illnesses, it is impermissible for patients suffering from psychiatric conditions. This claim is justified on the basis that psychiatric illnesses have certain morally relevant characteristics and/or implications that distinguish them from their somatic counterparts. In this paper, I address three arguments of this sort. First, that psychiatric conditions compromise a person’s decision-making capacity. Second, that we cannot have sufficient (...) certainty that a person’s psychiatric condition is untreatable. Third, that the institutionalisation of PAS for mental illnesses presents morally unacceptable risks. I argue that, if we accept that PAS is permissible for patients with somatic conditions, then none of these three arguments are strong enough to demonstrate that the exclusion of psychiatric patients from access to PAS is justifiable. (shrink)

Decisional capacity evaluations (DCEs) occur in clinical settings where it is unclear whether a consumer of medical services has the capacity to make an informed decision about the relevant medical options. DCEs are localized interventions, not the global loss of competence, that assign a surrogate decision maker to make the decision on behalf of the medical consumer. We maintain that one important necessary condition for a DCE to be morally justified, in cases of medical necessity, is that (...) the health care consumer under evaluation is incapable of expressing a preference for a certain outcome. (shrink)

This chapter makes it clear that a significant element of both leadership and decision making is the development aspect. Leaders develop in their decision making by being confronted with difficult decision situations. However, they also develop through various forms of systemized training and education. Different leaders tend to develop in different directions. For this reason, one can identify a number of key leadership styles based on different ways of leading. These different styles are appropriate for (...) various types of organization. Some organizations require a strict and authoritative style, while others are in greater need of a more democratic style. Senior leaders often have the capacity to switch between different leadership styles depending on how the situation develops. In addition, there are a number of key decision-making roles that leaders are expected to manage. These include the role of entrepreneur, problem-solver, resource-allocator and negotiator. Leaders must also learn to work with clarity, conviction, courage, and communication in order to facilitate their decisions. Research shows that leaders who face severe adversity in their careers often are forced to make many difficult decisions. As a result they develop. Being forced to make difficult decisions actually leads to reflection, self-awareness and self-knowledge of one’s own values. Leaders also develop by communicating their problems in a structured way with more experienced colleagues. The fact that leaders develop by making difficult decisions leads to various forms of action having a central role. It is by putting decisions into action that leaders develop, as well as by reflecting on what alternative decisions could have been made. An action perspective on leadership decisions is closely linked to the concept of sense-making. This phenomenon implies observation, action, revision and communication in the aftermath of a decision. There is research indicating that reflection, critical thinking, intuition, ethics and communication are important dimensions of leaders and decision makers who are generally perceived as wise. -/- . (shrink)

Abstract In light of the complexity of unfolding disasters, the diversity of rapidly evolving events, the enormous amount of generated information, and the huge pool of casualties, emergency responders (ERs) may be overwhelmed and in consequence poor decisions may be made. In fact, the possibility of transporting the wounded victims to one of several hospitals and the dynamic changes in healthcare resource availability make the decision process more complex. To tackle this problem, we propose a multicriteria decision support (...) service, based on the Analytic Hierarchy Process (AHP) method, that aims to avoid overcrowding and outpacing the capacity of a hospital to effectively provide the best care to victims by finding out the most appropriate hospital that meets the victims’ needs. The proposed approach searches for the most appropriate healthcare institution that can effectively deal with the victims’ needs by considering the availability of the needed resources in the hospital, the victim’s wait time to receive the healthcare, and the transfer time that represents the hospital proximity to the disaster site. The evaluation and validation results showed that the assignment of hospitals was done successfully considering the needs of each victim and without overwhelming any single hospital. (shrink)

Summary Background Self-binding directives instruct clinicians to overrule treatment refusal during future severe episodes of illness. These directives are promoted as having potential to increase autonomy for individuals with severe episodic mental illness. Although lived experience is central to their creation, service users’ views on self-binding directives have not been investigated substantially. This study aimed to explore whether reasons for endorsement, ambivalence, or rejection given by service users with bipolar disorder can address concerns regarding self-binding directives, decision-making capacity, (...) and human rights. Methods This study used qualitative data from an internet-based survey distributed to the mailing list of the UK charity Bipolar UK, which contained multiple closed and open questions on advance decision-making in bipolar disorder. Quantitative analysis of a closed question about self-binding directives had already demonstrated endorsement amongst a very high proportion of participants with bipolar disorder who completed the survey. We conducted thematic analysis of responses from those participants who answered a subsequent open question about reasons for their view. Research was co-produced within a multi-disciplinary team, with clinical, legal, and ethical expertise, and lived experience of bipolar disorder. Ideas and methodologies associated with all these areas of expertise were used in the analysis of these reasons and to gain insight into the thoughts of individuals with bipolar disorder about self-binding directives and associated issues. Findings Between Oct 23 and Dec 5, 2017, 932 individuals with a self-reported clinical diagnosis of bipolar disorder completed the internet survey, with 565 (154 men; 400 women; 11 transgender or other) providing free text answers to the open question. A large majority of respondents endorsed self-binding directives, nearly all describing a determinate shift to types of distorted thinking and decision-making when unwell as their key justification. Responses indicating ambivalence were dominated by logistical concerns about the drafting and implementation of self-binding directives, while those who rejected self-binding directives also cited logistical concerns, validity of their thinking when unwell, and potential contravention of human rights. Interpretation This study is, to our knowledge, the first large study of reasons why mental health service users might endorse or reject the use of self-binding directives. The findings provide empirical support for introducing self-binding directives into mental health advance decision-making practice and policy and may help to address enduring ethical concerns surrounding possible implementation of the directive while a person retains decision-making capacity. The opinions expressed here in responses given by multiple service users with bipolar disorder challenge a prominent view within international disability rights debates that involuntary treatment and recognition of impaired mental capacity constitute inherent human rights violations. Funding The Wellcome Trust . (shrink)

This paper aims, first, to argue against using opaque AI technologies in decision making processes, and second to suggest that we need to possess a qualitative form of understanding about them. It first argues that opaque artificially intelligent technologies are suitable for users who remain indifferent to the understanding of decisions made by means of these technologies. According to virtue ethics, this implies that these technologies are not well-suited for those who care about realizing their moral capacity. The (...) paper then draws on discussions on scientific understanding to suggest that an AI technology becomes understandable to its users when they are provided with a qualitative account of the consequences of using it. As a result, explainable AI methods can render an AI technology understandable to its users by presenting the qualitative implications of employing the technology for their lives. (shrink)

Lake et al. propose three criteria which, they argue, will bring artificial intelligence (AI) systems closer to human cognitive abilities. In this paper, we explore the application of these criteria to a particular domain of human cognition: our capacity for moral reasoning. In doing so, we explore a set of considerations relevant to the development of AI moral decision-making. Our main focus is on the relation between dual-process accounts of moral reasoning and model-free/model-based forms of machine learning. We (...) also discuss how work in embodied and situated cognition could provide a valu- able perspective on future research. (shrink)

Those of us who enjoy certain products of the global industrial economy but also believe it is wrong to consume them are often so demoralized by the apparent inefficacy of our individual, private choices that we are unable to resist. Although he was a deontologist, Kant was clearly aware of this ‘consequent-dependent’ side of our moral psychology. One version of his ‘moral proof’ is designed to respond to the threat of such demoralization in pursuit of the Highest Good. That version (...) of the argument says that the capacity that faith and trust in God has to sustain our moral resolve licenses that faith and trust, from a practical point of view. My goal here is to argue that Kant’s proof has a contemporary, secular analogue in modern industrial contexts where the apparent “inefficacy” of an individual consumer’s choices in the face of massive insensitive supply-chains is a threat to her moral resolve. I conclude by suggesting that the Kantian approach may license us in adopting (as an item of defeasible moral faith) an evidential decision-theoretic principle regarding what it is to ‘make a difference.’ This in turn licenses trust -- if not in God then in other right-minded people. (shrink)

La autonomía constituye uno de los pilares básicos de un sistema político como el democrático que se asocia a la capacidad de toma de decisiones de la ciudadanía como su núcleo moral principal. Los descubrimientos en el ámbito de las neurociencias y su aplicación al campo del marketing y a la comunicación política despiertan hoy en día las sospechas por la posible capacidad de activar el "botón del voto" de los electores. Este artículo tiene como objetivo adentrarse en el estudio (...) de los principales trabajos desarrollados sobre el neuromarketing político y la neuropolítica. La finalidad de esta propuesta consiste en presentar los debates éticos que irrumpen con el neuromarketing político. Autonomy is one of the basic pillars of a political system like democracy, which is associated with citizens’ decision-making capacity as its main moral core. Discoveries in the neurosciences domain and their application to the marketing and political communication field now arouse suspicions about the possible capacity of activating voter’s "voting button". The objective of this article is to examine the main works on political neuromarketing and neuropolitics. The purpose of this proposal consists in presenting the specific ethical debates that emerge around political neuromarketing. (shrink)