Recently, bioethicists and the UNCRPD have advocated for supported medical decision-making on behalf of patients with intellectual disabilities. But what does supported decision-making really entail? One compelling framework is Anita Silvers and Leslie Francis’ mental prosthesis account, which envisions supported decision-making as a process in which trustees act as mere appendages for the patient’s will; the trustee provides the cognitive tools the patient requires to realize her conception of her own good. We argue that supported decision-making (...) would be better understood as a collaborative process, giving patients with intellectual disabilities the opportunity to make decisions in a respectful relationship with trusted others. We offer an alternative account of supported decision-making where the primary constraint is to protect the patient from domination by the trustee. This is advantageous in its preservation of the prospects for genuine collaboration, for the mental prosthesis approach ultimately reinforces a problematic ideal of isolated patient self-determination. (shrink)

Machine intelligence already helps medical staff with a number of tasks. Ethical decision-making, however, has not been handed over to computers. In this proof-of-concept study, we show how an algorithm based on Beauchamp and Childress’ prima-facie principles could be employed to advise on a range of moral dilemma situations that occur in medical institutions. We explain why we chose fuzzy cognitive maps to set up the advisory system and how we utilized machine learning to train it. We report on (...) the difficult task of operationalizing the principles of beneficence, non-maleficence and patient autonomy, and describe how we selected suitable input parameters that we extracted from a training dataset of clinical cases. The first performance results are promising, but an algorithmic approach to ethics also comes with several weaknesses and limitations. Should one really entrust the sensitive domain of clinical ethics to machine intelligence? (shrink)

In recent decades, the intertwining ideas of self-determination and well-being have received tremendous support in bioethics. Discussions regarding self-determination, or autonomy, often focus on two dimensions—the capacity of the patient and the freedom from external coercion. The practice of obtaining informed consent, for example, has become a standard procedure in therapeutic and research medicine. On the surface, it appears that patients now have more opportunities to exercise their self-determination than ever. Nonetheless, discussions of patient autonomy in the bioethics literature, which (...) focus on individual patients making particular decisions, neglect the social structure within which health-care decisions are made. Looking through the lens of disability and informed by the feminist conception of relational autonomy, this essay argues that the issue of autonomy is much more complex than the individualist model suggests. The social system and the ableist ideology impose various forms of pressure or oppressive power that can affect people’s ability to choose according to their value system. Even if such powers are not directly coercive, they influence potential parents’ decisions indirectly—they structure their alternatives in such a way that certain options are never considered as viable and other decisions must be made. This paper argues that, instead of only focusing on the individual act of decision-making, we need to pay attention to the social structure that frames people’s decision. (shrink)

Respect for autonomy is a central moral principle in bioethics. The concept of autonomy can be construed in various ways. Under the non-ideal conceptualization proposed by Beauchamp and Childress, everyday choices of generally competent persons are autonomous to the extent that they are intentional and are made with understanding and without controlling influences. It is sometimes suggested that authenticity is important to personal autonomy, so that inauthenticity prevents otherwise autonomous persons from making autonomous decisions. Building from Beauchamp and Childress’s theory, (...) this article develops a non-ideal authenticity-based conceptualization of personal autonomy. Factors that indicate inauthentic decision-making are explicated, and the full concept is defended from three expected objections. The theory is then tested on a paradigm case which has concerned theorists and practitioners for some time, namely the possible inauthenticity of anorexia nervosa patients’ decision-making. It is concluded that the theory seems to be fruitful in analyses of the degree of autonomy of patients’ decision-making, and that it succeeds in providing reliable action-guidance in practical contexts. (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)

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)

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)

In this chapter, it is argued that some animal shelters fulfill the conditions that make triage protocols necessary, namely, the operation with limited financial budgets, space, medical resources, and staff. It is suggested that requirements presented for triage in humans can be fruitfully applied to the context of animal shelters. The focus lies on the criteria of maximizing benefit, justice, medical criteria, life-span considerations, fair decision-making, patient will, re-evaluation of triage decisions and changes in the therapeutic goal, and burden (...) of triage and staff support. The establishment of triage protocols for shelters will make the decision-making process less arbitrary, fairer, and more transparent. Furthermore, it is argued that, in situations where disagreement persist among shelter staff, an external Ethics Board could be called in to help analyze and potentially resolve some of the remaining ethical issues. (shrink)

Phenomenology gives rise to certain ontological considerations that have far-reaching implications for standard conceptions of patient autonomy in medical ethics, and, as a result, the obligations of and to patients in clinical decision-making contexts. One such consideration is the phenomenological reduction in classical phenomenology, a core feature of which is the characterisation of our primary experiences as immediately and inherently meaningful. This paper builds on and extends the analyses of the phenomenological reduction in the works of Husserl, Heidegger, and (...) Merleau-Ponty in order to identify and explain its implications for our current understanding of the principle of respect for patient autonomy and the norms of clinical decision making. (shrink)

Qualitative evidence concerning the relationship between QoL and a wide range of disabilities suggests that subjective judgments regarding other people’s QoL are wrong more often than not and that such judgments by medical practitioners in particular can be biased. Guided by their desire to do good and avoid harm, surgeons often rely on "the eyeball test" to decide whether a patient will or will not benefit from surgery. But the eyeball test can easily harbor a range of implicit judgments and (...) biases against patients with disabilities, including erroneous assumptions about QoL. We critique the use of the "eyeball" test and offer suggestions to reduce bias and ensure that patients’ values are more consistently prioritized in surgical decision-making. (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)

What precisely does a distraction threaten? An agent who spends an inordinate amount of time attending to her smartphone – what precisely is she lacking? I argue that whereas agency of attention is the agent’s non-automatic decision-making on what she currently pays attention to, autonomy of attention is the agent, through her second-order desires, effectively interfering with her non-automatic decision-making on what she currently pays attention to. Freedom of attention is the agent’s possibility to hold or switch her (...) focus of attention without fixating on any specific focus against her will or without distraction from chosen foci. This conceptual work provides resources to track manipulations that diminish a person’s freedom of attention. (shrink)

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)

According to one influential view, requirements to elicit consent for medical interventions and other interactions gain their rationale from the respect we owe to each other as autonomous, or self-governing, rational agents. Yet the popular presumption that consent has a central role to play in legitimate intervention extends beyond the domain of cases where autonomous agency is present to cases where far from fully autonomous agents make choices that, as likely as not, are going to be against their own best (...) interest. The question how we should understand the rationale for eliciting consent in this range of ‘non-ideal’ cases is comparatively ill understood. In this paper, I explore the prospects of accounting for consent requirements in such ‘non-ideal’ cases by appealing to a set of agency-based interests; including an interest in playing a meaningful part in joint decisions affecting ourselves and others. (shrink)

The novel coronavirus pandemic (COVID-19) has had far-reaching effects on public health around the world. Attempts to prevent the spread of the disease by quarantine have led to large-scale global socioeconomic disrup- tion. During the outbreak, public authorities and politicians have struggled with how to manage widespread ignorance regarding the virus. Drawing on insights from social epistemology and the emerging interdisciplinary field of ignorance studies, this article provides evidence that the temporality of non- knowing and its intersection with knowing is (...) a force that leads political decision-making during a crisis. Illuminating the epistemic analysis with statements given by the Finnish government to the media in decision- making documents and in press conferences, this paper proposes that a crisis situation, itself, seems to demand from political decision-makers dynamic action while simultaneously knowing little (‘non-knowing’) about the different fronts of tackling the pandemic. We conclude that non-knowing must be recognized explicitly as an enduring and central condition in deci- sion-making, which we call ‘epistemic humility.’. (shrink)

Psychopathy, which is characterized by a constellation of antisocial behavioral traits, may be subdivided on the basis of etiology: “primary” (low-anxious) psychopathy is viewed as a direct consequence of some core intrinsic deficit, whereas “secondary” (high-anxious) psychopathy is viewed as an indirect consequence of environmental factors or other psychopathology. Theories on the neurobiology of psychopathy have targeted dysfunction within ventromedial prefrontal cortex (vmPFC) as a putative mechanism, yet the relationship between vmPFC function and psychopathy subtype has not been fully explored. (...) In this study, we administered two laboratory decision-making tasks (the Ultimatum Game and the Dictator Game) to a group of prisoners (n=47) to determine whether the different subtypes of psychopathy (primary vs. secondary) are associated with characteristic patterns of economic decision-making, and furthermore, whether either subtype exhibits similar performance to patients with vmPFC lesions. Comparing primary psychopaths (n=6) to secondary psychopaths (n=6) and non-psychopaths (n=22), we found that primary psychopathy was associated with significantly lower acceptance rates of unfair Ultimatum offers and lower offer amounts in the Dictator Game. Moreover, primary psychopaths were quantitatively similar to vmPFC lesion patients in their response patterns. These results support the purported connection between psychopathy and vmPFC dysfunction, bolster the distinction between primary and secondary psychopathy, and demonstrate the utility of laboratory economic decision-making tests in differentiating clinical subgroups. (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.

What process ought to guide decision making for pediatric patients? The prevailing view is that decision making should be informed and guided by the best interest of the child. A widely discussed structural model proposed by Buchanan and Brock focuses on parents as surrogate decision makers and examines best interests as guiding and/or intervention principles. Working from two recent articles by Ross on “constrained parental autonomy” in pediatric decision making (which is grounded in the Buchanan and (...) Brock model), I discuss (supportively) features of Ross’s effort visa-vis the best interest standard. I argue that any pediatric decision-making model that brackets or formally limits an engagement with the child patient assumes too much. Further, any model that under appreciates the place of parents and their autonomy, and the dynamic parent-child relationship, misses an opportunity to broaden the clinical encounter by considering questions of justice for the child (Rawls) and within a family (Ross). In this context, I focus on the child’s emerging and ongoing emotional and intellectual development and autonomy—their capabilities and identifying primary goods. (shrink)

A core challenge for contemporary bioethics is how to address the tension between respecting an individual’s autonomy and promoting their wellbeing when these ideals seem to come into conflict (Not...

The aim of this contribution is to provide an overview of conceptual approaches to incorporating a decision maker’s non-knowledge into economic theory. We will focus here on the particular kind of non-knowledge which we consider to be one of the most important for economic discussions: non-knowledge of possible consequence-relevant uncertain events which a decision maker would have to take into account when selecting between different strategies.

Recently theorists have demonstrated a growing interest in the ethical aspects of resource allocation in international non-governmental humanitarian, development and human rights organizations (INGOs). This article provides an analysis of Thomas Pogge's proposal for how international human rights organizations ought to choose which projects to fund. Pogge's allocation principle states that an INGO should govern its decision making about candidate projects by such rules and procedures as are expected to maximize its long-run cost-effectiveness, defined as the expected aggregate moral (...) value of the projects it undertakes divided by the expected aggregate cost of these projects? I critique Pogge's argument on two fronts: (1) I demonstrate that his view is problematic on his own terms, even if we accept the cost-effectiveness framework he employs. (2) I take issue with his overall approach because it generates results which can undermine the integrity of INGOs. Further, his approach mis-characterizes the nature of INGOs, and this mistake is at the root of his problematic view of INGO priority-setting. Ultimately, I argue for a conception of INGOs in which they are understood as ?organizations of principle?, in the sense that they are independent moral agents and so should be permitted a fairly wide sphere of autonomy within reasonable moral constraints. (shrink)

What role should legislation or policy play in avoiding the complications of in-vitro fertilization? In this article, we focus on single versus double embryo transfer, and assess three arguments in favour of mandatory single embryo transfer: risks to the mother, risks to resultant children, and costs to society. We highlight significant ethical concerns about each of these. Reproductive autonomy and non-paternalism are strong enough to outweigh the health concerns for the woman. Complications due to non-identity cast doubt on the extent (...) to which children are harmed. Twinning may offer an overall benefit rather than burden to society. Finally, including the future health costs for children in reproductive policy is inconsistent with other decisions. We conclude that mandatory single embryo transfer is not justified and that a number of countries should reconsider their current embryo transfer policy. (shrink)

Background Men with antisocial personality disorder show lifelong abnormalities in adaptive decision making guided by the weighing up of reward and punishment information. Among men with antisocial personality disorder, modifi cation of the behaviour of those with additional diagnoses of psychopathy seems particularly resistant to punishment. Methods We did a case-control functional MRI (fMRI) study in 50 men, of whom 12 were violent off enders with antisocial personality disorder and psychopathy, 20 were violent off enders with antisocial personality disorder (...) but not psychopathy, and 18 were healthy non-off enders. We used fMRI to measure brain activation associated with the representation of punishment or reward information during an event-related probabilistic response-reversal task, assessed with standard general linear-model-based analysis. Findings Offenders with antisocial personality disorder and psychopathy displayed discrete regions of increased activation in the posterior cingulate cortex and anterior insula in response to punished errors during the task reversal phase, and decreased activation to all correct rewarded responses in the superior temporal cortex. This finding was in contrast to results for off enders without psychopathy and healthy non-off enders. Interpretation Punishment prediction error signalling in off enders with antisocial personality disorder and psychopathy was highly atypical. This finding challenges the widely held view that such men are simply characterised by diminished neural sensitivity to punishment. Instead, this fi nding indicates altered organisation of the information processing system responsible for reinforcement learning and appropriate decision making. This difference between violent offenders with antisocial personality disorder with and without psychopathy has implications for the causes of these disorders and for treatment approaches. (shrink)

This study compares the neural substrate of moral decision making processes between Korean and American participants. By comparison with Americans, Korean participants showed increased activity in the right putamen associated with socio-intuitive processes and right superior frontal gyrus associated with cognitive control processes under a moral-personal condition, and in the right postcentral sulcus associated with mental calculation in familiar contexts under a moral-impersonal condition. On the other hand, American participants showed a significantly higher degree of activity in the bilateral (...) anterior cingulate cortex (ACC) associated with conflict resolution under the moral-personal condition, and in the right medial frontal gyrus (MFG) associated with simple cognitive branching in non-familiar contexts under the moral-impersonal condition when a more lenient threshold was applied, than Korean participants. These findings support the ideas of the interactions between the cultural background, education, and brain development, proposed in the field of cultural psychology and educational psychology. The study introduces educational implications relevant to moral psychologists and educators. (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)

The era of AI-based decision-making fast approaches, and anxiety is mounting about when, and why, we should keep “humans in the loop” (“HITL”). Thus far, commentary has focused primarily on two questions: whether, and when, keeping humans involved will improve the results of decision-making (making them safer or more accurate), and whether, and when, non-accuracy-related values—legitimacy, dignity, and so forth—are vindicated by the inclusion of humans in decision-making. Here, we take up a related but distinct question, which (...) has eluded the scholarship thus far: does it matter if humans appear to be in the loop of decision-making, independent from whether they actually are? In other words, what is stake in the disjunction between whether humans in fact have ultimate authority over decision-making versus whether humans merely seem, from the outside, to have such authority? Our argument proceeds in four parts. First, we build our formal model, enriching the HITL question to include not only whether humans are actually in the loop of decision-making, but also whether they appear to be so. Second, we describe situations in which the actuality and appearance of HITL align: those that seem to involve human judgment and actually do, and those that seem automated and actually are. Third, we explore instances of misalignment: situations in which systems that seem to involve human judgment actually do not, and situations in which systems that hold themselves out as automated actually rely on humans operating “behind the curtain.” Fourth, we examine the normative issues that result from HITL misalignment, arguing that it challenges individual decision-making about automated systems and complicates collective governance of automation. (shrink)

The present study aims to examine the relationship between the cortical midline structures (CMS), which have been regarded to be associated with selfhood, and moral decision making processes at the neural level. Traditional moral psychological studies have suggested the role of moral self as the moderator of moral cognition, so activity of moral self would present at the neural level. The present study examined the interaction between the CMS and other moral-related regions by conducting psycho-physiological interaction analysis of functional (...) images acquired while 16 subjects were solving moral dilemmas. Furthermore, we performed Granger causality analysis to demonstrate the direction of influences between activities in the regions in moral decision-making. We first demonstrate there are significant positive interactions between two central CMS seed regions—i.e., the medial prefrontal cortex (MPFC) and posterior cingulate cortex (PCC)—and brain regions associated with moral functioning including the cerebellum, brainstem, midbrain, dorsolateral prefrontal cortex, orbitofrontal cortex and anterior insula (AI); on the other hand, the posterior insula (PI) showed significant negative interaction with the seed regions. Second, several significant Granger causality was found from CMS to insula regions particularly under the moral-personal condition. Furthermore, significant dominant influence from the AI to PI was reported. Moral psychological implications of these findings are discussed. The present study demonstrated the significant interaction and influence between the CMS and morality-related regions while subject were solving moral dilemmas. Given that, activity in the CMS is significantly involved in human moral functioning. (shrink)

It has been argued by disability advocates that supported decision-making must replace surrogate, or substituted, decision-making for people with cognitive disabilities. From a moral perspective surrogate decision-making it is said to be an indefensible form of paternalism. At the heart of this argument against surrogate decision-making is the belief that such paternalistic action expresses something fundamentally disrespectful about those upon whom it is imposed: that they are inferior, deficient or child-like in some way. Contrary to this (...) widespread belief, I will argue that surrogate decision-making sometimes expresses more respect for people with life-long, ‘severe’ or ‘profound’ cognitive disabilities than does the adoption of supported decision-making.. Specifically, I argue that in some cases supported decision-making can arguably express that people with severe or profound cognitive disabilities lack equal moral value. I also argue that supported decision-making for people with profound cognitive disabilities can arguably express that they lack complex and rich inner lives. If our aim is to ensure our behaviour and practices express respect for people with life-long ‘severe’ or ‘profound’ cognitive disabilities, then sometimes surrogate rather than supportive decision-making will be a better option. (shrink)

The republican ideal of non-domination identifies the capacity for arbitrary interference as a fundamental threat to liberty that can generate fearful uncertainty and servility in those dominated. I argue that republican accounts of domination can provide a powerful analysis of the nature of legal and institutional power that is encountered by people with mental disorders or cognitive disabilities. In doing so, I demonstrate that non-domination is an ideal which is pertinent, distinctive, and desirable in thinking through psychological (...) disability. Finally, I evaluate republican strategies for contesting domination, focusing on the limits of contestatory democracy, and proposing a participatory alternative which better addresses problems of political agency in the mentally disordered and cognitively disabled. (shrink)

It is often argued that future-directed decisions are effective at shaping our future conduct because they give rise, at the time of action, to a decisive reason to act as originally decided. In this paper, I argue that standard accounts of decision-based reasons are unsatisfactory. For they focus either on tie-breaking scenarios or cases of self-directed distal manipulation. I argue that future-directed decisions are better understood as tools for the non-manipulative, intrapersonal division of deliberative labor over time. A future-directed (...) decision to ϕ gives rise to a defeasible exclusionary reason to ϕ. This reason is grounded on the default authority that is normally granted to one’s prior self as an “expert” deliberator. I argue that this kind of exclusionary reason is the only one that can account for the effectiveness of future-directed decisions at shaping our diachronic agency without violating our autonomy over time. (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 a context of imperfect risk protection, households may protect against the impact of a health shock by employing various financial and non-financial coping mechanisms, such as foregoing or reducing needed medical care, labor substitution, consumption reduction, borrowing money, dissaving, and selling assets. However, leveraging certain coping mechanisms may reduce future productivity, potentially trapping households in chronic or persistent poverty. Resources and risk are not necessarily shared equitably within a household; the ability and willingness of the household to leverage coping (...) mechanisms, or the choice of coping mechanism may depend on the social protection policy context, household socioeconomic status, and type of intrahousehold risk sharing. Vietnam has been making policy changes aimed towards achieving Universal Health Coverage for the past several decades, culminating in a 2015 change mandating universal insurance coverage. This can potentially influence both providers in making decisions around service delivery and households around financing care. This research aims to contribute to the literature exploring the relationships among direct and indirect health care costs, potentially maladaptive coping mechanisms, and household living standards, within the particular health financing and social protection environment in Vietnam. (shrink)

While artificial intelligence (AI) is increasingly applied for decision-making processes, ethical decisions pose challenges for AI applications. Given that humans cannot always agree on the right thing to do, how would ethical decision-making by AI systems be perceived and how would responsibility be ascribed in human-AI collaboration? In this study, we investigate how the expert type (human vs. AI) and level of expert autonomy (adviser vs. decider) influence trust, perceived responsibility, and reliance. We find that participants consider humans (...) to be more morally trustworthy but less capable than their AI equivalent. This shows in participants’ reliance on AI: AI recommendations and decisions are accepted more often than the human expert’s. However, AI team experts are perceived to be less responsible than humans, while programmers and sellers of AI systems are deemed partially responsible instead. (shrink)

The principle that rational agents should maximize expected utility or choiceworthiness is intuitively plausible in many ordinary cases of decision-making under uncertainty. But it is less plausible in cases of extreme, low-probability risk (like Pascal's Mugging), and intolerably paradoxical in cases like the St. Petersburg and Pasadena games. In this paper I show that, under certain conditions, stochastic dominance reasoning can capture most of the plausible implications of expectational reasoning while avoiding most of its pitfalls. Specifically, given sufficient background (...) uncertainty about the choiceworthiness of one's options, many expectation-maximizing gambles that do not stochastically dominate their alternatives "in a vacuum" become stochastically dominant in virtue of that background uncertainty. But, even under these conditions, stochastic dominance will not require agents to accept options whose expectational superiority depends on sufficiently small probabilities of extreme payoffs. The sort of background uncertainty on which these results depend looks unavoidable for any agent who measures the choiceworthiness of her options in part by the total amount of value in the resulting world. At least for such agents, then, stochastic dominance offers a plausible general principle of choice under uncertainty that can explain more of the apparent rational constraints on such choices than has previously been recognized. (shrink)

This paper traces two contradicting beliefs about death and immortality in the writings of Rabbi Hayyim Hirschensohn, and examines these opposing beliefs in his Halakhic ruling, in the case of Autopsies. The paper opens by conceptualizing two possible attitudes regarding the relation between this-world and the ʽother-world’, and by analyzing two main beliefs regarding death and immortality in their relation to the body-spirit distinction (the naturalistic and the spiritualistic approach). It demonstrates how Hirschensohn was holding these two different views. The (...) paper then moves to examine whether his halakhic ruling may help us in understanding which approach was Hirschensohn’s favorable belief, by investigating his halakhic ruling regarding autopsies. Hirschensohn permits to perform such surgeries, however subject to some halakhic limitations. The paper concludes that the naturalistic belief regarding death appears to be the more dominant one in his thought. Finally, I point out a few consequences of this paper, for addressing some contemporary ethical dilemmas regarding human corpses. (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 widely accepted ethical constraints on decision-making assessment. (shrink)

Philosophers of science have insisted that evidence of underlying mechanisms is required to support claims about the effects of medical interventions. Yet evidence about mechanisms does not feature on dominant evidence-based medicine “hierarchies.” After arguing that only inferences from mechanisms (“mechanistic reasoning”)—not mechanisms themselves—count as evidence, I argue for a middle ground. Mechanistic reasoning is not required to establish causation when we have high-quality controlled studies; moreover, mechanistic reasoning is more problematic than has been assumed. Yet where the problems can (...) be overcome, mechanistic reasoning can and should be used as evidence. (shrink)

Suppose that we think it important that people have the chance to enjoy autonomous lives. An obvious corollary of this thought is that people should, if they want it, have control over the time and manner of their deaths, either ending their own lives, or by securing the help of others in doing so. So, generally, and even if we overall think that the practice should not be legalized on other grounds, it looks like common sense to think that considerations (...) of autonomy tell at least somewhat in favour of legalizing at least some acts of suicide and voluntary euthanasia. In this paper, I argue that, in fact, when we scrutinize the reasons for most end of life decisions, it turns out that they are seriously problematic from the point of view of autonomy. Full autonomy requires that we are responsible for the consequences of our decisions, and responsibility is precluded by non-voluntariness, which is to say decisions made because there are no acceptable alternatives. Since most end of life decisions are made for precisely this reason, it looks as though most such decisions are non-voluntary, and therefore undermine our autonomy: a discomforting and paradoxical claim. I argue that we should respond by taking the paradox to illuminate the context required by an autonomy-respecting framework for legalizing assisted suicide and euthanasia. People should have a legal right to a reasonable choice about when and how to die. However, this must go hand in hand with institutions that ensure, as far as possible, that such choices are made against a background which ensures, as far as possible, that people choose death clear-sightedly and not because nothing else is acceptable. (shrink)

Looks into evaluation of information provision probability from different sources, based on use of linguistic variables. Formation of functions appurtenant for its unclear variables provides for adoption of decisions by the decision maker, in conditions of nonprobabilistic equivocation. The development of market relations in Ukraine increases the independence and responsibility of enterprises in justifying and making management decisions that ensure their effective, competitive activities. As a result of the analysis, it is determined that the condition of economic facilities can (...) be described and determined by the decision-maker, in the presence of the necessary information. The confidence of the decision-maker in the information received is different and the decisions made have a correspondingly different level of information risk. It is important to substantiate the procedure for assessing the numerical extent of information risk in decision-making based on the information obtained in conditions of uncertainty. The use of a linguistic variable in the processing of expert data presented in the form of a matrix of binary relations of values of the membership function, which allowed to move to further processing of knowledge to support decision-making in the management of industrial, commercial, financial and other activities. As a mathematical model for estimating the numerical measure of information risk when making decisions based on the information obtained in conditions of non-stochastic uncertainty, a model has been developed to model natural language uncertainties, which differs from existing ones by formalizing knowledge taking into account uncertainty of input information. Making such a clear decision in a fuzzy environment has appropriate values of effectiveness and risk. The paper proposes all the functions and accessories of indicators of both quantitative nature and qualitative nature to bring their values in the field of definition to one scale. Then the indicator of the effectiveness of decision-making will be a measure of the clarity of the cross-section of fuzzy subsets, which correspond to the introduced indicators of information risk. The condition of economic facilities can be described and determined by the decision-maker, if the necessary information is available. Decision-making on thenumerical measure of information risk must be determined by a set of basic indicators, which can be both quantitative and qualitative in nature. Predictive values of indicators should be determined in conditions of nonstochastic uncertainty. In this case, the indicators of a quantitative nature can be determined by fuzzy triangular numbers, which implement a high level of confidence in the subjective judgments of experts. Indicators of qualitative nature should be presented in linguistic variables. The values of the indicators of qualitative nature that are predicted must be considered for all fuzzy variable terms-sets of linguistic variables introduced into consideration. For any fuzzy variable, the introduction to the consideration of a clear set of values as carriers of the α-level of its membership function allows to reduce to a single interpretation of the predicted values of indicators of quantitative and qualitative nature in terms of non-stochastic uncertainty. (shrink)

Theories that use expected utility maximization to evaluate acts have difficulty handling cases with infinitely many utility contributions. In this paper I present and motivate a way of modifying such theories to deal with these cases, employing what I call “Direct Difference Taking”. This proposal has a number of desirable features: it’s natural and well-motivated, it satisfies natural dominance intuitions, and it yields plausible prescriptions in a wide range of cases. I then compare my account to the most plausible alternative, (...) a proposal offered by Arntzenius :31–58, 2014). I argue that while Arntzenius’s proposal has many attractive features, it runs into a number of problems which Direct Difference Taking avoids. (shrink)

It is common to think that state enforcement is a restriction on freedom that is morally permitted or justified because of the unfortunate circumstances in which we find ourselves. Human frailty and material scarcity combine to make the compromise of freedom involved in exclusive state enforcement power necessary for other freedoms or other goods. In the words of James Madison, ‘if men were angels, no government would be necessary’ (1990: 267). But there is an opposing tradition, according to which the (...) very idea of freedom in society entails the necessity of state enforcement. However morally good human beings are, or whatever material conditions they find themselves in, on this view, the ideal of freedom we ought to be concerned to realise is such that it cannot be attained without state enforcement. It follows a priori from an important ideal of freedom that a state with exclusive enforcement power is necessary for individual liberty in society. In this paper, I argue against what I take to be the strongest argument of the a priori kind, which begins from the neo-republican ideal of freedom as non-domination, and thereby in (partial) defence of the alternative, Madisonian, view. Insofar as it is true that some sort of problematic domination will inevitably be present in a stateless society, I argue, the introduction of a state can do nothing to eliminate it. For the state to improve on even an ideal stateless society, it would need to give individuals control over the interference of potential dominators of a sort that could not be achieved in the ideal stateless society. -/- . (shrink)

Respect for autonomy is a central moral principle in bioethics. It is sometimes argued that authenticity, i.e., being “real,” “genuine,” “true to oneself,” or similar, is crucial to a person’s autonomy. Patients sometimes make what appears to be inauthentic decisions, such as when anorexia nervosa patients refuse treatment to avoid gaining weight, despite that the risk of harm is very high. If such decisions are inauthentic, and therefore non-autonomous, it may be the case they should be overridden for paternalist reasons. (...) However, it is not clear what justifies the judgment that someone or something is inauthentic. This article discusses one recent theory of what justifies judgments of inauthenticity. It is argued that the theory is seriously limited, as it only provides guidance in three out of nine identified cases. There are at least six authenticity-related problems to be solved, and autonomy theorists thus have reason to engage with the topic of authenticity in practical biomedicine. (shrink)

In this essay, we suggest practical ways to shift the framing of crisis standards of care toward disability justice. We elaborate on the vision statement provided in the 2010 Institute of Medicine (National Academy of Medicine) “Summary of Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations,” which emphasizes fairness; equitable processes; community and provider engagement, education, and communication; and the rule of law. We argue that interpreting these elements through disability justice entails a commitment to both (...) distributive and recognitive justice. The disability rights movement's demand “Nothing about us, without us” requires substantive inclusion of disabled people in decision‐making related to their interests, including in crisis planning before, during, and after a pandemic like Covid‐19. (shrink)

Aesthetic hedonism is the view that to be aesthetically good is to please. For most aesthetic hedonists, aesthetic normativity is hedonic normativity. This paper argues that Kant's third critique contains resources for a non-hedonic account of aesthetic normativity as sourced in autonomy as self-legislation. A case is made that the account is also Kant's because it ties his aesthetics into a key theme of his larger philosophy.

Since 2016, when the Facebook/Cambridge Analytica scandal began to emerge, public concern has grown around the threat of “online manipulation”. While these worries are familiar to privacy researchers, this paper aims to make them more salient to policymakers — first, by defining “online manipulation”, thus enabling identification of manipulative practices; and second, by drawing attention to the specific harms online manipulation threatens. We argue that online manipulation is the use of information technology to covertly influence another person’s decision-making, by (...) targeting and exploiting their decision-making vulnerabilities. Engaging in such practices can harm individuals by diminishing their economic interests, but its deeper, more insidious harm is its challenge to individual autonomy. We explore this autonomy harm, emphasising its implications for both individuals and society, and we briefly outline some strategies for combating online manipulation and strengthening autonomy in an increasingly digital world. (shrink)

In contemporary bioethics, the autonomy of the patient has assumed considerable importance. Progressing from a more limited notion of informed consent, shared decision making calls upon patients to voice the desires and preferences of their authentic self, engaging in choice among alternatives as a way to exercise deeply held values. One influential opinion in Jewish bioethics holds that Jewish law, in contradistinction to secular bioethics, limits the patient's exercise of autonomy only in those instances in which treatment choices are (...) sensitive to preferences. Here, we analyze a discussion in the Mishna, a foundational text of rabbinic Judaism, regarding patient autonomy in the setting of religiously mandated fasting, and commentaries in the Babylonian and Palestinian Talmuds, finding both a more expansive notion of such autonomy and a potential metaphysical grounding for it in the importance of patient self-knowledge. (shrink)

BACKGROUND: Little is known about how hospitalized patients share decisions with physicians. METHODS: We conducted an observational study of patient-doctor communication on an inpatient medicine service among 18 hospitalized patients and 9 physicians. A research assistant (RA) approached newly hospitalized patients and their physicians before morning rounds and obtained consent. The RA audio recorded morning rounds, and then separately interviewed both patient and physician. Coding was done using integrated analysis. RESULTS: Most patients were white (61%) and half were female. Most (...) physicians were male (66%) and of Southeast Asian descent (66%). All physicians explained the plan of care to the patients; most believed that their patient understood. However, many patients did not. Physicians rarely asked the patient for their opinion. In all those cases, the decision had been made previously by the doctors. No decisions were made with the patient. Patients sometimes disagreed. CONCLUSIONS: Shared decision-making may not be the norm in hospital care. Although physicians do explain treatment plans, many hospitalized patients do not understand enough to share in decisions. When patients do assert their opinion, it can result in conflict. PRACTICE IMPLICATIONS: Some hospitalized patients are interested in discussing treatment. Improving hospital communication can foster patient autonomy. (shrink)

L.A. Paul has recently argued that, on the standard model of rationality, individuals cannot make rational decisions about whether to have a child or not. In this paper, I show that Paul’s arguments do not plausibly demonstrate that the standard model of rationality precludes rational decisions to have a child. I argue that there are phenomenal and non-phenomenal values that can be used to determine the value that having a child will have for us and, in turn, that can be (...) used to make rational decisions about whether to have a child or not. I also argue that we can have an approximate idea of what it is like for us to have a child, even before we have a child and that, on the standard model, this is sufficient to make rational decisions to have a child. (shrink)