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)

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)

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)

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.

This chapter begins by sketching an account of morally responsible agency and the general conditions under which it may fail. We discuss how far individuals with psychiatric diagnoses may be exempt from morally responsible agency in the way that infants are, with examples drawn from a sample of diagnoses intended to make dierent issues salient. We further discuss a recent proposal that clinicians may hold patients responsible without blaming them for their acts. We also consider cognitively impaired subjects in the (...) light of related issues in moral and political theory, asking whether they have been unjustly excluded from liberal conceptions of political community due to their presumed lack of agency. (shrink)

In the first wave of the COVID-19 pandemic, healthcare workers in some countries were forced to make distressing triaging decisions about which individual patients should receive potentially life-saving treatment. Much of the ethical discussion prompted by the pandemic has concerned which moral principles should ground our response to these individual triage questions. In this paper we aim to broaden the scope of this discussion by considering the ethics of broader structural allocation decisions raised by the COVID-19 pandemic. More specifically, we (...) consider how nations ought to distribute a scarce life-saving resource across healthcare regions in a public health emergency, particularly in view of regional differences in projected need and existing capacity. We call this the regional triage question. Using the case study of ventilators in the COVID-19 pandemic, we show how the moral frameworks that we might adopt in response to individual triage decisions do not translate straightforwardly to this regional-level triage question. Having outlined what we take to be a plausible egalitarian approach to the regional triage question, we go on to propose a novel way of operationalising the ‘save the most lives’ principle in this context. We claim that the latter principle ought to take some precedence in the regional triage question, but also note important limitations to the extent of the influence that it should have in regional allocation decisions. (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)

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)

Background: Although inclusive education is widely discussed, its implementation has not, arguably, been far-reaching. There remains a lack of specific, targeted approaches towards fully including learners with physical and mental impairments in the educational space. Objectives: This study investigated the extent of the inclusion of learners with autism spectrum disorder (ASD) in three schools in Johannesburg. Method: A qualitative interpretivist design was adopted. Teachers who work with learners with ASD were interviewed using open-ended questions. The sampled data were analysed using (...) thematic analysis, making use of both a priori codes and emergent codes that arose from the open-ended questions. Results: The findings reveal numerous pedagogic strategies such as differentiation, scaffolding, use of visual cues, group work and collaboration that can include learners with ASD in the classroom space. Conclusion: Teacher collaboration and teacher training are vital in ensuring that learners with ASD are fully included in the classroom space. (shrink)

This volume brings together diverse sets of standpoints on liberalism in an era of growing skepticism and distrust regarding liberal institutions. The essays in the volume: - Relate concerns for liberal institutions with classical themes in perfectionist politics, such as the priority of the common good in decision-making or the role of comprehensive doctrines. - Analyse how perfectionist intuitions about the political life affect our concepts of public reason or public justification. - Outline various moral duties we have toward (...) other persons that underlie the liberal institutions or notions of rights functioning across the contemporary political landscape. - Explore various aspects of pluralism from within influential religious or philosophical traditions, applying insights from those traditions to issues in contemporary politics. The comprehensive volume will be of great interest to scholars, students, and researchers of politics, especially those in political philosophy and political theory. (shrink)

In response to the COVID‐19 pandemic philosophers and governments have proposed scarce resource allocation guidelines. Their purpose is to advise healthcare professionals on how to ethically allocate scarce medical resources. One challenging feature of the pandemic has been the large numbers of patients needing mechanical ventilatory support. Guidelines have paradigmatically focused on the question of what doctors should do if they have fewer ventilators than patients who need respiratory support: which patient should get the ventilator? There is, however, an important (...) higher level allocation problem. Namely, how are we to ethically distribute newly obtained ventilators across hospitals: which hospital should get the ventilator(s)? In this paper, we identify a set of principles for allocating newly obtained ventilators across hospitals. We focus particularly on low and middle income countries, who frequently have limited pre‐existing intensive care capacity, and have needed to source additional ventilators. We first provide some background. Second, we argue that the main population healthcare aim during the COVID‐19 pandemic should be to save the most lives. Next, we assess a series of potential heuristics or principles that could be used to guide allocation: allocation to the most densely populated cities, random allocation, allocation based on the ratio of patients to ICU personnel, prioritisation in terms of intrahospital mortality, prioritisation of younger populations, and prioritisation in terms of population mortality. We conclude by providing a plausible ranking of the principles, while noting a number of epistemological challenges, in terms of how they best further the aim of increasing the probability of saving the most lives. (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)

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)

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)

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)

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)

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)

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)

This article develops a detailed, empirically driven analysis of the nature of the transition costs incurred in becoming disabled. Our analysis of the complex nature of these costs supports the claim that it can be wrong to cause disability, even if disability is just one way of being different. We also argue that close attention to the nature of transition costs gives us reason to doubt that well-being, including transitory impacts on well-being, is the only thing that should determine the (...) wrongness of causing or removing disability. Non-welfare considerations also defeat the claim that it is always wrong to cause disability. The upshot of these conclusions is that closer attention to the nature of transition costs supports disabled people who strenuously contest the assumption that their well-being is lower than nondisabled people. It also suggests that, in addition, disabled people should contest their opponents’ narrow account of how we should make ethical decisions regarding causing or failing to prevent disability. (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)

In this study, we propose a new approach based on fuzzy TODIM (Portuguese acronym for interactive and multicriteria decision-making) for decision-making problems in uncertain environments. Our method incorporates group utility and individual regret, which are often ignored in traditional multicriteria decision-making (MCDM) methods. To enhance the analysis and application of fuzzy sets in decision-making processes, we introduce novel entropy and distance measures for q-rung picture fuzzy sets. These measures include an entropy measure based on the sine (...) function and a distance measure derived from the Jensen-Shannon divergence. In our methodology, incorporating the sine function into the entropy measure stands out as a distinctive decision, grounded in a profound understanding of the inherent characteristics of fuzzy sets. Utilizing the sine function proves especially advantageous when handling fuzzy sets that exhibit cyclical variations or fluctuations in their membership degrees. We effectively weight the criteria for an improved evaluation by using this new entropy measure. The introduced distance measure finds application in the TODIM approach, allowing the execution of TODIM method steps within a fuzzy environment until the determination of one alternative’s dominance over another—an advancement beyond traditional approaches. We apply our enhanced fuzzy TODIM method to a real-life construction project management problem from the literature and compare the results with those in the literature and obtained from other MCDM methods. Our proposed measures are robust, as demonstrated by the sensitivity analysis that varied the weights of group utility and individual regret, with the results visualized in a 3D sensitivity plot. The findings demonstrate the superiority of our method in providing a more comprehensive evaluation of alternatives, making it a useful tool for decision-makers facing complex and uncertain decision-making problems. (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)

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)

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)

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)

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)

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...

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)

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 stakes associated with an algorithmic decision are often said to play a role in determining whether the decision engenders a right to an explanation. More specifically, “high stakes” decisions are often said to engender such a right to explanation whereas “low stakes” or “non-high” stakes decisions do not. While the overall gist of these ideas is clear enough, the details are lacking. In this paper, we aim to provide these details through a detailed investigation of what we (...) will call the “Simple Stakes Thesis”. The Simple Stakes Thesis, as it will turn out, is too simple. For even if the stakes associated with a specific one-off decision are low—and hence does not engender a right to an explanation—such decisions may nevertheless form part of a high stakes pattern or aggregate of decisions. In such cases, we argue, even a low stakes decision may engender a right to explanation. Not only does this show that the right to explanation is more demanding than so far recognized. It also shows that the stakes thesis is significantly harder to apply in practice. (shrink)

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 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.

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)

With the rise and public accessibility of AI-enabled decision-support systems, individuals outsource increasingly more of their decisions, even those that carry ethical dimensions. Considering this trend, scholars have highlighted that uncritical deference to these systems would be problematic and consequently called for investigations of the impact of pertinent technology on humans’ ethical decision-making. To this end, this article conducts a systematic review of existing scholarship and derives an integrated framework that demonstrates how intelligent decision-support systems (IDSSs) shape (...) humans’ ethical decision-making. In particular, we identify resulting consequences on an individual level (i.e., deliberation enhancement, motivation enhancement, autonomy enhancement and action enhancement) and on a societal level (i.e., moral deskilling, restricted moral progress and moral responsibility gaps). We carve out two distinct methods/operation types (i.e., processoriented and outcome-oriented navigation) that decision-support systems can deploy and postulate that these determine to what extent the previously stated consequences materialize. Overall, this study holds important theoretical and practical implications by establishing clarity in the conceptions, underlying mechanisms and (directions of) influences that can be expected when using particular IDSSs for ethical decisions. (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)

While the challenges workers face in the gig economy are now well-known, reflections on emancipatory solutions in political philosophy are still underdeveloped. Some have pleaded for enhancing workers' bargaining power through unionisation; others for enhancing exit options in the labour market. Both strategies, however, come with unin-tended side-effects and do not exhaust the full potential for worker self-government present in the digital gig economy. Using the republican theory of freedom as non-domination , I argue that G.D.H. Cole's 20th-century defence (...) of guild socialism offers a promising avenue for enhancing worker autonomy in the gig economy. Platform companies rely on relational and structural domination to undermine worker autonomy, but Cole's guild socialism was specifically designed to enhance autonomy in the workplace. Following Cole's advice today would amount to a defence of worker-owned cooperative platforms. By putting workers in control of platform design and governance, cooperative platforms create new opportunities for worker autonomy. However, platform coopera-tivism faces serious challenges if it plans on becoming a realistic alternative to the traditional gig economy. (shrink)

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.

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 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)

The paper reports results of the very first survey-based study on the prevalence, frequency and nature of ethical or other non-medical difficulties faced by Polish physicians in their everyday clinical practice. The study involved 521 physicians of various medical specialties, practicing mainly in inpatient healthcare. The study showed that the majority of Polish physicians encounter ethical and other non-medical difficulties in making clinical decisions. However, they confront such difficulties less frequently than their foreign peers. Moreover, Polish doctors indicate different circumstances (...) as a source of the experienced problems. The difficulties most often reported relate to (i) patients (or their proxies) requests for medically non-indicated interventions; (ii) problems with communication with patients (or their proxies) due to the patients’ negative attitude, unwillingness to cooperate, or aggression; and (iii) various difficulties with obtaining informed consent. Polish physicians report difficulties associated with disagreements among care givers or scarcity of resources less frequently than doctors from other countries. The study’s findings provide support for the thesis that a significant portion of Polish physicians still follow a traditional, paternalistic, and hierarchical model of healthcare practice. Instead of promoting patient’s empowerment, engagement, and rights, they often consider these ideas as a threat to physicians’ professional authority and autonomy. The study leads to the conclusion that due to insufficient training in medical ethics, communication skills, and medical law, many Polish physicians lack the knowledge and competence necessary to adequately respond to challenges posed by modern healthcare practice. (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 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)

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)

When comparing alternative courses of action, modern military decision makers often must consider both the military effectiveness and the ethical consequences of the available alternatives. The basis, design, calibration, and performance of a principles-based computational model of ethical considerations in military decision making are reported in this article. The relative ethical violation (REV) model comparatively evaluates alternative military actions based upon the degree to which they violate contextually relevant ethical principles. It is based on a set of specific (...) ethical principles deemed by philosophers and ethicists to be relevant to military courses of action. A survey of expert and non-expert human decision makers regarding the relative ethical violation of alternative actions for a set of specially designed calibration scenarios was conducted to collect data that was used to calibrate the REV model. Perhaps unsurprisingly, the survey showed that people, even experts, disagreed greatly amongst themselves regarding the scenarios’ ethical considerations. Despite this disagreement, two significant results emerged. First, after calibration the REV model performed very well in terms of replicating the ethical assessments of human experts for the calibration scenarios. The REV model outperformed an earlier model that was based on tangible consequences rather than ethical principles, that earlier model performed comparably to human experts, the experts outperformed human non-experts, and the non-experts outperformed random selection of actions. All of these performance comparisons were measured quantitatively and confirmed with suitable statistical tests. Second, although humans tended to value some principles over others, none of the ethical principles involved—even the principle of not harming civilians—completely overshadowed all of the other principles. (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)

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)