The standard bioethics account is that respecting patient autonomy means ensuring that patients make their own decisions, and that requires that they give informed consent. In fact, respecting autonomy often has more to do with the overall shape and meaning of their health care regimes. Ideally, patients will sometimes take control of their health care but sometimes defer to medical authority. The physician's task is, in part, to inculcate patients into the appropriate good health care regimes.

Letter to editor of the Hastings Center Report on R. Kukla’s “Conscientious Autonomy: Displacing Decisions in Health Care” (HCR 35(2), 2005: 34-44).

This paper concerns itself with the concept of diminished competence with particular regard to the problems and options that mentally compromised patients raise for medical management. It proceeds through three general stages: (1) a restatement of the sense and grounds of the new patients' rights ethos which the existence of such patients calls into question; (2) a consideration of what expanded responsibilities and tactics physicians should embrace to protect and enhance such patients' autonomy; and (3) the standards, criteria, and (...) mechanisms by which paternalistic interventions might be justified in cases when the diminishment remains too substantial to merit acceptance of the patients' directives. (shrink)

According to the common view, conscientious objection is grounded in autonomy or in ‘freedom of conscience’ and is tolerated out of respect for the objector's autonomy. Emphasising freedom of conscience or autonomy as a central concept within the issue of conscientious objection implies that the conscientious objector should have an independent choice among alternative beliefs, positions or values. In this paper it is argued that: (a) it is not true that the typical conscientious (...) objector has such a choice when they decide to act upon their conscience and (b) it is not true that the typical conscientious objector exercises autonomy when developing or acquiring their conscience. Therefore, with regard to tolerating conscientious objection, we should apply the concept of autonomy with caution, as tolerating conscientious objection does not reflect respect for the conscientious objector’s right to choose but rather acknowledges their lack of real ability to choose their conscience and to refrain from acting upon their conscience. This has both normative and analytical implications for the treatment of conscientious objectors. (shrink)

The right to conscientious objection in the provision of healthcare is the subject of a lengthy, heated and controversial debate. Recently, a new dimension was added to this debate by the US Supreme Court's decision in Burwell vs. Hobby Lobby et al. which effectively granted rights to freedom of conscience to private, for-profit corporations. In light of this paradigm shift, we examine one of the most contentious points within this debate, the impact of granting conscience exemptions to healthcare providers (...) on the ability of women to enjoy their rights to reproductive autonomy. We argue that the exemptions demanded by objecting healthcare providers cannot be justified on the liberal, pluralist grounds on which they are based, and impose unjustifiable costs on both individual persons, and society as a whole. In doing so, we draw attention to a worrying trend in healthcare policy in Europe and the United States to undermine women's rights to reproductive autonomy by prioritizing the rights of ideologically motivated service providers to an unjustifiably broad form of freedom of conscience. (shrink)

Latin American countries have slowly enacted laws decriminalizing abortion in three circumstances: Life‐threatening risk for the pregnant woman, extra‐uterine non‐viability of malformed foetus, and pregnancy due to rape or incest. Chile is one of the last countries to adopt such a law, formulated in an increasingly restrictive format. Conservative politicians and Church‐related healthcare institutions promptly announced individual and institutional conscientious objection based on the right of private facilities to obey their ideology and personal moral integrity. Juridical consultations and Constitutional (...) Court rulings allowed private hospitals to uphold their objection even if contracted to provide some public health services. Under these conditions, only a few hundred women requested and obtained a legal abortion, while an estimated 100,000 continued to depend on unsafe procedures. Bioethical debate was silenced by the unfettered drive for conscientious objection that continues to limit women’s autonomy, and fails to ease the public health scourge of massive unsafe clandestine abortions. (shrink)

Abstract:Discussions of conscientious objection (CO) in healthcare often concentrate on objections to interventions that relate to reproduction, such as termination of pregnancy or contraception. Nevertheless, questions of conscience can arise in other areas of medicine. For example, the intensive care unit is a locus of ethically complex and contested decisions. Ethical debate about CO usually concentrates on the issue of whether physicians should be permitted to object to particular courses of treatment; whether CO should be accommodated. In this article, (...) I focus on the question of how clinicians ought to act: should they provide or support a course of action that is contrary to their deeply held moral beliefs? I discuss two secular examples of potential CO in intensive care, and propose that clinicians should adopt a norm of conscientious non-objection (CNO). In the face of divergent values and practice, physicians should set aside their personal moral beliefs and not object to treatment that is legally and professionally accepted and provided by their peers. Although there may be reason to permit conscientious objections in healthcare, conscientious non-objection should be encouraged, taught, and supported. (shrink)

Bernard Dickens seeks to undermine the legal and ethical protections accorded to health care workers and hospitals conscientiously objecting to abortion. First, he appeals to the rationale of antidiscrimination laws as a basis for arguing against conscientious objection. Second, he argues that conscientious objection undermines the rights of patients and their autonomy. Third, he holds that conscientiously objecting doctors have a duty to refer patients for abortion. Fourth, he believes that Kant’s principle of respect for humanity as (...) an end in itself is violated by conscientious objection to abortion. Fifth, Dickens quotes remarks by Pope John Paul II as support for the idea that physicians should not conscientiously object to abortion. Finally, he posits that institutions, such as Catholic hospitals, have a responsibility to provide abortions. I argue that all of the arguments offered by Dickens against conscientious objection are unsound. (shrink)

ABSTRACTSince 2007, when Mexico City decriminalized abortion during the first trimester, a debate has been taking place regarding abortion and the right to conscientious objection. Many people argue that, since the provision of abortions is now a statutory duty of healthcare personnel there can be no place for “conscientious objection.” Others claim that, even if such an objection were to be allowed, it should not be seen as a right, since talk about a right to CO may lead (...) to a slippery slope where we may end up recognizing a right to disobey the law. In this paper, I argue that there is a right to CO and that this may be justified through the notions of autonomy and integrity, which a liberal democracy should respect. However, it cannot be an absolute right, and in the case of abortion, it conflicts with women’s reproductive rights. Therefore, CO should be carefully regulated so that it does not obstruct the exercise o... (shrink)

This paper aims to demonstrate how public disclosure can be used to balance physicians9 conscientious objections with their professional obligations to patients – specifically respect for patient autonomy and informed consent. It is argued here that physicians should be permitted to exercise conscientious objections, but that they have a professional obligation to provide advance notification to patients about those objections. It is further argued here that public disclosure is an appropriate and ethically justifiable limit to the principle (...) of advance notification. The argument for publicly disclosing physicians9 conscientious objections is made in this paper by discussing three practical benefits of public disclosure in medicine, and then addressing how publicly disclosing physicians9 conscientious objections is not an undue invasion of privacy. Three additional concerns with public disclosure of physicians9 conscientious objections are briefly addressed – potential harassment of physicians, workplace discrimination, and mischaracterising physicians9 professional aptitude – concluding that each of these concerns requires further deliberation in the realm of business ethics. (shrink)

Background Regarding controversial medical services, many have argued that if physicians cannot in good conscience provide a legal medical intervention for which a patient is a candidate, they should refer the requesting patient to an accommodating provider. This study examines what US physicians think a doctor is obligated to do when the doctor thinks it would be immoral to provide a referral. Method The authors conducted a cross-sectional survey of a random sample of 2000 US physicians from all specialties. The (...) primary criterion variable was agreement that physicians have a professional obligation to refer patients for all legal medical services for which the patients are candidates, even if the physician believes that such a referral is immoral. Results Of 1895 eligible physicians, 1032 (55%) responded. 57% of physicians agreed that doctors must refer patients regardless of whether or not the doctor believes the referral itself is immoral. Holding this opinion was independently associated with being more theologically pluralistic, describing oneself as sociopolitically liberal, and indicating that respect for patient autonomy is the most important bioethical principle in one's practice (multivariable ORs, 1.6–2.4). Conclusions Physicians are divided about a professional obligation to refer when the physician believes that referral itself is immoral. These data suggest there is no uncontroversial way to resolve conflicts posed when patients request interventions that their physicians cannot in good conscience provide. (shrink)

Background: This study was developed as a result of a court case involving conflicts between midwives’ professional practice and their faith when caring for women undergoing abortions in Scotland. Research questions: What are practising Roman Catholics’ perspectives of potential conflicts between midwives’ professional practice in Scotland with regard to involvement in abortions and their faith? How relevant is the ‘conscience clause’ to midwifery practice today? and What are participants’ understandings of Canon 1398 in relation to midwifery practice? Research design: The (...) theoretical underpinning of this study was Gadamer’s hermeneutic out of which the method developed by Fleming et al. involving a five-stage approach was utilised. Participants and research context: The research was conducted in the south of Scotland. A purposive sampling method was used. Eight participants who were practising Roman Catholics familiar with the subject of conscientious objection who were either midwives, lawyers (civil, canon or both) or priests contributed. Ethical considerations: The major ethical issues related to respect for autonomy, maintaining confidentiality and obtaining voluntary informed consent. Parish priests agreed to act as gatekeepers to prospective participants. All legal requirements were addressed regarding data collection and storage. Approval was given by the ethics committee of the university with which one of the researchers were associated. Findings: Three key themes provide an understanding of the situation in which midwives find themselves when considering the care for a woman admitted for an abortion: competing legal systems, competing views of conscience and limits of participation. Conclusion: Clear guidelines for practice should be developed by a multi-professional and consumer group based on an update of the abortion law to reflect the change from a surgical to medical procedure. Clarification of Canon 1398 in relation to what is and is not participation in the procurement of abortion would be of benefit to midwives with a conscientious objection. (shrink)

Background The legitimacy of conscientious objection to abortion continues to fuel heated debate in Italy. In two recent decisions, the European Committee for Social Rights underlined that conscientious objection places safe, legal, and accessible care and services out of reach for most Italian women and that the measures that Italy has adopted to guarantee free access to abortion services are inadequate. Nevertheless, the Ministry of Health states that current Italian legislation, if appropriately applied, accommodates both the right to (...) conscientious objection and the right to voluntary abortion. Main body One empirical argument used to demonstrate that conscientious objection does not create barriers to abortion is the “no correlation” argument, which the Italian Committee for Bioethics employed to demonstrate that no association exists between conscientious objection and waiting times for voluntary abortion in Italy and to support the weak form of conventional comprise adopted by the Italian legislation to balance the conflict between women’ autonomy and healthcare professionals’ moral integrity. Conversely, we showed how the “no correlation” argument fails to demonstrate the absence of a relationship between the number of conscientious objectors and waiting times for voluntary abortion, and that the limitations of the “no correlation” argument itself demonstrate how it is still difficult to describe the real effect of conscientious objection on the access to abortion services and to evaluate the suitability of conventional compromise to effectively balance conflicting moral principles. Conclusion Further studies are needed to better describe the relationship between conscientious objection and waiting times for voluntary abortion. If new evidence would show that the increasing proportion of objectors does undermine the efficacy of the Italian law and the right of a woman to freely obtain a voluntary abortion, new ways will need to be found to address the conflict between moral principles and restrict the protection accorded to the principle of moral integrity. This would inevitably imply the need to constrain and to redefine the terms and conditions for claiming conscientious objection. (shrink)

Epistemic authority, according to L. Zagzebski’s theory, is essentially based on deliberative or first-personal reasons, which originate from epistemic admiration. In what follows, I shortly reconstruct her theory and try to defend it against two critical arguments. The first argument calls attention to circular relation of epistemic autonomy and authority. In order to determine the authoritative person for me, I always have to possess epistemic autonomy, which is understood as knowledge in the given domain. Thus I myself have (...) to have authority in the given domain in order to invest authority. I try to show that the investment of trust is based upon autonomy interpreted as an ability to exercise epistemic actions, accompanied by normative foreknowledge, that allows us to assess epistemic abilities and invest our trust without having sufficient propositional knowledge. The second argument insists on theoretical control for authoritative evidence and testimony. That contradicts preemptive character and content-independence inherent to authoritative testimony. Hence, this argument entirely misses the point of epistemic authority. Instead, as I argue, one can control epistemic authority by future reflexion on its conscientiousness and epistemic exercise as well as on origins of my admiration for authority. As a consequence, the trust invested in authority can be withdrawn and redistributed. (shrink)

Aulisio and Arora argue that the moral significance of value imposition explains the moral distinction between traditional conscientious objection and non-traditional conscientious objection. The former objects to directly performing actions, whereas the latter objects to indirectly assisting actions on the grounds that indirectly assisting makes the actor morally complicit. Examples of non-traditional conscientious objection include objections to the duty to refer. Typically, we expect physicians who object to a practice to refer, but the non-traditional conscientious objector (...) physician refuses to refer. Aulisio and Arora argue that physicians have a duty to refer because refusing to do so violates the patient’s values. While we agree with Aulisio and Arora’s conclusions, we argue value imposition cannot adequately explain the moral difference between traditional conscientious objection and non-traditional conscientious objection. Treating autonomy as the freedom to live in accordance with one’s values, as Aulisio and Arora do, is a departure from traditional liberal conceptions of autonomy and consequently fails to explain the moral difference between the two kinds of objection. We outline how a traditional liberal understanding of autonomy would help in this regard, and we make two additional arguments—one that maintains that non-traditional conscientious objection undermines society’s autonomy, and another that maintains that it undermines the physician-patient relationship—to establish why physicians have a duty to refer. (shrink)

While previous research has established that employees who have a more conscientious leader are more likely to perceive that their leader is ethical, the underlying mechanisms and boundary conditions of this linkage remain unknown. In order to better understand the relationship between leader conscientiousness and ethical leadership, we examine the potential mediating role of leader moral reflectiveness, as well as the potential moderating role of decision-making autonomy. Drawing from social cognitive theory, results from two samples of workgroup leaders (...) and their immediate reports situated in Africa and Asia show that leader conscientiousness is positively related to leader moral reflectiveness, which in turn, is positively associated with employees’ assessment of ethical leadership. Furthermore, and consistent with our hypothesis, results from the two samples show that leader decision-making autonomy moderates the indirect path from leader conscientiousness to ethical leadership through moral reflectiveness, such that only morally reflective leaders who have high decision-making autonomy at work engage in ethical leadership behaviors. In our discussion, we highlight the theoretical and practical implications of our findings and suggest ways in which organizations can better foster ethical leadership. (shrink)

In her paper ‘Cosmetic surgery and conscientious objection’, Minerva rightly identifies cosmetic surgery as an interesting test case for the question of conscientious objection in medicine. Her treatment of this important subject, however, seems problematic. It is argued that Minerva's suggestion that a doctor has a prima facie duty to satisfy patient preferences even against his better clinical judgment, which we call Patient Preference Absolutism, must be regarded with scepticism. This is because it overlooks an important distinction regarding (...) autonomy's meaning and place in clinical practice, and it makes obsolete the important concepts of expert clinical judgment and beneficence. Finally, we discuss two ideas which emerge from consideration of cosmetic surgery in relation to conscientious objection. These are the possible analogy between clinical judgment and conscientious objection, and the possible role the goals of medicine can play in defining the scope of conscientious objection. (shrink)

There can be little doubt, at least in the Western world, that autonomy is the ruling principle in contemporary bioethics. In spite of its ‘triumph’ however, the dominance of the utilitarian concept of autonomy is being increasingly questioned. In this paper, I explore the nature of autonomy, how it came to displace the Hippocratic tradition in medicine and how different concepts of autonomy have evolved. I argue that the reduction of autonomy to ‘the exercise of (...) personal choice’ in medicine has led to a ‘tyranny of autonomy’ which can be inimical to ethical medical practice rather than conducive to it. I take the case of Kerrie Wooltorton as an illustration of how misplaced adherence to respect for patient autonomy can lead to tragic consequences. An analysis of autonomy based on the work of Rachel Haliburton is described and applied to the role of autonomy in a recent bioethical debate — that arising from Savulescu's proposal that conscientious objection by health-care professionals should not be permit.. (shrink)

Background: The development of a profession’s autonomy closely relates to that profession’s level of autonomy in performing its specific role. For the nursing profession, this key role is nursing care. Objectives: This study was undertaken to evaluate the professional autonomy of nurses in care provision, from an ethical perspective. Research design: A mixed methods approach is employed in this research, which makes use of both quantitative and qualitative methods. The quantitative dimension of this research covers sociodemographic aspects (...) and makes use of the Sociotropy–Autonomy Scale. The qualitative dimension of the research relates to the factors that affect professional autonomy in nursing care. Participants and research context: The sample consisted of 30 nurses working in the orthopedics, neurology, or intensive care units of three hospitals. Ethical considerations: Before conducting this research, we received permission from the ethical committee, as well as written permits from all the institutions in which the research was carried out. Informed consent was obtained from all participants. Findings: According to the findings of this study, only 6.7% of the nurses surveyed stated that nurses had professional autonomy; they also stated that professional autonomy in nursing was mostly restricted by the need to be “dependent upon the physician in nursing implementations” and that autonomy in nursing care was mostly limited by a “high number of patients per nurse.” Discussion: This study determined that delays in resolving problems with regard to professional autonomy in nursing care in Turkey could be creating many of the professional and ethical problems that nurses face there. Conclusion: It is recommended that: individuals choose the nursing profession conscientiously; nurses need to be given professional awareness; their professional organizations need to be strengthened; and plans need to be made to increase research and to accumulate both knowledge and expertise. (shrink)

Contemporary bioethics generally stipulates that public moral deliberation must avoid allowing religious beliefs to influence or justify health policy and law. Secular premises and arguments are assumed to maintain the neutral, common ground required for moral deliberation in the public square of a pluralistic society. However, a careful examination of non-theistic arguments used to justify euthanasia (regarding contested notions of human dignity, individual autonomy, and death as annihilation) reveals a dependence on metaethical and metaphysical beliefs that are not universally (...) accepted in a pluralistic society. Such beliefs function in non-theistic arguments in the same way that foundational beliefs justify moral convictions in religious frameworks of belief. This parallel is apparent when religious belief is defined broadly (_a la_ John Reeder) as ‘the search for the good in light of the limits and possibilities of the real.’ Seen through this interpretive lens, frameworks comprising Secular foundational commitments function, in ethically relevant respects, like the guiding beliefs found in the comprehensive frameworks of traditional religions. When conscientious practice in healthcare is reconsidered in light of this foundational similarity between the religious and the secular, it is clear that those who object to the foundational beliefs underpinning Secular arguments for euthanasia should not be required to provide, participate in, or refer patients for euthanasia (or other ethically controversial practices similarly dependent on contested frameworks of belief) in pluralistic societies that prize moral freedom as a primary human good. (shrink)

The legitimacy of the refusal of South Australian nurses to care for second trimester abortion patients on grounds of conscience is examined as a test case for a theory of permissible limits on the autonomy of health care professionals. In cases of health care professional (HCP) conscientious refusal, it is argued that a balance be struck between the HCPs' claims to autonomous action and the consequences to them of having their autonomous action restricted, and the entitlement of patients (...) to care and the consequences for them of being refused such care. Conscientious action that results in the disruption or termination of health care services, however, is always impermissible on two grounds. Firstly, because it is at this point that the action '... invades a patient's autonomy, puts a patient at serious risk ... [and] treats a patient unjustly' (1) Secondly, because the consequences of such refusals turn them into political acts--acts of civil disobedience. It is arguable that in order for acts of civil disobedience to be legitimate, certain obligations are required of the dissenter by the community. It is concluded that the actions of the South Australian nurses, which have over the last few years both terminated and disrupted second trimester services, are morally impermissible. (shrink)

Background: The development of a profession’s autonomy closely relates to that profession’s level of autonomy in performing its specific role. For the nursing profession, this key role is nursing care. Objectives: This study was undertaken to evaluate the professional autonomy of nurses in care provision, from an ethical perspective. Research design: A mixed methods approach is employed in this research, which makes use of both quantitative and qualitative methods. The quantitative dimension of this research covers sociodemographic aspects (...) and makes use of the Sociotropy–Autonomy Scale. The qualitative dimension of the research relates to the factors that affect professional autonomy in nursing care. Participants and research context: The sample consisted of 30 nurses working in the orthopedics, neurology, or intensive care units of three hospitals. Ethical considerations: Before conducting this research, we received permission from the ethical committee, as well as written permits from all the institutions in which the research was carried out. Informed consent was obtained from all participants. Findings: According to the findings of this study, only 6.7% of the nurses surveyed stated that nurses had professional autonomy; they also stated that professional autonomy in nursing was mostly restricted by the need to be “dependent upon the physician in nursing implementations” and that autonomy in nursing care was mostly limited by a “high number of patients per nurse.” Discussion: This study determined that delays in resolving problems with regard to professional autonomy in nursing care in Turkey could be creating many of the professional and ethical problems that nurses face there. Conclusion: It is recommended that: individuals choose the nursing profession conscientiously; nurses need to be given professional awareness; their professional organizations need to be strengthened; and plans need to be made to increase research and to accumulate both knowledge and expertise. (shrink)

Robert Veatch and others have questioned whether there are internal moral rules of medicine. This paper examines the legal regulatory model for governing professions as the autonomous exercise of professional skills and asks whether there is a theoretical basis for this model. Taking John Rawls’s distinction between the justification of a practice and justification of the rules internal to the practice, this paper argues that the autonomous exercise of professional skills is justified so long as it benefits society. In opposition (...) to Christopher Boorse, it is argued that medicine is pathocentric and that physicians exercise skills in treating pathologies. The autonomous treatmentof pathologies is justified because non-interference with physicians will lead to greater treatment of pathologies and so benefit society. Finally, the analysis of medicine as the autonomous exercise of skills in treating pathologies yields the rule that physicians not be forced to cause pathologies. (shrink)

Irish Supreme Court upholds paramountcy of parental right to determine a child's best interests at the expense of the rights of children themselvesCan a court force on parents who are careful and conscientious a view of their child's welfare which is rational, but quite contrary to the parents sincerely held but non-rational beliefs? The Supreme Court of Ireland has recently held that it cannot do so, and that the Irish Constitution requires that the right of the family to determine (...) its own direction must be respected except in the most narrow of circumstances, such as an immediate threat to the life of the child or risk of serious injury. The ruling leaves the assessment of a child's best interests to the wide discretion of parents, but at the same time fails to offer a means to resolve potential conflicts between the rights of the family and the rights of the child.FACTS OF THE CASEIn North Western Health Board v W 1 an action was brought by a local health board against the parents of 14 month old Paul, seeking a declaration that their refusal to submit their son to the heel prick test for phenylketonuria was a failure to vindicate their son's rights and that it would be lawful to proceed without parental consent. Phenylketonuria is a metabolic condition which can lead to severe and untreatable mental impairment if not detected in its early stages, but a simple variation in diet can stave off this outcome. While Paul's parents did not doubt the veracity of this medical opinion, nor indeed the importance of the test, they refused to subject their son to the invasive heel prick, offering instead samples of urine or hair, such that the test could be carried out by non-invasive means. These means, however, are considerably …. (shrink)

This essay analyses the ethical importance and religious implications of ‘the man within’ in Adam Smith's moral philosophy. Not introduced until the second edition of Theory of Moral Sentiments, ‘the man within’ appears as the internalization of the impartial spectator. With the invention of the man within, Smith was able to explain how moral agents pursue virtues and behave morally beyond immediate and quotidian concerns with either praises or blames from society. Having complied with the general dictates of the impartial (...) spectator with conscience, humans become morally autonomous individuals whose moral judgements are derived from constant dialogues with the man within in an ethical microcosm within their breasts. The man within possesses a transcendent nature that preempts social judgements. Because of that transcendent nature, Smith also denominated the man within as ‘the substitute of Deity’. This essay also argues that even conscientious and virtuous individuals can be wronged and misjudged by socie... (shrink)

This paper contributes to the growing line of thought in bioethics that respect for autonomy should not be equated to the facilitation of individualistic self determination through standard requirements of informed consent in all healthcare contexts. The paper describes how in the context of donation for living related liver transplantation (LRLT) meaningful, responsible decision making is often embedded within family processes and its negotiation. We suggest that good donor risk communication in families promote “conscientious autonomy” and “reflective (...) trust”. From this, the paper offers the suggestion that transplant teams and other relevant professionals have to broaden their role and responsibility for risk communication beyond proper disclosure by addressing the impact of varied psychosocial conditions on risk interpretation and assessment for potential donors and family stakeholders. In conclusion, we suggest further research questions on how professional responsibility and role-taking in risk communication should be morally understood. (shrink)

Conscientious refusal is distinguished by its peculiar attitude towards the obligations that the objector refuses: the objector accepts the authority of the institution in general, but claims a right of conscience to refuse some particular directive. An adequate ethics of conscientious objection will, then, require an account of the institutional obligations that the objector claims a right to refuse. Yet such an account must avoid two extremes: ‘anarchism,’ where obligations apply only insofar as they match individual conscience; and (...) ‘totalitarianism,’ where even immoral obligations bind us. The challenge is to explain institutional obligations in such a way that an agent can be obligated to act against conscience, yet can object if the institution's orders go too far. Standard accounts of institutional obligations rely on individual autonomy, expressed through consent. This paper rejects the Consent model; a better understanding of institutional obligations emerges from reflecting on the intersecting goods produced by institutions and the intersecting autonomy of numerous distinct agents rather than only one. The paper defends ‘Professionalism’ as a grounding of professional obligations. The professional context can justify acting against conscience but more often that context partly shapes the professional conscience. Yet Professionalism avoids totalitarianism by distinguishing between (mere) injustice and abuse. When institutions are – or we conscientiously believe them to be – merely unjust, their directives still obligate us; when they are abusive, however, they do not. Finally, the paper applies these results to the problem of conscientious refusal in general and specifically to controversial reproduction cases. (shrink)

PHOTO ID 121339257© Designer491| Dreamstime.com ABSTRACT When physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be apparent conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters future physicians’ commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. We use an ethical dilemma that was presented to a group of third-year medical students to examine how ethics education might (...) be causing them to give undue deference to autonomy, thereby undermining their commitment to beneficence. INTRODUCTION The right of patients to choose which treatments they prefer is rooted in today’s social mores and taught as a principle of medical ethics as respect for autonomy. Yet, when physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be a conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters a commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. I. An Ethical Dilemma The impetus for this paper arose when students who were completing their third clinical year discussed a real-life ethical dilemma. A middle-aged man developed a pulmonary hemorrhage while on blood thinners for a recently placed coronary stent. The bleeding was felt to be reversible, but the patient needed immediate intubation or he would die. The cardiologist was told that the patient previously expressed to other physicians that he never wanted to be intubated. However, the cardiologist made the decision to intubate the patient anyway, and the patient eventually recovered.[1] Students were asked if they believed that the cardiologist had acted ethically. Their overwhelming response was, “No, the patient should have been allowed to die.” We looked into how students applied ethical reasoning to conclude that this outcome was ethically preferred. To explore how the third-year clinical experience might have formed the students’ judgment, we presented the same case to students who were just beginning their third year. Their responses were essentially uniform in recommending intubation. While there is likely more than one reasonable view in this case, we agree with the physician and the younger medical students that intubation was the ethically appropriate decision and will present an argument for it. But first, we explain the reasoning behind the more advanced medical students’ decision to choose patient autonomy at the expense of beneficence. II. Medical Ethics Education and the Priority of Autonomy Beauchamp and Childress’s Principles of Biomedical Ethics, first published in 1979 and now in its 8th edition, is a significant part of the formal ethics education in medical school.[2] Students learn an ethical decision-making approach based on respect for four ethical principles: autonomy, beneficence, nonmaleficence, and justice. While Beauchamp and Childress officially afford no prima facie superiority to any principle, the importance of respect for patient autonomy has increased through the editions of their book. For example, early editions of their book opposed the legalization of physician-assisted death compared to recent editions that defended it.[3] As another example, Beauchamp and Childress make paternalism harder to justify by adding an autonomy-protecting condition to the list of conditions for acceptable paternalism.[4] Authority, they contend, need not conflict with autonomy—provided the authority is autonomously chosen.[5] “The main requirement,” they write, “is to respect a particular patient’s or subject’s autonomous choices, whatever they may be.[6] In the principlism of Beauchamp and Childress, autonomy now seems to have a kind of default priority.[7] However, the bioethics discourse has strong counternarratives, noting some movement to elevate the role of beneficence and to respect the input of stakeholders, including the family and the healthcare team. Ethics education achieves particular relevance in the third clinical year when students become embedded in the care of patients and learn from what has been called the informal curriculum. They observe how attending physicians approach day-to-day ethical problems at the patient’s bedside. In this context, students observe the importance of informed consent for serious treatments or invasive procedures, a practice that highlights the principle of patient autonomy. In both the formal and informal curriculum, medical students observe how, in the words of Paul Wolpe, “patient autonomy has become the central and most powerful principle in ethical decision-making in American medicine.”[8] In short, students appear to learn a deference for patient autonomy. This curricular shift in favor of autonomy coincides with legal developments that protect patients’ rights and decision-making with respect to their healthcare choices. The priority of autonomy in medicine benefits patients by reflecting their choices and, in some cases, their fundamental liberty. III. The Practice of Medicine and the Commitment to Beneficence There are many critiques of the dominant place that autonomy has in biomedical ethics,[9] especially considering that autonomy seems to be biased toward individualistic, Western, and somewhat American culture-driven values.[10] In addition, many bioethical dilemmas are cast as a conflict between autonomy and beneficence. Our point is that medical students bring to their study of medicine a commitment to beneficence that seems to be suppressed by practical ethics education. We think this commitment is rationally defensible and should be nurtured. It is striking that young medical students have a pre-reflective commitment to beneficence at all. For, as we mentioned, it is not just medicine but Western culture generally that prioritizes autonomy in settling ethical dilemmas. In wanting to act for the good of others (rather than simply agreeing to what others want), physicians are already swimming somewhat against the cultural tide.[11] However, doing so makes sense, given the nature of medicine and the profession of healing. When prospective medical students are asked why they wish to become physicians, the usual answer is some variation on caring for the sick and preventing disease. It is unlikely that a reason to become a physician is to respect a patient’s autonomy. It would be easy to dismiss medical students’ commitment to beneficence as a mere intuition and contrary to a more reasoned and deliberative approach. Beauchamp and Childress seem to minimize the value of physician intuition, stating that justifications for certain procedures are “…supported by good reasons. They need not rest merely in intuition or feeling.”[12] Henry Richardson writes that “situational or perceptive intuition…leaves the reasons for decision unarticulated.”[13] We think this is a crude and rather thin way of understanding intuition. Some bioethicists have defended intuition as essential to the practice of medicine and not something opposed to reason.[14] In the case we describe, we believe the ethical justifications s for the patient’s intubation are fundamentally sound: the patient did not have a “do not intubate” order written in the chart, the emergency intubation had not been foreseen, so the patient did not have the opportunity to consent to or reject intubation; the patient had consented to the treatment for his cardiac disease so his consent for intubation could have been assumed;[15] and the consequences of respecting his autonomy did not justify allowing him to die.[16] While it is possible to have more than one reasonable view on this case, we think the case for beneficence is strong and certainly should not be dismissed out of hand. We do not deny that if a patient makes a clearly documented, well-informed decision to forgo intubation that this decision ought to be respected by the physician (even if the physician disagrees with the patient’s decision). But, in this situation, as in many others in the practice of medicine, the patient’s real wishes and preferences are not well-articulated in advance. There are many cases where a physician acts based on what she believes the patient, or the surrogate, would want, sometimes in situations that do not allow much time for reflection. An example might be resuscitation of a newborn at the borderline of viability. In their ethics education, beneficence would mean acting first to save a life. If the patient or surrogate makes an informed decision to the contrary, a beneficent physician respects that autonomous decision. In the case presented, the patient expressed gratitude to the cardiologist when extubated. But what if he had expressed anger at the physician for violating his autonomy? There are those who could argue that not only was intubation ethically wrong but that the cardiologist put himself in legal jeopardy by his actions (especially if there had been a written refusal applicable to the specific situation). In the example we use, we point out that the cardiologist may not have escaped a lawsuit if the patient had died without intubation. His family, when hearing the circumstances, may have sued for failure to act and dereliction of the cardiologist’s duty to save him. Beyond a potential legal challenge for either action or inaction, there is an overriding ethical question the cardiologist had to address: what course would be most satisfying to his conscience? Would he rather allow a patient to die for fear of recrimination, or act to save his life, regardless of the personal consequences? In the absence of real knowledge about the patient’s considered wishes, it is most reasonable to err on the side of promoting patient well-being. A physician’s commitment to beneficence is not necessarily a way of undermining a patient’s autonomy. In acting for the patient's good, physicians are also acting on what it is reasonable to believe a patient (or most patients, perhaps) would want, which is obviously connected to what a patient does want. Pellegrino and Thomasma argue that beneficence includes respect for a patient’s autonomy since “the best interests of the patient are intimately linked with their preferences.”[17] Instead of conceptualizing ethical dilemmas in medicine as conflicts between autonomy and beneficence, it is possible that medical schools could teach students that truly practicing beneficence is a way of valuing patient autonomy, especially when the patient’s wishes are not specific to the situation and are not clearly expressed. CONCLUSION It is important for students and practicing physicians to understand the principle of respect for patient autonomy in a pluralistic society that demands personal self-determination. However, the role of the physician as a beneficent healer should not be diminished by this respect for autonomy. Respecting a patient’s autonomy is grounded in and manifested by physician beneficence.[18] That is, seeking what is good for the patient can only be good if it respects their personhood and dignity. We propose that a commitment to beneficence, incipient in young medical students, should be developed over time with their other clinical reasoning skills. Such a commitment need not be sacrificed on the altar of patient autonomy. Beneficence needs greater relative moral weight with students as they proceed in their ethics education. - [1] S. Jauhar, “When Doctors Need to Lie,” New York Times, February 22, 2014, https://www.nytimes.com/2014/02/23/opinion/sunday/when-doctors-need-to-lie.html. [2] T. L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019). [3] Louise A. Mitchell, “Major Changes in Principles of Biomedical Ethics,” The National Catholic Bioethics Quarterly 14, no. 3 (2014): 459–75, https://doi.org/10.5840/ncbq20141438. [4] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019), 238. [5] Beauchamp and Childress, 103. [6] Beauchamp and Childress, p. 108. [7] For other accounts that prioritize autonomy, see e.g. Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of Surrogate Decision Making (Cambridge University Press, 1989), 38–39; R Gillon, “Ethics Needs Principles—Four Can Encompass the Rest—and Respect for Autonomy Should Be ‘First among Equals,’” Journal of Medical Ethics 29, no. 5 (October 2003): 307–12, https://doi.org/10.1136/jme.29.5.307. For examples of critiques of these accounts, see footnote 9. [8] P. R. Wolpe, “The Triumph of Autonomy in American Bioethics: A Sociological View,” in Bioethics and Society: Constructing the Ethical Enterprise, p. 43. [9] V. A. Entwistle et al., “Supporting Patient Autonomy: The Importance of Clinician-Patient Relationships,” Journal of General Internal Medicine 25, no. 7 (July 2010): 741–45; C. Foster, Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law, 1st ed. (Oxford ; Hart Publishing, 2009); O. O’Neill, Autonomy and Trust in Bioethics, The Gifford Lectures, University of Edinburgh 2001 (Cambridge, UK: Cambridge University Press, 2002). [10] P. Marshall and B. Koenig, “Accounting for Culture in a Globalized Bioethics,” The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics 32, no. 2 (2004): 252–66; R. Fan, “Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy,” Bioethics 11, no. 3–4 (1997): 309–22. [11] Arguments stressing the importance of beneficence, as ours does here, certainly approach paternalistic arguments. We set aside the complex issue of paternalism for purposes of this paper and simply note that the principle of beneficence as such does not say anything specifically about acting against the patient’s will. In the case study that focuses this paper, we do not believe the patient’s will or wishes were clearly indicated. [12] Beauchamp and Childress, Principles of Biomedical Ethics, p. 20, see note 2 above. [13] H. S. Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 25, no. 3 (January 1, 2000): 285–307, p. 287. [14] H. D. Braude, Intuition in Medicine a Philosophical Defense of Clinical Reasoning (Chicago ; University of Chicago Press, 2012). [15] R. Kukla, “Conscientious Autonomy: Displacing Decisions in Health Care,” The Hastings Center Report 35, no. 2 (2005): 34–44. [16] M. Schermer, The Different Faces of Autonomy: Patient Autonomy in Ethical Theory and Hospital Practice, vol. 13, Library of Ethics and Applied Philosophy (Dordrecht: Springer Netherlands, 2002). [17] E. D. Pellegrino and D. C. Thomasma, For the Patient’s Good - the Restoration of Beneficence in Health Care (New York, NY: Oxford University Press, 1988), p. 29. [18] Pellegrino and Thomasma, For the Patient’s Good. 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Though abortion is legal in Canada, policies currently in place at various levels of the health care system, and the individual actions of medical professionals, can inhibit access to abortion. This paper examines the various extra-legal barriers to abortion access that exist in Canada, and argues that these barriers are unjust because there are no good reasons for the restrictions on autonomy that they present. The paper then outlines the various policy measures that could be taken to improve access.

Background Safeguarding the right to die according to the principles of autonomy and freedom of each person has become more important in the last decade, therefore increasing regulation of Euthanasia and Medically Assisted Suicide (MAS). Aims To learn the opinions that the nurses of the autonomous region of Madrid have regarding Euthanasia and Medically Assisted Suicide. Research design Cross-sectional descriptive study. Participants and research context All registered nurses in Madrid. The study was done by means of a self-completed anonymous (...) questionnaire. The variables studied were social-demographic, giving opinions about Euthanasia and MAS. Ethical considerations Each participant was assured maximum confidentiality and anonymity, ensuring the ethical principles set out in the Declaration of Helsinki, as well as in the Organic Law 3/2018, on Personal Data Protection and guarantee of digital rights. Findings A total of 489 nurses answered the questionnaire. In total, 75.7% of the nurses confirmed that Euthanasia should be regulated in Spain. 66.3% indicated that information on Euthanasia should be provided jointly by doctors and nurses, and 42.3% considered that it could be applied by both medical and nursing professionals. A total of 87.2% advocated the participation of nurses in health policy, influencing the drafting of the law. In the face of possible regulation, 35% would request Conscientious Objection, being closely related to their religious beliefs. Discussion Different authors point out that nurses’ perceptions and attitudes towards Euthanasia are conditioned by different factors, such as religion, gender, poor palliative care, legality and the patient's right to die. Conclusion Nurses are positioned in favour of the regulation and practice of Euthanasia and MAS, depending on their age, years of experience, training, model of care and especially religious beliefs. (shrink)

Autonomy is good for you. A strong sense of competent self-control and effective choice-making promotes both physical and psychological well-being. Loss of autonomous control—and a sense of helplessness—causes depression, increased sensitivity to pain, greater vulnerability to disease, and death. Well established by a wide range of psychological and physiological studies, the positive effects of patient autonomy are well known to competent physicians, nurses, and therapists. Conscientious caregivers are thus moving beyond grudging acceptance of informed consent toward clinical (...) respect for patient autonomy. (shrink)

A collection of 17 essays on Kantian moral theory and practical ethics, including papers on autonomy, human dignity, utopian thinking, O'Neill and Rawls on constructivism, tragic choices, philanthropy, conscientious object, suicide, respect, self-respect, and an ideal attitude of appreciation beyond art, nature, and gratitude. TABLE OF CONTENTS Abbreviations for Kant’s Works INTRODUCTION PART II: KANT AND KANTIAN PERSPECTIVES (1) The Groundwork (2) Kant on Imperfect Duties to Oneself (3) Kantian Autonomy and Contemporary Ideas of Autonomy (4) (...) Rüdiger Bittner on Autonomy (5) Kantian Perspectives on the Rational Basis of Human Dignity (6) In Defense of Human Dignity (7) The Kingdom of Ends as an Ideal and Constraint on Legislation (8) Kantian Ethics and Utopian Thinking (9) Varieties of Constructivism PART II: PRACTICAL ETHICS (10) Human Dignity and Tragic Choices (11) Duties and Choices in Philanthropic Giving: A Kantian Perspective (12) Killing Ourselves (13) Conscientious Conviction and Conscience (14) Stability, A Sense of Justice, and Self-Respect (15) Two Conceptions of Virtue (16) Beyond Respect and Beneficence: An Ideal of Appreciation (17) Ideals of Appreciation and Expressions of Respect REFERENCES INDEX . (shrink)

The Moral Limits of Law analyzes the related debates concerning the moral obligation to obey the law, conscientious citizenship, and state legitimacy. Modern societies are drawn in a tension between the centripetal pull of the local and the centrifugal stress of the global. Boundaries that once appeared permanent are now permeable: transnational legal, economic, and trade institutions increasingly erode the autonomy of states. Nonetheless transnational principles are still typically effected through state law. For law's subjects, this tension brings (...) into focus the interaction of legal and moral obligations and the legitimacy of state authority. This volume incorporates a comprehensive critical analysis of the methodology and substance of the debates in recent legal, political, and moral philosophy, regarding political obligation and the moral obligation to obey the law. The author argues that traditional accounts of political obligation that assume a bounded conception of the polity are no longer tenable. Higgins therefore presents an original theory of the conscientious agent's attitude towards law that accommodates the contemporary social tension between local and global obligations. (shrink)

T. A. Cavanaugh's Hippocrates' Oath and Asclepius' Snake: The Birth of the Medical Profession articulates the Oath as establishing the medical profession's unique internal medical ethic - in its most basic and least controvertible form, this ethic mandates that physicians help and not harm the sick. Relying on Greek myth, drama, and medical experience (e.g., homeopathy), the book shows how this medical ethic arose from reflection on the most vexing medical-ethical problem -- injury caused by a physician -- and argues (...) that deliberate iatrogenic harm, especially the harm of a doctor choosing to kill (physician assisted suicide, euthanasia, abortion, and involvement in capital punishment), amounts to an abandonment of medicine as an exclusively therapeutic profession. The book argues that medicine as a profession necessarily involves stating before others what one stands for: the good one seeks and the bad one seeks to avoid on behalf of the sick, and rejects the view that medicine is purely a technique lacking its own unique internal ethic. It concludes noting that medical promising (as found in the White Coat Ceremony through which U. S. medical students matriculate) implicates medical autonomy which in turn merits respect, including honoring professional conscientious objections. (shrink)

The SARS-Cov-2 pandemic created a severe psychosocial and medical shock all over the world. For more than a year, humanity struggled with adjusting to different measures that governments imposed on the population worldwide. Educational systems all over the world were forced to comply with the new conditions of activity. In this context, different reactions emerged, and skills were used and developed. The coronavirus pandemic was and still is a stressful worldwide event that disrupted, among numerous other things, the everyday life (...) of professional activities and the manner of their deployment. This study aims to investigate the relationship between variables like analytical reasoning, text comprehension, detail perception, conscientiousness, emotional stability and autonomy. A sample of 327 students from Ovidius University of Constanta, aged between 19 and 50 years, were assessed using Cognitrom Assessment System. Results show that: there is a positive correlation between analytical reasoning, text comprehension and detail perception; analytical reasoning positively correlates with conscientiousness and emotional stability; text comprehension correlates with emotional stability; and detail perception has no significant correlation with any of the studied personality traits. Results are interpreted and discussed in the end of the article, in relationship with the use of these intellectual skills and personality traits in the context of the Covid-19 pandemic, especially by certain population categories which had to use the online environment for their regular professional activities. (shrink)

"Public Bioethics collects the most influential essays and articles of James F. Childress, a leading figure in the field of contemporary bioethics. These essays, including new, previously unpublished material, cohere around the idea of "public bioethics," which involves analyzing and assessing public policies in biomedicine, health care, and public health, often through public deliberative bodies. The volume is divided into four sections. The first concentrates on the principle of respect for autonomy and paternalistic policies and practices. The second explores (...) the tension among bioethics, public policy, and religious convictions. It pays particular attention to the role of religious convictions in the formation of public policies and to the basis and limits of exemptions of health care providers who conscientiously oppose providing certain legal and patient-sought services. The third section looks at practices and policies related to organ transplantation. Childress focuses particularly on determining death, obtaining first-person consent for deceased organ donation, and allocating donated organs effectively and fairly. The book's fourth and final section maps the broad terrain of public health ethics, proposes a triage framework for the use of resources in public health crises, addresses public health interventions that potentially infringe civil liberties, and sheds light on John Stuart Mill's misunderstood legacy for public health ethics."--Provided by publisher. (shrink)

In December 2017, Law 219/2017, ‘Provisions for informed consent and advance directives’, was approved in Italy. The law is the culmination of a year-long process and the subject of heated debate throughout Italian society. Contentious issues are addressed in the law. What emerges clearly are concepts such as quality of life, autonomy, and the right to accept or refuse any medical treatment – concepts that should be part of an optimal relationship between the patient and healthcare professionals. The law (...) maximizes the value of the patient’s time to decide. Every patient is allowed to make choices for the present as well as for the future, conceived as a continuation of the present, and to decide what comes next, based on what he/she already knows. The law identifies three distinct but converging paths towards the affirmation of a care relationship based on reciprocal trust and respect: the possibility to consent to or refuse treatment, the shared care planning, and advance directives. The fundamental point to emerge from the new Italian law is that consensus is an essential connotation of the treatment relationship. Consensus is not limited to the acceptance/rejection of medical treatment but is ongoing. It is projected into the future through shared care planning and advance directives which act as tools for self-determination and the manifestation of the beliefs and preferences of persons unable to express their will. These principles are in line with the idea of appropriate care as evaluated from two different perspectives, one of scientific adequacy and the other commensurate with the individual’s resources, fragility, values, and beliefs. Surely, however, the new law is not the end of the matter on issues such as conscientious objection, which is deeply rooted within the Italian cultural and political debate. In this regard, healthcare institutions and policymakers will be called upon to develop and implement organizational policies aimed at the management of foreseeable conscientious objection in this field. (shrink)

Every pharmacist, aware or not, is constantly making ethical choices. Sometimes these choices are dramatic, life-and-death decisions, but often they will be more subtle, less conspicuous choices that are nonetheless important. Assisted suicide, conscientious refusal, pain management, equitable and efficacious distribution of drug resources within institutions and managed care plans, confidentiality, and alternative and non-traditional therapies are among the issues that are of unique concern to pharmacists. One way of seeing the implications of such issues and the moral choices (...) they pose is to look at the experiences of practitioners and the kinds of choices they have had to make in situations typically faced by pharmacists. This book is a collection of those situations based on the real experiences of practicing pharmacists. The use of case studies in health care ethics is not new, but in pharmacy it is. This text is an important teaching tool that will help pharmacy students and pharmacists address the increasing number of ethical problems arising in their profession. It is not merely a compilation of cases, but rather is organized for the systematic study of applied ethics. Part I shows how to distinguish ethical problems from other kinds of evaluative judgments and examines the sources of values in pharmacy, posing basic questions about the meaning and justification of ethical claims. Part II explores the basic principles of ethics as they have an impact on pharmacy. Specific cases from clinical settings present in a systematic way the various questions raised by each of the major ethical principles -- benefiting the patient, distributing resources justly, respecting autonomy, dealing honestly with patients, keeping promises of confidentiality, and avoiding harm. Part II examines some of the special problems of contemporary pharmacy such as the linkages between pharmaceutical care and professional practice, human experimentation, reproductive issues, genetic technology, death and dying, and mental health. (shrink)

This book focuses upon the perennial question of the existence and nature of an obligation to obey the law. Leading writers have, at one time or another, emphasized considerations such as gratitude, 'divine ordering, ' prudence, contract, autonomy, and utility in seeking to justify, or to deny any justification for, some sort of obligation to obey the positive law. The book provides relevant selections from a sampling of the historical approaches to legal obligation taken by writers such as Plato, (...) Augustine, Aquinas, Hobbes, Locke, Hume, Rousseau, Thoreau, Bentham, Marx and Engels, and Martin Luther King, Jr. These classical discussions are augmented by critical questions and commentary, by independent discussions of the question of legal obligation by a wide range of contemporary writers, and by relevant judicial cases discussing matters such as conscientious objection and civil disobedience. (shrink)

In this paper, we use qualitative and quantitative research, along with reference to current philosophical literature to consider the question of whether the sport of free-soloing is inherently immoral given the unavoidable extreme risk taken by the climber and imposed upon others not directly participating in the sport. The first thing we look at is what kind of values climbers see in free-soloing and show, through interviews we conducted with soloers and through a review of the literature on the philosophy (...) of extreme sports, that climbers derive what might be called ‘higher pleasures’ from free-soloing. We then argue that despite its inherent riskiness, free-soloers ought to be allowed the autonomy and freedom to choose to engage in the sport, provided they are doing so in a conscientious manner. To show that they are, we again appeal to interviews we conducted to demonstrate that soloers decide to attempt a free-solo in a thoughtful manner, as prescribed by philosophers who work on the morality... (shrink)

Competent patients’ refusals of nursing care do not yet have the legal or ethical standing of refusals of life-sustaining medical therapies such as mechanical ventilation or blood products. The case of a woman who refused turning and incontinence management owing to pain prompted us to examine these situations. We noted several special features: lack of paradigm cases, social taboo around unmanaged incontinence, the distinction between ordinary versus extraordinary care, and the moral distress experienced by nurses. We examined this case on (...) the merits and limitations of five well-known ethical positions: pure autonomy, conscientious objection, paternalism, communitarianism, and feminism. We found each lacking and argue for a ‘negotiated reliance’ response where nurses and others tread as lightly as possible on the patient’s autonomy while negotiating a compromise, but are obligated to match the patient’s sacrifice by extending themselves beyond their usual professional practice. (shrink)

Pacifism involves a number of related moral positions, endorsed for different reasons, often evoking powerful emotional responses. To understand pacifism, we need to identify what pacifism is, or what pacifisms there are, by (1) looking at pacifism's core meaning, etymology, uses, near neighbors, and relationship to just war theory; (2) distinguishing absolute versus contingent pacifism; (3) categorizing pacifism's chief motivators such as nonviolence, nonkilling, moral autonomy, libertarianism, nuclear war, and religious teachings; (4) highlighting pacifism's role in international relations in (...) the United Nations, pacifist nations, the human rights debate, and legal standing as conscientious objectors; and (5) articulating and responding to pacifism's perennial criticisms. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Reading BayleJohn Christian LaursenThomas M. Lennon. Reading Bayle. Toronto: University of Toronto Press, 1999. Pp. xi + 202. Cloth, $60.00. Paper, $19.95.One of the more philosophically interesting things about Pierre Bayle is the difficulty of interpreting his work. A myriad of interpretations have been advanced, but "the whole is [still] a riddle, an enigma, an inexplicable mystery"—to apply David Hume's famous judgment about religion to Bayle's work. This (...) book proposes a Bakhtinian reading of Bayle's philosophical activity, which means that Bayle is understood as letting his interlocutors speak for themselves in an ongoing dialogue over which he does not have full control and in which no one "wins." Bakhtin thought that Dostoevsky was the first major author to do this, but Lennon shows that he was anticipated by Bayle.The discussion is broken up into sections on Bayle's views of integrity, authority, toleration, idolatry, and providence. Integrity turns out to be largely a matter of honesty and fairness in dialogue, and at times it sounds like Bayle is prefiguring Habermas and discourse ethics or recent Anglo-American theories of deliberative democracy.Bayle's view of authority emerges from his analysis of the fact/law (fait/droit) distinction. [End Page 278] This was part of larger debates among Jansenists, Jesuits, and other philosophers such as Arnauld and Malebranche. Here, Lennon's intimate knowledge of seventeenth-century philosophy is put to good use. He shows that in Bayle's hands the distinction cannot hold up, as questions of fact and law are always mutually dependent and each can undermine the other. The upshot is that in the absence of truths of fact or law, dialogue is all that we have. That is good, because history cannot be used as a tool of oppression or homogenization if dialogue must go on forever.Some of the claims about Bayle that are advanced here are debatable. That Bayle "treated everyone with dignity" (44) is simply not true of his treatment of millenarians and others that he thought were fanatics. Rather than extending "toleration almost without limit" (74), he was downright intolerant of such folks. Lennon suggests that Bayle may not have fully thought through the question of the conscientious persecutor (85n.). It would have been appropriate to mention Bayle's reflections on this matter in his last work, the Réponse aux questions d'un provincial.The book contains valuable accounts of aspects of Bayle's debates with Pierre Jurieu, in which it often emerges that there was no great gulf of principle between the two arch-enemies. Disagreements with Ruth Whelan and Elisabeth Labrousse add to the interest of Lennon's discussion.Idolatry is one of Bayle's chief targets, and he finds it above all in the Catholic doctrine of transubstantiation. Lennon nicely shows how this amounts to Spinozism, which in turn explains Bayle's hostility to both Spinoza and Rome. Both stifle Bakhtinian dialogue.One very interesting section of the book is on lotteries, which have important theological and philosophical significance. Often-forgotten authors like Barbeyrac, Ricotier, and Leti are discussed on this issue. Insights here include the observation that "it is hard to imagine Bayle praying" (146). Indeed it is. Mention of work by I. Hont, T. Hochstrasser, and others on Barbeyrac would have made Lennon's case stronger.One major conclusion is that Bayle's notion of providence and the problem of evil comes down to dialogue as well: evil emerges because God prefers to engage in open-ended dialogue with his creatures, which allows evil even if that is not God's intention (167). On this reading, we have a Kantian Bayle: autonomy is Bayle's most cherished value (182).Lennon's final evaluation of Bayle's fideism is that it is philosophically unsatisfactory. Blind and nonrational reliance on Scripture is, to say the least, undermined by Bayle's inability to establish that God is its author or to found his own beliefs in any way other than education. But if anybody still thinks that Pierre Bayle was merely a compiler and not a philosopher in his own right, this book and a lot of the other recent... (shrink)

In this paper we explore material simplicity, defined as the virtue disposing us to act appropriately within the sphere of our consumer decisions. Simplicity is a conscientious and restrained attitude toward material goods that typically includes (1) decreased consumption and (2) a more conscious consumption; hence (3) greater deliberation regarding our consumer decisions; (4) a more focused life in general; and (5) a greater and more nuanced appreciation for other things besides material goods, and also for (6) material goods (...) themselves. It is to be distinguished from simple-mindedness, a return to nature, or poverty. Simplicity overlaps with traditional virtues such as temperance, frugality, and wisdom, and sustains and enables traditional virtues such as justice and generosity. Simplicity is a virtue because it furthers human flourishing, both individual and social, and sustains nature’s ecological flourishing. For analytic purposes, we consider six areas in which simplicity can make important contributions: (1) basic individual flourishing, (2) basic societal flourishing, (3) individual freedom or autonomy, (4) the acquisition of knowledge, (5) living meaningfully, and (6) preserving and protecting nonhuman beings. The proven failure of materialism to secure subjective happiness or objective flourishing argues for the practice of voluntary simplicity and for the radical reform of modern consumer societies. (shrink)

Acts of civil disobedience are undertaken in defense of a variety of causes ranging from banning GMO crops and prohibiting abortion to fighting inequality and saving the environment. Recently, Brownlee has argued that the merit of a cause is not relevant to the establishment of a moral right to civil disobedience. Instead, it is the fact that a dissenter believes his cause for protest to be morally right that is salient. We may term her and similar such theories belief-relative theories (...) of civil disobedience. In this paper, I first argue that Brownlee’s important argument from conscientious conviction fails in its aim to establish a belief-relative moral right to civil disobedience. I then provide a more general argument that no purely belief-relative theory of civil disobedience grounded in a basic moral value will be tenable. Any moral warrant of civil disobedience that is derived from a value must be limited by the value from which it is derived, as well as by other similarly weighty values. If the moral warrant of civil disobedience is derived from the value of autonomy, then the warrant does not extend to acts of civil disobedience that violate the autonomy of others, or other similarly weighty values. Furthermore, granting a right to disobey in promotion of a grossly unjust view is problematic because civil disobedience ought to serve the role of promoting justice. (shrink)

Do citizens of any modern state have a general duty to acknowledge its authority to determine for them, for action guiding purposes, whether certain kinds of conduct are morally permissible, required, or forbidden? That is, is there a duty to obey the law? Moral Contractualism, I contend, entails that citizens of a liberal democratic state have such a duty. ;Treating others morally often requires agents to act collectively, but even agents who accept the moral necessity of collective action will sometimes (...) disagree over the specification of the ends to be achieved, and the means for doing so. I argue that a liberal democratic state can justifiably claim the authority to resolve such disagreements, which it does mainly by enacting and applying laws. Obedience to democratic laws expresses respect for others' autonomy. ;In defending these claims, particular attention is paid to the problem posed by disagreement over the design of democratic decision procedures, conflicts between democratically enacted laws and individual rights, and conflicts of rights. Civil disobedience, conscientious objection, and over-inclusive laws are also addressed. (shrink)

The basics -- The dignity of the human person -- Autonomy, consent, refusing treatment and boundaries -- Ethics and non-autonomous patients -- Confidentiality, privacy, data protection, truth telling and trust -- Ethical issues at the beginning of life -- Ethical issues about babies, children and young adults -- Ethical issues at the end of life -- Dying and death: ethical issues -- Loss, grief and bereavement, burn-out and the wounded healer -- Conscientious objection and loyalties.

In this paper it is argued that physicians’ restrictive attitudes in offering abortions during 1946–1965 in Sweden were due to their private values. The values, however, were rarely presented openly. Instead physicians’ values influenced their assessment of the facts presented—that is, the women's’ trustworthiness. In this manner the physicians were able to conceal their private values and impede the women from getting what they wanted and needed. The practice was concealed from both patients and physicians and never publicly discussed. It (...) is also argued that a similar tacit practice could currently be applied by palliative care physicians. Such practice might allow palliative care physicians to be restrictive when offering sedation therapy without appearing paternalistic or declaring conscientious objections. However, the practice runs counter to patients’ right to participate in making decisions. The women seeking abortion began to oppose the situation and eventually a new abortion law was introduced 1975. Patients at the end of life will never be able to protest against palliative care physicians’ restrictive attitudes. This is a vulnerable and weak group, unable to lodge complaints after the treatment. In order to respect patients’ autonomy, even suffering patients at the end of their lives, it is suggested that physicians should openly declare their values when it comes to providing treatments that might shorten life. Such transparency might facilitate more genuine shared decision-making and accordingly less suboptimal end-of-life care. (shrink)