This paper focuses on the relations between population ethics and metaethics. Population ethics gives rise to well-known paradoxes, such as the paradox of mere addition. After presenting a version of this paradox, it is argued that a different way to dismantle it might be by considering it as a way to change our standard view of justification in moral theory. Two possible views are considered: a non-cognitivist approach to justification and to the explanation of (...) inconsistency in morals; Parfit's suggestion that certain paradoxes might be «quarantined» without shaking our confidence in moral theories encapsulating them. (shrink)

Population ethics is defined and presented, and some of the paradoxes it encapsulates are spelled out. It is argued that the concept of the quality of a life or of a life worth living can- not be avoided if inquiry on many relevant ethical and political topics is to be pursued in a theoretically fitting mode. In particular, the article deals with the asymmetry between rea- sons for not creating unhappy lives and reasons for creating happy lives, the well-known (...) repugnant conclusion and the paradox of mere addition. (shrink)

The quality of a life is typically understood as a function of the actual goods and bads in it, that is, its actual value. Likewise, the value of a population is typically taken to be a function of the actual value of the lives in it. We introduce an alternative understanding of life quality: adjusted value. A life’s adjusted value is a function of its actual value and its ideal value (the best value it could have had). The concept (...) of adjusted value is useful for at least three reasons. First, it fits our judgments about how well lives are going. Second, it allows us to avoid what we call False Equivalence, an error related to the non-identity problem. Third, when we use adjusted value as an input for calculating the value of a population, we can avoid two puzzles that Derek Parfit calls the “Repugnant Conclusion” and the “Mere Addition Paradox.”. (shrink)

The multiverse theodicy proposes to reconcile the existence of God and evil by supposing that God created all and only the creation-worthy universes and that some universes like ours are, despite their evils, creation-worthy. Drawing on work in population ethics, this paper develops a novel challenge to the multiverse theodicy. Roughly, the challenge contends that the axiological underpinnings of the multiverse theodicy harbor a ‘mere addition paradox’: the assumption that creating creation-worthy universes would always make the world (...) better turns out to have morally repugnant consequences akin to those of the assumption that adding worthwhile lives to a population would always make the overall welfare of the population better. Further, the challenge leverages this difficulty into an argument against God’s having created all and only the creation-worthy universes, and hence against the multiverse theodicy. Responses to this challenge are considered but found wanting, largely because of commitments of the multiverse theodicy that have no analogs in population ethics. (shrink)

How can we resist the repugnant conclusion? James Griffin has plausibly suggested that part way through the sequence we may reach a world—let us call it “J”—in which the lives are lexically superior to those that follow. If it would be preferable to live a single life in J than through any number of lives in the next one, then it would be strange to judge K the better world. Instead, we may reasonably “suspend addition” and judge J (...) superior, as if aggregating the lives in the larger world intrapersonally. I argue that the addition of new people with separate preferences renders this inference illicit when comparing J+ and K. When one pairwise comparison suspends addition and the other does not, the result is an intransitive value judgement: J < J+ < K < J, producing the mere addition paradox. (shrink)

In the face of an impossibility result, some assumption must be relaxed. The Mere Addition Paradox is an impossibility result in population ethics. Here, I explore substantially weakening the decision-theoretic assumptions involved. The central finding is that the Mere Addition Paradox persists even in the general framework of choice functions when we assume Path Independence as a minimal decision-theoretic constraint. Choice functions can be thought of either as generalizing the standard axiological assumption of a binary (...) “betterness” relation, or as providing a general framework for a normative (rather than axiological) theory of population ethics. Path Independence, a weaker assumption than typically (implicitly) made in population ethics, expresses the idea that, in making a choice from a set of alternatives, the order in which options are assessed or considered is ethically arbitrary and should not affect the final choice. Since the result establishes a conflict between the relevant ethical principles and even very weak decision-theoretic principles, we have more reason to doubt the ethical principles. (shrink)

Duties to future persons contribute critically to many important contemporaneous ethical dilemmas, such as environmental protection, contraception, abortion, and population policy. Yet this area of ethics is mired in paradoxes. It appeared that any principle for dealing with future persons encountered Kavka's paradox of future individuals, Parfit's repugnant conclusion, or an indefensible asymmetry. In 1976, Singer proposed a utilitarian solution that seemed to avoid the above trio of obstacles, but Parfit so successfully demonstrated the unacceptability of this position (...) that Singer abandoned it. Indeed, the apparently intransitivity of Singer's solution contributed to Temkin's argument that the notion of "all things considered better than" may be intransitive. In this paper, I demonstrate that a time-extended view of Singer's solution avoids the intransitivity that allows Parfit's mere addition paradox to lead to the repugnant conclusion. However, the heart of the mere addition paradox remains: the time-extended view still yields intransitive judgments. I discuss a general theory for dealing with intransitivity that was inspired by Temkin's sports analogy, and demonstrate that such a solution is more palatable than Temkin suspected. When a pair-wise comparison also requires consideration of a small number of relevant external alternatives, we can avoid intransitivity and the mere addition paradox without infinite comparisons or rejecting the Independence of Irrelevant Alternatives Principle. (shrink)

One of Derek Parfit’s greatest legacies was the search for Theory X, a theory of population ethics that avoided all the implausible conclusions and paradoxes that have dogged the field since its inception: the Absurd Conclusion, the Repugnant Conclusion, the Non-Identity Problem, and the Mere Addition Paradox. In recent years, it has been argued that this search is doomed to failure and no satisfactory population axiology is possible. This chapter reviews Parfit’s life’s work in the (...) field and argues that he provided all the necessary components necessary for a Theory X. It then shows how these components can be combined together and applied to the global challenges Parfit argued matter most: preventing human extinction, managing catastrophic risks, and eradicating global poverty and suffering. Finally, it identifies a number of challenges facing his theory and suggests how these may be overcome. (shrink)

We report on the mechanisation of (preference-based) conditional normative reasoning. Our focus is on Åqvist's system E for conditional obligation, and its extensions. Our mechanisation is achieved via a shallow semantical embedding in Isabelle/HOL. We consider two possible uses of the framework. The first one is as a tool for meta-reasoning about the considered logic. We employ it for the automated verification of deontic correspondences (broadly conceived) and related matters, analogous to what has been previously achieved for the modal logic (...) cube. The equivalence is automatically verified in one direction, leading from the property to the axiom. The second use is as a tool for assessing ethical arguments. We provide a computer encoding of a well-known paradox (or impossibility theorem) in population ethics, Parfit's repugnant conclusion. While some have proposed overcoming the impossibility theorem by abandoning the presupposed transitivity of ‘better than’, our formalisation unveils a less extreme approach, suggesting among other things the option of weakening transitivity suitably rather than discarding it entirely. Whether the presented encoding increases or decreases the attractiveness and persuasiveness of the repugnant conclusion is a question we would like to pass on to philosophy and ethics. (shrink)

A set of arguments shows that either the Repugnant Conclusion and its variants are true or the better-than relation isn't transitive. Which is it? This is the most important question in population ethics. The answer will point the way to Parfit's elusive Theory X.

Population axiology concerns how to evaluate populations in regard to their goodness, that is, how to order populations by the relations “is better than” and “is as good as”. This field has been riddled with “paradoxes” which seem to show that our considered beliefs are inconsistent in cases where the number of people and their welfare varies. Already in Derek Parfit’s seminal contribution to the topic, an informal paradox — the Mere Addition Paradox — was presented and (...) later contributions have proved similar results.1 All of these contributions, however, have one thing in common: They all involve an adequacy condition that rules out Parfit’s Repugnant Conclusion: The Repugnant Conclusion: For any perfectly equal population with very high positive welfare, there is a population with very low positive welfare which is better, other things being equal.2 A number of theorists, however, have argued that we should accept the Repugnant Conclusion and hence that avoidance of this conclusion is not a convincing adequacy condition for a population axiology. Torbjörn Tännsjö, for example, argues that the Repugnant Conclusion is not at all repugnant but rather “an unsought, but acceptable, consequence of hedonistic utilitarianism”:3.. (shrink)

Population axiology concerns how to evaluate populations in regard to their goodness, that is, how to order populations by the relations “is better than” and “is as good as”. This field has been riddled with impossibility results which seem to show that our considered beliefs are inconsistent in cases where the number of people and their welfare varies.1 All of these results have one thing in common, however. They all involve an adequacy condition that rules out Derek Parfit’s (...) class='Hi'>Repugnant Conclusion: The Repugnant Conclusion: For any perfectly equal population with very high positive welfare, there is a population with very low positive welfare which is better, other things being equal.2 1 The informal Mere Addition Paradox in Parfit (1984), pp. 419ff is the locus classicus. For an informal proof of a similar result with stronger assumptions, see Ng (1989), p. 240. A formal proof with slightly stronger assumptions than Ng’s can be found in Blackorby and Donaldson (1991). For theorems with much weaker assumptions, see my (1999), (2000b), and especially (2000a), (2001), and (2009). 2 See Parfit (1984), p. 388. My formulation is more general than Parfit’s apart from that he doesn’t demand that the people with very high welfare are equally well off. Expressions such as “a population with very high positive welfare”, “a population with very low positive welfare”, etc., are elliptical for the more cumbersome phrases “a population consisting only of lives with.. (shrink)

I present a new argument for the repugnant conclusion. The core of the argument is a risky, intrapersonal analogue of the mere addition paradox. The argument is important for three reasons. First, some solutions to Parfit’s original puzzle do not obviously generalize to the intrapersonal puzzle in a plausible way. Second, it raises independently important questions about how to make decisions under uncertainty for the sake of people whose existence might depend on what we do. And, third, (...) it suggests various difficulties for leading views about the value of a person’s life compared to her nonexistence. (shrink)

Incommensurability is the impossibility to determine how two options relate to each other in terms of conventional comparative relations. This book features new research on incommensurability from philosophers who have shaped the field into what it is today, including John Broome, Ruth Chang and Wlodek Rabinowicz. The book covers four aspects relating to incommensurability. In the first part, the contributors synthesize research on the competing views of how to best explain incommensurability. Part II illustrates how incommensurability can help us deal (...) with seemingly insurmountable problems in ethical theory and population ethics. The contributors address the Repugnant Conclusion, the Mere Addition Paradox and so-called Spectrum Arguments. The chapters in Part III outline and summarize problems caused by incommensurability for decision theory. Finally, Part IV tackles topics related to risk, uncertainty and incommensurability. Value Incommensurability: Ethics, Risk, and Decision-Making will be of interest to researchers and advanced students working in ethical theory, decision theory, action theory, and philosophy of economics. (shrink)

The anti‐natalist philosopher David Benatar defends a position asserting that all life is harmful, and that it is, therefore, wrong to have children. In this paper, I critique Benatar's less‐discussed claim that his anti‐natalism provides solutions to population ethics problems, such as the Non‐Identity Problem, the Repugnant Conclusion, and the Mere Addition Problem, all of which are presented in Derek Parfit's Reasons and Persons. Since the publication of his Better Never to Have Been, Benatar has continued (...) to claim that its provision of such solutions strengthens his defense of anti‐natalism. Although Benatar's view has received much criticism, this argument has not been discussed at length. I undertake a thorough examination of the argument and identify reasons to reject it. The central point of my critique is that the implications of Benatar's views in determining ranges of wrong and not‐wrong cases of procreation are extensionally inadequate when applied to the problems of population ethics. (shrink)

James Griffin has considered a form of superiority in value that is weaker than lexical priority as a possible remedy to the Repugnant Conclusion. In this article, I demonstrate that, in a context where value is additive, this weaker form collapses into the stronger form of superiority. And in a context where value is non-additive, weak superiority does not amount to a radical value difference at all. These results are applied on one of Larry Temkin's cases against transitivity. I (...) demonstrate that Temkin appeals to two conflicting notions of aggregation. I then spell out the consequences of these results for different interpretations of Griffin's suggestion regarding population ethics. None of them comes out very successful, but perhaps they nevertheless retain some interest. (shrink)

This paper argues that the Repugnant Conclusion which the Mere Addition Paradox generates is not the same as the one which a sum-aggregative view like impersonal total utilitarianism leads to, but a slightly more moderate version of it. Given a spectrum of outcomes {A, B, C, …, X, Y, Z} such that in each of them there is a population that is twice as large as the previous one and has a level of wellbeing that is (...) just barely lower than the previous one, the Mere Addition Paradox implies that while almost all the outcomes of the spectrum are better than A, the last ones, such as Y and Z, will not, lest we accept that adding lives at a negative level is positive or neutral. This affects the way the Mere Addition Paradox should be presented. (shrink)

Two objects of valuation are said to be incommensurable if neither is better than the other, nor are they equally good. This negative, coarse-grained characterization fails to capture the nuanced structure of incommensurability. We argue that our evaluative resources are far richer than orthodoxy recognizes. We model value comparisons with the corresponding class of permissible preference orderings. Then, making use of our model, we introduce a potentially infinite set of degrees of approximation to better, worse, and equally good, which we (...) interpret as degrees of commensurability.One payoff is the solution our approach provides to a paradox in population ethics, generated by Parfit's “Continuum Argument”. Parfit imagines a sequence of populations, starting with one consisting of excellent lives and, by a sequence of apparent improvements, reaching a much larger population of lives barely worth living. What he dubs “the Repugnant Conclusion” is that the final population is better than the first. Developing Parfit's response, we argue that some of the populations in the sequence are merely almost better than their immediate predecessors. Almost better is not transitive (unlike better). We offer analogies to other ‘spectrum arguments’, Condorcet's paradox, and to developments in formal epistemology. (shrink)

Variable-Value axiologies avoid Parfit’s Repugnant Conclusion while satisfying some weak instances of the Mere Addition principle. We apply calibration methods to two leading members of the family of Variable-Value views conditional upon: first, a very weak instance of Mere Addition and, second, some plausible empirical assumptions about the size and welfare of the intertemporal world population. We find that such facts calibrate these two Variable-Value views to be nearly totalist, and therefore imply conclusions that (...) should seem repugnant to anyone who opposes Total Utilitarianism only due to the Repugnant Conclusion. (shrink)

This article examines several families of population principles in the light of a set of axioms. In addition to the critical-level utilitarian, number-sensitive critical-level utilitarian, and number-dampened utilitarian families and their generalized counterparts, we consider the restricted number-dampened family and introduce two new ones: the restricted critical-level and restricted number-dependent critical-level families. Subsets of the restricted families have non-negative critical levels, avoid the `repugnant conclusion' and satisfy the axiom priority for lives worth living, but violate an important (...) independence condition. (shrink)

As the title of this paper indicates, I’m going to discuss what we ought to do in situations where our actions affect future generations. More specifically, I shall focus on the moral problems raised by cases where our actions affect who’s going to live, their number and their well being. I’ll start, however, with population axiology. Most discussion in population ethics has concentrated on how to evaluate populations in regard to their goodness, that is, how to order populations (...) by the relations “is better than” and “is as good as”. This field has been riddled with “paradoxes” which purport to show that our considered beliefs are inconsistent in cases where the number of people and their welfare varies. Derek Parfit’s Mere Addition Paradox is a case in point. The main question of my paper concerns the implication of such axiological paradoxes for normative theories. Do the axiological paradoxes translate into paradoxes for normative theories or will they, as some believe, disappear if we switch to a normative framework? (shrink)

A principal aim of the branch of ethics called ‘population theory’ or ‘population ethics’ is to find a plausible welfarist axiology, capable of comparing total outcomes with respect to value. This has proved an exceedingly difficult task. In this paper I shall state and discuss two ‘trilemmas’, or choices between three unappealing alternatives, which the population ethicist must face. The first trilemma is not new. It originates with Derek Parfit's well-known ‘Mere Addition Paradox’, and was (...) first explicitly stated by Yew-Kwang Ng. I shall argue that one horn of this trilemma is less unattractive than Parfit and others have claimed. The second trilemma, which is a kind of mirror image of the first, appears hitherto to have gone unnoticed. Apart from attempting to resolve the two trilemmas, I shall suggest certain features which I believe a plausible welfarist axiology should possess. The details of this projected axiology will, however, be left open. (shrink)

The implications of the repugnant conclusion for consequentialist theories, such as total utilitarianism, have been extensively discussed since the work of Derek Parfit. These discussions make the paradoxes of population ethics depend on welfarist conditions, like the dominance condition (or the Pareto Principle). Thus, one might think that the repugnant conclusion is not a practical problem for deontologists, who deny that we always ought to do what produces the most aggregate welfare. In this study, we offer two (...) impossibility results using what we call the limit aggregation property. This states that when welfaristic and non-welfaristic considerations conflict, there is a threshold number of persons such that the former can override the latter as long as more people than the threshold number can enjoy increases in well-being levels. We argue that this property should be accepted even by deontologists, insofar as they do not commit themselves to the implausible absolutist position that fails to assign any moral weight to aggregate welfare. Our results therefore state that any normative population theory that is not absolutist entails (a variant of) the repugnant conclusion or some other implausible conclusion. Therefore, the repugnant conclusion must be taken seriously even by non-absolutist deontologists, not just consequentialists. (shrink)

In Reasons and Persons, Parfit (1984) posed a challenge: provide a satisfying normative account that solves the Non-Identity Problem, avoids the Repugnant and Absurd Conclusions, and solves the Mere-Addition Paradox. In response, some have suggested that we look toward person-affecting views of morality for a solution. But the person-affecting views that have been offered so far have been unable to satisfy Parfit's four requirements, and these views have been subject to a number of independent complaints. This paper (...) describes a person-affecting account which meets Parfit's challenge. The account satisfies Parfit's four requirements, and avoids many of the criticisms that have been raised against person-affecting views. (shrink)

In Reasons and Persons, Derek Parfit cannot find a theory of well-being that solves the Non-Identity Problem, the Repugnant Conclusion, the Absurd Conclusion, and all forms of the Mere Addition Paradox. I describe a “Quasi-Maximizing” theory that solves them. This theory includes (i) the denial that being better than is transitive and (ii) the “Conflation Principle,” according to which alternative B is hedonically better than alternative C if it would be better for someone to have all the (...) B-experiences. (i) entails that Quasi-Maximization is not a maximizing theory, but (ii) ensures that its evaluations will often coincide with such theories. (shrink)

Nebel argues for the Repugnant Conclusion via the “Intrapersonal Repugnant Conclusion,” on which certainty of a mediocre life is better for individuals than a sufficiently small chance of an excellent life. In this article, I deny that acceptance of the Intrapersonal Repugnant Conclusion leads us to the Repugnant Conclusion. I point out that on many views which avoid the Repugnant Conclusion we should discount very small probabilities down to zero. If we do, then Nebel’s crucial (...) premise of Ex Ante Pareto fails, because discounting at the individual level can fail to match up with discounting at the population level. (shrink)

Population axiology includes two major arguments. The first is the repugnant conclusion, which was originally formulated by Derek Parfit to criticize total utilitarianism. The second is the sadistic conclusion. In this study, I demonstrate that no additively separable principle can avoid both repugnant and sadistic conclusions if individual moral values have no upper bound. This impossibility holds not only for utilitarian principles but also for any population principles that guarantee the separability of people’s well-being. I emphasize (...) the importance of examining non-separable principles in population ethics. (shrink)

Recently, in his Rolf Schock Prize Lecture, Derek Parfit has suggested a novel way of avoiding the Repugnant Conclusion by introducing what he calls “imprecision” in value comparisons. He suggests that in a range of important cases, populations of different sizes are only imprecisely comparable. Parfit suggests that this feature of value comparisons opens up a way of avoiding the Repugnant Conclusion without implying other counterintuitive conclusions, and thus solves one of the major challenges in ethics. In this (...) article, I try to clarify Parfit's proposal and evaluate whether it will help us with the paradoxes in population ethics. (shrink)

It has been shown that the Mere Addition Paradox occurs in a choice-functional approach with Path Independence (Stewart R.T., 2021, Path independence and a persistent paradox of population ethics, Journal of Philosophy, forthcoming). The present study is a three-part response to this finding. First, I show that Path Independence is not an essential property leading to this paradox and that logically weaker properties can get the same result. Second, I present a rationalizable choice function that does not (...) yield the paradox. And third, I argue that menu-dependent relations are nicely examined if Path Independence is relaxed to Property $\alpha $ (or equivalently, Contraction Consistency). (shrink)

The spectre of the repugnant conclusion and the search for a population axiology that avoids it has endured as a focus of population ethics. This is in part because the repugnant conclusion is often interpreted as a defining problem for totalism, while the implications of averagism and related views are taken to illustrate the theoretical cost of avoiding the repugnant conclusion. However, we show that this interpretation cannot be sustained unless one focuses only on a (...) special case of the repugnant conclusion: namely, the subset of instances of the repugnant conclusion where there is no portion of the population unaffected by the choice between population outcomes (as in Derek Parfit’s original illustration). To avoid an inappropriate focus on only this proper subset of instances of the repugnant conclusion, we formulate a general characterization of the repugnant conclusion. We then prove formally that all leading welfarist axiologies imply this conclusion, including averagism and Ng’s Theory X0 , including probabilistic and ‘very repugnant’ variants that involve the addition of negative lives. We then prove that the full range of axiologies considered by population ethics each imply an extended version of the repugnant conclusion, including axiologies that are incomplete, intransitive, rank-dependent, person-affecting, and/or pluralist. The upshot is that the repugnant conclusion does not ultimately tell against any approach to axiology, and the methodological requirement to avoid the repugnant conclusion should be dropped from population axiology. (shrink)

Values are incommensurable when they cannot be measured on a single cardinal scale. Many philosophers suggest that incommensurability can help us solve the problems of population ethics. I agree. But some philosophers claim that populations bear incommensurable values merely because they contain different numbers of people, perhaps within some range. I argue that mere differences in how many people exist, even within some range, do not suffice for incommensurability. I argue that the intuitive neutrality of creating happy people (...) is better captured by a version of average utilitarianism. But this view is problematic. So I suggest a version of total utilitarianism that avoids the repugnant conclusion by appealing to incommensurable dimensions of wellbeing. (shrink)

Recently, Derek Parfit has offered a novel solution to the “Repugnant Conclusion” that compared with the existence of many people whose quality of life would be very high, there is some much larger number of people whose existence would be better but whose lives would be barely worth living. On this solution, qualitative differences between two populations will often entail that the populations are merely “imprecisely” comparable. According to Parfit, this fact allows us to avoid the Repugnant Conclusion (...) without violating the transitivity of better than. In this paper, I argue that Parfit’s view nevertheless implies two objectionable conclusions. The first is an alternative version of the Repugnant Conclusion that, Parfit suggests, may not be all that repugnant. The second is a revised version of the first that is nearly identical to the Repugnant Conclusion. I conclude that Parfit’s view offers no escape from repugnance. (shrink)

In “An Intrapersonal Addition Paradox,” Jacob Nebel provides a novel intrapersonal argument for the Repugnant Conclusion. The most controversial premise of Nebel’s argument is the “Probable Addition Principle,” on which it is better for individuals to receive additional chances of existence with a life worth living. I provide an alternative intrapersonal argument for the Repugnant Conclusion which does not assume the Probable Addition Principle. I also show that Pareto principles alone, when conjoined with very minimal (...) principles of prudence, imply a version of the Repugnant Conclusion. (shrink)

The person-affecting restriction, in its slogan form, states that an outcome can be better than another only if it is better for someone. It has a strong intuitive appeal and several theorists have suggested that it avoids certain counterintuitive implications in population ethics. At the same time, the restriction has highly counterintuitive implications and yields non-transitive orderings in some nonidentity cases. Many theorists have taken this criticism to be decisive. Recently, however, there have been some reformulations of the restriction, (...) suggesting that the restriction survives this “old” criticism. This paper investigates the viability of those reformulations, which are versions of “Comparativism,” and argues that most of them either have counterintuitive implications or are extensionally equivalent with impersonal theories, but that “Soft Comparativism” seems to have an advantage over impersonal theories. (shrink)

Separability is roughly the principle that, in comparing the value of two outcomes, one can ignore any people whose existence and welfare are unaffected. Separability is both antecedently plausible, at least as a principle of beneficence, and surprisingly powerful; it is the key to some of the best positive arguments in population ethics. This chapter surveys the motivations for and consequences of separability. In particular, it presents an ‘additivity theorem’ which explains how separability leads to total utilitarianism and closely (...) related axiological views. It then examines systematically how this family of views can avoid the Repugnant Conclusion by incorporating lexicality, a critical level, or a neutral range. (shrink)

Derek Parfit presents his Mere Addition Paradox in order to demonstrate that it is extremely difficult to avoid the Repugnant Conclusion. And in order to avoid it, Parfit has embraced perfectionism. However, Stuart Rachels and Larry Temkin, taking their lead from Parfit, have concluded, instead, that the Repugnant Conclusion can be avoided by denying the axiom of transitivity with respect to the all-things-considered-better-than relation. But this seems to present a major challenge to how we evaluate normatively. (...) In this article I show how the Mere Addition Paradox and the Repugnant Conclusion can both be avoided without subscribing to perfectionism, and without sacrificing the axiom of transitivity. (shrink)

The quantitative argument against the notion of a best possible world claims that, no matter how many worthwhile lives a world contains, another world contains more and is, other things being equal, better. Parfit’s ‘ Mere Addition Paradox ’ suggests that defenders of this argument must accept his ‘ Repugnant Conclusion ’ : that outcomes containing billions upon billions of lives barely worth living are better than outcomes containing fewer lives of higher quality. Several responses to the (...) Paradox are discussed and rejected as either inadequate or unavailable in a theistic context. The quantitative argument fails if some world is such that addition to it is not possible, i.e., if it is intensively infinite, as Liebniz claimed. If the notion of such a world is incoherent, then no world is quantitatively best and the quantitative argument succeeds, but only at the cost of embracing the Repugnant Conclusion. (shrink)

Why should ‘better than’ be transitive? The leading answer in ethics is that values do not change with context. But this cannot be the entire source of transitivity, I argue, since transitivity can fail even if values never change, so long as they are complex, with multiple dimensions combined non-additively. I conclude by exploring a new hypothesis: that all alleged cases of nontransitive betterness, such as Parfit’s Repugnant Conclusion, can and should be modelled as the result of complexity, not (...) context-relativity. (shrink)

Critical-Range Utilitarianism is a variant of Total Utilitarianism which can avoid both the Repugnant Conclusion and the Sadistic Conclusion in population ethics. Yet Standard Critical-Range Utilitarianism entails the Weak Sadistic Conclusion, that is, it entails that each population consisting of lives at a bad well-being level is not worse than some population consisting of lives at a good well-being level. In this paper, I defend a version of Critical-Range Utilitarianism which does not entail the Weak Sadistic (...) Conclusion. This is made possible by a fourth category of absolute value in addition to goodness, badness, and neutrality. (shrink)

The repugnant conclusion is acceptable from the point of view of total utilitarianism. Total utilitarians do not seem to be bothered with it. They feel that it is in no way repugnant. To me, a hard-nosed total utilitarian, this settles the case. However, if, sometimes, I doubt that total utilitarianism has the final say in ethics, and tend to think that there may be something to some objection to it or another, it is the objection to it brought (...) forward from egalitarian thought that first comes to mind. But if my argument in this article is correct, then it is clear that the repugnant conclusion should be equally acceptable to egalitarians of various different bents as it is to total utilitarians. (shrink)

This paper explores the notion of species-relative critical levels, which is a crucial ethical issue in multi-species population ethics. First, the formal conditions are provided under which there are species-relative critical levels (e.g., the critical level for human beings is different from that for non-human beings). In particular, we find it a salient question of animal ethics whether the existence of a human being is morally better than that of a non-human animal when their utility levels are the same. (...) Subsequently, we illustrate two general classes of multi-species critical-level utilitarian orderings. One class employs species-relative critical levels, which entails either the animal repugnant conclusion or the animal sadistic conclusion. The other employs species-relative critical levels plus species-lexical ordering. Although it can avoid both the animal repugnant conclusion and the animal sadistic conclusions, it has the problem of speciesism. (shrink)

Most people (including moral philosophers), when faced with the fact that some of their cherished moral views lead up to the Repugnant Conclusion, feel that they have to revise their moral outlook. However, it is a moot question as to how this should be done. It is not an easy thing to say how one should avoid the Repugnant Conclusion, without having to face even more serious implications from one's basic moral outlook. Several such attempts are presented in (...) this volume. This is the first volume devoted entirely to the cardinal problem of modern population ethics, known as 'The Repugnant Conclusion'. This book is a must for (moral) philosophers with an interest in population ethics. (shrink)

This chapter demonstrates how the assumptions made so far in the book imply that there is a single neutral level for existence. That is, there is a single level of wellbeing such that adding a person at that level is neither better nor worse than not adding her. It explains how this conclusion conflicts strongly with an intuition shared by many people: the ‘neutrality intuition’ that adding a person to the world’s population is generally ethically neutral. It uses examples (...) such as the mere addition paradox. It outlines various ways in which the conflict with intuition might be circumvented. (shrink)

Most people (including moral philosophers), when faced with the fact that some of their cherished moral views lead up to the Repugnant Conclusion, feel that they have to revise their moral outlook. However, it is a moot question as to how this should be done. It is not an easy thing to say how one should avoid the Repugnant Conclusion, without having to face even more serious implications from one's basic moral outlook. Several such attempts are presented in (...) this volume. This is the first volume devoted entirely to the cardinal problem of modern population ethics, known as 'The Repugnant Conclusion'. This book is a must for (moral) philosophers with an interest in population ethics. (shrink)

Economic policy evaluations require social welfare functions for variable-size populations. Two important candidates are critical-level generalized utilitarianism (CLGU) and rank-discounted critical-level generalized utilitarianism, which was recently characterized by Asheim and Zuber (2014) (AZ). AZ introduce a novel axiom, existence of egalitarian equivalence (EEE). First, we show that, under some uncontroversial criteria for a plausible social welfare relation, EEE suffices to rule out the Repugnant Conclusion of population ethics (without AZ’s other novel axioms). Second, we provide a new characterization (...) of CLGU: AZ’s set of axioms is equivalent to CLGU when EEE is replaced by the axiom same-number independence. (shrink)

Originally published in 1987 and re-issued in 2020 with a new Preface, this book presents and elaborates interrelated solutions to a number of problems in moral philosophy, from the location of intrinsic value and the nature of a worthwhile life, via the limits of obligation and the nature of justice, to the status of moral utterances. After developing a biocentric account of moral standing, the author locates worthwhile life in the development of the generic capacities of a creature, whether human (...) or nonhuman, and presents an account of relative intrinsic value which later generates a theory of interspecific justice. This value-theory also informs a consequentialist understanding of obligation, of moral rightness and of supererogation. The understanding thus supplied is shown to cope with the problems of integrity, of justice and of the 'Repugnant Conclusion' in population ethics. A cognitivist account of ethical conclusions such as those so far reached is then defended against non-cognitivist and relativist objections and a far-reaching naturalist theory is defended, integrating earlier conclusions with an account of the logic of the fundamental ethical concepts. This wide-ranging volume which maps the whole area of morality is thoroughly argued with reference both to contemporary philosophical developments and to classical theories. (shrink)

Ethicists and economists commonly assume that if A is all things considered better than B, and B is all things considered better than C, then A is all things considered better than C. Call this principle Transitivity. Although it has great conceptual, intuitive, and empirical appeal, I argue against it. Larry S. Temkin explains how three types of ethical principle, which cannot be dismissed a priori, threaten Transitivity: (a) principles implying that in some cases different factors are relevant to comparing (...) A to C than to comparing A to B or B to C; (b) principles of limited scope; (c) principles implying that morally relevant differences in degree can amount to differences in kind. My counterexamples employ a principle of type (c): pleasures and pains enormously different in intensity differ in kind. Temkin has also endorsed this type of counterexample, using arguments based on earlier drafts of this paper. (shrink)

We examine a general class of variable-value population principles. Our particular focus is on the extent to which such principles can avoid the repugnant and sadistic conclusions. We show that if a mild limit property is imposed, avoidance of the repugnant conclusion implies the sadistic conclusion. This result generalizes earlier observations by showing that they apply to a substantially larger class of principles. Our second theorem states that, under the limit property, the axiom of mere (...) class='Hi'>addition also conflicts with avoidance of the repugnant conclusion. This result is a consequence of a similar observation that appears in the earlier literature. (shrink)

Photo ID 71252867© Stepan Popov| Dreamstime.com Abstract While Medical Assistance in Dying (MAiD) has been legalized in Canada since 2016, it still excludes eligibility for persons who have mental illness as a sole underlying medical condition. This temporary exclusion was set to expire on March 17th, 2024, but was set 3 years further back by the Government of Canada to March 17th, 2027. This paper presents a critical appraisal of the case of MAiD for individuals with mental illness as the (...) sole underlying medical condition through the analysis of three ethical theories: principlism, deontology, and utilitarianism. Through evidence and discussion, it will be demonstrated that MAiD, in this context, may be ethically justifiable on the grounds of upholding human rights, protecting dignity, and minimizing suffering. Introduction In June of 2016, Medical Assistance in Dying (MAiD) was legalized in Canada.[1] Throughout the first six years, a temporary exclusion of eligibility for persons suffering solely from mental illness was extended.[2] The exclusion of mental illness as a sole underlying medical condition was set to expire on March 17, 2024.[3] However, on February 1, 2024, just over a month before the set expiration, the Government of Canada once again extended the exclusion, this time setting it back three years to March 17, 2027. There are currently several countries that allow MAiD for mental illness, including Belgium, the Netherlands, and Luxembourg.[4] Some countries, like Spain,[5] do not give specific guidance, leaving the matter under discussion by ethicists and courts. In these countries, there are specific (although different) requirements for the process; overall, for mental illness, the illness must be verifiable and not simply related to a perception of satisfaction with the length of life. This extension ignited discussion on whether MAiD for persons who have mental illness as a sole underlying medical condition in Canada is ethically acceptable. As a complex, multi-faceted, and interdisciplinary issue, ethicists assessing MAiD must take into account various moral obligations and considerations. This paper analyses MAiD in this context through the application of three ethical theories: principlism, deontology, and utilitarianism. This paper concludes that, based on the current evidence and knowledge of this developing situation, MAiD for persons with mental illness in Canada may be ethically justified on the grounds of upholding human rights, labour obligations, and dignity. Through the exploration of research and discussions, it will be demonstrated that society at large ought to protect liberty and act towards relieving suffering, thereby supporting the potential eligibility of MAiD for persons who have mental illness. Principlism: The Capacity and Ability to Assess and Decide for One’s Own Life Principlism is the application of four principles: autonomy, beneficence, non-maleficence, and justice. Principlism supports permitting MAiD for mental illness due to the importance of autonomy in decision-making, equitable and just practices for MAiD assessors, and reducing suffering for patients and their family member(s) and/or friend(s). Carter v. Canada, the Canadian Supreme Court ruling of 2015—which changed Canadian law to allow for MAiD—held that the prohibition of MAiD infringed on Canadians’ right to “life, liberty, and the security of the person.” In a unanimous decision, the Supreme Court of Canada decided that the criminal prohibition of MAiD violates the Canadian Charter of Rights and Freedoms.[6] The Court concluded that the criminal law prohibiting MAiD interfered with people’s autonomy and dignity, which are protected by the rights of liberty and security of the person.[7] The ruling emphasized that Canada’s constitution reflects the fundamental importance of individual autonomy in personal decision-making. Research provides evidence that MAiD improves autonomy: A study among psychiatric patients found that 8 of 48 psychiatric patients said the mere option of accessing MAiD was enough to assess their future options for living wholly.[8] These findings complement a study entailing interviews with 30 adults who have mental illness, which emphasized that the ability to access MAiD allows individuals to analyze their quality of life, envision their desired future, and make decisions accordingly.[9] Although not all participants agreed that mental illness as the only underlying medical condition was appropriate for MAiD eligibility, many participants agreed that patient autonomy in decision-making was paramount and should be respected. However, autonomy as an ethical principle does not immediately grant all persons with mental illness the option to access MAiD. There are multiple eligibility criteria for those who wish to receive MAiD, which still must be approved and assessed. Currently, eligibility criteria for MAiD states that individuals must “give informed consent to receive MAiD, meaning that the person has consented to receiving MAiD after they have received all information needed to make this decision.”[10] Consent requires capability or capacity, which is the ability to understand relevant information, appreciate its potential consequences, and make an informed decision for oneself.[11] Like for many other diseases, disabilities, and conditions, patient capability is determined on a case-by-case basis.[12] Given the stigma surrounding those struggling with mental health, this thorough case-by-case examination of an individual patient’s capability and capacity without prejudice or partiality should lead to equitable and fair treatment. Without appropriate testing, those with mental illness could be wrongly stripped of their decision-making power. Arguments against MAiD for those with mental illness have raised concerns about the potential for individuals to harm themselves and others. A survey of MAiD providers demonstrated that physicians believed that the bereavement experience following MAiD is challenging and profoundly distinct and that bereavement support for all members involved should be required.[13] However, while watching one die (of MAiD) may cause harm to their families, friends, and support system at large, it is also important to recognize that watching someone suffer and struggle through their mental health journey also poses significant harm. Qualitative studies in Ontario, Canada, have interviewed family members of persons with mental illness as a sole medical condition, and interviewees shared that witnessing the illness and its impacts on their close one's lives was a very difficult experience.[14] As it relates to MAiD, participants emphasized that those living with mental illness are in the best position to understand their own pain and suffering and, in turn, make their own decisions about relief.[15] In an interview, a MAiD provider stated that MAiD may provide less suffering and more peace, and that, although it “depends on the family,... usually the family is more prepared and at peace.”[16] On the contrary, a person who has mental illness may perceive choosing MAiD as beneficial to their family member(s) and/or friend(s). Among those who died by MAiD in 2021, 35.7 percent reported that they perceived themselves as a burden on their family and friends.[17] While some authors report their concerns regarding such social burden as a potential driving factor for MAiD requests, others report that there are other additional burdens associated with requesting MAiD that may be financial, societal, and personal.[18] As such, the extension of MAiD eligibility to those with mental illness will likely only allow a small number of people to be granted MAiD.[19] Many others will be diverted to appropriate services and treatments. Patients’ decision to choose MAID noted their ability to make choices about their own care, reflecting the value of autonomy.[20] Although it is difficult to determine what is good for families in individual cases, MAiD presents an option that is both beneficent and non-maleficent. Therefore, these arguments satisfy the principles which do not necessarily conflict with MAiD. Deontology: The Duty to Recognize Vulnerability and Relieve Suffering The argument here begins with the fundamental focus of deontology—that moral duty lies in an action rather than in its consequences. Further discussion is required to analyze the impact of MAiD on healthcare workers. The Canadian Medical Association (CMA) Code of Ethics and Professionalism requires physicians to abide by virtues, commitments, and responsibilities in delivering health care and service.[21] The code states that “a compassionate physician recognizes suffering and vulnerability, … and alleviate[s] the patient’s suffering.”[22] In the context of MAiD for persons with mental illness as a sole underlying medical condition, vulnerabilities could be wide in range. Many Canadians are concerned with the interaction between mental health and other social determinants of health, such as the lack of medical, disability, financial, housing, and social support and resources.[23] As a result, another layer to the ethical issue arises: Does permitting MAiD for mental illness treat the symptoms of the issue rather than the root problem itself (social, economic, and systemic inequities)? Some argue against MAiD, stating that the nation should first focus on developing better quality care and service.[24] Others support MAiD as a potential harm reduction approach, given that most of these unjust conditions require a higher level of long-term structural and public policy overhaul.[25] The CMA Code also calls upon physicians to recognize and alleviate patients’ suffering. Some argue that while physicians and medical professionals do work to relieve suffering, they are trained to do so through a primary care-based diagnose-and-treat approach.[26] Studies that have captured Canadian physicians’ experiences providing MAiD report that, although physicians stated that the work was rewarding, it came with many challenges, including strained relationships with coworkers, increased workload, and inadequate compensation.[27] Physicians report that a part of the problem is that MAiD rules are written by lawyers and experts who are removed from its reality in medical practice. As a result, there is a lack of clarity surrounding practice norms and a lack of support for physicians.[28] Thus, while healthcare practitioners have a duty to relieve patients’ suffering, they should feel adequately trained and supported in doing so. If physicians and healthcare professionals recognize vulnerability and relieve suffering, then they should act accordingly, regardless of potential associations or outcomes. Making persons with mental illness eligible for MAiD ensures that treatment to relieve their suffering is available. However, it is imperative that there are sufficient resources and support available to healthcare professionals to ensure that they feel prepared and supported to provide MAiD, should they wish to do so. Utilitarianism: Minimizing Intolerable Suffering and Dying with Dignity Overall, utilitarianism is largely concerned with the greatest happiness principle—to increase the amount of happiness for the greatest number of people. So far, this paper has analyzed individual, family, and practitioner-based ethical considerations. But if MAiD were to be extended to those with mental illness as a singular underlying medical condition, what implications would this have for the world and society at large? There is a global drive toward authorizing organized ending of life, with an increasing number of countries legalizing MAiD.[29] The medical system is generally seen as a safe and appropriate system to carry out MAiD, especially when suicide and self-harm are regarded as “alternatives.” Yet despite these worldwide efforts, many argue through the theory of utilitarianism that the inability to see long-term consequences renders MAiD a premature solution, particularly for those who are unable or unwilling to seek other forms of potentially healing treatment or for those who may undergo MAiD only for a technological innovation or biomedical advancement to later come along as a potential cure.[30] While it is true that MAiD does not prevent these “premature deaths,” it is also true that it does not claim to.[31] MAiD provides an option to alleviate intolerable suffering. Some individuals with severe mental illness do describe their condition as intolerable suffering. MAiD is seen as an option to minimize suffering. It can also be seen as a way to die with dignity and relief.[32] While predicting outcomes is difficult, extending MAiD eligibility for persons experiencing mental illness does not undermine its ability to end suffering. It allows eligible individuals to take charge of their health, their life, and their future. Conclusion Based on the current evidence, allowing MAiD for persons with mental illness as their sole underlying medical condition presents as an ethically justifiable action. The right to self-determination and fair accessibility demonstrates that there is more harm done by prohibiting MAiD for mental illness than allowing it. Such liberty is a right, and in the context of relieving suffering, it is a duty that healthcare workers must uphold, although the ability to opt out of providing MAiD is well established. Thus, to recognize vulnerability and relieve suffering means to provide methods, such as MAiD, for those deeply impacted by mental illness. These justifications stand at both the individual level and for society at large. Nevertheless, it remains imperative to take an upstream approach that addresses the social determinants of health and aims to prevent mental illness and promote long-term, beneficial social change for those suffering, struggling, and vulnerable in our communities. - [1] Jaro Kotalik and David W. Shannon, Medical Assistance in Dying (MAID) in Canada Key Multidisciplinary Perspectives, 1st ed. 2023., The International Library of Bioethics, 104 (Cham: Springer International Publishing, 2023), https://doi.org/10.1007/978-3-031-30002-8. [2] Department of Justice Government of Canada, “Canada’s Medical Assistance in Dying (MAID) Law,” February 21, 2024, https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html. [3] Health Canada, “Final Report of the Expert Panel on MAiD and Mental Illness,” transparency - other, May 13, 2022, https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advi sory-bodies/expert-panel-maid-mental-illness/final-report-expert-panel-maid-mental-illness.html. [4] Federal Public Service (FPS) Health Belgium, “Federal Commission for the Control and Evaluation of Euthanasia,” n.d., https://consultativebodies.health.belgium.be/en/advisory-and-consultative-bodies/federal-commission- control-and-evaluation-euthanasia.; Government of Netherlands, “Is Euthanasia Allowed in the Netherlands?,” n.d., https://www.government.nl/topics/euthanasia/is-euthanasia-allowed.; “Information on Requesting Euthanasia or Assisted Suicide,” n.d., https://guichet.public.lu/en/citoyens/sante/fin-vie/euthanasie/euthanasie-assistance-suicide.html. [5] Luis Espericueta, First official report on euthanasia in Spain: A comparison with the Canadian and New Zealand experiences, Medicina Clínica (English Edition), Volume 161, Issue 10, 2023, Pages 445-447, ISSN 2387-0206, https://doi.org/10.1016/j.medcle.2023.06.021. [6] Government of Canada, “The Canadian Charter of Rights and Freedoms,” March 15, 2021, https://www.justice.gc.ca/eng/csj-sjc/rfc-dlc/ccrf-ccdl/. [7] Supreme Court of Canada, “Carter v. Canada,” Constitutional Law, 2015, https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do.; Kotalik and Shannon, Medical Assistance in Dying (MAID) in Canada Key Multidisciplinary Perspectives. [8] Karandeep Sonu Gaind, “What Does ‘Irremediability’ in Mental Illness Mean?,” Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie 65, no. 9 (September 2020): 604–6, https://doi.org/10.1177/0706743720928656; Lieve Thienpont et al., “Euthanasia Requests, Procedures and Outcomes for 100 Belgian Patients Suffering from Psychiatric Disorders: A Retrospective, Descriptive Study,” BMJ Open 5, no. 7 (July 27, 2015): e007454, https://doi.org/10.1136/bmjopen-2014-007454. [9] Hamer Bastidas-Bilbao et al., “Walking Alongside: Views of Family Members on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition,” Qualitative Health Research 33 (September 29, 2023), https://doi.org/10.1177/10497323231197365. [10] Government of Canada, “Canada’s Medical Assistance in Dying (MAID) Law.” [11] Commission sur les soins de fin de vie, “Les conditions de l’admissibilité à l’aide médicale à mourir au Québec: la constance dans l’évolution de la loi concernant les soins de fin de vie,” June 9, 2023, https://csfv.gouv.qc.ca/ fileadmin/docs/autres_rapports/csfv_lcsfv_conditions_ amm_2023-06-29.pdf.; Trudo Lemmens, “When Death Becomes Therapy: Canada’s Troubling Normalization of Health Care Provider Ending of Life,” The American Journal of Bioethics 23, no. 11 (November 2, 2023): 79–84, https://doi.org/10.1080/15265161.2023.2265265. [12] Justine Dembo, Udo Schuklenk, and Jonathan Reggler, “‘For Their Own Good’: A Response to Popular Arguments Against Permitting Medical Assistance in Dying (MAID) Where Mental Illness Is the Sole Underlying Condition,” Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie 63, no. 7 (July 2018): 451–56, https://doi.org/10.1177/0706743718766055. [13] Konia Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” British Columbia Medical Journal 62, no. 1 (2020). [14] Bastidas-Bilbao et al., “Walking Alongside.” [15] Bastidas-Bilbao et al. [16] Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” 2020. [17] Ramona Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” Palliative & Supportive Care 21, no. 5 (October 2023): 871–78, https://doi.org/10.1017/S1478951523001025; Health Canada, “Third Annual Report on Medical Assistance in Dying in Canada 2021,” report on plans and priorities;transparency - other, July 26, 2022, https://www.canada.ca/en/health-canada/services/publications/health-system-services/annual-report-me dical-assistance-dying-2021.html; Lemmens, “When Death Becomes Therapy.” [18] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023.; Bastidas-Bilbao et al., “Walking Alongside.” [19] Olivia Stefanovich, “Opposition Parties Call for Indefinite Pause to MAID Expansion for Mental Illness | CBC News,” Canadian Broadcasting Corporation, January 28, 2024, https://www.cbc.ca/news/politics/special-joint-committee-maid-mental-illness-report-1.7095679; Benjamin Lopez Steven, “Number of Assisted Deaths Jumped More than 30 per Cent in 2022, Report Says | CBC News,” Canadian Broadcasting Corporation, October 27, 2023, https://www.cbc.ca/news/politics/maid-canada-report-2022-1.7009704. [20] Hamer Bastidas-Bilbao et al., “Searching for Relief from Suffering: A Patient-Oriented Qualitative Study on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition,” Social Science & Medicine 331 (August 1, 2023): 116075, https://doi.org/10.1016/j.socscimed.2023.116075. [21] Canadian Medical Association, “Canadian Medical Association Code of Ethics and Professionalism” (Canada: Canadian Medical Association, December 8, 2018), https://policybase.cma.ca/link/policy13937. [22] Canadian Medical Association. [23] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023; Stefanovich, “Opposition Parties Call for Indefinite Pause to MAID Expansion for Mental Illness | CBC News.” [24] John Paul Tasker, “Liberal Government Promoting a ‘culture of Death’ with Medical Assistance in Dying Law, Conservative MP Says | CBC News,” Canadian Broadcasting Corporation, March 6, 2023, https://www.cbc.ca/news/politics/culture-of-death-medical-assistance-in-dying-mental-illness-1.67695 04. [25] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023; Kayla Wiebe and Amy Mullin, “Choosing Death in Unjust Conditions: Hope, Autonomy and Harm Reduction,” Journal of Medical Ethics, April 26, 2023, https://doi.org/10.1136/jme-2022-108871. [26] Ramona Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” Palliative & Supportive Care 21, no. 5 (October 2023): 871–78, https://doi.org/10.1017/S1478951523001025. [27] Konia Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” British Columbia Medical Journal 62, no. 1 (2020), https://bcmj.org/articles/attitudes-and-expectations-regarding-bereavement-support-patients-family-m embers-and.; William Robert Nielsen, “MAiD in Canada: Ethical Considerations in Medical Assistance in Dying,” Canadian Journal of Bioethics 4, no. 2 (December 9, 2021): 93–98, https://doi.org/10.7202/1084456ar. [28] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023. [29] Lemmens, “When Death Becomes Therapy.” [30] William Robert Nielsen, “MAiD in Canada: Ethical Considerations in Medical Assistance in Dying,” Canadian Journal of Bioethics 4, no. 2 (December 1, 2021): 93–98, https://doi.org/10.7202/1084456ar. [31] Steven, “Number of Assisted Deaths Jumped More than 30 per Cent in 2022, Report Says | CBC News.” [32] A. Plaisance et al., “Quebec Population Highly Supportive of Extending Medical Aid in Dying to Incapacitated Persons and People Suffering Only from a Mental Illness: Content Analysis of Attitudes and Representations,” Ethics, Medicine and Public Health 21 (April 1, 2022): 100759, https://doi.org/10.1016/j.jemep.2022.100759. (shrink)