In several jurisdictions, irremediable suffering from a medical condition is a legal requirement for access to assisted dying. According to the expressivist objection, allowing assisted dying for a specific group of persons, such as those with irremediable medical conditions, expresses the judgment that their lives are not worth living. While the expressivist objection has often been used to argue that assisted dying should not be legalised, I show that there is an alternative solution available to its proponents. An autonomy- (...) class='Hi'>based approach to assisted suicide regards the provision of assisted suicide (but not euthanasia) as justified when it is autonomously requested by a person, irrespective of whether this is in her best interests. Such an approach has been put forward by a recent judgment of the German Federal Constitutional Court, which understands assisted suicide as an expression of the person’s right to a self-determined death. It does not allow for beneficence-based restrictions regarding the person’s suffering or medical diagnosis and therefore avoids the expressivist objection. I argue that on an autonomy-based approach, assisted suicide should not be understood as a medical procedure but rather as the person’s autonomous action. (shrink)

This paper aims to provide autonomy-based reasons in favour of limitarianism. Limitarianism affirms it is of primary moral importance that no one gets too much. The paper challenges the standard assumption that having more material resources always increases autonomy. It expounds five mechanisms through which having too much material wealth might undermine autonomy. If these hypotheses are true, a theory of justice guided by a concern for autonomy will support a limitarian distribution of wealth. Finally, (...) the paper discusses two issues autonomy-based limitarianism would raise. First, insofar as coercion invades autonomy, do autonomy-based reasons legitimate coercive measures to secure a limitarian distribution of wealth? Second, is a limitarian ethos consistent with the incentive to produce enough wealth to secure distributive justice? (shrink)

The patient preference predictor is a proposed computer-based algorithm that would predict the treatment preferences of decisionally incapacitated patients. Incorporation of a PPP into the decision-making process has the potential to improve implementation of the substituted judgement standard by providing more accurate predictions of patients’ treatment preferences than reliance on surrogates alone. Yet, critics argue that methods for making treatment decisions for incapacitated patients should be judged on a number of factors beyond simply providing them with the treatments they (...) would have chosen for themselves. These factors include the extent to which the decision-making process recognises patients’ freedom to choose and relies on evidence the patient themselves would take into account when making treatment decisions. These critics conclude that use of a PPP should be rejected on the grounds that it is inconsistent with these factors, especially as they relate to proper respect for patient autonomy. In this paper, we review and evaluate these criticisms. We argue that they do not provide reason to reject use of a PPP, thus supporting efforts to develop a full-scale PPP and to evaluate it in practice. There are no data in this work. (shrink)

Voluntarist accounts of secession are those that attempt to ground a moral right to secede in autonomy. This paper argues that no such account is likely to succeed. After describing the serious problems that plague the most straightforward Voluntarist approach, I examine two recent accounts that employ novel approaches designed to avoid those difficulties. I argue that both accounts fail, shedding considerable doubt on the possibility of a plausible autonomy-based account of the moral right to secede. I (...) go on to discuss what this pessimistic conclusion implies for the theory and practice of secession. (shrink)

The COVID-19 pandemic has provoked new interest in the notion of vulnerability and in identifying alternative approaches for responding to vulnerable patients and populations during health emergencies. In this paper, I argue that the autonomy-based approach (the most dominant approach in bioethics) to responding to vulnerability during health emergencies is deficient because it focuses only on the interests, values, and decisions of the individual patient. It overly emphasizes respect for autonomy and not respect for the patient as (...) it does not consider the patient as a social and relational agent. Indeed, relational approaches to autonomy like the feminist and indigenous sub-Saharan African ethical approaches are promising alternatives. In this essay, I use the indigenous African relational approach to autonomy as an example of an alternative method which can be used to respond to vulnerability during a global health emergency like COVID-19. (shrink)

Florijn’s analysis of the Dutch Supreme Court ruling on the Albert Heringa case demonstrates that the Dutch approach to justifying physician-assisted death is based primarily on the physician...

The claim that indigenous communities are entitled to have intellectual property rights (IPRs) to both their plant varieties and their botanical knowledge has been put forward by writers who wish to protect the plant genetic resources of indigenous communities from uncompensated use by biotechnological transnational corporations. We argue that while it is necessary for indigenous communities to have suchrights, the entitlement argument is an unsatisfactory justification for them. A more convincing foundation for indigenous community IPRs is the autonomy theory (...) developed by Will Kymlicka. (shrink)

The authors respond to four JME commentaries on their Feature Article, ‘Autonomy-based criticisms of the patient preference predictor’.

Marshall et al. (2024) persuasively argue that some patients with opiate use disorder (OUD), who refuse observation after naloxone resuscitation in the emergency department (ED), “may be making non...

The aim of this article is to present and critically investigate a type of argument against legalising assisted dying on request (ADR) for patients who are terminally ill and experiencing suffering. This type of argument has several variants. These—which we call ‘autonomy-based arguments’ against legalising ADR—invoke different specifications of the premise that we ought not to respect requests for assistance in dying made by terminally ill and suffering patients because the basic conditions of autonomy cannot be met (...) in scenarios where such requests are made. Specifically, it is argued either (1) that as a result of pain, anxiety or desperation, terminally ill patients are not competent decision makers or (2) that legalisation of ADR would lead to social pressure or in other ways change the patient's context of choice in ways that make such requests nonautonomous. We argue that these types of arguments are problematic in light both of empirical studies and the fact that we usually judge that it is morally right to respect the wishes and decisions of dying people even if they suffer. (shrink)

Respect for autonomy is typically considered a key reason for allowing physician assisted suicide and euthanasia. However, several recent papers have claimed this to be grounded in a misconception of the normative relevance of autonomy. It has been argued that autonomy is properly conceived of as a value, and that this makes assisted suicide as well as euthanasia wrong, since they destroy the autonomy of the patient. This paper evaluates this line of reasoning by investigating the (...) conception of valuable autonomy. Starting off from the current debate in end-of-life care, two different interpretations of how autonomy is valuable is discussed. According to one interpretation, autonomy is a personal prudential value, which may provide a reason why euthanasia and assisted suicide might be against a patient’s best interests. According to a second interpretation, inspired by Kantian ethics, being autonomous is unconditionally valuable, which may imply a duty to preserve autonomy. We argue that both lines of reasoning have limitations when it comes to situations relevant for end-of life care. It is concluded that neither way of reasoning can be used to show that assisted suicide or euthanasia always is impermissible. (shrink)

When a patient lacks sufficient capacity to make a certain treatment decision, whether because of deficits in their ability to make a judgement that reflects their values or to make a decision that reflects their judgement or both, the decision must be made by a surrogate. Often the best way to respect the patient’s autonomy, in such cases, is for the surrogate to make a ‘substituted’ judgement on behalf of the patient, which is the decision that best reflects the (...) patient’s values and identity-infused beliefs as they were when the patient last possessed capacity. It is by now well-known that there is troubling evidence that surrogates do only slightly better than chance at making accurate substituted judgements. The use of a patient preference predictor, an algorithm that predicts patient preferences based on characteristics like the patient’s age, gender, socioeconomic status and education level, could help. Rid and Wendler have done important work making a moral case for using the PPP.1 If it were shown to enhance accuracy, it is not at all obvious what objections there could be to its use. Yet several subtle criticisms of the PPP have emerged in the literature. In their feature article, Jardas, Wasserman and Wendler select six of the most prominent objections to the PPP in the literature and defend the PPP against them.2 Along the way they make significant contributions to broader issues concerning the proper uses of statistical evidence and limits on the kinds of preferences there can be reasons of autonomy to respect. Since I found the authors’ answers to the final two objections—that the PPP relies on naked statistical evidence and that it uses non-endorsed reasons—to be especially interesting and provocative, I will examine those answers and raise a few questions about …. (shrink)

Advance directives (ADs) have for some time been championed by ethicists and patient associations alike as a tool that people newly diagnosed with dementia, or prior to onset, may use to ensure that their future care and treatment are organized in accordance with their interests. The idea is that autonomous people, not yet neurologically affected by dementia, can design directives for their future care that caregivers are morally obligated to respect because they have been designed by autonomous individuals. In this (...) paper, we first criticize the idea that ADs can retain moral authority in severe dementia by arguing that it is paradoxical. Second, we consider two arguments that initially seem to refute this critique of ADs, but we eventually dismiss them. The first argument states that ADs retain moral authority in severe dementia because autonomously formed interests, for example, ADs, can only be appropriately discarded by autonomous persons. This we term the historical autonomy argument. We dismiss it by demonstrating how we, in analog cases, are not obligated to continue to respect autonomously formed interests even though they have been discarded under nonappropriate conditions. The second argument is that ADs can be justified by what we term external interests. While we agree that people with severe dementia plausible can be said to have external interests, we show that ADs cannot express such interests and hence cannot be justified by them. We conclude that none of the discussed arguments support the use of ADs and because of this, the idea of ADs should be reassigned. (shrink)

According to the “discrimination argument,” it would be discriminatory and hence impermissible to categorically exclude people with mental illness (PMI) from access to assisted suicide (AS) if AS is accessible to people with somatic illnesses. In objection to this, it could be argued that excluding PMI is not discriminatory, but rather based on their inability to meet certain eligibility criteria for AS. Which criteria are deemed necessary depends on the approach taken to justifying AS. In this article, we describe (...) two distinct ethical approaches to justifying AS and the eligibility criteria they entail and examine whether PMI can fulfill these criteria. A widespread “joint” approach based on beneficence and autonomy assumes that AS is justified when it alleviates the severe and irremediable suffering of a person who autonomously requests AS. An alternative, exclusively autonomy‐based approach assumes that providing AS is justified when a person's request is autonomous, regardless of whether AS is in her best interests. The latter approach underlies an important judgment of the German Federal Constitutional Court from 2020. We argue that PMI can in principle fulfill both beneficence‐ and autonomy‐based eligibility criteria for AS, and that a blanket exclusion of all PMI from AS is thus discriminatory on either approach. However, depending on which approach is taken, there are differences regarding the subgroups of PMI that would be eligible for AS. Whether the exclusion of specific PMI is discriminatory therefore depends on how we understand and justify AS. (shrink)

In the jurisprudence of constitutional courts around the world, there is an emerging trend towards an autonomy-based understanding of constitutional rights: increasingly, rights are interpreted as being about enabling people to live autonomous lives, rather than disabling the state in certain ways. This article investigates the conception of autonomy employed by courts by presenting two candidates and examining which of them explains the current practice of constitutional rights law better. The first, labelled the excluded reasons conception of (...) autonomy, claims that a person’s autonomy is violated if he is treated on the basis of certain impermissible—in particular, moralistic or paternalistic—reasons. It is concluded that, while this is a coherent understanding of autonomy, it cannot explain many of the rights that are widely accepted today. The second, the protected interests conception, argues that a person has autonomy interests in controlling certain domains of her life, and offers a scale on which the importance of the various autonomy interests can be assessed. The article demonstrates that this conception is coherent and adequately explains the current practice. The final section briefly explores some implications of this result for a comprehensive reconstructive theory of constitutional rights. (shrink)

Discussions of the proper role of conscience and practitioner judgement within medicine have increased of late, and with good reason. The cost of allowing practitioners the space to exercise their best judgement and act according to their conscience is significant. Misuse of such protections carve out societal space in which abuse, discrimination, abandonment of patients, and simple malpractice might occur. These concerns are offered amid a backdrop of increased societal polarization and are about a profession which has historically fought for (...) such privileged space. There is a great deal that has been and might yet be said about these topics, but in this paper I aim to address one recent thread of this discussion: justification of conscience protection rooted in autonomy. In particular, I respond to an argument from Greenblum and Kasperbaur and clarify a critique I offered of an autonomy-based conscience protection argument which Greenblum and Kasperbaur seek to improve and defend. To this end, I briefly recap the central contention of that argument, briefly describe Greenblum and Kasperbaur’s analysis of autonomy and of my critique, and correct what appears to be a mistake in interpretation of both my work and of autonomy-based defenses of conscience protection in general. (shrink)

Health Recommender Systems are promising Articial-Intelligence-based tools endowing healthy lifestyles and therapy adherence in healthcare and medicine. Among the most supported areas, it is worth mentioning active aging. However, current HRS supporting AA raise ethical challenges that still need to be properly formalized and explored. This study proposes to rethink HRS for AA through an autonomy-based ethical analysis. In particular, a brief overview of the HRS’ technical aspects allows us to shed light on the ethical risks and (...) challenges they might raise on individuals’ well-being as they age. Moreover, the study proposes a categorization, understanding, and possible preventive/mitigation actions for the elicited risks and challenges through rethinking the AI ethics core principle of autonomy. Finally, elaborating on autonomy-related ethical theories, the paper proposes an autonomy-based ethical framework and how it can foster the development of autonomy-enabling HRS for AA. (shrink)

The emerging international biomedical law tends to recognise the right not to know one’s genetic status. However, the basis and conditions for the exercise of this right remain unclear in domestic laws. In addition to this, such a right has been criticised at the theoretical level as being in contradiction with patient’s autonomy, with doctors’ duty to inform patients, and with solidarity with family members. This happens especially when non-disclosure poses a risk of serious harm to the patient’s relatives (...) who, without that vital information, could be deprived of preventive or therapeutic measures. This paper argues, firstly, that individuals may have a legitimate interest in not knowing their genetic make up to avoid serious psychological consequences; secondly, that this interest, far from being contrary to autonomy, may constitute an enhancement of autonomy; thirdly, that the right not to know cannot be presumed, but must be “activated” by the individual’s explicit choice, and fourthly, that this is not an absolute right, in the sense that it may be restricted when disclosure to the patient is necessary in order to avoid a risk of serious harm to third persons. (shrink)

Moral Case Deliberations are reflective dialogues with a group of participants on their own moral dilemmas. Although MCD is successful as clinical ethics support, it also has limitations. 1. Lessons learned from individual MCDs are not shared in order to be used in other contexts 2. Moral learning stays limited to the participants of the MCD; 3. MCD requires quite some organisational effort, 4. MCD deals with one individual concrete case. It does not address other, similar cases. These limitations warrant (...) research into complementary ways of providing CES to healthcare professionals. Our research objective was therefore to develop a low threshold CES tool based on a series of MCDs on autonomy in long-term care. We used a qualitative research design in which we analyzed the process and content of a series of MCDs, combined with reflections on the theoretical background of MCD. In total 28 MCDs were analyzed by means of a thematic content analysis. In various rounds of development, the results of the analysis were combined with theoretical reflections on CES. Consequently, the tool was evaluated in three focus groups and adjusted. The CES tool, called ‘moral compass’, guides the users through a series of six subsequent questions in order to methodically reflect on their concrete moral dilemma, in the form of a booklet of 23 pages. It combines a methodical element that encourages and structures a reflection process with a substantive element, including norms, values, options, strategies, and insights regarding dealing with client autonomy. By using data from a series of MCDs, combined with theoretical reflections on MCD, ethics support and moral learning, we developed a thematic, low-threshold CES tool that supports healthcare professionals in daily practice in dealing with moral questions regarding client autonomy. It integrates examples and insights from earlier MCDs on the same topic. The moral compass is not a replacement of, but can be used complementary to MCD. The feasibility and impact of the moral compass need to be investigated in an evaluative follow-up study. The methodology presented in this paper may be used to develop moral compasses on different topics in various healthcare organizations. (shrink)

The primary goal of this monograph is to justify the possibility of building a hybrid theory of normative ethics which can combine ethical consequentialism, deontology and virtue ethics. The aim of the book is to demonstrate the possibility of constructing a synthetic theory from ethical traditions that are generally considered to be contradictory. In addition, I propose an outline of an original theory which tries to carry out such a synthesis. I call it Institutional Function Consequentialism. The justification for a (...) hybrid theory of normative ethics requires the resolution of certain meta-ethical issues. I discuss them in part 1.1. After a brief overview of my research aims I consider the answer to the following questions: “What kind of meta-ethical beliefs must we assume for normative ethics?” and "Why should we build ethical theories?". I also discuss the various forms of ethical scepticism, which should be rejected if we develop a hybrid theory of normative ethics. I also describe possible methods of justifying any ethical theory. At the end of part 1.1 I explain that the best method for justifying any ethical theory is the method of wide reflective equilibrium. In parts 1.2, 1.3 and 1.4 I analyse three main types of normative ethics which are considered to be competitive: consequentialism, deontology, and virtue ethics. Part 1.2 is about consequentialism and its difference between utilitarianism and teleological theories. I also present the main reasons for the popularity of consequentialism. In part 1.3 I define deontology, present its variations and show important benefits that motivate its continuous growth. In part 1.4 I discuss virtue ethics, which is often referred as the viable alternative to consequentialism and deontology. If we want to build any new ethical theory, first we should describe the problems of the old ones. For this reason, in chapter 2 I describe the most important arguments against ethical consequentialism, and in chapter 3 I explain the difficulties of deontology. Critical remarks on virtue ethics are considered in part 1.4. The last two chapters directly concern the main aim of the monograph. Because in chapter 3 I show that deontology suffers from a number of problems such as the paradox of deontology, in chapters 4 and 5 I present only consequentialist versions of hybrid theories. These versions try to avoid the common pleas of utilitarianism and combine the advantages of opponents to utilitarianism. I answer the question (4.1) "What is hybrid consequentialism?" and briefly describe (4.2) the most important examples of hybrid theories by others. I discuss the prerogatives without restrictions idea by Samuel Scheffler, rule consequentialism by Brad Hooker, Kantian consequentialism by Richard M. Hare, David Cummiskey and Derek Parfit and consequentializing procedure proposed by Douglas W. Portmore. In the last chapter I present a new hybrid version of consequentialism that I call Institutional Function Consequentialism. I start from the thesis (5.1) that traditional meta-ethics of analytic philosophy incorrectly defines the main field of its research. Rather than focusing on the philosophy of language and metaphysics it should try to answer one question: “What should morality and ethics be for?”. Therefore I introduce an original methodology for meta-ethics that I call the Functional Model of Analysis (FMA). It is a meta-ethical framework in which the fundamental questions concern the practical functions of normative domains such as morality and ethics and the most rational way of achieving them. FMA is meta-ethical project that (a) explains the persistence of fundamental ethical disagreement among experts, (b) sets the background for explaining or justifying the correct structure of the ethical theory, (c) gives the possibility to create a hybrid theory of normative ethics. In part 5.2 I formulate a generalized argument against various popular theories of normative ethics which states that most of the popular theories are too narrow and one-sided, causing permanent dispute between them. There are many distinct practical functions of morality that are usually based on different types of normative theories such as Aristotelian ethics, utilitarianism, contractarianism and contractualism. In order to remove these conflicts, the correct ethical theory should try to take into account all of these relevant features of moral life. Unfortunately, most ethical theories are mono-functional. This means that their supporters consciously or unconsciously (1) recognize or accept only one genuine practical function, (2) think that this one practical function overrides all other practical functions or (3) try to reduce all practical functions to the one that is chosen. In part 5.2 I present a description and justification of a new normative account that I call Hybrid Function Consequentialism. The formal scheme of this consequentialism can be summarized in the following way: we should act according to some important focal points P1…Pn with contents C1…Cn that are selected on the basis of considerations about which kind of P with C will bring the best realization of the best mix of normative functions F1...Fn. In the next part (5.2.2) I present the new way of “consequentializing” particular theories of normative ethics by applying the scheme of Hybrid Function Consequentialism. As an example of the use of this procedure, I formulate perfectionist virtue consequentialism, contractarian institution consequentialism, contractualist rule consequentialism and consequentialism of salvation. In part 5.3 I formulate an original theoretical concept that I call Institutional Function Consequentialism (IFC). It is a hybrid theory that is based on the previously described Functional Model of Analysis and a reflection on the role of institutions in modern developed societies. IFC claims that we should always act according to some rules, virtues, motives and intentions that constitute the homeostasis of normative institutions whose internalization by the overwhelming majority of each new generation has maximum expected value in terms of the best realization of the equilibrium of the most important practical functions of normative domains. Responsibility and sanctions related to wrongful actions should be dependent on the particular institution whose standards have been violated. IFC has several unique features which are described and justified in part 5.3. It is a form of hybrid consequentialism – it mixes features of consequentialism, deontology and virtue ethics. It does this on three different levels: justification, structure and content. The main focal point of the theory is not rules or virtues, but normative institutions. Values to be optimized in the framework of consequentialism are not "happiness", "well-being" or "preferences", but the fulfilment of normative functions. IFC is not limited to the field of ethics only, but it is a meta-normative account of justification for an entire social order which is comprised of a number of different institutions. It also assumes a specific, circular relationship between practical ethics (e.g. research on such important issues as civil disobedience, fair distribution of wealth, philosophy of punishment or autonomy of conscience), and the content of the general rules that may constitute the optimal homeostasis of institutions. It rejects the simplistic belief that moral thinking is based solely on deductive implications from general ethical principles or meta-ethical beliefs. (shrink)

Through its adoption of the biomedical model of disease which promotes medical individualism and its reliance on the individual-based anthropology, mainstream bioethics has predominantly focused on respect for autonomy in the clinical setting and respect for person in the research site, emphasizing self-determination and freedom of choice. However, the emphasis on the individual has often led to moral vacuum, exaggeration of human agency, and a thin (liberal?) conception of justice. Applied to resource-poor countries and communities within developed countries, (...) autonomy-based bioethics fails to address the root causes of diseases and public health crises with which individuals or communities are confronted. A sociological explanation of disease causation is needed to broaden principles of biomedical ethics and provides a renewed understanding of disease, freedom, medical practice, patient-physician relationship, risk and benefit of research and treatment, research priorities, and health policy. (shrink)

Happy cow messages are instances of commercial speech by the animal industry which, by action or by omission, mislead consumers about the harmful effects that the industry has for nonhuman animals, the environment, or human health. Despite their ubiquity, happy cow messages have received little philosophical scrutiny. This paper aims to call attention to this form of speech, and to make the case for its restriction. To do so we first conceptualize happy cow messages. Second, we argue that they encroach (...) upon individual autonomy in two particularly objectionable ways: by impairing our ability to behave according to our moral convictions, and by thwarting our capacity to identify and reason about our moral duties. This, we hold, grounds a pro tanto case for stricter and more comprehensive regulations of commercial speech by the animal industry. Third, and against the objection that restricting happy cow messages would violate freedom of speech, we contend that none of the most influential arguments for free speech grants them protection. Indeed, we suggest, those rationales seem to call for their restriction. Fourth, and finally, we review some possible ways to defuse the misleading potential of happy cow messages through commercial speech regulations. (shrink)

ABSTRACT: When considering normative concepts, such as distributive justice, one must consider both the question how concepts can have normative force and which particular conceptions of these concepts have this normative force. In this article I consider the view that the human capacity for autonomy accounts for normativity, and argue that adopting this view commits one to a responsibility-sensitive theory of distributive justice. This conclusion puts me directly at odds with the work of John Rawls, who derives his responsibility-insensitive (...) difference principle from a similar account of autonomy. However, I argue that such an argument would be based on a mischaracterisation of what is significant about the human capacity for autonomy. RÉSUMÉ : Pour envisager des concepts normatifs, tels que la justice distributive, il faut à la fois considérer la question de savoir comment les concepts peuvent avoir une force normative et se demander aussi quelles conceptions de ces concepts en sont dotés. Cet article considère que la capacité propre à l’humain d’être autonome rend compte de la normativité nous engage à adopter une théorie de justice distributive qui est sensible à la responsabilité. Cette conclusion entre directement en conflit les théories de Rawls, qui tire d’une explication similaire sur l’autonomie son principe de responsabilité qui ne tient pas compte de la différence. Un tel argument se fonde sur une mauvaise caractérisation de ce qui est important dans la capacité propre à l’humain d’être autonome. (shrink)

Autonomy has been the central principle underpinning changes which have affected the practice of medicine in recent years. Medical education is undergoing changes as well, many of which are underpinned, at least implicitly, by increasing concern for autonomy. Some universities have embarked on graduate courses which utilize problem-based learning (PBL) techniques to teach all areas, including medical ethics. I argue that PBL is a desirable method for teaching and learning in medical ethics. It is desirable because the (...) nature of ethical enquiry is highly compatible with the learning processes which characterize PBL. But it is also desirable because it should help keep open the question of what autonomy really is, and how it should operate within the sphere of medical practice and medical education. (shrink)

BackgroundRespect for autonomy is a key concept in contemporary bioethics and end-of-life ethics in particular. Despite this status, an individualistic interpretation of autonomy is being challenged from the perspective of different theoretical traditions. Many authors claim that the principle of respect for autonomy needs to be reconceptualised starting from a relational viewpoint. Along these lines, the notion of relational autonomy is attracting increasing attention in medical ethics. Yet, others argue that relational autonomy needs further clarification (...) in order to be adequately operationalised for medical practice. To this end, we examined the meaning, foundations, and uses of relational autonomy in the specific literature of end-of-life care ethics.MethodsUsing PRESS and PRISMA procedures, we conducted a systematic review of argument-based ethics publications in 8 major databases of biomedical, philosophy, and theology literature that focused on relational autonomy in end-of-life care. Full articles were screened. All included articles were critically appraised, and a synthesis was produced.ResultsFifty publications met our inclusion criteria. Twenty-eight articles were published in the last 5 years; publications were originating from 18 different countries. Results are organized according to: (a) an individualistic interpretation of autonomy; (b) critiques of this individualistic interpretation of autonomy; (c) relational autonomy as theoretically conceptualised; (d) relational autonomy as applied to clinical practice and moral judgment in end-of-life situations.ConclusionsThree main conclusions were reached. First, literature on relational autonomy tends to be more a ‘reaction against’ an individualistic interpretation of autonomy rather than be a positive concept itself. Dichotomic thinking can be overcome by a deeper development of the philosophical foundations of autonomy. Second, relational autonomy is a rich and complex concept, formulated in complementary ways from different philosophical sources. New dialogue among traditionally divergent standpoints will clarify the meaning. Third, our analysis stresses the need for dialogical developments in decision making in end-of-life situations. Integration of these three elements will likely lead to a clearer conceptualisation of relational autonomy in end-of-life care ethics. This should in turn lead to better decision-making in real-life situations. (shrink)

이 논문에서는 자유주의 성윤리로서 제시되어온 기존의 입장들이 검토되고, 그 안에서 발견되는 긴장, 혼란, 그리고 한계들이 지적된다. 그리고 최종적으로이런 문제점들을 제거할 수 있는 이론적 자원을 갖춘 자유주의 성윤리가 새롭게 제안될 것이다. 이렇게 제안된 새로운 자유주의는 자유주의 담론이 가진 본래 취지를더 선명히 드러내며, 자유주의 성윤리에 대한 혼란과 오해를 줄일 수 있다. 첫째, 나는 자유주의가 비판의 대상으로 삼았던 보수주의 성윤리를 검토한다. 나는 여기서 보수주의 성윤리의 대표적인 네 가지 이론적 원천들을 검토하며 그 한계를 지적하지만, 그것들을 완전히 폐기하지는 않는다. 이것은 충분히 자유주의 성윤리 담론을 새롭게 (...) 구성할 좋은 이론적 자원을 보유하고 있기 때문이다. 둘째, 나는 자유주의 성윤리의 등장과 그 내적 혼란에 대해 검토한다. 기존의 자유주의 성윤리는 쾌락의 어법과 자율성의 어법을 동시에 포함하며 등장한다. 나는 이 두 어법이 친화적으로 보이지만 늘 상호 일관적으로 공존하지는 않는다는 점을 지적할것이다. 기존의 자유주의 성윤리는 쾌락의 어법에 좀 더 기울면서 자율성의 많은측면들을 훼손하기에 이른다. 나는 기존의 자유주의 성윤리가, 보수주의가 지닌 본질론들을 비판하면서도 그 스스로 또 다른 본질론을 견지하고 있고 그로 인해 몇가지 문제점이 발생하게 됨을 지적할 것이다. 그리고 더 나아가 나는 기존의 자유주의 성윤리가 성관계 당사자들만의 미시적 관계에 집중하고 그들을 둘러싼 사회구조적, 맥락적 성격에 대해서 고려하지 않는다는 점을 지적할 것이다. 마지막으로 나는 새로운 자유주의 성윤리를 제안한다. 그것은 기존의 자유주의성윤리가 견지하였던 본질론과 변태론을 거부하고 ‘개인적 목적론’의 정립을 제시한다. 단, 여기서 ‘개인적 목적론’은 정의(justice) 담론과 함께 제시되어야 한다. 정의 담론이 ‘개인적 목적론’들의 한계를 설정하는 역할을 하기 때문이다. 이 때 가장그럴듯한 정의 담론은 어떤 성격을 지녀야 하는지도 밝혀질 것이다. 이렇게 정립된새로운 자유주의 성윤리는 쾌락 중심적이고 남성 중심적이고 미시적 관계 중심적인 내용을 벗어나 자율성 중심적이고 여성적 관점을 고려하고 거시적 관점을 고려한 내용들을 제시한다. (shrink)

The Western focus on personal autonomy as the normative basis for securing persons’ consent to their treatment renders this autonomy-based approach to informed consent vulnerable to the charge that it is based on an overly atomistic understanding of the person. This leads to a puzzle: how does this generally-accepted atomistic understanding of the person fits with the emphasis on familial consent that occurs when family members are provided with the opportunity to veto a prospective donor’s wish (...) to donate after she has died and her organs are being considered for harvesting? It is argued in this paper that this charge can be met and this puzzle dissolved once it is recognized that autonomy is an inherently social concept. (shrink)

Evidence-based medicine (EBM) was developed to ensure that health-care decisions are based on the best available research evidence. Making this evidence available to patients is supposed to increase their autonomy by putting them in a position to make better-informed choices. In this paper, I draw on work in feminist bioethics to critique EBM’s approach to involving patients in decision making, in which patients are asked merely to select their preferences among various possible treatment outcomes but are not (...) encouraged to actively contend with the effects of illness on their lives as a whole. (shrink)

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

The notion of respect for autonomy dominates bioethical discussion, though what qualifies precisely as autonomous action is notoriously elusive. In recent decades, the notion of autonomy in medical contexts has often been defined in opposition to the notion of autonomy favoured by theoretical philosophers. Where many contemporary theoretical accounts of autonomy place emphasis on a condition of “authenticity”, the special relation a desire must have to the self, bioethicists often regard such a focus as irrelevant to (...) the concerns of medical ethics, and too stringent for use in practical contexts. I argue, however, that the very condition of authenticity that forms a focus in theoretical philosophy is also essential to autonomy and competence in medical ethics. After tracing the contours of contemporary authenticity-based theories of autonomy, I consider and respond to objections against the incorporation of a notion of authenticity into accounts of autonomy designed for use in medical contexts. By looking at the typical problems that arise when making judgments concerning autonomy or competence in a medical setting, I reveal the need for a condition of authenticity—as a means of protecting choices, particularly high-stakes choices, from being restricted or overridden on the basis of intersubjective disagreement. I then turn to the treatment of false and contestable beliefs, arguing that it is only through reference to authenticity that we can make important distinctions in this domain. Finally, I consider a potential problem with my proposed approach; its ability to deal with anorexic and depressive desires. (shrink)

In their paper titledChoosing death in unjust conditions: hope, autonomy and harm reduction,Wiebe and Mullin argue against the stance of diminished autonomy in chronically ill, disabled patients living in unjust sociopolitical environments who pursue medical assistance in dying (MAiD). They suggest that it would be paternalistic to deny these people this choice and conclude that MAiD should actually be seen as a form of harm reduction for them.This response to their article argues that basing discussions surrounding this important (...) topic on a single bioethical concept does not address the needs of this cohort and is restrictively siloed. The discussion should include considerations of human rights and the need for legislative reforms to address social conditions, in addition to traditional bioethical principles. Work in this area needs to become interdisciplinary and collaborative as well as integrate input from the patients themselves. The concept of the dignity of these patients, in its broadest sense, needs to be infused into the discussion in order to optimise the exploration for solutions for this cohort.The stance of MAiD as harm reduction, in this context, does not meet the definition of harm reduction, nor does it represent a commitment to the best interests of these patients. (shrink)

Charles Taylor's well-known essay, “Atomism”, criticizes libertarian theories of rights like Nozick's that make individual rights independent of any duties to belong to, support, or obey the law in the society in which those rights are to be enjoyed. Taylor argues that if one grounds rights to important liberties on the human capacity for autonomy, this commits one to the view that the development of autonomy in oneself and others is morally obligatory. Further, Taylor argues that most people (...) cannot develop autonomy in the absence of a certain sort of social and political environment. Hence, if it is morally obligatory to try to develop autonomy in oneself and others, it is also obligatory to belong to, support, and give obedience to those institutions which create the environment in which autonomy can be developed. (shrink)

Some have objected to human enhancement on the grounds that it violates the autonomy of the enhanced. These objections, however, overlook the interesting possibility that autonomy itself could be enhanced. How, exactly, to enhance autonomy is a difficult problem due to the numerous and diverse accounts of autonomy in the literature. Existing accounts of autonomy enhancement rely on narrow and controversial conceptions of autonomy. However, we identify one feature of autonomy common to many (...) mainstream accounts: reasoning ability. Autonomy can then be enhanced by improving people’s reasoning ability, in particular through cognitive enhancement; given how valuable autonomy is usually taken to be, this gives us extra reason to pursue such cognitive enhancements. Moreover, autonomy-based objections will be especially weak against such enhancements. As we will argue, those who are worried that enhancements will inhibit people’s autonomy should actually embrace those enhancements that will improve autonomy. (shrink)

African ethicists have so far not agreed on a single, precise, secular and comprehensive basic norm, an Afro-Grundnorm, which captures the core values of Ubuntu sub-Saharan African cosmopolitanism. This article constructs and proffers the ‘double-dignity’ Grundnorm that partly shares with Western stoic cosmopolitans the view that our common human ontological capacity for autonomy identifies us as members of the human species. This capacity grants our first dignity, inherent dignity. Inherent dignity only grants our universal basic (security and subsistence) rights. (...) Our duties to care of each other derive from the second dignity, acquired dignity. Acquired dignity itself derives from our second ontological capacity, our capacity for communion. Unlike inherent dignity, acquired dignity is neither universal nor automatically present in us. It is earned when we commune with others in fostering harmony as we earn ‘full personhood’. Since fostering harmony starts with nurturing communal identities and solidarities, Ubuntu entails efficiency-model moderate cosmopolitanism which permits prioritizing serving our immediate associates or compatriots not because of their special moral worthiness but because we more efficiently serve humanity at large when we do so. (shrink)

With widespread advances in the diffusion and application of medical technologies, the phenomena of misuse and overuse have become pervasive. These phenomena not only increase the cost of health care systems and deplete the accessibility and availability of health care services, they also jeopardize patient autonomy. From a literature review on this aspect of medical technology, an impact on patient autonomy is found in almost all cases, with the exception of philosophical or ethical writings, in which there is (...) not much practical application for health policy and law. In this article, the major finding is that in the area of patient autonomy, it does not matter much whether the “physician decides” or the “patient decides” in the current “disease care” health system, where most of the doctors focus only on disease treatment using aggressive medical technologies. It is also our “disease care” system that ensures that the patients, the health care professionals, or the health care management cannot safeguard their autonomy. Only when the genuine health care system is restored will patient autonomy be protected. (shrink)

In the debates regarding the ethics of human enhancement, proponents have found it difficult to refute the concern, voiced by certain bioconservatives, that cognitive enhancement violates the autonomy of the enhanced. However, G. Owen Schaefer, Guy Kahane and Julian Savulescu have attempted not only to avoid autonomy-based bioconservative objections, but to argue that cognition-enhancing biomedical interventions can actually enhance autonomy. In response, this paper has two aims: firstly, to explore the limits of their argument; secondly, and (...) more importantly, to develop a more complete understanding of autonomy and its relation to cognitive enhancement. By drawing a distinction between the capacity for autonomy and the exercise and achievement of autonomy and by exploring the possible effects of cognitive enhancement on both competence and authenticity conditions for autonomy, the paper identifies and explains which dimensions of autonomy can and cannot, in principle, be enhanced via direct cognitive interventions. This allows us to draw conclusions regarding the limits of cognitive enhancement as a means for enhancing autonomy. (shrink)

In this paper, I offer two arguments in support of the proposition that there are sometimes agent-relative prerogatives to impose harm on nonliable persons. The first argument begins with a famous case where most people intuitively agree it is permissible to perform an act that results in an innocent person’s death, and where there is no liability-based or consequentialist justification for acting. I show that this case is relevantly analogous to a case involving the intentional imposition of lethal (...) defensive harm on a nonliable person. In the final part of the paper, I provide a second, independent, argument in support of the proposition that there are agent-relative permissions to foreseeably harm or kill nonliable people under certain conditions. (shrink)

Background Home-based care workers mainly work alone in the patient’s home. They encounter a diverse patient population with complex health issues. This inevitably leads to several ethical challenges. Aim The aim is to gain insight into ethical challenges related to patient autonomy in home-based care and how home-based care staff handle such challenges. Research design The study is based on a 9-month fieldwork, including participant observation and interviews in home-based care. Data were analysed with (...) a thematic analysis approach. Participants and research context The study took place within home-based care in three municipalities in Eastern Norway, with six staff members as key informants. Ethical considerations The Norwegian Agency for Shared Services in Education and Research evaluated the study. All participants were competent to consent and signed an informed consent form. Findings A main challenge was that staff found it difficult to respect the patient’s autonomy while at the same time practicing appropriate care. We found two main themes: Autonomy and risk in tension; and strategies to balance autonomy and risk. These were explicated in four sub-themes: Refusing and resisting care; when choosing to live at home becomes risky; sweet-talking and coaxing; and building trust over time. Staff’s threshold for considering the use of coercion appeared to be high. Conclusions Arguably, home-based care staff need improved knowledge of coercion and the legislation regulating it. There is also a need for arenas for ethics reflection and building of competence in balancing ethical values in recurrent ethical problems. (shrink)

Several philosophers of education argue that schooling should facilitate students’ development of autonomy. Such arguments fall into two main categories: Student-centered arguments support autonomy education to help enable students to lead good lives; Public-goods-centered arguments support autonomy education to develop students into good citizens. Critics challenge the legitimacy of autonomy education—of the state imposing a schooling curriculum aimed at making children autonomous. In this paper, I offer a unified solution to the challenges of legitimacy that both (...) arguments for autonomy education face. I first defend a particular construal of liberal legitimacy, and then consider each legitimacy challenge in light of that construal. I argue that the legitimacy challenges confronting both types of argument can be overcome. Further, I explain why we should pursue both arguments, rather than resting the entire case for autonomy education on one or the other. I conclude that each argument—if it can justify autonomy education at all—can justify autonomy education consistent with the requirements of liberal democratic legitimacy. (shrink)

Some transgender and nonbinary people undergo phalloplasty and/or metoidioplasty as part of their medical transition process. Across surgical disciplines, a variety of resources are used to assist patients who are preparing for surgeries, including educational materials, workshops, peer support, and lifestyle changes. For gender-affirming surgeries, patients undergoing assessments to discern whether they are ready to undergo the surgery, and to assist them in achieving preparedness when needed. Little research investigates what resources are useful in helping patients to feel prepared to (...) undergo phalloplasty or metoidioplasty, and how assessments and resources can promote patient autonomy in the process. Respect for patient autonomy is one of the central tenets of ethical healthcare, yet historically, scholarship related to pre-surgical assessments for gender-affirming surgery has focused determining the ideal surgical candidate rather than respecting patient autonomy and ascertaining individual patient needs. This study sought to fill this gap by utilizing data from PROGRESS (Patient-Reported Outcomes of Genital Reconstruction and Experiences of Surgical Satisfaction), a cross-sectional, community-based survey of trans and nonbinary adults from the United States of America and Canada who had undergone one or more of these surgeries. Results revealed most participants (86%, n = 186) felt prepared to undergo surgery, though the majority of our sample (53%, n = 105) did not find referral letter assessments to be helpful. Peer support such as online resources/blogs were rated as highly useful, along with surgical consults. In a multivariable logistic regression, higher perceived preparedness was associated with identifying as queer (inclusive of gay, bi and pansexual compared to being straight), and feeling that one’s assessment process was useful (as opposed to not useful). Type of assessment was not significantly associated with preparedness; therefore, what is most useful when preparing for surgery may vary across individuals. Healthcare professionals who interact with preparing patients should develop new or utilize existing resources to assist patients in identifying their preparation needs and achieving preparedness. Our data supports assessments that center surgical care planning rather than assessing level of gender dysphoria. Future longitudinal research could further refine which assessment processes are most effective in helping patients who are preparing for these surgeries. Assessments should ensure that patients are appropriately prepared to undergo and recover from surgery through a robust process of informed consent. (shrink)

The American Journal of Bioethics, Volume 12, Issue 2, Page 30-31, February 2012.

This paper critically examines Alan Patten’s theory of neutrality of treatment. It argues that the theory assumes an inadequate conception of personal autonomy that undermines its plausibility. Because of this assumption the theory is unable to account for various configurations of power that work against personal autonomy. However, I suggest that the theory can resolve the problem by developing and reinterpreting its conception of autonomy and introducing an additional strategy for addressing the power misbalances that result from (...) the market-based interactions between individuals and their conceptions of the good. (shrink)

Contemporary production of machine-based images relay gradually on the autonomy of computing machines. Autonomous computing machines require the interaction with users like Human-Computer-Interaction technology and other interface technologies, especially computing machine-based images must also ask for viewer as an inter-actor, viewer’s participations. Whether this interaction of viewer-user is with machines or with images, if it is an interaction with each individual that have autonomy or self-organization, its interaction will be the interaction of each ecosystem. And the (...) forms of this environmental interaction are an exchange of energy in natural ecosystem or aesthetic communication in art. Hence the aesthetics of future autonomous machine-based images need to focus on a number of mesh-works and the ways of interactions between the aesthetic individuals and their structures, i.e. aesthetic ecosystems. (shrink)

Maternal mortality is still very high in Africa, despite progress in control efforts at the global level. One elemental link is the question of autonomy in maternal health, especially at the household level where intrinsic human rights are undermined. A rights-based consideration in bioethics is an approach that holds the centrality of the human person, with a compelling reference to the fundamental human rights of every person. A philosophical and sociological engagement of gender and the notion of (...) class='Hi'>autonomy within the household reveals some fundamental rights-based perplexities for bioethical considerations in maternal health. The right to self-determination is undermined, and therefore women’s dignity, freedom and autonomy, capacities, and choices are easily defiled. This study applies a rights-based approach to maternal health and demonstrates how rights concerns are associated with negative outcomes in maternal health in Africa. The discussion is situated at the household level, which is the starting point in health care. The paper submits that beyond legal and political rights within the context of the state, rights-based issues manifest at the household level. Many of those rights issues, especially relating to women’s autonomy, are detrimental to maternal health in Africa. Therefore, a rights-based approach in the social construction of maternal health realities will contribute to alleviating the burden of maternal mortality in Africa. (shrink)

This paper aims to critique the phenomenon of advanced patient autonomy and choice in healthcare within the specific context of self-testing devices. A growing number of self-testing medical devices are currently available for home use. The premise underpinning many of these devices is that they assist individuals to be more autonomous in the assessment and management of their health. Increased patient autonomy is assumed to be a good thing. We take issue with this assumption and argue that self-testing (...) provides a specific example how increased patient autonomy and choice within healthcare might not best serve the patient population. We propose that current interpretations of autonomy in healthcare are based on negative accounts of liberty to the detriment of a more relational understanding. We also propose that Kantian philosophy is often applied to the healthcare arena in an inappropriate manner. We draw on the philosophical literature and examples from the self-testing process to support these claims. We conclude by offering an alternative account of autonomy based on the interrelated concepts of relationality, care and responsibility. (shrink)

In this paper, I examine two versions of the so-called “hierarchical” approach to personal autonomy, based on the notion of “second-order desires”. My primary concern will be with the question of whether these approaches provide an adequate basis for understanding the dynamics of autonomy-ascription. I begin by distinguishing two versions of the hierarchical approach, each representing a different response to the oft-discussed “regress” objection. I then argue that both “structural hierarchicalism” (e.g., Frankfurt, Bratman) and “procedural hierarchicalism” (e.g., (...) Dworkin, Christman, Mele) have difficulties accommodating the dynamics of how the attribution of autonomy to persons is claimed, disputed, and resolved. Although they differ in details, both shortcomings can be traced to viewing autonomy as a metaphysical rather than a normative, practical matter. I conclude by suggesting that these difficulties underscore the advantages of a more constructivist and pragmatist. (shrink)