Patient-Centered Deontological Theories

Some sacrifices—like giving a kidney or heroically dashing into a burning building—are supererogatory: they are good deeds beyond the call of duty. But if such deeds are really so good, philosophers ask, why shouldn’t morality just require them? The standard answer is that morality recognizes a special role for the pursuit of self-interest, so that everyone may treat themselves as if they were uniquely important. This idea, however, cannot be reconciled with the compelling picture of morality as impartial—the view that (...) we are each anyone’s equal. I propose an alternative Self-Other Symmetric account of our moral freedom: the limits on what morality may demand of us are set by the duties we owe to ourselves. I begin with a defense of the Self-Other Symmetry: the idea that we owe the same duties to ourselves—and have the same rights against ourselves—as any relevantly similar other. Because we are consenting parties to our own actions, I argue, our rights against ourselves do not function like the rights of unwilling others. Instead, they play a permissive function, allowing us to block the demand to give up what is ours. I conclude by uniting, aggravating, and trying to solve some paradoxes of supererogatory permissions, guided by the idea that morality cannot be reduced to a ranking of options from best-to-worst. Rights against oneself are an irreducible second dimension, one that we need if we are to unify rights and supererogation into an impartial moral vision. (shrink)

The moral justification for targeted killing turns on it being justified as an act of self-defense. That justification can be assessed by addressing five questions: Is the targeted person a threat who lacks the right to threaten? Has the targeted person forfeited some of her claim not to be killed? Even if the answer to the first two questions is positive, is targeted killing a necessary and proportionate response? Is the evidence in favor of targeted killing high enough to meet (...) the relevant standard of proof? And insofar as a person is selected for targeting from a larger group of possible targets, is the selection justifiable? The legal justifiability of targeted killing should aim to track, as much as problems of administrability and limiting unwanted effects allow, the answers to those moral questions. (shrink)

Patient centred diagnosis is best practised through shared decision making; an iterative dialogue between doctor and patient, whichrespects a patient’s needs, values, preferences, and circumstances. -/- Shared decision making for diagnostic situations differs fundamentally from that for treatment decisions. This has important implications when considering its practical application. -/- The nature of dialogue should be tailored to the specific diagnostic decision; scenarios with higher stakes or uncertainty usually require more detailed conversations.

The more we know about medicine, the more we realize that many health questions have no one true answer. Realizing this, and thinking carefully about how medicine asks patients to treat their conditions, leads us to some questions. How reliable are the guidelines that might form the basis of doctors’ advice? Is it wrong, after all, to base an approach to medicine on patients’ preferences? And, given that there is often a distance between the treatment a doctor advises and what (...) a patient would like to do, how do we bridge the gap—especially in a health culture of inequality, technical proficiency, and increasing costs? In practical, engaging, narrative-driven chapters about common health conditions that millions of Americans are familiar with—depression and high blood pressure, arthritis and diabetes—Dr. Zackary Berger of Johns Hopkins demystifies the often bewildering disconnect between patients and doctors and asks us all to think more clearly about how best to protect and cure the human body. (shrink)

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

According to legal expressivism, neither crime nor punishment consists merely in intentionally imposing some kind of harm on another. Crime and punishment also have an expressive aspect. They are what they are in part because they enact attitudes toward others—in the case of crime, some kind of disrespect, at least, and in the case of punishment, society’s condemnation or reprobation. Punishment is justified, at least in part, because (and when) it uniquely expresses fitting condemnation or other retributive attitude. What makes (...) retributive attitudes fitting is that they protect the victim’s status as inviolable. Hate or bias crimes dramatize the expressive aspect of crime, as they are often designed to send a message to the victim’s group and society at large. Treating the enactment of contempt and denigration toward a historically underprivileged group as an aggravating factor in sentencing may be an appropriate way to counter this message, as it reaffirms and indeed realizes the fundamental equality and inviolability of all members of a democratic community. (shrink)

Victor Tadros defends a subjective, intention-focused interpretation of the means principle (MP), according to which to use another as a means is to form plans or intentions in which the other serves as a tool for advancing one's ends. My thesis here is that Tadros's defense of the subjective interpretation of the MP is unsuccessful. To make that case I argue for three claims. First, the subjective interpretation has implausibly harsh implications in certain cases, implying that certain people would be (...) guilty of much more serious wrongs than they can plausibly be thought to have committed. Second, the cases that Tadros offers to argue that the subjective interpretation of the MP must be right are better interpreted as showing that it is impermissible to act on an illicit intention -- one that would direct an agent under certain, foreseeable circumstances to perform impermissible acts -- than that it is impermissible to act for an illicit reason. Third, while Tadros correctly rejects the objective, causal-role-focused interpretation of the MP -- according to which to use another as a means is for the other to play the causal role of means to the good which might be offered to justify the act one performs -- there is another way of defending the significance of causal roles, one that has implications that track those of the MP fairly closely. I argue elsewhere at length for this other principle, which I call the Restricting Claims Principle. Here I simply sketch the basic idea in a way sufficient to show that one can escape the dilemma that the MP faces without grabbing either the subjective or the objective horn, and without moving into a consequentialist world in which it is permissible to punish the innocent for the sake of the general welfare. (shrink)

How should deontological theories that prohibit actions of type K — such as intentionally killing an innocent person — deal with cases of uncertainty as to whether a particular action is of type K? Frank Jackson and Michael Smith, who raise this problem in their paper "Absolutist Moral Theories and Uncertainty" (2006), focus on a case where a skier is about to cause the death of ten innocent people — we don’t know for sure whether on purpose or not — (...) by causing an avalanche; and we can only save the people by shooting the skier. One possible deontological attitude towards such uncertainty is what Jackson and Smith call the threshold view, according to which whether or not the deontological constraint applies depends on our degree of (justified) certainty meets a given threshold. Jackson and Smith argue against the threshold view that it leads to implausible paradoxical moral dilemmas in a special kind of case. In this response, we show that the threshold view can avoid these implausible moral dilemmas, as long as the relevant deontological constraint is grounded in individualistic patient-based considerations, such as what an individual person is entitled to object to. (shrink)