After describing the disorder of psychopathy, I examine the theories and the evidence concerning the psychopaths’ deficient moral capacities. I first examine whether or not psychopaths can pass tests of moral knowledge. Most of the evidence suggests that they can. If there is a lack of moral understanding, then it has to be due to an incapacity that affects not their declarative knowledge of moral norms, but their deeper understanding of them. I then examine two suggestions: it is their deficient (...) practical reason or their stunted emotions that are at fault. The evidence supports both explanations. I conclude with an overview of the debate concerning whether they are morally or legally responsible for their actions. (shrink)

Recent legal rulings concerning the status of advance statements have raised interest in the topic but failed to provide any definitive general guidelines for their enforcement. I examine arguments used to justify the moral authority of such statements. The fundamental ethical issue I am concerned with is how accounts of personal identity underpin our account of moral authority through the connection between personal identity and autonomy. I focus on how recent Animalist accounts of personal identity initially appear to provide a (...) sound basis for extending the moral autonomy of an individual - and hence their autonomous wishes expressed through an advance directive - past the point of severe psychological decline. I argue that neither the traditional psychological account nor the more recent Animalist account of personal identity manage to provide a sufficient basis for extending our moral autonomy past the point of incapacity or incompetence. I briefly explore how analogies to similar areas in law designed to facilitate autonomous decision, such as wills and trusts, provide at best only very limited scope for an alternative justification for granting advance statements any legal or moral authority. I conclude that whilst advance statements play a useful role in formulating what treatment is in a patient’s best interests, such statements do not ultimately have sufficient moral force to take precedence over paternalistic best interest judgements concerning an individual’s care or treatment. (shrink)

IntroductionExtended decision -making through the use of proxy decision -makers has been enshrined in a range of International Codes, Professional Guidance and Statute,For example, the UK Mental Capacity Act section 9.1; The General Medical Council ; the US National Guardianship Association ; Nuffield Council on Bioethics ; CIOMS-WHO section 6. Court cases such as Re Quinlan in the US have also contributed to establishing the groundings for the legal status of the proxy, albeit in terms of who might be suitable (...) as a proxy in cases where there was no clear appointment of them by a still competent individual. and is now widely seen as a useful means through which we can exercise control over decisions that affect our lives when we have lost capacity to make these decisions for ourselves.I will here limit myself to discussion of proxy consent for adults appointed prior to the loss of competence by the person they are acting as proxy for. The issue of p. (shrink)

Is it ethical for doctors or courts to prevent patients from making choices that will cause significant harm to themselves in the future? According to an important liberal principle the only justification for infringing the liberty of an individual is to prevent harm to others; harm to the self does not suffice.In this paper, I explore Derek Parfit’s arguments that blur the sharp line between harm to self and others. I analyse cases of treatment refusal by capacitous patients and describe (...) different forms of paternalism arising from a reductionist view of personal identity. I outline an Identity Relative Paternalistic Intervention Principle for determining when we should disallow refusal of treatment where the harm will be accrued by a future self, and consider objections including vagueness and non-identity.Identity relative paternalism does not always justify intervention to prevent harm to future selves. However, there is a stronger ethical case for doing so than is often recognised. (shrink)

Thought experiments that concoct bizarre possible world modalities are standard fare in debates on personal identity. Appealing to intuitions raised by such evocations is often taken to settle differences between conflicting theoretical views that, albeit, have practical implications for ethical controversies of personal identity in health care. Employing thought experiments that way is inadequate, I argue, since personhood is intrinsically linked to constraining facts about the actual world. I defend a moderate modal skepticism according to which intuiting across conceptually incongruent (...) worlds constitutes ‘invalid intuitioninferences’—i.e., carrying over intuitions gathered from facts about possible worlds that are at odds with facts about the actual world, for the purpose of making claims about real-life persons and their identity, leads to conceptual incongruences. Such a methodological fallout precludes accurate, informative judgments about personal identity in the actual world, calling into question the adequacy of thought experimental considerations for potential real world applications in medical ethics. (shrink)

Phineas Gage’s story is typically offered as a paradigm example supporting the view that part of what matters for personal identity is a certain magnitude of similarity between earlier and later individuals. Yet, reconsidering a slight variant of Phineas Gage’s story indicates that it is not just magnitude of similarity, but also the direction of change that affects personal identity judgments; in some cases, changes for the worse are more seen as identity-severing than changes for the better of comparable magnitude. (...) Ironically, thinking carefully about Phineas Gage’s story tells against the thesis it is typically taken to support. (shrink)

The personal identity relation is of great interest to philosophers, who often consider fictional scenarios to test what features seem to make persons persist through time. But often real examples of neuroscientific interest also provide important tests of personal identity. One such example is the case of Phineas Gage – or at least the story often told about Phineas Gage. Many cite Gage’s story as example of severed personal identity; Phineas underwent such a tremendous change that Gage “survived as a (...) different man.” I discuss a recent empirical finding about judgments about this hypothetical. It is not just the magnitude of the change that affects identity judgment; it is also the negative direction of the change. I present an experiment suggesting that direction of change also affects neuroethical judgments. I conclude we should consider carefully the way in which improvements and deteriorations affect attributions of personal identity. This is particularly important since a number of the most crucial neuroethical decisions involve varieties of cognitive enhancements or deteriorations. (shrink)

A competent patient has the right to refuse treatment necessary to sustain life. However, for many end-of-life decisions, we lack direct access to the wishes of a competent patient. Some treatment decisions near the end of life involve patients with severely diminished mental capacity, some involve patients who are unable to communicate, and some involve patients who are simply unable or unwilling to participate in decisionmaking due to the nature or severity of their illness.

Advance directives have been hailed for two decades as the best way to safeguard patients’ autonomy when they are totally or partially incompetent. In many national contexts they are written into law and they are mostly associated with end-of-life decisions. Although advocates and critics of ADs exchange relevant empirical and theoretical arguments, the debate is inconclusive. We argue that this is so for good reasons: the ADs’ project is fraught with tensions, and this is the reason why they are both (...) important and deeply problematic. We outline six such tensions, and conclude with some positive suggestions about how to better promote patients’ autonomy in end-of-life decision. We argue that ADs should continue to be an option but they cannot be the panacea that they are expected to be. (shrink)

A persistent question in discussions of the ethics of advance directives for euthanasia is whether patients who go through deep psychological changes retain their identity. Rather than seek an account of identity that answers this question, I argue that responsible policy should directly address indeterminacy about identity directly. Three sorts of indeterminacy are distinguished. Two of these—epistemic indeterminacy and metaphysical indeterminacy—should be addressed in laws/policies regarding advance directives for euthanasia.

In the mid to late 1980s a debate arose over the moral and legal authority of advance medical directives. At the center of this debate were two point-counterpoint law journal articles by Rebecca Dresser and Nancy Rhoden. What appeared to have the makings of an ongoing critical dialogue ended with the untimely death of Nancy Rhoden. Rebecca Dresser, however, has continued her challenge of advance directives in numerous publications, most recently in a critique of Ronald Dworkin's Life's Dominion. Like Rhoden, (...) Dworkin has been a staunch advocate of advance directives as an exercise of what has come to be referred to as prospective or precedent autonomy. In this paper I will consider a number of the issues that Dresser has repeatedly raised about the infirmities of advance directives, and suggest that it is from an understanding of and appreciation for the narrative dimension of the life of a person that advanced directives draw one of their most powerful justifications. (shrink)

Two contemporary strategies in cadaver organ transplantation, both with the potential to affect significantly expanding organ transplant waiting list sizes, have evolved: elective ventilation and use of nonheart-beating donors. Both are undergoing a period of critical review. It is not clear how widely EV is practiced around the world. In Great Britain, the Royal Devon and Exeter Hospital was the first hospital to develop an EV protocol, in 1988, after which other British hospitals followed suit. In the 1980s, new NHBD (...) protocols of two distinct types were implemented worldwide, although both rely on death confirmed by traditional cardiopulmonary criteria. The first type involves the removal of organs immediately after death, the preeminent example being the University of Pittsburgh Medical Center Protocol. The second involves the perfusion and cooling of kidneys immediately following death and subsequent organ removal. Protocols of this type have sprung up in Holland, Great Britain, Italy, France, Spain, Japan, and the United States. (shrink)

Two contemporary strategies in cadaver organ transplantation, both with the potential to affect significantly expanding organ transplant waiting list sizes, have evolved: elective ventilation and use of nonheart-beating donors. Both are undergoing a period of critical review. It is not clear how widely EV is practiced around the world. In Great Britain, the Royal Devon and Exeter Hospital was the first hospital to develop an EV protocol, in 1988, after which other British hospitals followed suit. In the 1980s, new NHBD (...) protocols of two distinct types were implemented worldwide, although both rely on death confirmed by traditional cardiopulmonary criteria. The first type involves the removal of organs immediately after death, the preeminent example being the University of Pittsburgh Medical Center Protocol. The second involves the perfusion and cooling of kidneys immediately following death and subsequent organ removal. Protocols of this type have sprung up in Holland, Great Britain, Italy, France, Spain, Japan, and the United States. (shrink)

Decisions about brain surgery pose existential challenges because they are often decisions about life or death, and sometimes about possible personality changes. Therefore they require rigorous neuroethical consideration. However, we doubt whether metaphysical interpretations of ambiguous statements of patients are useful for deriving ethical and legal conclusions. Particularly, we question the application of psychological theories of personal identity on neuroethical issues for several reasons. First, even the putative “standard view” on personal identity is contentious. Second, diverse accounts of personal identity (...) have been introduced into the neuroethical debate, which are incompatible. Third, the criteria for “diagnosing” the supposed changes in “identity” are ambiguous and indeterminate. Fourth, the metaphysical theories of personal identity imply highly questionable ethical and legal revisions, namely the denial of advance directives, particularly of Ulysses contracts, and, for patients with brain cancer, even therapeutic nihilism.We discuss three examples in which ideas from the personal identity debate in metaphysics are straightforwardly applied to discuss ethical issues of neurosurgery. We discuss revisions of the current medico-legal practice that have been proposed on grounds of psychological theories of personal identity. We argue that the established status quo in law and clinical practice is beneficial to the patients concerned. Furthermore, it is metaphysically neutral, which is an important principle of liberal, democratic, pluralistic societies.We recommend a pragmatic approach: empirical research on personality changes arising from brain disorders or interventions, comprehensive information about risks of personality changes, and advance directives, particularly Ulysses contracts. (shrink)

Philosophers who specialize in bioethics face a distinctive set of challenges in our work: to bring the theoretical insights of philosophical work and methodology to practical dilemmas affecting a diverse group of stakeholders every day. This article describes some of the key contributions that philosophy can make to the field of bioethics. It also identifies some of the pitfalls that can undermine the value of a philosophical approach when used to analyze questions arising in the real world. Recognition of the (...) importance of individual context, practical implications, and social considerations can help successfully bridge the gap between theory and practice. Using this wide-angle lens to view bioethical problems can enable philosophers working in our field to offer insights that are both rigorous and relevant. (shrink)

Women wishing hospital admission for childbirth are asked to sign very general pre-admission consent forms. The use of such forms suggests that women in labor are considered incompetent to give informed consent. This paper explores some of the problems with advance directives and general consent, and argues that since women in labor are not generally incompetent, it is not appropriate to require this kind of consent of them.

In a recent Dutch euthanasia case, a woman underwent euthanasia on the basis of an advance directive, having first been sedated without her knowledge and then restrained by members of her family while the euthanasia was administered. This article considers some implications of the criminal court’s acquittal of the doctor who performed the euthanasia. Supporters of advance euthanasia directives have welcomed the judgement as providing a clarification of the law, especially with regard to the admissibility of contextual evidence in interpreting (...) advance euthanasia directives, but suggested that the law regarding advance euthanasia directives should be further relaxed to remove the requirement of current suffering and that an unfortunate consequence of the prosecution is that it is likely to deter doctors from performing euthanasia even in more straightforward cases. This article argues that the court’s endorsement of the use of contextual evidence is problematic, that the case for prioritising prior decisions over current interests has not been advanced by the discussion surrounding this case and that worries about the alleged deterrent effect are not well founded. (shrink)

As patient autonomy expands, a highly controversial issue has emerged. Should the advance directives of refusing life-saving treatments or requesting euthanasia of persons with dementia who express changed minds or are often in a happy state be fulfilled? There are two autonomy-related positions. The mainstream position in philosophical discussions supports the priority of ADs based on precedent autonomy. Buchanan and Brock, and Dworkin represent this view. The other position supports the priority of PWDs’ current wishes based on minimal autonomy represented (...) by Jaworska. By rethinking the theoretical and practical challenges of the two positions and their arguments respectively, the paper concludes that in such a scenario, the priority of ADs is morally indefensible, and it is also challenging to establish minimal autonomy defend the moral priority of PWDs’ current wishes. For PWDs whose past values, beliefs, and preferences fade away but who retain apparent intrinsic sentience of well-being, a modified defined quality-of-life approach serves as another reasonable basis in their medical decision-making, and the ADs and the QoL should be further merged to reduce the uncertainty of the grey zone. (shrink)

This paper presents the results of a qualitative interview study exploring English and French physicians’ moral perspectives and attitudes towards end-of-life decisions when patients lack capacity to make decisions for themselves. The paper aims to examine the importance physicians from different contexts accord to patient preferences and to explore the role of advance directives in each context. The interviews focus on problems that emerge when deciding to withdraw/-hold life-sustaining treatment from both conscious and unconscious patients; decision-making procedures and the participation (...) of proxies/relatives; previous experience with ADs and views on their usefulness; and perspectives on ways in which the decision-making processes in question might be improved. The analysis reveals differences in the way patient preferences are taken into consideration and shows how these differences influence the reasons physicians in each country invoke to justify their reluctance to adhering to ADs. Identifying cultural differences that complicate efforts to develop the practical implementation of ADs can help to inform national policies governing ADs and to better adapt them to practice. (shrink)

Advance directives for psychiatric care are the subject of debate in a number of Western societies. By using psychiatric advance directives , it would be possible for mentally ill persons who are competent and with their disease in remission, and who want timely intervention in case of future mental crisis, to give prior authorisation to treatment at a later time when they are incompetent, have become non-compliant, and are refusing care. Thus the devastating consequences of recurrent psychosis could be minimised.Ulysses (...) contracts raise a number of ethical questions. In this article the central issues of concern and debate are discussed from a narrative perspective. Ulysses contracts are viewed as elements of an ongoing narrative in which patient and doctor try to make sense of and get a hold on the recurrent crises inherent in the patient's psychiatric condition. (shrink)

In W v M, a judge concluded that M's past statements should not be given weight in a best interests assessment. Several commentators in the ethics literature have argued this approach ignored M's autonomy. In this short article I demonstrate how the basic tenets of speech act theory can be used to challenge the inherent assumption that past statements represent an individual's beliefs, choices or decisions. I conclude that speech act theory, as a conceptual tool, has a valuable contribution to (...) make to this debate. (shrink)

One reading of the Doctrine of Original Sin has it that we are guilty of a sin committed by Adam, thousands of years ago. Fission theorists account for this by saying that Adam fissioned after he sinned and that each of us is one of his ‘fission successors’. This paper recaps the current discussion in the literature about this theory, arguing that the proposed version does not work for reasons already raised by Rea and Hudson. I then introduce a new (...) version of fission theory that avoids the Rea-Hudson objection. (shrink)

On a Parfit-inspired account of culpability, as the psychological connections between a person’s younger self and older self weaken, the older self’s culpability for a wrong committed by the younger self diminishes. Suppose we accept this account and also accept a culpability-based upper limit on punishment severity. On this combination of views, we seem forced to conclude that perpetrators of distant past wrongs should either receive discounted punishments or be exempted from punishment entirely. This article develops a strategy for resisting (...) this conclusion. I propose that, even if the perpetrators of distant past wrongs cannot permissibly be punished for the original wrongs, in typical cases they can permissibly be punished for their ongoing and iterated failures to rectify earlier wrongs. Having set out this proposal, I defend it against three objections, before exploring how much punishment it can justify. (shrink)

While pain is common among seniors, it is not adequately treated or managed. In particular, pain in seniors with dementia is often undertreated and undermanaged. Although the undertreatment of pain among persons with cognitive impairments represents a serious ethical concern for pain clinicians, most writers in the area explain the undertreatment of pain by focusing on issues related to liability, fears of addiction to opioids, and erroneous beliefs that pain is a normal part of the ageing process. We argue that (...) the philosophical notion of personhood must also be given careful attention when considering the problem of pain undermanagement. In this paper, we consider the undertreatment of pain among seniors with dementia, while focusing on the ontology of relationships and on existential philosophy. Moreover, we outline a series of recommendations to help minimize the probability of pain undertreatment in this population and to encourage considerations relating to personhood when treating people with dementia. (shrink)

There is a flood of papers being published on new ways to diagnose Alzheimer disease before it is symptomatic, involving a combination of invasive tests , and pen and paper tests. This changes the landscape with respect to genetic tests for risk of AD, making rational suicide a much more feasible option. Before the availability of these presymptomatic tests, even someone with a high risk of developing AD could not know if and when the disease was approaching. One could lose (...) years of good life by committing suicide too soon, or risk waiting until it was too late and dementia had already sapped one of the ability to form and carry out a plan. One can now put together what one knows about one's risk, with continuing surveillance via these clinical tests, and have a good strategy for planning one's suicide before one becomes demented. This has implications for how these genetic and clinical tests are marketed and deployed, and the language one uses to speak about them. The phrase ‘there is nothing one can do’ is insulting and disrespectful of the planned suicide option, as is the language of the Risk Evaluation and Education for Alzheimer's Disease studies and others that conclude that it is ‘safe’ to tell subjects their risk status for AD. Further, the argument put forward by some researchers that presymptomatic testing should remain within research protocols, and the results not shared with subjects until such time as treatments become available, disrespects the autonomy of people at high risk who consider suicide an option. (shrink)

Americans who are afraid of living for many years with Alzheimer's might seek a way to end their lives early, when their dementia has just entered the moderate phase. There is no legal process for doing so. In this paper I argue that advance directives, in particular, are not a legal solution for those who prefer to die rather than suffer years of dementia. The problem is that an advance directive only works to hasten death when there is a life-threatening (...) illness for which one can refuse treatment; more often than not, Alzheimer's kills the self long before it kills the body. (shrink)

Patientenselbstbestimmung und Patientenverfügungen haben zunehmende Bedeutung und Beachtung erfahren. In der vorliegenden qualitativen Studie wurden 15 Patientinnen und Patienten mit amyotropher Lateralsklerose —einer unheilbaren, chronisch-degenerativen Erkrankung mit vorhersehbarer Symptomatik—interviewt, um zu erfahren, welche Werte und Kriterien sie bei prospektiven Entscheidungen am Lebensende und bei der Abfassung von PV zugrunde legen. Die Auswertung erfolgte nach der Methode der „grounded theory“. Die befragten Patientinnen und Patienten befürworteten einen Verzicht auf lebenserhaltende Behandlungen, wenn sie keine hinreichenden Lebensmöglichkeiten mehr sahen, d. h. wenn sie (...) die aktuelle Lebensqualität für unzureichend erachteten und die Chance auf Besserung als gering einschätzten. Dem Patientenwillen sprachen sie bei der Entscheidungsfindung ein Vetorecht zu. Patientenverfügungen fassten sie erst ab, als sie keine Hoffnung mehr auf Besserung ihrer Erkrankung hatten. Sie verstanden diese als Instrumente zur vorsorglichen Erklärung ihres Wunsches, auf lebensverlängernde Maßnahmen zu verzichten, wenn die LM inakzeptabel geworden sind. Damit wollten sie sich gegenüber dem Arzt absichern, den sie in der Rolle eines Anwalts des Lebens sahen und mit dem sie daher ihre Behandlungswünsche nicht besprochen haben. Trotz vorhersehbarer Symptomatik legten sie in ihren PV keine spezifischen Behandlungswünsche nieder, sondern verwendeten allgemeine Formularmuster ohne konkreten Bezug zu ihrer Erkrankung. Daher bestehen auch bei dieser Patientengruppe Zweifel, ob die PV in einer konkreten Behandlungssituation hilfreich sind. (shrink)

Some of the concerns that have been raised in connection to the use of advance directives are of the epistemic variety. Such concerns highlight the possibility that adhering to an advance directive may conflict with what the author of the directive actually wants at the time of treatment. However, at least one objection to the employment of advance directives is metaphysical in nature. The objection to be discussed here, first formulated by Rebecca Dresser and labeled by Allen Buchanan as the (...) slavery argument and David DeGrazia the someone else problem, aims to undermine the legitimacy of certain uses of advance directives by concluding that such uses rest upon an incorrect assumption about the identity over time of those ostensibly governed by the directives. There have been numerous attempts to respond to this objection. This paper aims to assess two strategies that have been pursued to cope with the problem. (shrink)

Is a theory of identity necessary for bioethics? In this paper I investigate that question starting from an empirical explication of identity based on post-genomics, in particular on epigenetics. After analysing whether the classic problems a theory of identity has to cope with also affect the proposed epigenetic account of identity, I deal with three topics to offer an insight on the relationship between that account and bioethics.

In the paper, after clarifying terms such as ‘identity’, ‘self’ and ‘personhood’, I propose an empirical account of identity based on the notion of “whole phenotype”. This move allows one to claim the persistence of the individuals before and after their being affected by dementia. Furthermore, I show how this account permits us to address significant questions related to demented individuals’ loss of the capacity of moral decisions.

Philosophically, the most interesting objection to the reliance on advance directives to guide treatment decisions for formerly competent patients is the argument from the loss of personal identity. Starting with a psychological continuity theory of personal identity, the argument concludes that the very conditions that bring an advance directive into play may destroy the conditions necessary for personal identity, and so undercut the authority of the directive. In this article, I concede that if the purpose of a theory of personal (...) identity is to provide an answer to the question What is it for a person to persist over time?, then reflection on personal identity poses a potentially serious threat to the moral authority of advance directives. However, as Marya Schechtman observes, questions about how a single person persists through change are not what most of us are interested in when we think about who a person is. Rather, we are interested in what it means to say that a particular set of actions, experiences, and characteristics is that of a given person rather than someone else. (shrink)

Philosophically, the most interesting objection to the reliance on advance directives to guide treatment decisions for formerly competent patients is the argument from the loss of personal identity. Starting with a psychological continuity theory of personal identity, the argument concludes that the very conditions that bring an advance directive into play may destroy the conditions necessary for personal identity, and so undercut the authority of the directive. In this article, I concede that if the purpose of a theory of personal (...) identity is to provide an answer to the question What is it for a person to persist over time?, then reflection on personal identity poses a potentially serious threat to the moral authority of advance directives. However, as Marya Schechtman observes, questions about how a single person persists through change are not what most of us are interested in when we think about who a person is. Rather, we are interested in what it means to say that a particular set of actions, experiences, and characteristics is that of a given person rather than someone else. (shrink)

A ‘Ulysses arrangement’ (UA) is an agreement where a patient may arrange for psychiatric treatment or non-treatment to occur at a later stage when she expects to change her mind. In this article, I focus on ‘competence-insensitive’ UAs, which raise the question of the permissibility of overriding the patient’s subsequent decisionally competent change of mind on the authority of the patient’s own prior agreement. In “The Ethical Justification for Ulysses Arrangements”, I consider sceptical and supportive arguments concerning competence-insensitive UAs, and (...) argue that there are compelling reasons to give such UAs serious consideration. In “Decisional Competence and Legal Capacity in UAs”, I examine the nature of decisional competence and legal capacity as they arise in UAs, an issue neglected by previous research. Using the distinctions which emerge, I then identify the legal structure of a competence-insensitive UA in terms of the types of legal capacity it embodies and go on to explain how types of legal capacity might be shared between the patient and a trusted other to offer support to the patient in the creation and implementation of a competence-insensitive UA. This is significant because it suggests possibilities for building patient support mechanisms into models of legal UAs, which has not addressed in the literature to date. Drawing on this, in “Using Insights from the Competence/Capacity Distinction to Enhance Patient Support in UAs”, I offer two possible models to operationalize competence-insensitive UAs in law that allow for varying degrees of patient support through the involvement of a trusted other. Finally, I outline some potential obstacles implementing these models would face and highlight areas for further research. (shrink)

This paper explores the use of advance directives in clinical dementia research. The focus is on advance consent to participation of demented patients in non-therapeutic research involving more than minimal risks and/or burdens. First, morally relevant differences between advance directives for treatment and care, and advance directives for dementia research are discussed. Then attention is paid to the philosophical issue of dementia and personal identity, and the implications for the moral authority of research advance directives. Thirdly, a number of practical (...) shortcomings of advance directives for non-therapeutic dementia research are explored and attention is paid to the role of proxies. It is concluded that upon a closer look the initial attractiveness of advance directives for dementia research is lessened, and that it is doubtful whether these instruments can compensate for the lack of subject consent in case of non-therapeutic dementia research involving more than minimal risks and/or burdens for the incompetent demented subject. (shrink)

The idea that people’s numerical identity may sometimes be discontinuous over time initially appears to provide useful material for defending restrictions on putatively self-harming behaviour in a non-paternalistic manner. According to this line of thinking, sometimes a putatively self-harming act is, in fact, a matter of ‘harm to others’. Yet, in this paper I argue that if we, as we ought to do, take into consideration the non-identity problem, this challenges the notion that the agent at T1 is in fact (...) imposing harm on anyone, even when we accept that he or she is numerically different from the agent at T2. If the life of the agent at T2 is still worth living, the agent is not worse off than he or she would have been in spite of the consequences pertaining to the putatively self-harming act since he or she would otherwise never have come into existence. In this way, the argument I put forward in this paper calls in question the ability of the shifting identity argument to actually justify imposing restrictions on self-harming behaviour. (shrink)

What justifies our holding a person morally responsible for some past action? Why am I justified in having a special prudential concern for some future persons and not others? Why do many of us think that maximizing the good within a single life is perfectly acceptable, but maximizing the good across lives is wrong? In these and other normative questions, it looks like any answer we come up with will have to make an essential reference to personal identity. So, for (...) instance, it seems we are justified in holding X responsible for some past action only if X is identical to the person who performed that action. Further, it seems I am justified in my special concern for some future person only if he will be me. Finally, many of us think that while maximization within a life affects only one person, a metaphysical unity, maximization across lives affects many different, metaphysically distinct, persons, and so the latter is wrong insofar as it ignores this fundamental separateness of persons. (shrink)

As older people begin to develop dementia, we confront ethical questions about when and how to intervene in their increasingly compromised decision-making. The prevailing approach in bioethics to tackling this challenge has been to develop theories of “decision-making capacity” based on the same characteristics that entitle the decisions of moral persons to respect in general. This article argues that this way of thinking about the problem has missed the point. Because the disposition of property is an identity-dependent right, what matters (...) in dementia and decision-making is an individual’s personal identity with their prior self, not their moral personhood. Therefore, in considering when and how we ought to intervene in the decision-making of those with dementia, we must look to the philosophy of personal identity rather than personhood. (shrink)

Animalism—the view that the identity across time of individuals like us consists in the persistence of our animal organisms—does poorly at accounting for our identity-related practical concerns. The reason is straightforward: whereas our practical concerns seem to track the identity of psychological creatures—persons—animalism focuses on the identity of human organisms who are not essentially persons. This lack of fit between our practical concerns and animalism has been taken to reduce animalism’s plausibility (relative to psychological criteria of identity). In this paper, (...) I survey the three leading replies to this challenge, finding them either implausible or incomplete. I will then attempt to construct the only viable response, one that begins by admitting that our practical concerns actually do not consist in a monolithic set; rather, there are distinctly different types of practical concerns, and while some are clearly grounded on psychological relations, some are actually grounded on others, including animalistic and humanistic relations; furthermore, their actual connection to identity is tenuous at best. What these concerns are, how they divide up, and what they are grounded on in each instance—these are the issues it is my second aim in this paper to take up. (shrink)

Ordinary Language Philosophy has largely fallen out of favour, and with it the belief in the primary importance of analyses of ordinary language for philosophical purposes. Still, in their various endeavours, philosophers not only from analytic but also from other backgrounds refer to the use and meaning of terms of interest in ordinary parlance. In doing so, they most commonly appeal to their own linguistic intuitions. Often, the appeal to individual intuitions is supplemented by reference to dictionaries. In recent times, (...) Internet search engine queries for expressions of interest have become quite popular. Apparently, philosophers attempt to surpass the limits of their own linguistic intuitions by appealing to experts or to factual uses of language. I argue that this attempt is commendable but that its execution is wanting. Instead of appealing to dictionaries or Internet queries, philosophers should employ computer-based linguistic corpora in order to confirm or falsify hypotheses about the factual use of language. This approach also has some advantages over methods employed by experimental philosophers. If the importance of ordinary language is stressed, the use of linguistic corpora is hardly avoidable. (shrink)

Distributive egalitarians believe that distributive justice is to be explained by the idea of distributive equality (DE) and that DE is of intrinsic value. The socio-relational critique argues that distributive egalitarianism does not account for the “true” value of equality, which rather lies in the idea of “equality as a substantive social value” (ESV). This paper examines the socio-relational critique and argues that it fails because – contrary to what the critique presupposes –, first, ESV is not conceptually distinct from (...) DE, and second, the idea of ESV cannot serve as a “foundation” or “root” of distributive egalitarianism. (shrink)

The law of England and Wales provides that an adult with capacity has the right to refuse medical treatment both contemporaneously and in an advance refusal. Legislation separates general advance refusals of treatment from advance refusals of life-sustaining treatment. The law, outlined in ss.24 to 26 of the Mental Capacity Act 2005, is stricter for creation of the latter. These sections brought with them a new age of interests by purporting to elevate individual autonomy as the primary concern. Beginning with (...) the classical tale of Odysseus and a general discussion of the value to be found in a law seeking to preserve individual autonomy, this thesis seeks to act as a critique of the current enactment in practice. The provisions are already under-used and under-applied; without change, they may never reach the stage where they are ethically and practically viable. It is argued that the advance refusals provisions are not taking full effect due to a combination of lacking moral grounding and general dismissal of key ethical dilemmas at the forefront of application. Building on this, the moral basis for this thesis is found in Alan Gewirth’s Principle of Generic Consistency (PGC) which links directly with the general application of human rights. The PGC becomes a compass for determining how best to treat persons when addressing the three most prominent challenges faced by the 2005 Act which are: the debate between the conferred right of autonomy versus the right to life; the issue of personhood; and, the personal identity problem. Ultimately, unless framework provisions are strengthened, and the Mental Capacity Act 2005 is rethought in light of prominent ethical, legal and social considerations, the constraints of the Act on paper will continue to suppress the important underlying values promulgating individual autonomy. (shrink)