This essay explores three issues in respect for autonomy that pose unfinished business for the concept. By this, I mean that the dialogue over them is ongoing and essentially unresolved. These are: whether we ought to respect persons or their autonomous choices; the role of relational autonomy; and whether nonhuman animals can be autonomous. In attending to this particular set of unfinished business, I highlight some critical moral work left aside by the concept of respect for autonomy as understood in (...) Beauchamp and Childress’ Principles of Biomedical Ethics. Specifically, while significant pragmatic traction is gained by the authors’ focus on autonomous choice, carving such a focus out from the broader questions of moral respect and the autonomy of the person leaves aside a number of questions that we might have thought a view about respect for autonomy in biomedicine ought to answer. These include: How should physicians respond when autonomous patients make decisions that appear nonautonomous? What is the impact of the view that autonomy is “relational” for cross-cultural differences in how autonomy is respected? If chimpanzees can be autonomous, what does that mean for how they should be treated? (shrink)

Anthropologists and sociologists offer numerous critiques of bioethics. Social scientists criticize bioethicists for their arm-chair philosophizing and socially ungrounded pontificating, offering philosophical abstractions in response to particular instances of suffering, making all-encompassing universalistic claims that fail to acknowledge cultural differences, fostering individualism and neglecting the importance of families and communities, and insinuating themselves within the “belly” of biomedicine. Although numerous aspects of bioethics warrant critique and reform, all too frequently social scientists offer ungrounded, exaggerated criticisms of bioethics. Anthropological and sociological (...) critiques of bioethics are hampered by the tendency to equate bioethics with clinical ethics and moral theory in bioethics with principlist bioethics. Also, social scientists neglect the role of bioethicists in addressing organizational ethics and other “macro-social” concerns. If anthropologists and sociologists want to provide informed critiques of bioethics they need to draw upon research methods from their own fields and develop richer, more informed analyses of what bioethicists say and do in particular social settings. (shrink)

W pierwszej części artykułu charakteryzuję trzy rodzaje profesjonalizmu lekarskiego: profesjonalizm tradycyjny, odnowiony i kompleksowy. Omawiam także czynniki kulturowe, ekonomiczne i aksjologiczne wpływające na ich kształtowanie się. Stawiam tezę, że profesjonalizm kompleksowy ze względu na jego skomplikowanie i arbitralne wyodrębnianie elementów składowych jest nieprzydatny w edukacji moralnej studentów i lekarzy. W części drugiej rekonstruuję wady i zalety profesjonalizmu tradycyjnego i odnowionego. Uzasadniam pogląd, że najważniejsza zaleta profesjonalizmu wynika z jego ambiwalencji moralnej. Nie traktuję więc tej dwuznaczności jako wyłącznie wady. Lekarz profesjonalista (...) powinien mieć świadomość jasnych i ciemnych stron profesjonalizmu oraz umiejętność właściwego ich ważenia w danych okolicznościach – poszukiwania Arystotelesowskiego złotego środka. W ostatniej części argumentuję za umiarkowanie optymistycznym przekonaniem o przydatności profesjonalizmu tradycyjnego i odnowionego w moralnym formowaniu studentów medycyny i młodych lekarzy. (shrink)

The author congratulates Dr Brian Hurwitz, who recently reported the successful “intimidation” of an elderly competent widow into accepting badly needed therapy for a huge ulcerated carcinoma. He reports approvingly of the Israeli Patients' Rights Law, enacted in 1996, which demands detailed informed consent from competent patients before permitting treatment. But the law also provides an escape clause which permits coercing a competent patient into accepting life-saving therapy if an ethics committee feels that if treatment is imposed the patient will (...) give his/her consent retroactively. He suggests this approach as an appropriate middle road between overbearing paternalism and untrammelled autonomy. (shrink)

Objective: Contemporary ethical accounts of the patient-provider relationship emphasise respect for patient autonomy and shared decision making. We sought to examine the relative influence of involvement in decisions, confidence and trust in providers, and treatment with respect and dignity on patients’ evaluations of their hospital care.Design: Cross-sectional survey.Setting: Fifty one hospitals in Massachusetts.Participants: Stratified random sample of adults discharged from a medical, surgical, or maternity hospitalisation between January and March, 1998. Twelve thousand six hundred and eighty survey recipients responded.Main outcome (...) measure: Respondent would definitely be willing to recommend the hospital to family and friends.Results: In a logistic regression analysis, treatment with respect and dignity 3.4, 99% confidence interval 2.8 to 4.2) and confidence and trust in providers were more strongly associated with willingness to recommend than having enough involvement in decisions . Courtesy and availability of staff , continuity and transition , attention to physical comfort , and coordination of care were also significantly associated with willingness to recommend.Conclusions: Confidence and trust in providers and treatment with respect and dignity are more closely associated with patients’ overall evaluations of their hospitals than adequate involvement in decisions. These findings challenge a narrow emphasis on patient autonomy and shared decision making, while arguing for increased attention to trust and respect in ethical models of health care. (shrink)

When individual patients' medical decisions contribute to population-level trends, physicians may struggle with how to promote justice while maintaining respect for patient autonomy. This article argues that this tension might be resolved by using the informed consent conversation as an opportunity to position patients as societal stewards.

In this article, I reject the “principlism” of Tom Beauchamp and James Childress and argue that respect for autonomy is, and ought to be, the fundamental value of bioethics. To do so, I offer a reconstruction of what I call the field's “founding myth,” a genealogy that affords primacy to the right to be respected as a human being with dignity. Next, I examine the relationship between this basic right and a derivative right of autonomy. I suggest that principlism has (...) promulgated an uncharitable understanding of respect for autonomy, one that ensures that the principle cannot occupy the central position I claim for it. Finally, I sketch a more plausible understanding of respect for autonomy and explore its implications. (shrink)

A normatively adequate public health ethics needs to be anchored in political philosophy rather than in ethics. Its central ethical concerns are likely to include trust and justice, rather than autonomy and informed consent.

There is a remedy available for many of our ailments: Psychopharmacology promises to alleviate unsatisfying memory, bad moods, and low self-esteem. Bioethicists have long discussed the ethical implications of enhancement interventions. However, they have not considered relevant evidence from psychology and economics. The growth in autonomy in many areas of life is publicized as progress for the individual. However, the broadening of areas at one’s disposal together with the increasing individualization of value systems leads to situations in which the range (...) of options asks too much of the individual. I scrutinize whether increased self-determination and unbound possibilities are really in a person’s best interests. Evidence from psychology and economics challenges the assumption that unlimited autonomy is best in all cases. The responsibility for autonomous self-formation that comes with possibilities provided by neuro-enhancement developments can be a burden. To guarantee quality of life I suggest a balance of beneficence, support, and respect for autonomy. (shrink)

Public health ethics in the future will be distinguished from public health ethics in the past by this new subfield being labeled as such, acknowledged, and called upon for service. Ethical dilemmas have been present throughout the history of public health. The question of whether to force Henning Jacobson to be immunized in 1905 in accordance with the 1902 Massachusetts smallpox vaccination law was one of ethics as well as law. How Thomas Parran, Surgeon General in 1936, chose to respond (...) to a raging syphilis epidemic in the United States in the early part of the 2W century raised considerable moral debate in determining the appropriate public health response for a government? More recently, questions have arisen concerning the appropriate reach of government in controlling HIV banning smoking, or promoting healthy lifestyles. Debates over government infringement, morality, and justice recur throughout the history of public health. (shrink)

This essay is a revision of ?Rudiments of an Ethics of News Reporting,?; which won honorable mention in the 1985 Carol Burnett/University of Hawaii/ AEJMC Prize for Student Papers on Journalism Ethics. It argues that news reporting suffers from a misplaced faith in individual autonomy, a faith that resists a sense of social duty on the basis of negative freedom; therefore, journalism stands in need of a moral theory that recognizes community and personhood as fundamental human characteristics essential to ethical (...) decision?making. (shrink)

The family, like so many other modern institutions, often looks more like an arena of competing wills than an ordered life in common. If we hope, therefore, to protect the special role that parents should have in relation to their children, and that the family in general should have in relation to its members, we will need a much more developed account of the goods that are at stake and why we think they are important enough to require authority, even (...) when members of the family oppose the decisions of that authority. This essay develops an older account of authority, one rooted in the thought of Aristotle and St. Thomas Aquinas, and applies this account to our present difficulties concerning the authority of the family over its members in health care decision making. (shrink)

An increase in autonomy and freedom is often considered one ofthe main arguments in favour of a broad use of genetic testing.Starting from Gerald Dworkin's reflections on autonomy and choicethis article examines some of the implications which accompanythe increase in choices offered by prenatal genetic diagnosis.Although personal autonomy and individual choice are importantaspects in the legitimation of prenatal genetic diagnosis, itseems clear that an increase in choice offered by prenatalgenetic diagnosis also leads to various implications that maynegatively influence the freedom (...) of the persons involved. (shrink)

Assumptions about what it is to be human are implicit in most philosophical reflections upon ethical and epistemological issues. Although such assumptions are not usually elaborated into a comprehensive theory of human nature, they are nonetheless influential in beliefs about what kinds of problem are worthy of consideration, and in judgments about the adequacy of proposed solutions. Claims to the effect that one should not be swayed by feelings and loyalties in the making of moral decisions, for example, presuppose that (...) human beings are creatures whose nature is amenable to guidance by reason rather than emotion and are creatures capable of living well when they act as impartially as possible. Analogously, claims to the effect that knowledge, to merit that title, should be acquired out of independent cognitive endeavour uncluttered by opinion and hearsay, suggest that human beings are creatures who can come to know their environment through their own unaided efforts. And claims to the effect that knowledge, once acquired, is timelessly and universally true depend upon assumptions about the constancy and uniformity of human nature across historical and cultural boundaries. (shrink)

Precision medicine promises to develop diagnoses and treatments that take individual variability into account. According to most specialists, turning this promise into reality will require adapting the established framework of clinical research ethics, and paying more attention to participants’ attitudes towards sharing genotypic, phenotypic, lifestyle data and health records, and ultimately to their desire to be engaged as active partners in medical research.Notions such as participation, engagement and partnership have been introduced in bioethics debates concerning genetics and large-scale biobanking to (...) broaden the focus of discussion beyond individual choice and individuals’ moral interests. The uptake of those concepts in precision medicine is to be welcomed. However, as data and medical information from research participants in precision medicine cohorts will be collected on an individual basis, translating a participatory approach in this emerging area may prove cumbersome. Therefore, drawing on Joseph Raz’s perfectionism, we propose a principle of respect for autonomous agents that, we reckon, can address many of the concerns driving recent scholarship on partnership and public participation, while avoiding some of the limitations these concept have in the context of precision medicine. Our approach offers a normative clarification to how becoming partners in precision is compatible with retaining autonomy.Realigning the value of autonomy with ideals of direct engagement, we show, can provide adequate normative orientation to precision medicine; it can do justice to the idea of moral pluralism by stressing the value of moral self-determination: and, finally, it can reconcile the notion of autonomy with other more communitarian values such as participation and solidarity. (shrink)

This paper analysed the nature of autonomy, in particular respect for autonomy in medical ethics/bioethics in Japan. We have undertaken a literature survey in Japanese and English and begin with the historical background and explanation of the Japanese wordJiritsu (autonomy). We go on to identify patterns of meaning that researchers use in medical ethics / bioethics discussions in Japan, namely, Beauchamp and Childress’s individual autonomy, relational autonomy, and O’Neill’s principled autonomy as the three major ways that autonomy is understood. We (...) examine papers discussing these interpretations. We propose using the term ‘a form of autonomy’ first used by Edmund Pellegrino in 1992 and examine the nature of ‘a form of autonomy.’ We finally conclude that the crux of what Pellegrino calls ‘something close to autonomy,’ or ‘a form of autonomy' might best be understood as the minimization of physician paternalism and the maximization of respect for patient preference. Simultaneously, we introduce a family-facilitated approach to informed consent and respond to criticism by Laura Sullivan. Finally, we discuss cross-cultural approaches and global bioethics. Furthermore, we use the term ‘Bioethics across the Globe’ instead of ‘Global Bioethics’, calling for international scholars to write works to provide an in-depth understanding of each country. We conclude that deep understanding of others is pivotal for dialogue to be of value. We hope this article will deepen the reader’s understanding of Japan and will contribute to the progress of bioethics worldwide. (shrink)

According to the doctrine of informed consent medical procedures are morally permissible when a patient has consented to the treatment. Problematically it is possible for a patient to consent to or refuse treatment which consequently leads to a decline in her best interests. Standardly, such conflicts are resolved by prioritising the doctrine of informed consent above the requirement that the medical practitioner acts in accordance with the duty of care. This means that patient free choice is respected regardless as to (...) whether her choice leads to a decline in her best interests, since to disrespect patient choice would be an instance of ‘unwarranted’ paternalism. This thesis defends the claim that in cases where patient consent comes into conflict with her best interests, paternalistic interference is in fact justified. The ambition of the thesis is thus twofold: in the first place I argue that the doctrine of informed consent cannot be used as an ethical guarantor for medical decision making. Secondly I will conclude that hard paternalism is justified in medical practice, thereby calling for a reversal of the prioritisation of informed consent procedures over the medical practitioner’s duty of care. (shrink)

The doctrine of informed consent, defined as respect for autonomy, is the tool used to govern the relationship between physicians and patients. Its framework relies on rights and duties that mark these relationships. The main purpose of informed consent is to promote human rights and dignity. Some researchers claim that informed consent has successfully replaced patients' historical predispositions to accept physicians' advice without much explicit resistance. Although the doctrine of informed consent promotes ideals worth pursuing, a successful implementation of these (...) ideals in practice has yet to occur. What has happened in practice is that attorneys, physicians, and hospital administrators often use consent forms mainly to protect physicians and medical facilities from liability. Consequently, ethicists, legal theorists, and physicians need to do much more to explain how human rights and human dignity relate to the practice of medicine and how the professionals can promote them in practice. This is especially important because patients' vulnerability has increased just as the complexity and power of medical science and technology have increased. Certain health care practices can shed light on the difficulties of implementing the doctrine of informed consent and explain why it is insufficient to protect patients' rights and dignity. Defining a normal biological event as a disease, and routinely prescribing hormone drug therapy to menopausal women for all health conditions related to menopause, does not meet the standards of free informed consent. Clinicians provide insufficient disclosure about risks related to long-term use of hormone therapies and about the absence of solid evidence to support their bias toward hormone therapies as a treatment of choice for menopause related health conditions. The contributing problem is women's failure to act as autonomous agents because they either choose not to take an active part in their own therapy or because they fear to question physicians' medical authority. To insure that patients' autonomy and free choice are a part of every physician-patient interaction, physicians and patients need actively to promote them as values that are absolutely indispensable in physicians' offices, clinics, and hospitals. (shrink)