Nothing can kill a promising research program in ethics more quickly than a plausible argument to the effect that it is committed to a morally repellent consequence. It is especially troubling when a theory one favors is jeopardized in this way. I have this worry about Harry Frankfurt's theory of free will, autonomous agency and moral responsibility, for there is a very plausible argument to the effect that aspects of his view commit him to a version of the late Stoic (...) thesis that acting freely is a matter of ‘making do,’ that is, of bringing oneself to be motivated to act in accordance with the feasible, so that personal liberation can be achieved by resigning and adapting oneself to necessity. In this paper I try to determine whether the theory does in fact commit Frankfurt to this result and, if so, what can be done to prevent it. (shrink)

Nothing can kill a promising research program in ethics more quickly than a plausible argument to the effect that it is committed to a morally repellent consequence. It is especially troubling when a theory one favors is jeopardized in this way. I have this worry about Harry Frankfurt's theory of free will, autonomous agency and moral responsibility, for there is a very plausible argument to the effect that aspects of his view commit him to a version of the late Stoic (...) thesis that acting freely is a matter of ‘making do,’ that is, of bringing oneself to be motivated to act in accordance with the feasible, so that personal liberation can be achieved by resigning and adapting oneself to necessity. In this paper I try to determine whether the theory does in fact commit Frankfurt to this result and, if so, what can be done to prevent it. (shrink)

With the waves of reform occurring in mental health legislation in England and other jurisdictions, mental capacity is set to become a key medico-legal concept. The concept is central to the law of informed consent and is closely aligned to the philosophical concept of autonomy. It is also closely related to mental disorder. This paper explores the interdisciplinary terrain where mental capacity is located. Our aim is to identify core dilemmas and to suggest pathways for future interdisciplinary research. The terrain (...) can be separated into three types of discussion: philosophical, legal and psychiatric. Each discussion approaches mental capacity and judgmental autonomy from a different perspective yet each discussion struggles over two key dilemmas: whether mental capacity and autonomy is/should be a moral or a psychological notion and whether rationality is the key constitutive factor. We suggest that further theoretical work will have to be interdisciplinary and that this work offers an opportunity for the law to enrich its interpretation of mental capacity, for psychiatry to clarify the normative elements latent in its concepts and for philosophy to advance understanding of autonomy through the study of decisional dysfunction. The new pressures on medical and legal practice to be more explicit about mental capacity make this work a priority. (shrink)

A person enters the moral realm when she affirms that other persons matter in the same way that she does. This, of course, is just the beginning, for she must then determine what follows from this affirmation. One way in which we treat other persons as mattering is by respecting them. And one way in which we respect persons is by respecting their wishes, desires, decisions, choices, ends, and goals. I will call all of these things ‘aims.’ Sometimes we respect (...) another person's aims simply byrefrainingfrom doing certain things, such as treating her in ways that thwart her aims, or interfering with her attempt to pursue them. Other times we respect a person's aims by taking positive action to help her pursue them.But how exactly does respect forpersonstranslate into respect for theiraims?And which aims merit respect? One answer comes from Kant. (shrink)

A person enters the moral realm when she affirms that other persons matter in the same way that she does. This, of course, is just the beginning, for she must then determine what follows from this affirmation. One way in which we treat other persons as mattering is by respecting them. And one way in which we respect persons is by respecting their wishes, desires, decisions, choices, ends, and goals. I will call all of these things ‘aims.’ Sometimes we respect (...) another person's aims simply byrefrainingfrom doing certain things, such as treating her in ways that thwart her aims, or interfering with her attempt to pursue them. Other times we respect a person's aims by taking positive action to help her pursue them.But how exactly does respect forpersonstranslate into respect for theiraims?And which aims merit respect? One answer comes from Kant. (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)

The autonomous person is one who has, in some sense, mastery over their desires. The prevailing way to understand such personal autonomy is in terms of a hierarchy of desires. For Harry Frankfurt, persons not only have first-order desires, but possess the additional capacity to form second-order desires. Second-order desires are formed through reflection on first-order desires and are thus expressive of the rational capacity which is characteristic of persons. Frankfurt's account of freedom of the will is founded on his (...) analysis of persons. It is only because persons possess second-order desires, resulting from their capacity for rational evaluation of first-order desires, that persons (and not those Frankfurt calls 'wantons') are well placed to possess freedom of will. Various objections have been raised in the literature against such second-order desire accounts of freedom of the will or autonomy. In my article, I raise the problem of instrumental second-order desires. I discuss the forms instrumental second-order desires can take and attempt to show that these cannot be the second-order desires that Frankfurt has in mind in his account. I then extend my critique by looking at non-instrumental second-order desires. I consider various forms which non-instrumental second-order desires can take and advance the argument that Frankfurt cannot have second-order desires such as these in mind either. Finally, I note that none of the suggestions considered will deliver a second-order desire account of autonomy, and that it is baffling just what Frankfurt does have in mind. (shrink)

For decades, the greater part of efforts to improve regulatory frameworks for research ethics has focused on informed consent procedures; their design, codification and regulation. Why is informed consent thought to be so important? Since the publication of the Belmont Report in 1979, the standard response has been that obtaining informed consent is a way of treating individuals as autonomous agents. Despite its political success, the philosophical validity of this Belmont view cannot be taken for granted. If the Belmont view (...) is to be based on a conception of autonomy that generates moral justification, it will either have to be reinterpreted along Kantian lines or coupled with a something like Mill’s conception of individuality. The Kantian interpretation would be a radical reinterpretation of the Belmont view, while the Millian justification is incompatible with the liberal requirement that justification for public policy should be neutral between controversial conceptions of the good. This consequence might be avoided by replacing Mill’s conception of individuality with a procedural conception of autonomy, but I argue that the resulting view would in fact fail to support a non-Kantian, autonomy-based justification of informed consent. These difficulties suggest that insofar as informed consent is justified by respect for persons and considerations of autonomy, as the Belmont report maintained, the justification should be along the lines of Kantian autonomy and not individual autonomy. (shrink)

The justification for advance directives is grounded in the notion that they extend patient autonomy into future states of incompetency through patient participation in decision making about end-of-life care. Four objections challenge the necessity and sufficiency of individual autonomy, perceived to be a defining feature of liberal philosophical theory, as a basis of advance care planning. These objections are that the liberal concept of autonomy (i) implies a misconception of the individual self, (ii) entails the denial of values of social (...) justice, (iii) does not account for justifiable acts of paternalism, and (iv) does not account for the importance of personal relationships in the advance care planning process. The last objection is especially pertinent in light of recent empirical research highlighting the importance of personal relationships in advance care planning. This article examines these four objections to autonomy, and the liberal theoretical framework with which it is associated, in order to re-evaluate the philosophical basis of advance care planning. We argue that liberal autonomy (i) is not a misconceived concept as critics assume, (ii) does not entail the denial of values of social justice, (iii) can account for justifiable acts of paternalism, though it (iv) is not the best account of the value of personal relationships that arise in advance care planning. In conclusion, we suggest that liberalism is a necessary component of a theoretical framework for advance care planning but that it needs to be supplemented with theories that focus explicitly on the significance of personal relationships. (shrink)

This paper addresses whether universal, general education programs are enough to satisfy basic criteria of human rights, or whether comprehensive family planning programs, in conjunction with universal education programs, might also be morally required. Even before the Reagan administration instituted the ‘global gag rule’ at the 1984 conference in Mexico City, prohibiting funding to nongovernmental organizations that included providing information about abortion as a possible method of family planning, the moral acceptability of family planning programs has been called into question. (...) This paper makes a moral argument for family planning by appealing to both data and to theory: data about the efficacy of universal and comprehensive family planning education programs at reducing fertility and infant mortality, and theory about what is required for the establishment of autonomy. It reasons that universal educational programs are insufficient for the promotion of autonomy, and therefore argues on substantive autonomy grounds for comprehensive family planning programs in addition to universal education programs. (shrink)

Autonomy, the ability to make decisions for ourselves about ourselves, is among the most prized of human liberties. In this review we reconsider the key conditions necessary for autonomous decision making, long debated by moral philosophers and ethicists, in light of current neuroscientific evidence. The most widely accepted criteria for autonomy are that decisions are made by a rationally deliberative and reflective agent and that these decisions are free of undue external influences. The corpus of neuroscientific data suggest that human (...) brains are capable of the hierarchical control required for reflective thought, but that decisions conventionally perceived as autonomous may not be rational with respect to the deliberative process itself, and are rarely free from covert external influences. These findings cast doubt upon the capacity for autonomy as traditionally defined, and suggest that we reconsider valorizing the right to autonomy in order to align our moral values with neuroscientific naturalism. (shrink)

In recent years, several studies have advocated the need to expand the concept of patient autonomy beyond the capacity to deliberate and make decisions regarding a specific medical intervention or treatment (decision-making or decisional autonomy). Arguing along the same lines, this paper proposes a multidimensional concept of patient autonomy (decisional, executive, functional, informative and narrative) and argues that determining the specific aspect of autonomy affected is the first step towards protecting or promoting (and respecting) patient autonomy. These different manifestations of (...) autonomy are not mutually dependent; there may be patients who have problems in one dimension, while at the same time being fully autonomous in others. Nevertheless, a close interaction has been observed between the various dimensions and indeed, a phenomenological analysis shows that damage to or a reduction in one aspect of people’s capacity for self-government generally affects other aspects of their autonomy, which in turn disrupts their identity and the way in which they see themselves and are seen by others. In this paper, I shall examine some of these interactions and show how they may lie at the heart of the problem of poor treatment adherence (where adherence is defined as being the extent to which a patient’s behavior over time coincides with the recommendations made by and agreed with their health professional). One example given is that of psoriasis, a chronic skin disease with a very poor adherence record. In Spain, it is calculated that 85% of patients diagnosed with mild to moderate psoriasis fail to comply properly with their treatment, and figures from other parts of the world are similar. Although there are many possible causes for non-adherence among psoriasis patients, assessing their decisional, executive and narrative capacities and taking appropriate action based on the results may help increase adherence rates. (shrink)

Like being able to drive a car, being autonomous is a socially attributed, claimed, and contested status. Normative debates about criteria for autonomy (and what autonomy entitles one to) are best understood, not as debates about what autonomy, at core, really is, but rather as debates about the relative merits of various possible packages of thresholds, entitlements, regulations, values, and institutions. Within different “regimes” of autonomy, different criteria for (degrees of) autonomy become authoritative. Neoliberal, solidaristic, and perfectionist regimes entail conflicting (...) understandings of what gets you autonomy and what autonomy gets you—for example, in relation to policies regarding physician-assisted suicide or financial support for senior citizens. In light of this, justifying a particular understanding of autonomy is inseparable from the task of arguing for the context-specific merits of a regime of autonomy as a whole and in relation to other ethical and political commitments. (shrink)

Many think that love would be a casualty of free will skepticism. I disagree. I argue that love would be largely unaffected if we came to deny free will, not simply because we cannot shake the attitude, but because love is not chosen, nor do we want it to be. Here, I am not alone; others have reached similar conclusions. But a few important distinctions have been overlooked. Even if hard incompatibilism is true, not all love is equal. Although we (...) have only minimal control over love, it can be more or less authentic. I develop my position by considering the fictional trope of love potions and the implications of a futuristic psychotropic, Lovezac—Viagra for the heart. But I am not as optimistic as some. Even though free will skepticism would not jeopardize love-the-feeling, there are reasons to think that loving relationships might not be immune. (shrink)

Part I of the dissertation examines the cognitive aspects of autonomy. The central question concerns what kind of cognitive capacity autonomy is. It will be argued that the concept of autonomy is best understood in terms of a metacognitive capacity of the individual. It is argued that metacognition has two components: procedural reflexivity and metarepresentation. Metarepresentation in turn can be divided into inferential reflexivity and other-attributiveness. These two components are essential for autonomy. Particular emphasis is put on procedural reflexivity. Further, (...) since the essential function of metacognition is control, it is argued that the concept of autonomy, understood as a metacognitive capacity, can be interpreted in terms of control. Issues arising from empirical data from neuroscience on functional, as well as impaired, metacognition, and on undermined autonomy, are dealt with. It is argued that autonomy cannot be determined with respect to subjective conditions. Neurological impairments, like Anton’s Syndrome, dementia, and thought insertion in schizophrenia, are put forward in support of this claim. To determine autonomy we require external conditions. In order to determine whether an individual is autonomous, both the metacognitive status of the individual and the external setting must be considered, since they are in interplay and consequently influence each other. In Part II, the analysis put forward in Part I is applied to Swedish healthcare. It is argued that the distinction between autonomy as a right and as a capacity must be explicit in order to understand what autonomy means and to deal with it effectively in healthcare practice. A discussion about whether or not the patient’s right to autonomy sometimes tends to be over-emphasized in healthcare is put forward. Special emphasis is placed on psychitaric issues such as deinstitutionalization and participation. Following the closure of the mental hospitals, deinstitutionalization and community-based care have become central topics in psychiatry. At the same time, the implementation of such care can be demanding for patients suffering from a persistent mental disorder. In part II it is also suggested that the metacognitive account of the concept of autonomy might help clarify the criteria governing coercive care. Finally, some suggestions concerning developments and improvements in Swedish healthcare, especially in psychiatry, where the concept of autonomy is important but problematic, are put forward. (shrink)

Mental capacity and autonomy are often understood to be normatively neutral? the only values or other norms they may presuppose are those the assessed person does or would accept. We show how mental disorder threatens normatively neutral accounts of autonomy. These accounts produce false positives, particularly in the case of disorders that affect evaluative abilities. Two normatively neutral strategies for handling autonomy-undermining disorder are explored and rejected: a blanket exclusion of mental disorder, and functional tests requiring consistency, expression of identity, (...) reflective non-alienation or lack of compulsion. Finally, we suggest ways in which substantivist alternatives to neutrality can be made more promising through increased transparency, democratic contestability of conditions for capacity and autonomy, and a historically sensitive caution concerning restrictions of liberty. (shrink)