A governing principle in medical ethics is respect for patient autonomy. This principle is commonly drawn upon in order to argue for the permissibility of assisted dying. In this paper I explore the proper role that respect for patient autonomy should play in this context. I argue that the role of autonomy is not to identify a patient’s best interests, but instead to act as a side-constraint on action. The surprising conclusion of the paper is that whether or not it (...) is in the best interests for the patient to die is a morally objective matter. This allows for the possibility that it can be in the best interests of the patient to die even if she autonomously considers it to be in her best interest to continue living. I argue that concerns about ‘mandatory’ euthanasia can be met when patient autonomy is respected as a side-constraint on action. Ultimately, this means that assisted dying is permissible, not because the autonomous patient views her suffering to be unbearable, but because it is in her objective best interests and she permitted it via her consent. (shrink)

Lifestyle-induced diseases are becoming a burden on healthcare, actualizing the discussion on health responsibilities. Using data from the National Association for Heart and Lung Diseases ’s 2015 Health Survey, this study examined the public’s attitudes towards personal and social health responsibility in a Norwegian population. The questionnaires covered self-reported health and lifestyle, attitudes towards personal responsibility and the authorities’ responsibility for promoting health, resource-prioritisation and socio-demographic characteristics. Block-wise multiple linear regression assessed the association between attitudes towards health responsibilities and individual (...) lifestyle, political orientation and health condition. We found a moderate support for social responsibility across political views. Respondents reporting unhealthier eating habits, smokers and physically inactive were less supportive of health promotion policies. The idea that individuals are responsible for taking care of their health was widely accepted as an abstract ideal. Yet, only a third of the respondents agreed with introducing higher co-payments for treatment of ‘self-inflicted’ conditions and levels of support were patterned by health-related behaviour and left-right political orientation. Our study suggests that a significant support for social responsibility does not exclude a strong support for personal health responsibility. However, conditional access to healthcare based on personal lifestyle is still controversial. (shrink)

While the concept of adaptive preferences is an important tool for criticizing injustice, it is often claimed that using the concept involves showing disrespect for persons judged to have adaptive preferences. In this paper, I propose an account of adaptive preferences that does the relevant political work while still showing persons two centrally important kinds of respect. My account is based in what I call an indirect substantive account of autonomy, which places substantive requirements on the options available to a (...) person, rather than on the option that she ultimately prefers. This allows us to pinpoint cases in which a person's circumstances have rendered her insufficiently autonomous, without saying that any conception of the good must be non-autonomous tout court. (shrink)

Is implementing the beneficent nudge program morally permissible in worlds like ours? I argue that there is reason for serious doubt. I acknowledge that beneficent nudging is highly various, that nudges are in some circumstances morally permissible and even called for, and that nudges may exhibit respect for genuine autonomy. Nonetheless, given the risk of epistemic injustice that nudges typically pose, neither the moral permissibility of beneficent nudging in the abstract, nor its case-by-case vindication, appears sufficient to justify implementing a (...) nudge program in worlds like ours. Drawing on Miranda Fricker’s account of epistemic injustice, I argue that the cogent defense of any nudge program, relative to worlds like ours, stands in need of serious attention to its potential for fostering or sustaining epistemic injustice. A more specific point hinges on recognizing a form of epistemic injustice not enough attended to in the literature to date, which I call reflective incapacitational injustice. This includes relative disadvantages in the attaining of the capacity to engage in critical reason, such as the capacity to go in for potentially critical reasoned deliberation and discursive exchange concerning ends. Since Cass Sunstein’s First Law of behaviorally informed regulation would be taken, in worlds like ours, to justify indeterminately many nudges leading to such epistemic injustice we have general grounds for doubting the moral permissibility of this nudge program. We should hence oppose the implementation of any such program until it is shown not to violate the demands of epistemic justice. (shrink)

Are the small and indolent cancers found in abundance in cancer screening normal variations, risk factors, or disease? Naturalists in philosophy of medicine turn to pathophysiological findings to decide such questions objectively. To understand the role of pathophysiological findings in disease definition, we must understand how they mislead in diagnostic reasoning. Participants on all sides of the definition of disease debate attempt to secure objectivity via reductionism. These reductivist routes to objectivity are inconsistent with the Bayesian nature of clinical reasoning; (...) when they appeal to the sciences, they are inconsistent with what philosophy of biology tells us about its natural kinds. Proposals that we narrow the scope of our claims in the disease definition debates are useful, but paradigms can still distort our reasoning in particular cases, even when we are self-conscious about their status. (shrink)

In bioethics and health policy, we often discuss the appropriate boundaries of public funding; how the interface of public and private purchasers and providers should be organized and regulated receives less attention. In this paper, I discuss ethical and regulatory issues raised at this interface by three medical practice models in which physicians provide insured services while requiring or requesting that patients pay for services or for the non-insured services of the physicians themselves or their associates. This choice for such (...) practice models is different from the decision to design an insurance plan to include or exclude user fees, co-payments and deductibles. I analyze the issues raised with regards to familiar health care values of equity and efficiency, while highlighting additional concerns about fair terms of access, provider integrity, and fair competition. I then analyze the common Canadian regulatory response to block fee models, considering their extension to wellness clinics, with regards to fiduciary standards governing the physician–patient relationship and the role of informed consent. I close by highlighting briefly issues that are of common concern across different fundamental normative frameworks for health policy. (shrink)

As behavioural economics reveals, human decision-making deviates from neoclassical assumptions about human behaviour and people (often) fail to make the ‘right’ welfare-enhancing choice. The purpose of Sunstein and Thaler’s concept of ‘nudge’ is to improve individual welfare. To provide normative justification, they argue that the only relevant normative criterion is whether the individual is ‘better off as judged by themselves’, so that the direction in which people are to be nudged is defined by their own preferences. In light of behavioural (...) findings, however, people’s choices do not provide a sound basis for eliciting preferences and thus for assessing welfare. In this paper, I aim to challenge Sunstein and Thaler’s normative view, arguing that it is unreasonable to rely on conventional welfare economics, particularly considering the given context. Sunstein and Thaler depend on an approach of ‘preference purification’ which assumes informed, latent, and true preferences: As a result they face crucial methodological, epistemological, and practical objections, and cannot show how their approach enhances individual welfare. By building on the concepts of R. Sugden and C. Schubert, I develop an alternative normative framework for behavioural public policy, based on a contractualist perspective in which people may consent to collective choice rules in order to align future behaviour with values, to achieve particular goals or to preserve personal integrity. Individual consent and citizens’ participation and deliberation are crucial to this approach. This contractualist approach may provide a normative justification for behavioural public policy, and help to reconcile behavioural and normative economics. (shrink)

Nudging is a tool of libertarian paternalism. It involves making use of certain psychological tendencies in order to help people make better decisions without restricting their freedom. However, some have argued that nudging is objectionable because it interferes with, or undermines, the rational decision-making of the nudged agents. Opinions differ on why this is objectionable, but the underlying concerns appear to begin with nudging’s threat to rational decision-making. Those who discuss this issue do not make it clear to what this (...) threat to rationality amounts. In this paper I evaluate what effect nudging has on our decision-making and I argue that it does not typically interfere with our rationality in a problematic way. Perhaps nudging is objectionable for other reasons, but we should not argue that nudging is objectionable based on concerns about rational decision-making. (shrink)

Our decision-making is often subject to framing effects: alternative but equally informative descriptions of the same options elicit different choices. When a decision-maker is vulnerable to framing, she may consent under one description of the act, which suggests that she has waived her right, yet be disposed to dissent under an equally informative description of the act, which suggests that she has not waived her right. I argue that in such a case the decision-maker’s consent is simply irrelevant to the (...) permissibility of proceeding. I then consider two alternative views. According to the first, people susceptible to framing are able to give valid consent so long as they are sufficiently informed. This suggestion, I argue, maintains an overly narrow focus on mere quantity of information to the exclusion of other choice-affecting factors. A second response, which appeals to hypothetical consent, is likewise of little use in resolving the moral problem posed by framing effects. I conclude that if susceptibility to framing undermines the validity of consent, we may have good reason to reconsider whether consent has the rights-waiving function commonly attributed to it. (shrink)

Thaler and Sunstein justify nudge policies from welfaristic premises: nudges are acceptable because they benefit the individuals who are nudged. A tacit assumption behind this strategy is that we can identify the true preferences of decision-makers. We argue that this assumption is often unwarranted, and that as a consequence nudge policies must be justified in a different way. A possible strategy is to abandon welfarism and endorse genuine paternalism. Another one is to argue that the biases of decision that choice (...) architects attempt to eliminate create externalities. For example, in the case of intertemporal discounting, the costs of preference reversals are not always paid by the discounters, because they are transferred onto other individuals. But if this is the case, then nudges are best justified from a political rather than welfaristic standpoint. (shrink)

Trotz der überwältigenden öffentlichen wie wissenschaftlichen Resonanz, auf die der Nudge-Ansatz von Thaler und Sunstein gestoßen ist, bleiben die genauen Konturen dieses Theorie und Policyvorschlages unscharf. So ist an vielen Stellen unklar, worin die spezifische Differenz gegenüber klassischen Formen der Verhaltenssteuerung liegen soll. Für eine Bewertung des Ansatzes in seinen Vorzügen und Nachteilen gegenüber klassischen Steuerungsformen ist eine solche klärende Einordnung jedoch notwendige Vorbedingung. Der Aufsatz arbeitet daher die bestehenden Definitions- und Abgrenzungsprobleme von „Nudge“ und „Libertärem Paternalismus“ heraus und plädiert (...) sodann für einen Kernbegriff von „Nudge“, der dessen Extension einschränkt, um ihn als originären und eigenständigen Vorschlag einzugrenzen. Ein so präzisiertes Verständnis von Nudge wird dann hinsichtlich seiner Eigenschaften sowie der Gemeinsamkeiten und Unterschiede zu klassischen Formen der Verhaltenssteuerung ins Verhältnis gesetzt. (shrink)

Many contemporary defenders of paternalist interventions favor a version of paternalism focused on how people often choose the wrong means given their own ends. This idea is typically justified by empirical results in psychology and behavioral economics. To the extent that paternalist interventions can then target the promotion of goals that can be said to be our own, such interventions are prima facie less problematic. One version of this argument starts from the idea that it is meaningful to ascribe to (...) us preferences that we would have if were fully rational, informed and in control over our actions. It is argued here, however, that the very body of empirical results that means paternalists typically rely on also undermines this idea as a robust enough notion. A more modest approach to paternalist interventions, on which such policies are understood as enmeshed with welfare-state policies promoting certain primary goods, is then proposed instead. (shrink)

Online information intermediaries such as Facebook and Google are slowly replacing traditional media channels thereby partly becoming the gatekeepers of our society. To deal with the growing amount of information on the social web and the burden it brings on the average user, these gatekeepers recently started to introduce personalization features, algorithms that filter information per individual. In this paper we show that these online services that filter information are not merely algorithms. Humans not only affect the design of the (...) algorithms, but they also can manually influence the filtering process even when the algorithm is operational. We further analyze filtering processes in detail, show how personalization connects to other filtering techniques, and show that both human and technical biases are present in today’s emergent gatekeepers. We use the existing literature on gatekeeping and search engine bias and provide a model of algorithmic gatekeeping. (shrink)

Anonymising technologies are cyber-tools that protect people from online surveillance, hiding who they are, what information they have stored and what websites they are looking at. Whether it is anonymising online activity through ‘TOR’ and its onion routing, 256-bit encryption on communications sent or smart phone auto-deletes, the user’s identity and activity is protected from the watchful eyes of the intelligence community. This represents a clear challenge to intelligence actors as it prevents them access to information that many would argue (...) plays a vital part in locating and preventing threats from being realised. Moreover, such technology offers more than ordinary information protections as it erects ‘warrant-proof’ spaces, technological black boxes that no matter what some authority might deem as being legitimately searchable is protected to the extent that there are very limited or non-existent means of forcing oneself in. However, it will be argued here that not only is using such anonymising technology and its extra layer of protection people’s right, but that it is ethically mandatory. That is, due to the en masse surveillance—from both governments and corporations—coupled with people’s limited awareness and ability to comprehend such data collections, anonymising technology should be built into the fabric of cyberspace to provide a minimal set of protections over people’s information, and in doing so force the intelligence community to develop more targeted forms of data collection. (shrink)

:Contemporary global governance is organized around an odd pairing: care and control. On the one hand, much of global governance is designed to reduce human suffering and improve human flourishing, with the important caveat that individuals should be allowed to decide for themselves how they want to live their lives. On the other hand, these global practices of care are also entangled with acts of control. Peacebuilding, public health, emergency aid, human rights, and development are expressions of this tension between (...) care and control. There is a concept that captures this tension: paternalism. Drawing on our moral intuitions, I argue that paternalism is the attempt by one actor to substitute his judgment for another actor's on the grounds that such an imposition will improve the welfare of the target actor. After discussing and defending this definition, I note how our unease with paternalism seems to grow as we scale up from the interpersonal to the international, which I argue owes to the evaporation of community and equality. After exploring the implications of this definition and distinguishing it from other forms of intervention, I consider how different elements of paternalism combine to generate different configurations. Specifically, I point to five dimensions that are most relevant for examining the paternalism found in contemporary global and humanitarian governance: the tools used to restrict another actor’s liberty ; the scope of the interference ; the purpose of the intervention ; the source of the paternalizer’s confidence ; and the mechanisms of accountability. These different elements often correlate historically, suggestive of two ideal types of global paternalism: strong and weak. Contemporary global and humanitarian governance is largely the weak variety: force is severely proscribed, interference is relatively restricted, the paternalizer’s confidence has epistemic roots, and accountability to local populations remains a noble but rarely practiced goal. I further speculate that a major reason for this difference is the effects of liberalism and rationalization. I use this taxonomy to suggest how two different global efforts to improve the lives of those peoples living in what were perceived to be unstable and illiberal territories — the civilizing missions of the nineteenth century and the peacebuilding operations of the post-Cold War period — exhibited different kinds of paternalism. I conclude by reflecting on the ethics of international paternalism. (shrink)