Our primary focus is on analysis of the concept of voluntariness, with a secondary focus on the implications of our analysis for the concept and the requirements of voluntary informed consent. We propose that two necessary and jointly sufficient conditions must be satisfied for an action to be voluntary: intentionality, and substantial freedom from controlling influences. We reject authenticity as a necessary condition of voluntary action, and we note that constraining situations may or may not undermine voluntariness, depending on the (...) circumstances and the psychological capacities of agents. We compare and evaluate several accounts of voluntariness and argue that our view, unlike other treatments in bioethics, is not a value-laden theory. We also discuss the empirical assessment of individuals? perceptions of the degrees of noncontrol and self-control. We propose use of a particular Decision Making Control Instrument. Empirical research using this instrument can provide data that will help establish appropriate policies and procedures for obtaining voluntary consent to research. (shrink)

What happens when someone acts? A familiar answer goes like this. There is something that the agent wants, and there is an action that he believes conducive to its attainment. His desire for the end, and his belief in the action as a means, justify taking the action, and they jointly cause an intention to take it, which in turn causes the corresponding movements of the agent's body. I think that the standard story is flawed in several respects. The flaw (...) that will concern me in this paper is that the story fails to include an agent-or, more precisely, fails to cast the agent in his proper role. (shrink)

This essay challenges the widely accepted principle that a person is morally responsible for what he has done only if he could have done otherwise. The author considers situations in which there are sufficient conditions for a certain choice or action to be performed by someone, So that it is impossible for the person to choose or to do otherwise, But in which these conditions do not in any way bring it about that the person chooses or acts as he (...) does. In such situations the person may well be morally responsible for what he chooses or does despite his inability to choose or to do otherwise. Finally the author considers certain suggestions for revising the principle he rejects or for replacing it with a principle of an altogether different kind. (shrink)

This chapter discusses some concerns regarding the effects of enhancement technologies on autonomy and authenticity, insofar as authenticity relates to autonomy. As a preliminary, it describes how enhancement and autonomy should be understood in this context along with some examples of enhancement. The chapter moves on to explain why enhancement can promote autonomy. Three types of concerns regarding the effect of enhancement technologies on autonomy are raised: (i) that medical technologies should not be used to enhance autonomy, since this is (...) not the proper use of such technologies; (ii) that some enhancement technologies are inimical to our authenticity; and (iii) that the widespread use of some enhancement technologies have negative overall consequences on people's autonomy. Different kinds of enhancements typically arouse different kinds of concerns as regards autonomy. These include cognitive, mood, physical, and aesthetic enhancement. (shrink)

I argue against the orthodox view of the relationship between propositional and doxastic justification. The view under criticism is: if p is propositionally justified for S in virtue of S's having reason R, and S believes p on the basis of R, then S's belief that p is doxastically justified. I then propose and evaluate alternative accounts of the relationship between propositional and doxastic justification, and conclude that we should explain propositional justification in terms of doxastic justification. If correct, this (...) proposal would constitute a significant advance in our understanding of the sources of epistemic justification. (shrink)

There are a number of premises underlying much of the vigorous debate on pharmacological cognitive enhancement. Among these are claims in the enhancement literature that such drugs exist and are effective among the cognitively normal. These drugs are deemed to enhance cognition specifically, as opposed to other non-cognitive facets of our psychology, such as mood and motivation. The focus on these drugs as cognitive enhancers also suggests that they raise particular ethical questions, or perhaps more pressing ones, compared to those (...) raised by other kinds of neuroenhancement. Finally, the use of these drugs is often claimed to be significant and increasing. Taken together, these premises are at the heart of the flurry of debate on pharmacological cognitive enhancement. In this article, it is argued that these are presumptions for which the evidence does not hold up. Respectively, the evidence for the efficacy of these drugs is inconsistent; neurologically it makes little sense to distinguish the cognitive from non-cognitive as separate targets of pharmacological intervention; ethically, the questions raised by cognitive enhancement are in fact no different from those raised by other kinds of neuroenhancement; and finally the prevalence rates of these drugs are far from clear, with the bulk of the claims resting on poor or misrepresented data. Greater conceptual clarity along with a more tempered appreciation of the evidence can serve to deflate some of the hype in the associated literature, leading to a more realistic and sober assessment of these prospective technologies. (shrink)

Manipulation by another person often undermines freedom. To explain this, a distinction is drawn between two forms of manipulation: indoctrination is defined as causing another person to respond to reasons in a pattern that serves the manipulator’s ends; coercion as supplying another person with reasons that, given the pattern in which he responds to reasons, lead him to act in ways that serve the manipulator’s ends. It is argued that both forms of manipulation undermine freedom because manipulators track the compliance (...) of their victims, while neutral causal mechanisms do not. Manipulators see to it that their victims comply even in the face of forces that threaten to derail them from the manipulator’s desired course. It is suggested that this has an impact on freedom because part of what we desire in wanting to be free is the availability of forms of life very different from those we actually enjoy. (shrink)

This paper argues that we should replace the common classification of theories of welfare into the categories of hedonism, desire theories, and objective list theories. The tripartite classification is objectionable because it is unduly narrow and it is confusing: it excludes theories of welfare that are worthy of discussion, and it obscures important distinctions. In its place, the paper proposes two independent classifications corresponding to a distinction emphasised by Roger Crisp: a four-category classification of enumerative theories (about which items constitute (...) welfare), and a four-category classification of explanatory theories (about why these items constitute welfare). (shrink)

Opposition to inducement payments for research subjects is an international orthodoxy amongst writers of ethics committee guidelines. We offer an argument in favour of these payments. We also critically evaluate the best arguments we can find or devise against such payments, and except in one very limited range of circumstances, we find these unconvincing.

In “Disentangling Conscience Protections,” in this issue of the Hastings Center Report, Nadia Sawicki offers a taxonomy of conscience protection laws (conscience clauses) that highlights the expansive protections they can offer to health professionals who refuse to provide a medical service for reasons of conscience. Conscience clauses can protect health professionals from adverse actions by public actors (such as administrative agencies, prosecutors, and government funders) or private actors (such as employers, private professional associations, and injured patients), and they can also (...) protect health professionals from being subject to adverse actions for their beliefs, their conduct, or harm that results from their conduct. This taxonomy provides an accurate description of the broad range of protections conscience clauses can offer and thereby is a valuable contribution to the scholarly literature on conscientious objection in health care. But it remains to consider whether the distinctions Sawicki identifies disentangle conscience protections beyond merely providing a taxonomy. In particular, does the taxonomy identify relevant distinctions in relation to determining whether a conscience clause is justified? (shrink)

John Christman has argued that constitutively relational accounts of autonomy, as defended by some feminist theorists, are problematically perfectionist about the human good. I argue that autonomy is constitutively relational, but not in a way that implies perfectionism: autonomy depends on a dialogical disposition to hold oneself answerable to external, critical perspectives on one's action-guiding commitments. This type of relationality carries no substantive value commitments, yet it does answer to core feminist concerns about autonomy.

The twentieth century saw a vigorous debate over the nature of rights. Will theorists argued that the function of rights is to allocate domains of freedom. Interest theorists portrayed rights as defenders of well-being. Each side declared its conceptual analysis to be closer to an ordinary understanding of what rights there are, and to an ordinary understand- ing of what rights do for rightholders. Neither side could win a decisive victory, and the debate ended in a standoff.

In the subsequent pages, I want to develop a distinction between wanting and valuing which will enable the familiar view of freedom to make sense of the notion of an unfree action. The contention will be that, in the case of actions that are unfree, the agent is unable to get what he most wants, or values, and this inability is due to his own "motivational system." In this case the obstruction to the action that he most wants to do (...) is his own will. It is in this respect that the action is unfree: the agent is obstructed in and by the very performance of the action. (shrink)

The standard notion of autonomy in medical ethics does not require that autonomous choices not be irrational. The paper gives three examples of seemingly irrational patient choices and discusses how a rational autonomy analysis differs from the standard view. It then considers whether a switch to the rational autonomy view would lead to overriding more patient decisions but concludes that this should not be the case. Rather, a determination of whether individual patient decisions are autonomous is much less relevant than (...) usually considered in determining whether health care providers must abide by these decisions. Furthermore, respect for rational autonomy entails strong positive requirements of respect for the autonomy of the person as a rational decision maker. The rationality view of autonomy is conceptually stronger than the standard view, allows for a more nuanced understanding of the practical moral calculus involved in respecting patient autonomy, and promotes positive respect for patient autonomy. (shrink)

The notion of autonomy commonly employed in medical ethics literature and practices is inadequate on three fronts: it fails to properly identify nonautonomous actions and choices, it gives a false account of which features of actions and choices makes them autonomous or nonautonomous, and it provides no grounds for the moral requirement to respect autonomy. In this paper I offer a more adequate framework for how to think about autonomy, but this framework does not lend itself to the kinds of (...) practical application assumed in medical ethics. A general problem then arises: the notion of autonomy used in medical ethics is conceptually inadequate, but conceptually adequate notions of autonomy do not have the practical applications that are the central concern of medical ethics. Thus, a revision both of the view of autonomy and the practice of “respect for autonomy” are in order. (shrink)

It is generally held that doctors and researchers have an obligation to obtain informed consent. Over time there has been a move in relation to this obligation from a requirement to disclose information to a requirement to ensure that that information is understood. Whilst this change has been resisted, in this article I argue that both sides on this matter are mistaken. When investigating what information is needed for consent to be informed we might be trying to determine what information (...) a person would need in order to consent at all, or we might be trying to determine what information a person needs in order to make an informed choice about whether or not to consent. I argue that the obligation to ensure understanding only applies to information generated by the first type of enquiry; but that much of the information generally thought necessary in order for consent to be informed is only required if our concern is with the second type of enquiry. For this reason it is neither the case that doctors and researchers should ensure all the information they provide is understood, nor is it the case that their only obligation is to disclose it. (shrink)

Suppose that we want to frame a conception of reasons that isn't relativized to the inclinations of particular agents. That is, we want to identify particular things that count as reasons for acting simpliciter and not merely as reasons for some agents rather than others, depending on their inclinations. One way to frame such a conception is to name some features that an action can have and to say that they count as reasons for someone whether or not he is (...) inclined to care about them. The problem with the resulting conception, as we have seen, is that it entails the normative judgment that one ought to be inclined to care about the specified features, on pain of irrationality, and this normative judgment requires justification. The advantage of internalism is that it avoids these normative commitments. It says that things count as reasons for someone only if he is inclined to care about them, and so it leaves the normative question of whether to care about them entirely open. Yet if we try to leave this question open, by defining things as reasons only for those inclined to care about them, we'll end up with a definition that's relativized to the inclinations of particular agents—won't we? Not necessarily. For suppose that all reasons for acting are features of a single kind, whose influence depends on a single inclination. And suppose that the inclination on which the influence of reasons depends is, not an inclination that distinguishes some agents from others, but rather an inclination that distinguishes agents from nonagents. In that case, to say that these features count as reasons only for those who are inclined to care about them will be to say that they count as reasons only for agents—which will be to say no less than that they are reasons for acting, period, since applying only to agents is already part of the concept of reasons for acting. The restriction on the application of reasons will drop away from our definition, since it restricts their application, not to some proper subset of agents, but rather to the set of all agents, which is simply the universe of application for reasons to act. (shrink)

How a "right to die" may become a "coercive option".

Clinicians cannot obtain valid consent to treatment because they cannot guess which treatment option will serve a particular patient's best interests. These guesses could be made more accurately if patients were paired with providers who share their deep values.

This articles assesses the arguments that bioethicists have presented for the view that patient’ autonomy has value over and beyond its instrumental value in promoting the patients’ wellbeing. It argues that this view should be rejected and concludes that patients’ autonomy should be taken to have only instrumental value in medicine.

I argue against the view that there is intrinsic value in making one's own decisions about the direction and shape of one's life.

Metaphysicians, ethical theorists and philosophers of law squabble endlessly about what it is for a person to act — or perhaps even to ‘will’ — more or less freely. A vital issue in this controversy is how we should analyse two obvious but surprisingly problematical contrasts. The first antithesis is between things we do because we are forced, and deeds we perform because we want to — sometimes after having discovered preponderant reasons in their favour. The other polarity is more (...) general. In most situations, if I act on my desire, I act more freely than if I had not had the desire. But what if my attitude is the product of childhood conditioning — or later brainwashing, brain surgery, hypnosis, behaviour modification, alcoholisim, narcotics addiction, neurosis, psychosis or worse? Then isn't my autonomy diminished? What is it about these latter desires, or their origin, that differentiates them from their unthreatening congeners? (shrink)

Those who advocate a “historicist” outlook on moral responsibility often hold that people who unwillingly acquire corrupt dispositions are not blameworthy for the wrong actions that issue from these dispositions; this contention is frequently supported by thought experiments involving instances of forced psychological manipulation that seem to call responsibility into question. I argue against this historicist perspective and in favor of the conclusion that the process by which a person acquires values and dispositions is largely irrelevant to moral responsibility. While (...) the thought experiments introduced by historicists raise perplexing questions about personal identity and involve clear instances of moral wrongs done to the manipulated subjects, neither of these considerations bear on the question of moral responsibility. Rather, questions about moral responsibility in manipulation cases should be answered, I argue, by considering whether a manipulated agent is capable of expressing through her actions the objectionable attitudes that make blame appropriate in normal cases of wrongdoing. (shrink)

According to the standard view of informed consent, a prospective subject's consent to participate in a research study is invalid if the individual fails to comprehend the information about the study standardly disclosed to him. I argue that this involves three mistakes. First, the standard view confuses an ethical aspiration with a minimum ethical standard. Second, it assigns the entire responsibility for producing comprehension in study participants to the investigators. Most importantly, the standard view requires the termination of many otherwise (...) perfectly ethical research studies. This last conclusion follows from appreciating a pervasive phenomenon that is known as the "therapeutic misconception." I argue that a prospective subject's consent to participate in research can be perfectly valid even if he or she does not comprehend the information that investigators are required to disclose. Furthermore, I explain that this alternative view does not in the least compromise the vital goal of ensuring the protection of subjects in research. (shrink)

A recent article from Archives of Disease in Childhood outlined problems with the act of gaining child assent for research participation. However the arguments used in the article are incomplete or misguided. Rather than being harmful, assent should be seen as an ethically-appropriate way in which we can engage with the child about his participation in research. While additional clarification of the concept of assent is needed, the child's family context can provide us with a valuable guide to the way (...) we involve him in the decision-making process. (shrink)

Many liberals believe that government should not base its decisions on any particular conception of the good life. Many believe, further, that this principle of neutrality is best defended through appeal to some normative principle about autonomy. In this essay, I shall discuss the prospects of mounting one such defense. I say only “one such defense” because neutralists can invoke the demands of autonomy in two quite different ways. They can argue, first, that because autonomy itself has such great value, (...) the state can produce the best results by simply allowing each citizen to shape his own life; or they can argue, second, that even if non-neutral policies would produce the most value, the state remains obligated to eschew them out of respect for its citizens' autonomy. Here I shall discuss only the first and more consequentialist of these arguments. (shrink)

Although philosophers have explored several connections between neuroscience and moral responsibility, the issue of how real-world neurological modifications, such as Deep Brain Stimulation, impact moral responsibility has received little attention. In this article, we draw on debates about the relevance of history and manipulation to moral responsibility to argue that certain kinds of neurological modification can diminish the responsibility of the agents so modified. We argue for a historicist position - a version of the history-sensitive reflection view - and defend (...) that account against a rival, relational view of responsibility. We conclude that DBS can, under certain conditions, diminish responsibility, and explore the circumstances under which this might be so. We conclude by suggesting that philosophical debates about moral responsibility, manipulation, and history have greater practical relevance than is sometimes thought, and that attention to practical cases can help inform and deepen this body of scholarship. (shrink)

Our aim is to expand the regulative ideal governing consent. We argue that consent should not only be informed but also based on rational beliefs. We argue that holding true beliefs promotes autonomy. Information is important insofar as it helps a person to hold the relevant true beliefs. But in order to hold the relevant true beliefs, competent people must also think rationally. Insofar as information is important, rational deliberation is important. Just as physicians should aim to provide relevant information (...) regarding the medical procedures prior to patients consenting to have those procedures, they should also assist patients to think more rationally. We distinguish between rational choice/action and rational belief. While autonomous choice need not necessarily be rational, it should be based on rational belief. The implication for the doctrine of informed consent and the practice of medicine is that, if physicians are to respect patient autonomy and help patients to choose and act more rationally, not only must they provide information, but they should care more about the theoretical rationality of their patients. They should not abandon their patients to irrationality. They should help their patients to deliberate more effectively and to care more about thinking rationally. We illustrate these arguments in the context of Jehovah's Witnesses refusing life-saving blood transfusions. Insofar as Jehovah's Witnesses should be informed of the consequences of their actions, they should also deliberate rationally about these consequences. (shrink)

ABSTRACT It is accepted that treatment of previously competent, now incompetent patients can be limited if that is what the patient would desire, if she were now competent. Expressed past preferences or an advance directive are often taken to constitute sufficient evidence of what a patient would now desire. I distinguish between desires and rational desires. I argue that for a desire to be an expression of a person's autonomy, it must be or satisfy that person's rational desires. A person (...) rationally desires a course of action if that person desires it while being in possession of all available relevant facts, without committing relevant error of logic, and “vividly imagining” what its consequences would be like for her. I argue that some competent, expressed desires obstruct autonomy. I show that several psychological mechanisms operate to prevent a person rationally evaluating what future life in a disabled state would be like. Rational evaluation is difficult. However, treatment limitation, if it is to respect autonomy, must be in accord with a patient's rational desires, and not merely her expressed desires. I illustrate the implications of these arguments for the use of advance directives and for the treatment of competent patients. (shrink)

I contrast Robert Veatch's recent liberal vision of medical decision‐making with a more rationalist liberal model. According to Veatch, physicians are biased in their determination of what is in their patient's overall interests in favour of their medical interests. Because of the extent of this bias, we should abandon the practice of physicians offering what they guess to be the best treatment option. Patients should buddy up with physicians who share the same values —‘deep value pairing’. The goal of choice (...) is maximal promotion of patient values. I argue that if subjectivism about value and valuing is true, this move is plausible. However, if objectivism about value is true — that there really are states which are good for people regardless of whether they desire to be in them — then we should accept a more rationalist liberal alternative. According to this alternative, what is required to decide which course is best is rational dialogue between physicians and patients, both about the patient's circumstances and her values, and not the seeking out of people, physicians or others, who share the same values. Rational discussion requires that physicians be reasonable and empathic. I describe one possible account of a reasonable physician. (shrink)

In patient centred care, shared decision making is a central feature and widely referred to as a norm for patient centred medical consultation. However, it is far from clear how to distinguish SDM from standard models and ideals for medical decision making, such as paternalism and patient choice, and e.g., whether paternalism and patient choice can involve a greater degree of the sort of sharing involved in SDM and still retain their essential features. In the article, different versions of SDM (...) are explored, versions compatible with paternalism and patient choice as well as versions that go beyond these traditional decision making models. Whenever SDM is discussed or introduced it is of importance to be clear over which of these different versions are being pursued, since they connect to basic values and ideals of health care in different ways. It is further argued that we have reason to pursue versions of SDM involving, what is called, a high level dynamics in medical decision-making. This leaves four alternative models to choose between depending on how we balance between the values of patient best interest, patient autonomy, and an effective decision in terms of patient compliance or adherence: Shared Rational Deliberative Patient Choice, Shared Rational Deliberative Paternalism, Shared Rational Deliberative Joint Decision, and Professionally Driven Best Interest Compromise. In relation to these models it is argued that we ideally should use the Shared Rational Deliberative Joint Decision model. However, when the patient and professional fail to reach consensus we will have reason to pursue the Professionally Driven Best Interest Compromise model since this will best harmonise between the different values at stake: patient best interest, patient autonomy, patient adherence and a continued care relationship. (shrink)

Clinicians and health researchers frequently encounter opportunities to rescue people. Rescue cases can generate a moral duty to aid those in peril. As such, bioethicists have leveraged a duty to rescue for a variety of purposes. Yet, despite its broad application, the duty to rescue is under-analyzed. In this paper, we assess the state of theorizing about the duty to rescue. There are large gaps in bioethicists’ understanding of the force, scope, and justification of the two most cited duties to (...) rescue—the individual duty of easy rescue and the institutional rule of rescue. We argue that the duty of easy rescue faces unresolved challenges regarding its force and scope, and the rule of rescue is indefensible. If the duty to rescue is to help solve ethical problems, these theoretical gaps must be addressed. We identify two further conceptions of the duty to rescue that have received less attention—an institutional duty of easy rescue and the professional duty to rescue. Both provide guidance in addressing force and scope concerns and, thereby, traction in answering the outstanding problems with the duty to rescue. We conclude by proposing and propose research priorities for developing accounts of duties to rescue in bioethics. (shrink)

The emerging international biomedical law tends to recognise the right not to know one’s genetic status. However, the basis and conditions for the exercise of this right remain unclear in domestic laws. In addition to this, such a right has been criticised at the theoretical level as being in contradiction with patient’s autonomy, with doctors’ duty to inform patients, and with solidarity with family members. This happens especially when non-disclosure poses a risk of serious harm to the patient’s relatives who, (...) without that vital information, could be deprived of preventive or therapeutic measures. This paper argues, firstly, that individuals may have a legitimate interest in not knowing their genetic make up to avoid serious psychological consequences; secondly, that this interest, far from being contrary to autonomy, may constitute an enhancement of autonomy; thirdly, that the right not to know cannot be presumed, but must be “activated” by the individual’s explicit choice, and fourthly, that this is not an absolute right, in the sense that it may be restricted when disclosure to the patient is necessary in order to avoid a risk of serious harm to third persons. (shrink)

Philosophy has much to offer psychiatry, not least regarding ethical issues, but also issues regarding the mind, identity, values, and volition. This has become only more important as we have witnessed the growth and power of the pharmaceutical industry, accompanied by developments in the neurosciences.