In “The Ethics of Anonymous Gamete Donation: Is There a Right to Know One's Genetic Origins?,” Inmaculada de Melo‐Martín deconstructs the interests the right is supposed to protect. She argues that these interests are not set back or thwarted when one has no access to one's genetic origins. The basis of her argument is that we lack robust empirical evidence that donor‐conceived individuals suffer certain alleged harms, and that even when such harms are present, they do not provide strong enough (...) justification to ground the right.Indeed, the research on the needs, preferences, and well‐being of donor‐conceived individuals is scant. In fact, we lack robust empirical evidence regarding all aspects of donor conception. I argue, however, that the right to know one's genetic origins does not rest on empirical evidence. Some donor‐conceived individuals who are unable to know their genetic origins may suffer great harms. Others may suffer no harm at all. But all are treated wrongly when they are deprived of the ability to access information about their genetic origins. They are deprived of an important aspect of their autonomy: the liberty to choose what meaning they assign to the genetic components of their identity. (shrink)

Choice architecture describes the environment in which choices are presented to decision-makers. In recent years, public and private actors have looked at choice architecture with great interest as they seek to influence human behaviour. These actors are typically called choice architects. Increasingly, however, this role of architecting choice is not performed by a human choice architect, but an algorithm or artificial intelligence, powered by a stream of Big Data and infused with an objective it has been programmed to maximise. (...) We call this entity the autonomous choice architect. In this paper, we present an account of why artificial intelligence can fulfil the role of a choice architect and why this creates problems of transparency, responsibility and accountability for nudges. We argue that choice architects, be them autonomous computational systems or human-beings, at a most basic level select, from a range of designs, the design which is most likely to maximise a pre-determined objective. We then proceed to argue that, given the growing demand for targeted, personalised choice architecture and for faster, dynamic reconfigurations of choice architecture, as well as the ever-expanding pool of data from which feedback can be drawn, the role of the human choice architect is increasingly obscured behind algorithmic, artificially intelligent systems. We provide a discussion of the implications of autonomous choice architects, focusing on the importance of the humans who programme these systems, ultimately arguing that despite technological advances, the responsibility of choice architecture and influence remains firmly one human beings must bear. (shrink)

There is robust scientific evidence from meta-analyses in psychotherapy research that common factors such as the alliance between patients and therapists, empathy, goal consensus/collaboration, positive regard/affirmation and genuineness have a much greater effect on the overall psychotherapy outcome than the so-called specific factors like particular treatment methods or ingredients of therapy.1 The current evidence base also suggests that the effects of telepsychiatric treatment are comparable with those of face-to-face treatment, not only regarding clinical outcome parameters but also with respect to (...) patient satisfaction, acceptance and adherence—all common factors of psychotherapy.2 According to a comprehensive review of the main ethical arguments for and against different forms of online psychotherapy, the online setting provides several weighty advantages: for example, increased access, availability, flexibility, convenience, satisfaction, acceptance and increased demand.3 Among the arguments against online psychotherapy, privacy, confidentiality and data security issues, emergency issues, as well as communication issues have been mentioned.3 Frittgen and Haltaufderheide 4 are concerned that telepsychiatry could ‘impact ethically relevant aspects of the therapeutic relationship’. They conclude that ‘there is evidence for ethically relevant changes of the therapeutic relationship in video-based telepsychiatric consultations’,4 particularly pertaining to ‘respect for autonomy, lucidity, fidelity, justice and humanity towards each other’.4 Indeed, video-based consultations as technically mediated communication ‘do not only transmit but transform what can be perceived, …. (shrink)

Next SectionThe principle of respect for autonomy has shaped much of the bioethics' discourse over the last 50 years, and is now most commonly used in the meaning of respecting autonomous choice. This is probably related to the influential concept of informed consent, which originated in research ethics and was soon also applied to the field of clinical medicine. But while available choices in medical research are well defined, this is rarely the case in healthcare. Consideration of ordinary (...) medical practice reveals that the focus on patient choice does not properly grasp the moral aspects involved in healthcare. Medical decisions are often portrayed as if doctors and patients in confidence confront specific decisions about examinations or treatment, yet the reality often involves many different participants, with decisions being made over time and space. Indeed, most of the decisions are never even presented to patients, as it would be unethical to suggest something that is not medically justifiable. The options patients do confront are somewhat arbitrarily constructed within the narrow framework of both what is deemed to be medically appropriate and how the healthcare system is organised practically. While the autonomy discourse has proven valuable, a failure to distinguish between the fields of medical research and clinical medicine has generated a focus on patient choice that does not reflect what is really at stake in healthcare settings. This is alarming, because the current discourse misrepresents medical practice in a way that actually contributes to bioethical self-delusion. (shrink)

There is a concern that the widespread deployment of autonomous machines will open up a number of ‘responsibility gaps’ throughout society. Various articulations of such techno-responsibility gaps have been proposed over the years, along with several potential solutions. Most of these solutions focus on ‘plugging’ or ‘dissolving’ the gaps. This paper offers an alternative perspective. It argues that techno-responsibility gaps are, sometimes, to be welcomed and that one of the advantages of autonomous machines is that they enable us (...) to embrace certain kinds of responsibility gap. The argument is based on the idea that human morality is often tragic. We frequently confront situations in which competing moral considerations pull in different directions and it is impossible to perfectly balance these considerations. This heightens the burden of responsibility associated with our choices. We cope with the tragedy of moral choice in different ways. Sometimes we delude ourselves into thinking the choices we make were not tragic ; sometimes we delegate the tragic choice to others ; sometimes we make the choice ourselves and bear the psychological consequences. Each of these strategies has its benefits and costs. One potential advantage of autonomous machines is that they enable a reduced cost form of delegation. However, we only gain the advantage of this reduced cost if we accept that some techno-responsibility gaps are virtuous. (shrink)

Enhancement of autonomous choice may be considered as an important reason for facilitating the use of genetic tests such as preimplantation genetic diagnosis. The principle of respect for autonomy is a crucial component not only of Western liberal traditions but also of Western bioethics. This is especially so in bioethical discussions and analyses of clinical encounters within medicine. On the basis of an analysis of qualitative research interviews performed with British, Italian and Swedish geneticists and gynaecologists on ethical aspects (...) of preimplantation genetic diagnosis, the plausibility of the notion of autonomy within reproductive medicine is discussed. The analysis of interviews indicates not only that there is a gap between theoretical discussions and concrete practice, but also that an increase in choice — paradoxically — can hamper couples' choice. (shrink)

Attention to individual choice is a valuable dimension of public health policy; however, the creation of effective public health programmes requires policy makers to address the material and social structures that determine a person’s chance of actually achieving a good state of health. This statement summarizes a well understood and widely held view within public health practice. In this article, we (i) argue that advocates for public health can and should defend this emphasis on ‘structures’ by reference to citizen autonomy (...) and not simply by emphasizing concern for counter-balancing values such as ‘population health’ or ‘fairness’, (ii) map and critically explore the contrasting conceptions of autonomy that feature in such debates, with particular attention to conceptions of autonomy that might feature in the defence of an emphasis on structures. We draw on (i) a relational conception of autonomy and (ii) the distinction that can be made between autonomous deliberation and autonomous action to suggest that offering people the opportunity to make choices about their health without also supporting their capability to achieve the object of these choices falls short of what is often considered to be morally and politically important about promoting autonomy in relation to health. (shrink)

The exponential rise in transgender self-identification invites consideration of what constitutes an ethical response to transgender individuals’ claims about how best to promote their well-being. In this paper, we argue that ‘accepting’ a claim to medical transitioning in order to promote well-being would be in the person’s best interests iff at the point of request the individual is correct in their self-diagnosis as transgender (i.e., the distress felt to reside in the body does not result from another psychological and/or societal (...) problem) such that the medical interventions they are seeking will help them to realise their preferences. If we cannot assume this—and we suggest that we have reasonable grounds to question an unqualified acceptance in some cases—then ‘acceptance’ potentially works against best interests. We propose a distinction between ‘acceptance’ and respectful, in-depth exploration of an individual’s claims about what promotes their well-being. We discuss the ethical relevance of the unconscious mind to considerations of autonomy and consent in working with transgender individuals. An inquisitive stance, we suggest, supports autonomous choice about how to realise an embodied form that sustains well-being by allowing the individual to consider both conscious and unconscious factors shaping wishes and values, hence choices. (shrink)

The often‐posed dichotomy between the interest and choice theory of rights can obfuscate a proper understanding of children's rights. We need a gradualist model in which the grounds for attributing rights to a being change in response to the development of autonomy. Rights for children initially function to protect their interests but, as they develop into full‐fledged autonomous choosers, rights function to ensure that their choices, even those that do not serve their welfare, are respected.

One of the moral questions concerning autonomous vehicles (henceforth AVs) is the choice between types that differ in their built-in algorithms for dealing with rare situations of unavoidable lethal collision. It does not appear to be possible to avoid questions about how these algorithms should be designed. We present the results of our study of moral preferences (N = 2769) with respect to three types of AVs: (1) selfish, which protects the lives of passenger(s) over any number of bystanders; (...) (2) altruistic, which minimizes the number of casualties, even if this leads to death of passenger(s); and (3) conservative, which abstains from interfering in such situations. We differentiate between scenarios in which participants are to make their decisions privately or publicly, and for themselves or for their offspring. We aim to answer two research questions: (1) whether the public visibility of the choice of an AV type choice make this choice more altruistic and (2) which type of situation makes it more difficult to choose altruistically: when choosing for society as a whole, when choosing only for oneself, or when choosing only for one’s offspring. Our results show that respondents exhibit a preference for an altruistic strategy for AVs and that it is reinforced when signaled to others. The altruistic preference is strongest when applies to everybody else, weaker when it reflects a solely personal choice, and weakest when choosing for one’s own child. We conclude that a public choice is considerably more likely to pressure consumers into accepting a more socially beneficial solution. (shrink)

In the Philebus Plato argues that every rational human being, given the choice, will prefer a life that is moderately thoughtful and moderately pleasant to a life that is utterly thoughtless or utterly pleasureless. This is true, he thinks, even if the thoughtless life at issue is intensely pleasant and the pleasureless life at issue is intensely thoughtful. Evidently Plato wants this argument to show that neither pleasure nor thought, taken by itself, is sufficient to make a life (...) choiceworthy for us. But there is some disagreement among commentators about whether or not he also wants the argument to show why. Is the argument designed to establish that we should reject thoughtless and pleasureless lives because some pleasures and some thoughts are goods? Or is it silent on this issue? Many interpreters take the first option, claiming that Plato uses the argument to attack both the hedonist view that only pleasures are goods and the intellectualist view that only thoughts are goods. My aim in this paper is to show that the second option is at least as attractive as the first, both exegetically and philosophically. (shrink)

Diagnostic self-testing devices are being developed for many illnesses, chronic diseases and infections. These will be used in hospitals, at point-of-care facilities and at home. Designed to allow earlier detection of diseases, self-testing diagnostic devices may improve disease prevention, slow the progression of disease and facilitate better treatment outcomes. These devices have the potential to benefit both the individual and society by enabling individuals to take a more proactive role in the maintenance of their health and by helping society improve (...) health and reduce health costs. However, the full implications of future home-based diagnostic technology for individuals and society remain unclear due to their novelty. We argue that the development of diagnostic tools, especially for home use, will heighten a number of ethical challenges. This paper will explore some of the ethical implications of home-based self-testing diagnostic devices for the autonomous and relational dimensions of the person. This will be facilitated by examining the impact of diagnostic devices for individual autonomy, for the delivery of accurate diagnosis and for the personal significance of the information for the user. The latter will be examined using Charles Taylor's view of personhood and his emphasis on human agency and interpretation. While the ethical issues are not necessarily new, the development of home-based self-testing diagnostic devices will make issues regarding autonomy, accuracy of information and personal significance more and more demanding. This will be the case particularly when an individual's autonomous choices come into conflict with the person's relational responsibilities. (shrink)

It is commonly held that, given multiple medically permissible ways of proceeding, each with a different impact on the patient’s future, it is extremely important, and part of respecting patient autonomy, that patients not be under substantial pressure to defer to their physicians’ presumed authority. Some, however, worry that the focus on patient autonomy can be detrimental and that, at least in cases where it is hard to grasp what it is really like to live with certain outcomes without any (...) first‐hand or second‐hand experience, it is best if patient choice is firmly directed, or at least effectively nudged, by the recommendation of an experienced medical professional. The idea seems to be that, since physicians cannot get their patients to promptly assimilate a large amount of information and experience, physicians must, if they are to really help their patients make good decisions in hard cases, exert non‐argumentative influence on them. But this neglects an interesting possibility, namely the possibility of influencing patients by providing them with evidence regarding what decisions have proved most satisfactory for patients with their profile. Approximations of patient profile tests are already employed in medical practice. But the potential of the profile‐test approach in medical practice (and research) has been obscured by ongoing debate that neglects the significance of the approach with respect to the apparent dilemma faced by patients who need to make informed, autonomous decisions but cannot be expected to fully assimilate, in short order, the knowledge and experience of their physicians. (shrink)

Since the late 1960s, the legal doctrine of consent has occasionally been subject to severe criticism from within the bioethical discourse. The criticism was often based on observations indicating that consents and refusals, which had been considered valid from legal or institutional points of view, had frequently failed to reflect genuinely autonomous decision making, hence genuinely autonomous choices.This has led several critics to conclude that informed consent is a legal fiction. To clarify the concept, a legal fiction (...) is a supposition of fact taken to be true by the courts of law, irrespective of whether it is true or not, and even though it might not be true .1 What these critics probably meant to say was that the law deems any person who has given a legally valid consent to be genuinely task specifically autonomous, regardless of whether this is true or not and even though it might not be true. In other words, informed consent is a legal fiction, since it presupposes—that is, claims to reflect—genuine task specific autonomy, however baselessly.It was precisely this potentially embarrassing conclusion that prompted Faden and Beauchamp to develop a brilliant and remarkably effective argument in defence of the legal doctrine of consent. In their seminal work, AHistory and Theory of Informed Consent, they indeed acknowledged that effective consent often fails to be compatible with autonomous authorisation . Indeed, they recognised that effective consent does not necessarily entail autonomous authorisation. They argued, however, that the former is not a legal fiction, since it does not presuppose the …. (shrink)

Causal Determinism (CD) entails that all of a person’s choices and actions are nomically related to events in the distant past, the approximate, but lawful, consequences of those occurrences. Assuming that history cannot be undone nor those (natural) relations altered, that whatever results from what is inescapable is itself inescapable, and the contrariety of inevitability and freedom, it follows that we are completely devoid of liberty: our choices are not freely made; our actions are not freely performed. Instead (...) of disputing the soundness of this reasoning, some philosophers prefer to maintain that we could yet have a small measure of freedom were CD true of our world: although being unable to choose or act differently, one could at least under normal circumstances truly claim to be acting ‘on one’s own’, beyond the control of ‘outside forces’, in a word, autonomous. They further argue that being free in this sense suffices for moral responsibility. Call their philosophy ‘Autonomy Compatibilism’ (AC). -/- In adopting here reactive attitudes towards an agent, one is choosing to highlight the fact that the individual in question is of sound mind, reasoning and acting free from the interference of others. These facts alone, the adherent of AC claims, justify his stance, despite the necessity of the agent’s choices. Why would we not regard a sane individual who is not being coerced, intimidated, deceived or unduly put upon as in charge of his life so as to be responsible for his activities? -/- The Manipulation Argument (MA) is supposed to cut off this line of retreat. Its authors hold that, were CD true of our world, we would be no more autonomous than a victim of “covert, non-constraining control” (CNC): manipulation whereby one person causes another, through the use of methods such as brainwashing or circumspect operant conditioning, to ‘do his bidding’ without the latter being aware of his subjugation or feeling in any way coerced. Since a CNC victim obviously lacks autonomy, then so must “persons” living in a deterministic universe. Defenders of AC have, then, the following argument with which to contend: -/- 1. Victims of CNC (obviously) lack autonomy. 2. Thus, AC would be true only if some definition of autonomy succeeds in specifying a freedom relevant difference between victims of CNC and agents whose choices/actions are necessary consequences of prior events. 3. There could be no such definition. 4. Therefore, AC must be false. -/- The challenge issued here is clear: find a way to refute the claim that being subject to natural laws would be tantamount to being a victim of CNC, to show that Nature is no manipulator. Moreover, this challenge cannot be met by responding with a Frankfurt case: a situation in which things have been surreptitiously arranged so that an agent is unable to avoid doing something that he manages to do ‘on his own’, thus, being autonomous despite his inability to act otherwise. For, even if CD is not inconsistent with autonomy because it eliminates the ability to do otherwise per se, it may yet entail that no human agent ever does act of his own accord, an implication of which would be a lack of alternatives on anyone’s part. In other words, the fact that causally determined beings could never act differently than they do does is perhaps only symptomatic of the reason why such beings would lack autonomy: forces beyond their control would have dominion over their psychological development. Thus, AC advocates must show that the way that an agent’s character would be shaped, were she (merely) subject to natural laws, would leave unimpaired an ability that CNC would destroy. What follows is a definition of this ability, which I also use to solve the Problem of Freedom and Foreknowledge. (shrink)

While autonomous vehicles (AVs) are not designed to harm people, harming people is an inevitable by-product of their operation. How are AVs to deal ethically with situations where harming people is inevitable? Rather than focus on the much-discussed question of what choices AVs should make, we can also ask the much less discussed question of who gets to decide what AVs should do in such cases. Here there are two key options: AVs with a personal ethics setting (PES) (...) or an “ethical knob” that end users can control or AVs with a mandatory ethics setting (MES) that end users cannot control. Which option, a PES or an MES, is best and why? This chapter argues, by drawing on the choice architecture literature, in favor of a hybrid view that requires mandated default choice settings while allowing for limited end user control. (shrink)

ABSTRACTDiagnostic self‐testing devices are being developed for many illnesses, chronic diseases and infections. These will be used in hospitals, at point‐of‐care facilities and at home. Designed to allow earlier detection of diseases, self‐testing diagnostic devices may improve disease prevention, slow the progression of disease and facilitate better treatment outcomes. These devices have the potential to benefit both the individual and society by enabling individuals to take a more proactive role in the maintenance of their health and by helping society improve (...) health and reduce health costs. However, the full implications of future home‐based diagnostic technology for individuals and society remain unclear due to their novelty.We argue that the development of diagnostic tools, especially for home use, will heighten a number of ethical challenges. This paper will explore some of the ethical implications of home‐based self‐testing diagnostic devices for the autonomous and relational dimensions of the person. This will be facilitated by examining the impact of diagnostic devices for individual autonomy, for the delivery of accurate diagnosis and for the personal significance of the information for the user. The latter will be examined using Charles Taylor's view of personhood and his emphasis on human agency and interpretation.While the ethical issues are not necessarily new, the development of home‐based self‐testing diagnostic devices will make issues regarding autonomy, accuracy of information and personal significance more and more demanding. This will be the case particularly when an individual's autonomous choices come into conflict with the person's relational responsibilities. (shrink)

Animals are usually considered to lack the status of autonomous agents. Nevertheless, they do appear to make ostensible choices. This article considers whether, and how, I should respect animals' choices. I propose a concept of volitionality which can be respected if, and insofar as, doing so is in the best interests of the animal. Applying that concept, I will argue that an animals' choices be respected when the relevant human decision maker's capacities to decide are potentially (...) challenged or compromised. For example, it will be best to respect the animals' choice when the human decision maker: lacks accurate knowledge of the animal's subjective experiences; does not know what will lead to desirable experiences or allow for the avoidance of undesirable ones; is biased; is less aware of the animal's specific situation; cannot appreciate all elements comprehensively, including considering any value to the animal being allowed to make and implement a choice, such as where a lack of control or liberty would be unpleasant or where an animal would usefully learn from the process of choice-making; and when the animal's choice is achievable. This additionally suggests that we may often beneficially choose to set up situations that empower animals to make better choices. (shrink)

I aim to analyze in this dissertation what a desirable basic institutional structure looks like from the perspective of rationality. While the main topic is thus normative in nature, I start by clarifying in the first part what the notion of rationality exactly entails. I do so by focusing explicitly on the economic conception of rationality, according to which a rational individual is motivated to serve his self-interest on the basis of cost-benefit calculations. Such a Homo Economicus is characterized by (...) his intentional and instrumental actions, his perfectly informed beliefs and his exogenously given and egoistic preferences. In my view, however, this model is inadequate if one aims to understand what it means to be rational. The requirements that actions should be instrumental, beliefs should be based on perfect information and preferences should be exogenously given and egoistic in nature turn out to be overly demanding in this respect. That is why I propose to drop these assumptions in what I label the minimal conception of rationality. Since the latter turns out to be very formal indeed, I propose two further alternatives, which focus not so much on the choice of means to achieve certain goals, as they focus on the choice of these goals themselves. According to the first, broad conception, actions are rational if they are based on good reasons, which are further qualified as well-informed beliefs and autonomous preferences. According to the second, expressive conception, actions, beliefs and preferences are rational if they express the things the individual at hand cares about. The latter requires that individuals can reflect upon and identify with their reasons, which implies a capacity to reflect upon and distance themselves from their own bundle of preferences. In the second part of this dissertation, I try to show the value and limitations of these conceptions by applying them to the context of large-scaled elections. In this respect, it becomes immediately clear that the economic conception fails to explain why quite a lot of people go out and vote. After all, since a single vote has only an infinitesimal impact on the electoral result, it does not enable people to serve their interests or realize their goals. This leads to the so-called voting paradox, according to which no rational individual will decide to vote. The standard solution is to assume that individuals vote because they derive satisfaction from the very act itself. However, this strategy is rather ‘ad hoc’ and does not explain how people vote once they find themselves inside the voting booth. The expressive conception of rationality does better in this respect. It suggests that people vote because they care about democracy in general or about a specific political candidate or ideology. Since they conceive of themselves as being a good citizen, they express this aspect of their identity by going out to vote. In the third part of this dissertation, I analyze more fully the normative implications of the different conceptions of rationality. More specifically, I try to answer the question which basic institutional structure is desirable if one assumes that people are by and large rational. This immediately shows that both the normative issue and the explanatory issue are closely connected. In my view, proposals regarding institutional design and reform should be based on empirically adequate models of individual actions and motivations. This search for a realistic utopia goes against the conventional strategy of most economists. They rely on the Homo Economicus model, even if this fails to explain individual behavior. To explain more fully what the normative implications are of the counterfactual assumption that all people are economically rational, I focus on the work of James Buchanan. In his theory of constitutional choice, he argues in favor of a minimal state whose only task is to make sure that the market functions properly. Buchanan thus favors strict constitutional limitations for governments, which tend to expand beyond legitimate borders as soon as politicians and public servants are allowed to serve their own interests. In my view, however, the abovementioned criticisms of the Homo Economicus model have theoretical as well as normative implications. After all, the empirically supported fact that a majority of individuals does not act in economically rational ways creates more room for legitimate government intervention. Expressively rational citizens will, for example, more easily agree on the necessity and desirability of a collective provision of certain public goods. In addition, expressively rational politicians and public servants can be more easily trusted to serve the public interest rather than their narrowly defined self-interest. As an alternative to Buchanan’s one-sided focus on economic rationality and the market, I focus on the work of Samuel Bowles en Herbert Gintis. More specifically, I explore their work on the phenomenon of strong reciprocity, which refers to the widespread tendency of people to reward prosocial behavior and punish antisocial behavior, even if this is costly for themselves. Since this is clearly economically irrational, Bowles and Gintis propose to complement the Homo Economicus model with the Homo Reciprocans model. This model, which comes close to the expressive conception of rationality, is able to incorporate the insight that social norms surrounding reciprocity, cooperation and fairness are crucial in regulating interactions. At the normative level, Bowles and Gintis stress that such norms often lead to socially desirable outcomes, since they enable people to live in harmony without relying on coercive and costly government interventions. This suggests that the debate between proponents of the market on the one hand and the state on the other hand neglects the importance of communities where people spontaneously interact on the basis of generally prosocial norms. As such, the insights of Bowles and Gintis lead to a defense of a basic institutional structure in which markets, states and communities mutually complement and reinforce each other. They also justify a general optimism as regards to the capacity and motivation of people to try and improve the rules and institutions that govern their everyday lives. (shrink)

Leading contemporary argumentation theories such as those of Ralph Johnson, van Eemeren and Houtlosser, and Tindale, in their attempt to address rhetoric, tend to define rhetorical argumentation with reference to (a) the rhetorical arguer’s goal (to persuade effectively), and (b) the means he employs to do so. However, a central strand in the rhetorical tradition itself, led by Aristotle, and arguably the dominant view, sees rhetorical argumentation as defined with reference to the domain of issues discussed. On that view, the (...) domain of rhetorical argumentation is centered on choice of action in the civic sphere, and the distinctive nature of issues in this domain is considered crucial. Hence, argumentation theories such as those discussed, insofar as they do not see rhetoric as defined by its distinctive domain, apply an understanding of rhetoric that is historically inadequate. It is further suggested that theories adopting this understanding of rhetoric risk ignoring important distinctive features of argumentation about action. (shrink)

The recent progress in the development of autonomous cars has seen ethical questions come to the forefront. In particular, life and death decisions regarding the behavior of self-driving cars in trolley dilemma situations are attracting widespread interest in the recent debate. In this essay we want to ask whether we should implement a mandatory ethics setting for the whole of society or, whether every driver should have the choice to select his own personal ethics setting. While the consensus view (...) seems to be that people would not be willing to use an automated car that might sacrifice themselves in a dilemma situation, we will defend the somewhat contra-intuitive claim that this would be nevertheless in their best interest. The reason is, simply put, that a PES regime would most likely result in a prisoner’s dilemma. (shrink)

Principles of rationality are invoked for several purposes: they are often deployed in explanation and prediction; they are also used to set standards for rational health for deliberating agents or to furnish blueprints for rational automata; and they are intended as guides to perplexed decision makers seeking to regulate their own attitudes and conduct. These purposes are quite different. It is far from obvious that what serves well in one capacity will do so in another. Indeed, I shall argue later (...) on in this essay that when principles of rationality are intended for use as norms for self-criticism, they cannot also serve as laws in explanation and prediction or as blueprints for rational automata. (shrink)

Theorists who support the legalisation of active euthanasia usually base their arguments on the principle of autonomy. In their view the wish of a severely ill person not to continue his or her life must be respected. However, some opponents of the legalisation of active euthanasia refer to the principle of autonomy as well. They are concerned that patients may be held responsible for burdening others with the provision of care. Thus family members, physicians or nurses may exert pressure on (...) patients to opt for active euthanasia. In this article it is argued that these worries are justified; the occurrence of social coercion poses a real danger. However, neither the prohibition nor the permission of active euthanasia enables each individual to make an autonomous choice. Comparing the risks involved in both options, legalisation seems to be preferable to maintaining the status quo. (shrink)

In this paper I argue for what I call ‘the inherency thesis’: the thesis that an autonomous choice that succeeds in expressing an agent’s authentic identity is inherently prudentially valuable for the choosing agent. I argue that this is the case because autonomous choice is a vehicle for the expression of authentic identity, the satisfaction of which is intrinsically prudentially valuable. Moreover, I argue that no such inherent relation exists between fulfilled autonomous choice and the exemplification of (...) moral, aesthetic or perfectionist value. These conclusions suggest that accounts of the normativity of personal autonomy should focus on the notion that the demand to respect personal autonomy is grounded on the demand to promote the prudential value – and hence well-being – of others. (shrink)

This article is based on a qualitative empirical project about a distinct kinship group who were among the first identified internationally as having a genetic susceptibility to cancer. 50 were invited to participate. 15, who had all accepted testing, were interviewed. They form a unique case study. This study aimed to explore interviewees’ experiences of genetic testing and how these influenced their family relationships. A key finding was that participants framed the decision to be tested as ‘common sense’; the idea (...) of choice around the decision was negated and replaced by a moral imperative to be tested. Those who did not follow ‘common sense’ were judged to be imprudent. Family members who declined testing were discussed negatively by participants. The article addresses what is ethically problematic about how test decliners were discussed and whether these ethical concerns extend to others who are offered genetic testing. Discussions showed that genetic testing was viewed as both an autonomous choice and a responsibility. Yet the apparent conflict between the right to autonomy and the moral imperative of responsibility allowed participants to defend test decliners’ decisions by expressing a preference for or defending choice over responsibility. The ‘right not to know’ seemed an important moral construct to help ethically manage unpopular decisions made by close family who declined testing. In light of this research, the erosion of the ‘right not to know’ in the genomic age could have subtle yet profound consequences for family relationships. (shrink)

Recently, many AI researchers and practitioners have embarked on research visions that involve doing AI for “Good”. This is part of a general drive towards infusing AI research and practice with ethical thinking. One frequent theme in current ethical guidelines is the requirement that AI be good for all, or: contribute to the Common Good. But what is the Common Good, and is it enough to want to be good? Via four lead questions, the concept of Ethics Pen-Testing identifies challenges (...) and pitfalls when determining, from an AI point of view, what the Common Good is and how it can be enhanced by AI. The current paper reports on a first evaluation of EPT. EPT is applicable to various artefacts that have ethical impact, including designs for or implementations of specific AI technology, and requirements engineering methods for eliciting which ethical settings to build into AI. The current study focused on the latter type of artefact. In four independent sessions, participants with close but varying involvements in “AI and ethics” were asked to deconstruct a method that has been proposed for eliciting ethical values and choices in autonomous car technology, an online experiment modelled on the Trolley Problem. The results suggest that EPT is well-suited to this task: the remarks made by participants lent themselves well to being structured by the four lead questions of EPT, in particular, regarding the question what the problem is and about which stakeholders define it. As part of the problem definition, the need became apparent for thorough technical domain knowledge in discussions of AI and ethics. Thus, participants questioned the framing and the presuppositions inherent in the experiment and the discourse on autonomous cars that underlies the experiment. They transitioned from discussing a specific AI artefact to discussing its role in wider socio-technical systems. Results also illustrate to what extent and how the requirements engineering method forces us to not only have a discussion about which values to “build into” AI systems, the substantive building blocks of the Common Good, but also about how we want to have this discussion at all. Thus, it forces us to become explicit about how we conceive of democracy and the constitutional state and the procedural building blocks of the Common Good. (shrink)

This article discusses a familiar version of trope theory as opposed to a familiar version of the theory of universals, examining how these two rivals address the problem of “attribute agreement”—a problem that has been at the root of the very reason for developing these theories in the first place. The article shows that there is not much of a difference between the ways these two theories handle the problem, and in a more general way it argues that there is (...) little reason for preferring one theory over the other. It is not interested in this claim only for the sake of the debate between trope theory and the theory of universals. Indeed, the reasons why it claims that it is so difficult to choose one theory over the other can be applied to other cases as well (where they might lead to claims of metaphysical equivalence). (shrink)

What makes a choice difficult, beyond being complex or difficult to calculate? Characterizing difficult choices as posing a special challenge to the agent, and as typically involving consequences of significant moment as well as clashes of values, the article proceeds to compare the way difficult choices are handled by rational choice theory and by the theory that preceded it, Kurt Lewin's "conflict theory." The argument is put forward that within rational choice theory no choice is in principle difficult: (...) if the object is to maximize some value, the difficulty can be at most computational. Several prototypes of choices that challenge this argument are surveyed and discussed ; special attention is given to difficult choices faced by doctors and layers. The last section discusses a number of devices people employ in their attempt to cope with difficult choices: escape, "reduction" to non-difficult choices, and second-order strategies. (shrink)

We were interested in exploring the associations and effects of experimental language (i.e., native – L1, or foreign – L2), dilemma type (i.e., personal – D1 or impersonal – D2), the digital device participants used (i.e., PC/laptop or smartphone), along with gender and age in sacrificial COVID-19 and non-COVID moral dilemmas. We performed two studies involving 522 participants aged 18 to 69 in April 2020. In Study 1, we found no significant associations between the dilemma type and the digital device. (...) However, most participants chose to sacrifice an older COVID-19 patient in a critical medical condition to prioritize rescuing similar, younger patients (i.e., 45-year-old males). Results also suggested that male and younger participants were more likely to choose the utilitarian option when the sacrificial dilemma was presented in French. In study 2 (i.e., non-COVID-19), participants made significantly more utilitarian choices in the personal dilemmas presented in French. Results are discussed concerning the SARS-CoV-2 pandemic context and its emotional impact on moral judgment. (shrink)

It is frequently argued that home birth is morally irresponsible because it involves the taking of risks on behalf of the fetus. Against this position, I argue three things. First, the fact that home birth involves risks does not necessarily entail that choosing or attending one is morally unacceptable, irresponsible or wrong. Second, parents have a prima facia prerogative to decide on behalf of their fetuses and children whether risks should be taken. While this prima facia prerogative can be overridden, (...) reasonable and widely accepted criteria for doing so are not met in the case of home birth. Third, since the current attitudes and behaviours of physicians with regard to home birth constitute a de facto morally and socially unjustifiable overriding of an informed parental decision, physician autonomy should be restricted so as to preserve the autonomy of the medical consumer. (shrink)

Thousands of lives are lost each year because of a lack of organs available for transplant, but currently, in the UK and many other countries, organs cannot be taken from a deceased donor without explicit consent from the donor or his or her relatives. Switching to an ‘opt‐out’ system for organ donation could substantially increase the supply of organs, and save many lives. However, it has been argued in some quarters that there are serious ethical objections to an opt‐out policy, (...) and that it would be better to adopt a different policy known as the ‘presumptive approach’, that requires explicit consent while also attempting to sway the choices of potential donors and family in the direction of donating, using various persuasive techniques. This article shows how reflection on the impact of a well‐known cognitive bias known as ‘status quo bias’ can explain why moving from the status quo to an opt‐out policy might be effective in increasing organ availability, even without impinging on anyone's autonomous choices, why we might have overestimated the strength of the objections to an opt‐out policy, and why the presumptive approach is morally objectionable, while an opt‐out policy is not. (shrink)

Focusing mainly on respect for autonomy, particularly autonomous choices and actions in bioethical decisions, I examine several complexities of enacting this respect through the case of a fourteen-year-old boy who died after being allowed to refuse a necessary blood transfusion on religious grounds. I argue that thicker concepts of autonomy, closely connected with relational autonomy, direct our attention to aspects of respect for autonomy that are often neglected or underappreciated in much bioethical theory and practice. In particular, they (...) illuminate the interpretive complexity of respecting autonomous choices by focusing attention on the relational context of individuals’ decisions, on respect for individuals’ social-cultural beliefs and values, and on the temporality of selves, as expressed in their past consent or future consent as well as in—and sometimes in contradiction to—their present consent or dissent. However, it is important not to convert the illuminating and valuable insights from theories of relational autonomy into necessary conditions of autonomous choices and actions and hence of respect for autonomy. (shrink)

The current dominant perspective on addiction as a brain disease has been challenged recently by Marc Lewis, who argued that the brain-changes related to addiction are similar to everyday changes of the brain. From this alternative perspective, addictions are bad habits that can be broken, provided that people are motivated to change. In that case, autonomous choice or “free will” can overcome bad influences from genes and or environments and brain-changes related to addiction. Even though we concur with Lewis (...) that there are issues with the brain disease perspective, we also argue that pointing to black swans can be important, that is: there can be severe cases where addiction indeed tips over into the category of brain disease, but obviously that does not prove that every case of addiction falls into the disease category, that all swans are black. We argue that, for example, people suffering from Korsakoff’s syndrome, can be described as having a brain disease, often caused by alcohol addiction. Moreover, the brain changes occurring with addiction are related to choice-behaviour, habit formation and insight, hence essential mental abilities to break the addiction. We argue for a more graded perspective, where both black swans and white swans are rare, and most cases of addiction come as geese in different shades of gray. (shrink)

PHOTO ID 121339257© Designer491| Dreamstime.com ABSTRACT When physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be apparent conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters future physicians’ commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. We use an ethical dilemma that was presented to a group of third-year medical students to examine how ethics education might be causing (...) them to give undue deference to autonomy, thereby undermining their commitment to beneficence. INTRODUCTION The right of patients to choose which treatments they prefer is rooted in today’s social mores and taught as a principle of medical ethics as respect for autonomy. Yet, when physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be a conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters a commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. I. An Ethical Dilemma The impetus for this paper arose when students who were completing their third clinical year discussed a real-life ethical dilemma. A middle-aged man developed a pulmonary hemorrhage while on blood thinners for a recently placed coronary stent. The bleeding was felt to be reversible, but the patient needed immediate intubation or he would die. The cardiologist was told that the patient previously expressed to other physicians that he never wanted to be intubated. However, the cardiologist made the decision to intubate the patient anyway, and the patient eventually recovered.[1] Students were asked if they believed that the cardiologist had acted ethically. Their overwhelming response was, “No, the patient should have been allowed to die.” We looked into how students applied ethical reasoning to conclude that this outcome was ethically preferred. To explore how the third-year clinical experience might have formed the students’ judgment, we presented the same case to students who were just beginning their third year. Their responses were essentially uniform in recommending intubation. While there is likely more than one reasonable view in this case, we agree with the physician and the younger medical students that intubation was the ethically appropriate decision and will present an argument for it. But first, we explain the reasoning behind the more advanced medical students’ decision to choose patient autonomy at the expense of beneficence. II. Medical Ethics Education and the Priority of Autonomy Beauchamp and Childress’s Principles of Biomedical Ethics, first published in 1979 and now in its 8th edition, is a significant part of the formal ethics education in medical school.[2] Students learn an ethical decision-making approach based on respect for four ethical principles: autonomy, beneficence, nonmaleficence, and justice. While Beauchamp and Childress officially afford no prima facie superiority to any principle, the importance of respect for patient autonomy has increased through the editions of their book. For example, early editions of their book opposed the legalization of physician-assisted death compared to recent editions that defended it.[3] As another example, Beauchamp and Childress make paternalism harder to justify by adding an autonomy-protecting condition to the list of conditions for acceptable paternalism.[4] Authority, they contend, need not conflict with autonomy—provided the authority is autonomously chosen.[5] “The main requirement,” they write, “is to respect a particular patient’s or subject’s autonomous choices, whatever they may be.[6] In the principlism of Beauchamp and Childress, autonomy now seems to have a kind of default priority.[7] However, the bioethics discourse has strong counternarratives, noting some movement to elevate the role of beneficence and to respect the input of stakeholders, including the family and the healthcare team. Ethics education achieves particular relevance in the third clinical year when students become embedded in the care of patients and learn from what has been called the informal curriculum. They observe how attending physicians approach day-to-day ethical problems at the patient’s bedside. In this context, students observe the importance of informed consent for serious treatments or invasive procedures, a practice that highlights the principle of patient autonomy. In both the formal and informal curriculum, medical students observe how, in the words of Paul Wolpe, “patient autonomy has become the central and most powerful principle in ethical decision-making in American medicine.”[8] In short, students appear to learn a deference for patient autonomy. This curricular shift in favor of autonomy coincides with legal developments that protect patients’ rights and decision-making with respect to their healthcare choices. The priority of autonomy in medicine benefits patients by reflecting their choices and, in some cases, their fundamental liberty. III. The Practice of Medicine and the Commitment to Beneficence There are many critiques of the dominant place that autonomy has in biomedical ethics,[9] especially considering that autonomy seems to be biased toward individualistic, Western, and somewhat American culture-driven values.[10] In addition, many bioethical dilemmas are cast as a conflict between autonomy and beneficence. Our point is that medical students bring to their study of medicine a commitment to beneficence that seems to be suppressed by practical ethics education. We think this commitment is rationally defensible and should be nurtured. It is striking that young medical students have a pre-reflective commitment to beneficence at all. For, as we mentioned, it is not just medicine but Western culture generally that prioritizes autonomy in settling ethical dilemmas. In wanting to act for the good of others (rather than simply agreeing to what others want), physicians are already swimming somewhat against the cultural tide.[11] However, doing so makes sense, given the nature of medicine and the profession of healing. When prospective medical students are asked why they wish to become physicians, the usual answer is some variation on caring for the sick and preventing disease. It is unlikely that a reason to become a physician is to respect a patient’s autonomy. It would be easy to dismiss medical students’ commitment to beneficence as a mere intuition and contrary to a more reasoned and deliberative approach. Beauchamp and Childress seem to minimize the value of physician intuition, stating that justifications for certain procedures are “…supported by good reasons. They need not rest merely in intuition or feeling.”[12] Henry Richardson writes that “situational or perceptive intuition…leaves the reasons for decision unarticulated.”[13] We think this is a crude and rather thin way of understanding intuition. Some bioethicists have defended intuition as essential to the practice of medicine and not something opposed to reason.[14] In the case we describe, we believe the ethical justifications s for the patient’s intubation are fundamentally sound: the patient did not have a “do not intubate” order written in the chart, the emergency intubation had not been foreseen, so the patient did not have the opportunity to consent to or reject intubation; the patient had consented to the treatment for his cardiac disease so his consent for intubation could have been assumed;[15] and the consequences of respecting his autonomy did not justify allowing him to die.[16] While it is possible to have more than one reasonable view on this case, we think the case for beneficence is strong and certainly should not be dismissed out of hand. We do not deny that if a patient makes a clearly documented, well-informed decision to forgo intubation that this decision ought to be respected by the physician (even if the physician disagrees with the patient’s decision). But, in this situation, as in many others in the practice of medicine, the patient’s real wishes and preferences are not well-articulated in advance. There are many cases where a physician acts based on what she believes the patient, or the surrogate, would want, sometimes in situations that do not allow much time for reflection. An example might be resuscitation of a newborn at the borderline of viability. In their ethics education, beneficence would mean acting first to save a life. If the patient or surrogate makes an informed decision to the contrary, a beneficent physician respects that autonomous decision. In the case presented, the patient expressed gratitude to the cardiologist when extubated. But what if he had expressed anger at the physician for violating his autonomy? There are those who could argue that not only was intubation ethically wrong but that the cardiologist put himself in legal jeopardy by his actions (especially if there had been a written refusal applicable to the specific situation). In the example we use, we point out that the cardiologist may not have escaped a lawsuit if the patient had died without intubation. His family, when hearing the circumstances, may have sued for failure to act and dereliction of the cardiologist’s duty to save him. Beyond a potential legal challenge for either action or inaction, there is an overriding ethical question the cardiologist had to address: what course would be most satisfying to his conscience? Would he rather allow a patient to die for fear of recrimination, or act to save his life, regardless of the personal consequences? In the absence of real knowledge about the patient’s considered wishes, it is most reasonable to err on the side of promoting patient well-being. A physician’s commitment to beneficence is not necessarily a way of undermining a patient’s autonomy. In acting for the patient's good, physicians are also acting on what it is reasonable to believe a patient (or most patients, perhaps) would want, which is obviously connected to what a patient does want. Pellegrino and Thomasma argue that beneficence includes respect for a patient’s autonomy since “the best interests of the patient are intimately linked with their preferences.”[17] Instead of conceptualizing ethical dilemmas in medicine as conflicts between autonomy and beneficence, it is possible that medical schools could teach students that truly practicing beneficence is a way of valuing patient autonomy, especially when the patient’s wishes are not specific to the situation and are not clearly expressed. CONCLUSION It is important for students and practicing physicians to understand the principle of respect for patient autonomy in a pluralistic society that demands personal self-determination. However, the role of the physician as a beneficent healer should not be diminished by this respect for autonomy. Respecting a patient’s autonomy is grounded in and manifested by physician beneficence.[18] That is, seeking what is good for the patient can only be good if it respects their personhood and dignity. We propose that a commitment to beneficence, incipient in young medical students, should be developed over time with their other clinical reasoning skills. Such a commitment need not be sacrificed on the altar of patient autonomy. Beneficence needs greater relative moral weight with students as they proceed in their ethics education. - [1] S. Jauhar, “When Doctors Need to Lie,” New York Times, February 22, 2014, https://www.nytimes.com/2014/02/23/opinion/sunday/when-doctors-need-to-lie.html. [2] T. L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019). [3] Louise A. Mitchell, “Major Changes in Principles of Biomedical Ethics,” The National Catholic Bioethics Quarterly 14, no. 3 (2014): 459–75, https://doi.org/10.5840/ncbq20141438. [4] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019), 238. [5] Beauchamp and Childress, 103. [6] Beauchamp and Childress, p. 108. [7] For other accounts that prioritize autonomy, see e.g. Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of Surrogate Decision Making (Cambridge University Press, 1989), 38–39; R Gillon, “Ethics Needs Principles—Four Can Encompass the Rest—and Respect for Autonomy Should Be ‘First among Equals,’” Journal of Medical Ethics 29, no. 5 (October 2003): 307–12, https://doi.org/10.1136/jme.29.5.307. For examples of critiques of these accounts, see footnote 9. [8] P. R. Wolpe, “The Triumph of Autonomy in American Bioethics: A Sociological View,” in Bioethics and Society: Constructing the Ethical Enterprise, p. 43. [9] V. A. Entwistle et al., “Supporting Patient Autonomy: The Importance of Clinician-Patient Relationships,” Journal of General Internal Medicine 25, no. 7 (July 2010): 741–45; C. Foster, Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law, 1st ed. (Oxford ; Hart Publishing, 2009); O. O’Neill, Autonomy and Trust in Bioethics, The Gifford Lectures, University of Edinburgh 2001 (Cambridge, UK: Cambridge University Press, 2002). [10] P. Marshall and B. Koenig, “Accounting for Culture in a Globalized Bioethics,” The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics 32, no. 2 (2004): 252–66; R. Fan, “Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy,” Bioethics 11, no. 3–4 (1997): 309–22. [11] Arguments stressing the importance of beneficence, as ours does here, certainly approach paternalistic arguments. We set aside the complex issue of paternalism for purposes of this paper and simply note that the principle of beneficence as such does not say anything specifically about acting against the patient’s will. In the case study that focuses this paper, we do not believe the patient’s will or wishes were clearly indicated. [12] Beauchamp and Childress, Principles of Biomedical Ethics, p. 20, see note 2 above. [13] H. S. Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 25, no. 3 (January 1, 2000): 285–307, p. 287. [14] H. D. Braude, Intuition in Medicine a Philosophical Defense of Clinical Reasoning (Chicago ; University of Chicago Press, 2012). [15] R. Kukla, “Conscientious Autonomy: Displacing Decisions in Health Care,” The Hastings Center Report 35, no. 2 (2005): 34–44. [16] M. Schermer, The Different Faces of Autonomy: Patient Autonomy in Ethical Theory and Hospital Practice, vol. 13, Library of Ethics and Applied Philosophy (Dordrecht: Springer Netherlands, 2002). [17] E. D. Pellegrino and D. C. Thomasma, For the Patient’s Good - the Restoration of Beneficence in Health Care (New York, NY: Oxford University Press, 1988), p. 29. [18] Pellegrino and Thomasma, For the Patient’s Good. 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This book examines a basic problem in critical approaches to political and social inquiry: in what way is social inquiry animated by a practical intent? This practical intent is not external to inquiry as an add-on or a choice by the inquirer, but is inherent to the process of inquiry. The practical intent in inquiry derives from the connection between social inquiry and the participant's perspective. The social inquirer, in order to grasp the sense of those who are the subject (...) of inquiry, has to adopt the perspective of the participant in the social world. Caterino opposes the view that research is an autonomous activity distinct from or superior to a participant's perspective. He argues that since the inquirer is on the same level as the participant, all inquiry should be considered mutual critique in which those who are addressed by inquiry have an equal right and an equal capacity to criticize addressors. Brian Caterino is an independent researcher who works in public media. He is the co-editor of Making Political Science Matter (2006) with Sanford Schram and has published in a variety of journals. His most recent article "Lowering the Basement Floor" appeared in New Political Science. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Confidentiality and Its LimitsMaude Laliberté, John D. Lantos, and Sonia GowdaMultiple sclerosis is believed to be an autoimmune disease of the central nervous system. However, according to Italian physician Paolo Zamboni, it is related to cerebrospinal vascular insufficiency. Zamboni claims that MS can be treated by remedying this condition with venous angioplasty. This surgery is offered as treatment for MS in various countries—Poland, Bulgaria, and Costa Rica, for example. (...) But the Medical Board of Quebec, Canada, does not allow its members to perform the surgery and strongly advises patients against seeking it elsewhere. This opposition is based on the lack of evidence to support the procedure and the serious risks associated with it (including venous thrombosis, stroke, and pulmonary embolism). As a result, many Canadian MS patients have traveled to other countries to receive the surgery. Quebec physicians have been reluctant to provide surgical follow-up for patients who undergo the surgery in other countries due to the lack of information regarding the procedure. No alternative treatments are effective to partially or completely cure MS, and so the treatments available in Canada aim only to manage its symptoms.Jade is a forty-year-old Canadian woman with MS. She is on long-term disability leave, complains of growing fatigue and muscle stiffness, and has painful sensations in her limbs. She has been followed by an interdisciplinary team in a specialized hospital in Quebec for the past twenty years, since she was diagnosed. At her last appointment, Jade told her physical therapist that she recently underwent the experimental Zamboni surgery in Poland, despite her physician’s strong recommendation not to. Jade fears her physician’s reaction, so she asks the physical therapist to keep this information from the rest of her medical team.Jade is shy and tends to distrust health care professionals. It took many years for her physical therapist to gain her trust and to develop a positive therapeutic relationship with her. However, the physical therapist knows that serious complications can occur in patients who have had Zamboni’s surgery. Not telling Jade’s physician about the surgery could result in harm; Jade could have complications that are not recognized. Providing the information to the rest of the team would allow them to adjust her treatment to respond to the surgery and give her information and postoperative education that she will need. Moreover, keeping this secret could threaten team cohesion and trust if they find out about it later.Jade decided to undergo a risky surgery against her doctor’s advice in the hope of improving her quality of life. This was her autonomous choice. How should the physical therapist respond?CommentaryMaude Laliberte (bio)Laws and professional codes of ethics direct clinicians to respect their patients’ autonomy through confidentiality and informed consent unless there are compelling reasons not to do so. Health professionals are deeply committed to helping patients; above all, they want to avoid harming them. Therefore, a key component of this case is the possibility that respecting Jade’s desire to conceal information from the team may put her at direct risk if any postoperative complications are not detected, and at indirect risk if Jade’s trust in her medical team is undermined to the point where she turns away from them.The physical therapist must determine if the possible physical risks to Jade are imminent and serious enough to go against her autonomous choice. One risk that can occur following Zamboni’s surgery is inflammation of a vein caused by a blood clot. This is a life-threatening situation (although it may not be a likely complication for Jade). But the physical therapist can teach Jade to recognize the physical signs that can alert her to this problem, giving her ample time to seek treatment. Thus, even though she may be in danger from a life-threatening risk, there may be ways to manage it besides violating her confidentiality.The respect for autonomous choice is a crucial aspect of our democratic values. It promotes a process of exchange in the therapeutic alliance: the professional guides and informs the patient, but the patient is a partner in care planning and treatment. An important... (shrink)

The European Union’s policies regarding genetically modified food are based on the precautionary principle and the requirement of respecting consumers’ autonomy. We ask whether the requirement of respecting consumers’ autonomy regarding GMF implies that both GMF and non-GMF products should be available in the market. According to one line of thought, consumers’ choices may be autonomous even when the both types of products are not available. A food market with only GMF or only non-GMF products does not strictly (...) speaking compel people to buy the type of products available, and a possibility to refuse to buy is enough for consumers’ choice to be autonomous. According to another line of thought, the unavailability of GMF or non-GMF products restricts the autonomy of those consumers who are unwilling to use the only type of products available in the market. From the point of view of autonomy, a food market with only GMF or only non-GMF products does not offer enough alternatives for consumers. Moreover, the whole point of the European Union’s requirement of respecting consumers’ autonomy is to enable an autonomous choice between GMF and non-GMF—not just to give a possibility to refrain from buying. However, this does not imply that producers, processors, wholesalers, retailers, or public authorities have a moral duty to see that there are both GMF and non-GMF products available in the market. The requirement to respect autonomy is prima facie in nature, and in the context of GMF, other prima facie requirements are often stronger and override it. Not only the consumers’ autonomy of choice but also environmental values, other people’s well-being, and the autonomous choice of farmers, retailers, and other relevant parties should be respected. Thus, according to the both lines of thought, the requirement to respect consumers’ autonomy of choice does not imply that there should be both GMF and non-GMF products available in the market. (shrink)

Should a growing market for genetic self-tests be welcomed or feared? From the point of view of personal autonomy the increasing availability of predictive health information seems promising. Yet it is frequently pointed out that genetic information about future health may cause anxiety, distress and even loss of “life-hopes.” In this article the argument that genetic self-tests undermine personal autonomy is assessed and criticized. I contend that opportunities for autonomous choice are not reduced by genetic information but by misperceptions (...) and misunderstandings of the results of genetic tests. Since the interpretation of genetic information is sometimes distorted by the information provided about the genetic products, more attention should be given to deceitful marketing that overblows the utility of genetic products. Yet personal autonomy is reduced neither by genetic tests nor by genetic information and there is consequently no compelling case for the conclusion that genetic self-tests should be prohibited. (shrink)

Absent mistake or misrepresentation, most scholars assume that parties who agree to contract do so voluntarily. Scholars tend further to regard that choice as an important exercise in moral agency. Hanoch Dagan and Michael Heller are right to question the quality of our choices. Where the fundamental contours of the transaction are legally determined, parties have little opportunity to exercise autonomous choice over the terms on which they deal with others. To the extent that our choices in (...) contract do not reflect our individual moral constitutions — our values, virtues, vices, the set of reasons we reject and the set of reasons we endorse — we are not justified in regulating contracts reluctantly. Contracts are entitled to the privilege of liberal regulatory deference only to the extent that they are the work product of individual autonomy. The assumption that contract is voluntary does enormous work in most normative theories of contract. This Article takes still more seriously the obstacles to autonomous choice that contracting parties face. The most important constraints are not in contract law itself but in the material and moral imperatives that dictate parties’ contracting preferences. Many contracts are driven by circumstantial considerations or actual background obligations. While these contracts are not wholly lacking in the element of voluntariness, we should distinguish them from those choices — and those contracts — which more fully realize our potential to self-consciously author our relations with others. Autonomous choice in contract requires more than Dagan and Heller imply, and it is likely beyond the power of contract law standing alone to deliver it. (shrink)

Individual choices are commonly taken to manifest personal preferences. The present study investigated whether social and statistical cues influence young children's inferences about the generalizability of preferences. Preschoolers were exposed to either 1 or 2 demonstrators’ selections of objects. The selected objects constituted 18%, 50%, or 100% of all available objects. We found that children took a single demonstrator's choices as indicative only of his or her personal preference. However, when 2 demonstrators made the same selection, then children (...) inferred that it generalized to other agents of the same kind as the original demonstrator's, but not to agents of a different kind. Lastly, only when both demonstrators blatantly violated random selection (i.e., in the 18% condition) did children generalize the preference even to an agent of a different kind. Thus, from a young age, social and statistical cues inform children's naïve sociology. (shrink)

Objectives: To compare attitudes of medical and law students toward informing a cancer patient about diagnosis and prognosis and to examine whether differences are related to different convictions about benefit or harm of information.Setting and design: Anonymous questionnaires were distributed to convenience samples of students at the University of Geneva containing four vignettes describing a cancer patient who wishes, or alternatively, who does not wish to be told the truth.Participants: One hundred and twenty seven medical students and 168 law students.Main (...) outcome measures: Five point Likert scale of responses to the vignettes ranging from “certainly inform” to “certainly not inform” the patient.Results: All medical students and 96% of law students favoured information about the diagnosis of cancer if the patient requests it. Seventy four per cent of medical students and 82% of law students favoured informing a cancer patient about his or her prognosis . Thirty five per cent of law students and 11.7% of medical students favoured telling about the diagnosis and 25.6% of law students and 7% of medical students favoured telling about the prognosis even if the patient had clearly expressed his wish not to be informed. Law students indicated significantly more often than medical students reasons to do with the patient’s good, legal obligations, and the physician’s obligation to tell the truth, and significantly less often than medical students that their attitude had been determined predominantly by respect for the autonomous choice of the patient.Conclusion: Differences in attitudes according to the type of case and the type of studies were related to convictions about the benefit or harm to the patient caused by being given information. The self reported reasons of future physicians and future lawyers are helpful when considering means to achieve a better acceptance of patients’ right to know and not to know. (shrink)

Health checks or health screenings identify disease in people without a specific medical indication. So far, the perspective of health check users has remained underexposed in discussions about the ethics and regulation of health checks. In 2017, we conducted a qualitative study with lay people from the Netherlands. We asked what participants consider characteristics of good and bad health checks, and whether they saw a role for the Dutch government. Participants consider a good predictive value the most important characteristic of (...) a good health check. Information before, during and after the test, knowledgeable and reliable providers, tests for treatable disease, respect for privacy, no unnecessary health risks and accessibility are also mentioned as criteria for good health checks. Participants make many assumptions about health check offers. They assume health checks provide certainty about the presence or absence of disease, that health checks offer opportunities for health benefits and that the privacy of health check data is guaranteed. In their choice for provider and test they tend to rely more on heuristics than information. Participants trust physicians to put the interest of potential health check users first and expect the Dutch government to intervene if providers other than physicians failed to do so by offering tests with a low predictive value, or tests that may harm people, or by infringing the privacy of users. Assumptions of participants are not always justified, but they may influence the choice to participate. This is problematic because choices for checks with a low predictive value that do not provide health benefits may create uncertainty and may cause harm to health; an outcome diametrically opposite to the one intended. Also, this may impair the relationship of trust with physicians and the Dutch government. To further and protect autonomous choice and to maintain trust, we recommend the following measures to timely adjust false expectations: advertisements that give an accurate impression of health check offers, and the installation of a quality mark. (shrink)

People across cultures consider everyday choices in the context of perceived various external life-determining forces: such as fate and gods (two teleological forces) and such notions as luck and chance (two non-teleological forces). There is little cross-cultural evidence (except for a belief in gods) showing how people relate these salient notions of life-determining forces to prosociality and a sense of well-being. The current paper provides preliminary cross-cultural data to address this gap. Results indicate that choice is the most important (...) life-determining factor. Regression analyses indicate that choice and belief in gods and fate emerged as significant predictors of prosociality towards strangers. Moreover, luck was a significant predictor of decreased prosociality. A relation between life-determining forces and life satisfaction followed the same pattern: choice, gods, and fate emerged as significant predictors of greater life satisfaction, whereas luck was associated with decreased life satisfaction. The overall pattern of results indicates that participants across different cultures might sense being bounded to share or not to care depending on the perceived intentional agency and meaning in the external forces. (shrink)

BackgroundThere has been no in-depth research of public attitudes on withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. The aim of this study was to examine these attitudes and their correlation with sociodemographic characteristics, religion, political orientation, tolerance of personal choice, trust in physicians, health status, experiences with death and caring for the seriously ill, and attitudes towards death and dying. MethodsA cross-sectional study was conducted on a three-stage random sample of adult citizens of (...) the Republic of Croatia, stratified by regions, counties, and locations within those counties. In addition to descriptive statistics, ANOVA and Chi-square tests were used to determine differences, and factor analysis, correlation analysis and multiple regression analysis for data analysis.Results38.1% of the respondents agree with granting the wishes of dying people experiencing extreme and unbearable suffering, and withholding life-prolonging treatment, and 37.8% agree with respecting the wishes of such people, and withdrawing life-prolonging treatment. 77% of respondents think that withholding and withdrawing procedures should be regulated by law because of the fear of abuse. Opinions about the practice and regulation of euthanasia are divided. Those who are younger and middle-aged, with higher levels of education, living in big cities, and who have a more liberal worldview are more open to euthanasia. Assisted suicide is not considered to be an acceptable practice, with only 18.6% of respondents agreeing with it. However, 40.1% think that physician assisted suicide should be legalised. 51.6% would support the dying person’s autonomous decisions regarding end-of-life procedures.ConclusionsThe study found low levels of acceptance of withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. In addition, it found evidence that age, level of education, political orientation, and place of residence have an impact on people’s views on euthanasia. There is a need for further research into attitudes on different end-of-life practices in Croatia. (shrink)

Concerns about advertising take one of two forms. Some people are worried that advertising threatens autonomous choice. Others are worried not about autonomy but about the values spread by advertising as a powerful institution. I suggest that this bifurcation stems from misunderstanding autonomy. When one turns from autonomous choice to autonomy of persons, or what is often glossed as self-rule, then one has reason to think that advertising poses a moral problem of a sort so far unrecognized. I (...) diagnose this problem using Charles Taylor''s work on "strong evaluation". This problem turns out to have political ramifications that have been only dimly recognized in business ethics circles. (shrink)

Psychiatric patients may try (or express a desire) to injure themselves in hospital in order to cope with overwhelming emotional pain. Some health care practitioners and patients propose allowing a controlled amount of self-injury to occur in inpatient facilities, so as to prevent escalation of distress. Is this approach an example of professional assistance with harm? Or, is the approach more likely to minimise harm, by ensuring safer self-injury? In this article, I argue that health care practitioners who use harm-minimisation (...) can be considered to be helping physical injury to occur, although they do not encourage the act. I consider why there are compelling reasons to believe that a patient who self-injures is not maximally autonomous in relation to that choice. However, I then move onto argue that allowing a degree of self-injury may enable engagement with psychotherapy (enhancing autonomy) and behavioural change. In these circumstances, allowing injury (with precautions) may not be harm, all things considered. (shrink)

The author applies Albert Hirschman's "Exit, Voice and Loyalty" framework to the dilemmas faced by humanitarian aid workers in complex settings where local or international political and military realities may "taint" the purposes and uses of aid. She reviews the pro and con arguments surrounding the difficult choices of whether to go or not, whether to stay or leave and whether to speak out or remain silent in such circumstances. Because international humanitarians insert themselves into circumstances that are not (...) their own where they see there is need for a humanitarian response, the author suggests a fourth category of choice should be added to Hirschman's three - namely that of "engagement." This option involves entering and/or staying, coupled with a quiet, off-the-record voice intended to work with and try to change from within nefarious circumstances. Concluding that none of the four options is "pure" in that all have direct impacts on the welfare and likelihood of survival of suffering people, the author argues for making each decision on its own particular merits, weighing both the personal/moral and practical/political realities of that situation. She offers guides for how such decisions may best be made, relying on differences of analyses and opinion offered by colleagues to provide grounding for one's own difficult choice. (shrink)

We examined the management of completed advance directives including why participants completed a document, what procedures and values they chose, with whom they held end-of-life conversations, and where they stored their document. Participants elected to complete a SurveyMonkey survey that was made available to individuals who wrote an advance directive through Texas-LivingWill.org; 491 individuals elected to fill out the survey, aged 19 to 94 years. The survey asked multiple questions about why participants completed an advance directive, where they would store (...) it, and with whom they had conversations about their end-oflife wishes. A list of procedures and values allowed participants to indicate what they refused or requested in their advance directive. Advance directives are most often completed to allow patients to prepare and control the healthcare they wish to receive when dying. One-half to two-thirds of individuals refuse common end-of-life medical procedures, and the rest request the procedures. We found a correlation between the choice to refuse or request a procedure and the age of the participant. Participants reported that their end-of-life conversations most often occurred with their spouse. Respondents often reported that their advance directive was stored with their physician and power of attorney for healthcare, conversations with those individuals rarely happened. Advance directives document patients’ requests for and refusals of end-of-life care. Physicians and surrogates need to be better educated so that the documents are part of a meaningful conversation with the patient. Because patients’ choices change over their lifespan, these documents need to be revisited regularly and not completed as a onetime event. (shrink)