Le politiche di sicurezza hanno assunto nel corso degli ultimi decenni un ruolo centrale all’interno dell’Unione Europea (UE) e ne costituiscono attualmente uno dei settori più controversi. Nel porsi come attore in grado di garantire sicurezza, l’Unione assume da un lato sempre più compiti e funzioni che sin dall’inizio dell’età moderna sono stati prerogativa del potere statale, senza poter direttamente avvalersi, dall’altro lato, dei principi di legittimazione propri dello Stato. Gli sviluppi recenti delle politiche di sicurezza UE, inoltre, sono fortemente (...) condizionati dai processi di digitalizzazione. Questi favoriscono l’emergere di nuovi modi di intenderle, caratterizzati da un approccio “preemptivo”. Questo denota un modo di affrontare la criminalità che si concentra sugli effetti piuttosto che sulle cause e, attraverso la formulazione di prognosi, mira a intervenire prima che determinati avvenimenti si manifestino al fine di evitarli. Il libro esplora questi sviluppi e discute se, alla luce di essi, i principi fondamentali di legittimità dell’UE siano in grado di esercitare effettivamente la propria funzione di limitazione del potere e tutela dei diritti fondamentali. Attraverso analisi di pratiche concrete quali l’utilizzo e il potenziamento di grosse banche dati, tra cui il sistema di informazione Schengen (SIS), l’analisi dei codici di prenotazione recentemente introdotti dalla Direttiva PNR e l’incremento dell’interoperabilità tra le banche dati europee, il volume mette in atto un approccio filosofico “critico-realistico”, che si ancora nella realtà ma non rinuncia alla normatività e all’elaborazione di proposte alternative. Nel far ciò, le ricerche qui esposte intendono offrire un contributo agli ambiti disciplinari della filosofia politica e della filosofia del diritto, e, più specificamente, dei Security Studies e degli European Studies. (shrink)

In this article, I shall examine some of the issues and questions involved in the technology of autonomous robots, a technology that has developed greatly and is advancing rapidly. I shall do so with reference to a particularly critical field: autonomous military robotic systems. In recent times, various issues concerning the ethical implications of these systems have been the object of increasing attention from roboticists, philosophers and legal experts. The purpose of this paper is not to deal with these issues, (...) but to show how the autonomy of those robotic systems, by which I mean the full automation of their decision processes, raises difficulties and also paradoxes that are not easy to solve. This is especially so when considering the autonomy of those robotic systems in their decision processes alongside their reliability. Finally, I would like to show how difficult it is to respond to these difficulties and paradoxes by calling into play a strong formulation of the precautionary principle. (shrink)

This paper discusses how the general and abstract concept of legitimacy applies to international institutions, using the United Nations Security Council as an example. We argue that the evaluation of the Security Council’s legitimacy requires considering three significant and interrelated aspects: its purpose, competences, and procedural standards. We consider two possible interpretations of the Security Council’s purpose: on the one hand, maintaining peace and security, and, on the other, ensuring broader respect for human rights. Both of (...) these purposes are minimally morally acceptable for legitimacy. Second, we distinguish between three different competences of the UNSC: 1) the decision-making competence, 2) the quasi-legislative competence, and 3) the referral competence. On this basis, we argue that different procedural standards are required to legitimise these competences, which leads to a more differentiated understanding of the Security Council’s legitimacy. While maintaining that the membership structure of the Council is a severe problem for its legitimacy, we suggest other procedural standards that can help to improve its overall legitimacy, which include broad transparency, deliberation, and the revisability of the very terms of accountability themselves. (shrink)

Decision-making capacity (DMC) plays an important role in clinical practice—determining, on the basis of a patient’s decisional abilities, whether they are entitled to make their own medical decisions or whether a surrogate must be secured to participate in decisions on their behalf. As a result, it’s critical that we get things right—that our conceptual framework be well-suited to the task of helping practitioners systematically sort through the relevant ethical considerations in a way that reliably and transparently delivers correct verdicts (...) about who should and should not have the authority to make their own medical decisions. Unfortunately, however, the standard approach to DMC does not get things right. It is of virtually no help in identifying and clarifying the relevant ethical considerations. And, embedded in the prevailing anti-paternalist paradigm, DMC assessments obfuscate and distort the underlying ethical justification for granting or withholding decisional authority. Here, we describe the core commitments of the standard approach to DMC and then highlight three problems with it. We then argue that these problems are significant enough that they call for more than merely tinkering and fine tuning—variations of the standard approach cannot adequately address them. Instead, we should ditch DMC. (shrink)

Autonomous weapons are systems that, once activated, can identify, select and engage targets by themselves. Scharre (2018. Army of None: Autonomous Weapons and the Future of War. New York: Norton) has given a definition of autonomy based on three dimensions: the automatized tasks, the relationship with the human user and the sophistication of the machine’s decision-making process. Based on this definition of autonomy, this article provides an overview of systematic biases that may occur in each of these three dimensions. (...) Before the deployment of autonomous systems in war it is important to know how various biases can affect the functioning of the machines and how these biases can be compensated for. (shrink)

Adolescents present a puzzle. There are foundational unclarities about how they should be regarded as decision-makers. Although superficially adolescents may appear to have mature decisional capacity, their decision-making is in many ways unlike that of adults. Despite this seemingly obvious fact, a concern for the claims of autonomy has led to the development of the legal doctrine of the mature minor. This legal construct considers adolescents, as far as possible, as equivalent to adults for the purpose of medical (...) decision-making. The movement to support independent decision-making by adolescents through providing information to them and securing their consent apart from their parents is encouraged by those legal understandings that hold that unemancipated minors should generally be considered as possessing effective decisional capacity. Such legal structures, however, do not adequately take account of the wide variations in adolescent capacities, the immaturity of most adolescent decision-makers, or the important contributions made by parents to the development of their adolescents through parental partnering in the adolescent’s decision-making. The data available indicate that in general adolescents should be regarded as apprentice decision-makers who should make decisions in collaboration with their parents until at least the age of 18. Steps should not be taken pre-emptively to isolate adolescents from the guidance of their parents. As a general rule, what Piker has referred to as “collaborative paternalism” appears most likely both to protect adolescents from their own untoward choices, while also very importantly helping them with parental guidance to develop into mature decision-makers with the capacity to make medical choices on their own. (shrink)

In recent years, autonomous systems have become an important research area and application domain, with a significant impact on modern society. Such systems are characterized by different levels of autonomy and complex communication infrastructures that allow for collective decision-making strategies. There exist several publications that tackle ethical aspects in such systems, but mostly from the perspective of a single agent. In this paper we go one step further and discuss these ethical challenges from the perspective of an aggregate of (...) autonomous systems capable of collective decision-making. In particular, in this paper, we propose the Caesar approach through which we model the collective ethical decision-making process of a group of actors—agents and humans, as well as define the building blocks for the agents participating in such a process, namely Caesar agents. Factors such as trust, security, safety, and privacy, which affect the degree to which a collective decision is ethical, are explicitly captured in Caesar. Finally, we argue that modeling the collective decision-making in Caesar provides support for accountability. (shrink)

In the western healthcare, shared decision making has become the orthodox approach to making healthcare choices as a way of promoting patient autonomy. Despite the fact that the autonomy paradigm is poorly suited to paediatric decision making, such an approach is enshrined in English common law. When reaching moral decisions, for instance when it is unclear whether treatment or non-treatment will serve a child’s best interests, shared decision making is particularly questionable because agreement does not ensure moral (...) validity. With reference to current common law and focusing on intensive care practice, this paper investigates what claims shared decision making may have to legitimacy in a paediatric intensive care setting. Drawing on key texts, I suggest these identify advantages to parents and clinicians but not to the child who is the subject of the decision. Without evidence that shared decision making increases the quality of the decision that is being made, it appears that a focus on the shared nature of a decision does not cohere with the principle that the best interests of the child should remain paramount. In the face of significant pressures toward the displacement of the child’s interests in a shared decision, advantages of a shared decision to decisional quality require elucidation. Although a number of arguments of this nature may have potential, should no such advantages be demonstrable we have cause to revise our commitment to either shared decision making or the paramountcy of the child in these circumstances. (shrink)

The principle of autonomy presupposes Patient Decision Making Competence (PDMC). For a few decades a considerable amount of empirical research has been done into PDMC. In this contribution that research is explored. After a short exposition on four qualities involved in PDMC, different approaches to assess PDMC are distinguished, namely a negative and a positive one. In the negative approach the focus is on identifying psychopathologic conditions that impair sound decision making; the positive one attempts to assess whether (...) a patient actually has the required abilities and qualities. Characteristic of the latter approach is the use of (or development of) test-like instruments for PDMC assessment. Some of these tests are discussed and commented on. Although they may be useful in investigating aspects of PDMC, none of the described approaches and tests offers a reliable and valid method for PDMC assessment. In response to a potential misuse of tests, the concept of a supportive situation is briefly introduced in order to draw attention to the risk of prematurely deeming patients incompetent on the basis of low test scores, whereas their insufficient performance may be (partly) attributable to alack of situational support. Also, the need for and possibility of an emotionalist concept of PDMC are suggested, as an alternative to the more common rationalist one. In this regard,the legitimacy of competence being conceived as a presumption or fiction of law, deserves further investigation. (shrink)

The increasing use of Artificial Intelligence for making decisions in public affairs has sparked a lively debate on the benefits and potential harms of self-learning technologies, ranging from the hopes of fully informed and objectively taken decisions to fear for the destruction of mankind. To prevent the negative outcomes and to achieve accountable systems, many have argued that we need to open up the “black box” of AI decision-making and make it more transparent. Whereas this debate has primarily focused (...) on how transparency can secure high-quality, fair, and reliable decisions, far less attention has been devoted to the role of transparency when it comes to how the general public come to perceive AI decision-making as legitimate and worthy of acceptance. Since relying on coercion is not only normatively problematic but also costly and highly inefficient, perceived legitimacy is fundamental to the democratic system. This paper discusses how transparency in and about AI decision-making can affect the public’s perception of the legitimacy of decisions and decision-makers and produce a framework for analyzing these questions. We argue that a limited form of transparency that focuses on providing justifications for decisions has the potential to provide sufficient ground for perceived legitimacy without producing the harms full transparency would bring. (shrink)

Phenomenology gives rise to certain ontological considerations that have far-reaching implications for standard conceptions of patient autonomy in medical ethics, and, as a result, the obligations of and to patients in clinical decision-making contexts. One such consideration is the phenomenological reduction in classical phenomenology, a core feature of which is the characterisation of our primary experiences as immediately and inherently meaningful. This paper builds on and extends the analyses of the phenomenological reduction in the works of Husserl, Heidegger, and (...) Merleau-Ponty in order to identify and explain its implications for our current understanding of the principle of respect for patient autonomy and the norms of clinical decision making. (shrink)

BackgroundIn most Anglophone nations, policy and law increasingly foster an autonomy-based model, raising issues for large numbers of people who fail to fit the paradigm, and indicating problems in translating practical and theoretical understandings of ‘good death’ to policy. Three exemplar populations are frail older people, people with dementia and people with severe traumatic brain injury. We hypothesise that these groups face some over-lapping challenges in securing good end-of-life care linked to their limited agency. To better understand these challenges, we (...) conducted a scoping review and thematic synthesis.MethodsTo capture a range of literature, we followed established scoping review methods. We then used thematic synthesis to describe the broad themes emerging from this literature.ResultsInitial searches generated 22,375 references, and screening yielded 49, highly heterogeneous, studies that met inclusion criteria, encompassing 12 countries and a variety of settings. The thematic synthesis identified three themes: the first concerned the processes of end-of-life decision-making, highlighting the ambiguity of the dominant shared decision-making process, wherein decisions are determined by families or doctors, sometimes explicitly marginalising the antecedent decisions of patients. Despite this marginalisation, however, the patient does play a role both as a social presence and as an active agent, by whose actions the decisions of those with authority are influenced. The second theme examined the tension between predominant notions of a good death as ‘natural’ and the drive to medicalise death through the lens of the experiences and actions of those faced with the actuality of death. The final theme considered the concept of antecedent end-of-life decision-making, its influence on policy and decision-making, and some caveats that arise from the studies.ConclusionsTogether these three themes indicate a number of directions for future research, which are likely to be applicable to other conditions that result in reduced agency. Above all, this review emphasises the need for new concepts and fresh approaches to end of life decision-making that address the needs of the growing population of frail older people, people with dementia and those with severe traumatic brain injury. (shrink)

Freedom as non-domination provides a distinctive criterion for assessing the justifiability of migration controls, different from both freedom of movement and autonomy. Migration controls are dominating insofar as they threaten to coerce potential migrants. Both the general right of states to control migration, and the wide range of discretionary procedures prevalent in migration controls, render outsiders vulnerable to arbitrary power. While the extent and intensity of domination varies, it is sufficient under contemporary conditions of globalization to warrant limits on states’ (...) discretion with respect to admission. Reducing domination requires, rather than removing all immigration restrictions or democratically justifying them to all, that there be certain constraints on states’ freedom to control migration: giving migrants a publicly secured status somewhat analogous to that enjoyed by citizens, subjecting migration controls to higher legal regulation, and making immigration policies and decision contestable by those who are subject to them. (shrink)

In recent years, somatosensory interaction technology, represented by Microsoft’s Kinect hardware platform, has been widely used in various fields, such as entertainment, education, and medicine. Kinect technology can easily capture and record behavioral data, which provides new opportunities for behavioral and psychological correlation analysis research. In this paper, an automatic decision-style recognition method is proposed. Experiments involving 240 subjects were conducted to obtain face data and individual decision-making style score. The face data was obtained using the Kinect (...) camera, and the decision-style score were obtained via a questionnaire. To realize automatic recognition of an individual decision-making style, machine learning was employed to establish the mapping relationship between the face data and a scaled evaluation of the decision-making style score. This study adopts a variety of classical machine learning algorithms, including Linear regression, Support vector machine regression, Ridge regression, and Bayesian ridge regression. The experimental results show that the linear regression model returns the best results. The correlation coefficient between the linear regression model evaluation results and the scale evaluation results was 0.6, which represents a medium and higher correlation. The results verify the feasibility of automatic decision-making style recognition method based on facial analysis. (shrink)

In her book Democracy and Truth: The Conflict between Political and Epistemic Virtues, Snjezana Prijic Samarzija advocates that a purely procedural justification which defines the authority and legitimacy of democracy only in relation to the fairness of the procedure itself is not enough for a full justification of democracy. Some epistemic values should also be included. This epistemic quality of democracy depends on the quality of the decisions that the democratic procedures produce. In that sense, the author is advocating a (...) hybrid theory that secures harmony between political and epistemic values, favoring deliberative procedure for this purpose, and thus promotes equal respect for both democratic values. In doing so, she is advocating the specific type of division of epistemic labor that I will attempt to critically re-examine here, as well as to bring into question the privileged role of the experts in democratic decision-making. (shrink)

Machine learning algorithms are expected to improve referral decisions. In this article I discuss the legitimacy of deferring referral decisions in primary care to recommendations from such algorithms. The standard justification for introducing algorithmic decision procedures to make referral decisions is that they are more accurate than the available practitioners. The improvement in accuracy will ensure more efficient use of scarce health resources and improve patient care. In this article I introduce a proceduralist framework for discussing the legitimacy of (...) algorithmic referral decisions and I argue that in the context of referral decisions the legitimacy of an algorithmic decision procedure can be fully accounted for in terms of the instrumental values of accuracy and fairness. I end by considering how my discussion of procedural algorithmic legitimacy relates to the debate on algorithmic fairness. (shrink)

This book offers a new perspective on advance directives through a combined legal, ethical and philosophical inquiry. In addition to making a significant and novel theoretical contribution to the field, the book has an interdisciplinary and international appeal. The book will help academics, healthcare professionals, legal practitioners and the educated reader to understand the challenges of creating and implementing advance directives, anticipate clinical realities, and preparing advance directives that reflect a higher degree of assurance in terms of implementation.

In patient-centred care, shared decision-making is advocated as the preferred form of medical decision-making. Shared decision-making is supported with reference to patient autonomy without abandoning the patient or giving up the possibility of influencing how the patient is benefited. It is, however, not transparent how shared decision-making is related to autonomy and, in effect, what support autonomy can give shared decision-making. In the article, different forms of shared decision-making are analysed in relation to five (...) different aspects of autonomy: (1) self-realisation; (2) preference satisfaction; (3) self-direction; (4) binary autonomy of the person; (5) gradual autonomy of the person. It is argued that both individually and jointly these aspects will support the models called shared rational deliberative patient choice and joint decision as the preferred versions from an autonomy perspective. Acknowledging that both of these models may fail, the professionally driven best interest compromise model is held out as a satisfactory second-best choice. (shrink)

Beauchamp and Childress’ definition of autonomous decision‐making includes the conditions of intentionality, understanding, and non‐control. In genetics, however, a relational conception of autonomy has been increasingly recognized. This article aims to empirically assess aspects of social influence in genetic testing decision‐making and to connect these with principlist and relational theories of autonomy. We interviewed 18 adult genetic counsellees without capacity issues considering predictive genetic testing for cancer predisposition for themselves and two counselling physicians in Switzerland. We conducted a (...) qualitative analysis, building on a grounded theory study about predictive genetic testing decision‐making. We found that some participants agreed to predictive genetic testing predominantly because relatives wanted them to do it, with some even acting contrary to their own convictions. Others, in contrast, based their decision on purely individualistic reasons but expressed difficulties in explaining their decision to their social environment. Healthcare professionals had a critical influence on decision‐making in many cases without being manipulative, as perceived by counsellees. Still, cases of coercion and social pressure occurred within social relationships. In conclusion, predictive genetic testing decision‐making includes relational and individualistic aspects, and both are compatible with autonomous decision‐making. While the principlist and relational notions of autonomy compete on a theoretical level, they are two sides of the same coin when used as analytical lenses for genetic testing decision‐making. Social acceptance of refusal of testing should be improved to mitigate social pressure. Individuals should be encouraged to decide for themselves how much their social environment influences their decision regarding predictive genetic testing. (shrink)

Marshall and colleagues (2024) contribute to the literature on autonomy and decision-making capacity by focusing on the case of individuals with opioid use disorder who refuse to remain in the hosp...

An often overlooked tension in liberal theory turns on its commitment to procedural accounts of legitimacy on the one hand, and to the robust protection of the right of citizens to dissent on the other. To the extent that one evaluates legitimate decision-making on the basis of the procedures that bear on it, determining how extra-procedural expressions of dissent fit into the picture becomes a complex undertaking. This is especially true if one accepts that protecting extra-procedural expressions of dissent (...) is itself foundational to the overall legitimacy of the state. My aim in this paper is to explore some of the implications that follow from this tension. The paper proceeds in two parts. In the first part, I review the political grounds that support a protection on dissent. By drawing on its republican foundations, I argue that the functional role that the right to dissent serves in complex political communities is intimately connected to concerns over legitimacy. I claim that for the right to perform its function successfully, protections must be placed on both procedural and extra-procedural forms of dissent. The second part of the paper issues a direct challenge to procedural accounts of legitimacy. If a protection on citizen dissent is vital to legitimating government action, and if that protection necessarily extends to both procedural and extra-procedural forms of dissent, it follows that legitimacy cannot be captured by procedure alone—even procedures that secure the fair and equal participation by all affected parties. (shrink)

ABSTRACT In this paper, I address some of the shortcomings of established clinical ethics centring on personal autonomy and consent and what I label the Doctrine of Respecting Personal Autonomy in Healthcare. I discuss two implications of this doctrine: 1) the practice for treating patients who are considered to have borderline decision‐making competence and 2) the practice of surrogate decision‐making in general. I argue that none of these practices are currently aligned with respectful treatment of vulnerable individuals. Because (...) of ‘structural arbitrariness’ in the whole process of how we assess decision‐making competence, this area is open to disrespectful treatment of people. The practice of surrogate decision‐ making on the basis of a single person's judgment is arguably not consistent with ethical and political requirements derived from the doctrine itself. In response to the inadequacies of the doctrine, I suggest a framework for reasonableness in surrogate decision‐making which might allow practice to avoid the problems above. I conclude by suggesting an extended concept of Patient Autonomy which integrates both personal autonomy and the regulative idea of morality that is required by reasonableness in deciding for non‐competent others. (shrink)

In this paper, I address some of the shortcomings of established clinical ethics centring on personal autonomy and consent and what I label the Doctrine of Respecting Personal Autonomy in Healthcare. I discuss two implications of this doctrine: 1) the practice for treating patients who are considered to have borderline decision-making competence and 2) the practice of surrogate decision-making in general. I argue that none of these practices are currently aligned with respectful treatment of vulnerable individuals. Because of (...) ‘structural arbitrariness’ in the whole process of how we assess decision-making competence, this area is open to disrespectful treatment of people. The practice of surrogate decision- making on the basis of a single person's judgment is arguably not consistent with ethical and political requirements derived from the doctrine itself. In response to the inadequacies of the doctrine, I suggest a framework for reasonableness in surrogate decision-making which might allow practice to avoid the problems above. I conclude by suggesting an extended concept of Patient Autonomy which integrates both personal autonomy and the regulative idea of morality that is required by reasonableness in deciding for non-competent others. (shrink)

This article argues that supported decision making is ideal for people with dynamic cognitive and functional impairments that place them at the margins of autonomy. First, we argue that guardianship and similar surrogate decision-making frameworks may be inappropriate for people with dynamic impairments. Second, we provide a conceptual foundation for supported decision making for individuals with dynamic impairments, which integrates the social model of disability with relational accounts of autonomy. Third, we propose a three-step model that specifies (...) the necessary conditions of supported decision making: identifying domains for support; identifying kinds of supports; and reaching a mutually acceptable and formal agreement. Finally, we identify a series of challenges for supported decision making, provide preliminary responses, and highlight avenues for future bioethics research. (shrink)

In this article some of the presuppositions that underly the current ideas about decision making capacity, autonomy and independence are critically examined. The focus is on chronic disorders, especially on chronic physical disorders. First, it is argued that the concepts of decision making competence and autonomy, as they are usually applied to the problem of legal (in)competence in the mentally ill, need to be modified and adapted to the situation of the chronically (physically) ill. Second, it is argued (...) that autonomy and dependence must not be considered as two mutually exclusive categories. It is suggested that decision making may take on the form of a more or less conscious decision not to be involved in making all kinds of explicit and deliberate decisions. Elaborating on Agich's distinction between ideal and actual autonomy, the concept of Socratic autonomy is introduced. (shrink)

Making decisions is an important component of everyday living, and issues surrounding autonomy and self-determination are crucial for persons with intellectual disabilities. Article 12 (Equal Recognition before the Law) of the UN Convention on the Rights of Persons with Disabilities addresses this issue of decision-making for persons with disabilities: the recognition of legal capacity. Legal capacity means recognizing the right to make decisions for oneself. Article 12 is also moving in the direction of supported decision-making, as an alternative (...) to substituted decision-making. The objective of this paper is to show conceptually the connection between supported decisionmaking and the preservation of personal autonomy for persons with intellectual disabilities. This paper discusses supported decision-making based on Bach and Kerzner's model: (a) legally independent status, (b) supported decision- making status, and (c) facilitated decision-making status. Arguments will be made based on John Stuart Mill's concept of autonomy and arguments against it using Sarah Conly's argument for paternalism. (shrink)

Making decisions is an important component of everyday living, and issues surrounding autonomy and self-determination are crucial for persons with intellectual disabilities. Adults with intellectual disabilities are characterized by the limitations in their intellectual functioning and in their adaptive behavior, which compromises three skill types, and this starts before the age of 18. Though persons with intellectual disabilities are characterized by having these limitations, they are thought to face significant decisionmaking challenges due to their disability. Moving away from this generalization, (...) Article 12 of the United Nations Convention on the Rights of Persons with Disabilities addresses this issue of decision-making for persons with disabilities, recognizing the right to legal capacity. (shrink)

Shared Decision Making (‘SDM’) is one of the most significant developments in Western health care practices in recent years. Whereas traditional models of care operate on the basis of the physician as the primary medical decision maker, SDM requires patients to be supported to consider options in order to achieve informed preferences by mutually sharing the best available evidence. According to its proponents, SDM is the right way to interpret the clinician-patient relationship because it fulfils the ethical imperative (...) of respecting patient autonomy. However, there is no consensus about how decisions in SDM contexts relate to the principle of respect for autonomy. In response, I demonstrate that in order to make decisions about what treatment they will or will not receive, patients will be required to meet different conditions depending on the approach proponents of SDM take to understanding personal autonomy. Due to the fact that different conceptions of autonomy yield different obligations, I argue that if physicians and patients satisfied all the conditions described in standard accounts of SDM, then SDM would undermine patient autonomy. (shrink)

In combating the ongoing global health threat of the COVID-19 pandemic, decision-makers have to take actions based on a multitude of relevant health data with severe potential consequences for the affected patients. Because of their presumed advantages in handling and analyzing vast amounts of data, computer systems of algorithmic decision-making are implemented and substitute humans in decision-making processes. In this study, we focus on a specific application of ADM in contrast to human decision-making, namely the allocation (...) of COVID-19 vaccines to the public. In particular, we elaborate on the role of trust and social group preference on the legitimacy of vaccine allocation. We conducted a survey with a 2 × 2 randomized factorial design among n = 1602 German respondents, in which we utilized distinct decision-making agents and prioritization of a specific social group as design factors. Our findings show that general trust in ADM systems and preference for vaccination of a specific social group influence the legitimacy of vaccine allocation. However, contrary to our expectations, trust in the agent making the decision did not moderate the link between social group preference and legitimacy. Moreover, the effect was also not moderated by the type of decision-maker. We conclude that trustworthy ADM systems must not necessarily lead to the legitimacy of ADM systems. (shrink)

Medical paternalism has long been a common medical practice. However, patient autonomy in healthcare has been recently adopted by doctors and patients alike. This study explored whether doctors and patients in a tertiary care hospital in Saudi Arabia preferred autonomy or paternalism in shared decision‐making. A total of 118 participants (51 patients requiring total knee replacement, owing to stages 3–4 of osteoarthritis, and 67 doctors) from the Eastern province, Saudi Arabia. responded to a 17‐question category‐based questionnaire involving four scales (...) of autonomy. Descriptive statistics and chi‐square test results revealed that in this hospital, patients preferred a paternalistic approach toward their medical care along with a full disclosure of the risks related to surgical procedures. We recommend health education regarding the specific autonomy subscales (doctor knows best, patient should decide, right to non‐participation, and obligatory risk information), and the implementation of protocols that protect patients' rights and enhance personal autonomy. (shrink)

Background Respect for autonomy is a key principle in bioethics. However, respecting autonomy in practice is complex because most people define themselves and make decisions influenced by a complex network of social relationships. The extent to which individual autonomy operates for each partner within the context of decision-making within marital or similar relationships is largely unexplored. This paper explores issues related to decision-making by couples for health care and the circumstances under which such a practice should be respected (...) as compatible with autonomous decision-making. Discussion We discuss the concept of autonomy as it applies to persons and to actions, human interdependency and gender roles in decision-making, the dynamics and outcomes of couples’ joint decision-making, and the ethics of couples’ joint decision-making. We believe that the extent to which couples’ joint decision-making might be deemed ethically acceptable will vary depending on the context. Given that in many traditional marriages the woman is the less dominant partner, we consider a spectrum of scenarios of couples’ joint decision-making about a woman’s own health care that move from those that are acceptably autonomous to those that are not consistent with respecting the woman’s autonomous decision-making. To the extent that there is evidence that both members of a couple understand a decision, intend it, and that neither completely controls the other, couples’ joint decision-making should be viewed as consistent with the principle of respect for the woman’s autonomy. At the other end of the spectrum are decisions made by the man without the woman’s input, representing domination of one partner by the other. Conclusions We recommend viewing the dynamics of couples’ joint decision-making as existing on a continuum of degrees of autonomy. This continuum-based perspective implies that couples’ joint decision-making should not be taken at face value but should be assessed against the specific cultural, ethnic, and religious backgrounds and personal circumstances of the individuals in question. (shrink)

Respect for autonomy is a key principle in bioethics. However, respecting autonomy in practice is complex because most people define themselves and make decisions influenced by a complex network of social relationships. The extent to which individual autonomy operates for each partner within the context of decision-making within marital or similar relationships is largely unexplored. This paper explores issues related to decision-making by couples for health care and the circumstances under which such a practice should be respected as (...) compatible with autonomous decision-making. We discuss the concept of autonomy as it applies to persons and to actions, human interdependency and gender roles in decision-making, the dynamics and outcomes of couples’ joint decision-making, and the ethics of couples’ joint decision-making. We believe that the extent to which couples’ joint decision-making might be deemed ethically acceptable will vary depending on the context. Given that in many traditional marriages the woman is the less dominant partner, we consider a spectrum of scenarios of couples’ joint decision-making about a woman’s own health care that move from those that are acceptably autonomous to those that are not consistent with respecting the woman’s autonomous decision-making. To the extent that there is evidence that both members of a couple understand a decision, intend it, and that neither completely controls the other, couples’ joint decision-making should be viewed as consistent with the principle of respect for the woman’s autonomy. At the other end of the spectrum are decisions made by the man without the woman’s input, representing domination of one partner by the other. We recommend viewing the dynamics of couples’ joint decision-making as existing on a continuum of degrees of autonomy. This continuum-based perspective implies that couples’ joint decision-making should not be taken at face value but should be assessed against the specific cultural, ethnic, and religious backgrounds and personal circumstances of the individuals in question. (shrink)

In this essay I defend an institutional approach to democratic legitimacy against proceduralist approaches that are commonly endorsed by deliberative democrats. Although deliberative democrats defend a complex view of democratic legitimacy that aims to account for both the procedural and substantive dimensions of legitimacy, most accounts of the relationship between these dimensions currently on offer are too proceduralist to be plausible (I). By contrast, I argue that adopting an institutional approach helps provide a more convincing account of the interplay between (...) procedural and substantive aspects of democratic legitimacy which in turn illuminates the intricate relationship between public deliberation and decision-making procedures such as voting (II). This account also enables us to see what is wrong with interpreting the legitimacy of majoritarian and non-majoritarian institutions in terms of an alleged conflict between popular sovereignty and rights protections. In opposition to this view, I argue that the proper standard for judging the democratic legitimacy of both majoritarian and non-majoritarian institutions is whether they enable an ongoing recursive process of deliberative contestation or whether they generate antidemocratic shortcuts instead (III). (shrink)

In their article, “Supported Decision Making with People at the Margins of Autonomy,” Peterson, Karlawish, and Largent point to the fact that the concept of ‘supported decision-making’ has recently...

Fourteen experienced psychiatric nurses participated in a pilot study aimed at describing the experiential aspect of making decisions for the patient. In-depth interviews focused on conflicts, were transcribed, coded, and categorized according to the Grounded Theory method. The theoretical construct, 'modifying autonomy' and its dimensions, such as being aware of the patient's vulnerability, caring for and caring about the patient, were identified. The findings in this study make clear the need for further research into the experiential aspect of ethical (...) class='Hi'>decision-making in psychiatric practice. (shrink)

In recent years the formerly quite strong interest in patient compliance has been questioned for being too paternalistic and oriented towards overly narrow biomedical goals as the basis for treatment recommendations. In line with this there has been a shift towards using the notion of adherence to signal an increased weight for patients’ preferences and autonomy in decision making around treatments. This ‘adherence-paradigm’ thus encompasses shared decision-making as an ideal and patient perspective and autonomy as guiding goals of (...) care. What this implies in terms of the importance that we have reason to attach to (non-)adherence and how has, however, not been explained. In this article, we explore the relationship between different forms of shared decision-making, patient autonomy and adherence. Distinguishing between dynamically and statically framed adherence we show how the version of shared decision-making advocated will have consequences for whether one should be interested in a dynamically or statically framed adherence and in what way patient adherence should be assessed. In contrast to the former compliance paradigm (where non-compliance was necessarily seen as a problem), using observations about (non-)adherence to assess the success of health care decision making and professional-patient interaction turns out to be a much less straightforward matter. (shrink)

We join McCarthy and Howard (2023) in advocating supported decision-making for patients with diminished mental capacity that meaningfully expands the role of trustees beyond merely channeling the i...

Cognitive scientists have identified a wide range of biases and heuristics in human decision making over the past few decades. Only recently have bioethicists begun to think seriously about the implications of these findings for topics such as agency, autonomy, and consent. This article aims to provide an overview of biases and heuristics that have been identified and a framework in which to think comprehensively about the impact of them on the exercise of autonomous decision making. I analyze (...) the impact that these biases and heuristics have on the following dimensions of autonomy: understanding, intentionality, absence of alienating or controlling influence, and match between formally autonomous preferences or decisions and actual choices or actions. (shrink)

According to many of its proponents, shared decision making ("SDM") is the right way to interpret the clinician-patient relationship because it respects patient autonomy in decision-making contexts. In particular, medical ethicists have claimed that SDM respects a patient's relational autonomy understood as a capacity that depends upon, and can only be sustained by, interpersonal relationships as well as broader health care and social conditions. This paper challenges that claim. By considering two primary approaches to relational autonomy, this paper (...) argues that standard accounts of SDM actually undermine patient autonomy. It also provides an overview of the obligations generated by the principle of respect for relational autonomy that have not been captured in standard accounts of SDM and which are necessary to ensure consistency between clinical practice and respect for patient autonomy. (shrink)

On what basis should we judge whether a parent’s medical decision for their child is morally acceptable? In a recent article, Johan Bester attempts to answer this question by defending a version of the Best Interest Standard for parental decision making. The purpose of this paper is to identify a number of problems faced by Bester’s version of BIS and to suggest ways to redress these problems. Accordingly, we intend to advance the project of formulating a method for (...) guiding parents’ medical decision making for their children. We argue that Bester’s standard fails to accommodate the autonomy of the child and that his criteria for assessing the reasonableness of the parents’ argument for their decision is too weak. We conclude that properly addressing these worries renders his test otiose and that it ought to be replaced with the three commonly held principles of bioethics—the principles of autonomy, beneficence, non-maleficence—and a standard of reasonableness. (shrink)

Given that many people with disabilities have been excluded from political deliberation and subjected to infantilizing and degrading treatment from others, many members of the disability rights movement are understandably critical of policies and practices that speak on behalf of people with disabilities and presume to know what is really in their best interest. Yet, this analysis argues that a general principle of anti-paternalism is not desirable for disability politics. In particular, people with cognitive disabilities are sometimes unable to make (...) important decisions by themselves, and may require assistance from family members or more cognitively able and verbally fluent citizens to make their political voices and choices heard. Drawing from John Locke and Alasdair MacIntyre, this article reconsiders the relationship between paternalism and autonomy, suggesting that autonomous decisionmaking and expression are best thought of as collaborative processes undertaken between people with a range of capacities. (shrink)

Often-cited papal pronouncements regarding organ donation emphasize the importance of gift giving and the consent of the donor. However, a critical reading reveals an ill-defined separation of living organ donation and donation after death. Given that a corpse cannot engage in gift giving, nor can it give consent, the family, acting as good stewards, is the proper decision maker for organ donation after death. A historical examination of relics and human anatomical dissection reveals that the Catholic Church has primarily (...) favored the decisional authority of the family over the first-person consent of the dead. Given this history, family-based consent (as opposed to opt-in or opt-out criteria) is the best model to ensure the dignity of the dead. (shrink)

Machine learning algorithms are increasingly used to support decision-making in the exercise of public authority. Here, we argue that an important consideration has been overlooked in previous discussions: whether the use of ML undermines the democratic legitimacy of public institutions. From the perspective of democratic legitimacy, it is not enough that ML contributes to efficiency and accuracy in the exercise of public authority, which has so far been the focus in the scholarly literature engaging with these developments. According to (...) one influential theory, exercises of administrative and judicial authority are democratically legitimate if and only if administrative and judicial decisions serve the ends of the democratic law maker, are based on reasons that align with these ends and are accessible to the public. These requirements are not satisfied by decisions determined through ML since such decisions are determined by statistical operations that are opaque in several respects. However, not all ML-based decision support systems pose the same risk, and we argue that a considered judgment on the democratic legitimacy of ML in exercises of public authority need take the complexity of the issue into account. This paper outlines considerations that help guide the assessment of whether a ML undermines democratic legitimacy when used to support public decisions. We argue that two main considerations are pertinent to such normative assessment. The first is the extent to which ML is practiced as intended and the extent to which it replaces decisions that were previously accessible and based on reasons. The second is that uses of ML in exercises of public authority should be embedded in an institutional infrastructure that secures reason giving and accessibility. (shrink)

The question of when we have justification for overriding ordinary, everyday decisions of persons with dementia is considered. It is argued that no single criterion for competent decision-making is able to distinguish reliably between decisions we can legitimately override and decisions we cannot legitimately override.

A core challenge for contemporary bioethics is how to address the tension between respecting an individual’s autonomy and promoting their wellbeing when these ideals seem to come into conflict (Not...