In lieu of an abstract, here is a brief excerpt of the content:Autonomy, Experience, and TherapyDominic Murphy (bio)The contemporary philosophical idea of autonomy has a psychological implication, to wit, that there exists a comprehensive set of ideal competences, realized in our mind/brain, that enable a person to be self-governing. Autonomy is normally accorded individuals who enjoy a certain kind of psychological functioning and, perhaps, a certain sort of psychological history (Christman 1991). We think that autonomous individuals critically (...) evaluate their life and actions, endorse them as self-determined rather than imposed from without, and guide their own lives in accordance with the plans and values they have worked out for themselves. Such self-government has to depend on some psychological structures, but philosophers have tended to theorize about what these structures might be at a considerable distance from what the behavioral sciences can tell us. Anderson and Lux's paper is a welcome contribution to the growing literature that tries to connect issues in ethics with empirical considerations. This sort of methodological, as opposed to merely metaphysical, naturalism, is only just coming into vogue in ethics, even in moral psychology.1 Anderson and Lux are, as far as I am aware, the first people to reflect seriously on what we can learn about autonomy from clinical experience. Theirs is a very suggestive and fruitful paper that looks at real-life cases of loss of autonomy and tries to reach conclusions about what the deficits in performance tell us about the psychological preconditions of autonomy. Their paper also opens the way for an investigation into the precise neurologic and computational underpinnings of these capacities, which is essential if we are to get a serious moral psychology underway.I find little to quarrel with in the story that Anderson and Lux tell, but I will try to modify it slightly to bring out what I think is the important psychological point they make and explore some ramifications. I begin by claiming that they have scored a decisive point in favor of an external conception of autonomy. Second, I suggest that what Anderson and Lux have really put their finger on is less a requirement of accurate self-assessment than a requirement of sensitivity to feedback from the environment. I conclude by raising some of these issues about the relations between autonomy and assessments of psychological function when the deficit responsible is less amenable to clear cut neurologic identification.The External Perspective on AutonomyOne way of taking the paper (although this goes beyond anything that Anderson and Lux suggest) is that there is a smooth naturalistic picture of the cognitive basis of autonomy. When people have a normally functioning neurocomputational setup in their heads, we should assume that they are autonomous, and vice versa. However, autonomy cannot simply be identifiable with a mind that is working as some scientific theory says it should, because a mind that is [End Page 303] in that sense working correctly could, nonetheless, be directed by forces other than the agent. Servile or deluded individuals might endorse their lives even if those lives are the product of indoctrination, self-deception, or internalized oppression (Mackinnon 1997; Mele 1995). Normal mechanisms of belief fixation, for example, may not foster one's autonomy if the only context in which they are exercised is one in which many possible ways of life are simply unavailable for consideration, having been excluded from consideration by the dominant forces around one. We might, then, think of full autonomy as depending on relational rather than intrinsic properties. Perhaps autonomy requires a subject to have both normal psychological capacities and the right sort of environment in which to exercise them. I do not follow-up on this suggestion, but I mention it because it introduces two dimensions, within the subject and around the subject, where the externalist perspective on autonomy can get a grip. I discuss the former, but I do not mean to suggest that the latter is not important. A full account must deal with both. But even the psychological structures that foster autonomy cannot be identified with a mind working according to some scientific theory, as we shall see.Many writers on autonomy argue that we must recognize appropriate, objective constraints... (shrink)

In this paper, two central questions will be addressed: ought we to implement medical AI technology in the medical domain? If yes, how ought we to implement this technology? I will critically engage with three options that exist with respect to these central questions: the Neo-Luddite option, the Assistive option, and the Substitutive option. I will first address key objections on behalf of the Neo-Luddite option: the Objection from Bias, the Objection from Artificial Autonomy, the Objection from Status Quo, (...) and the Objection from Inscrutability. I will thereafter present the Demographic Trends Argument and the Human Enhancement Argument in support of alternatives to the Neo-Luddite option. In the second half of the paper, I will argue against the Substitutive option and in favour of the Assistive option, given the existence of two chief formal deficits in medical AI technology: the causality deficit and the care deficit. (shrink)

Autonomy of people on the autism-spectrum has only been very rarely conceptually explored. Autism spectrum is commonly considered a hetereogenous disorder, and typically described as a behaviorally-defined neurodevelopmental disorder associated with the presence of social-communication deficits and restricted and repetitive behaviors. Autism research mainly focuses on the behavior of autistic people and ways to teach them skills that are in line with social norms. Interventions such as therapies are being justified with the assumption that autists lack the capacity to (...) be self-reflective and to be “author of their lives”. We question this assumption, as some empirical research shows that autists are aware of their strengths and are critical about social norms, we take this as a starting point to reconsider the beliefs about autistic people’s capacities. As a theoretical framework, we draw on Berlin’s idea of positive and negative liberty as he clearly distinguishes between one’s own developed preferences and the simple absence of interference. By drawing on the concept of positive liberty, we illustrate that a lot of autists are aware of their own needs, and usually do not deny their own needs, values and interests. This makes them less prone than non-autistic people to adapt their preferences to external influences, which might be seen as sticking to an authentic way of living. Our analysis shows that many autists are hindered to be autonomous due to unjustified interference, unreflected assumptions about their self-determination, or by paternalistic actions. These observations contribute to a better understanding when help and interference are justified and a more differentiated understanding of autonomy of autistic people. (shrink)

The clinical application of the concept of patient autonomy has centered on the ability to deliberate and make treatment decisions (decisional autonomy) to the virtual exclusion of the capacity to execute the treatment plan (executive autonomy). However, the one-component concept of autonomy is problematic in the context of multiple chronic conditions. Adherence to complex treatments commonly breaks down when patients have functional, educational, and cognitive barriers that impair their capacity to plan, sequence, and carry out tasks (...) associated with chronic care. The purpose of this article is to call for a two-component re-conceptualization of autonomy and to argue that the clinical assessment of capacity for patients with chronic conditions should be expanded to include both autonomous decision-making and autonomous execution of the agreed-upon treatment plan. We explain how the concept of autonomy should be expanded to include both decisional and executive autonomy, describe the biopsychosocial correlates of the two-component concept of autonomy, and recommend diagnostic and treatment strategies to support patients with deficits in executive autonomy. (shrink)

Acts of civil disobedience, which imply the open violation of a legal directive, often result in the forceful imposition of a choice upon others (e.g. blockades). This is sometimes justifiable, within a democracy, in cases of ‘democratic deficit’, namely, when fundamental rights of an oppressed minority are at stake. In this article, I claim that the use of physical force, in a democracy, may also be justified by the rights of (at least some of) the very people upon whom (...) force is applied. Focusing on the nature of civil disobedience as a ‘form of address’, I argue: (1) using physical force to address others in the democratic arena does not entail infringing upon their status as autonomous agents; (2) using physical force to address others in the democratic arena may contribute to the fulfilment of a positive duty to promote the autonomy of (at least some of) those very people upon whom force is applied. This is not a defence of paternalism: I claim that using force against others, in the democratic arena, may be constitutive of a behaviour that treats others with the respect due to their status as autonomous agents. (shrink)

Minors with attention-deficit-hyperactivity disorders are liable to use pharmacological treatment against their will and may find their authentic “I” modified. Thus, their use is widely criticized. In this study, the effect of ADHD drugs on adolescents’ personal experience is examined. The goal is to understand how psychological changes that young people experience when they take these medications interrelate with their attitude toward being medicated. Methylphenidate is the most common pharmacological treatment for ADHD. We look into the change that Israeli (...) adolescents undergo when they use it; their experience in controlling the change, and their assessment of the meaning of the change for their lives. Thirty-eight adolescents participated in semi-structured interviews. The findings, analyzed using grounded theory, show that methylphenidate affects the participants’ demeanor, mood, and even preferences. The participants, aware of these effects, apply discretion in taking methylphenidate and thus influence their traits and their willingness to engage in various activities. When needing to prepare for a matriculation exam, for example, they take methylphenidate; when they need to be creative or sociable, they avoid it and enjoy what they consider the advantages of ADHD, such as creativity and spontaneity. As discretionary users, they shape their life stories in a way that makes them more meaningful and diverse, better tailored to their social surroundings, and more useful in maintaining personal autonomy in the course of pharmacological treatment of ADHD. (shrink)

The ethics of care, adopted in much of the nursing literature, is usually framed in opposition to the Kantian ethics of principle. Irrespective of whether the ethics of care is grounded in gender, as with Gilligan and Noddings, or inscribed on Heidegger's ontology, as with Benner, Kant remains the philosophical adversary, honouring reason rather than emotion, universality rather than context, and individual autonomy rather than interdependence. During the past decade, however, a great deal of Kantian scholarship – including feminist (...) scholarship – has rendered this series of oppositions questionable, challenging the view that an ethics of care and Kant's moral law are irreconcilable. This paper therefore re‐examines Kant's writings, drawing on recent scholarship, and argues both that they provide the care ethicists with everything they require, and that they offer something beyond an ethics of care, something that repairs the deficits in philosophies of caring. It concludes by suggesting that a Kantian ethics of care has significant implications for the construction of nursing knowledge. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Lack of Autonomy: A View From the InsideSteve Weiner (bio)Keywordsagency, autonomy, deficit, determinismThe most vivid and truly overwhelming response I have to all arguments stressing agency/autonomy, that is, what lay people call free will, is this: that I’ve never had the sensation of acting autonomously since the onset of my mental illness on August 28, 1965. I have never been comfortable with saying that “I (...) made a choice,” or with other people either lecturing me or attempting to reassure me, often at the same time, by saying that I acted with autonomy/primary agency, as it were. That is my overwhelming subjective experience. I usually refrain from attempting to make a general case for determinism about myself or the universe in general, although, again, I feel far more determined than free. (I would note that Mary Midgley [2006] points out that the word determined and the concept, by extension, of determinism have two different meanings in say, social theory and geometry.)One strong criticism of this article I would put forward is that the Davidson and Shahan seemed to mention only depression among many diagnoses to make their case, although their French mentors/ co-thinkers apparently focused on schizophrenia, however unusually defined by them. In obsessive-compulsive disorder, we all have the very strong impression of the obsessive thoughts having been forced into our mind by something or someone else. My impression is that we all engage in our warding-off rituals, especially in the later, most frequent, most ritualistic repetitions, “against our will.”My most frequent diagnoses over the decades have been paranoid schizophrenia and schizoaffective disorder, and I more or less agree most of the time with those labels. I find Louis Sass’ “discovery” that our delusions are better thought of as semi-delusions with our simultaneously believing and not believing them, and our usual failure to take action on them, pretty well describes my own long-term experience. I know he is insistent on ascribing some degree of agency/whole personality involvement to us as compared with the standard National Alliance on Mental Illness/biological model, but I feel that he is getting closer to most of the “truth” when he talks about a subtle interweaving of affliction/deficit and agency.The authors’ reliance on French thinkers almost inevitably sends me back to a once-prominent French intellectual, one of my favorite writers Albert Memmi, the Tunisian-Jewish born socialist and Zionist. In a book that mentions The Story of O, (Memmi 1984) a story of extreme sexual submission or masochism, he makes the striking remark that the mentally ill are “oppressed from within.” I have spoken of this often because it seems to touch perfectly on my experience and that of fellow mentally ill people I have met. From the perspective of the outsider, it seems that the whole [End Page 237] and integrated person is involved in every behavior. What looks like agency to others, especially when it comes to undesirable behaviors, when experienced from within, is actually a situation of affliction from a seemingly autonomous place. We experience this as coming, yes, from within us, but not ultimately of us.I cannot be sure, but a belief in some degree of metaphysical choice from the beginning of one’s life seems to me the only way the authors of this article can firmly, enthusiastically come down on the side of agency as opposed to deficit/malfunction in trying to explain human problems. In contrast, I suppose I could be called a physicalist. I have noticed that physical substances (alcohol, caffeine, psychiatric drugs) have such a vivid and consistent effect on my mind that it makes sense to me to conclude that yes, mind is probably ultimately reducible to brain/body/experience of the senses. That is my private opinion based on experience as mediated through knowledge/intellect.One final point: Despite the (almost certainly) radical left politics of the authors, as an officially disabled person almost completely dependent on the welfare state, I fear that in competitive individualist America, the authors’ hoped-for far greater emphasis on autonomy will feed into popular “blame the victim” ideology. I believe... (shrink)

Understanding the relationship between experts and laypeople is crucial for understanding today’s world of post-truth and the contemporary crisis of liberal democracy. The emergence of post-truth has been linked to various phenomena such as a flawed social and mass media ecosystem, poor citizen education, and the manipulation tactics of powerful interest groups. The paper argues that the problem is, however, more profound. The underlying issue is laypeople’s inevitable epistemic dependence on experts. The latter is part and parcel of the “risk (...) society” in which people question the scientific consensus and thus are able to manipulate the facts. It is a powerful weapon in the hands of illiberal democrats, though liberal democrats can make no use of it. The latter downplay the problem of citizens’ epistemic deficits and of the epistemic asymmetries between them. The third and fourth generations of deliberative democrats are a perfect example. The paper argues that the concepts of interactional expertise and epistemic dependence explain why understanding between experts and laypeople is impossible. The said phenomena undermine liberalism’s unrealistic assumptions concerning citizens’ decision-making competence. (shrink)

The Kurdish-led autonomous entity called Autonomous Administration of North and East Syria - also known as Rojava - considers women?s liberation an imperative condition for shaping a democratic society. The practice of autonomy in NES shares strong resemblances with Non- Territorial Autonomy models; however, it introduces a novelty in the role of women as active agents in building a plurinational democracy. This paper examines the intellectual and political origins of the political role ascribed to women in autonomous administrations (...) and how the practice of autonomy in Rojava has advanced women?s rights by shedding light on both institutional implementation of women?s rights, as well as the creation of -territorial spaces of women?s emancipation within the autonomous model. The argument made is that the conceptual framework of the Rojava model goes beyond the Kurdish question and can be considered an attempt to resolve a democratic deficit of liberal democratic nation-states through bringing together solutions that address the intertwined subordination of minorities and women. nema. (shrink)

When a patient lacks sufficient capacity to make a certain treatment decision, whether because of deficits in their ability to make a judgement that reflects their values or to make a decision that reflects their judgement or both, the decision must be made by a surrogate. Often the best way to respect the patient’s autonomy, in such cases, is for the surrogate to make a ‘substituted’ judgement on behalf of the patient, which is the decision that best reflects the (...) patient’s values and identity-infused beliefs as they were when the patient last possessed capacity. It is by now well-known that there is troubling evidence that surrogates do only slightly better than chance at making accurate substituted judgements. The use of a patient preference predictor, an algorithm that predicts patient preferences based on characteristics like the patient’s age, gender, socioeconomic status and education level, could help. Rid and Wendler have done important work making a moral case for using the PPP.1 If it were shown to enhance accuracy, it is not at all obvious what objections there could be to its use. Yet several subtle criticisms of the PPP have emerged in the literature. In their feature article, Jardas, Wasserman and Wendler select six of the most prominent objections to the PPP in the literature and defend the PPP against them.2 Along the way they make significant contributions to broader issues concerning the proper uses of statistical evidence and limits on the kinds of preferences there can be reasons of autonomy to respect. Since I found the authors’ answers to the final two objections—that the PPP relies on naked statistical evidence and that it uses non-endorsed reasons—to be especially interesting and provocative, I will examine those answers and raise a few questions about …. (shrink)

I am grateful for the insightful comments that have been furnished by Drs. Gala, Moseley, and Perring following their reading of my paper. Happily, I find myself in the position of being able to accept many of their criticisms, which identify many of the limitations of my argument as I see them. In only a few cases do I feel that their remarks are misplaced.The first concern raised by Moseley and Gala is that the paper gives the regrettable impression that (...) persons with anorexia nervosa generally have few cognitive deficits and primarily experience problems in valuing. But as is widely known, this is false: many persons with AN reason poorly and suffer perceptual distortions. I did not. (shrink)

The clinical application of the concept of patient autonomy has centered on the ability to deliberate and make treatment decisions to the virtual exclusion of the capacity to execute the treatment plan. However, the one-component concept of autonomy is problematic in the context of multiple chronic conditions. Adherence to complex treatments commonly breaks down when patients have functional, educational, and cognitive barriers that impair their capacity to plan, sequence, and carry out tasks associated with chronic care. The purpose (...) of this article is to call for a two-component re-conceptualization of autonomy and to argue that the clinical assessment of capacity for patients with chronic conditions should be expanded to include both autonomous decision-making and autonomous execution of the agreed-upon treatment plan. We explain how the concept of autonomy should be expanded to include both decisional and executive autonomy, describe the biopsychosocial correlates of the two-component concept of autonomy, and recommend diagnostic and treatment strategies to support patients with deficits in executive autonomy. (shrink)

The women’s liberation movements that emerged in Britain in the late 1960s are rarely thought of through their relationship with technology and technical knowledge. To overlook this is to misunderstand the movement’s social, cultural and economic interventions; it also understates how the technical environment conditioned the emergence of autonomous, women-centred politics. This article draws on archival evidence to demonstrate how the autonomous women’s liberation movement created experimental social contexts that enabled de-skilled, feminised social classes to confront their technical environment and (...) the deficits they experienced within it. The context for forging such politics was the workshop. More than a one-off, skill-sharing event, the workshop was a mobile habitus, adapted from a Marxist craft politics that prioritised the distribution of collective knowledge and responsibility and enabled the realisation of women's self-determination and autonomy. The workshop was discursively extended through women-authored publications in the 1970s and 1980s and designated a specific orientation within knowledge that supported women to practise a range of technical knowledge and gain expertise. An important, and largely forgotten political legacy of women's liberation is its world-making activisms: how it created social contexts that supported de-skilled, feminised classes to substantially intervene, shape and re-build their environments. Such histories can inspire how we practise politics today within an environment characterised, some theorists claim, by dramatic scales of de-skilling and dispossession. (shrink)

Adaptive preferences give rise to puzzles in ethics, political philosophy, decision theory, and the theory of action. Like our other preferences, adaptive preferences lead us to make choices, take action, and give consent. In 'False Consciousness for Liberals', recently published in The Philosophical Review, David Enoch (2020) proposes a criterion by which to identify when these choices, actions, and acts of consent are less than fully autonomous; that is, when they suffer from what Natalie Stoljar (2014) calls an 'autonomy (...) deficit'. According to Enoch, such actions are not protected in the usual way against interference by others; there is not the same prohibition against trying to prevent someone from acting in a particular way when that action is motivated by such adaptive preferences and is an attempt to satisfy them. In this note, I raise two concerns about Enoch's criterion. (shrink)

This chapter first considers whether and to what extent the European Union labors under a democratic deficit. When considering the contending conceptions of democracy in Europe it is needed to keep in mind that there also are analysts who disagree that the European Union suffers from a democratic deficit. The chapter briefly assesses the European Union against the two criteria of autonomy and accountability, in order to get a clearer sense of the Union's democratic deficit, which (...) then appears as a representative‐democratic deficit. The chapter examines the effects of the crisis on the prospects of remedying the European Union's democratic deficit. Most citizens are still exhibiting restraint and there appear to be further crisis handling measures in the pipeline. Many of the proposals for further changes underline the need to strengthen democracy, including measures to reinforce interparliamentary coordination and cooperation. (shrink)

Debates over how to conceptualize the nursing role were prominent in the nursing literature during the latter part of the twentieth century. There were, broadly, two schools of thought. Writers like Henderson and Orem used the idea of a self‐care deficit to understand the nurse as doing for the patient what he or she could not do alone. Later writers found this paternalistic and emphasized the importance of the patient's free will. This essay uses the ideas of positive and (...) negative freedom to explore the differing conceptions of autonomy which are implicit in this debate. The notion of positive freedom has often been criticized as paternalistic, and the criticisms of self‐care in the nursing literature echo criticisms from political philosophy. Recent work on relational autonomy and on the relationship between autonomy and identity are used to address these objections. This essay argues for a more nuanced conception of the obligation to support autonomy that includes both positive (freedom to) and negative (freedom from) dimensions. This conception of autonomy provides a moral foundation for conceptualizing nursing in something like Henderson's terms: as involving the duty to expand the patient's capacities. The essay concludes by generalizing the lesson. Respect for autonomy on the part of any health care provider requires both respect for the patient's choices and a commitment to expand the patient's ability to actualize their choices. (shrink)

The Pharmaceutical Benefits Scheme, operating in Australia under the National Health Act 1953, provides citizens equal access to subsidised pharmaceuticals. With ever-increasing costs of medicines and global financial pressure on all commodities, the sustainability of the PBS is of crucial importance on many social and political fronts. Direct-to-consumer advertising (DTCA) of prescription medicines is fast expanding, as pharmaceutical companies recognise and reinforce marketing potentials not only in healthcare professionals but also in consumers. DTCA is currently prohibited in Australia, but pharmaceutical (...) companies continuously lobby for the ban to be lifted. There is evidence that such marketing strategies influence consumer behaviour and concerns have been raised about whether DTCA could affect government expenditure on the PBS in Australia. This pharmacy-based study explored Australian consumer attitudes towards DTCA and whether consumer attitudes regarding DTCA differ based on socioeconomic status, measured in terms of income and education. Consumers from different socioeconomic areas in Sydney were asked to respond to a survey about an advertisement created specifically for the promotion of a mock prescription medicine. Their views about the intent, value and reliability of the advertisement were explored. The study found that consumers of lower socioeconomic status were more likely to perceive DTCA as a source of valuable and reliable medical information, and that they were more likely to request an advertised medication from their physician. If DTCA of prescription medicines was to be introduced in Australia, an increase in government expenditure on the PBS would be anticipated. Findings of this study also expose a deficit in respect for patients’ right to autonomy and informed consent which should be based on evidence-based, unbiased, information rather than advertisements. (shrink)

Pharmakologisches „cognition enhancement“ zielt auf die Verbesserung der geistigen Leistungsfähigkeit mithilfe von Präparaten, die primär als Medikamente eingesetzt werden. Der Beitrag befasst sich mit der ethischen Bewertung des Gebrauchs von Stimulanzien als „enhancer“ durch Kinder und Jugendliche. Am Beispiel von Diagnose und Behandlung der Aufmerksamkeitsdefizit-Hyperaktivitätsstörung (ADHS) werden die Schwierigkeiten der Abgrenzung von Therapie und Enhancement beschrieben und daraus auf verschiedenen Ebenen ethisch relevante Fragen bezüglich Cognition enhancement entwickelt. Diese betreffen z. B. die Wirkungen von Stimulanzien auf ein sich entwickelndes System (...) und eine mögliche grundlegende Änderung der Erziehungs- und Sozialisationssituation durch pharmakologisches Enhancement, aber auch das Problem der Normierung von Verhalten und der Einschränkung der Autonomie der Betroffenen. Die vorgestellten Überlegungen geben Anlass, Cognition enhancement durch Stimulanzien im Jugendbereich vorläufig kritisch zu beurteilen. (shrink)

Faced with current urgent calls for more trust in experts, especially in high impact and politically sensitive domains, such as climate science and COVID-19, the complex and problematic nature of public trust in experts and the need for a more critical approach to the topic are easy to overlook. Scepticism – at least in its Humean mitigated form that encourages independent, questioning attitudes – can prove valuable to democratic governance, but stands in opposition to the cognitive dependency entailed by epistemic (...) trust. In this paper, we investigate the tension between the value of mitigated scepticism – understood as the exercise of reason-based doubt in a particular domain – and the need for trust in experts. We offer four arguments in favour of mitigated scepticism: the argument from loss of intellectual autonomy; the argument from democratic deficit; the argument from the normative failures of science; and the argument from past and current injustices. These arguments highlight the tension between the requirements for trust and justified scepticism about the role of experts. One solution, which we reject, is the idea that reliance, rather than trust, is sufficient for the purposes of accommodating experts in policy matters. The solution we endorse is to create a ‘climate of trust’, where questioning experts and expertise is welcomed, but the epistemic trust necessary for action upon information which the public cannot obtain first-hand is enabled and encouraged through structural, institutional, and justice-based measures. (shrink)

Assessment of decision-making capacity can be difficult in acquired brain injury particularly with the syndrome of organic personality disorder. Clinical neuroscience may help but there are challenges translating its constructs to the decision-making abilities considered relevant by law and ethics. An in-depth interview study of DMC in OPD was undertaken. Six patients were purposefully sampled and rich interview data were acquired for scrutiny using interpretative phenomenological analysis. Interview data revealed that awareness of deficit and thinking about psychological states can (...) be present. However, the awareness of deficit may not be “online” and effectively integrated into decision-making. Without this online awareness of deficit the ability to appreciate or use and weigh information in the process of deciding some matters appeared absent. We argue that the decision-making abilities discussed are: necessary for DMC, threatened by ABI, and assessable at interview. Some advice for practically incorporating these abilities within assessments of DMC in patients with OPD is outlined. (shrink)

The current care deficit—which is evident in the nursing crisis, for example—calls for new valuation and recognition of care services. Therefore, the macrosocial value of care is being discussed intensively in many subject areas. This study introduces a fundamental theological and ethical contribution into the current discourse. It challenges Protestant ethics and deaconry to place greater importance on dependency relations, to reconsider guiding principles such as autonomy and reciprocity, and to comprehend care as an ethical paradigm.

Abstract:This paper considers novel ethical issues pertaining to near-future artificial intelligence (AI) systems that seek to support, maintain, or enhance the capabilities of older adults as they age and experience cognitive decline. In particular, we focus on smart assistants (SAs) that would seek to provide proactive assistance and mediate social interactions between users and other members of their social or support networks. Such systems would potentially have significant utility for users and their caregivers if they could reduce the cognitive load (...) for tasks that help older adults maintain their autonomy and independence. However, proactively supporting even simple tasks, such as providing the user with a summary of a meeting or a conversation, would require a future SA to engage with ethical aspects of human interactions which computational systems currently have difficulty identifying, tracking, and navigating. If SAs fail to perceive ethically relevant aspects of social interactions, the resulting deficit in moral discernment would threaten important aspects of user autonomy and well-being. After describing the dynamic that generates these ethical challenges, we note how simple strategies for prompting user oversight of such systems might also undermine their utility. We conclude by considering how near-future SAs could exacerbate current worries about privacy, commodification of users, trust calibration and injustice. (shrink)

When parents must rely on public assistance and family shelters to provide for their children's most basic needs, they lose autonomy. Within a system of public assistance that already stigmatizes and isolates its beneficiaries, their family lives become subject to public scrutiny and criticism. They are _parenting in public._ This book is an in-depth examination of the realities of life for parents and their children in family shelters. The author uses the Massachusetts family shelter system to explore the impact (...) of asset and deficit-oriented help-giving approaches as they are experienced by mothers and service providers. The format of the book is unique. Following each chapter are the "reflections" of a mother who has parented in a shelter, a front-line worker, and a shelter director. The author and contributors propose a "Power With" policy and practice framework that runs counter to the prevailing "Power Over" cultural policy trends. Contributors include Rosa Clark, Brenda Farrell, Deborah Gray, Michele Kahan, Margaret A. Leonard, Mary T. Lewis, Nancy Schwoyer, and Elizabeth Ward. (shrink)

Le but de cette these consiste a degager l'influence constitutive de l'heritage kantien dans l'elaboration contemporaine du paradigme cosmopolitique en ethique internationale. Cependant, une certaine ambivalence caracterise les ecrits politiques de Kant, oscillant entre un realisme politique et un idealisme moral. L'interpretation rawlsienne du foedus pacificum, quant a elle, reconduit une conception fondamentalement etatiste du projet de paix kantien. Face au fait du pluralisme, Rawls tente d'accommoder certaines preoccupations communautariennes au detriment de l'individualisme normatif et de l'egalite politique des citoyens (...) constitutifs de la democratie liberale. Nous soutenons, contre Rawls, qu'une perspective cosmopolitique d'obedience kantienne ne peut accorder une telle preseance indue aux droits collectifs au prejudice des droits fondamentaux des individus. ;Par contraste, nous soutenons la justification normative d'une theorie particuliere de la democratie cosmopolitique fondee sur la notion de souverainete differenciee dont les representants les plus importants sont David Held et Thomas W. Pogge. Ce modele de gouvernance globale sans gouvernement s'inspire du foedus pacificum kantien qui concoit la possibilite d'une communaute cosmopolitique sans Etat mondial. Nous affirmons que la theorie de la souverainete differenciee, fondee sur le principe de l'autonomie, permet de concilier le fait du pluralisme avec l'universalisme moral des droits fondamentaux. ;Une telle perspective cosmopolitique s'appuie sur une approche pragmatique qui tient compte des criteres de plausibilite historique et institutionnelle. De sorte qu'elle tente d'articuler les prescriptions normatives a partir des caracteristiques empiriques de la globalisation. Or, une analyse attentive du phenomene de la globalisation atteste d'un changement de paradigme en relations internationales qui bouleverse les parametres conceptuels en relations internationales. Ce changement de paradigme libere de nouvelles possibilites conceptuelles en ce qui a trait aux notions traditionnelles de la souverainete de l'Etat et de la democratie. C'est dans la foulee de ces transformations, a la fois structurelles et philosophiques, que l'ideal regulateur d'un partage plus equitable de la souverainete, audela et en deca des bornes territoriales de l'Etat, parait plausible. Dans l'esprit de certaines intuitions kantiennes, il est possible d'elaborer une conception de la citoyennete cosmopolitique et de la sphere publique transnationale capable de surmonter, d'une certaine facon, le deficit de democratie et de representation electorale qui caracterisent presentement les changements inherents a la globalisation. ;Cette these tente de demontrer en quoi le projet de paix kantien constitue la genese philosophique du modele de gouvernance cosmopolitique, fondee sur la theorie de la souverainete differenciee, nous permettant d'envisager certaines propositions de reformes institutionnelles en relations internationale. (shrink)

ABSTRACTIn Freedom’s Right, Axel Honneth articulates the social freedom of friendship with reference to its institutionalised norms. These action norms, however, are not specific to friendship; they apply to modern intimacy per se. Such non-specificity cannot adequately account for the experience of social freedom in friendship. Addressing this issue, I evaluate friendship as a form of recognition and identify a generative recognition deficit functional to its relational autonomy. Then, taking Honneth’s institutional approach to friendship as a point of (...) departure, I ascertain an institutional deficit that both sustains friendship’s autonomy and constrains the generalisability of its social freedom by way of institutional connectivity to heterosexuality. I suggest that only a differentiating approach to friendship that fathoms its extraordinary position among interpersonal relationships can yield new insights. That done, friendship can in turn provide a prism through which to assess the conceptual approach... (shrink)

One of Fichte's most important ideas - that nature can place limits on our ability to govern ourselves, and that anyone who values autonomy is thereby committed to the value of basic research and of the development of autonomy-enhancing technologies - has received little attention in the interpretative literature on Fichte, and has little currency in contemporary ethics. This volume aims to address both deficits. Beginning from a reconstruction of Fichte's theory of rational agency, this volume examines his (...) arguments for the thesis that rational agency must have two constitutive ends: substantive and formal independence. It argues for a novel interpretation of Fichte's conception of substantive independence, and shows how Fichte's account of moral duties is derived from the end of substantive independence on that conception. It also argues for a new interpretation of Fichte's conception of formal independence, and explains why the usual understanding of this end as providing direct guidance for action must be mistaken. It encompasses a systematic reconstruction of Fichte's first-order claims in normative ethics and the philosophy of right. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical CommentaryChong Siow Ann, Associate ProfessorDr. G appears to experiencing symptoms of schizophrenia, which is arguably the most severe mental disorder and which afflicts about one in a hundred people. This is a psychotic disorder that causes disturbances and distortions in thinking, including neurocognitive impairments, perception and behaviour. There is no cure for this often devastating disorder. Current antipsychotic medications can alleviate some of the symptoms but it often (...) comes at a price as these antipsychotics have burdensome side effects.A feature of this disorder is anosognosia, which is a lack of awareness or “insight” that an illness is present. This lack of insight presents a particular challenge because these individuals would, as in the case of Dr. G, refuse needed treatment as they do not perceive that they are ill. This is not necessarily an all-or-none phenomenon but is rather more complex and multidimensional; there might be an unawareness or recognition on behalf of the patient that they are suffering from a mental illness, the failure to appreciate the necessity of treatment; and/or the inability to recognise and define the psychotic symptoms like unusual thoughts and hallucinations as signs of illness1 and in many instances, all three are present. It is also by no means uncommon. Studies have found that between 60% and 80% of people with schizophrenia lack awareness of their illness to varying degrees.2This phenomenon remains an enigma. Some regard it as a form of psychological defence against the harsh reality of a psychotic illness — awareness of having a chronic and devastating illness might lead to demoralisation, hopelessness and suicide.3 Recent research, however, [End Page 250] indicates that this psychological denial plays a small part, if any, and instead has found an association with certain neuropsychological and neurocognitive deficits,4 as well as functional and structural brain abnormalities in the frontal lobe of the brain.5The prevailing clinical view thus is that this is an intrinsic and organic aspect of the schizophrenic illness which has nothing to do with wilfulness but rather the incapacity to perceive the presence of the illness. Edwin Fuller Torrey, an eminent psychiatrist and executive director of the Stanley Medical Research Foundation, calls anosognosia the “single largest reason why individuals with schizophrenia and bipolar disorder do not take their medications”, and he has remarked that “to keep talking about civil liberty is illogical. Patients are anything but free when they’re at the beck and call of their own delusions”.6It is also this view that it is a product of a brain disorder that some — particularly patients — find unacceptable. At one level, it does not take into context the person’s own experiences, and at a deeper level it calls into question the conception of the self with its capacity to exercise judgements and the autonomy to make decisions.This is a perennial ethical issue in psychiatry when people with severe mental illnesses refuse treatment. This becomes a Catch-22 situation where part of the illness that needs treatment is also preventing any treatment to be given: implicit in the principle of informed consent for treatment is that the person should be aware of the nature and course of their illness and acknowledge the need for treatment. While there are laws for involuntary commitment, the bar is usually high in that there must be a clear and present risk of harm to the person or others. Alan Stone, a professor of law and psychiatry at Harvard University proposed a possible justification for involuntary treatment based on his “thank-you theory” which assumes that patients will become well and subsequently agree that the intervention was in their best interests but research suggests that only half of these patients would admit so.7One suggested mechanism is the use of advance directives — psychiatry’s version of the living will in which people can specify what sort of medical care they would like should they become mentally unwell and unable to exercise appropriate judgement. An intrinsic part of this might include a “Ulysses contract” — just as Ulysess instructed his crew to lash him to the mast of the his ship so that he could... (shrink)

Kantian deontology is one of three classic moral theories, among virtue ethics and consequentialism. Issues in medical ethics are frequently addressed within a Kantian paradigm, at least – although not exclusively – in European medical ethics. At the same time, critical voices have pointed to deficits of Kantian moral philosophy which must be examined and discussed. It is argued that taking concrete situations and complex relationships into account is of paramount importance in medical ethics. Encounters between medical or nursing staff (...) and patients are rarely symmetrical relationships between autonomous and rational agents. Kantian ethics, the criticism reads, builds on the lofty ideal of such a relationship. In addition to the charge of an individualist and rationalist focus on autonomy, Kantian ethics has been accused of excluding those not actually in possession of these properties or of its rigorism. It is said to be focussed on laws and imperatives to an extent that it cannot appreciate the complex nuances of real conflicts. As a more detailed analysis will show, these charges are inadequate in at least some regards. This will be demonstrated by drawing on the Kantian notion of autonomy, the role of maxims and judgment and the conception of duties, as well as the role of emotions. Nevertheless the objections brought forward against Kantian moral theory can help determine, with greater precision, its strengths and shortcomings as an approach to current problems in medical ethics. (shrink)

Despite the diversity of ageing, society and academics often describe and label older persons as a vulnerable group. As the term vulnerability is frequently interchangeably used with frailty, dependence, or loss of autonomy, a connection between older age and deficits is promoted. Concerning this, the question arises to what extent it may be helpful to refer to older persons as vulnerable specifically in the context of health care. After analyzing different notions of vulnerability, I argue that it is illegitimate (...) to conclude that older age is related to increased vulnerability. Much more, identifying older adults as a vulnerable group is closely related to ageism and can be associated with paternalistic benevolence and a tendency to overprotection, especially within health care. Additionally, even though older adults are more often in situations of increased vulnerability due to their potentially higher need for health care, I argue further that older adults mainly become a vulnerable group due to ageism. In this way, it can be concluded that the vulnerability of older adults does not originate in certain attributes of the group, but arises from a characteristic of society and, in turn, health personnel, namely ageism. Labeling older adults as vulnerable therefore is only helpful, when it is used to raise awareness of the widespread ageism in society, in this context, especially in the setting of health care, and the negative consequences thereof for older adults. (shrink)

Public reason liberalism demands that political decisions be publicly justified to the citizens who are subjected to them. Much recent literature emphasises the differences between the two main interpretations of this requirement, justificatory and political liberalism. In this paper, I show that both views share structural democratic deficits. They fail to guarantee political autonomy, the expressive quality of law, and the justification to citizens, because they allow collective decisions made by incompletely theorised agreements. I argue that the result can (...) only be avoided by changing public reason’s role in collective decision-making. Instead of incompletely theorised agreements, we should demand agreement both on the public reasons themselves and on the other premises that justify political decisions. In this way, it is always possible to point to a procedure-independent reason that justifies democratic decisions, and the reasoning of the state is public and contestable. Finally, I explain how this, in turn, implies that only political liberalism can be rescued—by accepting what I will call strong political liberalism. Modifying justificatory liberalism in the necessary way will inevitably open the door to an objectionable form of perfectionism. (shrink)

Osoba odnosno osobni identitet kao izvorno filozofski pojmovi nalaze primjenu i u medicinskim diskursima. Usto se njihova tumačenja ne izvode isključivo iz historijskog konteksta filozofijskih i teologijskih predodžbi, već poprimaju etičku dimenziju na razini ljudskog ponašanja. Njihovo osebujno značenje dosežu u interakciji između liječnika i pacijenta, interakciji koja se manifestira u tjelesno-fenomenalnoj interpretaciji personaliteta: isti se proteže od autonomije i svojevoljnosti refleksivno ustrojene svijesti do prividne disocijacije tijela i osobe u okviru pojma moždane smrti. Razumijevanje čovjeka kao osobe pritom je (...) dio one antropološke paradigme koja u medicinskim kriznim situacijama predstavlja temelj etički opravdanog ophođenja s njime. Deficit izazvan gubitkom osobne autonomije time postaje smjernicom k onoj deficijentnoj tjelesnosti koju je medicina definirala kao predmet vlastita istraživanja.Person and personal identity, originally philosophical concepts, find its application also in medical discourses. Moreover, their interpretations are not derived exclusively from historical context of philosophical and theological ideas, but acquire an ethical dimension on the level of human behaviour. Their special meaning is obtained in the patient-physician interaction, which is manifested in the bodily-phenomenal interpretation of personality: this ranges from autonomy and purposiveness of a reflectively structured consciousness to the apparent dissociation of the body and the person in the concept of brain death. The understanding of the human being as person is thereby a part of the anthropological paradigm that presents the basis for ethically acceptable action in medical crisis situations. The deficiency caused by the loss of personal autonomy is therefore an indication of a deficient corporeality, which medicine has chosen as its research object..La personne et l’identité personnelle, en tant que concepts à l’origine philosophiques, trouvent également leur application dans les discours médicaux. Ce faisant leurs inteprétations ne sont pas tirées uniquement du contexte historique des représentations philosophiques et théologiques, mais gagnent une dimension éthique à l’échelle du comportement humain. Ils prennent leur signification particulière dans l’interaction entre le médecin et le patient, laquelle se manifeste dans l’interprétation physico-phénoménale de la personnalité : celle-ci s’étend de l’autonomie et de l’arbitraire d’une conscience organisée de manière réflexive jusqu’à la dissociation apparente du corps et de la personne dans le cadre de la notion de mort cérébrale. La compréhension de l’homme en tant que personne fait en même temps partie de ce paradigme anthropologique qui dans des situations médicales de crise représente la base d’un rapport avec lui éthiquement justifié. Le déficit subi par la perte de l’autonomie personnelle est ainsi également une indication de ce physique déficient que la médecine a désigné comme objet de sa recherche.Person und personale Identität finden als ursprünglich philosophische Begriffe auch in medizinischen Diskursen Anwendung. Dabei leiten sich ihre Deutungen nicht allein aus dem historischen Kontext philosophischer und theologischer Vorstellungen ab, sondern gewinnen eine ethische Dimension auf der Ebene menschlichen Verhaltens. Ihre besondere Bedeutung erlangen sie in der Auseinandersetzung zwischen Arzt und Patient, die sich in einer leiblich-phänomenalen Interpretation der Personalität offenbart: diese reicht von der Autonomie und Willentlichkeit eines reflexiven geordneten Bewusstseins bis zur scheinbaren Dissoziierung von Leib und Person im Begriff des Hirntodes. Das Verständnis des Menschen als Person ist dabei Teil jenes anthropologischen Paradigmas, das die Grundlage eines ethisch verantwortbaren Umganges mit diesem in medizinischen Krisensituationen darstellt. Der im Verlust personaler Autonomie erlebte Mangel ist damit auch ein Hinweis auf jene defiziente Leiblichkeit, welche sich die Medizin zum Forschungsgegenstand erkoren hat. (shrink)

Research over the past few decades has shown the positive influence that cognitive, social, and physical activities have on older adults’ cognitive and affective health. Especially interventions in health-related behaviors, such as cognitive activation, physical activity, social activity, nutrition, mindfulness, and creativity, have shown to be particularly beneficial. Whereas most intervention studies apply unimodal interventions, such as cognitive training, this study investigates the potential to foster cognitive and affective health factors of older adults by means of an autonomy-supportive multimodal (...) intervention. The intervention integrates everyday life recommendations for six evidence-based areas combined with psychoeducational information. This randomized controlled trial study compares the effects of a MMI and CT on those of a waiting control group on cognitive and affective factors, everyday life memory performance, and activity in everyday life. Three groups, including a total of 119 adults aged 65–86 years, attended a 5- or 10-week intervention. Specifically, one group completed a 10-week MMI, the second group completed 5-week of computer-based CT followed by a 5-week MMI, whereas the third group paused before completing the MMI for the last 5 weeks. All participants completed online surveys and cognitive tests at three test points. The findings showed an increase in the number and variability of activities in the everyday lives of all participants. Post hoc analysis on cognitive performance of MMI to CT indicate similar or better effects. Furthermore, results on far transfer variables showed interesting trends in favor of the MMI, such as increased well-being and attitude toward the aging brain. Also, the MMI group showed the biggest perceived improvements out of all groups for all self-reported personal variables. The results implicate a positive trend toward MMI on cognitive and affective factors of older adults. These tendencies show the potential of a multimodal approach compared to training a specific cognitive function. Moreover, the findings suggest that information about MMI motivates participants to increase activity variability and frequency in everyday life. Finally, the results could also have implications for the primary prevention of neurocognitive deficits and degenerative diseases. (shrink)

Abstract: In this essay a set of principles is defended that yields a determinate allocation of sovereign competences across a global system of territorially nested jurisdictions. All local sovereign competences are constrained by a universal, justiciable human rights regime that also incorporates a conception of cross-border distributive justice and regulates the competence to control immigration for a given territory. Subject to human rights constraints, sovereign competences are allocated according to a conception of global democracy. The proposed allocation scheme can accommodate (...) substantial local autonomy while at the same time ensuring that everyone has a voice in the political decisions that affect his or her interests. The relevant class of affected interests is fully specified. Relevant affects are of two kinds: those that impose norms of governance on individuals, and those that impose external costs on them. The favored sense of "an external cost" is developed and defended. (shrink)

The lung allocation score system in the United States and several European countries gives more weight to risk of death without transplantation than to survival following transplantation. As a result, centers transplant sicker patients, leading to increased length of initial hospitalization. The care of patients who have accumulated functional deficits or additional organ dysfunction during their prolonged stay can be ethically complex. Disagreement occurs between the transplant team, patients and families, and non-transplant health care professionals over the burdens of ongoing (...) intensive intervention. These cases highlight important ethical issues in organ transplantation, including the nature and requirements of transplant informed consent, the limits of physician prognostication, patient autonomy and decision-making capacity following transplant, obligations to organ donors and to other potential recipients, and the impact of program metrics on individualized recipient care. We outline general ethical principles for the care of lung transplant recipients with prolonged hospitalization and give regulatory, research, and patient-centered recommendations for these cases. (shrink)

Emmanuel Picavet | : Les droits individuels fondamentaux ne sont-ils pas fragilisés, dans les contextes de prise en charge liés au vieillissement ou aux situations de handicap, si leur lien avec l’autonomie individuelle apparaît perturbé par la perte ou l’absence de capacités individuelles jugées importantes? Il est montré dans cet article que les inquiétudes à cet égard reposent sur des présupposés qui concernent le pouvoir de décision des individus. Un point de vue renouvelé sur ce pouvoir contribue à lever les (...) inquiétudes. Il est ensuite montré que cet enrichissement nécessaire est pertinent pour l’organisation en vue de la prise en charge. | : If the connection between the basic rights of individuals and their autonomy turns out to be impacted by individual capacity losses or deficits, shouldn’t we expect a weakened status of these rights in the context of collective care? In this article, it is shown that such expectations only acquire meaning in association with presuppositions which relate to individuals’s decision-making power. Taking a renewed perspective of this power alleviates the fears in this respect. Then it is shown that this modified view is relevant to organization in the face of care challenges. (shrink)

The credit policy of the«Communal Bank» is based on objective criteria in order to respect local autonomy. The financial results of the consolidation are difficult to determine. Several factors could have influenced the present state of municipal finances : the consolidation being done in a period of economic difficulties, the crisis of the public finances, the reform of the Municipal Fund, and the transformation of the Centers for Public Assistance into Public Centers for Social Welf are. The consolidations did (...) not generale any savings, but it al,so did not cause an alarming increase of expenses. With respect to budget balancing, the amalgamated municipalities should do better than the non-amalgamated municipalities. To keep the increase of expenses low in comparison with the revenues, the municipalities had to make cuts in several sectors.As to the current fniancial situation in the three regions, the municipalities of the Brussels regon are in a very painful situation ; in Flanders, the number of municipalities with deficits is higher than in Wallonia, but the deficits in W allonia are bigger. To stop this negative evolution one must strive for balanced budgets and reshape them into reliable instruments. (shrink)

Fibromyalgia is characterised by chronic, continuous, widespread pain, often associated with a sense of fatigue, non-restorative sleep and physical exhaustion. Due to the nature of this condition and the absence of other neurological issues potentially able to induce disorders in body representations per se, it represents a perfect model since it provides an opportunity to study the relationship between pain and the bodily self. Corporeal illusions were investigated in 60 participants with or without a diagnosis of FM by means of (...) an ad hoc devised interview. In addition, motor imagery was investigated and illusions relating to body part movements and changes in body size, feelings of alienness, and sensations of body parts not belonging to one’s own body were found. Crucially, these symptoms do not correlate with any of the clinical measures of pain or functional deficits. The results showed that motor imagery was also impaired, and the severity of the deficits found correlated with the functional impairment of the participant. This indicates that disorders in body representations and motor imagery are part of the clinical expression of FM. However, while motor imagery seems to be linked to reduced autonomy and functional deficits, bodily illusions are independent and potentially represent a concurrent symptom. (shrink)

Although there has been critical analysis of how the informed consent process functions in relation to participation in research and particular ethical 'dilemmas', there has been little examination of consenting to more routine medical procedures. We report a qualitative study of 25 women who consented to surgery. Of these, nine were ambivalent or opposed to having an operation. When faced with a consent form, women's accounts suggest that they rarely do anything other than obey professionals' requests for a signature. An (...) interactionist analysis suggests that women's capacity to act is reduced by the hospital structure of tacit, socially-imposed rules of conduct. Bourdieu's concepts of habitus, capital and symbolic power/violence show how the practical logic that women apply confers a 'sense of place' relative to professionals. Women experience deficits in capital that constrain their ability to exercise choice. This work demonstrates the weakness of the consent process as a safeguard of autonomy. (shrink)

Hegel’s Philosophy of Law deals in theLaw section of the categories: person, property and contract. Research critically reconstructs this theory from a Marxist perspective. In the concept of person, first of all, the singular will is reduced to a solipsist will unrelated to intersubjectivity. Then, the concept of Hegelian property bases the private appropriation of property as the externalization of the singular will. This legal property guarantees the maintenance and reproduction of private property, that is, it will guarantee the private (...) accumulation of capital, Marx will say. Anyway, the theory of the contract would link the autonomy of the contracting wills, however, it is a mere appearance, because, in fact, the owners’ wills are under the domination of the capitalist market, as it is explained in Marx’s Capital. The theoretical deficit of Hegel’s Philosophy of Law in general is that the legal concepts of person and property correspond to the abstract will. Hegel describes the juridical description of the legal system of the modern state as the development of free will that legitimizes the asymmetry of civil society in its socioeconomic inequalities. (shrink)