There is mounting evidence that methylphenidate (MPH; Ritalin) is being used by healthy college students to improve concentration, alertness, and academic performance. One of the key concerns associated with such use of pharmaceuticals is the degree of freedom individuals have to engage in or abstain from cognitive enhancement (CE). From a pragmatic perspective, careful examination of the ethics of acts and contexts in which they arise includes considering coercion and social pressures to enhance cognition. We were interested in understanding (...) how university students, parents of university students, and healthcare providers viewed autonomy and coercion in CE using MPH. We found that perspectives converged on the belief that CE is a matter of personal and individual choice. Perspectives also converged on the existence of tremendous social pressures to perform and succeed. Parents emphasized personal responsibility and accountability for CE choices, and expressed feelings of worry, sadness and fear about CE. Students emphasized the importance of personal integrity in CE, expressed tolerance for personal choices of others, and highlighted the challenge that CE poses to maintaining one’s personal integrity. Healthcare providers emphasized the health consequences of CE. These results illustrate: (1) the importance of understanding how context is viewed in relation to perspectives on autonomous choice; (2) the limitations of individualistic libertarian approaches that do not consider social context; and (3) the ethical implications of public health interventions in a value-laden debate where perspectives diverge. (shrink)

Most of the attention regarding the balance between autonomy and paternalism has been focused on the therapeutic relation. Much less attention has been devoted to the problem of autonomy in the application of medical knowledge for preventive purposes. Here, because the good to be achieved is social as well as individual, an unavoidable dilemma ensues. Effective preventive measures of benefit to all must necessarily limit autonomy and involve some coercion. I argue that there are principles which (...) can be established to guide society in a moral use of coercion. The question of employing medical knowledge is not, as it is in therapeutic medicine, to preserve or enhance autonomy. Rather its aim is to enhance voluntary co-operation. Principles for moral use of coercion must thereby be derived from health as a moral value. (shrink)

For the past three decades philosophical discussions of both personal autonomy and what it is for a person to “identify” with her desires have been dominated by the “hierarchical” analyses of these concepts developed by Gerald Dworkin and Harry Frankfurt. The longevity of these analyses is owed, in part, to the intuitive appeal of their shared claim that the concepts of autonomy and identification are to be analyzed in terms of hierarchies of desires, such that it is a (...) necessary condition for a person to be autonomous with respect to a desire that moves her to act, that she desires that this desire so move her. Despite the intuitive appeal of these analyses, however, Irving Thalberg has argued that they should be rejected. This is because, he argues, a person who is forced to perform an action by being subjected to duress of a certain degree of harshness will desire to be moved by her desire to submit. Thus, he continues, the proponents of hierarchical analyses of autonomy and identification will be forced to hold that such a person acted willingly, and did not suffer from any impairment in her autonomy. This, Thalberg concludes, is so counterintuitive as to justify rejecting hierarchical analyses. (shrink)

This essays provides a critical overview of the the significance of sexual activity and the important role consent as a necessary condition for its permissibility.

The debate concerning whether to legalize and regulate the global market in human organs is hindered by a lack of adequate bioethical language. The author argues that the preferential option for the poor, a theological category, can provide the grounding for an inductive moral epistemology adequate for reforming the use of culturally Western bioethical language. He proposes that the traditional, Western concept of bioethical coercion ought to be modified and expanded because the conditions of the market system, as viewed (...) from the perspective of organ vendors systemically deprived of access to sufficient resources, are sufficiently exploitative as to diminish the possibility of these vendors giving informed consent. Moreover, empirical studies conducted by professionals in medicine, sociology, psychiatry, economics, and medical anthropology continue to contribute support to the growing interdisciplinary consensus that functionally coercive structural factors exert the most significant influence upon a vendor's decision to sell an organ within any market, regardless of legality or degree of regulation. Therefore any proposal to legalize and regulate the organ market remains patently unethical because doing so would likely function to constrain further the agency of poor potential vendors. (shrink)

The use of coercive measures in the care for the addicted has changed over the past 20 years. Laws that have adopted the “dangerousness” criterion in order to secure patients’ rights to non-intervention are increasingly subjected to critique as many authors plead for wider dangerousness criteria. One of the most salient moral issues at stake is whether addicts who are at risk of causing danger to themselves should be involuntarily admitted and/or treated. In this article, it is argued that the (...) dilemma between coercion on the one hand and abandonment on the other cannot be analysed without differentiated perspectives on the key notions that are used in these debates. The ambiguity these notions carry within care practice indicates that the conflict between the prevention of danger and respect for autonomy is not as sharp as the legal systems seem to imply. Some coercive measures need not be interpreted as an infringement of autonomy—rather, they should be interpreted as a way to provide good care. (shrink)

In psychiatry, caregivers try to get free and informed consent of patients, but often feel required to restrict freedom and to use coercion. The present article develops ethical advice given by an Ethics Committee for Mental Health Care. The advice recommends an ethical ideal of shared deliberation, consisting of information, motivation, consensus and evaluation. For the exceptional use of coercion, the advice develops three criteria, namely incapacity to deliberate, threat of serious harm and proportionality between harm and (...) class='Hi'>coercion.The article also discusses the viewpoints of the ethical advice and of the European Convention on Human Rights and Biomedicine: is the advice in agreement with the Convention and can the advice refine the guidelines of the Convention for the particular context of psychiatry? Although the Convention emphasises the autonomy of the individual patient, whereas the advice focuses on the relationships between the partners involved, the advice enjoys a complementary and supportive function in the application of the Convention. (shrink)

Colburn’s ambition in this book is to defend a ‘political morality of autonomy-minded liberalism’. Colburn defines autonomy as the ability to live in accordance with what one has deemed valuable, and to bear responsibility for this decision. There is a traditional debate that forces liberalism either to identify itself as anti-perfectionist and thus as neutral on the question of autonomy’s value , or as pro-autonomy and perfectionist. Colburn alleges that this debate is premised on a logical (...) error. In Chapter 1, Colburn proposes a content-neutral account of autonomy in the tradition of liberal individualism espoused by Wilhelm von Humboldt and John Stuart Mill, and more recently by Joseph Raz and Steven Wall. In Chapter 2, Colburn offers an account of autonomy as a global phenomenon ; lives, rather than episodes of individual choice and action, are at issue. Colburn’s account is an amalgam of ideas defended by Gerald Dworkin, Harry Frankfurt, Mill, and philosophers who defend some form of a social-historical relational account of autonomy. The autonomous agent has values she would hypothetically endorse under conditions of independence, free of factors such as hypnosis or coercion that might derail her critical faculties. Colburn helpfully develops the independence condition by specifying that one’s general commitments to a way of life must be ‘content-sensitive’; they must not ‘depend on something other than the nature of that thing’ deemed valuable. Moreover, the agent must perceive the reasons for her endorsement of a value. The final condition of autonomy might be labelled the relational one of actually ‘living life in accordance with values’ and ‘putting one’s decisions into effect’ . The heart of the book lies in Colburn’s argument for his ‘Equivalence Claim’ in Chapter 3, and in his discussion of the relationship …. (shrink)

In bioethics, the predominant categorization of various types of influence has been a tripartite classification of rational persuasion (meaning influence by reason and argument), coercion (meaning influence by irresistible threats—or on a few accounts, offers), and manipulation (meaning everything in between). The standard ethical analysis in bioethics has been that rational persuasion is always permissible, and coercion is almost always impermissible save a few cases such as imminent threat to self or others. However, many forms of influence fall (...) into the broad middle terrain—and this terrain is in desperate need of conceptual refining and ethical analysis in light of recent interest in using principles from behavioral science to influence health decisions and behaviors. This paper aims to address the neglected space between rational persuasion and coercion in bioethics. First, I argue for conceptual revisions that include removing the “manipulation” label and relabeling this space “nonargumentative]influence,” with two subtypes: “reason-bypassing” and “reason-countering.” Second, I argue that bioethicists have made the mistake of relying heavily on the conceptual categories themselves for normative work and instead should assess the ethical permissibility of a particular instance of influence by asking several key ethical questions, which I elucidate, that relate to (1) the impact of the form of influence on autonomy and (2) the relationship between the influencer and the influenced. Finally, I apply my analysis to two examples of nonargumentative influence in health care and health policy: (1) governmental agencies such as the Food and Drug Administration (FDA) trying to influence the public to be healthier using nonargumentative measures such as vivid images on cigarette packages to make more salient the negative effects of smoking, and (2) a physician framing a surgery in terms of survival rates instead of mortality rates to influence her patient to consent to the surgery. (shrink)

Autonomy is an ideal of self‐creation, or self‐authorship; it consists in an agent's successful pursuit of willingly embraced, valuable options, where the agent's activities are not dominated by worries about mere survival. Autonomy in its primary sense is to be understood as the actual living of an autonomous life; autonomy in its secondary sense is to be understood as the capacity to live autonomously. To be autonomous, agents have to meet three conditions: they must possess certain mental (...) capacities, they must have an adequate range of valuable options, and they must enjoy independence from coercion and manipulation. Autonomy should be distinguished from self‐realization, as autonomous persons may choose not to realize their capacities. Autonomy itself, in an environment that supports autonomy, is not similarly optional, as living autonomously is the only way of flourishing within an autonomy‐supporting environment. (shrink)

Stephen Schulhofer's book, Unwanted Sex: The Culture of Intimidation and the Failure of Law, provides a carefully constructed and powerful case for rape-law reform. His effort is distinctive in three ways: (1) it takes the basic question of reform to be the moral one of determining which sexual interactions ought to be the subject of the criminal law, (2) it takes the right of sexual autonomy to serve as the basis for any successful legal reform, and (3) it makes (...) a philosophically sophisticated case for his own reform proposal. Schulhofer's efforts should be of great interest to philosophers, especially feminist legal philosophers, interested in questions that bear direct relevance to the relationships between autonomy, coercion, and consent as constrained by the requirements of due process. His careful and scrupulously fair discussion of influential reform recommendations set the stage for his own position (discussed in section VII), a critical evaluation thereof (sections VII and VIII), and sympathetic recommendations in VIII and IX. Of special value here is Schulhofer's attempt to extend his analysis of coerced consent to include certain "offers" made in contexts (e.g., the workplace) characterized by significant power differentials between persons. Section IX offers suggestions, generally friendly to Schulhofer's overall reform proposals, for identifying wrongful sexual interactions occurring in certain institutional or professional contexts. (shrink)

Health insurance coverage for incarcerated citizens is generally acceptable by Western standards. However, it creates internal tensions with the prevailing justifications for public healthcare. In particular, a conceptualization of medical care as a source of autonomy enhancement does not align with the decreased autonomy of incarceration and the needs-based conceptualization of medical care in cases of imprisonment; and rejecting responsibility as a criterion for assigning medical care conflicts with the use of responsibility as a criterion for assigning punishment. (...) The recent introduction of sofosbuvir in Germany provides a particularly instructive illustration of such tensions. It requires searching for a refined reflective equilibrium regarding the scope, limits, and justifications of publicly guaranteed care. (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)

This paper aims to provide a clarification of the long debate on whether enhancement will or will not diminish authenticity. It focuses particularly on accounts provided by Carl Elliott and David DeGrazia. Three clarifications will be presented here. First, most discussants only criticise Elliott’s identity argument and neglect that his conservative position in the use of enhancement can be understood as a concern over social coercion. Second, Elliott’s and DeGrazia’s views can, not only co-exist, but even converge together as (...) an autonomy based theory of authenticity. Third, the current account of autonomy provided by DeGrazia fails to address the importance of rationality and the ability of self-correction, which, as a result impedes the theory to provide a fully developed account for authenticity. In conclusion, a satisfactory account of authenticity cannot focus only on identity or subjective preference. (shrink)

In several jurisdictions, sex offenders may be offered chemical castration as an alternative to further incarceration. In some, agreement to chemical castration may be made a formal condition of parole or release. In others, refusal to undergo chemical castration can increase the likelihood of further incarceration though no formal link is made between the two. Offering chemical castration as an alternative to further incarceration is often said to be partially coercive, thus rendering the offender’s consent invalid. The dominant response to (...) this objection has been to argue that any coercion present in such cases is compatible with valid consent. In this article, we take a different tack, arguing that, even if consent would not be valid, offering chemical castration will often be supported by the very considerations that underpin concerns about consent: considerations of autonomy. This is because offering chemical castration will often increase the offender’s autonomy, both at the time the offer is made and in the future. (shrink)

Respect for autonomy and beneficence are frequently regarded as the two essential principles of medical ethics, and the potential for these two principles to come into conflict is often emphasised as a fundamental problem. On the one hand, we have the value of beneficence, the driving force of medicine, which demands that medical professionals act to protect or promote the wellbeing of patients or research subjects. On the other, we have a principle of respect for autonomy, which demands (...) that we respect the self-regarding decisions of individuals. As well as routinely coming into opposition with the demands of beneficence in medicine, the principle of respect for autonomy in medical ethics is often seen as providing protection against beneficial coercion (i.e. paternalism) in medicine. However, these two values are not as straightforwardly opposed as they may appear on the surface. In fact, the way that we understand autonomy can lead us to implicitly sanction a great deal of paternalistic action, or can smuggle in paternalistic elements under the guise of respect for autonomy. -/- This paper is dedicated to outlining three ways in which the principle of respect for autonomy, depending on how we understand the concept of autonomy, can sanction or smuggle in paternalistic elements. As the specific relationship between respect for autonomy and beneficence will depend on how we conceive of autonomy, I begin by outlining two dominant conceptions of autonomy, both of which have great influence in medical ethics. I then turn to the three ways in which how we understand or employ autonomy can increase or support paternalism: firstly, when we equate respect for autonomy with respect for persons; secondly, when our judgements about what qualifies as an autonomous action contain intersubjective elements; and thirdly, when we expect autonomy to play an instrumental role, that is, when we expect people, when they are acting autonomously, to act in a way that promotes or protects their own wellbeing. I then provide a proposal for how we might work to avoid this. I will suggest that it may be impossible to fully separate paternalistic elements out from judgements about autonomy. Instead, we are better off looking at why we are motivated to use judgements about autonomy as a means of restricting the actions of patients or research subjects. I will argue that this is a result of discomfort about speaking directly about our beneficent motivations in medical ethics. Perhaps we can reduce the incentive to smuggle in these beneficent motivations under the guise of autonomy by talking directly about beneficent motivations in medicine. This will also force us to recognise paternalistic motivations in medicine when they appear, and to justify paternalism where it occurs. (shrink)

Evolutionary changes and interspecific diversity in sexual coercion and autonomy are often linked to indirect selection on mate preferences. Yet, this approach overlooks the small fraction of indirect selection in total selection on mate choice and assumes unnecessarily specific conditions in the recent ‘autonomy-enhancing’ risk-reduction model. This paper proposes a more parsimonious approach based on direct selection and basic signalling theory, incorporating ecological variables to better explain sexual biodiversity. Particularly, the spatial dimensionality of mating environments is emphasized (...) for its role in enhancing sexual freedom through both diminishing monopolization and elevating escape potential from sexual coercion. Empirical evidence, ranging from waterfowl to humans, seems to better align with this ecologically constrained signalling perspective. Furthermore, it suggests that choosers keep coercion risk at ecological baseline by leveraging their escape potential. This repositions intriguing protective elements like bowerbirds' constructions as courtship features that have been bargained to respect sexual autonomy rather than enhancing it through indirect selection. It implies that courtship induced risks, such as reduced mobility, may in principle increase substantially precisely because they are offset by protective measures. Future research could reveal the prevalence of such risk-balancing strategies, advancing our understanding of mating dynamics. This work suggests new theoretical and empirical research avenues within the ecology of mating dynamics. (shrink)

Feminist legal scholarship has questioned the usefulness of non-consent as a criterion for rape. Under conditions of generalized sexual oppression, consent may not be an adequate for absence of coercion. I defend this argument and propose that rape law reform can be usefully informed by state protection of workers in the capitalist labor market, where it is assumed that the parties occupy an unequal bargaining position.

In recent decades, the intertwining ideas of self-determination and well-being have received tremendous support in bioethics. Discussions regarding self-determination, or autonomy, often focus on two dimensions—the capacity of the patient and the freedom from external coercion. The practice of obtaining informed consent, for example, has become a standard procedure in therapeutic and research medicine. On the surface, it appears that patients now have more opportunities to exercise their self-determination than ever. Nonetheless, discussions of patient autonomy in the (...) bioethics literature, which focus on individual patients making particular decisions, neglect the social structure within which health-care decisions are made. Looking through the lens of disability and informed by the feminist conception of relational autonomy, this essay argues that the issue of autonomy is much more complex than the individualist model suggests. The social system and the ableist ideology impose various forms of pressure or oppressive power that can affect people’s ability to choose according to their value system. Even if such powers are not directly coercive, they influence potential parents’ decisions indirectly—they structure their alternatives in such a way that certain options are never considered as viable and other decisions must be made. This paper argues that, instead of only focusing on the individual act of decision-making, we need to pay attention to the social structure that frames people’s decision. (shrink)

A growing focus on pleasure in human rights discourse has been used to address patterns of sexual exclusion, often when addressing the problems of people with disabilities (PWD). As convincingly argued by Liberman, however, not all PWD suffer from sexual exclusion, and not all who suffer from sexual exclusion are PWD. Danaher and Liberman have thus argued in various ways for a broader range of measures, addressing sexual exclusion. This article builds on previous research and offers a conceptual framework for (...) addressing sexual pleasure and exclusion in terms of human rights. It argues that human rights aim to safeguard autonomy, which is interpreted as multidimensional. It, thus, divides autonomy into the four dimensions of liberty (freedom from threat and coercion), opportunity (options to choose between), capacity (what an agent is capable of doing) and authenticity (the extent to which choices are genuine). Furthermore, it distinguishes between distinct egalitarian strategies, which offer different problems and possibilities, and may be combined. Thus, there is direct egalitarian distribution, indirect egalitarian distribution, baseline or threshold strategies and general promotion strategies. By way of conclusion, the importance of sexual authenticity as the ultimate aim of sexual rights is emphasised. (shrink)

End-of-life debates in medical ethics often centre around several interrelated issues: improving care, avoiding coercion, and recognising the dignity and rights of the terminally ill. Care ethics advocates relational autonomy and non-abandonment. These commitments, however, face system pressures—economic, social and legal—that can be coercive. This article takes up two related aspects in this domain of ethics. Firstly, that competence and communication are core clinical ethics principles that can sidestep the overplayed dichotomies in end-of-life care. And secondly, it questions (...) the assumption that advance directives are universally benevolent—comparing the provisions of the Council of Europe’s 1999 recommendations on protection of human rights and dignity of the dying within the framework of the Irish context. The article also registers the unintended impacts of changing legal frameworks in relation to euthanasia and assisted suicide in Europe, including recent proposals in the Netherlands. A focus on human dignity can provide a theologically and philosophically shared normative orientation that argues for present directives rather than only advance directives, and a presumption in favour of ‘living up to death’. Dignity approaches not only grant rights but secure them by supporting ongoing initiatives that honour, rather than erode, the ‘longevity dividend’. (shrink)

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Gaylin and Jennings tell us that we must change the everyday behavior shaping the landscape of modern American society. Our current culture of autonomy is predicated on rationality as the basis of human conduct. But, we are reminded here, man is not inherently rational; appeals to emotion are far more effective than logical argument in changing our conduct.

In this dissertation I develop a general theory of coercion that allows one to distinguish cases of interpersonal coercion from cases of persuasion or manipulation, and cases of institutional coercion from cases of oppression. The general theory of coercion that I develop includes as one component a theory of second-order coercion. Second-order coercion takes place whenever one person intentionally impairs the formation of the second-order desires of another person, or constrains them after their formation, (...) in a way that frustrates or eliminates the possibility of the victim fulfilling certain of his or her first-order desires. The concept of second-order coercion is important because it suggests that a person's autonomy may be violated in ways that have not been previously recognized. In this dissertation I argue that the unique feature of all cases of coercion is that the alternatives available to the victim, with regard to the formation of his or her will, are intentionally constrained by another person in a way that violates the victim's autonomy. A general theory of coercion should be able to explain how institutions may be understood as coercive. I argue that if institutions are understood as social practices maintained for the purpose of achieving some end, then they may be properly understood as capable of coercion. ;This theory of coercion allows me to make two arguments concerning moral responsibility. First, I argue that current discussions of moral responsibility are inadequate because they fail to take seriously the claim that a person may be responsible, at least in part, for having the beliefs and desires that make a particular action a case of coercion. Second, I argue that discussions of moral responsibility are inadequate because they fail to recognize that an agent may not be responsible for the state of his or her will because he or she may have been coerced in a way that has not been previously recognized. (shrink)

In this paper we analyse the ideas implicit in the style of exhibition favoured by contemporary galleries and museums, and argue that unless the audience is empowered to ascribe meaning and significance to artwork through critical dialogue, the power not only of the audience is undermined but also of art. We argue that unless (i) indeterminacy is understood, (ii) the critical rather than coercive nature of art is facilitated, and (iii) the conditions for inter-subjectivity provided, galleries and museums preside over (...) an experience economy devoid of art. (shrink)

This study concerns the sociotechnical bases of human autonomy. Drawing on recent literature on AI ethics, philosophical literature on dimensions of autonomy, and on independent philosophical scrutiny, we first propose a multi-dimensional model of human autonomy and then discuss how AI systems can support or hinder human autonomy. What emerges is a philosophically motivated picture of autonomy and of the normative requirements personal autonomy poses in the context of algorithmic systems. Ranging from consent to (...) data collection and processing, to computational tasks and interface design, to institutional and societal considerations, various aspects related to sociotechnical systems must be accounted for in order to get the full picture of potential effects of AI systems on human autonomy. It is clear how human agents can, for example, via coercion or manipulation, hinder each other’s autonomy, or how they can respect each other’s autonomy. AI systems can promote or hinder human autonomy, but can they literally respect or disrespect a person’s autonomy? We argue for a philosophical view according to which AI systems—while not moral agents or bearers of duties, and unable to literally respect or disrespect—are governed by so-called “ought-to-be norms.” This explains the normativity at stake with AI systems. The responsible people (designers, users, etc.) have duties and ought-to-do norms, which correspond to these ought-to-be norms. (shrink)

Background: To better understand the kinds of ethical challenges that emerge when using coercion in mental healthcare, and the importance of these ethical challenges, this article presents a systematic review of scientific literature. Methods: A systematic search in the databases MEDLINE, PsychInfo, Cinahl, Sociological Abstracts and Web of Knowledge was carried out. The search terms derived from the population, intervention, comparison/setting and outcome. A total of 22 studies were included. Ethical considerations: The review is conducted according to the Vancouver (...) Protocol. Results: There are few studies that study ethical challenges when using coercion in an explicit way. However, promoting the patient’s best interest is the most important justification for coercion. Patient autonomy is a fundamental challenge facing any use of coercion, and some kind of autonomy infringement is a key aspect of the concept of coercion. The concepts of coercion and autonomy and the relations between them are very complex. When coercion is used, a primary ethical challenge is to assess the balance between promoting good (beneficence) and inflicting harm (maleficence). In the included studies, findings explicitly related to justice are few. Some studies focus on moral distress experienced by the healthcare professionals using coercion. Conclusion: There is a lack of literature explicitly addressing ethical challenges related to the use of coercion in mental healthcare. It is essential for healthcare personnel to develop a strong awareness of which ethical challenges they face in connection with the use of coercion, as well as challenges related to justice. How to address ethical challenges in ways that prevent illegitimate paternalism and strengthen beneficent treatment and care and trust in connection with the use of coercion is a ‘clinical must’. By developing a more refined and rich language describing ethical challenges, clinicians may be better equipped to prevent coercion and the accompanying moral distress. (shrink)

The concept of autonomy has assumed increasing importance in contemporary political philosophy. Philosophers such as Rawls, Wolff, Scanlon, Raz and Hurley have employed the concept to ground principles and illuminate issues such as the choice of principles of justice, the justification of political authority, the limits of free speech, the nature of the liberal state and the justification of democracy.

Within now prolific debates surrounding the compatibility of feminism and multiculturalism in liberal societies, the need arises for a normative conception of women’s self-determination that does not violate the self-understandings or values of women of different backgrounds and forms of life. With reference to the recent British debate about forced marriage, this article proposes an innovative approach to this problem in terms of the idea of ‘plural autonomy’. While the capacity for autonomy is plural, in the sense of (...) varying across cultures, autonomy in any world-view involves a capacity to ‘endorse’ one’s decisions in certain crucial spheres of life. Non-endorsement, coercion or force occurs if one risks being alienated from the (cultural) goods and relationships that structure one’s capacity to act in the world. This approach counsels more caution than prominent liberal approaches with respect to negotiating the contested boundary between freedom and force in a diverse society. (shrink)

This essay considers how we are to understand the decision to end one’s life under medical aid-in-dying (MAID) statutes and the role of influencing others. Bioethical concerns about the potential for abuse in MAID have focused predominantly on the risk of coercion and other forms of undue influence. Most bioethical analyses of relational influences in MAID have been made by opponents of MAID, who argue that MAID is unethical, in part, because it cannot cleanly accommodate relational influences. In contrast, (...) proponents of MAID have downplayed the role of relational influences because they may threaten the pillars of autonomy and voluntariness on which the ethics of MAID rest. Drawing on a case study collected as part of an ethnographic study of MAID in Vermont, we show how relations of care are central to MAID decision-making. Such relations may muddle motives for assisted death, exposing the limits of conventional bioethics thinking on MAID and relational influence. Here, we argue that ethical frameworks for MAID should account for the role of relational influences in decision-making, and acknowledge that relational influences may support, as well as undermine, a decision for MAID. We then outline an evaluative framework for determining whether relational influences are undue that identifies six key domains for consideration: mental competence, authenticity, relationship context, having an adequate range options, financial considerations and irremediability. We conclude by suggesting that social relationships may constitute an important source of value in end-of-life decision-making and not only a liability. (shrink)

This paper considers three modes of captivity with an eye to examining the effects of captivity on free agency and whether these modes depend on or constitute coercion. These modes are: physical captivity, psychological captivity, and social/legal captivity. All these modes of captivity may severely impact capacities a person relies on for free agency in different ways. They may also undermine or destroy a person’s identity-constituting cares and values. On a Nozick-style view of coercion, coercion amounts to (...) conditional threats and so many of the processes creating captivity are not coercive. However, this view overlooks the role that barriers to action play in making threats effective. Thus, an enforcement view of coercion is better to understand the coercion that takes place in captivity but the effects of the use of power on a captive’s psychology remains an important area of investigation. (shrink)

Kögel et al propose a multicriteria alternative to the standard early clinical selection method for xenotransplantation trials. As they note, existing recommendations for inclusion criteria indicate that only the most seriously ill—those lacking any viable alternative—should be considered for xenotransplantation. Rather than basing selection on, to put it indelicately, a Hail Mary in the face of certain death, Kögel et al recommend a selection system based on four ethical criteria: medical need, capacity to benefit, patient choice and compliance (the latter (...) being an exclusion criterion). Taken together, they paint a picture of an ethically ideal first-in-human xenotransplantation clinical trial participant: someone ‘in need of a heart replacement with a good capacity to benefit from a xenotransplantation who [has] a choice in terms of alternative potentially life-sustaining treatment options.’1 In other words, they argue that potential xenotransplantation organ recipients (they specify heart, but said criteria would apply to any vital organ recipient) should not be facing their imminent demise as this would inherently constrain that person’s freedom of choice, thus rendering them vulnerable. Instead, Kögel et al argue that trial participants should be selected from groups possessing genuine alternatives to xenotransplantation but opt to receive an animal organ. Now, their concern regarding the presence of coercion in the context of what is an experimental medical intervention is fully justified, as is their claim that those facing limited viable choices at the end of their lives are an inherently vulnerable population. Autonomy and consent are largely uncontroversial bedrocks on which most medical and research ethics theories are built. We are, all of us, familiar with the horrors from history—both distant and recent—where participant consent has taken …. (shrink)

Critics have charged that John Stuart Mill''s discussion as of paternalism in On Liberty is internally inconsistent, noting, for example, the numerous instances in which Mill explicitly endorses examples of paternalistic coercion. Similarly, commentators have noted an apparent contradiction between Mill''s political liberalism – according to which the state should be neutral among competing conceptions of the good – and Mill''s condemnation of non-autonomous ways of life, such as that of a servile wife. More generally, critics have argued that (...) while Mill professes an allegiance to utilitarianism, he actually abandons it in favor of a view that values personal autonomy as the greatest intrinsic good. This paper presents an interpretation of Mill that provides a viable and consistent treatment of paternalism, thereby refuting each of the aforementioned critiques. Mill''s views, it argues, are consistently utilitarian. Moreover, the interpretation accounts for all of Mill''s departures from his otherwise blanket prohibition of paternalistic legislation. In particular, it explains his most notorious example, the condemnation of voluntary contracts for slavery. The interpretation emphasizes Mill''s conceptual linkage between autonomy and utility, noting his implicit use of at least three different senses of the notion of autonomy. (shrink)

It is commonly claimed that when X coerces Y into consenting to Z φ-ing, Y’s consent is invalid, and Z is only permitted to φ if this reduces harm or increases optionality for Y. This article demonstrates that Y’s consent in such cases is valid if Y is choosing between options that include all those Z has a duty to offer Y and no autonomy-reducing options Z has a duty to not offer Y. When these conditions are met, Z (...) acts permissibly in φ-ing even if φ-ing does not reduce harm for Y or increase Y’s optionality. (shrink)

Evidence shows that during birth women frequently experience unconsented care, coercion, and a loss of autonomy. For many countries, this contradicts both the law and medical ethics guidelines, which emphasize that competent and fully informed women’s autonomy must always be respected. To better understand this discordance, we empirically describe perinatal maternity care providers’ and women’s moral deliberation surrounding coercive measures during birth. Data were obtained from 1-on-1 interviews with providers (N = 15) and women (N = 14), (...) and a survey of women (N = 118). Analyses focused on an in-depth exploration of responses to a question on the permissibility of coercion in birth whose wording was borrowed from a Swiss medical-ethical guideline. Reasons for and against a principle permissibility of coercive measures in birth were grouped into clusters of reasons to build a coherent explanatory framework. Factors considered morally relevant when deliberating on coercion included women’s decisional capacity, beneficence/non-maleficence, authority through knowledge on the part of providers, flaws of the medical system, or the imperative to protect the most vulnerable. Also, we identified various misconceptions, such as the conviction that a pathological birth can justify coercion or that fetal rights can justifiably infringe on women’s autonomy. Information and education on the issue of coercion in birth are urgently needed to enable women to fully exercise their reproductive autonomy, to prevent long-term adverse health outcomes of women and children, and to reconcile the medical vigilance which has lead to a reduction of perinatal morbidity and mortality with women’s enfranchisement in their own care. (shrink)

Legal coercion seems morally problematic because it is susceptible to the Hegelian objection that it fails to respect individuals in a way that is ‘due to them as men’. But in what sense does legal coercion fail to do so? And what are the grounds for this requirement to respect? This paper is an attempt to answer these questions. It argues that legal coercion fails to respect individuals as reason-responsive agents; and individuals ought to be respected as (...) such in virtue of the fact that they are human beings. Thus it is in this sense that legal coercion fails to treat individuals with the kind of respect ‘due to them as men’. (shrink)

In this chapter, we aim to argue that 1) the idea of autonomy fails to justify the neutrality principle, according to which the state should be neutral between particular, disputed conceptions of the good life; and 2) autonomy raises a serious challenge to perfectionism, which is the view that it is permissible for the state to use any means, even coercion, to promote the good. By analyzing two aspects of autonomy: autonomy as coherence and (...) class='Hi'>autonomy as independence, we attempt to demonstrate that a person’s living a way of life is manifestly valuable only if she is pursuing it autonomously. While some methods of advancing particular conceptions of the good life may violate the citizens’ autonomy, we argue, other methods are compatible with the value of autonomy. (shrink)

There is a ‘catch 22’ situation about applying coercion in psychiatric care. Autonomous choices undeniably are rights of patients. However, emphasizing rights for a mentally-ill patient could jeopardize the chances of the patient receiving care or endanger the public. Conversely, the beneficial effects of coercion are difficult to predict. Thus, applying coercion in psychiatric care requires delicate balancing of individual-rights, individual well-being and public safety, which has not been achieved by current frameworks. Two current frameworks may be (...) distinguished: the civil liberty approach and the Stone model. Both frameworks are restrictive, and not respectful of human dignity. In a civil liberty approach, individuals who are severely mentally-ill but not dangerous would be denied care because they do not meet the dangerousness threshold or because the use of coercion will not lead to rebirthing of autonomy. This is unsatisfactory. Albeit involuntary interventions such as talk therapies, peer-support etc., may not always lead to rebirthing of autonomy or free patients from mental illness; they can however help to maintain the dignity of each mentally ill patient. In place of these frameworks, this study proposes a new ethical framework for applying coercion in psychiatric care that is respectful of human dignity. Specifically, it draws on insights from the African ethico-cultural system by using the Yoruba concept Omo-olu-iwabi to develop this new framework. This way, the study shows that only a more respectful approach for applying coercion in psychiatric care can lead to the careful balancing of the competing interests of individual's rights, individual's well-being and public safety. (shrink)

This paper critically discusses an argument that is sometimes pressed into service in the ethical debate about the use of assisted reproduction. The argument runs roughly as follows: we should prevent women from using assisted reproduction techniques, because women who want to use the technology have been socially coerced into desiring children - and indeed have thereby been harmed by the patriarchal society in which they live. I call this the argument from coercion. Having clarified this argument, I conclude (...) that although it addresses important issues, it is highly problematic for the following reasons. First, if women are being coerced to desire to use AR, we should eradicate the coercive elements in pro-natalist ideology, not access to AR. Second, the argument seems to have the absurd implication that we should prevent all woman, whether fertile or not, to try to have children. Third, it seems probable that women's welfare will be greater if we let well informed and decision-competent women decide for themselves whether they want to use AR. (shrink)

Background Home-based care workers mainly work alone in the patient’s home. They encounter a diverse patient population with complex health issues. This inevitably leads to several ethical challenges. Aim The aim is to gain insight into ethical challenges related to patient autonomy in home-based care and how home-based care staff handle such challenges. Research design The study is based on a 9-month fieldwork, including participant observation and interviews in home-based care. Data were analysed with a thematic analysis approach. Participants (...) and research context The study took place within home-based care in three municipalities in Eastern Norway, with six staff members as key informants. Ethical considerations The Norwegian Agency for Shared Services in Education and Research evaluated the study. All participants were competent to consent and signed an informed consent form. Findings A main challenge was that staff found it difficult to respect the patient’s autonomy while at the same time practicing appropriate care. We found two main themes: Autonomy and risk in tension; and strategies to balance autonomy and risk. These were explicated in four sub-themes: Refusing and resisting care; when choosing to live at home becomes risky; sweet-talking and coaxing; and building trust over time. Staff’s threshold for considering the use of coercion appeared to be high. Conclusions Arguably, home-based care staff need improved knowledge of coercion and the legislation regulating it. There is also a need for arenas for ethics reflection and building of competence in balancing ethical values in recurrent ethical problems. (shrink)

The ethical principle of autonomy is among the most fundamental in ethics, and it is particularly salient for those in public health, who must constantly balance the desire to improve health outcomes by changing behavior with respect for individual freedom. Although there are some areas in which there is a genuine tension between public health and autonomy—childhood vaccine mandates, for example—there are many more areas where not only is there no tension, but public health and autonomy come (...) down to the same thing. These areas of overlap are often rendered invisible by a thin understanding of autonomy. Better integrating newer theoretical insights about autonomy into applied ethics can make discussions of public health ethics more rigorous, incisive, and effective. Even more importantly, bringing modern concepts of autonomy into public health ethics can showcase the many areas in which public health and autonomy have the same goals, face the same threats, and can be mutually advanced by the same kinds of solutions. This article provides a schema for relational autonomy in a public health context and gives concrete examples of how autonomy can be served through public-health interventions. It marshals insights from sociology, psychology, and philosophy to advance a theory of autonomy and coercion that recognizes three potential threats to autonomy: threats to choice sets, threats to knowledge, and threats to preferences. (shrink)

In his rich and stimulating book, Blake argues that comprehensive coercion triggers egalitarian obligations of distributive justice. I argue that coercion is not a necessary condition for egalitarian justice to apply; Blake’s use of a moralised conception of coercion is a mistake; coercion is a redundant member of any set of sufficient conditions that might explain why distributive justice applies; Blake’s emphasis on providing conditions for the exercise of autonomy might support a much more cosmopolitan (...) theory of distributive justice. (shrink)

Background: Informal coercion, that is, situations where caregivers use subtle coercive measures to impose their will on patients, is common in adult psychiatric inpatient care. It has been described as ‘a necessary evil’, confronting nurses with an ethical dilemma where they need to balance between a wish to do good, and the risk of violating patients’ dignity and autonomy. Aim: To describe nurses’ experiences of being involved in informal coercion in adult psychiatric inpatient care. Research design: The (...) study has a qualitative, inductive design. Participants and research context: Semi-structured interviews with 10 Swedish psychiatric nurses were analysed with qualitative content analysis. Ethical considerations: The study was performed in accordance with the Declaration of Helsinki. In line with the Swedish Ethical Review Act, it was also subject to ethical procedures at the university. Findings: Four domains comprise informal coercion as a process over time. These domains contain 11 categories focusing on different experiences involved in the process: Striving to connect, involving others, adjusting to the caring culture, dealing with laws, justifying coercion, waiting for the patient, persuading the patient, negotiating with the patient, using professional power, scrutinizing one’s actions and learning together. Discussion: Informal coercion is associated with moral stress as nurses might find themselves torn between a wish to do good for the patient, general practices and ‘house rules’ in the caring culture. In addition, nurses need to be aware of the asymmetry of the caring relationship, in order to avoid compliance becoming a consequence of patients subordinating to nurse power, rather than a result of mutual understanding. Reflections are thus necessary through the process to promote mutual learning and to avoid violations of patients’ dignity and autonomy. Conclusion: If there is a need for coercion, that is, if the coercion is found to be an ‘unpleasant good’, rather than ‘necessary evil’ considering the consequences for the patient, it should be subject to reflecting and learning together with the patient. (shrink)

Should tobacco be banned? The answer depends largely on two further questions. How much are smokers benefitted by being made to stop, or to not start? And what is the moral cost of their being made to stop by their government, as opposed to stopping due to the influence of policies that fall short of coercion? Grill and Voigt provide one answer to the first question. They argue that the benefits of cessation are high enough to justify a ban (...) on tobacco products.1 I partly agree: I share their view that the harms of tobacco consumption are great enough to justify at least some policies that force (rather than merely encourage) people to not smoke.i But the differences between policies of this sort are large enough that any general conclusion in favour of ‘a ban’ is incomplete.ii By not elaborating on what a ban might come to, Grill and Voigt leave the second question rather unaddressed. Of course, the authors hardly mean to say that anything goes when it comes to forming policies that force people to not smoke. Nevertheless, it is appropriate to build on their defence of the benefits of forced cessation by comparing different sorts of bans, and by comparing bans with other sorts of coercive policies. I will pick up, therefore, where they leave off: granting that a ban's effects on well-being would be overall positive, a principal moral cost of a ban can be measured in terms of its infringement of smokers’ autonomy. Comparisons, then, can be sought in terms of how different policies infringe autonomy in different ways. What exactly might it mean, however, to speak of smokers’ autonomy? According to Grill and Voigt, autonomy should be thought of as a sort of ‘self-direction’ which obtains given ‘the absence of external …. (shrink)

The ideal of autonomy, together with pluralism, underlies the doctrine of political freedom. Autonomy underlies both positive and negative freedom. Toleration is underpinned by the competitive pluralism that is essential to autonomy. Autonomy is consistent with perfectionism, yet also underlies the ‘harm principle’, which asserts that the only purpose for which the law may use its coercive power is to prevent harm. Perfectionism and the harm principle are consistent with one another because the recommended type of (...) perfectionism abjures coercion, focusing instead on maintaining the framework conditions that are conducive for pluralism and autonomy. (shrink)

Psychiatric inpatients with capacity may be treated paternalistically under the Mental Health Act 1983. This violates bodily autonomy and causes potentially significant harm to health and moral status, both of which may be long-lasting. I suggest that such harms may extend to killing moral persons through the impact of psychotropic drugs on psychological connectedness. Unsurprisingly, existing legislation is overwhelmingly disliked by psychiatric inpatients, the majority of whom have capacity. I present four arguments for involuntary treatment: individual safety, public safety, (...) authentic wishes and protection of autonomy. I explore these through a case study: a patient with schizophrenia admitted to a psychiatric hospital under the Mental Health Act 1983 after an episode of self-poisoning. Through its discussion of preventative detention, the public safety argument articulates the (un)ethical underpinnings of the current position in English law. Ultimately, none of the four arguments are cogent—all fail to justify the current legal discrimination faced by psychiatric inpatients. I conclude against any use of involuntary treatment in psychiatric inpatients with capacity, endorsing the fusion approach where only psychiatric patients lacking capacity may be treated involuntarily. (shrink)

Out of a concern for keeping suicidal patients alive, some psychotherapists may use hard persuasion or coercion to keep them in treatment. However, more recent evidence-supported interventions have made respect for patient autonomy a cornerstone, showing that the effective interventions that promote the wellbeing of suicidal patients also prioritize respect for patient autonomy. This article details how psychotherapists can incorporate respect for patient autonomy in the effective treatment of suicidal patients by listening to them, explaining treatments (...) to them, involving them in decisions, and inviting evaluations from them on the process and progress of their treatment. It also describes how processes that respect patient autonomy can supplement interventions that directly address some of the drivers of suicide. (shrink)