In this paper I look at various ways that interpersonal and social relations can be seen as required for autonomy. I then consider cases where those dynamics might play out or not in potentially paternalistic situations. In particular, I consider cases of especially vulnerable persons who are attempting to reconstruct a sense of practical identity required for their autonomy and need the potential paternalist’s aid in doing so. I then draw out the implications for standard liberal principles of (...) paternalism, specifically in clinical or therapeutic situations. The picture of potential paternalism that emerges here is much more of a dynamic, interpersonal scenario rather than a case of two separate individuals making decisions independent of each other. (shrink)

Legal restrictions of the right to self-determination increasingly pretend to be compatible with the liberal concept of autonomy: they act upon a ‘soft’ or autonomy-orientated paternalistic rationale. Conventional liberal critique of paternalism turns out to be insensitive to the intricate normative problems following from ‘soft’ or ‘libertarian’ paternalism. In fact, these autonomy-oriented forms of paternalism could actually be even more problematic and may infringe liberty rights even more intensely than hard paternalistic regulation. This paper (...) contributes to the systematic differentiation of soft and hard paternalism by discussing the (legal) concept of autonomy and elaborates the moral and legal limits of autonomy-orientated paternalism. (shrink)

Respecting and encouraging autonomy in the elderly is basic to the practice of geriatrics. In this paper, we examine the practice of cardiopulmonary resuscitation (CPR) and "artificial" feeding in a geriatric unit in a general hospital subscribing to jewish orthodox religious principles, in which the sanctity of life is a fundamental ethical guideline. The literature on the administration of food and water in terminal stages of illness, including dementia, still shows division of opinion on the morality of withdrawing nutrition. (...) We uphold the principle that as long as feeding by naso-gastric (N-G) or percutaneous endoscopic gastrostomy (PEG) does not constitute undue danger or arouse serious opposition it should be given, without causing suffering to the patient. This is part of basic care, and the doctor has no mandate to withdraw this. The question of CPR still shows much discrepancy regarding elderly patients' wishes, and doctors' opinions about its worthwhileness, although up to 10 percent survive. Our geriatric patients rarely discuss the subject, but it is openly ventilated with families who ask about it, who are then involved in the decision-making, and the decision about CPR or "do-not-resuscitate" (DNR) is based on clinical and prognostic considerations. (shrink)

ABSTRACT This paper examines some arguments which deny the existence of an individual right to remain ignorant about genetic information relating to oneself – often referred to as ‘a right to genetic ignorance’ or, more generically, as ‘a right not to know’. Such arguments fall broadly into two categories: 1) those which accept that individuals have a right to remain ignorant in self‐regarding matters, but deny that this right can be extended to genetic ignorance, since such ignorance may be harmful (...) to others, particularly those to whom one is genetically related (the ‘harm to others objection’) and 2) those which contend that, even if genetic ignorance is only self harming, it is not something to which individuals can rationally or morally claim to have a ‘right’ at all, since they defend their claims on autonomy‐respecting grounds and ignorance is inimical to autonomy (the ‘incoherence objection’). I argue that defenders of a right not to know have some plausible responses to the ‘harm to others objection’, but that in trying to respond to the ‘incoherence objection’, they and their opponents reach an impasse in which both sides are left voicing concerns about the paternalistic implications of the other's point of view. I conclude that defenders of a right not to know would, therefore, advance their position further by analysing it in terms of values other than those of autonomy and rights. (shrink)

This article discusses the response of our ethics consultation service to an exceptional request by a patient to have his implantable cardioverter defibrillator removed. Despite assurances that the device had saved his life on at least two occasions, and cautions that without it he would almost certainly suffer a potentially lethal cardiac event within 2 years, the patient would not be swayed. Although the patient was judged to be competent, our protracted consultation process lasted more than 8 months as we (...) consulted, argued with, and otherwise cajoled him to change his mind, all to no avail. Justifying our at times aggressive paternalistic intervention helped us to reflect on the nature of autonomy and the dynamics of the legal, moral, and personal relationships in the clinical decision-making process. (shrink)

What is it about a person's becoming an adult that makes it generally inappropriate to treat that person paternalistically any longer? The Standard View holds that a mere difference in age or stage of life cannot in itself be morally relevant, but only matters insofar as it is correlated with the development of capacities for mature practical reasoning. This paper defends the contrary view: two people can have all the same general psychological attributes and yet the mere fact that one (...) person is at the beginning of a life and another in the middle of one can justify treating the younger person more paternalistically than the older one. Recognising the moral relevance of age, moreover, is crucial if one is to accommodate both the liberal moral ideal of respect for autonomy and our demanding educational aims, given that these otherwise come into conflict with one another. (shrink)

Patient autonomy and distributive justice are fundamental ethical principles that may be at risk in liver transplant units where decisions are dictated by the need to maximise the utility of scarce donor organs. The processes of patient selection, organ allocation and prioritisation on the wait list have evolved in a constrained environment, leading to high levels of complexity and low transparency. Regarding paternalism, opaque listing and allocation criteria, patient factors such as passivity, guilt, chronic illness and sub-clinical encephalopathy (...) are cited as factors that may inhibit patient engagement. Regarding justice, established regional, gender and race based inequities are described. The paradox whereby hepatologists both advocate for individual patients and discharge their duty of stewardship to apportion organs according to larger utilitarian principles is explored. Competing subjective factors such as physicians’ perception of moral responsibility, the qualitative nature of expert medical assessment and institutional or personal loyalty to re-transplantation candidates are described. Realistic limits of self-determination and justice are discussed, and possible future directions in terms of patient involvement proposed. (shrink)

Since Mill's seminal work On Liberty, philosophers and political theorists have accepted that we should respect the decisions of individual agents when those decisions affect no one other than themselves. Indeed, to respect autonomy is often understood to be the chief way to bear witness to the intrinsic value of persons. In this book, Sarah Conly rejects the idea of autonomy as inviolable. Drawing on sources from behavioural economics and social psychology, she argues that we are so often (...) irrational in making our decisions that our autonomous choices often undercut the achievement of our own goals. Thus in many cases it would advance our goals more effectively if government were to prevent us from acting in accordance with our decisions. Her argument challenges widely held views of moral agency, democratic values and the public/private distinction, and will interest readers in ethics, political philosophy, political theory and philosophy of law. (shrink)

Euthanasia and physician-assisted suicide are controversial issues in medical ethics and medical law. In the debate, several arguments against the moral acceptability and legal feasibility of active involvement of physicians in bringing about a patient’s death can be found.One argument refers back to the Ten Commandments: “Thou shall not kill”. Killing another human being is morally abject. According to the argument, this is certainly so for medical doctors, as can be seen in the Hippocratic Oath, which explicitly forbids abortion (...) and euthanasia. A less apodictic argument refers to the slippery slope: if euthanasia would be permitted, a downhill movement is set in motion. The end of this movement would be, on the one hand, that physicians will feel forced to assist people who ask for termination of life on whatever grounds. On the other hand, it might lead to a situation in which it becomes normal to kill people who are no longer useful for society.In the literature and in the public debate, there are also arguments in favour of euthanasia and physician-assisted suicide. One such argument invokes the right to die. According to this argument, decisions concerning life and death should be up to the individual who is concerned. In many countries, suicide is morally and legally accepted. If people are allowed to kill themselves, why should they be without rights when they are no longer able to perform the act themselves?In medical ethics and medical law, patient autonomy is a central pivot. Patients have the right to refuse treatment even if this leads to their death. Shouldn’t people also have the right to determine the moment of dying, if they are in a situation which is unbearable, and without prospect of improvement? Another argument focuses on the duty of the physician to alleviate pain and suffering. If there is no other option, the doctor, in fulfilling this duty, should be allowed to actively end the patient’s life. This argument is not based on autonomy, but on beneficence.The debate concerning euthanasia involves fundamentally different moral principles. This makes the debate interesting, if not central to medical ethics and medical law. Yet, the principles are normally presented in an abstract way. Discussants stick to very general ideas, which lack reference to specific social and historical conditions, and are not related to concrete experiences. To invoke the Ten Commandments, or plea for a right to die, implies the use of universal standards, which tend to be general and empty.From a philosophical perspective, this type of argumentation can be criticized. Following Aristotle, ethics should be based upon experience. Ethical knowledge requires participation in concrete practices. Central to ethics is a feeling for the concrete situation, which is always contingent and historical. From this perspective, it makes sense to consider how practitioners in specific situations deal with moral issues, for instance concerning euthanasia. What role do they give to notions such as autonomy and beneficence, how do they interpret them and apply them to the concrete situation?In this paper I will present the Dutch experience with euthanasia. I will focus upon the way in which during the past thirty years the arguments in favour of euthanasia have been developed, in interaction with euthanasia practice. I will show that patient autonomy has been a crucial pivot. Yet, the Dutch interpretation of autonomy is not purely liberal. It does not only involve rights, but also obligations. Next, I will make clear that the physician plays a central role, in that the moral and legal basis of euthanasia is a conflict of duties on the side of the physician.This brings in the issue of beneficence. Yet the Dutch interpretation of the duty to help is not simply paternalistic. In Dutch health care, the physician-patient relationship is based upon deliberation and mutual agreement. Therefore, my conclusion will be that the Dutch practice of euthanasia has a moral ground, which goes beyond the traditional opposition between autonomy and beneficence. (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)

Law, Economics, and Morality examines the possibility of combining economic methodology and deontological morality through explicit and direct incorporation of moral constraints into economic models. Economic analysis of law is a powerful analytical methodology. However, as a purely consequentialist approach, which determines the desirability of acts and rules solely by assessing the goodness of their outcomes, standard cost-benefit analysis is normatively objectionable. Moderate deontology prioritizes such values as autonomy, basic liberties, truth-telling, and promise-keeping over the promotion of good (...) outcomes. It holds that there are constraints on promoting the good. Such constraints may be overridden only if enough good is at stake. While moderate deontology conforms to prevailing moral intuitions and legal doctrines, it is arguably lacking in methodological rigor and precision. Eyal Zamir and Barak Medina argue that the normative flaws of economic analysis can be rectified without relinquishing its methodological advantages and that moral constraints can be formalized so as to make their analysis more rigorous. They discuss various substantive and methodological choices involved in modeling deontological constraints. Zamir and Medina propose to determine the permissibility of any act or rule infringing a deontological constraint by means of mathematical threshold functions. Law, Economics, and Morality presents the general structure of threshold functions, analyzes their elements and addresses possible objections to this proposal. It then illustrates the implementation of constrained CBA in several legal fields, including contract law, freedom of speech, antidiscrimination law, the fight against terrorism, and legal paternalism. (shrink)

The principle of patient autonomy dominates the contemporary debate over medical ethics. In this examination of the doctor-patient relationship, physician and philosopher Alfred Tauber argues that the idea of patient autonomy -- which was inspired by other rights-based movements of the 1960s -- was an extrapolation from political and social philosophy that fails to ground medicine's moral philosophy. He proposes instead a reconfiguration of personal autonomy and a renewed commitment to an ethics of care. In this (...) formulation, physician beneficence and responsibility become powerful means for supporting the autonomy and dignity of patients. Beneficence, Tauber argues, should not be confused with the medical paternalism that fueled the patient rights movement. Rather, beneficence and responsibility are moral principles that not only are compatible with patient autonomy but strengthen it. Coordinating the rights of patients with the responsibilities of their caregivers will result in a more humane and robust medicine.Tauber examines the historical and philosophical competition between facts and values in medicine. He analyzes the shifting conceptions of personhood underlying the doctor-patient relationship, offers a "topology" of autonomy, from Locke and Kant to Hume and Mill, and explores both philosophical and practical strategies for reconfiguring trust and autonomy. Framing the practicalities of the clinical encounter with moral reflections, Tauber calls for an ethical medicine in which facts and values are integrated and humane values are deliberately included in the program of care. (shrink)

This paper argues that potential cases of oppression, such as sex trafficking, can sometimes comprise autonomous choices by the trafficked individuals. This issue still divides radical from liberal feminists, with the former wanting to ‘rescue’ the ‘victims’ and the latter insisting that there might be good reasons for ‘hiding from the rescuers.’ This article presents new arguments for the liberal approach and raises two demands: first, help organizations should be run by affected women and be open-minded about whether or not (...) the trafficked individuals should remain in the sex industry. Second, the career choices of trafficked individuals should be expanded by the introduction of an opportunity-extending right to asylum. (shrink)

Cases of paternalism usually involve disagreement between the paternalist and the paternalized subject. But not all the disagreements that give rise to paternalism are of the same kind and, as a result, not all instances of paternalism are morally on a par. There is, in other words, a moral difference between different kinds of paternalism, which can be explained in terms of the nature of the disagreements that give rise to the paternalism in the (...) first place. This paper offers a novel account of how to characterize the nature of these disagreements such that we can explain this moral difference. (shrink)

The basic relationship between people should be care, and the caring life is the highest which humans can live. Unfortunately, care that is not thoughtful slides into illegitimate intrusion on autonomy. Autonomy is a basic good, and we should not abridge it without good reason. On the other hand, it is not the only good. We must sometimes intervene in the lives of others to protect them from grave harms or provide them with important benefits. The reflective person, (...) therefore, needs guidelines for caring. Some contemporary moralists condemn paternalism categorically. This work examines weaknesses in their arguments and proposes new guidelines for paternalism, which it calls "parentalism" to avoid the patriarchal connotations of the old term. Its antiparentalism is more moderate than standard antipaternalism based on an exaggerated respect for autonomy. The work explores implications for both the personal sphere of interactions between individuals, such as friends and family members, and the public sphere of institutions, legislation, and the professional practices. (shrink)

Medical practitioners are duty-bound to tell their patients the truth about their medical conditions, along with the risks and benefits of proposed treatments. Some patients, however, would rather not receive medical information. A recent response to this tension has been to argue that that the disclosure of medical information is not optional. As such, patients do not have permission to refuse medical information. In this paper I argue that, depending on the context, the disclosure of medical information can undermine the (...) patient’s ability to exercise her autonomy or have therapeutically detrimental effects. In the light of these insights I go on to develop a context-sensitive approach to medical disclosure. The advantage of this account is that it addresses concerns on both sides of the debate; whilst it acknowledges that patients do not have an exercisable ‘right not to know,’ it allows that in some cases medical information ought to be withheld. (shrink)

A series of cases have crystallized disputes about when medical treatments are useful or futile, and consequently about the doctor-patient relationship, resource allocation, communication, empathy, relief of suffering, autonomy, undertreatment, overtreatment, paternalism and palliative care. It is helpful to understand that utility and futility are complimentary concepts and that judgments about whether treatments are useful or futile in the contested cases have common features. They are: (1) grounded in medical science, (2) value laden, (3) at or near the (...) threshold of utility, and (4) burdensome. No schema for linedrawing escapes borderline cases and we should focus upon justification of the empirical, ethical and evaluative components underlying these judgments, rather than make an arbitrary decision about whether doctors, patients or societal consensus should be the final arbiter. Keywords: futility, ethics, physician authority, consent CiteULike Connotea Del.icio.us What's this? (shrink)

This paper addresses the issue of paternalism in child-rearing. Since the parent–child relationship seems to be the linguistic source of the concept, one may be tempted to assume that raising a child represents a particularly appropriate sphere for paternalism. The parent–child relationship is generally understood as a relationship that is supposed to promote the development and autonomy-formation of the child, so that the apparent source of the concept is a form of autonomy-oriented paternalism. Far from (...) taking paternalism to be overtly unproblematic in such paradigmatic, pedagogical settings, this article analyzes how an effort should be made to understand a child’s capacities and which standards parents should be held to when deciding whether interference truly serves the child’s interests. (shrink)

The concept of paternalism is intricately tied to the concept of autonomy. It is commonly assumed that when paternalistic interventions are wrong, they are wrong because they impede individuals’ autonomy. Our aim in this paper is to show that the recent shift towards conceiving of autonomy relationally highlights a separate conceptual space for a nonpaternalistic kind of interpersonal intervention termed maternalism. We argue that maternalism makes a twofold contribution to the debate over the ethics of interpersonal (...) action and decision-making. Descriptively, it captures common experiences that, while not unusual in everyday life, are largely absent from the present discussion. Normatively, it describes a type of intervention with justification conditions distinct from the standard framework of paternalism. We explicate these contributions by describing six key differences between maternalism and paternalism, and conclude by anticipating and responding to potential objections. (shrink)

Recent legal rulings concerning the status of advance statements have raised interest in the topic but failed to provide any definitive general guidelines for their enforcement. I examine arguments used to justify the moral authority of such statements. The fundamental ethical issue I am concerned with is how accounts of personal identity underpin our account of moral authority through the connection between personal identity and autonomy. I focus on how recent Animalist accounts of personal identity initially appear (...) to provide a sound basis for extending the moral autonomy of an individual - and hence their autonomous wishes expressed through an advance directive - past the point of severe psychological decline. I argue that neither the traditional psychological account nor the more recent Animalist account of personal identity manage to provide a sufficient basis for extending our moral autonomy past the point of incapacity or incompetence. I briefly explore how analogies to similar areas in law designed to facilitate autonomous decision, such as wills and trusts, provide at best only very limited scope for an alternative justification for granting advance statements any legal or moral authority. I conclude that whilst advance statements play a useful role in formulating what treatment is in a patient’s best interests, such statements do not ultimately have sufficient moral force to take precedence over paternalistic best interest judgements concerning an individual’s care or treatment. (shrink)

Honoring a living will typically involves treating an incompetent patient in accord with preferences she once had, but whose objects she can no longer understand. How do we respect her precedent autonomy by giving her what she used to want? There is a similar problem with subsequent consent: How can we justify interfering with someone''s autonomy on the grounds that she will later consent to the interference, if she refuses now?Both problems arise on the assumption that, to respect (...) someone''s autonomy, any preferences we respect must be among that person''s current preferences. I argue that this is not always true. Just as we can celebrate an event long after it happens, so can we respect someone''s wishes long before or after she has that wish. In the contexts of precedent autonomy and subsequent consent, the wishes are often preferences about which of two other, conflicting preferences to satisfy. When someone has two conflicting preferences, and a third preference on how to resolve that conflict, to respect his autonomy we must respect that third preference. People with declining competence may have a resolution preference earlier, favoring the earlier conflicting preference (precedent autonomy), whereas those with rising competence may have it later, favoring the later conflicting preference (subsequent consent). To respect autonomy in such cases we must respect not a current, but a former or later preference. (shrink)

Among bioethicists, and perhaps ethicists generally, the idea that we are obliged to respect autonomy is something of a shibboleth. Appeals to autonomy are commonly put to work to support legal and moral claims about the importance of consent, but they also feed a wider discourse in which the patient’s desires are granted a very high importance and medical paternalism is regarded as almost self-evidently indefensible.

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)

Although the principle of respect for personal autonomy has been the subject of debate for almost 40 years, the conversation has often suffered from lack of clarity regarding the philosophical traditions underlying this principle. In this article, I trace a genealogy of autonomy, first contrasting Kant’s autonomy as moral obligation and Mill’s teleological political liberty. I then show development from Mill’s concept to Beauchamp and Childress’ principle and to Julian Savulescu’s non-teleological autonomy sketch. I argue (...) that, although the reach for a new principle to guide choices in physician–patient relationships can rightfully be seen as important, the notion that is now called autonomy within bioethics has corollaries that undermine critical aspects of medical care. As such, there is need for a richer account of the interplay between the free choice of patients and the informed recommendations of doctors. (shrink)

Is it allowable for your government, or anyone else, to influence or coerce you 'for your own sake'? This is a question about paternalism, or interference with a person's liberty or autonomy with the intention of promoting their good or averting harm, which has created considerable controversy at least since John Stuart Mill's On Liberty. Mill famously decried paternalism of any kind, whether carried out by private individuals or the state. In this volume of new essays, leading (...) moral, political and legal philosophers address how to define paternalism, its justification, and the implications for public policy, professional ethics and criminal law. So-called 'libertarian' or non-coercive paternalism receives considerable attention. The discussion addresses the nature of freedom and autonomy and the relation of individuals to law, policy and the state. The volume will interest a wide range of readers in political philosophy, public policy and the philosophy of law. (shrink)

Donald VanDeVeer probes the moral complexities of the question: under what conditions is it permissible to intervene invasively in the lives of competent persons--for example, by deception, force, or coercive threat--for their own good? In a work with broad significance for law, public policy, professional-client relations, and private interactions, he presents a theory of an autonomy-respecting" paternalism. Originally published in 1986. The Princeton Legacy Library uses the latest print-on-demand technology to again make available previously out-of-print books from (...) the distinguished backlist of Princeton University Press. These editions preserve the original texts of these important books while presenting them in durable paperback and hardcover editions. The goal of the Princeton Legacy Library is to vastly increase access to the rich scholarly heritage found in the thousands of books published by Princeton University Press since its founding in 1905. (shrink)

The objective of this article is to investigate ethical aspects of technology through the moral term “paternalism”. The field of investigation is medicine. The reason for this is twofold. Firstly, “paternalism” has gained moral relevance through modern medicine, where physicians have been accused of behaving paternalistic and threatening patients’ autonomy. Secondly, medicine is a brilliant area to scrutinise the evaluative aspects of technology. It is argued that paternalism is a morally relevant term for the (...) ethics of technology, but that its traditional conception is not adequate to address the challenges of modern technology. A modification towards a “technological paternalism” is necessary. That is, “technological paternalism” is a fruitful term in the ethics of technology. Moreover, it is suited to point out the deficiencies of the traditional concept of paternalism and to reform and vitalise the conception of paternalism in ethics in order to handle the challenges of technology. (shrink)

Presenting real life cases from clinical practice, this book claims that children can be conceived of as moral equals without ignoring the fact that they still are children and in need of strong family relationships. Drawing upon recent advances in childhood studies and its key feature, the ‘agentic child’, it uncovers the ideology of adultism which has seeped into much what has been written about childhood ethics. However, this book also critically examines those positions that do accord moral (...) equality to children but on grounds not strong enough to support their claim. It lays the groundwork for a theory of moral equality by assessing the concepts of parenthood, family, best interest, paternalism, and, above all, autonomy and trust which are so important in envisioning what we owe the child. It does not only show how children – like adults – should be considered moral agents from infancy but also how ethical theories addressing adults can significantly profit from recognizing this. The analysis takes into account contributions from European as well as American scholars and makes use of a wide range of ethical, psychological, cultural, and social-scientific research. (shrink)

Discusses Autonomy and Paternalism; becoming and ceasing to be a person, or human being; whether reductionism about persons undermines desert. It examines personal identity and commitments; the separateness of persons and principles of distributive justice – whether we should extend the scope of these principles, and give them less weight, whether the units for distributive principles should be lives, successive selves, or people at times, and how a reductionist view gives some support to the utilitarian rejection of distributive (...) principles. (shrink)

Respecting the autonomy of agents grounds various obligations to others such as non-interference, deference to her authority over self-regarding decisions, limitations on paternalism, and so on. According to a broadly liberal moral sensibility, respecting others in this way implies accepting the valuesValue they autonomously hold even if they are judged problematic, immoral, self-destructive, or otherwise non-ideal. In discussions of such respect, it is generally assumed that persons expressing that respect have no direct bearing on whether the subject (...) of that respect is herself autonomous. However, in many situations, persons interact in a way that helps establish or re-establish the autonomy of one or both of these agents themselves.For example, the would-be paternalist may be a therapist whose professional obligationObligations is to facilitate the process of re-establishing autonomy for vulnerable victims of traumaTrauma. In such scenarios, the usual lines between hardPaternalismhard and softPaternalismsoft paternalism, as well as the standard liberal rejection of the former, do not apply. Still, it would be wrong for the aid workerAid workers to simply impose her views of a decent life on the struggling person. How, then, do we reformulate restrictions on paternalism and other such normative strictures grounded in respect forAutonomyrespect for autonomy in scenarios where the relationshipRelationships between client and aid workerAid workers is itself a crucial part of the process that results in the self-governingSelf-governing agency of the client?This paper explores these issues and argues that such scenarios indicate that conceptions of autonomy must view the self as diachronic as well as socially constituted but also must be sensitive to the ways that autonomy can sometimes be established only with others’ help. In particular, the obligationObligations to remain relatively neutralNeutral toward the content of others’ values in showing respect forPersonsrespect for their autonomy must be reformulated to take into account the way interpersonal dynamics themselves help establish the autonomy with which persons hold the values that they hold. These observations are applied to certain cases of aid and care where such questions are central. (shrink)

This important new book develops a new concept of autonomy. The notion of autonomy has emerged as central to contemporary moral and political philosophy, particularly in the area of applied ethics. professor Dworkin examines the nature and value of autonomy and uses the concept to analyse various practical moral issues such as proxy consent in the medical context, paternalism, and entrapment by law enforcement officials.

ABSTRACT If it could be shown that law is, in some sense, a moral system the apparent contradiction between (moral) autonomy and (legal) heteronomy might be challenged. In order to prepare for such a challenge this paper questions the prevailing view that law is not in the business of enforcing morals. That is done primarily by using decisions of the criminal courts to show that the law does not always criminalise conduct merely to prevent harm to others. (...) Paternalism is distinguished from the harm principle in order to show that the law (rightly or wrongly) sometimes seeks to secure that which is (thought to be) morally good, irrespective of the prevention of harm, at least overall harm. If such an insight is well founded there are consequences for legal theory in that neither of the ruling paradigms (naturalism and positivism) seems able adequately to accommodate the view of law which emerges. Consequently, an attempt is made in the essay to develop a middle theory of law, between naturalism and positivism, which is referred to as ‘normative positivism‘. The theory presented has, in turn, consequences for political practice. If law can be seen as community morality rather than as merely the morality of officials, then everyone has a stake in the moral content of law and there may be good moral reasons for disobeying official laws. Civil disobedience is the citizen's ultimate resort against the official morality that has appropriated to itself the eulogistic name of ‘law‘. That law may be seen as community morality also calls into question some ruling paradigms as to the nature of morality but, if the claim can be sustained, then the legal system may be seen as applied moral philosophy in action. (shrink)

Several influential characterizations of paternalism or its distinctive wrongness emphasize a belief or judgement that it typically involves—namely, 10 the judgement that the paternalized is likely to act irrationally, or some such. But it's not clear what about such a belief can be morally objectionable if it has the right epistemic credentials (if it is true, say, and is best supported by the evidence). In this paper, I elaborate on this point, placing it in the context of the relevant (...) epistemological discussions. I explain how 15 evidentialism is opposed to such thoughts; I show that possible ways of rejecting evidentialism (along lines analogous to those of pragmatic encroachment) won't work; and I sketch an account of the wrongness of paternalism that doesn't depend on any flaw in the belief about others' likely behaviour. (shrink)

Paternalistic interventions restrict individuals’ liberty or autonomy so as to guide their decisions towards options that are more beneficial for them than the ones they would choose in the absence of such interventions. Although some philosophers have emphasised that there is a case for justifiable paternalism in certain circumstances, much of contemporary moral and political philosophy works from a strong presumption against paternalistic interventions. However, Richard Arneson has argued that there are egalitarian reasons that support the case (...) for paternalism: paternalistic interventions can protect poor decision-makers from making ‘bad’ choices, thus preventing inequalities between them and those with better decision-making skills. This paper seeks to clarify and advance our understanding of the egalitarian argument for paternalism. Arneson’s argument adds an important and often neglected dimension to the debate about paternalism but also raises a number of questions about equality, paternalism and the relationship between the two. (shrink)

abstract Debate about physician‐assisted suicide has typically focused on the values of autonomy and patient wellbeing. This is understandable, even reasonable, given the import‐ance of these values in bioethics. However, these are not the only moral values there are. The purpose of this paper is to examine physician‐assisted suicide on the basis of the values of equality and justice. In particular, I will evaluate two arguments that invoke equality, one in favour of physician‐assisted suicide, one against it, and (...) I will eventually argue that a convincing equality‐based argument in support of physician‐assisted suicide is available. I will conclude by showing how an equality‐based perspective transforms some secondary features of debate about this issue. (shrink)

Introduction -- Self-definition -- Self-realisation -- Self-unification -- Self-constitution -- Application -- The autonomy of agents -- Paternalism, consent, and moral responsibility -- Autonomy under oppression -- Aids to autonomy.

There has been a significant increase in the use of radiological services in the past 30 years. There are many reasons for this, but one has received little attention: the increased role of patient autonomy in healthcare. Patients demand x rays, CT scans, MRI, and positron emission tomography scans. The key question in this article is how a moral principle, such as respect for patient autonomy, can influence the extension of radiological services. A literature review reveals how (...) patient autonomy is acknowledged in radiology, and how it is used both to explain and to justify the increase in radiological examinations. Furthermore, it also shows how the premises favouring patients’ exercise of their autonomy are not always present, which makes patient autonomy subject to adverse side effects and even abuse. Patient autonomy can be used to reduce the professionals’ responsibility for radiological examinations , to increase the popularity of the profession , to increase the income of the professionals or their institutions, and to promote professional activity. Patient autonomy intended to reduce paternalism, to legitimise otherwise morally unjustifiable actions , and to protect patients, can easily be used as a moral means for opposite ends. These adverse effects are not peculiar to radiology. However, they emerge particularly clearly in explanations and justifications of the substantial increase in radiological services, as well as in debates on overuse of radiological services. (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.

Are there any deep or systematic connections between paternalism and people's rights? Perhaps the connection is definitional: part of what makes an action or policy paternalistic is that it violates a right. Or perhaps the connection is normative: paternalism is (always? often? only sometimes?) morally problematic because it violates people's rights (even if we don't define "paternalism" in terms of a rights violation). My main goal in this paper is to argue for the normative connection. Part of (...) the task will be to explain exactly what the normative connection is. That will involve answering the questions embedded in the claim as well as offering an account of the right(s) that is (are) connected to paternalism's normative status. (shrink)

In this article I argue for a particular analysis of paternalism. I start by examining Dworkin's conditions for the paternalist act and make a case for alternative conditions. I argue that the paternalist actor acts irrespective of what she believes the wishes of the target of her action are and the paternalist actor acts because she has a positive epistemic standing that the act may or will improve the welfare of the target of her action. I also argue that (...) it is consistent with my analysis that there are paternalist acts that don't interfere with the autonomy of the object of the paternalist act. I describe some such acts and make the case that such acts, when they are paternalist acts, may be morally permissible and outline the factors that bear on their permissibility. Finally I locate my analysis in the literature by comparing it to a number of other accounts. (shrink)

Such thinkers as John Stuart Mill, Gerald Dworkin, and Richard Doerflinger have appealed to the value of freedom to explain both what is wrong with slavery and what is wrong with selling oneself into slavery. Practical ethicists, including Dworkin and Doerflinger, sometimes use selling oneself into slavery in analogies intended to illustrate justifiable forms of paternalism. I argue that these thinkers have misunderstood the moral problem with slavery. Instead of being a central value in itself, I argue that (...) freedom is a means of serving the real value of autonomy. Moreover, I argue that autonomy is ambiguous. In cases of conflict, autonomous choice, here called "shallow autonomy", can justifiably be limited to serve "deep autonomy", or self-rule. I use these notions to give a better understanding of the problem with selling oneself into slavery, and argue that the work of Dworkin has to be seriously revised, and Doerflinger's position has to be given up altogether.\\\ John Stuart Mill, Gerald Dworkin y Richard Doerflinger han recurrido al valor de la libertad para explicar tanto porque está mal moralmente la esclavitud como venderse uno mismo como esclavo. Los teóricos de la ética práctica, incluidos Dworkin y Doerflinger, a veces utilizan el caso de venderse uno mismo como esclavo en analogias que pretenden ilustrar formas justificables de paternalismo. Sostengo que estos pensadores han malinterpretado el problema moral con la esclavitud. Argumento que en lugar de ser un valor fundamental en si mismo, la libertad es un medio para el valor real de la autonomia. Arguyo, por otra parte, que la autónomia es ambigua. En casos de conflicto, la elección autonóma, denominada aqui "autonomia superficial", puede justificadamente estar limitada a servir a la "autonomia profunda", o autogobierno. Utilizo estas nociones para ofrecer una mejor interpretatión del problema moral con venderse uno mismo como esclavo, y sostengo que la obra de Dworkin se debe revisar con seriedad, y que se debe abandonar por completo la postura de Doerflinger. (shrink)

Introduction -- Self-definition -- Self-realisation -- Self-unification -- Self-constitution -- Application -- The autonomy of agents -- Paternalism, consent, and moral responsibility -- Autonomy under oppression -- Aids to autonomy.

Many people feel that respecting a person’s autonomy is not sufficiently important to obligate us to stay out of their affairs in all cases; but the ground for interference may often turn out to be a hunch that the agent cannot really be competent, or cannot really know what her decision implies; for if she were both of these things, surely she would not make such a foolish decision. This paper suggests a justification of paternalism that does not (...) rely on such appeals. I argue that in cases where an agent will undergo a significant alteration in their evaluative outlook – ‘evaluative shift’ – three central, persuasive objections to paternalism lose their force, and offer a prima facie case for paternalism in some of these cases. I then suggest that we can extend this argument to some cases where evaluative alteration is not predictable, but where the risk and harm are both significant. In such cases, paternalism may be justified. (shrink)

Within a framework of rights that protects children's interests and seek to balance their developing interests in welfare and agency, I consider how contexts of war impact children's lives to argue that such contexts provide opportunities to advance or set back both the development of moral powers, namely capacities for a sense of justice and a conception of the good, and capacities for autonomy. Besides an interest in satisfying their basic needs and protection, children have an interest in (...) developing their moral powers and growing into autonomous agents. Evidence shows great variation in children's responses to traumatic circumstances, from severe psychological disorders to enhanced resiliency and moral reasoning. As moral powers and autonomy ground the permissibility for paternalistic treatment and the exclusion of children from certain rights, I argue that once the war is over children are entitled to an adequate assessment of how their interests and capacities have changed. For children whose development was set back, states should grant opportunities for recovery and further development, which suggests strengthening welfare and protection rights; while for children whose development was advanced, states should recognize such advancement and grant opportunities for the exercise of their newfound capacities, which suggests granting certain agency rights alongside welfare and protection. (shrink)

Seat belt mandates seem like a paradigmatic case of justified paternalism. Even those who generally object to paternalism often concede that seat belt laws are justified. Against this near-consensus in favor of mandates, I argue that seat belt laws are unjust and public officials should not enforce them. The most plausible exceptions to a principle of anti-paternalism do not justify seat belt mandates. Some argue that seat belt mandates are not paternalistic because unbelted riders are not fully (...) autonomous. Others claim that the decision to ride unbelted harms other people. Yet these attempts to defend seat belt mandates on non-paternalistic grounds cannot overcome the case against seat belt mandates. I therefore conclude that even seat belt mandates are unjust. With this comprehensive case against seat belt mandates, I demonstrate the more general difficulties in justifying any form of coercive paternalism. (shrink)

This paper is concerned with the practical importance of different forms of paternalism for educational theory and practice. Contrary to the traditional treatment of paternalism as a sometimes necessary and rather messy aspect of educational practices, I demonstrate that paternalism is to be regarded as an “indigenous concept” of educational theory and as the ‘indigenous model of justification’ that underlies the structure of educational practices. Based on an analysis of the intricate nexus between autonomy-oriented forms of (...) paternalism and educational forms of autonomy-based perfectionism I furthermore argue that a perfectionistically structured conception of autonomy provides a more adequate evaluative framework for justifying autonomy as an educational aim than alternative educational regimes of autonomy can deliver. Finally, I discuss some major theoretical problems of bridging the gap between general ethical principles and their application in practical fields. (shrink)

Advance directives are intended to extend patient autonomy by enabling patients to prospectively direct the care of their future incapacitated selves. There has been much discussion about issues such as whether the future incompetent self is identical to the agent who issues the advance directives or whether advance directives can legitimately secure patient autonomy. However, there is another important question to ask: to what extent and in what conditions is it ethically appropriate for one to limit the liberty (...) or agency of one’s future incompetent self by issuing an advance directive? -/- In this paper, I use a virtue-ethical approach to explore this question, focusing on the case of an advance directive for the future self with moderate dementia. First, I examine virtuous attitudes with regard to autonomy and argue that one can manifest vices or ethically undesirable character traits in trying to intervene in the future self’s life. In particular, I argue that this case can manifest vices such as disdainfulness, intellectual arrogance, and self-dictatorship, which is the vice of trying to control one’s life to an excessive degree, and that a self-dictator fails to give due moral consideration to the future self’s liberty or agency. I then introduce the Daoist idea of wu-wei, which recommends embracement of what happens in one’s life, as one of the possible remedies for the overemphasis on the value of autonomy and control. (shrink)