In this paper I get clearer on the considerations that ought to inform the evaluation and development of medico-legal competency criteria—where this is taken to be a question regarding the abilities that ought to be needed for a patient to be found competent in medico-legal contexts. In the “Decisional Competency in Medico-Legal Contexts” section I explore how the question regarding the abilities that ought to be needed for decisional competence is to be interpreted. I begin by considering an (...) interpretation that takes the question to be asking about the abilities needed to satisfy an idealized view of competent decision-making, according to which decisional competency is a matter of possessing those abilities or attributes that are needed to engage in good or effective or, perhaps, substantially autonomous or rational decision-making. The view has some plausibility—it accords with the way decisional competency is understood in a number of everyday contexts—but fails as an interpretation of the question regarding the abilities that should be needed for decisional competence in medico-legal contexts. Nevertheless, consideration of why it is mistaken suggests a more accurate interpretation and points the way in which the question regarding the evaluation of medico-legal competency criteria is to be answered. Building on other scholarly work in the area, I outline in the “Primary and Secondary Requirements” section several requirements that decisional competence criteria ought to satisfy. Then, in the “Applying the Framework” section, I say something about the extent to which medico-legal competency criteria, as well as some models of decisional competency proposed in the academic literature, fulfil those requirements. (shrink)

Limits to paternalism are, in the liberal democracies, partially defined by the concepts of decision-making capacity/incapacity (mental competence/incompetence). The paper is a response to Ian Wilkss (1997) recent attempt to defend the idea that the standards for decisional capacity ought to vary with the degree of risk incurred by certain choices. Wilkss defense is based on a direct appeal to the logical features of examples and analogies, thus attempting to by-pass earlier criticisms (e.g., Culver Gert, 1990) of risk-based standards. (...) Wilkss argument is found wanting on the grounds that he misconstrues the logic of such capacity, especially in accounting for conceptual and pragmatic ties with issues of decisional authority. A diagnosis is offered as to the source of Wilkss error (the assumption that mental competence is a species of wider genus of competence), and an alternative way of accounting for risk within the predominant contemporary legal framework is sketched. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Appreciating Anorexia:Decisional Capacity and the Role of ValuesThomas Grisso (bio) and Paul S. Appelbaum (bio)Keywordscompetence, consent, anorexia, appreciation, decision makingTan and her colleagues (2006) reported that persons with anorexia nervosa typically manifest no difficulty satisfying the criteria for abilities associated with competence to consent to or refuse treatment. Their results led them to conclude that these patients generally had no problem grasping the nature of anorexia and its (...) possible consequences (understanding), typically did not have difficulty processing information when making treatment decisions (reasoning), and usually neither denied that they had a disorder nor manifested distorted beliefs about the potential consequences of treatment for the disorder.Nevertheless, these authors found, some anorexia patients said that they knew they might die and that they would rather die than suffer the alternative consequences (e.g., loss of identity, feeling of being disgusting). They point out that these beliefs, suggesting questionable competence, were not identified by the usual criteria for competence to consent to treatment. Therefore, they propose that we should consider a modification of the criteria for competence to consent to treatment. They argue for inclusion of "pathological values" as the basis for a finding of incompetence. Their notion of a pathological value (as we summarize it based on their Discussion) includes (a) a personal value (b) on which treatment refusal is based, that (c) is not authentic, and (d) is due to a mental disorder.Second, Tan and colleagues were concerned that the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), currently used widely to assess competence to consent to treatment, did not seem to take values into account when examining deficits related to lack of appreciation or reasoning. They point out that most patients with anorexia nervosa in their study had "pathological values" that influenced their thinking about treatment, yet they did not obtain poor scores on the instrument's appreciation scale, which assesses whether patients deny that they have the illness or offer reasons for accepting or refusing treatment that are based on delusional premises or a serious distortion of reality. Moreover, almost all of the anorexia patients in the study obtained adequate scores on reasoning, which examines the ability to process options and consequences when weighing a treatment decision. [End Page 293]Reasons for Caution in Altering Criteria for CompetenceA fundamental step in considering Tan and her co-worker's proposal is to examine whether it is necessary to add a concept of "pathological values" to the legal construct of competence to consent to treatment. Modifying the legal doctrine of consent is important if that is needed to improve its validity or reliability. But modifications of the doctrine would have considerable costs, including a long process of producing logical and empirical evidence for its necessity, developing methods to assess the new concept, and then a process of debate, persuasion, and education to change laws, ethical guidelines, and medical training. Moreover, principles of theory building urge parsimony. A theory should employ no more concepts or assumptions than are required to account for the phenomena that the theory seeks to organize or explain. So one must be sure that modifications are truly necessary before adding complexity to the theory of decisional competence.In addition, there is an inherent danger in altering a concept like competence to consent to treatment on the basis of the study of any one mental disorder. It is not at all clear how the modification might influence findings of competence when applied to other disorders. Using a study of patients with anorexia nervosa as the impetus for changing the competence concept runs this risk. For example, anorexia is one of a class of mental disorders that is characterized by a failure to abstain from behavior (here, limiting food intake and other behaviors designed to reduce weight) that has negative consequences for the person. Other conditions in this category might include substance abuse disorders and impulse control disorders (e.g., pathological gambling). Even if one concludes that revised criteria for competence would reduce false-positive findings of competence in this group of disorders, one would have to consider carefully its impact on the full range of disabling mental conditions.Moreover, the sensitivity... (shrink)

Objective Although patients exercise greater autonomy than in the past, and shared decision making is promoted as the preferred model for doctor-patient engagement, tensions still exist in clinical practice about the primary locus of decision-making authority for complex, scarce, and resource-intensive medical therapies: patients and their surrogates, or physicians. We assessed physicians’ attitudes toward decisional authority for adult venoarterial extracorporeal membrane oxygenation (VA-ECMO), hypothesizing they would favor a medical locus. Design, Setting, Participants A survey of resident/fellow physicians (...) and internal medicine attendings at an academic medical center, May to August 2013. Measurements We used a 24-item, internet-based survey assessing physician-respondents’ demographic characteristics, knowledge, and attitudes regarding decisional authority for adult VA-ECMO. Qualitative narratives were also collected. Main Results A total of 179 physicians completed the survey (15 percent response rate); 48 percent attendings and 52 percent residents/ fellows. Only 32 percent of the respondents indicated that a surrogate’s consent should be required to discontinue VA-ECMO; 56 percent felt that physicians should have the right to discontinue VA-ECMO over a surrogate’s objection. Those who self-reported as “knowledgeable” about VA-ECMO, compared to those who did not, more frequently replied that there should not be presumed consent for VA-ECMO (47.6 percent versus 33.3 percent, p = 0.007), that physicians should have the right to discontinue VAECMO over a surrogate’s objection (76.2 percent versus 50 percent, p = 0.02) and that, given its cost, the use of VA-ECMO should be restricted (81.0 percent versus 54.4 percent, p = 0.005). Conclusions Surveyed physicians, especially those who self-reported as knowledgeable about VA-ECMO and/or were specialists in pulmonary/ critical care, favored a medical locus of decisional authority for VA-ECMO. VA-ECMO is complex, and the data may (1) reflect physicians’ hesitance to cede authority to presumably less knowledgeable patients and surrogates, (2) stem from a stewardship of resources perspective, and/or (3) point to practical efforts to avoid futility and utility disputes. Whether these results indicate a more widespread reversion to paternalism or a more circumscribed usurping of decisional authority occasioned by VA-ECMO necessitates further study. (shrink)

Many state laws specify procedures for determining surrogate or proxy decision-makers for end-of-life care in the absence of an advance directive, living will, or other designation. Some laws also set forth criteria that the decision-maker must follow when making medical decisions for an incapacitated patient and determining whether to withdraw life-sustaining treatment. This article provides analysis of a medical ethics case on the question of how to address family allegations that the proxy decision-maker suffers from dementia and is unable to (...) make decisions for the patient. Cases such as this involve interwoven legal and ethical considerations including: how to address concerns that the proxy is making questionable or unreasonable decisions, how to evaluate the proxy's decisional capacity, strategies for enhancing communication, and standards for removing a proxy. This article suggests that “surrogacy ladders” in state law serve not only as a procedural mechanism, but also protect important ethical values such as tiers of moral authority for decision-making, relational autonomy, and privacy. (shrink)

An increasing vaccine hesitancy among parents, which has resulted in insufficient rates of immunization, provides reason to reconsider childhood vaccination practices. Studies suggest that parents' decision-making process concerning whether to vaccinate their child is highly influenced by cognitive biases. These biases can be utilized to increase vaccination uptake via changes in the choice context. This article considers childhood vaccination programmes, which involve children being vaccinated in school or daycare unless their parents actively ‘opt out’. We suggest that such programmes reconcile (...) parents' decisional authority and vaccination duties. First, opt-out childhood vaccination based in schools or daycare centres are not disrespectful of parental authority. Second, the programme aligns the default setting with a moral obligation to vaccinate one's child that most parents have. (shrink)

An increasing vaccine hesitancy among parents, which has resulted in insufficient rates of immunization, provides reason to reconsider childhood vaccination practices. Studies suggest that parents' decision‐making process concerning whether to vaccinate their child is highly influenced by cognitive biases. These biases can be utilized to increase vaccination uptake via changes in the choice context. This article considers childhood vaccination programmes, which involve children being vaccinated in school or daycare unless their parents actively ‘opt out’. We suggest that such programmes reconcile (...) parents' decisional authority and vaccination duties. First, opt‐out childhood vaccination based in schools or daycare centres are not disrespectful of parental authority. Second, the programme aligns the default setting with a moral obligation to vaccinate one's child that most parents have. (shrink)

In “Conscientious of the Conscious: Interactive Capacity as a Threshold Marker for Consciousness” (2013), Fischer and Truog argue that recent studies showing that some patients diagnosed as being in a vegetative state are in fact in a minimally conscious state raise various ethical questions for clinicians and family members. I argue that these findings raise a further ethical dilemma about how and whether to seek the involvement of the minimally conscious person herself in decisions about her care. There may be (...) a conflict between doing what is believed to accord with the patient’s prior stated wishes and/or her best interests, on the one hand, and respecting her own potential decision-making capacity and epistemic authority, on the other. (shrink)

En este trabajo se defiende la existencia de un lugar específico para las decisiones de política educativa. Las decisiones de política educativa se presentan como un tipo de decisión ubicado entre la decisión técnica y la decisión moral. La racionalidad política, situada entre la racionalidad moral y la racionalidad científico-tecnológica, tiene una especial relevancia en el ámbito de la educación. Las decisiones de política educativa que no se confunden con la teoría interpretativa denominada Política de la Educación, ni con la (...) teoría práctica denominada Política Pedagógica, usan el conocimiento de la educación. En el trabajo se analiza con detenimiento la posibilidad de los hechos y las decisiones pedagógicas. El carácter axiológico de los hechos hace posible hablar de la orientación de la acción con fundamento en el conocimiento del propio proceso. Se mantiene que la decisión técnica es específica de la Pedagogía y su techo superior es el ámbito de la decisión moral. A su vez, las decisiones de política educativa se estudian en su especificidad y se concluye que los dos grandes errores en la polémica "ciencia-moral-política" son el reduccionismo del proceso al ciencismo o la subsunción de toda decisión en la decisión moral. El trabajo concluye que las peculiaridades de la decisión de política educativa, obligan a considerar que las finalidades no son criterios de decisión externos al sistema, sino constantes aceptadas provisionalmente en los procesos de planificación. Esta posición va más allá del esquema causal medios-fines y de la concepción taylorista de la organización, para defender frente a las largas cadenas de derivación de fines la formación de subsistemas de toma de decisiones. /// This article is engaged in upholding the appropiate place for decisions in Educational Politics and Policy. All that inside the knowledge of Education. Political decision making in the educational arena has got a place between technical decisions and moral decisions. That one has increasedy its relevance in educational forum. On the other point of view, this kind of decision must mot be understood as a result of the discipline "Politics of Education" or as a consequence of practical theories which are known like "Politica Pedag6gica" (Pedagogy into Politics). Decisions in educational policy are applied knowledge of Education but they are not made only with pedagogical facts and technical decisions. It's posible to think of technical decisions as the ones which come not only from the process, but from the knowledge of the process in its own. Pedagogy as a discipline of education let you make technical decisions. Upper these ones, we find the moral decision. To study the special characteristics of political decisions shows two bigs mistakes into the controversy "Science-Moral-Politics": scientism and moral subsunction of Political decision in that. In the last pages, this work goes beyond the causal relation between "means-ends". The authors suggest, for the field of goals, to make subsystem levels for decision making, in stead of using the taylorist model in order to organize several stages of goals. (shrink)

When mature minors face a decision with important consequences, such as whether to undergo a risky but potentially life-saving medical procedure, who should decide? Relying on liberal political theory’s account of the importance of decisional autonomy for adults, and given the scalar nature of the capacities needed to exercise decisional autonomy, I argue that mature minors with the requisite capacities and commitments have a right to decisional autonomy though they are not yet 18. I argue for this (...) right using a ‘balancing of interest’ account of rights: the interest mature minors have in decisional autonomy outweighs their parents’ interest in shaping their children as a means of ‘creative self-extension’. But I propose two limitations on this right: requests for waivers of the rule that one must be at least 18 to decide cannot be so numerous as to make adjudication impractical; and though a competent adult’s voluntary decision to refuse medical treatment should generally be respected, the state may reject a mature minor’s decision upon review by an indifferent judge of the minor’s capacities and reasons. The judge reviews not the substantive merits or prudence of the decision, but whether the decision promotes the interest in decisional autonomy, by asking among other things whether the decision is the minor’s own, is tethered to core commitments rather than based on arbitrary preferences, and could be regarded as reasonable to the minor’s ‘future self’. (shrink)

Hastings Center Report, Volume 52, Issue 1, Page 4-7, January/February 2022.

Inherent in providing healthcare for youth lie tensions among best interests, decision-making capacity, rights, and legal authority. Transgender youth experience barriers to needed gender-affirming care, often rooted in ethical and legal issues, such as healthcare provider concerns regarding youth capacity and rights to consent to hormone therapy. Even when decision-making capacity is present, youth may lack the legal authority to give consent. The aims of this paper are therefore to provide an empirical analysis of minor trans youth capacity (...) to consent to hormone therapy and to address the normative question of whether there is ethical justification for granting trans youth the authority to consent to this care. Through qualitative content analysis of interviews with trans youth, parents, and healthcare providers, we found that trans youth demonstrated the understandings and abilities characteristic of the capacity to consent to hormone therapy and that they did consent to hormone therapy with positive outcomes. Employing deontological and consequentialist reasoning and drawing on a foundation of empirical evidence, human rights, and best interests we conclude that granting trans youth with decisional capacity both the right and the legal authority to consent to hormone therapy via the informed consent model of care is ethically justified. (shrink)

How ought we to understand the sources and limits of the authority of family members to make health care decisions for their decisionally incapacitated relatives? This question is becoming increasingly crucial as the population ages and the power of medical technology waxes. It is also becoming increasingly contested, as faith in advance directives shows signs of waning, and the moral complexities of intimate relationship become more theoretically patent.This last point—the newly visible moral richness of intimate relationship—provides this paper with (...) its field. I am interested in probing the images of the relationship between self and other, particularly self and intimate other, that seem presupposed by some leading attempts to determine the basis for proxy decision-making authority, and what constraints it must observe. In the light of both recent work in the philosophy of mind and considerations closer to common experience, the reigning images seem too slight to support the weight of current practices and beliefs about proxy authority; supplanting them with images more faithful to our experience will have implications for our practice with proxies. (shrink)

Drawing on the principle of subsidiarity, this article develops a framework for allocating medical decision-making authority in the absence of capacity to consent and argues that decisional authority in paediatric transgender healthcare should generally lie in the patient. Regardless of patients’ capacity, there is usually nobody better positioned to make medical decisions that go to the heart of a patient’s identity than the patients themselves. Under the principle of subsidiarity, decisional authority should only be held (...) by a higher level decision-maker, such as parents or judges, if lower level decision-makers are incapable of satisfactorily addressing the issue even with support and the higher level decision-maker is better positioned to satisfactorily address the issue than all lower level decision-makers. Because gender uniquely pertains to personal identity and self-realisation, parents and judges are rarely better positioned to make complex medical decisions. Instead of taking away trans youth’s authority over their healthcare decisions, we should focus on supporting their ability to take the best possible decision for themselves. (shrink)

Based on extensive questionnaire data, this paper focuses on parents’ views about children’s right to decide about participation in research. The data originates from 4000 families participating in a longitudinal prospective screening as 1997. Although current regulations and recommendations underline that children should have influence over their participation, many parents in this study disagree. Most (66%) were positive providing information to the child about relevant aspects of the study. However, responding parents were split about whether or not children should at (...) some point be allowed decisional authority when participating in research: 41.6% of the parents reported being against or unsure. Those who responded positively believed that children should be allowed to decide about blood-sampling procedures (70%), but to a less extent about participation (48.5%), analyses of samples (19.7%) and biological bank storage (15.4%). That as many as possible should remain in the study, and that children do not have the competence to understand the consequences for research was strongly stressed by respondents who do not think children should have a right to decide. When asked what interests they consider most important in paediatric research, child autonomy and decision-making was ranked lowest. We discuss the implications of these findings. (shrink)

BackgroundResearchers conducting community-based participatory action research (CBPAR) in highly collectivistic and socioeconomically disadvantaged community settings in sub-Saharan Africa are confronted with the distinctive challenge of balancing universal ethical standards with local standards, where traditional customs or beliefs may conflict with regulatory requirements and ethical guidelines underlying the informed consent (IC) process. The unique ethnic, socioeconomic, and cultural diversities in these settings have important implications for the IC process, such as individual decisional autonomy, beneficence, confidentiality, and signing the IC document.Main (...) textDrawing on insights and field observations from conducting CBPARs across several rural, highly communal, low literate, and low-income communities in Ghana, we discuss some theoretical, ethico-cultural, and methodological challenges associated with applying the universal, Western individualistic cultural value-laden IC process in sub-Saharan Africa. By citing field situations, we discuss how local cultural customs and the socioeconomic adversities prevalent in these settings can influence (and disrupt) the information disclosure process, individual decisional authority for consent, and voluntariness. We review the theoretical assumptions of the Declaration of Helsinki’s statement on IC and discuss its limitations as an ultimate guide for the conduct of social science research in the highly communal African context. We argue that the IC process in these settings should include strategies directed at preventing deception and coercion, in addition to ensuring respect for individual autonomy. We urge Universities, research institutions, and institutional review boards in Africa to design and promote the use of context-appropriate ethical IC guidelines that take into consideration both the local customs and traditional practices of the people as well as the scientific principles underpinning the universal IC standards.ConclusionWe recommend that, rather than adopt a universal one-size-fits-all IC approach, researchers working in the rural, highly collectivistic, low literate, socioeconomically disadvantaged settings of sub-Saharan Africa should deeply consider the roles and influence of cultural values and traditional practices on the IC and the research process. We encourage researchers to collaborate with target communities and stakeholders in the design and implementation of context-appropriate IC to prevent ethics dumping and safeguard the integrity of the research process. (shrink)

Over the past decade or so, the predominant patient-centered ethos in American bioethics has come under attack by critics who claim that it is morally deficient in certain respects, particularly when viewed in the context of acute-care decisionmaking. One line of criticism has been that the current ethic of patient autonomy gives an individual competent patient far too much decisional authority over the terms of his own treatment so that the patient is at complete liberty to neglect the (...) ways in which his medical decisions can drastically and negatively affect the lives of other family members. Given that family members must help shoulder the financial, emotional, and rehabilitative burdens involved in the patient's care, it has been argued that they too have a legitimate interest in choosing what sort of medical treatment the patient eventually receives. Another closely related line of criticism is that the prevailing focus on patient autonomy gives short shrift to the moral significance of the family as a genuine community. Echoing a view of the person advanced by most communitarian political theorists, some commentators have argued that the patient comes to the clinic so thoroughly embedded in a complex web of familial relationships and obligations that it does not make sense to identify him as the only person in the family to make decisions about treatment. (shrink)

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

Families play an essential role in deceased organ procurement. As the person cannot directly communicate his or her wishes regarding donation, the family is often the only source of information regarding consent or refusal. We provide a systematic description and analysis of the different roles the family can play, and actions the family can take, in the organ procurement process across different jurisdictions and consent systems. First, families can inform or update healthcare professionals about a person’s donation wishes. Second, families (...) can authorize organ procurement in the absence of deceased’s preferences and the default is not to remove organs, and oppose donation where there is no evidence of preference but the default is to presume consent; in both cases, the decision could be based on their own wishes or what they think the deceased would have wanted. Finally, families can overrule the known wishes of the deceased, which can mean preventing donation, or permitting donation when the deceased refused it. We propose a schema of 4 levels on which to map these possible family roles: no role, witness, surrogate, and full decisional authority. We conclude by mapping different jurisdictions onto this schema to provide a more comprehensive understanding of the consent system for organ donation and some important nuances about the role of families. This classificatory model aims to account for the majority of the world’s consent systems. It provides conceptual and methodological guidance that can be useful to researchers, professionals, and policymakers involved in organ procurement. (shrink)

Frail and elderly persons approaching end of life who suffer cardiac arrest are often subject to rigorous, undignified, and inappropriate resuscitation attempts despite poor outcomes. This scoping review aims to investigate how people feel about the appropriateness of CPR in this population. This review was guided by the PRISMA-ScR methodological framework. A search strategy was developed for four online databases (MEDLINE, EMCARE, PSYCHINFO, CINAHL). Two reviewers were utilised for title/abstract screening, full text review and data extraction. Full text, peer reviewed (...) studies were eligible for inclusion which discussed perspectives in the frail and/or elderly population with a focus on cardiopulmonary resuscitation (CPR). The database search yielded 3693 references (MEDLINE n = 1417, EMCARE n = 1505, PSYCHINFO n = 13, CINAHL n = 758). Following removal of duplicates (n = 953), title and abstract screening was performed on 2740 papers. A total of 2634 articles did not meet the inclusion criteria. Twenty-five studies were included in the scoping review and analysed for data extraction. Five themes emerged: (i) Preferences towards CPR, (ii) Preferences against CPR, (iii) Poor knowledge of CPR/Estimated survival rates, (iv) Do Not Resuscitate Orders, and (v) Decisional authority. This scoping review maps and describes the common perspectives shared by CPR stakeholders in the frail/elderly population. Findings revealed CPR decisions are often made based on incorrect knowledge, DNAR orders are frequently underused, CPR decisional authority remains vague and healthcare professionals have mixed views on the appropriateness of CPR in this population. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Introduction to the Special Issue on Pediatric Decision-MakingErica K. SalterUnlike in the traditional decisional dyad in adult-based care, pediatric decision-making typically involves a triadic relationship among the patient, their parents, and the health-care providers. This complex relationship raises questions and concerns regarding each party’s expectations, obligations, and authority. For example, should a parent be allowed to withhold a poor diagnosis from an adolescent patient? Should an HLA-matched (...) six-year-old sister be permitted to serve as a bone marrow donor for her older sibling with lysosomal storage disease? Or, should parents be given decisional authority to consent to gender-affirming care for an adolescent with gender dysphoria? Cases like these are among the most ethically challenging decisions faced by parents and health-care providers because they present competing interests and values, and it’s not always clear what is in the best interests of the child.In the context of American medicine, the best interest standard has been identified as the primary ethical and legal guide for decision-making. In its most prominent form, the best interest standard requires parents and pediatric practitioners to choose the medical treatment that maximizes benefits and minimizes harms to the particular child in question. However, over the past few decades, the standard has come under significant scrutiny, with discussions and debate in the academic bioethics literature asking whether the standard is able to serve the [End Page 181] purposes it is thought to serve and whether alternative standards might be better suited to the task(s). Despite vigorous interest in these issues, the academic literature did not seem to generate any sense of identifiable consensus about how others ought to make health-care decisions on behalf of children.Thus, in June 2022, 17 scholar-experts on pediatric decision-making standards gathered in St. Louis, MO, for a three-day symposium of discussion and consensus-building. The participating authors represented different disciplinary perspectives and different viewpoints in the debate about guidance principles that underlie pediatrics. Despite apparent disagreement about such standards in the literature, the group was able to generate a set of six consensus-based recommendations (see Table 1) for pediatric decision-making. These recommendations, as well as their application, justification, and limitations, were published as a special article in Pediatrics in August 2023 (Salter et al. 2023), which was composed with the primary goals of accessibility, teachability, and implementability for practicing pediatric clinicians. Click for larger view View full resolutionTable 1.Six consensus recommendations for pediatric decision-makingWhile the group was able to find agreement about these six central principles of pediatric decision-making, there remained several related issues that were outside of the scope of the symposium aims. For example, should these recommendations apply to neonates, children in state custody, or adolescents, and if so, how would their application be operationalized? What specific conditions should justify state intervention on parental authority? How should parents and health-care providers think about obligations to siblings in health-care decisions? This [End Page 182] special issue of Perspectives in Biology and Medicine provides a forum for our authors and collaborators to further explore these, and other, important questions.The issue opens with a piece by the symposium organizers and editors of this special issue, Erica Salter, Lainie Friedman Ross, and D. Micah Hester, describing the symposium’s inspiration and design, its execution, and the implications it might have for pediatric ethics. This contribution compares the six symposium recommendations with existing statements about pediatric decision-making, in particular the statements developed by the American Academy of Pediatrics (AAP). In “How We Found Consensus on Pediatric Decision-Making and Why It Matters,” readers will find a detailed account of the process engaged to develop the six consensus-based recommendations, as well as a discussion of the value and limitations of such a process, which may serve as a model of consensus-building useful for other unsettled topics of interest in the bioethics community.The issue’s second article, “Childhood Interests: What They Are, and Why It Matters,” by Johan Bester and Jeffrey Blustein, dives into the conceptual foundation of the symposium’s first two recommendations. This... (shrink)

Developmentally, adolescence sits in transition between childhood and adulthood. Involving adolescents in their medical decision-making prompts important and complex ethical questions. Originating in the UK, the concept of Gillick competence is a dominant framework for navigating adolescent medical decision-making from legal, ethical and clinical perspectives and is commonly treated as comprehensive. In this paper, we argue that its utility is far more limited, and hence over-reliance on Gillick risks undermining rather than promoting ethically appropriate adolescent involvement. We demonstrate that Gillick (...) only provides guidance in the limited range of cases where legal decisional authority needs to be clarified. The range of cases where use of Gillick actually promotes adolescent involvement is narrower still, because several features must be present for Gillick to be enacted. Each of these features can, and do, act as barriers to adolescent involvement. Within these limited situations, we argue that Gillick is not specific or strong enough and is reliant on ethically contestable principles. Moreover, in most situations in adolescent healthcare, Gillick is silent on the ethical questions around involving adolescents. This is because it focuses on decisional authority—having the final say in decision-making—which is one small subset of the many ways adolescents could be involved in decision-making. The implication of our analysis is that use of Gillick competence tends to limit or undermine adolescent involvement opportunities. We propose that those working with adolescents should be judicious in seeking Gillick’s guidance, instead drawing on and developing alternative frameworks that provide a comprehensive model for adolescent involvement. (shrink)

This paper evaluates the Hong Kong approach to consent regarding the forgoing of life-sustaining treatment for incompetent elderly patients. It analyzes the contextualized approach in the Hong Kong process-based, consensus-building model, in contrast to other role-based models which emphasize the establishment of a system of formal laws and a clear locus of decisional authority.Without embracing relativism, the paper argues that the Hong Kong model offers an instructive example of how strategic ambiguities can both make good sense within particular (...) cultural context and serve important moral goals. (shrink)

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

Using a multidisciplinary framework, this article examines the Office of Refugee Resettlement’s (ORR) policy decision to prohibit teens in federal immigration custody from obtaining abortions. As we argue, this appropriation of decisional authority over their reproductive bodies discursively cast them as doubly subversive for first breaching the southern border of the United States and then insisting upon the right to ‘abortion on demand’. Mapping these twinned agendas onto their bodies, these teens were configured as a threat to the (...) racialised national order during the Trump era. Centring our analysis on the much publicised constitutional challenge to ORR’s abortion ban in Garza v. Hargan, we interrogate this policy as a powerful expression of legal duplicity, the spatial and bodily containment of those deemed other, and the privileging of the citizen-foetus over their undocumented mothers. (shrink)

As diachronic agents, we deliberate and decide in the present to perform future courses of action. Such future‐directed decisions normally enjoy a distinctive species of rational authority over subsequent thought and action. But what is the nature of this authority, and what underwrites its normative force? In this paper, I argue that our answer to this question must begin by situating future‐directed deciding within an intrapersonal model of cross‐temporal influence. The role of future‐directed deciding (and intending), then, is (...) not to generate a novel decision‐based reason for action, but instead to preserve a certain positive normative status over time. I develop an entitlement approach to decisional authority, according to which an agent who rationally decides to ϕ enjoys a practical entitlement, rather than a reason‐based practical justification, to ϕ at the appointed time. This entitlement is underwritten, I argue, by the warrant‐preserving nature of the sequence taking an agent from deliberation to subsequent action. (shrink)

A ‘Ulysses arrangement’ (UA) is an agreement where a patient may arrange for psychiatric treatment or non-treatment to occur at a later stage when she expects to change her mind. In this article, I focus on ‘competence-insensitive’ UAs, which raise the question of the permissibility of overriding the patient’s subsequent decisionally competent change of mind on the authority of the patient’s own prior agreement. In “The Ethical Justification for Ulysses Arrangements”, I consider sceptical and supportive arguments concerning competence-insensitive UAs, (...) and argue that there are compelling reasons to give such UAs serious consideration. In “Decisional Competence and Legal Capacity in UAs”, I examine the nature of decisional competence and legal capacity as they arise in UAs, an issue neglected by previous research. Using the distinctions which emerge, I then identify the legal structure of a competence-insensitive UA in terms of the types of legal capacity it embodies and go on to explain how types of legal capacity might be shared between the patient and a trusted other to offer support to the patient in the creation and implementation of a competence-insensitive UA. This is significant because it suggests possibilities for building patient support mechanisms into models of legal UAs, which has not addressed in the literature to date. Drawing on this, in “Using Insights from the Competence/Capacity Distinction to Enhance Patient Support in UAs”, I offer two possible models to operationalize competence-insensitive UAs in law that allow for varying degrees of patient support through the involvement of a trusted other. Finally, I outline some potential obstacles implementing these models would face and highlight areas for further research. (shrink)

Standard views on surrogate decision making present alternative ideal models of what ideal surrogates should consider in rendering a decision. They do not, however, explain the physician''s responsibility to a patient who lacks decisional capacity or how a physician should regard surrogates and surrogate decisions. The authors argue that it is critical to recognize the moral difference between a patient''s decisions and a surrogate''s and the professional responsibilities implied by that distinction. In every case involving a patient who lacks (...) decisional capacity, physicians and the treatment team have to make judgments about the appropriateness of both the surrogate and the surrogate''s decision. They have to assess the surrogate''s decisional capacity and attitude toward the patient as well as the reasons that support the surrogate''s decision. This paper provides a model for acceptable surrogate decisions and a standard for blocking inappropriate surrogates. Only decisions based on widely shared reasons are allowable for surrogate refusal of highly beneficial treatment. (shrink)

. The author discusses the conditions necessary to accept the one right answer theory. The argument is based on an analysis of the deep structure of the justified fractional decisions pertaining to the substantive decisional model of the judicial application of law within the statutory law system. The role of evaluative choices is needed to justify the decisions in question at least in hard cases. This makes the theory of one right answer unacceptable in a noncognitivist axiological framework.

ABSTRACT Objectives: To investigate whether Chinese adolescents in Hong Kong share similar perceptions with their Western counterparts regarding their capacity for autonomous decision‐making, and secondarily whether Chinese parents underestimate their adolescent children's desire and capacity for autonomous decision‐making. Method:‘Healthy Adolescents’ and their parents were recruited from four local secondary schools, and ‘Sick Adolescents’ and their parents from the pediatric wards and outpatient clinics. Their perceptions of adolescents' understanding of illnesses and treatments, maturity in judgment, risk‐taking, openness to divergent opinions, pressure (...) from parents and doctors, submission to parental authority and preference for autonomy in medical decision‐making are surveyed by a 50‐item questionnaire on a five‐point Likert scale. Results: Findings indicate that Chinese adolescents aged 14–16 perceive themselves to possess the necessary cognitive abilities and maturity in judgment to be autonomous decision‐makers like their Western counterparts. Paradoxically, although they hesitate to assert their autonomy, they are also unwilling to surrender that autonomy to their parents even under coercion or intimidation. Parents tend to underestimate their adolescents' preferences for making autonomous decisions and overestimate the importance of parental authority in decision‐making. Conclusion:‘14‐and‐above’ Chinese adolescents in Hong Kong perceive themselves as capable of autonomous decision‐making in medically‐related matters, but hesitate to assert their autonomy, probably because of the Confucian values of parental authority and filial piety that are deeply embedded in the local culture. (shrink)

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) requires as a condition of accreditation that every health care institution -- hospital, nursing home, or home care agency -- have a standing mechanism to address ethical issues. Most organizations have chosen to fulfill this requirement with an interdisciplinary ethics committee. The best of these committees are knowledgeable, creative, and effective resources in their institutions. Many are wellmeaning but lack the information, experience, and skills to negotiate adequately the complex ethical (...) issues that arise in clinical and organizational settings. Handbook for Health Care Ethics Committees is the first resource designed to address the range of work performed by ethics committees as part of their multiple responsibilities, including education, case consultation, and policy development. It features an eight-chapter curriculum reviewing the content of contemporary health care bioethics and discussing the ethical foundations of clinical practice, with each subsequent section focusing on a set of ethical issues that commonly arise in the clinical setting. Through case studies, the authors explore issues such as informed consent and refusal, decision making and decisional capacity, truth telling, decision-making concerns of minors, end-of-life issues, palliation, justice in and access to health care services, and organizational ethics. They offer sample policies and procedures, draft guidelines and protocols, and key legal cases. Providing both a strong theoretical foundation and practical applications, this handbook will be essential reading for every member of a health care ethics committee. (shrink)

Objectives: To investigate whether Chinese adolescents in Hong Kong share similar perceptions with their Western counterparts regarding their capacity for autonomous decision-making, and secondarily whether Chinese parents underestimate their adolescent children's desire and capacity for autonomous decision-making.Method:‘Healthy Adolescents’ and their parents were recruited from four local secondary schools, and ‘Sick Adolescents’ and their parents from the pediatric wards and outpatient clinics. Their perceptions of adolescents' understanding of illnesses and treatments, maturity in judgment, risk-taking, openness to divergent opinions, pressure from parents (...) and doctors, submission to parental authority and preference for autonomy in medical decision-making are surveyed by a 50-item questionnaire on a five-point Likert scale.Results: Findings indicate that Chinese adolescents aged 14–16 perceive themselves to possess the necessary cognitive abilities and maturity in judgment to be autonomous decision-makers like their Western counterparts. Paradoxically, although they hesitate to assert their autonomy, they are also unwilling to surrender that autonomy to their parents even under coercion or intimidation. Parents tend to underestimate their adolescents' preferences for making autonomous decisions and overestimate the importance of parental authority in decision-making.Conclusion:‘14-and-above’ Chinese adolescents in Hong Kong perceive themselves as capable of autonomous decision-making in medically-related matters, but hesitate to assert their autonomy, probably because of the Confucian values of parental authority and filial piety that are deeply embedded in the local culture. (shrink)

The ethics of autonomous vehicles has received a great amount of attention in recent years, specifically in regard to their decisional policies in accident situations in which human harm is a likely consequence. Starting from the assumption that human harm is unavoidable, many authors have developed differing accounts of what morality requires in these situations. In this article, a strategy for AV decision-making is proposed, the Ethical Valence Theory, which paints AV decision-making as a type of claim mitigation: different (...) road users hold different moral claims on the vehicle’s behavior, and the vehicle must mitigate these claims as it makes decisions about its environment. Using the context of autonomous vehicles, the harm produced by an action and the uncertainties connected to it are quantified and accounted for through deliberation, resulting in an ethical implementation coherent with reality. The goal of this approach is not to define how moral theory requires vehicles to behave, but rather to provide a computational approach that is flexible enough to accommodate a number of ‘moral positions’ concerning what morality demands and what road users may expect, offering an evaluation tool for the social acceptability of an autonomous vehicle’s ethical decision making. (shrink)

Most of the literature on phase one trials has focused on ethical and safety issues in research on patients with advanced cancer, but this article focuses on healthy, adult subjects. The article makes six specific recommendations for protecting the rights and welfare of healthy subjects in phase one trials: 1) because phase one trials are short in duaration (usually 1 to 3 months), researchers should gather more data on the short-term and long-term risks of participation in phase one studies by (...) healthy subjects; 2) researchers should develop strict inclusion/exclusion criteria that exclude unhealthy or vulnerable subjects, such as decisionally impaired people, in phase one studies; 3) subjects should not participate in more than one phase one study at the same time and should wait at least 30 days between participating in different studies; 4) researchers should develop a database to keep track of phase one participants; 5) subjects should be guaranteed a minimum wage equivalent to the equivalent type of unskilled labor, but there should be no upper limits on wages; and 6) subjects should be allowed to engage in collective bargaining with research sponsors. *Disclaimer: The ideas and opinions expressed in this article are the authors' personal views and do not represent the views of the National Institute of Environmental Health Sciences, the National Institutes of Health, or the United States government. (shrink)

The legal basis of informed consent in Texas may on first examination suggest an unqualified affirmation of persons as the source of authority over themselves. This view of individuals in the practice of informed consent tends to present persons outside of any social context in general and outside of their families in particular. The actual functioning of law and medical practice in Texas, however, is far more complex. This study begins with a brief overview of the roots of Texas (...) law and public policy regarding informed consent. This surface account is then contrasted with examples drawn from the actual functioning of Texas law: Texas legislation regarding out-of-hospital do-not-resuscitate (DNR) orders. As a default approach to medical decision-making when patients lose decisional capacity and have failed to appoint a formal proxy or establish their wishes, this law establishes a defeasible presumption in favor of what the law characterizes as “qualified relatives” who can function as decision-makers for those terminal family members who lose decisional capacity. The study shows how, in the face of a general affirmation of the autonomy of individuals as if they were morally and socially isolated agents, space is nevertheless made for families to choose on behalf of their own members. The result is a multi-tier public morality, one affirming individuals as morally authoritative and the other recognizing the decisional standing of families. (shrink)

Muchos autores que se han ocupado de la autonomía personal parecen identificar la capacidad de autonomía esencialmente con la capacidad de todo agente racional para identificar preferencias y tomar decisiones conforme a las mismas. Estos autores -entre los que podríamos ubicar a C. Nino- prescinden a menudo de ulteriores elementos o condiciones para su ejercicio. Sin embargo, resulta fundamental ahondar en esos aspectos a veces pasados por alto; ahondar principalmente en las opciones y el proceso de formación de preferencias de (...) los agentes, para delinear mejor los aspectos normativos de la autonomía. En este trabajo propongo recuperar un elemento central del concepto que ha sido extensamente desarrollado en la literatura feminista, me refiero al contexto de relaciones que ha dado lugar a la llamada "autonomía relacional". Propongo incorporar esta noción al núcleo conceptual de la autonomía sin renunciar, sin embargo, a otros elementos del concepto entre los que destacaré las "opciones relevantes", es decir, la presencia de cursos de acción, de oportunidades, que la persona es capaz de reconocer como propuestas no solo viables sino legítimas para sí. Para desarrollar esta idea comenzaré por definir la autonomía a través de los que considero los elementos o condiciones centrales del concepto, deteniéndome especialmente en la condición de opciones relevantes. A continuación se abordará la cuestión relativa al modo en que las opciones se perfilan, se construyen y son percibidas por los sujetos. En este punto el estudio se fijará específicamente en el entorno contextual y de relaciones que sirve de trasfondo para la construcción de las opciones, para proponer la noción de opciones relacionales. Many authors have written about autonomy focusing mainly on the capacity of the autonomous agent for identifying preferences and making decisions. These authors -C. Nino among them- do not take into consideration further elements or conditions for being autonomous. However, it is necessary to take other aspects into consideration; mainly it is important to take account of both options and the building of the agent’s preferences. This way, autonomy normative aspects will be better understood. I propose here to analyse the concept of "relational autonomy", which has been largely elaborated within feminist theory. My aim is to incorporate relations and options to the core of the concept of personal autonomy. In this article, I will define personal autonomy first, highlighting the importance of relevant options. Second, I will describe the way options are built and their perception by the agent. Finally, I will focus on the context and relations on the background, and I will propose the notion of relational options. (shrink)

This paper distinguishes between two main questions regarding the notion of privacy: “What is privacy?” and “Why do/should we value privacy?”. In developing a social-ontological recognitional model of privacy, it gives an answer to the first question. According to the SORM, Privacy is a second order quality of roles within social practices. It is a function of who is or should be recognized as a “standard authority”. Enjoying standard authority means to have the right to interpret and contest (...) role behavior and role obligations within a specific practice, as well as evaluate the normative structure, the fundamental practice norms as well as the roles and their status. The SORM utilizes the concept of standard authority to explicate privacy with regard to two categories that capture the relevant phenomena of privacy: decisional and informational privacy. Within a practice, an actor is said to have decisional privacy if she as a BCR does not recognize bearers of accidental roles as standard authorities. Vice versa, an actor is said to enjoy informational privacy if all other BCRs recognize her as a standard authority. Additionally, the requirement of mutual recognition by the practice participants as standard authorities introduces a “weak normativity” into the theory, which can be used to identify deficient privacy arrangements within practices. (shrink)

Se exponen precisiones en torno al concepto de cultura científica sobre la base de numerosos referentes actuales y a partir de las diferencias en su tratamiento, en el que generalmente se asume como categoría que es vinculada a las grandes masas y que, por su oficio, deben portar los individuos que se relacionan directa o indirectamente con la construcción del conocimiento científico y los resultados o salidas derivados de estos. También se propone el concepto de cultura científico investigativa que parte (...) de una intencionalidad como regularidad del pensamiento científico en el modo de actuación del sujeto consciente y desarrollador de esa categoría esencial, núcleo de capacidades transformadoras que median el pensamiento científico y la toma de decisiones en función de las demandas sociales. On the basis of current references about of scientific culture concept, the authors detailed the differences in the treatment in which it is generally assumed as a category that is linked to the masses and which, due to their profession, must have the individuals that are directly or indirectly related to the construction of scientific knowledge and the results or outputs derived from them. In addition, the concept of scientific research culture is proposed, from intentionality as a regularity of scientific thinking in the action mode of the conscious individual and developer of that essential category, a nucleus of transformative capacities that mediate scientific thinking and decision making in function of social demands. (shrink)

The term “ethics” covers a multitude of virtues and possibly some sins where ethical perspectives differ. Given the diversity of ethical philosophies there is a question about what common ground can, or should, inform health research ethics. At a minimum it must be consistent with the law. Beyond that, ethics embraces a variety of possible approaches. This raises the question—what criteria are applied in determining the appropriate approach and what standards by way of quality control are applied to its (...) class='Hi'>decisional application by ethics committees or other authorities exercising responsibility in this difficult area. The particular issue of ethical perspectives on the use of “big data” in medical research also raises complex issues for consideration. (shrink)

The article aims to assess Hobbes’ methodological legacy. After a brief review of different interpretations of Hobbes relevant to the subject, I center the discussion on the reading advanced by Norberto Bobbio and the notion of three “different forms and levels of rationality”: First, Hobbes’ dichotomy-based reasoning that radically contended the Aristotelian tradition, as well as biblical hermeneutics used by medieval theologians. Second, individualism as a method for collective decision making, one that led to socalled “game theory” and moral individualism (...) (quite significant in contemporary political philosophy). Finally, the rationality of political power that imposes on Sovereignty binding rules for gaining and maintaining power.After the discussion of the three different forms and levels of rationality, the article concludes that Thomas Hobbes, instead of being primarilyre- ferred to as an advocate of autocratic regimes, should be considered, at the very beginning of the long history of rule of law, as one of the key authors of modern constitutionalism and democracy.Resumen:Después de un rápido recorrido sobre las múltiples interpretaciones del pensamiento hobbesiano, el ensayo retoma y desarrolla la lectura que de Hobbes propuso Norberto Bobbio. Con base en esta lectura, se busca evaluar el legado metodológico de Hobbes, el cual se despliega a través de distintos niveles de racionalidad: en primer lugar, el razonamiento basado en dicotomías, el cual desafió de manera contundente la tradición aristotélica, la labor de los historiadores antiguos y la hermenéutica bíblica de los teólogos medievales. En segundo lugar, el individualismo como método para tomar decisiones colectivas, lo que abrió la puerta a la así llamada “teoría de juegos” y al individualismo moral tan notable en la filosofía política contemporánea. Y finalmente, la racionalidad del poder político, que lógicamente impone sobre la soberanía ciertas reglas vinculantes para obtener y mantener el poder.En conjunto, con el análisis de las distintas formas y niveles de racionalidad se pretende respaldar la idea de que Hobbes —antes de ser identificado como un defensor de regímenes autocráticos— puede ser considerado como un autor clave para la democracia y el constitucionalismo moderno, colocado en el justo inicio de la larga historia del Estado de derecho. (shrink)

Richard Thaler and Cass Sunstein define a nudge as “any aspect of the choice architecture that alters people's behavior in a predictable way without forbidding any options or significantly changing their economic incentives.” Much has been written about the ethics of nudging competent adult patients. Less has been written about the ethics of nudging surrogates’ decision‐making and how the ethical considerations and arguments in that context might differ. Even less has been written about nudging surrogate decision‐making in the context of (...) pediatrics, despite fundamental differences that exist between the pediatric and adult contexts. Yet, as the field of behavioral economics matures and its insights become more established and well‐known, nudges will become more crafted, sophisticated, intentional, and targeted. Thus, the time is now for reflection and ethical analysis regarding the appropriateness of nudges in pediatrics. We argue that there is an even stronger ethical justification for nudging in parental decision‐making than with competent adult patients deciding for themselves. We give three main reasons in support of this: (1) child patients do not have autonomy that can be violated (a concern with some nudges), and nudging need not violate parental decision‐making authority; (2) nudging can help fulfill pediatric clinicians’ obligations to ensure parental decisions are in the child's interests, particularly in contexts where there is high certainty that a recommended intervention is low risk and of high benefit; and (3) nudging can relieve parents’ decisional burden regarding what is best for their child, particularly with decisions that have implications for public health. (shrink)

Resumen En esta nota crítica presento un análisis de los materiales textuales que constituyen el capítulo 19 de la serie Early Greek Philosophy de A. Laks y G. Most dedicado a Parménides. Después de comparar cuantitativamente los textos de este capítulo con las ediciones de H. Diels y A.H. Coxon, así como de precisar cuáles son los textos "nuevos" que figuran en esta edición y las formas en que los editores decidieron presentarlos, ofrezco algunas consideraciones sobre el concepto mismo de (...) recepción y su operatividad en este capítulo, sobre la superación definitiva de la distinción entre testimonios y fragmentos y sobre las ventajas y desventajas que supone cortar los textos para la presentación esquemática y temática de los contenidos. Por último, examino el modo en que la doctrina de Parménides se presenta en este capítulo y muestro algunas de las decisiones que los autores tomaron sobre los innumerables problemas de transmisión textual del Poema.In this critical note, I will present an analysis of the textual materials that constitute the 19th chapter, dedicated to Parmenides, of the Early Greek Philosophy series by A. Laks and G. Most. After offering a quantitative comparison of the texts in this chapter and the editions of H. Diels and A.H. Coxon, and after specifying which "new" texts figure in this edition and how they are presented, I will provide considerations on the concept of reception and how it operates throughout this chapter, on the definite overcoming of the distinction between testimonia and fragmenta, and on the advantages and disadvantages of cutting out the texts for the schematic and thematic presentation of its contents. Finally, I examine how Parmenides' doctrine is presented and comment on some of the decisions that the authors made on a few of the innumerable problems related to the textual transmission of the Poem. (shrink)

Resumen En los días actuales, la democracia se resiente de la escalada virtual-tecnocrática, un incremento de la virtualidad sin precedentes. Los cambios redefinen no solo las formas de interacción entre los sujetos, sino pasan a influenciar la toma de decisiones. La virtualidad se transforma en un único medio para manejar las materias de interés público, sin compromiso moral. El aspecto central se relaciona a la gramática pronominal y al uso de los pronombres personales en la interacción comunicativa. Por eso, si (...) todos los sujetos tienen voz activa, ellos son coautores en la reconstrucción del consenso intersubjetivo, participantes activos de las justificaciones. Mientras tanto, a veces, la utilización del pronombre en la tercera persona pone en evidencia un sujeto presente, pero indeseado y molestador. Se trata de un sujeto en la voz pasiva, una forma de reconocimiento discriminatoria, actitud que niega su status de coautor.In the present days, democracy suffers from the virtual-technocratic climbing, an increase of virtuality unprecedented. Changes redefine not only the forms of interaction between subjects, but a/so influence decision making. The virtuality is transformed into a single means to handle matters of public interest without moral commitment. The central aspect is related to the pronominal grammar and the use of personal pronouns in the communicative interaction. Therefore, if all subjects have an active voice, they are co-authors in the reconstruction of the intersubjective consensus, active participants in the justifications. Meanwhile, sometimes, the use of the pronoun in the third person reveals a subject present, but unwanted and annoying. It is a subject in the passive voice, a form of discriminatory recognition, an attitude that denies its co-author status. (shrink)

RESUMEN. El autor describe algunos elementos distintivos del estatus y de las funciones del ciudadano en la Atenas del siglo V así como en el contexto democrático ateniense, en el que nació la figura del ciudadano. Pone de relieve el carácter excluyente y las instituciones "limitadas" que hacen de la ciudadanía un estatus exclusivo, reservado para los hombres, para los hijos de ambos padres atenienses y que de esa manera excluía a los extranjeros residentes (metecos), a los otros griegos y (...) a los bárbaros. A partir de la categoría aristotélica de "ciudadano en sentido absoluto", el autor muestra cómo incluso dentro de la comunidad de los atenienses libres, por varias razones, grupos como el de los jóvenes, de los ancianos y de las mujeres en particular, estén excluidos de la plena participación en la vida política de la ciudad, en definitiva, a las decisiones y la gestión del poder. Al mismo tiempo, la investigación muestra cómo los atenienses, a pesar de que sean una minoría de hombres libres dentro de la ciudad, durante dos siglos en forma gradual desarrollen un alto nivel de participación en la vida política de la ciudad, en el sentido de que incluso las clases menos privilegiadas pudieran ocupar cargos políticos que antes eran reservados solo para los más ricos. De este modo se aplicaría plenamente el principio democrático con el cual todo el pueblo gobierna y, al mismo tiempo, a través del primer ejército hecho enteramente de ciudadanos, defiendan sus propias decisiones. ABSTRACT. The author describes a number of distinctive traits of the status and role of citizens in the democratic Athens of the 5th-century BC and in the Athenian democratic framework which saw the establishment of the figure of the citizen. He highlights the exclusiveness of citizenship and the legal institutes that “closed” access to citizenship status. Citizenship was reserved to males born to Athenian parents, and excluded resident aliens (meteci), the other Greeks and the Barbarians. Starting with the Aristotelian category of “citizens in the absolute sense”, the author shows that even within the community of free Athenians, young people, the elderly and, above all, women, were barred from fully participating in the political life of the city for various reasons. Such categories were in all effects excluded from the decision-making process and from the management of power. At the same time the research shows how Athenian citizens, made up of free men which formed but a minority in the city population, succeeded within two centuries to fully develop a high degree of participation in the political life of the city. It was not long before members of lower-income groups started holding key positions in the city that were previously reserved to individuals belonging to the wealthier classes. It was a turnaround that reflected the full realisation of the democratic principle according to which it was the people of Athens as a whole that governed and defended the choices made with an army made up of Athenian citizens. (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)

Resumen En esta nota crítica presento un análisis de los materiales textuales que constituyen el capítulo 19 de la serie Early Greek Philosophy de A. Laks y G. Most dedicado a Parménides. Después de comparar cuantitativamente los textos de este capítulo con las ediciones de H. Diels y A.H. Coxon, así como de precisar cuáles son los textos "nuevos" que figuran en esta edición y las formas en que los editores decidieron presentarlos, ofrezco algunas consideraciones sobre el concepto mismo de (...) recepción y su operatividad en este capítulo, sobre la superación definitiva de la distinción entre testimonios y fragmentos y sobre las ventajas y desventajas que supone cortar los textos para la presentación esquemática y temática de los contenidos. Por último, examino el modo en que la doctrina de Parménides se presenta en este capítulo y muestro algunas de las decisiones que los autores tomaron sobre los innumerables problemas de transmisión textual del Poema.In this critical note, I will present an analysis of the textual materials that constitute the 19th chapter, dedicated to Parmenides, of the Early Greek Philosophy series by A. Laks and G. Most. After offering a quantitative comparison of the texts in this chapter and the editions of H. Diels and A.H. Coxon, and after specifying which "new" texts figure in this edition and how they are presented, I will provide considerations on the concept of reception and how it operates throughout this chapter, on the definite overcoming of the distinction between testimonia and fragmenta, and on the advantages and disadvantages of cutting out the texts for the schematic and thematic presentation of its contents. Finally, I examine how Parmenides' doctrine is presented and comment on some of the decisions that the authors made on a few of the innumerable problems related to the textual transmission of the Poem. (shrink)

Downie and Schuklenk1 provide a clear narrative of the development of Canadian policy on medically assisted dying. This is very helpful for considering specific aspects of the continuing deliberations in Canada. This commentary presents an alternative perspective on the authors’ argument that narrow eligibility criteria for medical assistance in dying are discriminatory and unjustified. I argue that disability or mental illness as sole reason for accessing MAiD removes protections for all people who have times in their life when they have (...) mental illness or disability combined with intolerable suffering. I claim that individuals do not make their best, self-actualising decisions at those times and the supposed protections of vague terms such as incurable, advanced and decline are not clinically useful for evaluating eligibility for individuals with chronic health conditions. Within discussion of the impact of social determinants of health on access to MAiD, the authors present the argument that decisionally capable people with mental illness or disabilities as their sole underlying condition should be allowed to access MAiD. The authors state that opposing this access sacrifices patient rights and strips people of their agency. To support their argument, they embrace the idea that people with mental illness or disabilities belong to an identifiable cohort. They claim that …. (shrink)

Routine infant circumcision is one of the most common surgical procedures performed in the U.S. Despite its broad societal acceptance, the practice is not without controversy. The stories included in this symposium offer rich insight into the diverse set of attitudes, values, and beliefs related to the practice of circumcision. They additionally offer insight into the complex web of personal, interpersonal, and social dynamics that inform the circumcision choices parents make for their children, the reasons parents make them, and how (...) others can influence decisional choices. More broadly, these narratives raise important ethical questions mirrored today in broader contemporary bioethical and public discourse on the scope and limits of parental authority to make decisions for their children, power dynamics in medical decision making, and the ethics of healthcare activism. In this commentary, I discuss three sets of themes related to the ethics of circumcision running through the symposium narratives, comment on the ethical tensions and questions which emerge from each set of themes, gently problematize some of the rhetoric surrounding the ethical permissibility of circumcision, and gesture towards the future of bioethical inquiry on circumcision discourse. (shrink)

This chapter contains section titled: Dimensions of Privacy Theories of Privacy Liberty and Decisional Privacy Justifying a Right to Informational Privacy Secrecy and Authority Note References.

Advance Care Planning, of which Advance directive is only a part, is a process of planning for future medical care under circumstances of impaired decisional capacity. Advance care planning involves a structured discussion between patient and ideally their primary care physician to explore the goals of care in the context of current and hypothetical illness states, discusses treatment options in the context of these goals of care and finally articulates and docu- ments treatment and care preferences of the patient.1 (...) Advance care planning should be a routine part of preventive health care in order to avoid unneces- sary extra ordinary measures against a person’s wishes and to reserve resources which are wasted in futile care. Instead advance care planning is either non-existent or severely under-utilized in primary care practice in Pakistan. The author explores the factors that prevent Pakistani physicians’ from incorporating advance care planning into practice. In addition to this, various steps in terms of the principles, policies and procedures are discussed which could help physicians and institutions navigate the advance care planning process. (shrink)