The continued debate in the field of bioethics, and my experience in the field, led to a pursuit of the question of collective moral claims and their justification. Being confronted with collective agency, the research process had to diverge from the traditional bioethics framework of individual autonomy to take into consideration the situation on the ground. This paper reflects on the fieldwork bioethical experiences which could inform current bioethical standpoints. My research findings suggest the consenting process in (...) Botswana communities differs from conventional research ethics that are employed in other settings. Further research is required to determine the involvement of Kgosi [Community Leader] in the autonomy process in order to enhance protection of human subjects in local context. The findings in this study could help inform ongoing research on human subjects in the Botswana context as well as other settings with social autonomy realities. (shrink)

Both autonomy and local specificity are compatible with observed interconnectivity at the cell level when considering two different levels: cell assemblies and brain systems. Early syntactic structuring processes in particular are likely to representan autonomous module in the language/brain system.

There seems to be a deep tension between two aspects of aesthetic appreciation. On the one hand, we care about getting things right. On the other hand, we demand autonomy. We want appreciators to arrive at their aesthetic judgments through their own cognitive efforts, rather than deferring to experts. These two demands seem to be in tension; after all, if we want to get the right judgments, we should defer to the judgments of experts. The best explanation, I suggest, (...) is that aesthetic appreciation is something like a game. When we play a game, we try to win. But often, winning isn’t the point; playing is. Aesthetic appreciation involves the same flipped motivational structure: we aim at the goal of correctness, but having correct judgments isn’t the point. The point is the engaged process of interpreting, investigating, and exploring the aesthetic object. Deferring to aesthetic testimony, then, makes the same mistake as looking up the answer to a puzzle, rather than solving it for oneself. The shortcut defeats the whole point. This suggests a new account of aesthetic value: the engagement account. The primary value of the activity of aesthetic appreciation lies in the process of trying to generate correct judgments, and not in having correct judgments. -/- *There is an audio version available: look for the Soundcloud link, below.*. (shrink)

Accounts of aesthetic valuing emphasize two constraints on the formation of aesthetic belief. We must form our own aesthetic beliefs by engaging with aesthetic value first-hand (the acquaintance principle) and by using our own capacities (the autonomy principle). But why? C. Thi Nguyen’s proposal is that aesthetic valuing has an inverted structure. We often care about inquiry and engagement for the sake of having true beliefs, but in aesthetic engagement this is flipped: we care about arriving at good aesthetic (...) beliefs for the sake of the values that arise in the process of doing so. The engagement is the point, so we must use our own capacities in first-hand encounters. Here I challenge Nguyen’s account. I argue that it misconstrues the value of aesthetic belief; it conflicts with restrictions on aesthetic testimony; and it has trouble harnessing engagement-value for a theory of aesthetic value. A better approach emphasizes the social character of aesthetic valuing. On this view, aesthetic valuing is a social practice structured around the collaborative exercise and improvement of certain special capacities. The autonomy and acquaintance principles tell us to engage these capacities in forming our aesthetic beliefs. Understood aright, and contrary to consensus, these rules are identical. (shrink)

I present an account of epistemic autonomy as a distinctively wide-ranging epistemic virtue, one that helps us to understand a range of phenomena that might otherwise seem quite disparate – from the appropriate selection of epistemic methods, stances and topics of inquiry, to the harms of epistemic oppression, gaslighting and related phenomena. The account draws on four elements commonly incorporated into accounts of personal autonomy: (i) self-governance, (ii) authenticity, (iii) self-creation and (iv) independence. I further argue that for (...) a distinctively epistemic virtue of autonomy; the above elements must ultimately reliably lead to valuable epistemic goods (for the agent herself and others). I then turn to the domains or ways in which epistemic autonomy so understood, can be made manifest. I suggest that epistemic autonomy is a virtue that allows us to appropriately choose (i) subject matters and areas of inquiry, (ii) methods, sources, and processes of belief formation, (iii) epistemic goals and (iv) epistemic stances or frameworks. So understood, epistemic autonomy has a role to play in shaping most every aspect of our epistemic lives. (shrink)

Critics of persuasive advertising argue that it undermines the autonomy of consumers by manipulating their desires in morally problematic ways. My aim is this paper is to refine that argument by employing a conception of autonomy that is not at odds with certain forms of manipulation. I argue that the charge of manipulation is not sufficient for condemning persuasive advertising. On my view, manipulation of an agent’s desires through advertising is justifiable in cases where the agent accepts the (...) process through which the desires were developed. I show how the standard manipulation objection proves too much as it would also condemn cases of that kind. I argue that this distinction is especially important when we consider the implications of “new media.” In addition to increasing vulnerability to manipulation, new media have considerable impacts on well-being. By siding with the traditional autonomy argument, we would be compelled to take an implausible stand against all forms of manipulation through advertising, but I suggest that only a proper subset of those cases are morally problematic. This conclusion opens up a space for persuasive advertising that is permissible while nevertheless condemning cases that violate consumers’ autonomy. (shrink)

Autonomy has been central to moral and political philosophy for millenia, and has been positioned as a critical aspect of both justice and wellbeing. Research in psychology supports this position, providing empirical evidence that autonomy is critical to motivation, personal growth and psychological wellness. Responsible AI will require an understanding of, and ability to effectively design for, human autonomy (rather than just machine autonomy) if it is to genuinely benefit humanity. Yet the effects on human (...) class='Hi'>autonomy of digital experiences are neither straightforward nor consistent, and are complicated by commercial interests and tensions around compulsive overuse. This multi-layered reality requires an analysis that is itself multidimensional and that takes into account human experience at various levels of resolution. We borrow from HCI and psychological research to apply a model (“METUX”) that identifies six distinct spheres of technology experience. We demonstrate the value of the model for understanding human autonomy in a technology ethics context at multiple levels by applying it to the real-world case study of an AI-enhanced video recommender system. In the process we argue for the following three claims: 1) There are autonomy-related consequences to algorithms representing the interests of third parties, and they are not impartial and rational extensions of the self, as is often perceived; 2) Designing for autonomy is an ethical imperative critical to the future design of responsible AI; and 3) Autonomy-support must be analysed from at least six spheres of experience in order to approriately capture contradictory and downstream effects. (shrink)

In recent years, an increasing number of theoretical biologists and philosophers of biology have been opposing reductionist research agendas by appealing to the concept of biological autonomy which draws on the older concept of autopoiesis. In my paper, I investigate some of the ontological implications of this approach. The emphasis on autonomy and autopoiesis, together with the associated idea of organisational closure, might evoke the impression that organisms are to be categorised ontologically as substances: ontologically independent, well-individuated, discrete (...) particulars. However, I argue that this is mistaken. Autopoiesis and biological autonomy, properly understood, require a rigorous commitment to a process ontological view of life. (shrink)

Joseph Raz’s The Morality of Freedom is well known for defending both a perfectionist form of liberalism and an ‘externalist’ conception of autonomy. John Christman proposes that there is a logical connection between the two theses and argues that externalist accounts of autonomy should be rejected on the basis that they are perfectionist. Christman’s perfectionism argument contains two premises: externalist theories of autonomy entail political perfectionism and political perfectionism is not defensible. I argue that neither premise is (...) true. Externalist theories of autonomy do not entail political perfectionism. Further, even assuming for the sake of argument that premise is true, premise is false. The strongest challenge to political perfectionism is that it is incompatible with the value of respect. I argue that those defending political perfectionism misconstrue what is required for respect. Once we see that respect is secured through features inherent in processes, the value of respect can be reconciled with political perfectionism. Political perfectionism is a defensible thesis and premise is false. (shrink)

Research on autonomy exhibits a constellation of variegated perspectives, from the problem of the crude deprivation of it to the study of the distinction between personal and moral autonomy, and from the problem of the role of a “self as narrator”, who classifies its own actions as autonomous or not, to the importance of the political side and, finally, to the need of defending and enhancing human autonomy. My precise concern in this article will be the examination (...) of the role of the human cognitive processes that give rise to the most important ways of tracking the external world and human behavior in their relationship to some central aspects of human autonomy, also to the aim of clarifying the link between autonomy and the ownership of our own destinies. I will also focus on the preservation of human autonomy as an important component of human dignity, seeing it as strictly associated with knowledge and, even more significantly, with the constant production of new and pertinent knowledge of various kinds. I will also describe the important _paradox of autonomy_, which resorts to the fact that, on one side, cognitions (from science to morality, from common knowledge to philosophy, etc.) are necessary to be able to perform autonomous actions and decisions because we need believe in rules that justify and identify our choices, but, on the other side, these same rules can become (for example, as a result of contrasting with other internalized and approved moral rules or knowledge contents) oppressive norms that diminish autonomy and can thus, paradoxically, defeat agents’ autonomous capacity “to take ownership”. (shrink)

The patient preference predictor is a computer-based algorithm devised to predict the medical treatment that decisionally incapacitated patients would have preferred. The target paper argues against various criticisms to the effect that the use of a PPP is inconsistent with proper respect for patient autonomy.1 In this commentary, I aim to add some clarifications to the complex relationship between autonomy and the PPP. First, I highlight one way in which the decision of a surrogate designated by the patient (...) realises respect for patient autonomy in a way that PPP cannot realise by introducing the idea of shared agency. Second, I show how the attempt to predict someone’s hypothetical choice can be disrespectful to her autonomy. Following the treatment decision of a surrogate designated by the patient counts as a way of respecting the patient’s own autonomy. Designating someone as one’s surrogate is a case of entrusting her with the task of making important life decisions on one’s behalf. To entrust someone with a certain matter is to assign her the responsibility for that matter based on the trust that she will take a good care of it. When a patient entrusts a surrogate decision-maker, what is the matter that she is trusted to take a good care of? In many contexts, the surrogate is r egarded as an epistemic proxy, one who is likely to know the patient’s preferences the best. It is often thought that the point of practising surrogate decision making is to respect the patient’s autonomy by following what the patient most likely would have preferred. Using a PPP in the decision-making process has the same goal of making a more accurate prediction of the patient’s treatment preference. However, at least in some cases, designating the patient’s intimates or ones she loves and cares …. (shrink)

Autonomy has been the central principle underpinning changes which have affected the practice of medicine in recent years. Medical education is undergoing changes as well, many of which are underpinned, at least implicitly, by increasing concern for autonomy. Some universities have embarked on graduate courses which utilize problem-based learning (PBL) techniques to teach all areas, including medical ethics. I argue that PBL is a desirable method for teaching and learning in medical ethics. It is desirable because the nature (...) of ethical enquiry is highly compatible with the learning processes which characterize PBL. But it is also desirable because it should help keep open the question of what autonomy really is, and how it should operate within the sphere of medical practice and medical education. (shrink)

Autonomy in bioethics is coming under sustained criticism from a variety of perspectives. The criticisms, which target personal or individual autonomy, are largely justified. Moral conceptions of autonomy, such as Kant’s, on the other hand, cannot simply be applied in bioethical situations without moralizing care provision and recipience. The discussion concludes with a proposal for re-thinking autonomy by focusing on what different agents count as reasons for choosing one rather than another course of action, thus recognising (...) their involvement in the decision process. (shrink)

It has been argued that Thomson's defense of abortion, if successful, implies that abortion is permissible only until the point of viability. After that point, if one wanted to end a pregnancy, one must do so by birthing the fetus through induction or cesarean. In this paper, I argue that Thomson's defense of abortion does, in fact, imply that abortion after the point of viability is sometimes permissible. To show this, I point out that the process of birthing a (...) fetus makes use of the body of the pregnant person in significant ways. Indeed, the body of the pregnant person is as much a part of this process as it is a part of the process of carrying a fetus during pregnancy. Thus, just as it is sometimes morally permissible to choose to have an abortion rather than continue a pregnancy, it is sometimes morally permissible to choose to have an abortion rather than undergo an induction or cesarean. Those who support Thomson's defense of abortion, then, have reason not to support the view that induction or cesarean are the only permissible procedures for ending an unwanted pregnancy with a viable fetus. I then use this discussion to suggest that autonomy rights are more complicated than initially thought. Given the extent to which the body is involved in detaching the fetus, it is not merely that one has a right to detach a fetus, but also a right to actualize one's reasonable preferences over the method of detachment. (shrink)

Background: The increasing number of elderly people in nursing homes with failing competence to give consent represents a great challenge to healthcare staff’s protection of patient autonomy in the issues of life-prolonging treatment, hydration, nutrition and hospitalisation. The lack of national guidelines and internal routines can threaten the protection of patient autonomy. Objectives: To place focus on protecting patient autonomy in the decision-making process by studying how relatives experience their role as substitute decision-makers. Design: A qualitative (...) descriptive design with analysis of the contents of transcribed in-depth interviews with relatives. Participants: Fifteen relatives of 20 patients in 10 nursing homes in Norway. Results and Interpretations: The main findings reveal deficient procedures for including relatives in decision-making processes. Relatives have poor knowledge about the end of life, and there is little discussion about their role as substitute decision-makers for patients who are not competent to give consent. Few relatives understand the concept of patient autonomy. In Norway the treating physician is responsible for patient treatment. When relatives are included in discussions on treatment, they perceive themselves as responsible for the decision, which is a burden for them afterwards. This qualitative study describes relatives’ experiences, thus providing important information on the improvement potential with the main objective of safeguarding patient autonomy and caring for relatives. Conclusion: The study reveals failing procedures and thus a great potential for improvement. Both ethical and legal aspects must be addressed when considering patient autonomy. (shrink)

Every indigenous people around the world has its own autonomy process, expressed in various relevant dimensions of daily life. This paper argues that autonomy in indigenous communities can be considered as a common good dynamic, and therefore autonomy processes can be studied within the framework of the common good approach to development. To this end, the paper first identifies the general dimensions of any autonomy process by considering the perspective of indigenous peoples – drawing (...) partly on official documents, but more significantly on their lived experiences and explicit demands in the Mexican context. It then links these dimensions to a matrix of common good dynamics developed by the Instituto Promotor del Bien Común (IPBC). Finally, the paper explores the dynamics of the autonomy process of the Nahua community of Cuauhtamazaco in Puebla, Mexico, in the light of this common good metric. It finds that the social, cultural, and political dimensions are essential to indigenous peoples’ autonomy processes and can be inferred within the common good approach framework. However, as the important dimension of territory is missing from the approach, its incorporation needs to be evaluated. (shrink)

This paper addresses the question of the relationship between creativity and autonomy - originally related to each other in the concept of the `self' as one of the crucial parts of the Meadian and symbolic interactionist heritage - and asks how we should construe this relation today. After a brief reconstruction of the history of the notions of `self' and `identity' the paper takes up the postmodern challenge of these notions by clarifying and partially revising them. It discusses the (...) three aspects of a possibly over-socialized conception of the person, the irreducibility of difference between socialized individuals and the role of power and exclusion in processes of identity formation. (shrink)

This paper aims to critique the phenomenon of advanced patient autonomy and choice in healthcare within the specific context of self-testing devices. A growing number of self-testing medical devices are currently available for home use. The premise underpinning many of these devices is that they assist individuals to be more autonomous in the assessment and management of their health. Increased patient autonomy is assumed to be a good thing. We take issue with this assumption and argue that self-testing (...) provides a specific example how increased patient autonomy and choice within healthcare might not best serve the patient population. We propose that current interpretations of autonomy in healthcare are based on negative accounts of liberty to the detriment of a more relational understanding. We also propose that Kantian philosophy is often applied to the healthcare arena in an inappropriate manner. We draw on the philosophical literature and examples from the self-testing process to support these claims. We conclude by offering an alternative account of autonomy based on the interrelated concepts of relationality, care and responsibility. (shrink)

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

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

Respect for autonomy has become a fundamental principle in human research ethics. Nonetheless, this principle and the associated process of obtaining informed consent do have limitations. This can lead to some groups, many of them vulnerable, being left understudied. This book considers these limitations and contributes through legal and philosophical analyses to the search for viable approaches to human research ethics. It explores the limitations of respect for autonomy and informed consent both in law and through the (...) examination of cases where autonomy is lacking (infants), diminished (addicts), and compromised (low socio-economic status). It examines alternative and complementary concepts to overcome the limits of respect for autonomy, including beneficence, dignity, virtue, solidarity, non-exploitation, vulnerability and self-ownership. It takes seriously the importance of human relationality and community in qualifying, tempering and complementing autonomy to achieve the ultimate end of human research - the good of humankind. (shrink)

BackgroundPatient autonomy is a fundamental, yet challenging, principle of professional medical ethics. The idea that individual patients should have the freedom to make choices about their lives, including medical matters, has become increasingly prominent in current literature. However, this has not always been the case, especially in communist countries where paternalistic attitudes have been interwoven into all relationships including medical ones. Patients’ expectations and the role of the doctor in the patient-physician relationship are changing. Croatia, as a transitional country, (...) is currently undergoing this particular process.MethodsQualitative research was conducted by means of six focus group discussions held in the years 2012 and 2013 in Croatia. Focus groups were held separately with each of the following: first year and final year medical students, physicians engaged in medical ethics education, physicians practicing in a clinical hospital, family medicine residents and individuals representing patients with chronic disease. This research specifically addresses issues related to patient autonomy, in particular, the principles of truth telling, confidentiality, and informed consent. All focus group discussions were audio taped and then transcribed verbatim and systematized according to acknowledged qualitative analysis methods.Results and discussionPatient autonomy is much more than a simple notion defined as the patient’s right to make treatment decisions independently. It has to be understood in context of the broader socio-cultural setting. At present, both patients and medical doctors in Croatia are increasingly appreciating the importance of promoting the principle of autonomy in medical decision-making. However, the current views of medical students, physicians and patients reveal inconsistencies.Conclusions Knowing how to respect the various facets of patients’ autonomy should be part of physician’s professional duties, and also be reflected in his or her core clinical competencies. For this reason greater importance should be dedicated to patient autonomy issues in medical education in Croatia. (shrink)

What makes democracy valuable? One traditional answer holds that participating in democratic self-government amounts to a kind of autonomy: it enables citizens to be the authors of their political affairs. Many contemporary philosophers, however, are skeptical. We are autonomous, they argue, when important features of our lives are up to us, but in a democracy we merely have a say in a process of collective choice. In this paper, we defend the possibility of democratic autonomy, by advancing (...) a conception of it which is impervious to this objection. At the core of our account is the idea of joint authorship. You are a joint author of something when that thing expresses your joint intentions. Democracy may not make any one of us sole author of our political affairs, but it can make us their joint authors. It is in such joint authorship, we claim, that the intrinsic value of democratic self-government consists. (shrink)

AI risks are typically framed around physical threats to humanity, a loss of control or an accidental error causing humanity's extinction. However, I argue in line with the gradual disempowerment thesis, that there is an underappreciated risk in the slow and irrevocable decline of human autonomy. As AI starts to outcompete humans in various areas of life, a tipping point will be reached where it no longer makes sense to rely on human decision-making, critical thinking or even creativity. What (...) may follow is a process of gradual de-skilling, where we lose skills that we currently take for granted. Traditionally, it is argued that AI will gain human skills over time and that these skills are innate and immutable in humans. By contrast, I argue that humans may lose such skills as critical thinking, decision-making and even creativity in an AGI world. The biggest threat to humanity is, therefore, not that machines will become more like humans, but that humans will become more like machines. (shrink)

Over the last several years, as cesarean deliveries have grown increasingly common, there has been a great deal of public and professional interest in the phenomenon of women 'choosing' to deliver by cesarean section in the absence of any specific medical indication. The issue has sparked intense conversation, as it raises questions about the nature of autonomy in birth. Whereas mainstream bioethical discourse is used to associating autonomy with having a large array of choices, this conception of (...) class='Hi'>autonomy does not seem adequate to capture concerns and intuitions that have a strong grip outside this discourse. An empirical and conceptual exploration of how delivery decisions ought to be negotiated must be guided by a rich understanding of women's agency and its placement within a complicated set of cultural meanings and pressures surrounding birth. It is too early to be 'for' or 'against' women's access to cesarean delivery in the absence of traditional medical indications – and indeed, a simple pro- or con- position is never going to do justice to the subtlety of the issue. The right question is not whether women ought to be allowed to choose their delivery approach but, rather, taking the value of women's autonomy in decision-making around birth as a given, what sorts of guidelines, practices, and social conditions will best promote and protect women's full inclusion in a safe and positive birth process. (shrink)

(1994). Identity and autonomy of psychology in cognitive sciences: Some remarks from language processing and knowledge representation. World Futures: Vol. 42, No. 1-2, pp. 71-78.

This essay considers the impact of digital networks in organizations on worker autonomy. Worker autonomy, the control that workers have over their own work situation, is claimed in this essay to be a key determinant for the quality of work, as well as an important moral goal. Digital networks pose significant threats to worker autonomy as well as opportunities for its enhancement. In this essay, the notion of worker autonomy is analyzed and evaluated for its importance (...) and moral relevance. It is then considered how digital networks both threaten worker autonomy and offer opportunities for its enhancement. Three major opportunities (enhanced communicative powers, increased informedness, teleworking) and threats (electronic monitoring, task prestructuring, and dependency creation) are discussed and analyzed. Finally, the dynamics that determine the impact on worker autonomy of the introduction of a digital network in organizations are investigated. A particular model for analyzing these dynamics and their impacts, Bryan Pfaffenberger's model of a technological drama. It will be illustrated how this model illuminates these dynamics by analyzing them as a dialectic of strategies of technological regularization by design constituencies and technological adjustment by impact constituencies. It will also be assessed what role network design has in this process. (shrink)

Significant criticisms have been raised regarding the ethical and psychological basis of living wills. Various solutions to address these criticisms have been advanced, such as the use of surrogate decision makers alone or data science‐driven algorithms. These proposals share a fundamental weakness: they focus on resolving the problems of living wills, and, in the process, lose sight of the underlying ethical principle of advance care planning, autonomy. By suggesting that the same sweeping solutions, without opportunities for choice, be (...) applied to all, individual patients are treated as population‐level groups—as a theoretical patient who represents a population, not the specific patient crafting his or her individualized future care plans. Instead, advance care planning can be improved through a multimodal approach that both mitigates cognitive biases and allows for customization of the decision‐making process by allowing for the incorporation of a variety of methods of advance care planning. (shrink)

This paper argues that the ubiquitous digital networks in which we are increasingly becoming immersed present a threat to our ability to exercise free will. Using process philosophy, and expanding upon understandings of causal autonomy, the paper outlines a thematic analysis of diary studies and interviews gathered in a project exploring the nature of digital experience. It concludes that without mindfulness in both the use and design of digital devices and services we run the risk of allowing such (...) services to direct our daily lives in ways over which we are increasingly losing control. (shrink)

The patient preference predictor is a proposed computer-based algorithm that would predict the treatment preferences of decisionally incapacitated patients. Incorporation of a PPP into the decision-making process has the potential to improve implementation of the substituted judgement standard by providing more accurate predictions of patients’ treatment preferences than reliance on surrogates alone. Yet, critics argue that methods for making treatment decisions for incapacitated patients should be judged on a number of factors beyond simply providing them with the treatments they (...) would have chosen for themselves. These factors include the extent to which the decision-making process recognises patients’ freedom to choose and relies on evidence the patient themselves would take into account when making treatment decisions. These critics conclude that use of a PPP should be rejected on the grounds that it is inconsistent with these factors, especially as they relate to proper respect for patient autonomy. In this paper, we review and evaluate these criticisms. We argue that they do not provide reason to reject use of a PPP, thus supporting efforts to develop a full-scale PPP and to evaluate it in practice. There are no data in this work. (shrink)

Conceptions of individual autonomy and of rational autonomy have played large parts in twentieth century moral philosophy, yet it is hard to see how either could be basic to morality. Kant's conception of autonomy is radically different. He predicated autonomy neither of individual selves nor of processes of choosing, but of principles of action. Principles of action are Kantianly autonomous only if they are law-like in form and could be universal in scope; they are heteronomous if, (...) although law-like in form, they cannot have universal scope. Puzzles about claims linking morality, reason and autonomy are greatly reduced by recognising the distinctiveness of Kantian autonomy. (shrink)

Nurses are increasingly faced with situations in practice regarding the prolongation of life and withdrawal of treatment. They play a central role in the care of dying people, yet they may find themselves disempowered by medical paternalism or ill-equipped in the decision-making process in end-of-life situations. This article is concerned with the ethical relationships between patient autonomy and medical paternalism in end-of-life care for an advanced cancer patient. The nurse’s role as the patient’s advocate is explored, as are (...) the differences between nursing and medicine when confronted with the notion of patient autonomy. The impetus for this discussion stems from a clinical encounter described in the following scenario. (shrink)

BackgroundPsychiatric staff members have the power to decide the options that frame encounters with patients. Intentional as well as unintentional framing can have a crucial impact on patients’ opportunities to be heard and participate in the process. We identified three dominant ethical perspectives in the normative medical ethics literature concerning how doctors and other staff members should frame interactions in relation to patients; paternalism, autonomy and reciprocity. The aim of this study was to describe and analyse statements describing (...) real work situations and ethical reflections made by staff members in relation to three central perspectives in medical ethics; paternalism, autonomy and reciprocity.MethodsAll staff members involved with patients in seven adult psychiatric and six child and adolescent psychiatric clinics were given the opportunity to freely describe ethical considerations in their work by keeping an ethical diary over the course of one week and 173 persons handed in their diaries. Qualitative theory-guided content analysis was used to provide a description of staff encounters with patients and in what way these encounters were consistent with, or contrary to, the three perspectives.ResultsThe majority of the statements could be attributed to the perspective of paternalism and several to autonomy. Only a few statements could be attributed to reciprocity, most of which concerned staff members acting contrary to the perspective. The result is presented as three perspectives containing eight values.•Paternalism; 1) promoting and restoring the health of the patient, 2) providing good care and 3) assuming responsibility.•Autonomy; 1) respecting the patient’s right to self-determination and information, 2) respecting the patient’s integrity and 3) protecting human rights.•Reciprocity; 1) involving patients in the planning and implementation of their care and 2) building trust between staff and patients.ConclusionsPaternalism clearly appeared to be the dominant perspective among the participants, but there was also awareness of patients’ right to autonomy. Despite a normative trend towards reciprocity in psychiatry throughout the Western world, identifying it proved difficult in this study. This should be borne in mind by clinics when considering the need for ethical education, training and supervision. (shrink)

This paper argues that the ubiquitous digital networks in which we are increasingly becoming immersed present a threat to our ability to exercise free will. Using process philosophy, and expanding upon understandings of causal autonomy, the paper outlines a thematic analysis of diary studies and interviews gathered in a project exploring the nature of digital experience. It concludes that without mindfulness in both the use and design of digital devices and services we run the risk of allowing such (...) services to direct our daily lives in ways over which we are increasingly losing control. (shrink)

Background Participation in a therapeutic clinical trial can be a challenging decision for patients with cancer and their family caregivers. Despite the implications of clinical trials for caregivers, there is little empirical research about how caregivers participate in clinical trial decision-making. This qualitative study sought to identify how caregivers view their role in these decisions and the attitudes and experiences of clinical trial staff regarding inclusion of caregivers in the informed consent process.Methods We performed four focus groups—two with clinical (...) trial staff and two with caregivers of patients offered a cancer clinical trial—followed by 15 semi-structured interviews with caregivers. Focus group results informed interview guide development. Transcripts were analyzed using an abductive approach to content analysis, incorporating the theory of relational autonomy.Results Caregivers viewed their role as enhancing patient autonomy by helping to interpret clinical trial information and acting as a sounding board. They expressed ambivalence regarding the appropriate degree of influence caregivers should have in the final decision and were cautious not to overly sway patients. Clinical trial staff viewed caregivers as highly influential in decision-making and vital to supporting patient adherence to the study protocol. Caregiver relationships with the oncologist and research staff were influential in their perception of the benefits of the clinical trial and comfort with their loved one participating.Conclusions Caregivers’ key role in facilitating clinical trial decision-making and protocol adherence merits further attention from bioethicists and researchers. Uncertainty regarding their appropriate decisional role highlights the need for assessment of shared decision-making (SDM) preferences to include caregivers in addition to the traditional patient-physician dyad. Future research should develop and test SDM tools incorporating relational autonomy to identify appropriate decisional roles based on patient-caregiver relationship dynamics and values. (shrink)

Background: The intensive care unit environment focuses on interventions and support therapies that prolong life. The exercise by nurses of their autonomy impacts on perception of the role they assume in the multidisciplinary team and on their function in the intensive care unit context. There is much international research relating to nurses’ involvement in end-of-life situations; however, there is a paucity of research in this area in Brazil. In the Brazilian medical scenario, life support limitation generated a certain reluctance (...) of a legal nature, which has now become unjustifiable with the publication of a resolution by the Federal Medical Council. In Brazil, the lack of medical commitments to end-of-life care is evident. Objective: To understand the process by which nurses exercise autonomy in making end-of-life decisions in intensive care units. Research design: Symbolic Interactionism and Corbin and Strauss theory methodology were used for this study. Participants and research context: Data were collected through single audio-recorded qualitative interviews with 14 critical care nurses. The comparative analysis of the data has permitted the understanding of the meaning of nurse’s experience in exercising autonomy relating to end-of-life decision-making. Ethical considerations: Institutional ethics approval was obtained for data collection. Participants gave informed consent. All data were anonymized. Findings: The results revealed that nurses experience the need to exercise autonomy in intensive care units on a daily basis. Their experience expressed by the process of increase opportunities to exercise autonomy is conditioned by the pressure of the intensive care unit environment, in which nurses can grow, feel empowered, and exercise their autonomy or else can continuously depend on the decisions made by other professionals. Conclusion: Nurses exercise their autonomy through care. They work to create new spaces at the same time that they acquire new knowledge and make decisions. Because of the complexity of the end-of-life situation, nurses must adopt a proactive attitude that inserts them into the decision-making process. (shrink)

The research approaches the problem of illegitimate external influences through the hierarchical analysis of personal autonomy and the analysis of theories of personal autonomy that arose as a constructive and critical reaction to it, which contributes to the establishment of criteria for demarcation between legitimate and illegitimate external influences. In addition, the relationship between personal autonomy and political legitimacy in a democratic context is examined, and the preconditions for political decision-making by autonomous citizens are defined. Using conceptual (...) analysis, the critical-evaluative method, and thought experiments, it is shown that personal autonomy cannot completely depend on the subjective assessment of the agent. The criterion of independence ought to have the status of a social convention that implies uniformity in its application to all agents in a relatively similar position. Personal autonomy implies being able to resist the possible arbitrary influence of others. In the political context, this means that respecting the personal autonomy of each citizen requires a participatory deliberative democracy in which the quality of the argument will be the only relevant factor in the formation of a collective decision. The legitimacy of a political decision is based on respect for personal autonomy, not only during the democratic process but also in the period that preceded it. Given that citizens are exposed to the arbitrary use of power that affects the impartiality of their judgment, autonomy-sensitive participatory deliberative democracy should take into account deliberative constraints in order to ensure the legitimacy of political decision-making. (shrink)

This book uses the example of informed consent guidelines for international research on human subjects to demonstrate how a philosophical analysis can assist in understanding how underlying concepts affect public policy; how and why such policies are exclusionary; and what methodology can be used to remedy injustices in public policy and practice. Epidemics, such as AIDS, have resulted in an increase in medical research in less developed countries. In an attempt to be more globally applicable, current international guidelines for research (...) on human subjects have attempted to acknowledge the importance of community. This book explains how these attempts fail to adequately acknowledge the importance community has for many people in less developed countries, and how these guidelines fail to attend to constraints to autonomy that oftentimes get magnified once community is involved in the informed consent process. The book further explains how these problems can be traced to a mistaken underlying notion of autonomy and what policymakers can do to remedy these problems . (shrink)

Do psychological perspectives constitute the only way through which the role of musical creativity in education can be addressed, researched and theorised? This essay attempts to offer an alternative view of musical creativity as a deeply social and political form of human praxis, by proposing a perspective rooted in the thought of the political philosopher and activist Cornelius Castoriadis (1922–1997). This is done in two steps. First, an attempt is made to place the pursuit of the concept of musical creativity (...) within a larger educational and societal context of conflicting trajectories that run through (a) Modernity and (b) Education. Then, I revisit the issue of educational value of improvising and composing through creating conceptual links between the process of music-making through improvisation and composition and the project of political autonomy as conceived by Castoriadis. By foregrounding instituting imaginary over instituted imaginary, improvising and composing become active processes of positing new legitimacies, and of creating a music-making context that searches for its own foundations. It is in and through creative musical praxis that we can think about issues of hierarchies, musical values, social dimensions of different music-making processes, our relationship to past values and to historical dimensions of music. By arguing that improvisation and composition might be seen as ways of positing the issue of political autonomy in musical terms, this paper emphasises the role of improvisation and composition as a mode of potentially transformative educational practice that may foster the development of critical consciousness, linking music education to a larger project of re-discovering and at the same time re-defining democracy. (shrink)

An enduring puzzle for theorists of autonomy in the broadly Kantian tradition is how to theorize failures of practical reason. If norms of practical rationality are supposed to be constitutive of agency itself, how can failures to live up them nonetheless be understood as expressions of that agency? Hegelian diagnoses of these difficulties typically emphasize the dichotomies that structure Kantian theories of autonomy, between activity and passivity, reason and nature, norm and desire. They seek to flesh out an (...) alternative that preserves a recognisably post-Kantian notion of autonomy whilst understanding freedom as something that essentially comes in degrees, insisting that self-determination always involves elements of other-determination, and stressing how free subjectivity is inseparable from socio-historically and institutionally bounded character-formation. This article contributes to articulating a Hegelian corrective to Kantian theories of autonomy by beginning to explain the role of habit in Hegel's conception of agency. Building on recent work on Hegel's metaphysics of expression, it shows how he allows us to see conative responses to the world as integral to character development and thus as expressive of free agency, rather than as interruptions to the proper functioning of practical reason. On Hegel's account, the expressive behaviour of mature, reflective agents is grounded in a pre-intentional, affective dimension of subjectivity and presupposes processes of habituation, which he locates at the level of the human ‘soul’. Habit, far from being ‘lifeless, contingent and particular’, is the means by which agents come to make objective contents their own. Understanding the role of habit in Hegel's system is integral to allowing an alternative conceptualization of autonomy to come into view, one on which rational agents express themselves through their affective and emotional responses, rather than merely being a contingent site of those responses. (shrink)

The goal of this article is to augment the ethical discussion among nurses with the findings from empirical research on autonomy of older adults with type 2 diabetes mellitus. There are many factors influencing autonomy. These include: health conditions, treatment, knowledge, experience and skills, personal approach as well as familial patterns, type of relationship, life history and social context. Fifteen older adults with type 2 diabetes mellitus were interviewed in a nurse-led diabetes clinic. These participants perceive three processes (...) which support autonomy in responsive relationships: preserving patterns of concern and interaction, nurturing collaborative responsibilities and being closely engaged in trustful and helpful family relations. People with diabetes realize autonomy in various responsive relationships in their unique life context. Next, we performed a literature review of care ethics and caring in nursing with regard to relational autonomy. We classified the literature in five strands of care: attitude-oriented, dialogue-oriented, activity-oriented, relationship-oriented and life-oriented. According to our respondents, autonomy in responsive relationships is fostered when patient, nurses, professionals of the health team and family members carry out care activities supported by a relational attitude of care. They can best realize autonomy in relationships with others when several essential aspects of care and caring are present in their lives. Therefore, we advocate a comprehensive approach to care and caring. (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)

On received philosophical doctrine, history is simply methodologically immature. History's autonomy can be established not by showing scientific explanations impossible for "history," but by coupling a demonstration that hypothetico-deductive explanation cannot exhaustively analyze historical knowledge with a critique of the proto-science view's assumption that legitimate modes of understanding must be analyzable by an explicit methodology. Certain views historians accept, e.g., that events are unique, while inadequate as a general theory of events, reveal historical understanding's distinctive feature: synoptic judgment, which, (...) irreducible to analytic techniques, interprets a complex process as a function of component events, their interrelationships, importance, and context. (shrink)

‘The art of living with ICTs ’ today not only means finding new ways to cope, interact and create new lifestyles on the basis of the new digital technologies individually, as ‘consumer-citizens’. It also means inventing new modes of living, producing and, not in the least place, struggling collectively, as workers and producers. As the so-called digital revolution unfolds in the context of a neoliberal cognitive and consumerist capitalism, its ‘innovations’ are predominantly employed to modulate and control both production processes (...) and consumer behavior in view of the overall goal of extracting surplus value. Today, the digital networks overwhelmingly destroy social autonomy, instead engendering increasing social heteronomy and proletarianization. Yet it is these very networks themselves, as technical pharmaka in the sense of French ‘technophilosopher’ Bernard Stiegler, that can be employed as no other to struggle against this tendency. This paper briefly explores this possibility by reflecting upon current diagnoses of our ‘technological situation’ by some exemplary post-operaist Marxists from a Stieglerian, pharmacological perspective. (shrink)

We argue that genuine biological autonomy, or described at human level as free will, requires taking into account quantum vacuum processes in the context of biological teleology. One faces at least three basic problems of genuine biological autonomy: (1) if biological autonomy is not physical, where does it come from? (2) Is there a room for biological causes? And (3) how to obtain a workable model of biological teleology? It is shown here that the solution of all (...) these three problems is related to the quantum vacuum. We present a short review of how this basic aspect of the fundamentals of quantum theory, although it had not been addressed for nearly 100 years, actually it was suggested by Bohr, Heisenberg, and others. Realizing that the quantum mechanical measurement problem associated with the “collapse” of the wave function is related, in the Copenhagen Interpretation of quantum mechanics, to a process between self-consciousness and the external physical environment, we are extending the issue for an explanation of the different processes occurring between living organisms and their internal environment. Definitions of genuine biological autonomy, biological aim, and biological spontaneity are presented. We propose to improve the popular two-stage model of decisions with a biological model suitable to obtain a deeper look at the nature of the mind-body problem. In the newly emerging picture biological autonomy emerges as a new, fundamental and inevitable element of the scientific worldview. (shrink)

Scientific research that requires space flight has always been subject to comparatively strong external control. Its agenda has often had to be adapted to vacillating political target specifications. Can space scientists appeal to one or the other form of the widely acknowledged principle of freedom of research in order to claim more autonomy? In this paper, the difficult question of autonomy within planned research is approached by examining three arguments that support the principle of freedom of research in (...) differing ways. Each argument has its particular strengths and limitations. Together they serve to demonstrate particular advantages of scientific autonomy, but in the case of space science, their force ultimately remains limited. However, as the arguments highlight the interrelations between scientific autonomy, the democratic process and the collective interest in scientific knowledge, they suggest that a coherent and sustained space science agenda might best be ensured by increasing the transparency of science policy decisions and involving the democratic public. (shrink)

Should the existence of moral disagreement reduce one’s confidence in one’s moral judgments? Many have claimed that it should not. They claim that we should be morally self-sufficient: that one’s moral judgment and moral confidence ought to be determined entirely one’s own reasoning. Others’ moral beliefs ought not impact one’s own in any way. I claim that moral self-sufficiency is wrong. Moral self-sufficiency ignores the degree to which moral judgment is a fallible cognitive process like all the rest. In (...) this paper, I take up two possible routes to moral self-sufficiency.First, I consider Robert Paul Wolff’s argument that an autonomous being is required to act from his own reasoning. Does Wolff’s argument yield moral self-sufficiency? Wolff’s argument does forbid unthinking obedience. But it does not forbid guidance: the use of moral testimony to glean evidence about nonmoral states of affairs. An agent can use the existence of agreement or disagreement as evidence concerning the reliability of their own cognitive abilities, which is entirely nonmoral information. Corroboration and discorroboration yields nonmoral evidence, and no reasonable theory of autonomy can forbid the use of nonmoral evidence. In fact, by using others to check on my own cognitive functionality, an agent is reasoning better and is thereby more autonomous.Second, I consider Philip Nickel’s requirement that moral judgment proceed from personal understanding. I argue that the requirement of understanding does forbid unthinking obedience, but not discorroboration. When an agent reasons morally, and then reduces confidence in their judgments through discorroboration, they are in full contact with the moral reasons, and with the epistemic reasons. Discorroboration yields more understanding, not less. (shrink)

Reproductive autonomy is a fundamental ethical principle in healthcare, yet insurance denials of care often undermine patient decision-making. This article examines a case in which a 35-year-old patient with stage 4 endometriosis sought a total hysterectomy and bilateral salpingo-oophorectomy to manage severe, refractory pelvic pain. Despite the patient’s informed and autonomous decision, her insurer denied authorization based on a paternalistic concern for her future fertility. Through an ethical analysis, this article critiques the role of insurers in reproductive decision-making, highlighting (...) the inherent conflict of interest, lack of clinical nuance, and burdens imposed on clinicians. The disproportionate scrutiny of sterilization procedures, rooted in a history of reproductive injustice, further complicates the ethical landscape. To address these challenges, we propose integrating interinstitutional ethics consultations into prior authorization processes, ensuring that patient autonomy is respected while maintaining oversight for medical necessity. This case underscores the need to balance oversight with respect for reproductive autonomy to optimize patient care and equitable access to necessary procedures. (shrink)