According to Dewey, we are responsible for our conduct because it is “ourselves objectified in action”. This idea lies at the heart of an increasingly influential deep self approach to moral responsibility. Existing formulations of deep self views have two major problems: They are often underspecified, and they tend to understand the nature of the deep self in excessively rationalistic terms. Here I propose a new deep self theory of moral responsibility called the Self-Expression account that addresses these issues. The (...) account is composed of two parts. The first part answers the question, What is a deep self? Theorists have tended to favor cognitive views that understand the deep self in terms of rationally formed evaluative judgment. I propose instead a conative view that says one’s deep self consists of a distinctive kind of pro-attitude, cares, and I provide an account of cares in terms of their distinctive psychological functional role. The second part answers the question, When does an action express one’s deep self? I criticize the agentially demanding conditions set out in existing views and propose a more minimalist alternative. I show that the Self-Expression account handles issues that bedeviled traditional deep self views, including how to explain moral responsibility for spontaneous, out of character, and weak-willed actions. (shrink)

Many forms of contemporary morality treat the individual as the fundamental unit of moral importance. Perhaps the most striking example of this moral vision of the individual is the contemporary global human rights regime, which treats the individual as, for all intents and purposes, sacrosanct. This essay attempts to explore one feature of this contemporary understanding of the moral status of the individual, namely the moral significance of a subject’s actual affective states, and in particular her cares and commitments. I (...) argue that in virtue of the moral significance of actual individuals, we should take actual cares and values very seriously—even if those cares and values are not expressions of the person’s autonomy—as partially constituting that individual as a concrete subject who is the proper object of our moral attention. In particular, I argue that a person’s actual cares and values have non-derivative moral significance. Simply because someone cares about something, that care is morally significant. In virtue of this non-derivative moral significance of cares, we ought to adopt of a commitment to accommodate others’ cares and a commitment not to frustrate their cares. (shrink)

Gadow's understanding of nursing as a relational narrative anchored in a dialectic between the fundamental subjectivity of the individual client and the objectification of his illness poses some interesting questions for nursing ethics and care. For Gadow, nursing is an encounter with the immediate vulnerability of the client and also lends it responsibilities to the medical objectification of illness aiming at disease treatment and control. Hence, nursing agency is divided between its responsibilities induced by the personal vulnerability of the patient (...) and the more impersonal, but benevolent intention shaped by medical knowledge. Medical knowledge is impersonal in the sense that it is knowledge detached from the subjectivity of the patient. But how is nursing able to reconcile the interests derived from personal and experienced vulnerability with the more impersonal and often conflicting demands of medical knowledge? This question is even more intriguing because there seems to be an objective dimension within a patient's subjectivity itself: an autonomous person can critically evaluate his own subjectivity as a basis for informed self‐interest. The sick person is thus confronted with objectivity on two important levels: the objective facts of his disease and his detachment from his own experiential vulnerability when engaged in the critical evaluation of his self‐interest. This paper will discuss the normative dimensions of these complex and, frequently, conflicting perspectives from the theoretical perspectives of Thomas Nagel's normative responsibility and Sally Gadow's clinical epistemology and relational narratives. The empirical basis for the discussion will be an ongoing study of the ethical dimensions of pain relief and sedation in an intensive care unit. (shrink)

The leading accounts of the ethics of proxy decision making implicitly draw on internalist conceptions of the philosophy of mind, or so this essay tries to demonstrate. Using the views of Ronald Dworkin as its jumping‐off point, the essay argues that accepting the sort of externalism associated with writers such as Putnam and Burge would alter Dworkin's conclusions concerning how we should respond to the current or precedent decisions of people suffering from dementia. Building on the views of Agnieszka Jawarska, (...) it argues that accepting “active” externalism à la Clark and Chambers would provide currently competent people with new resources for establishing the authority of their present values over inconsistent values they might come to entertain should they become demented. (shrink)

Philosophers have taken little heed of the fact that people often act contrary to their better judgment not because they suffer a volitional infirmity like weakness of will or compulsion but instead because they care too little about what they judge best (they are unconcerned) or they care too much about something else (they are compromised). Unconcerned and compromised action, being varieties of akratic action that do not involve volitional infirmity, are phenomena worth examining not only in their own right (...) but also for what they reveal about the better known varieties of akratic action for which they might easily be mistaken, such as weak-willed action and action (or inaction) that stems from accidie. Unconcern and compromise also are worth examining for what they reveal about a topic beyond philosophical psychology, namely, moral and legal accountability. Forgiveness, resentment, and retributive punishment each may have less to do with what an offender (morally) believes than with what he cares about. (shrink)

Almost all jurisdictions where physician-assisted death is legal require that the requesting individual be competent to make medical decisions at time of assistance. The requirement of contemporary competence is intended to ensure that PAD is limited to people who really want to die and have the cognitive ability to make a final choice of such enormous import. Along with terminal illness, defined as prognosis of death within six months, contemporary competence is regarded as an important safeguard against mistake and abuse, (...) arguably the strongest objections to legalizing PAD.The insistence on contemporary competence is problematic. It means that someone who has dementia is ruled out as a candidate for PAD, even if she is terminally ill and suffering terrible and unrelievable pain. It also rules out individuals with strong and unwavering desires not to end their life in dementia. (shrink)

Competent patients have considerable legal authority to control life‐and‐death care. They may refuse medical life support, including medically delivered food and fluids. Even when they are not in need of any life‐saving care, they may expedite death by refusing food and water by mouth—voluntarily stopping eating and drinking, or VSED. Neither right is limited to terminal illness. In addition, in four U.S. states, competent patients, if terminally ill, may obtain lethal drugs for aid‐in‐dying.For people who have dementia and are no (...) longer competent, however, control over the end of life is much less extensive. They may have written a clear advance directive for refusing life‐saving care in specified circumstances yet subsequently find themselves living for years in severe dementia with no need for life‐saving care that could be refused. Chronic progressive dementia is not itself life threatening until its very final stage. Even in jurisdictions that permit active aid‐in‐dying, individuals with advanced dementia are not eligible; they lack the required current competence, and they are seldom deemed terminally ill. As for the right to VSED, its very name—voluntarily stopping eating and drinking—is seen as excluding noncompetent persons.One option for ensuring that one does not live years in severe dementia is to use advance directives to withhold food and water by mouth. The driving element behind VSED is that forcing people to ingest food is as objectionable an intrusion on bodily integrity, privacy, and liberty as imposing unwanted medical treatment. Thus, if incompetent people do not lose their rights to refuse life‐saving treatment, and if people when competent have just as strong a right to VSED as they do to refuse life‐saving treatment, then people do not lose their right to VSED when incompetent either. They only have to exercise it by AD. (shrink)

The American Journal of Bioethics, Volume 12, Issue 10, Page 39-41, October 2012.

This essay examines the goals of care and the exercise of guardianship authority in the long-term care of persons with Alzheimer's disease and other forms of chronic, progressive dementia. It counters philosophical views that deny both agency and personhood to individuals with Alzheimer's on definitional or analytic conceptual grounds. It develops a specific conception of the quality of life and offers a critique of hedonic conceptions of quality of life and models of guardianship that are based on a hedonic legal (...) standard of “best interests.” As an alternative, it proposes a conception of quality of life based on the notions of “semantic agency” and “memorial personhood.”. (shrink)

Medical clinicians – doctors, nurses, nurse practitioners etc. – are charged to act for the good of their patients. But not all ways of acting for a patient's good are on par: some are paternalistic; others are not. What does it mean to act paternalistically, both in general and specifically in a medical context? And when, if ever, is it permissible for a clinician to act paternalistically? -/- This paper deals with the first question, with a special focus on paternalism (...) in medicine. While it is easy to give a rough characterization of paternalism (i.e. acting for another's good against that person's will), it is surprisingly difficult to provide a unified account of the myriad of actions that seem to count as paternalistic. After surveying four accounts of paternalism, I argue that two – what I call the authority and beneficence accounts – are the strongest on offer. According to the authority account, a clinician acts paternalistically when, for her patient's good, she usurps his decision-making authority. According to the beneficence account, a clinician acts paternalistically when, for her patient's good, she acts only or overrindingly out of concern for his good. I show how the difference between these accounts matters (in part) for how we should think about the nature of surrogate decision making in medicine. I argue that there are reasons – albeit hardly decisive – to prefer the beneficence account to the authority account. I conclude by considering whether attempts by clinicians to rationally persuade their patients to pursue a particular course of action should be thought of as paternalistic. (shrink)

The paper investigates whether it is plausible to hold the late stage demented criminally responsible for past actions. The concern is based on the fact that policy makers in the United States and in Britain are starting to wonder what to do with prison inmates in the later stages of dementia who do not remember their crimes anymore. The problem has to be expected to become more urgent as the population ages and the number of dementia patients increases. This paper (...) argues that the late-stage demented should not be punished for past crimes. Applicable theories of punishment, especially theories with an appropriate expressivist, or communicative element, fail to justify the imprisonment of the late-stage demented. Further imprisonment would require a capacity for comprehension on the part of the punished, and, under certain narrowly specified conditions, even a capacity to be at least in principle capable of recalling the crime again. (shrink)

Promising ourselves is familiar, yet some find it philosophically troubling. Though most of us take the promises we make ourselves seriously, it can seem mysterious how a promise made only to oneself could genuinely bind. Moreover, the desire to be bound by a promise to oneself may seem to expose an unflattering lack of trust in oneself. In this paper I aim to vindicate self-promising from these broadly skeptical concerns. Borrowing Nietzsche’s idea of a memory of the will, I suggest (...) that self-promising involves an activity of the will, aimed at the preservation and protection of one’s values. I explain how, understood in this way, these promises can indeed bind, and show that the motivation for making them need not involve mistrust or other alienated attitudes. I then turn to interpersonal promising, arguing that this same activity of the will is required for sincerely promising others: in effect, making a sincere promise to another requires making a promise to oneself. Attention to this under-appreciated aspect of interpersonal promising enriches our understanding of all promises, and helps to correct a narrow and distorted picture of what it means to be bound. (shrink)

Implicit intergroup biases have been shown to impact social behavior in many unsettling ways, from disparities in decisions to “shoot” black and white men in a computer simulation to unequal gender-based evaluations of résumés and CVs. It is a difficult question whether, and in what way, agents are responsible for behaviors affected by implicit biases. I argue that in paradigmatic cases agents are responsible for these behaviors in the sense that the behavior is “attributable” to them. That is, behaviors affected (...) by implicit biases reflect upon who one is as a moral agent. (shrink)