The topic of consent in paediatrics is made more difficult, and at the same time more interesting, by the complexity of the issues involved and the consequent diversity of viewpoints. In a teaching session for senior medical students on consent in paediatrics it proved necessary to reinstate previous learning from a range of disciplines. Philosophical medical ethics, developmental psychology, communication skills and the appropriate legal definitions all contributed to a proper understanding of the cases presented. The two most important additional (...) components appeared to be a) a basic knowledge of cognitive development and how to apply it, and b) an awareness of the need to balance an individual child's rights or best interests, with those of the family unit, as well as the wider society. (shrink)

This paper focuses on a hypothetical case that represents an intervention request familiar to those who work with individuals with intellectual disability. Stacy has autism and moderate intellectual disability. Her parents have requested treatment for her hand flapping. Stacy is not competent to make her own treatment decisions; proxy consent is required. There are three primary justifications for proxy consent: the right to an open future, substituted judgment, and the best interest standard. The right to an open future justifies proxy (...) consent on the assumption of future autonomy whereas substituted judgment justifies proxy consent via reference to past autonomy. Neither applies. Stacy has not been, nor will she be, competent to make her own treatment decisions. The best interest standard justifies proxy consent on the grounds of beneficence. It is unlikely that hand flapping harms Stacy. None of the three primary means of justifying proxy consent apply to Stacy’s case. (shrink)

Counterfactuals about what a patient would consent to, if he were able to consent, are often cited as justifications, or partial justifications, for acts of euthanasia. In virtue of this fact, they deserve special scrutiny by moral philosophers. ;In Chapter I, I examine terminology that is essential to further understanding the relationship between euthanasia and counterfactual consent. I propose a definition of 'euthanasia', an analysis of 'consent', and I present a brief description of counterfactuals. ;In Chapter II, I consider two (...) questions. The first is, "When it is appropriate to invoke counterfactual consent in an attempt to justify an act of euthanasia?" By making use of an improved version of the voluntary, nonvoluntary, and involuntary distinction among acts of euthanasia, I am able to determine when it is appropriate to cite counterfactuals about consent in an attempt to justify an act of euthanasia. The second is, "to what end is counterfactual consent used?" I contend that counterfactual consent does morally justify some acts of euthanasia, and defend an argument for this claim. Finally, I look at the role of counterfactual consent as a possible legal justification for acts of euthanasia. ;In Chapter III, I use possible world semantics to analyze counterfactual consent. Traditional counterfactuals are determined to be true if in the closest world at which their antecedent is true, their consequent is also true. Counterfactuals about consent have a less straightforward reading. I consider and reject several possible ways of reading counterfactuals about consent, before settling on the correct reading of counterfactuals about consent. ;In Chapter IV, I consider evidence for the truth of claims about counterfactual consent. I consider and reject the claim that no counterfactual is either true or false. I examine both Living Wills and the practice of surrogacy, neither of which offers sufficient evidence for the truth of claims about counterfactual consent. ;In Chapter V, I contrast counterfactual consent with actual consent. I review and refute the arguments for the claim that actual consent is preferable to counterfactual consent. I conclude by presenting a principle about the relationship between actual and counterfactual consent. (shrink)