Paternalism in Applied Ethics

According to some philosophers, if moral agency is understood in behaviourist terms, robots could become moral agents that are as good as or even better than humans. Given the behaviourist conception, it is natural to think that there is no interesting moral difference between robots and humans in terms of moral agency. However, such moral differences exist: based on Strawson’s account of participant reactive attitude and Scanlon’s relational account of blame, I argue that a distinct kind of reason available to (...) humans—call it human-relative reason—is not available to robots. The difference in moral reason entails that sometimes an action is morally permissible for humans, but not for robots. Therefore, when developing moral robots, we cannot consider only what humans can or cannot do. I use examples of paternalism to illustrate my argument. (shrink)

Many of us hold false beliefs about matters that are relevant to public policy such as climate change and the safety of vaccines. What can be done to rectify this situation? This question can be read in two ways. According to the descriptive reading, it concerns which methods will be effective in persuading people that their beliefs are false. According to the normative reading, it concerns which methods we are permitted to use in the service of persuading people. Some effective (...) methods—a programme of brainwashing, say—would not be permissible. In this paper I compare “methods of rational persuasion” with what you might call “marketing methods” such as how one frames the problem of climate change. My aim is to show that “marketing methods” are preferable to “methods of rational persuasion”. My argument has two parts. First, I argue that the evidence suggests that “marketing methods” are more effective in persuading people to change their minds. Second, I argue that “marketing methods” are an acceptable response to the normative question. (shrink)

The aim of this paper is to (i) examine the concept of epistemic paternalism and (ii) explore the consequences of normative questions one might ask about it. I begin by critically examining several definitions of epistemic paternalism that have been proposed, and suggesting ways they might be improved. I then contrast epistemic and general paternalism and argue that it’s difficult to see what makes epistemic paternalism an epistemic phenomenon at all. Next, I turn to the various normative questions one might (...) ask about epistemic paternalism and discuss the literature’s assumptions of epistemic consequentialism and veritism. I close by comparing and contrasting epistemic paternalism with other topics in social epistemology, such as disagreement or testimony. (shrink)

Una sintetica introduzione alle principali questioni etiche e filosofiche riguardanti la comunicazione sanitaria: la comunicazione fra medico e paziente e quella fra istituzioni, sanitari e cittadini. In uno scenario in cui autonomia e consenso della persona sono sempre più rilevanti nelle scelte di cura e di tutela della salute, l’autrice delinea un quadro concettuale aggiornato per affrontare temi problematici come la comunicazione della diagnosi, l’impostazione delle campagne di prevenzione e salute pubblica, il ruolo dei medici come esperti nei media. -/- (...) Indice del volume: Introduzione. - I. Concetti per la bioetica. - II. La comunicazione tra medico e paziente. - 3. La comunicazione delle istituzioni sanitarie. - IV. Gli esperti e i media nella comunicazione della salute. - Riferimenti bibliografici. - Indice analitico. -/- . (shrink)

In this article, I argue that even if we hold that at least some paternalistic behaviour is impermissible when directed towards innocent persons, in certain cases, the same behaviour is permissible when directed towards criminal offenders. I also defend the claim that in some cases it is morally preferable to behave paternalistically towards offenders as an alternative to traditional methods of punishment. I propose that the reason paternalistic behaviour is sometimes permissible towards an offender is the same reason that inflicting (...) intentional harm on an offender is permissible – namely, that it is sometimes a morally justified method of punishing an offender for his wrongdoing. (shrink)

Paternalistic behaviour directed towards a person’s informed and competent decisions is often thought to be morally impermissible. This view is supported by what we can call the Anti-Paternalism Principle. While APP might seem plausible when employed to show the wrongness of paternalism by the state, there are some cases of paternalistic behaviour between private, informed, and competent individuals where APP seems mistaken. This raises a difficulty for supporters of APP. Either they need to reject APP to accommodate our intuitions in (...) these cases, or provide grounds for thinking that paternalistic behaviour between certain private individuals is different in a morally relevant sense. In this paper, I explore several possible morally relevant differences, and find all of them unsatisfactory as grounds for maintaining the plausibility of APP. (shrink)

The COVID-19 pandemic has brought significant challenges to healthcare systems worldwide, and in Africa, given the lack of resources, they are likely to be even more acute. The usefulness of Traditional African Healers in helping to mitigate the effects of pandemic has been neglected. We argue from an ethical perspective that these healers can and should have an important role in informing and guiding local communities in Africa on how to prevent the spread of COVID-19. Particularly, we argue not only (...) that much of the philosophy underlying Traditional African Medicine is adequate and compatible with preventive measures for COVID-19, but also that Traditional African Healers have some unique cultural capital for influencing and enforcing such preventive measures. The paper therefore suggests that not only given the cultural context of Africa where Traditional African Healers have a special role, but also because of the normative strength of the Afro-communitarian philosophy that informs it, there are good ethical reasons to endorse policies that involve Traditional Healers in the fight against COVID-19. We also maintain that concerns about Traditional African Healers objectionably violating patient confidentiality or being paternalistic are much weaker in the face of COVID-19. (shrink)

Most adult persons with anorexia satisfy the existing criteria widely used to assess decision-making capacity, meaning that incapacity typically cannot be used to justify coercive intervention. After rejecting two other approaches to justification, Professor Radden concludes that it is most likely not possible to justify coercive medical intervention for persons with anorexia in liberal terms, though she leaves it open whether some other framework might succeed. I shall assume here that the standard approach to assessing decisionmaking capacity is adequate.1 The (...) question then is whether we can justify—within a liberal framework—coercive intervention with the decision of a competent... (shrink)

The late Robert Veatch, one of the United States’ founders of bioethics, never tired of reminding us that the paradigm-shifting contribution that bioethics made to patient care was to liberate patients out of the hands of doctors, who were traditionally seen to know best, even when they decidedly did not know best. It seems to us that with the advent of COVID-19, health policy has come full-circle on this. COVID-19 gave rise to a large number of purportedly “ethical” guidance documents (...) aiming to assist health care providers and practitioners with responding to the ethical challenges that might arise in their response to the pandemic. Ethics has two primary functions: provide clear action guidance, and provide clear action justification. The documents in question arguably reflect the ultimate policy triumph of bioethical “principlism”, and, perhaps surprisingly, as a corollary, the ultimate triumph of “doctor-knows-best”. (shrink)

Adolescents are routinely treated differently to adults, even when they possess similar capacities. In this article, we explore the justification for one case of differential treatment of adolescents. We attempt to make philosophical sense of the concurrent consents doctrine in law: adolescents found to have decision-making capacity have the power to consent to—and thereby, all else being equal, permit—their own medical treatment, but they lack the power always to refuse treatment and so render it impermissible. Other parties, that is, individuals (...) who exercise parental responsibility or a court, retain the authority to consent on an adolescent’s behalf. We explore four defences of the doctrine. We reject two attempts to defend the asymmetry in the power to consent to and refuse medical treatment by reference to transitional paternalism. We then consider and reject a stage of life justification. Finally, we articulate a justification based on the distinctiveness of adolescent well-being. (shrink)

Since its advent in the 20th century, informed consent has become a cornerstone of ethical healthcare, and obtaining it a core obligation in medical contexts. In my dissertation, I aim to examine the theoretical underpinnings of informed consent and identify what values it is taken to protect. I will suggest that the fundamental motivation behind informed consent rests in something I’ll call bodily self-sovereignty, which I argue involves a coupling of two groups of values: autonomy and non-domination on the one (...) hand, and self-ownership and personal integrity on the other. I will then go on to consider two 'case studies' I take to shed light on what is at stake in securing informed consent - consent in psychiatrically ill populations, and consent to interventions that involve the modification of the genetic germline. (shrink)

This volume considers forms of information manipulation and restriction in contemporary society, paying special attention to contemporary paternalistic practices in big data and scientific research, as the way in which the flow of information or knowledge might be curtailed by the manipulations of a small body of experts or algorithms.

Our aim in this brief essay is not to defend a particular policy or attitude toward lockdown measures in the United States or elsewhere, but to consider the scope and limits of different types of arguments that can be offered for them. Understanding the complexity of these issues will, we hope, go some way to helping us understand each other and our attitudes toward state responses to the pandemic.

Nudging is the idea that people’s decisions should be influenced in predictable, non-coercive ways by making changes to the way that options are presented to them. Central to the debate about nudging is the question of whether it is morally permissible to intentionally nudge others. Libertarian paternalists maintain that this can be the case. In this paper, I present the libertarian paternalistic criteria for the moral permissibility of intentional nudges. Having done this, I motivate two objections. The first one targets (...) the moral permissibility of nudging in general. The second one targets the moral permissibility of only a subset of nudges. After evaluating both of these objections, I conclude that although they are unsuccessful, the evaluation of The Manipulation Objection shows that the libertarian paternalistic criteria for the moral permissibility of intentional nudges fails. I end by suggesting a possible revision to the criteria that avoids the problem, considering its limitations, and providing examples of its applications. (shrink)

Thaler and Sunstein advocate 'libertarian paternalism'. A libertarian paternalist changes the conditions under which people act so that their cognitive biases lead them to choose what is best for themselves. Although libertarian paternalism manipulates people, Thaler and Sunstein say that it respects their autonomy by preserving the possibility of choice. Conly argues that libertarian paternalism does not go far enough, since there is no compelling reason why we should allow people the opportunity to choose to bring disaster upon themselves if (...) sometimes they will make the wrong decision. She defends 'coercive paternalism'. The present paper argues that errors in reasoning are not due only to cognitive biases. People also make errors because they have an insufficient level of general intelligence. Intelligence is distributed on a continuum. Those who fall on higher levels of the continuum have greater abilities, in certain contexts, to reason about both their own and others' interests. Coercive paternalism may sometimes be appropriate to prevent less intelligent people from engaging in self-destructive behavior due to errors of reasoning. (shrink)

A recent paper by Bullock (2018) raises a dilemma for proponents of epistemic paternalism. If epistemic paternalists contend that epistemic improvements contribute to one’s wellbeing, then their view conflates with general paternalism. Instead, if they appeal to the notion of a distinctive epistemic value, their view is unjustified, in that concerns about epistemic value fail to outweigh concerns about personal sovereignty. In this chapter, I address Bullock’s challenge in a way that safeguards the legitimacy of epistemic paternalism, albeit restricting its (...) scope to a limited range of cognitive projects. After shedding light on a problem with how Bullock singles out cases to which the dilemma applies, I argue that there is at least one reasonable way of interpreting the notion of ‘personal autonomy’ which legitimates and justifies undertaking epistemically paternalistic interferences for one’s epistemic good. (shrink)

Response to commentaries on 'The right not to know and the obligation to know'.

There is significant controversy over whether patients have a ‘right not to know’ information relevant to their health. Some arguments for limiting such a right appeal to potential burdens on others that a patient’s avoidable ignorance might generate. This paper develops this argument by extending it to cases where refusal of relevant information may generate greater demands on a publicly funded healthcare system. In such cases, patients may have an ‘obligation to know’. However, we cannot infer from the fact that (...) a patient has an obligation to know that she does not also have a right not to know. The right not to know is held against medical professionals at a formal institutional level. We have reason to protect patients’ control over the information that they receive, even if in individual instances patients exercise this control in ways that violate obligations. (shrink)

The traditional liberal view on conflicts between care for wellbeing and respect for choice and desire is that we should look to degrees of competence and voluntariness to determine which moral imperative should take priority. This view has likely influenced the common view that children’s choices should be considered only to the extent that this promotes their future autonomy and helps us determine their best interests. I reject both the general traditional liberal view and its application to children. Competence and (...) voluntariness, as well as maturity, are at best proxies for what really matters, which is wellbeing, choice and desire. We typically have reason to respect children’s choices, irrespective of any further positive consequences. If we should more often make children do what they do not want to do, this is mainly because, though we should care about respecting their choices, we should care even more about their wellbeing and future autonomy. (shrink)

In this comment on Kenneth Iserson’s article, ”Do You Believe in Magic? Shove, Don’t Nudge: Advising Patients at the Bedside,” I discuss the definition of and the moral evaluation of nudging. I propose that using persuasive descriptions and intentionally building trust in patients by one’s demeanor is a form of nudging. I argue that nudging is not necessarily morally problematic, but that it can be controlling and can limit liberty, despite proponents’ claims to the contrary. I agree with Iserson that (...) clinicians should give their patients explicit advice, but add that they should ideally also be aware of the more subtle psychological effects of advice giving. (shrink)

The fear of the largely unknown consequences of being exposed to coronavirus should have brought a more dynamic interplay of beliefs and opinions for those who in the footsteps of J.S. Mill believe that the limits of power, which can be legitimately exercised by society over the individual, is to prevent harm to others. It is surprising that not much debate or critical interaction has taken place on the choice of locking down most of the populace in 185 countries after (...) the outbreak of COVID-19. The general lockdown, instead of testing and isolating the sick, can be seen as ‘a gross usurpation upon the liberty of private life.’ The axiological and ethical question confronting philosophers relates to the type and degree of authority needed during this period. As Mill claims, no general basic liberties can be respected overall without some previous and gradual evolution, that is, before other more specific liberties have met sustainable social practice. This essay reviews some of the problematic situations highlighting that no society is free or can achieve the objective of a fairly pluralistic set of values without a given social practice of these values, and shows how this logic of spreading of values unfolds in the context of the Coronavirus crisis. (shrink)

Epistemic paternalism is the practice of interfering with someone’s inquiry, without their consent, for their own epistemic good. In this chapter, I explore the relationship between epistemic paternalism and two other epistemological theses: epistemic permissivism and standpoint epistemology. I argue that examining this relationship is fruitful because it sheds light on a series of cases in which epistemic paternalism is unjustified and brings out notable similarities between epistemic permissivism and standpoint epistemology.

According to one influential view, requirements to elicit consent for medical interventions and other interactions gain their rationale from the respect we owe to each other as autonomous, or self-governing, rational agents. Yet the popular presumption that consent has a central role to play in legitimate intervention extends beyond the domain of cases where autonomous agency is present to cases where far from fully autonomous agents make choices that, as likely as not, are going to be against their own best (...) interest. The question how we should understand the rationale for eliciting consent in this range of ‘non-ideal’ cases is comparatively ill understood. In this paper, I explore the prospects of accounting for consent requirements in such ‘non-ideal’ cases by appealing to a set of agency-based interests; including an interest in playing a meaningful part in joint decisions affecting ourselves and others. (shrink)

Personal autonomy is often lauded as a key value in contemporary Western bioethics. Though the claim that there is an important relationship between autonomy and rationality is often treated as uncontroversial in this sphere, there is also considerable disagreement about how we should cash out the relationship. In particular, it is unclear whether a rationalist view of autonomy can be compatible with legal judgments that enshrine a patient's right to refuse medical treatment, regardless of whether the reasons underpinning the choice (...) are known and rational, or indeed whether they even exist. Jonathan Pugh brings recent philosophical work on the nature of rationality to bear on the question of how we should understand personal autonomy in contemporary bioethics. In doing so, he develops a new framework for thinking about the concept of autonomy, one that is grounded in an understanding of the different roles that rational beliefs and rational desires have to play in it. Pugh's account allows for a deeper understanding of d the relationship between our freedom to act and our capacity to decide autonomously. His rationalist perspective is contrasted with other prominent accounts of autonomy in bioethics, and the revisionary implications it has for practical questions in biomedicine are also outlined. (shrink)

Political communities across the world have recently sought to tackle rising rates of vaccine hesitancy and refusal, by implementing coercive immunization programs, or by making existing immunization programs more coercive. Many academics and advocates of public health have applauded these policy developments, and they have invoked ethical reasons for implementing or strengthening vaccine mandates. Others have criticized these policies on ethical grounds, for undermining liberty, and as symptoms of broader government overreach. But such arguments often obscure or abstract away from (...) the diverse values that are relevant to the ethical justifications of particular political communities’ vaccine‐mandate policies. We argue for an expansive conception of the normative issues relevant to deciding whether and how to establish or reform vaccine mandates, and we propose a schema by which to organize our thoughts about the ways in which different kinds of vaccine‐mandate policies implicate various values. (shrink)

When are we morally obligated as a society to help the homeless, and is coercive interference justified when help is not asked for, even refused? To answer this question, we propose a comprehensive taxonomy of different types of homelessness and argue that different levels of autonomy allow for interventions with varying degrees of pressure to accept help. There are only two categories, however, where paternalism proper is allowed, be it heavily qualified. The first case is the homeless person with severely (...) diminished autonomy as a result of mental illness, and the second case is the homeless person who runs a risk of serious and imminent harm to self. In the first case, namely, that of soft paternalism, we argue that coercive intervention in the case of a refusal to accept help should be focused on the provision of housing that meets basic needs—needs that we outline in the article. In the case of imminent and severe harm to self, the case of hard paternalism, we argue that forced intervention can only be allowed if it is temporary and local, namely focused on getting someone out of harm’s way. (shrink)

It is increasingly clear that children's excessive consumption of products high in added sugar causes obesity and obesity-related health problems like type 2 diabetes, cardiovascular disease, and metabolic syndrome. Less clear is how best to address this problem through public health policy. In contrast to policies that might conflict with adult's right to self-determination — for example sugar taxes and soda bans — this article proposes that children's access to products high in added sugars should be restricted in the same (...) way that children's access to tobacco products is restricted. The article first considers how the recommended policy will protect a child's right to an open future while not violating parental rights. The article then explores how the implementation of the recommended policy can help transform the social meaning of sugar and thereby curb the parental supply of added sugar to children — a central cause of obesity. The article also addresses several potential objections. (shrink)

In this paper, I argue against the commonly held view that paternalism is all things considered wrong when it interferes with a person’s autonomy. I begin by noting that the plausibility of this view rests on the assumption that there is a morally relevant difference in the normative reasons concerning an intervention in a person’s self-regarding actions and an intervention in his other-regarding actions. I demonstrate that this assumption cannot be grounded by wellbeing reasons, and that autonomy-based reasons of non-interference (...) also cannot adequately explain the difference. Following this, I propose that the difference in the reasons related to an intervention in a person’s self-regarding actions and an intervention in his other-regarding actions can be explained by the value of holding a person responsible for his choices. Nonetheless, this does not result in paternalistic behavior that interferes with autonomy being all things considered wrong. Instead, I show that the reason to hold a person responsible for a diminution of his wellbeing does not necessarily defeat the wellbeing reasons that count in favor of paternalistic behavior. (shrink)

Here I pursue two main aims: (1) to articulate and defend a Kantian conception of duties to self, and (2) to explore the ramifications of such duties for the moral justification of paternalism. I conclude that there is a distinctive reason to resent paternalistic intercessions aimed at assisting others in fulfilling their duties to self (or the self-regarding virtues necessary thereunto), based on the fact that the goods realized via their fulfillment are historical, i.e., their value depends on an individual's (...) casual contribution to their fulfillment. (shrink)

Epistemic paternalism is the thesis that in some circumstances we are justified in interfering with the inquiry of another for their own epistemic good without consulting them on the issue. In this paper, I address the issue of who is rationally entitled to undertake paternalistic interferences, and in virtue of which features one has this entitlement. First, I undermine the view according to which experts are the most apt people to act as paternalist interferers. Then, I argue that epistemic authorities (...) are in a better position to satisfy the requirements of justified epistemic paternalism, when conceived according to the service model of epistemic authority. Finally, I offer a virtue-based account of paternalist interferers and show how it can apply to cases in which the interferer is a group or an institution. (shrink)

In many or most instances of paternalism, more than one person acts paternalistically, or more than one person is treated paternalistically. This chapter discusses some complications that arise in such group cases, which are largely ignored in the conceptual debate. First, a group of people who together perform an action may do so for different reasons, which makes it more challenging to determine whether the action is paternalistic. This gives us some reason not to pin the property of being paternalistic (...) on actions, since we may alternatively pin it on reasons for actions and allow that these differ between members in the group. Second, the prevention of harmful consensual interactions is sometimes paternalism towards both or all involved, but only if all benefit from interference with themselves rather than with other members in the group, or if all want the harm or risk (more or less) for its own sake. Third, interrelations between three components of paternalism - interference, benevolence and consent - gives us reason to allow that an action can be paternalistic towards some but not others of those affected. This makes it even more difficult, and less relevant, to determine whether or not actions are paternalistic. (shrink)

Debates on the nature and justifiability of paternalism typically focus only on adults, sometimes presuming without argument that paternalism towards children is a non-issue or obviously justified. Debates on the moral and political status of children, in turn, rarely connect with the rich literature on paternalism. This chapter attempts to bridge this gap by exploring how issues that arise in the general debate on paternalism are relevant also for the benevolent interference with children. I survey and discuss various views and (...) argue for my own: that paternalism towards children is in most respects like paternalism towards adults and stands in the same need of justification, though such justification is more often forthcoming both because children are typically less prudent than adults and so benefit more from interference, and because, in some respects, interference is less harmful to them. (shrink)

While paternalism has been a long-standing philosophical issue, it has recently received renewed attention among scholars and the general public. Comprising twenty-seven chapters by a team of international contributors, this handbook is divided into five parts: (i) What is Paternalism; (ii) Paternalism and Ethical Theory; (iii) Paternalism and Political Philosophy; (iv) Paternalism without Coercion; (v) Paternalism in Practice. Within these sections central debates, issues, and questions are examined, including: how should paternalism be defined or characterized? How is paternalism related to (...) such moral notions as rights, well-being, and autonomy? When is paternalism morally objectionable? What are the legitimate limits of government benevolence? To what extent should medical practice be paternalistic? (shrink)

Many philosophers distinguish between "hard" paternalism, which supposedly violates autonomy, and "soft" paternalism, which does not. This chapter begins by critically assessing Joel Feinberg's account of the distinction, according to which hard paternalism interferes with voluntary self-regarding choices while soft paternalism interferes with substantially nonvoluntary self-regarding choices. It then considers several other ways to draw the hard/soft distinction. Ultimately, the chapter concludes that although the hard/soft distinction is a crucially important component of most antipaternalist views, it is surprisingly difficult to (...) draw in a satisfying way. (shrink)

In Our Best Interest argues that it is permissible to intervene in a person's affairs whenever doing so serves her best interest without wronging others. Jason Hanna makes the case for paternalism, responding to common objections that paternalism is disrespectful or that it violates rights, and arguing that popular anti-paternalist views confront serious problems.

Dworkin’s dignity framework has little explanatory value for one moral topic for which it should be especially suited: paternalistic intervention by one adult with another. The dignity framework has little epistemic value for morality regarding paternalism. Dworkin’s conception of dignity is too inchoate to illuminate why and when individual paternalism is wrong, all things considered. Dignity does somewhat better at illuminating why some types of individual paternalism are pro tanto wrong; but not other types. Moreover, the conception of dignity cannot (...) be refined by the process described above and retain any epistemic value on this matter. One would expect that a very natural -- indeed, a central -- use of the conception of dignity dHedgehogs would be to explain and illuminate moral claims about paternalism. That Dworkin’s conception of dignity largely fails to do so is, therefore, particularly important. (shrink)

According to rational will views of paternalism, the wrongmaking feature of paternalism is that paternalists disregard or fail to respect the rational will of the paternalized, in effect substituting their own presumably superior judgments about what ends the paternalized ought to pursue or how they ought to pursue them. Here I defend a version of the rational will view appealing to three rational powers that constitute rational agency, which I call recognition, discrimination, and satisfaction. By appealing to these powers, my (...) version of the rational will view can rank the wrongfulness of paternalistic acts in terms of the extent to which such acts (a) amount to supplanting the paternalized individual’s identity as a rational agent with that of the paternalist, and (b) the degree of mistrust the paternalistic act shows in the paternalized individual’s rational agency. My rational powers account thus provides a more complete account of why paternalism is a powerful, but not decisive or absolute, objection to an act or policy. My rational powers account also provides powerful explanations of why rational suasion deflects charges of paternalism; why consenting to intercessions in one’s rational agency negates paternalism; why we ordinarily believe that strong paternalism is more objectionable than weak paternalism; and why we ordinarily believe that hard paternalism is more objectionable than soft paternalism. (shrink)

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

Health incentive schemes aim to produce healthier behaviors in target populations. They may do so both by making incentivized options more salient and by making them less costly. Changes in costs only result in healthier behavior if the individual rationally assesses the cost change and acts accordingly. Not all people do this well. Those that fail to respond rationally to incentives will typically include those who are least able to make prudent choices more generally. This group will typically include the (...) least advantaged more generally, since disadvantage inhibits one's effective ability to choose well and since poor choices tend to cause or aggravate disadvantage. Therefore, within the target population, health benefits to the better off may come at the cost of aggravated inequity. This is one instance of a problem I name the Able Chooser Problem, previously emphasized by Richard Arneson in relation to coercive paternalism. I describe and discuss this problem by distinguishing between policy options and their effects on the choice situation of individuals. Both positive and negative incentives, as well as mandates that are less than perfectly effective, require some sort of rational deliberation and action and so face the Able Chooser Problem. In contrast, effective restriction of what options are physically available, as well as choice context design that makes some options more salient or appealing, do not demand rational agency. These considerations provide an equity-based argument for preferring smart design of our choice and living environment to incentives and mandates. (shrink)

Jeffrey Brown, Greg Hoskins and Elizabeth Sperry pose questions about three different policy questions that are discussed in From Field to Fork: Food Ethics for Everyone: policy interventions to address obesity, welfare guidelines for egg production, and the safety of genetically engineered foods. However all three critiques turn on the question of what we can expect a non-specialist to know, and how much information they can be expected to process in making an ethical decision about what to eat. My response (...) situates each question within literature on so-called “fast” and “slow” thinking. I argue that while ethical theories appear to have supposed that people are slow thinkers who can be expected to process a great deal of complexity, food ethics must be founded on principles that respect the habitual and heuristic basis of much eating behavior. (shrink)

Respect for autonomy and beneficence are frequently regarded as the two essential principles of medical ethics, and the potential for these two principles to come into conflict is often emphasised as a fundamental problem. On the one hand, we have the value of beneficence, the driving force of medicine, which demands that medical professionals act to protect or promote the wellbeing of patients or research subjects. On the other, we have a principle of respect for autonomy, which demands that we (...) respect the self-regarding decisions of individuals. As well as routinely coming into opposition with the demands of beneficence in medicine, the principle of respect for autonomy in medical ethics is often seen as providing protection against beneficial coercion (i.e. paternalism) in medicine. However, these two values are not as straightforwardly opposed as they may appear on the surface. In fact, the way that we understand autonomy can lead us to implicitly sanction a great deal of paternalistic action, or can smuggle in paternalistic elements under the guise of respect for autonomy. -/- This paper is dedicated to outlining three ways in which the principle of respect for autonomy, depending on how we understand the concept of autonomy, can sanction or smuggle in paternalistic elements. As the specific relationship between respect for autonomy and beneficence will depend on how we conceive of autonomy, I begin by outlining two dominant conceptions of autonomy, both of which have great influence in medical ethics. I then turn to the three ways in which how we understand or employ autonomy can increase or support paternalism: firstly, when we equate respect for autonomy with respect for persons; secondly, when our judgements about what qualifies as an autonomous action contain intersubjective elements; and thirdly, when we expect autonomy to play an instrumental role, that is, when we expect people, when they are acting autonomously, to act in a way that promotes or protects their own wellbeing. I then provide a proposal for how we might work to avoid this. I will suggest that it may be impossible to fully separate paternalistic elements out from judgements about autonomy. Instead, we are better off looking at why we are motivated to use judgements about autonomy as a means of restricting the actions of patients or research subjects. I will argue that this is a result of discomfort about speaking directly about our beneficent motivations in medical ethics. Perhaps we can reduce the incentive to smuggle in these beneficent motivations under the guise of autonomy by talking directly about beneficent motivations in medicine. This will also force us to recognise paternalistic motivations in medicine when they appear, and to justify paternalism where it occurs. (shrink)

Considerations of objective-value freedom and status freedom do impose constraints on policies that restrict access to cigarettes. As to the objective-value freedom, something of value is lost when anti-alcohol policies lead to pub closures interfering with valued life styles, and a similar, though weaker, argument can be made for cigarettes. As to status freedom, non-arbitrariness requires consultation with vulnerable populations to learn what might aid them with smoking cessation.

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

Epistemic paternalism is the thesis that a paternalistic interference with an individual's inquiry is justified when it is likely to bring about an epistemic improvement in her. In this article I claim that in order to motivate epistemic paternalism we must first account for the value of epistemic improvements. I propose that the epistemic paternalist has two options: either epistemic improvements are valuable because they contribute to wellbeing, or they are epistemically valuable. I will argue that these options constitute the (...) foundations of a dilemma: either epistemic paternalism collapses into general paternalism, or a distinctive project of justified epistemic paternalism is implausible. (shrink)

Lifelong smokers lose on average a decade of life vis-à-vis non-smokers. Globally, tobacco causes about 5–6 million deaths annually. One billion tobacco-related deaths are predicted for the 21st century, with about half occurring before the age of 70. In this paper, we consider a complete ban on the sale of cigarettes and find that such a ban, if effective, would be justified. As with many policy decisions, the argument for such a ban requires a weighing of the pros and cons (...) and how they impact on different individuals, both current and future. The weightiest factor supporting a ban, we argue, is the often substantial well-being losses many individuals suffer because of smoking. These harms, moreover, disproportionally affect the disadvantaged. The potential gains in well-being and equality, we argue, outweigh the limits a ban places on individuals’ freedom, its failure to respect some individuals’ autonomous choice and the likelihood that it may, in individual cases, reduce well-being. (shrink)

Public health policies typically assume that there are characteristics and constraints over health that an individual cannot control and that there are choices that an individual could change if he is nudged or provided with incentives. We consider that health is determined by a range of personal, social, economic and environmental factors and we discuss to what extent an individual can control these factors. In particular, we assume that the observed health status of an individual is a result of factors (...) within the individual’s control and constraints the individual faces. We suggest three different constraints: budget, time and psychological constraints and position various determinants of health according to increasing levels of constraint and increasing degrees of individual control. We finally discuss public health policies such as nudging, intervening and rewarding within this new framework and show that the level of constraints and the degree of individual control on health status are essential dimensions to consider when designing and implementing public health policies. (shrink)