In the intellectual confusion prevailing since the demise of Marxism and “marxism”, the attempt is made to define democracy as a matter of pure procedure, explicitly avoiding and condemning any reference to substantive objectives. It can easily be shown, however, that the idea of a purely procedural “democracy” is incoherent and self-contradictory. No legal system whatsoever and no government can exist in the absence of substantive conditions which cannot be left to chance or to the workings of the “market” (...) but must be posited as objectives of political activity. The confusion results from a deficient understanding of what makes a society and an empty idea of “freedom”. The objective of politics is not happiness, an affair to be left to the individuals, but it certainly is liberty understood as participation in the governance of the polity; it is also the pursuit of the common good, defined as the sum of the prerequisites and facilitations of individual autonomy depending on collective action, and as the realization of commonly agreed collective goals. (shrink)

This dissertation is dedicated to developing a principle of autonomy that is suited to human rational agents situated in particular and contingent settings. In doing so, I start out by examining a very influential conception of autonomy which defines autonomy in terms of an agent's ability to "transcend" her particular and contingent life-situation. I call such a conception of autonomy deontological autonomy. I argue that there is an inherent inconsistency in the deontological approach since deontological (...) autonomy cannot accommodate the inescapable contingency in the concrete and particular life of each individual. I propose the notion of procedural autonomy as a more plausible conception of autonomy for humans, since it is achievable in one's particular and concrete setting. ;What makes us procedurally autonomous in contingent human conditions is the process of critical deliberation which consists of two stages: The first stage requires that an agent should examine hierarchically lower intentions and beliefs with her plan of life, the hierarchically most prior set of intentions and beliefs. In the second stage an agent must choose an adequate plan of life for herself, which can be chosen only when the agent is fully aware of various alternative life plans and has given each serious consideration for adoption. The injunction that an agent should be engaged in the two stages of critical deliberation in order to be procedurally autonomous is termed the Principle of Procedural Autonomy. This principle is an ethical principle that is hierarchically prior to moral principles, and it is a procedural principle which is primarily concerned with how one should act rather than what ends should be attained. ;I conclude by applying the Principle of Procedural Autonomy to the debate concerning moral maturity of rational agents in which certain feminist objections have been raised against the concept of autonomy; I argue that procedural autonomy escapes their criticism. ;In developing my position I consider Kant and Aristotle, and a number of contemporary thinkers including J. Rawls, M. Bratman, D. Parfit, B. Williams, C. Gilligan and N. Noddings, among others. (shrink)

Gambling self-exclusion agreements enable a person to have themselves prevented from gambling for some future period. In light of evidence of their effectiveness in helping problem gamblers manage their addiction, these agreements enjoy growing popularity. In particular, several jurisdictions now oblige gambling operators to offer self-exclusion to their clientele. If self-exclusion has a unique value that is distinct from paternalistic measures, such as forced exclusion, it is surely because it prizes the gambler’s autonomy. In this article, however, I will (...) argue that self-exclusion’s theoretical basis cannot, in fact, be found in a procedural theory of autonomy that only regards agents’ own values and decisions. Rather, I will contend that if agents may bind their future selves in only some ways—for example, by preventing themselves from gambling but not preventing themselves from self-excluding or selling themselves into slavery—it can only be because of a normative, substantive claim. (shrink)

As cognitive enhancement research advances, important ethical questions regarding individual autonomy and freedom are raised. Advocates of cognitive enhancement frequently adopt a procedural approach to autonomy, arguing that enhancers improve an individual’s reasoning capabilities, which are quintessential to being an autonomous agent. On the other hand, critics adopt a more nuanced approach by considering matters of authenticity and self-identity, which go beyond the mere assessment of one’s reasoning capacities. Both positions, nevertheless, require further philosophical scrutiny. In this (...) paper, we investigate the ethics of cognitive enhancement through the lenses of political and philosophical arguments about autonomy and freedom. In so doing, we contend that a substantive, relational account of individual autonomy offers a more holistic understanding of the ethical concerns of cognitive enhancement. (shrink)

The concerns regarding patient autonomy presented in August A. Culbert et al.’s “Navigating Informed Consent and Patient Safety in Surgery: Lessons for Medical Students and Junior Trainees” fall just short of addressing the main issue. Patient autonomy is not something that just one member of a team should consider, and it should not be something that any protocol should have the power to subvert, particularly in an environment as tenuous as the operating room. This article will take the (...) concerns regarding the ethics of removing a patient’s hearing aid prior to entering the operating room presented in the aforementioned article and show the necessity for a new standard operating procedure. (shrink)

Respect for patient autonomy is paramount in resolving ethical tensions in end-of-life care. The concept of relational autonomy has contributed to this debate; however, scholars often use this concept in a fragmented manner. This leads to partial answers on ascertaining patients’ true wishes, meaningfully engaging patients’ significant others, balancing interests among patients and significant others, and determining clinicians’ obligations to change patients’ unconventional convictions to enhance patient autonomy. A satisfactory solution based on relational autonomy must incorporate (...) patients’ competence (apart from decisional capacity), authenticity (their true desires or beliefs) and the involvement level of their significant others. To that end, we argue that John Christman’s procedural approach to relational autonomy provides critical insights, such as the diachronic or socio-historical personhood, sustained critical reflection and his recent explication of the nature of asymmetrical relationships and helpful interlocutors. This study reviews Christman’s account, proposes minor modifications and advocates for an integrated three-dimensional model for medical decision-making. Clarifying the relationship among the three elements promotes an ethical framework with a coherent understanding of relational autonomy. This model not only provides a descriptive and normative framework for end-of-life care practice but also reconsiders the nature of the clinician–patient relationship and its normative implications. We further present a case study to illustrate the merits of our proposed model. Altogether, our proposal will help navigate complex medical decision-making, foster trust and negotiate shared values between patients and their significant others, particularly in end-of-life care. (shrink)

Miller analyzes the relationship between consent and autonomy by offering three pictures. For autonomy, Miller distinguishes between procedural, substantive, and weak substantive autonomy. The corresponding views of consent are what Miller has termed as consensual minimalism, consensual idealism, and consensual realism. The requirements of sexual consent under consensual minimalism are a voluntary informed agreement. However, feminist critiques reveal the inadequacies of this simple position. Consensual idealism, which corresponds with substantive autonomy, offers a robust picture where (...) consent and autonomy must be based on non-oppression. However, this view is considered too ideal and it ignores context. Weak substantive autonomy takes into account the context in the sexual domain. Correspondingly, consensual realism takes into account the context and still fulfills the requirements of consent. (shrink)

Pauline Kleingeld and Marcus Willaschek, in a co-authored article, declare that their purportedly new interpretation of Immanuel Kant’s writings on autonomy reveals that his moral philosophy is neither realist nor constructivist. However, as I explain here, John Rawls already occupies the area of intellectual territory to which Kleingeld and Willaschek attempt to lay claim: Rawls interprets Kant’s moral philosophy as neither realist, as Kleingeld and Willaschek evidently construe this term, nor constructivist, as they evidently construe this term. Contra Kleingeld (...) and Willaschek, the moral constructivism attributed to Kant by Rawls is not voluntarist, and Rawls’s account of Kant’s concept of autonomy is not paradoxical. In order to understand autonomy, it is necessary to understand Kant’s complex conception of the will, which structures his moral philosophy (as Rawls, unlike Kleingeld and Willaschek, explains). Rawls, like Kant, but unlike Kleingeld and Willaschek, clearly distinguishes between certain importantly different questions about normativity and obligation. Kant’s moral philosophy, according to Rawls’s insightful interpretation, is a form of objective moral constructivism. (shrink)

Democratic theorists often distinguish between two views of democratic procedures. ‘Outcomes theorists’ emphasize the instrumental nature of these procedures and argue that they are only valuable because they tend to produce good outcomes. In contrast, ‘proceduralists’ emphasize the intrinsic value of democratic procedures, for instance, on the grounds that they are fair. In this paper. I argue that we should reject pure versions of these two theories in favor of an understanding of the democratic ideal that recognizes a commitment to (...) both intrinsically valuable democratic procedures and democratic outcomes. In instances in which there is a conflict between these two commitments, I suggest they must be balanced. This balancing approach offers a justification of judicial review on the grounds that it potentially limits outcomes that undermine democracy. But judicial review is not justifiable in any instance in which a bad democratic outcome results from democratic procedures. When the loss that would result from overturning a democratic procedure is greater than the gain to democracy that would result from ensuring against an undemocratic outcome; judicial review is not justifiable. Loss or gain to democracy is defined by the negative or positive impact of each action on the core democratic values of equality and autonomy, aspects of the democratic ideal. Even when judicial review is justified, the fact that it overturns intrinsically valuable procedures suggests that such review is never ideal from the standpoint of democracy. (shrink)

In this paper, I examine two versions of the so-called “hierarchical” approach to personal autonomy, based on the notion of “second-order desires”. My primary concern will be with the question of whether these approaches provide an adequate basis for understanding the dynamics of autonomy-ascription. I begin by distinguishing two versions of the hierarchical approach, each representing a different response to the oft-discussed “regress” objection. I then argue that both “structural hierarchicalism” (e.g., Frankfurt, Bratman) and “procedural hierarchicalism” (e.g., (...) Dworkin, Christman, Mele) have difficulties accommodating the dynamics of how the attribution of autonomy to persons is claimed, disputed, and resolved. Although they differ in details, both shortcomings can be traced to viewing autonomy as a metaphysical rather than a normative, practical matter. I conclude by suggesting that these difficulties underscore the advantages of a more constructivist and pragmatist. (shrink)

BackgroundRespect for autonomy is a key concept in contemporary bioethics and end-of-life ethics in particular. Despite this status, an individualistic interpretation of autonomy is being challenged from the perspective of different theoretical traditions. Many authors claim that the principle of respect for autonomy needs to be reconceptualised starting from a relational viewpoint. Along these lines, the notion of relational autonomy is attracting increasing attention in medical ethics. Yet, others argue that relational autonomy needs further clarification (...) in order to be adequately operationalised for medical practice. To this end, we examined the meaning, foundations, and uses of relational autonomy in the specific literature of end-of-life care ethics.MethodsUsing PRESS and PRISMA procedures, we conducted a systematic review of argument-based ethics publications in 8 major databases of biomedical, philosophy, and theology literature that focused on relational autonomy in end-of-life care. Full articles were screened. All included articles were critically appraised, and a synthesis was produced.ResultsFifty publications met our inclusion criteria. Twenty-eight articles were published in the last 5 years; publications were originating from 18 different countries. Results are organized according to: (a) an individualistic interpretation of autonomy; (b) critiques of this individualistic interpretation of autonomy; (c) relational autonomy as theoretically conceptualised; (d) relational autonomy as applied to clinical practice and moral judgment in end-of-life situations.ConclusionsThree main conclusions were reached. First, literature on relational autonomy tends to be more a ‘reaction against’ an individualistic interpretation of autonomy rather than be a positive concept itself. Dichotomic thinking can be overcome by a deeper development of the philosophical foundations of autonomy. Second, relational autonomy is a rich and complex concept, formulated in complementary ways from different philosophical sources. New dialogue among traditionally divergent standpoints will clarify the meaning. Third, our analysis stresses the need for dialogical developments in decision making in end-of-life situations. Integration of these three elements will likely lead to a clearer conceptualisation of relational autonomy in end-of-life care ethics. This should in turn lead to better decision-making in real-life situations. (shrink)

Challenging many of the currently accepted conceptions of autonomy and of how it is valued, Oshana develops a social-relational account of autonomy that is constituted by a person's relations with others and by the absence of certain social relations. She denies that command over one's motives and the freedom to realize one's will are sufficient to secure the kind of command over one's life that autonomy requires, and argues against psychological, procedural, and content neutral accounts of (...) autonomy. (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)

In several jurisdictions, irremediable suffering from a medical condition is a legal requirement for access to assisted dying. According to the expressivist objection, allowing assisted dying for a specific group of persons, such as those with irremediable medical conditions, expresses the judgment that their lives are not worth living. While the expressivist objection has often been used to argue that assisted dying should not be legalised, I show that there is an alternative solution available to its proponents. An autonomy-based (...) approach to assisted suicide regards the provision of assisted suicide (but not euthanasia) as justified when it is autonomously requested by a person, irrespective of whether this is in her best interests. Such an approach has been put forward by a recent judgment of the German Federal Constitutional Court, which understands assisted suicide as an expression of the person’s right to a self-determined death. It does not allow for beneficence-based restrictions regarding the person’s suffering or medical diagnosis and therefore avoids the expressivist objection. I argue that on an autonomy-based approach, assisted suicide should not be understood as a medical procedure but rather as the person’s autonomous action. (shrink)

Medical paternalism has long been a common medical practice. However, patient autonomy in healthcare has been recently adopted by doctors and patients alike. This study explored whether doctors and patients in a tertiary care hospital in Saudi Arabia preferred autonomy or paternalism in shared decision‐making. A total of 118 participants (51 patients requiring total knee replacement, owing to stages 3–4 of osteoarthritis, and 67 doctors) from the Eastern province, Saudi Arabia. responded to a 17‐question category‐based questionnaire involving four (...) scales of autonomy. Descriptive statistics and chi‐square test results revealed that in this hospital, patients preferred a paternalistic approach toward their medical care along with a full disclosure of the risks related to surgical procedures. We recommend health education regarding the specific autonomy subscales (doctor knows best, patient should decide, right to non‐participation, and obligatory risk information), and the implementation of protocols that protect patients' rights and enhance personal autonomy. (shrink)

For decades, the greater part of efforts to improve regulatory frameworks for research ethics has focused on informed consent procedures; their design, codification and regulation. Why is informed consent thought to be so important? Since the publication of the Belmont Report in 1979, the standard response has been that obtaining informed consent is a way of treating individuals as autonomous agents. Despite its political success, the philosophical validity of this Belmont view cannot be taken for granted. If the Belmont view (...) is to be based on a conception of autonomy that generates moral justification, it will either have to be reinterpreted along Kantian lines or coupled with a something like Mill’s conception of individuality. The Kantian interpretation would be a radical reinterpretation of the Belmont view, while the Millian justification is incompatible with the liberal requirement that justification for public policy should be neutral between controversial conceptions of the good. This consequence might be avoided by replacing Mill’s conception of individuality with a procedural conception of autonomy, but I argue that the resulting view would in fact fail to support a non-Kantian, autonomy-based justification of informed consent. These difficulties suggest that insofar as informed consent is justified by respect for persons and considerations of autonomy, as the Belmont report maintained, the justification should be along the lines of Kantian autonomy and not individual autonomy. (shrink)

Individuals’ food choices are intimately connected to their self-images and world views. Some dietary choices adopted by consumers pose restrictions on their use of genetically modified food (GMF). It is quite generally agreed that some kind of labeling is necessary for respecting consumers’ autonomy of choice regarding GMF. In this paper, we ask whether the current practice of mandatory labeling of GMF products in the European Union is a sufficient administrative procedure for respecting consumers’ autonomy. Three issues concerning (...) this question are discussed. First, we argue that labeling needs to be accompanied by relevant and understandable information on genetic modification, genetically modified food, and the European practice of GMF labeling. Second, we claim that this type of informing makes it less likely that consumers start to avoid GMF products just because labels make them suspicious of the products. It is further noted that even though some consumers may react to labels this way, labels do not restrict their autonomy of choice. Third, a need for more precise labels indicating the source of the transferred gene is considered. It is found out that such labels are not morally necessary when also non-GMF products are available and no relevant differences (such as differences in price and healthiness) exist between them and GMF products. However, in some other cases more precise labels may be needed for respecting consumers’ autonomy of choice. (shrink)

Advancements in machine learning have fuelled the popularity of using AI decision algorithms in procedures such as bail hearings, medical diagnoses and recruitment. Academic articles, policy texts, and popularizing books alike warn that such algorithms tend to be opaque: they do not provide explanations for their outcomes. Building on a causal account of transparency and opacity as well as recent work on the value of causal explanation, I formulate a moral concern for opaque algorithms that is yet to receive a (...) systematic treatment in the literature: when such algorithms are used in life-changing decisions, they can obstruct us from effectively shaping our lives according to our goals and preferences, thus undermining our autonomy. I argue that this concern deserves closer attention as it furnishes the call for transparency in algorithmic decision-making with both new tools and new challenges. (shrink)

Procedures such as organ or tissue donation, elective ventilation and non‐therapeutic research can be said to be against the medical interests of the participant. Competent adults can consent to procedures such as these that are against their medical interests, but when, if ever, should incompetent persons participate in such procedures? Legal approaches to decision‐making in the area of the medical care of incompetent persons are generally based on respect for the patient's autonomy, or protection of her welfare, or some (...) combination of the two. The limitations of these approaches become apparent upon examination of their application in this context. Societal interests are also used to justify the participation of the incompetent in procedures which are against their medical interests, for example, the societal interest in pursuing non‐therapeutic research on incompetents in order to benefit future incompetents. These types of approaches are implicit in much current policy and reform proposals on non‐therapeutic research, contributing to the disrespect for incompetent persons that is implicit in many research projects and much argument on the categorization of risks, and the repeated failure to consider the burdens imposed on incompetent persons in the interests of society. (shrink)

In “Autonomy and the Feminist Intuition,” Natalie Stoljar asks whether a procedural or a substantive approach to autonomy is best for addressing feminist concerns. In this paper, I build on Stoljar’s argument that feminists should adopt a strong substantive approach to autonomy. After briefly reviewing the problems with a purely procedural approach, I begin to articulate my own strong substantive theory by focusing specifically on the problem of internalized oppression. In the final section, I briefly (...) address some of the concerns raised by procedural theorists who are leery of a substantive approach. (shrink)

One of the more intractable problems in the debate over autonomy is how we should distinguish autonomy-enhancing from autonomy-compromising forms of socialization. In this paper I first survey a range of theories of autonomy, from the procedural through to the substantive, and argue that none offers sufficient resources to resolve the problem of socialization. In the second half of the paper I develop an alternative theory that can both differentiate benign from pernicious socialization and, more (...) importantly, provide an explanation for the means by which pernicious socialization compromises autonomy. (shrink)

Access to public healthcare services for Belgium’s undocumented migrants is regulated through a parallel, administrative procedure within the legal framework of Urgent Medical Aid. This imposes several constraints on their access to healthcare services. Drawing on empirical-ethical methodologies, we show how this procedure impacts on the relationship between patients with undocumented status and healthcare workers. We use the concept of relational autonomy to show how the imposed legal constraints reduce the formal treatment options available to healthcare workers, but simultaneously (...) lead to informal care practices, and how the latter increase the discretionary power of the healthcare workers. We argue that in this context, provision becomes unpredictable and arbitrary, with undocumented migrants tending to value strong personal relations with one particular, trusted healthcare worker. Although this leads to increased dependence, it also increases patients’ options and autonomy by providing access to wider professional networks attached to that healthcare worker. (shrink)

An ongoing debate between ‘procedural’ and ‘substantive’ theorists of personal autonomy addresses the following question: should agents have the final say on their own autonomy or should the object...

An ongoing debate between ‘procedural’ and ‘substantive’ theorists of personal autonomy addresses the following question: should agents have the final say on their own autonomy or should the object...

Despite receiving considerable philosophical attention, the concept of autonomy remains contested. In this paper, we diagnose one source of the continuing problem—an excessive emphasis on reflective self-appraisal in the dominant procedural models of autonomy—and suggest a solution. We argue that minimalist conceptions of rational self-appraisal are subject to fatal counterexamples. Yet, attempts to provide a more robust account of rational self-appraisal are too demanding to capture our intuitions about who counts as an autonomous agent. We argue that (...) no procedure of rational reflection will confer autonomy; rather autonomy is a matter of an agent’s actions flowing from her substantive commitments. Instead of rational self-reflection, autonomous actions are the product of the motive of care, which anchors an agent’s occurent desires to her system of value. (shrink)

COVID-19 has turned many ethical principles and presuppositions upside down. More precisely, the principle of respect for autonomy has been shown to be ill suited to face the ethical challenges posed by the current health crisis. Individual wishes and choices have been subordinated to public interests. Patients have received trial therapies under extraordinary procedures of informed consent. The principle of respect for autonomy, at least in its mainstream interpretation, has been particularly questioned during this pandemic. Further reflection on (...) the nature and value of autonomy is urgently needed. Relational autonomy has been proposed as an alternative account of autonomy that can more adequately respond to contemporary ethical issues in general and to a pandemic such as the one we are currently facing in particular. As relational autonomy is an emerging notion in current bioethics, it requires further consideration and development to be properly operationalized. This paper aims to show how six different philosophical branches––namely, philosophy of nature, philosophical anthropology, existential phenomenology, discourse ethics, hermeneutics, and cultural anthropology––have incorporated the category of relation throughout the twentieth century. We first delve into primary philosophical sources and then apply their insights to the specific field of medical ethics. Learning from the historical developments of other philosophical fields may provide illumination that will enable bioethics to experience a successful “relational turn”, which has been partially initiated in contemporary bioethics but not yet achieved. (shrink)

In the intellectual confusion prevailing since the demise of Marxism and “marxism”, the attempt is made to define democracy as a matter of pure procedure, explicitly avoiding and condemning any reference to substantive objectives. It can easily be shown, however, that the idea of a purely procedural “democracy” is incoherent and self‐contradictory. No legal system whatsoever and no government can exist in the absence of substantive conditions which cannot be left to chance or to the workings of the “market” (...) but must be posited as objectives of political activity. The confusion results from a deficient understanding of what makes a society and an empty idea of “freedom”. The objective of politics is not happiness, an affair to be left to the individuals, but it certainly is liberty understood as participation in the governance of the polity; it is also the pursuit of the common good, defined as the sum of the prerequisites and facilitations of individual autonomy depending on collective action, and as the realization of commonly agreed collective goals. (shrink)

While the fundamental laws of physics are time-reversal invariant, most macroscopic processes are irreversible. Given that the fundamental laws are taken to underpin all other processes, how can the fundamental time-symmetry be reconciled with the asymmetry manifest elsewhere? In statistical mechanics, progress can be made with this question. What I dub the ‘Zwanzig–Zeh–Wallace framework’ can be used to construct the irreversible equations of SM from the underlying microdynamics. Yet this framework uses coarse-graining, a procedure that has faced much criticism. I (...) focus on two objections in the literature: claims that coarse-graining makes time-asymmetry ‘illusory’ and ‘anthropocentric’. I argue that these objections arise from an unsatisfactory justification of coarse-graining prevalent in the literature, rather than from coarse-graining itself. This justification relies on the idea of measurement imprecision. By considering the role that abstraction and autonomy play, I provide an alternative justification and offer replies to the illusory and anthropocentric objections. Finally, I consider the broader consequences of this alternative justification: the connection to debates about inter-theoretic reduction and the implication that the time-asymmetry in SM is weakly emergent. 1Introduction 1.1Prospectus2The Zwanzig–Zeh–Wallace Framework3Why Does This Method Work? 3.1The special conditions account3.2When is a density forwards-compatible?4Anthropocentrism and Illusion: Two Objections 4.1The two objections in more detail4.2Against the justification by measurement imprecision5An Alternative Justification 5.1Abstraction and autonomy5.2An illustration: the Game of Life6Reply to Illusory7Reply to Anthropocentric8The Wider Landscape: Concluding Remarks 8.1Inter-theoretic relations8.2The nature of irreversibility. (shrink)

Over the last few years, policies have been introduced in the UK that identify and treat patients as potential organ donors before death. Patients incapacitated due to catastrophic brain injury may now undergo intensive ante-mortem interventions to improve the chances of successfully transplanting their organs into third parties after death. The most significant ethical and legal problem with these policies is that they are not based on the individual’s specific wishes in the circumstances. Policy-makers appear reluctant to inform potential registrants (...) on the Organ Donor Register about ante-mortem donor optimisation procedures and to provide an opportunity to record specific wishes in advance. They are reliant on blind trust in the organ donation programme, which as I argue in this paper, presents significant risks for the achievement of its aim of securing an adequate supply of organs for transplantation. I argue that informed trust, based on accurate information about the future consequences of registra... (shrink)

Philosophy & Social Criticism, Ahead of Print. An ongoing debate between ‘procedural’ and ‘substantive’ theorists of personal autonomy addresses the following question: should agents have the final say on their own autonomy or should the objective circumstances in which agents live take prevalence when assessing their autonomy? Proceduralists favour the first strategy and substantive theorists restrict more explicitly the conditions under which autonomy is possible. I focus on forms of heteronomy which derive from oppressive circumstances (...) and accept that substantive theorists are correct in contending that forms of oppression common in contemporary liberal societies tend to increase heteronomy; and the heteronomy which derives from social oppression tends to fly below the radar of procedural accounts. Still, I argue that a revised procedural strategy could limit these forms of heteronomy as long as it avoids the injunctions to ‘authenticity’ common in procedural models. I proceed by reconstructing John Christman’s model which, I argue, constitutes the most promising procedural account to assess autonomy under oppression. Christman’s theory, however, needs to be reinforced to ensure self-problematisation in light of a social perspective. I show that the latter is necessary to experience the forms of alienation which are markers of heteronomy according to Christman. (shrink)

In the age of artificial intelligence, the common interest in human autonomy is experiencing a revival. Autonomy has formerly and mostly been investigated from a theoretical scientific perspective, in which scholars from various disciplines have linked autonomy with the concepts of dignity, independence from others, morality, self-awareness, and unconventionality. In a series of three semi-qualitative, preregistered online studies, we investigated laypersons' understanding of autonomy with a bottom-up procedure to find out how far lay intuition is consistent (...) with scientific theory. First, in Study 1, participants provided us with at least three and up to 10 examples of autonomous behaviors, for a total of 807 meaningful examples. With the help of blinded research assistants, we sorted the obtained examples into categories, from which we generated 34 representative items for the following studies. Next, in Study 2, we asked a new sample of participants to rate the degree of autonomy reflected in each of these 34 items. Last, we presented the five highest-rated and the five lowest-rated items to the participants of Study 3, whom we asked to evaluate how strongly they represented the components of autonomy: dignity, independence from others, morality, self-awareness, and unconventionality. We identified that dignity, independence from others, morality, and self-awareness significantly distinguished between high- and low-autonomy items, implying that high autonomy items were rated higher on dignity, independence from others, morality, and self-awareness than low autonomy items, but unconventionality did not. Our findings contribute to both our understanding of autonomous behaviors and connecting lay intuition with scientific theory. (shrink)

Philosophy & Social Criticism, Ahead of Print. An ongoing debate between ‘procedural’ and ‘substantive’ theorists of personal autonomy addresses the following question: should agents have the final say on their own autonomy or should the objective circumstances in which agents live take prevalence when assessing their autonomy? Proceduralists favour the first strategy and substantive theorists restrict more explicitly the conditions under which autonomy is possible. I focus on forms of heteronomy which derive from oppressive circumstances (...) and accept that substantive theorists are correct in contending that forms of oppression common in contemporary liberal societies tend to increase heteronomy; and the heteronomy which derives from social oppression tends to fly below the radar of procedural accounts. Still, I argue that a revised procedural strategy could limit these forms of heteronomy as long as it avoids the injunctions to ‘authenticity’ common in procedural models. I proceed by reconstructing John Christman’s model which, I argue, constitutes the most promising procedural account to assess autonomy under oppression. Christman’s theory, however, needs to be reinforced to ensure self-problematisation in light of a social perspective. I show that the latter is necessary to experience the forms of alienation which are markers of heteronomy according to Christman. (shrink)

Background Respect for patients’ autonomy is usually considered to be an important ethical principle in Western countries; privacy is one of the implications of such respect. Healthcare professionals frequently encounter ethical dilemmas during their practice. The past few decades have seen an increased use of courts to resolve intractable ethical dilemmas across both the developed and the developing world. However, Chinese and American bioethics differ largely due to the influence of Chinese Confucianism and Western religions, respectively, and there is (...) a dearth of comparative studies that explore cases of ethical dilemmas between China and the United States. Methods This paper discusses four typical cases with significant social impact. First, it compares two cases concerning patient privacy: the “Shihezi University Hospital Case”, in which a patient was used as a clinical teaching object without her permission, and the “New York-Presbyterian Hospital Case”, in which the hospital allowed the filming of a patient’s treatment without his consent. Second, it compares two cases regarding patient autonomy and potentially life-saving medical procedures: the “Case of Ms. L”, concerning a cohabitant’s refusal to sign a consent form for a pregnant woman’s caesarean, and the “Case of Mrs. V”, concerning a hospital’s insistence upon a blood transfusion for a dissenting patient. This paper introduces the supporting and opposing views for each case and discusses their social impact. It then compares and analyses the differences between China and the United States from cultural and legislative perspectives. Conclusions Ethical dilemmas have often occurred in China due to the late development of bioethics. However, the presence of bioethics earlier in the US than in China has not spared the US of ethical dilemmas. This paper highlights lessons and inspiration from the cases for healthcare professionals and introduces readers to the role and weight of privacy and autonomy in China and in the US from the perspectives of different cultures, religions and laws. (shrink)

This paper discusses how computational modeling combines the autonomy of models with the automation of computational procedures. In particular, the case of ab-initio methods in quantum chemistry will be investigated to draw two lessons from the analysis of computational modeling. The first belongs to general philosophy of science: Computational modeling faces a trade-off and enlarges predictive force at the cost of explanatory force. The other lesson is about the philosophy of chemistry: The methodology of computational modeling puts into doubt (...) claims about the reduction of chemistry to physics. (shrink)

This book explores, in rich and rigorous ways, the possibilities and limitations of “thick” autonomy in light of contemporary debates in philosophy, ethics, and bioethics. Many standard ethical theories and practices, particularly in domains such as biomedical ethics, incorporate minimal, formal, procedural concepts of personal autonomy and autonomous decisions and actions. Over the last three decades, concerns about the problems and limitations of these “thin” concepts have led to the formulation of “thick” concepts that highlight the mental, (...) corporeal, biographical and social conditions of what it means to be a human person and that enrich concepts of autonomy, with direct implications for the ethical requirement to respect autonomy. The chapters in this book offer a wide range of perspectives on both the elements of and the relations between “thin” and “thick” concepts of autonomy as well as their relative roles and importance in ethics and bioethics. This book offers valuable and illuminating examinations of autonomy and respect for autonomy, relevant for audiences in philosophy, ethics, and bioethics. (shrink)

Recommender Systems (RecSys) have been around since the early days of the Internet, helping users navigate the vast ocean of information and the increasingly available options that have been available for us ever since. The range of tasks for which one could use a RecSys is expanding as the technical capabilities grow, with the disruption of Machine Learning representing a tipping point in this domain, as in many others. However, the increase of the technical capabilities of AI-powered RecSys did not (...) come with a thorough consideration of their ethical implications and, despite being a well-established technical domain, the potential impacts of RecSys on their users are still under-assessed. This paper aims at filling this gap in regards to one of the main impacts of RecSys: personal autonomy. We first describe how technology can affect human values and a suitable methodology to identify these effects and mitigate potential harms: Value Sensitive Design (VSD). We use VSD to carry out a conceptual investigation of personal autonomy in the context of a generic RecSys and draw on a nuanced account of procedural autonomy to focus on two components: competence and authenticity. We provide the results of our inquiry as a value hierarchy and apply it to the design of a speculative RecSys as an example. (shrink)

In numerous accounts of both autonomy and freedom, social or relational elements have been offered as conceptual requirements in addition to purely procedural conditions. In addition, it is claimed that social recognition of the normative authority or self-trust of the agent is conceptually required for autonomy. In this paper I argue that in cases where people find themselves completely dislocated from the social and cultural homes that had provided them with the language in which to formulate and (...) express their values, it is clear that social recognition of the sort defended in relational models is causally but not conceptually required for agency to be (re-)established. This is shown by noting that often victims of human tracking or smuggling find themselves in foreign settings where it is quite up for grabs where and how they will attempt to reconstruct a life narrative which they can generally embrace. Therefore, seeing social recognition as conceptually required for autonomous agency or freedom would ignore the variability in the ways that such recognition must be expressed. (shrink)

In recent decades, the intertwining ideas of self-determination and well-being have received tremendous support in bioethics. Discussions regarding self-determination, or autonomy, often focus on two dimensions—the capacity of the patient and the freedom from external coercion. The practice of obtaining informed consent, for example, has become a standard procedure in therapeutic and research medicine. On the surface, it appears that patients now have more opportunities to exercise their self-determination than ever. Nonetheless, discussions of patient autonomy in the bioethics (...) literature, which focus on individual patients making particular decisions, neglect the social structure within which health-care decisions are made. Looking through the lens of disability and informed by the feminist conception of relational autonomy, this essay argues that the issue of autonomy is much more complex than the individualist model suggests. The social system and the ableist ideology impose various forms of pressure or oppressive power that can affect people’s ability to choose according to their value system. Even if such powers are not directly coercive, they influence potential parents’ decisions indirectly—they structure their alternatives in such a way that certain options are never considered as viable and other decisions must be made. This paper argues that, instead of only focusing on the individual act of decision-making, we need to pay attention to the social structure that frames people’s decision. (shrink)

In this article, I argue that autonomy has to be conceived substantively in order to serve as the qualifying condition for receiving the full set of individual liberal rights. I show that the common distinction between content‐neutral and substantive accounts of autonomy is riddled with confusion and ambiguities, and provide a clear alternative taxonomy. At least insofar as we are concerned with liberal settings, the real question is whether or not the value and norm implied by an account (...) of autonomy are acceptable to reasonable people, not whether these accounts are content‐neutral, procedural or input‐focused. Finally, I demonstrate how substantive constraints are compatible with, or even implied in, the notion of autonomy at play in political liberalism. Overall, I present a normative reconstruction, clarification, and internal critique of liberalism, drawing on case law and statutes from England and Wales. (shrink)

Three main claims are made in this paper. First, it is argued that Onora O’Neill has uncovered a serious problem in the way medical ethicists have thought about both respect for autonomy and informed consent. Medical ethicists have tended to think that autonomous choices are intrinsically worthy of respect, and that informed consent procedures are the best way to respect the autonomous choices of individuals. However, O’Neill convincingly argues that we should abandon both these thoughts. Second, it is argued (...) that O’Neill’s proposed solution to this problem is inadequate. O’Neill’s approach requires that a more modest view of the purpose of informed consent procedures be adopted. In her view, the purpose of informed consent procedures is simply to avoid deception and coercion, and the ethical justification for informed consent derives from a different ethical principle, which she calls principled autonomy. It is argued that contrary to what O’Neill claims, the wrongness of coercion cannot be derived from principled autonomy, and so its credentials as a justification for informed consent procedures is weak. Third, it is argued that we do better to rethink autonomy and informed consent in terms of respecting persons as ends in themselves, and a characteristically liberal commitment to allowing individuals to make certain categories of decisions for themselves. Respect for autonomy is in trouble. In recent work in this journal1 and elsewhere,2 O’Neill has forcefully argued that respect for autonomy, as it has come to be used in medical ethics, is philosophically indefensible. If her arguments are sound, then, contrary to the standard view, respect for autonomy cannot be the source of the ethical requirement to seek informed consent before treating a patient or enrolling a participant in a trial. So her critique goes to the heart of contemporary medical ethics: if O’Neill is right, medical ethicists have systematically misunderstood two of the most fundamental concepts they deal with—respect for autonomy and informed consent. This paper has four sections. Section 1 distinguishes between three different ways of talking about respect for autonomy, and looks in more detail at the one that has come to be central to bioethical writing on informed consent—namely, the idea that we should respect autonomous choices. Section 2 argues, following O’Neill, that it is implausible to think that the purpose of informed consent requirements is to respect autonomous choices. Section 3 argues that O’Neill’s proposed reworking of autonomy and informed consent is inadequate. O’Neill’s approach requires us to adopt a more modest view of the purpose of informed consent procedures. In her view, the purpose of informed consent procedures is simply to avoid deception and coercion, and the ethical justification for informed consent derives from a different ethical principle, which she calls principled autonomy. I argue that contrary to what O’Neill claims, we cannot derive the wrongness of coercion from principled autonomy, and so its credentials as a justification for informed consent procedures is weak. Section 4 argues that we do better to rethink autonomy and informed consent in terms of respecting persons as ends in themselves, and a characteristically liberal commitment to allowing individuals to make certain categories of decisions for themselves. (shrink)

What is the moral value of formal democratic decision-making? Egalitarian accounts of democracy provide a powerful answer to this question. They present formal democratic procedures as a way for a society of equals to arrive at collective decisions in a transparent and mutually acceptable manner. More specifically, such procedures ensure and publicly affirm that all members of a political community, in their capacity as autonomous actors, are treated as equals who are able and have a right to participate in collective (...) decision-making. Recently, a number of authors have raised what I describe as the ‘no impact’ objection. This objection focuses on the egalitarian emphasis on autonomy to cast doubt on the moral value of formal democratic procedures. It holds that individual participation in formal democratic decision-making has no impact on the eventual result, and therefore cannot be understood as an exercise in autonomy. Consequently, the ‘no impact’ objection claims that the moral value of formal democracy cannot be explained with reference to an egalitarian ideal of ‘rule by the people’. In this article, I refute this objection by complementing an egalitarian account of democracy with an account of basic autonomy. (shrink)

© 2015 The Authors. Journal of Applied Philosophy published by John Wiley & Sons Ltd on behalf of Society for Applied Philosophy. In this article, I argue that autonomy has to be conceived substantively in order to serve as the qualifying condition for receiving the full set of individual liberal rights. I show that the common distinction between content-neutral and substantive accounts of autonomy is riddled with confusion and ambiguities, and provide a clear alternative taxonomy. At least insofar (...) as we are concerned with liberal settings, the real question is whether or not the value and norm implied by an account of autonomy are acceptable to reasonable people, not whether these accounts are content-neutral, procedural or input-focused. Finally, I demonstrate how substantive constraints are compatible with, or even implied in, the notion of autonomy at play in political liberalism. Overall, I present a normative reconstruction, clarification, and internal critique of liberalism, drawing on case law and statutes from England and Wales. (shrink)

Objectives: Evidence based patient choice seems based on a strong liberal individualist interpretation of patient autonomy; however, not all patients are in favour of such an interpretation. The authors wished to assess whether ideals of autonomy in clinical practice are more in accordance with alternative concepts of autonomy from the ethics literature. This paper describes the development of a questionnaire to assess such concepts of autonomy.Methods: A questionnaire, based on six moral concepts from the ethics literature, (...) was sent to aneurysm patients and their surgeons. The structure of the questionnaire was assessed by factor analysis, and item reduction was based on reliability.Results: Ninety six patients and 58 surgeons participated. The questionnaire consisted of four scales. Two of the scales reflected the paternalistic and consumerist poles of the liberal individualist model, one scale reflected concepts of Socratic autonomy and of procedural independence, and the fourth scale reflected ideals of risk disclosure.Discussion: The Ideal Patient Autonomy Scale is a 14 item normative instrument. It is clearly distinct from the generally used psychological preference questionnaires that assess preferences for physician-patient roles. (shrink)

This paper seeks to argue that although fair trial standards are commonly portrayed as a set of minimum coherent standards applicable across a range of different legal traditions, there is a tension between those standards that accentuate the importance of individual will and autonomy and those that emphasise the importance of accurate outcome through an effective defence. This tension has been managed for the most part by enabling individuals to be represented by legal counsel who present the defence on (...) the basis of their clients’ instructions. Human rights law has recognised the importance of legal assistance at trial and pre-trial stages of criminal procedures. Despite this certain developments in domestic and international criminal processes have led to a growing number of cases being decided without an effective defence being provided by legal counsel. Such cases have been disposed on the basis of defendants’ ‘consent’ and this supposed autonomy has held sway over any effective defence. The paper begins by tracing different dimensions of the fair trial standards and exposes a tension between the need for defendants to exercise autonomy over their case and the need for an effective defence. The paper then argues that the right to counsel has acted as a bridge between these two competing demands. Recent developments are then reviewed which have served to impede counsel from providing an effective defence in the interests of the client’s freedom to choose how her case should be handled. The examples examined are the growing number of cases that are pleaded or diverted out of court with no real examination of the strength of the prosecution case, the emergence of special advocates who do not take instructions from defendants and the increasing tendency for defendants to represent themselves in certain types of cases. The paper concludes by arguing that we need to make a sharper distinction between individual rights and procedural standards and argues for greater attention to be given to the latter on the design of criminal procedure. (shrink)

Gerald Dworkin's influential account of Personal Autonomy offers the following two conditions for autonomy: Authenticity - the condition that one identify with one's beliefs, desires and values after a process of critical reflection, and Procedural Independence - the identification in must not be "influenced in ways which make the process of identification in some way alien to the individual" . I argue in this thesis that there are cases which fulfil both of Dworkin's conditions, yet are clearly (...) not cases of autonomy. Specifically, I argue that we can best assess the adequacy of Dworkin's account of autonomy through literature, because it provides a unique medium for testing his account on the very terms he sets up for himself - ie. that autonomy apply to, and make sense of, persons leading lives of a certain quality. The examination of two novels - Kazuo Ishiguro's The Remains of the Day and Henry James's The Portrait of a Lady - shows that Dworkin's explanation of identification and critical reflection is inadequate for capturing their role in autonomy and that he does not pay enough attention to the role of external factors in preventing or supporting autonomy. As an alternative, I offer the following two conditions for autonomy: critical reflection of a certain kind - radical reflection, and the ability to translate the results of into action - competence. The novels demonstrate that both conditions are dependent upon considerations of the content of one's beliefs, desires, values etc. Certain of these will prevent or hinder the achievement of autonomy because of their content, so autonomy must be understood in relation to substantial considerations, rather than in purely formal terms, as Dworkin argues. (shrink)

To operate in an unpredictable environment, a vehicle with advanced driving assistance systems, such as a robot or a drone, not only needs to register its surroundings but also to combine data from different sensors into a world model, for which it employs filter algorithms. Such world models, as this article argues with reference to the SLAM problem in robotics, consist of nothing other than probabilities about states and events arising in the environment. The model, thus, contains a virtuality of (...) possible worlds that are the basis for adaptive behavior. The article shows that the current development of these technologies requires new concepts because their complex adaptive behaviors cannot be explained by referring them to mere algorithmic processes. Instead, it proposes the heuristic instrument of microdecisions to designate the temporality of decisions between alternatives that are created by probabilistic procedures of world modeling. Microdecisions are more than the implementation of deterministic processes—they decide between possibilities and, thus, always open up the potential of their otherness. By describing autonomous adaptive technologies with this heuristic, the question of sovereignty inevitably arises. It forces us to re-think what autonomy means when decisions can be automated. (shrink)

An ongoing debate between ‘procedural’ and ‘substantive’ theorists of personal autonomy addresses the following question: should agents have the final say on their own autonomy or should the objective circumstances in which agents live take prevalence when assessing their autonomy? Proceduralists favour the first strategy and substantive theorists restrict more explicitly the conditions under which autonomy is possible. I focus on forms of heteronomy which derive from oppressive circumstances and accept that substantive theorists are correct (...) in contending that (i) forms of oppression common in contemporary liberal societies (e.g. gender or racial oppression) tend to increase heteronomy; and (ii) the heteronomy which derives from social oppression tends to fly below the radar of procedural accounts. Still, I argue that a revised procedural strategy could limit these forms of heteronomy as long as it avoids the injunctions to ‘authenticity’ common in procedural models. I proceed by reconstructing John Christman’s model which, I argue, constitutes the most promising procedural account to assess autonomy under oppression. Christman’s theory, however, needs to be reinforced to ensure self-problematisation in light of a social perspective. I show that the latter is necessary to experience the forms of alienation which are markers of heteronomy according to Christman. (shrink)