Decision-making capacity (DMC) plays an important role in clinical practice—determining, on the basis of a patient’s decisional abilities, whether they are entitled to make their own medical decisions or whether a surrogate must be secured to participate in decisions on their behalf. As a result, it’s critical that we get things right—that our conceptual framework be well-suited to the task of helping practitioners systematically sort through the relevant ethical considerations in a way that reliably and transparently delivers correct verdicts about (...) who should and should not have the authority to make their own medical decisions. Unfortunately, however, the standard approach to DMC does not get things right. It is of virtually no help in identifying and clarifying the relevant ethical considerations. And, embedded in the prevailing anti-paternalist paradigm, DMC assessments obfuscate and distort the underlying ethical justification for granting or withholding decisional authority. Here, we describe the core commitments of the standard approach to DMC and then highlight three problems with it. We then argue that these problems are significant enough that they call for more than merely tinkering and fine tuning—variations of the standard approach cannot adequately address them. Instead, we should ditch DMC. (shrink)

Prediction-based decisions, which are often made by utilizing the tools of machine learning, influence nearly all facets of modern life. Ethical concerns about this widespread practice have given rise to the field of fair machine learning and a number of fairness measures, mathematically precise definitions of fairness that purport to determine whether a given prediction-based decision system is fair. Following Reuben Binns (2017), we take ‘fairness’ in this context to be a placeholder for a variety of normative egalitarian considerations. We (...) explore a few fairness measures to suss out their egalitarian roots and evaluate them, both as formalizations of egalitarian ideas and as assertions of what fairness demands of predictive systems. We pay special attention to a recent and popular fairness measure, counterfactual fairness, which holds that a prediction about an individual is fair if it is the same in the actual world and any counterfactual world where the individual belongs to a different demographic group (cf. Kusner et al. (2018)). (shrink)

Decision-making Capacity matters to whether a patient’s decision should determine her treatment. But why it matters in this way isn’t clear. The standard story is that dmc matters because autonomy matters. And this is thought to justify dmc as a gatekeeper for autonomy – whereby autonomy concerns arise if but only if a patient has dmc. But appeals to autonomy invoke two distinct concerns: concern for authenticity – concern that a choice is consistent with an individual’s commitments; and concern for (...) sovereignty – concern that an individual exercises control over that which is hers to control. Here, I argue, neither concern can alone explain why dmc matters. Instead, dmc matters because it indicates a harmony between the two concerns – the demands of each concern are more likely to agree if a patient has dmc. This vindicates the standard story, but also makes clear that dmc is an inappropriate gatekeeper for autonomy. (shrink)

It is natural to think that there is a tight connection between whether someone is responsible for some outcome and whether it is appropriate to hold her accountable for that outcome. And this natural thought naturally extends to health: if someone is responsible for her health, then, all else being equal, she is accountable for it. Given this, some have thought that responsibility for health has an important role to play in distributing the benefits and burdens of healthcare. But there (...) is a reason for caution. That health is influenced by social, economic, and environmental factors is a matter of consensus. And some have argued that in light of these social determinants of health, individuals are not typically responsible for their health, rendering inappropriate policies that employ a responsibility‐for‐health criterion. This debate implicates a number of overlapping concepts and questions that are often difficult to pull apart. And I worry that those who maintain that social determinants undermine responsibility for health have latched on to the wrong target. The social determinants of health are relevant to such policies, but, I argue, not by globally undermining responsibility. Rather, social determinants are sometimes responsibility‐undermining, sometimes responsibility‐preserving, and often relevant to whether we should hold individuals accountable for their health regardless of their responsibility. This calls for a more nuanced appraisal of the ways in which the social determinants of health are relevant to such policies. And here I attempt to provide one. (shrink)

There are cases of ineffable learning — i. e., cases where an agent learns something, but becomes certain of nothing that she can express — where it is rational to update by Jeffrey conditionalization. But there are likewise cases of ineffable learning where updating by Jeffrey conditionalization is irrational. In this paper, we first characterize a novel class of cases where it is irrational to update by Jeffrey conditionalization. Then we use the d-separation criterion to develop a causal understanding of (...) when and when not to Jeffrey conditionalize that bars updating by Jeffrey conditionalization in these cases. Finally, we reflect on how the possibility of so-called “unfaithful” causal systems bears on the normative force of the causal updating norm that we advocate. (shrink)

Navin, Brummett, and Wasserman (2022) argue—successfully, we think—that the standard “comparative” account of decision-making capacity (DMC) fails to capture an important range of cases in which a...

The question of how to treat an incapacitated patient is vexed, both normatively and practically—normatively, because it is not obvious what the relevant objectives are; practically, because even once the relevant objectives are set, it is often difficult to determine which treatment option is best given those objectives. But despite these complications, here is one consideration that is clearly relevant: what a patient prefers. And so any device that could reliably identify a patient’s preferences would be a promising tool for (...) guiding the treatment of incapacitated patients. The patient preference predictor is just such a tool—an algorithm that takes as inputs a patient’s sociodemographic characteristics, and outputs a reliable prediction about that patient’s treatment preferences.1 But some have worried that the use of such a tool would violate or fail to appropriately respect patients’ autonomy. There are, I think, two ways to understand this kind of criticism. First, globally—as a worry that any systematic implementation of the PPP would be problematic on the grounds that it would result in significant or pervasive autonomy violations. Second, locally—as a worry that in some important range of cases, certain uses of the PPP would be problematic on autonomy grounds. Jardas et al, as I read them, address global autonomy-based criticisms, arguing—convincingly, in my view—that there’s no reason to suspect the autonomy concerns raised by the PPP would be so significant and pervasive as to render any implementation of it generally problematic.1 But even with the global criticisms rebuffed, there remains work to be done. Any ethically acceptable implementation of the PPP must be sensitive to the more local autonomy-based criticisms, with restrictions and safeguards in place to ensure respect for autonomy in the kinds of cases in which the use of the PPP might otherwise threaten …. (shrink)

One natural way to argue for the existence of some subjective constraint on agents’ obligations is to maintain that without that particular constraint, agents will sometimes be obligated to do that which they lack the ability to do. In this paper, I maintain that while such a strategy appears promising, it is fraught with pitfalls. Specifically, I argue that because the truth of an ability ascription depends on an (almost always implicit) characterization of the relevant possibility space, different metaethical accounts (...) take obligation to be constrained by different senses of ability. As a result, what initially looks to be a point of consensus—that ability constrains obligation—turns out to be a point of contention, and arguments with this at the foundation are much more likely to obscure, rather than resolve, metaethical disputes. Despite this, appeals to ability in metaethics aren’t doomed to be fruitless. On the contrary, if we can independently establish a particular sense of ability as the normatively relevant one, then we have good grounds for ruling out metaethical accounts that are inconsistent with it. In the final section, I make just such an argument. What seems right about the thought that ability constrains obligation is that an agent cannot be obligated to do that which her circumstances prevent her from doing. I argue that only a sense of ability that is both epistemically and motivationally restricted adequately respects the limits of agential control. (shrink)

Marshall et al. (2024) persuasively argue that some patients with opiate use disorder (OUD), who refuse observation after naloxone resuscitation in the emergency department (ED), “may be making non...

In this paper, we raise and discuss a puzzle about the relationships among goods, reasons, and deontic status. Suppose you have it within your power to give someone something they would enjoy. The following claims seem platitudinous: you can use this power to reward whatever kind of option you want, thereby making that option better and generating a reason for that person to perform it; this reason is then weighed alongside and against the other reasons at play; and altogether, the (...) reasons determine the deontic statuses of that person’s options. We show, however, that in a certain class of cases at least one of these apparent platitudes must be false. In particular, we show that in a certain kind of case wrongfulness cannot be rewarded. In some cases, if one tries to reward wrongfulness, something surprising must go awry: either what you attempt to give as a reward would not, in fact, be good, or it would not generate a reason, or it would have a surprising effect on the deontic status of the relevant options. The upshot is that the relationships among goods, reasons, and deontic status are complicated in ways that have not previously been remarked. (shrink)

Pickering, Newton-Howes, and Young argue for externalism about competence—the view that “welfare judgments are part of judgments about competence” and posit an “explanatory connection” betwe...

The failure of many patients with chronic conditions to correctly follow medical advice that they hope or intend to follow is a major concern, especially as effective long‐term therapies for chronic conditions materialize. Some US healthcare providers have responded with strategies that involve implementing contracts with their patients, including provisions that may deny future treatments after continued nonadherence. This is among the first articles to explicitly discuss the ethics of patient contracts.