Challenging the bioethical application of the autonomy principle within multicultural societies

This article critically re-examines the application of the principle of patient autonomy within bioethics. In complex societies such as those found in North America and Europe health care professionals are increasingly confronted by patients from diverse ethnic, cultural, and religious backgrounds. This affects the relationship between clinicians and patients to the extent that patients' deliberations upon the proposed courses of treatment can, in various ways and to varying extents, be influenced by their ethnic, cultural, and religious commitments. The principle of patient autonomy is the main normative constraint imposed upon medical treatment. Bioethicists typically appeal to the principle of patient autonomy as a means for generally attempting to resolve conflict between patients and clinicians. In recent years a number of bioethicists have responded to the condition of multiculturalism by arguing that the autonomy principle provides the basis for a common moral discourse capable of regulating the relationship between clinicians and patients in those situations where patients' beliefs and commitments do or may contradict the ethos of biomedicine. This article challenges that claim. I argue that the precise manner in which the autonomy principle is philosophically formulated within such accounts prohibits bioethicists' deployment of autonomy as a core ideal for a common moral discourse within multicultural societies. The formulation of autonomy underlying such accounts cannot be extended to simply assimilate individuals' most fundamental religious and cultural commitments and affiliations per se. I challenge the assumption that respecting prospective patients' fundamental religious and cultural commitments is necessarily always compatible with respecting their autonomy. I argue that the character of some peoples' relationship with their cultural or religious community acts to significantly constrain the possibilities for acting autonomously. The implication is clear. The autonomy principle may be presently invalidly applied in certain circumstances because the conditions for the exercise of autonomy have not been fully or even adequately satisfied. This is a controversial claim. The precise terms of my argument, while addressing the specific application of the autonomy principle within bioethics, will resonate beyond this sphere and raises questions for attempts to establish a common moral discourse upon the ideal of personal autonomy within multicultural societies generally.     

The heteronomous moral value of shame

Recent work in moral theory has argued against according shame any moral value in virtue of its supposed heteronomy. Authors who have defended shame's moral value have generally argued that shame is, in fact, autonomous. In the present article, I draw on the work of Jean-Paul Sartre, Stanley Cavell and Adam Smith to develop an argument for shame's moral worth based on its heteronomy. I then contrast my defence with work that holds shame's moral value to be based on its autonomy. I argue that that view goes wrong by construing shame on the model of private experience. This psychology is unconvincing in its own right and can underwrite moral failings.     

What Must We Mean By “Community”? A Processive Account

The term "community" in ethics and bioethics traditionally has been used to designate either a specific kind of moral relationship available to rational agents or, in contrast, the context in which any sense of rational agency can even be understood. I argue that bioethics is better served when both "selves" and "community" are expressed through a more processive language that highlights the functional character of such concepts. In particular, I see the turn to "processive" community in bioethics as a turn towards method, contextualization, and narrative. In clinical practice, such a processive account demands that bioethics concentrate on methods of developing healthy dialogue and deeper understanding from within the problematic situation rather than trying to "fix" problems using ethical tools developed from outside the present situation. "Community," I argue, is in and of the interactive processes of inquiry itself. Such inquiry, such "communitying," requires that we engage individual patients in context; it demands more than simply gaining their permission or mere consent; it demands developing a supportive environment for participation.     

Islamist Women's Agency and Relational Autonomy

Mainstream conceptions of autonomy have been surreptitiously gender‐specific and masculinist. Feminist philosophers have reclaimed autonomy as a feminist value, while retaining its core ideal as self‐government, by reconceptualizing it as “relational autonomy.” This article examines whether feminist theories of relational autonomy can adequately illuminate the agency of Islamist women who defend their nonliberal religious values and practices and assiduously attempt to enact them in their daily lives. I focus on two notable feminist theories of relational autonomy advanced by Marina Oshana and Andrea Westlund and apply them to the case of Women's Mosque Movement participants in Egypt. I argue that feminist conceptions of relational autonomy, centered around the ideal of self‐government, cannot elucidate the agency of Women's Mosque Movement participants whose normative ideal involves perfecting their moral capacity.     

On the Moral Agency of Computers

Can computer systems ever be considered moral agents? This paper considers two factors that are explored in the recent philosophical literature. First, there are the important domains in which computers are allowed to act, made possible by their greater functional capacities. Second, there is the claim that these functional capacities appear to embody relevant human abilities, such as autonomy and responsibility. I argue that neither the first (Doman-Function) factor nor the second (Simulacrum) factor gets at the central issue in the case for computer moral agency: whether they can have the kinds of intentional states that cause their decisions and actions. I give an account that builds on traditional action theory and allows us to conceive of computers as genuine moral agents in virtue of their own causally efficacious intentional states. These states can cause harm or benefit to moral patients, but do not depend on computer consciousness or intelligence.     

Stigma,Stereotype, and Self-Presentation

How should we interpret the popular objection that stigmatised subjects are not treated as individuals? The Eidelson View claims that stigma, because of its connection to stereotypes, violates an instance of the general requirement to respect autonomy. The Self-Presentation View claims that stigma inhibits the functioning of certain morally important capacities, notably the capacity for self-presentation. I argue that even if we are right to think that stigma violates a requirement to respect autonomy, this is insufficient to account for the full weight of the charge that stigmatised subjects are not treated as individuals. We need the Self-Presentation View to explain a special threat to agency. I then address the worry that focusing on a concern with being treated as individuals opens the door to the suggestion that treating as superior can be just as morally troubling as stigma. This objection is fatal for the Eidelson View. But the Self-Presentation View has a number of resources for deflating the worry. We should not exclude the possibility of a moral symmetry between some cases of stigma and some cases of treating as superior. Rather, we should provide a nuanced account of the circumstances in which either phenomenon is detrimental for self-presentation.     

CONSCIENCE, MORAL TRUTH, AND MORAL ERRORS: SOME RESPONSES TO EDMUND LEITES

Edmund Leites's lucid article on conscience, casuistry, and moral decision in the Church of England in the late 17th and early 18th centuries has amply demonstrated how the idea of conscience developed and changed from a background assumption of moral autonomy to that of self-reliance in addition to the belief in moral autonomy. In this shift the art of moral casuistry has gradually lost its original relevance and even become a forgotten idea. It may be wondered why this happened and what significance may be adduced from this. It may also be wondered what philosophical evaluation can be rendered of casuistry independent of the historical nexus of its transformation. From a comparative perspective in connection with the Chinese heritage, Leites's paper provides excellent evidence for the surprising existence of similar strains of thought on conscience in Chinese and Western traditions even though the metaphysical and religious contexts and backgrounds of these strains of thought are radically different. This difference in metaphysical and religious contexts and backgrounds raises some profound philosophical questions which are indicated in Leites's comments on my original article. In this response, I shall first discuss similar strains of thought on conscience in Chinese and English sources, and then explore briefly the different metaphiscal structures underlying these thoughts. I shall finally consider what theoretical conclusions are warranted in light of both the article and the comments of Edmund Leites.     

In defense of the mirror thesis

In this journal, Luke Russell defends a sophisticated dispositional account of evil personhood according to which a person is evil just in case she is strongly and highly fixedly disposed to perform evil actions in conditions that favour her autonomy. While I am generally sympathetic with this account, I argue that Russell wrongly dismisses the mirror thesis—roughly, the thesis that evil people are the mirror images of the morally best sort of persons—which I have defended elsewhere. Russell’s rejection of the mirror thesis depends upon an independently implausible account of moral sainthood, one that is implausible for reasons that Russell himself suggests in another context. Indeed, an account of moral sainthood that parallels Russell’s account of evil personhood is plausible for the same reasons that his account of evil personhood is, and that suggests that Russell himself is actually committed to the mirror thesis.     

Power and responsibility in the practice of medicine

The evident power of the medical profession in the contemporary provision of health care requires a careful moral evaluation. The demand for professional autonomy may well lead to misuses of power. To illustrate the dangers of 'clinical freedom' and of the failure of the profession to monitor the actions of its members adequately, a case study is presented based on the recently published findings of a judicial inquiry into inadequate treatment of cervical cancer in Auckland, New Zealand. From this case study there emerge questions concerning professional autonomy, the autonomy of patients, and the need for a patient's advocate. These issues are assessed in light of the application to medical practice of the autonomy/heteronomy distinction in moral theory. Finally, three theological themes are briefly related to the issues which have emerged: the nature of agape, the limitations of human moral authority and the vision for humankind contained in the doctrines of incarnation and redemption.     

Can liberal perfectionism justify religious toleration? Wall on promoting and respecting

Toleration is perhaps the core commitment of liberalism, but this seemingly simple feature of liberal societies creates tension for liberal perfectionists, who are committed to justifying religious toleration primarily in terms of the goods and flourishing it promotes. Perfectionists, so it seems, should recommend restricting harmful religious practices when feasible. If such restrictions would promote liberal perfectionist values like autonomy, it is unclear how the perfectionist can object. A contemporary liberal perfectionist, Steven Wall, has advanced defense of religious toleration that grounds perfectionist toleration in an innovative account of reasons of respect. He thus defends perfectionist toleration on two grounds: (i) the appropriate manner of responding to perfectionist goods like autonomy and membership is to respect the religious choices of others; (ii) citizens can acquire reasons to respect the religious choices of others through internalizing a value-promoting moral and political code. I argue that both defenses fail. The cornerstone of both arguments is the connection Wall draws between reasons to promote value and reasons to respect it. I claim that Wall’s conception of the relationship between promoting and respecting value is inadequate. I conclude that the failure of Wall’s defense of perfectionist toleration should motivate liberal perfectionists to develop more sophisticated accounts of normative reasons. The viability of a truly liberal perfectionism depends upon such developments.     

Gregersen's Vision of a Theonomous Universe

In his article, "The Idea of Creation and the Theory of Autopoietic Processes," Niels H. Gregersen has proposed an important thesis: God supports and sustains autopoietic processes in nature. This contribution underscores what Paul Tillich called theonomy , a conception of the divine presence or action as one which under-girds, makes possible, and brings to perfection the creature's autonomy and creativity. The concept of theonomy is represented not only in contemporary Christian theology, but also in the work of Alfred North Whitehead and the Japanese Buddhist thinker, Tanabe Hajime. Gregersen shows that this concept extends not only to existential realities, but also to science and the processes of nature. There are connections, as well as differences, to be noted between Gregersen and Whitehead. This train of thought would be further enhanced if it included a discussion of the concept of God as the power to be—a connection that certainly is implied in Gregersen's argument.     

Anthropocene in Context: A Response to Rasmussen

In response to Larry Rasmussen's article about religious ethics in the Anthropocene, I offer an analysis that both contextualizes and elaborates upon his ideas. I introduce other humanities disciplines that have already wrestled with this question, and scholars of color whose voices offer needed correctives to the colonial heritage of most academic disciplines. I explore topics including human agency, non-human agency, exploitation, and refuge. I encourage scholars in our field to move beyond questions of responsibility and lamentations of moral incompetence and into concepts of right relationality and analysis of grassroots climate action already taking place in religious, ethical contexts.     

Naturalizing Ethics: the Biology and Psychology of Moral Agency

Moral agency is a central feature of both religious and secular conceptions of human beings. In this paper I outline a scientific naturalistic model of moral agency making use of current findings and theories in sociobiology,developmental psychology, and social cognitive theory. The model provides answers to four central questions about moral agency: (1) what it is, (2) how it is acquired, (3) how it is put to work, and (4) how it is justified. I suggest that this model can provide religious and secular moral theories with a basis for a common understanding of moral agency.     

A NEO‐STOIC APPROACH TO EPISTEMIC AGENCY

What is the best model of epistemic agency for virtue epistemology? Insofar as the intellectual and moral virtues are similar, it is desirable to develop models of agency that are similar across the two realms. Unlike Aristotle, the Stoics present a model of the virtues on which the moral and intellectual virtues are unified. The Stoics’ materialism and determinism also help to explain how we can be responsible for our beliefs even when we cannot believe otherwise. In this paper I show how a neo‐Stoic model of epistemic agency can address common objections to treating epistemic and moral agency similarly and allow a robust explanatory role for character in determining our actions and beliefs. The picture of epistemic responsibility that flows from this model also explains why we often deserve credit for our knowledge, while demonstrating that the truth of our beliefs is not something for which we are epistemically responsible.     

Schizophrenia and Moral Responsibility: A Kantian Essay

In this paper, I give a Kantian answer to the question whether and why it would be inappropriate to blame people suffering from mental disorders that fall within the schizophrenia spectrum. I answer this question by reconstructing Kant’s account of mental disorder, in particular his explanation of psychotic symptoms. Kant explains these symptoms in terms of various types of cognitive impairment. I show that this explanation is plausible and discuss Kant’s claim that the unifying feature of the symptoms is the patient’s inability to enter into an exchange of reasons with others. After developing a Kantian Quality of Will Thesis, I analyze some real life cases. Firstly, I argue that delusional patients who are unable to enter into an exchange of epistemic reasons are exempted from doxastic rather than moral responsibility. They are part of the moral community and exonerated from moral blame only if their actions do not express a lack of good will. Secondly, I argue that disorganized patients who are unable to form intentions and to make plans are exempted from moral responsibility because they do not satisfy the conditions for agency.     

A relational account of intellectual autonomy

According to relational views of autonomy, some social relations or forms of dependence are necessary for autonomous agency. Recent relational theorists have primarily focused on autonomy of action or practical autonomy, and the result has been a shift away from individualistic conceptions of autonomy in the practical realm. Despite these trends, individualistic conceptions are still the default when it comes to autonomy of belief or intellectual autonomy. In this paper, I argue for a relational account of intellectual autonomy. Specifically, I claim that intellectual autonomy requires a sense of one’s standing as an equal member of the epistemic community.     

Religion,Inclusive Individualism,and Volunteering in Europe

A well supported finding in social science is that religiosity is associated with pro-social behaviours such as volunteering, but the religious decline in Europe characterising the latter part of the twentieth century has not been accompanied by decline in voluntary participation. This period is also associated with a sharp increase in the moral emphasis on individual autonomy and inclusiveness over social norms and traditions. In this analysis of the European Values Study (2008–2010), I examine the relationship between religion and volunteering, taking both individual values and aggregate norms into account. Religious attendance is found to be associated with volunteering at the individual level. However, the average citizen’s likelihood of volunteering is lower in more religious countries. This could be due in part to secular countries’ high levels of inclusive individualism (autonomy values and generalised trust) which are positively associated with volunteering among both religious and non-religious respondents.     

Bigotry and Religious Belief

Attacks on religious doctrines are often characterized as a form of bigotry and traditional analyses of the concept support this view. I argue that regarding such attacks as bigotry is inconsistent with a variety of contemporary moral attitudes and social goals. I offer an improved account of when we should ascribe bigotry – one that is more coherent with views on tolerance and the importance of open debate. This account focuses upon the justification for hostile attitudes and also limits the target of bigoted thought to persons, not to doctrines, religious or otherwise. I argue that while it is indeed possible to adopt bigoted attitudes toward people classified on the basis of their religious beliefs, it is not possible to hold bigoted attitudes against the beliefs themselves.