Paternalism in the neonatal intensive care unit

Two factors are discussed which have important implications for the issue of paternalism in the neonatal intensive care unit (NICU): the physician's role as advocate for the patient; and the range of typical responses of parents who learn that their neonate has a serious illness. These factors are pertinent to the task of identifying those actions which are paternalistic, as well as to the question of whether paternalism is justified. It is argued that certain behavior by physicians which is often thought to be paternalistic is not in fact so. Furthermore, an argument in defense of paternalism which has largely been overlooked is presented. Examples are given to illustrate how paternalism actually arises in the NICU, and it is argued that paternalism is justified in some cases.     

Technology, Recommendation and Design: On Being a ‘Paternalistic’ Philosopher

Philosophers have talked to each other about moral issues concerning technology, but few of them have talked about issues of technology and the good life, and even fewer have talked about technology and the good life with the public in the form of recommendation. In effect, recommendations for various technologies are often left to technologists and gurus. Given the potential benefits of informing the public on their impacts on the good life, however, this is a curious state of affairs. In the present paper, I will examine why philosophers are seemingly reluctant to offer recommendations to the public. While there are many reasons for philosophers to refrain from offering recommendations, I shall focus on a specific normative reason. More specifically, it appears that, according to a particular definition, offering recommendations can be viewed as paternalistic, and therefore is prima facie wrong to do so. I will provide an argument to show that the worry about paternalism is unfounded, because a form of paternalism engendered by technology is inevitable. Given the inevitability of paternalism, I note that philosophers should accept the duty to offer recommendations to the public. I will then briefly turn to design ethics, which has reconceptualised the role of philosophers and, in my mind, fitted well with the inevitability of paternalism. Finally, I shall argue that design ethics has to be supplemented by the practice of recommendation if it is to sustain its objective.     

Autonomy, Slavery, and Mill's Critique of Paternalism

Critics have charged that John Stuart Mill's discussion as of paternalism in On Liberty is internally inconsistent, noting, for example, the numerous instances in which Mill explicitly endorses examples of paternalistic coercion. Similarly, commentators have noted an apparent contradiction between Mill's political liberalism – according to which the state should be neutral among competing conceptions of the good – and Mill's condemnation of non-autonomous ways of life, such as that of a servile wife. More generally, critics have argued that while Mill professes an allegiance to utilitarianism, he actually abandons it in favor of a view that values personal autonomy as the greatest intrinsic good. This paper presents an interpretation of Mill that provides a viable and consistent treatment of paternalism, thereby refuting each of the aforementioned critiques. Mill's views, it argues, are consistently utilitarian. Moreover, the interpretation accounts for all of Mill's departures from his otherwise blanket prohibition of paternalistic legislation. In particular, it explains his most notorious example, the condemnation of voluntary contracts for slavery. The interpretation emphasizes Mill's conceptual linkage between autonomy and utility, noting his implicit use of at least three different senses of the notion of autonomy.     

Governing [through] Autonomy. The Moral and Legal Limits of “Soft Paternalism”

Legal restrictions of the right to self-determination increasingly pretend to be compatible with the liberal concept of autonomy: they act upon a ‘soft’ or autonomy-orientated paternalistic rationale. Conventional liberal critique of paternalism turns out to be insensitive to the intricate normative problems following from ‘soft’ or ‘libertarian’ paternalism. In fact, these autonomy-oriented forms of paternalism could actually be even more problematic and may infringe liberty rights even more intensely than hard paternalistic regulation. This paper contributes to the systematic differentiation of soft and hard paternalism by discussing the (legal) concept of autonomy and elaborates the moral and legal limits of autonomy-orientated paternalism.     

Against Two Modest Conceptions of Hard Paternalism

People in our liberal pluralistic society have conflicting intuitions about the legitimacy of coercive hard paternalism, though respect for agency provides a common source of objection to it. The hard paternalist must give adequate reasons for her coercion which are acceptable to a free and equal agent. Coercion that fails to meet with an agent’s reasonable evaluative commitments is at least problematic and risks being authoritarian. Even if the coercer claims no normative authority over the coercee, the former still uses coercion to replace the latter’s reasons or will with his own reasons or will. But does every hard paternalistic view have to invite such objection? Throughout I will assume that defenders of what I will call “Neutral Paternalism” (NP) and “Commonsense Paternalism” (CP) aim to offer reasons for coercion all can reasonably endorse despite evaluative diversity, in opposition to more objectionable forms of coercive paternalism, such as those which defend it on religious or perfectionist grounds. I will argue, nonetheless, that Gerald Dworkin’s defense of NP and Danny Scoccia’s defense of CP succumb to the same problems of objectionable imposition that saddle other forms of coercive paternalism. The shortcomings in their views suggest that even modest hard paternalism is nonetheless problematic for liberals.     

How permissive consent works

Consent that is voluntary, informed and given by a competent person sometimes transforms a wrong into a right act. How does consent that meets these requirements change the moral property of an act, namely that of being a wronging of a person? This is the question this paper will deal with. Some authors argue that valid consent changes the moral property of an act by changing the reasons which speak against the act. This account of the normative force of consent will be critically examined and rejected. An alternative model will then be put forward and defended according to which consent changes the moral property of an act if and only if the wrong-making property of the act is that it is not consented to. The upshot will be that consent does not eliminate the wrong-making property if the unconsented act is wrong for other reasons than not being consented to.     

Hume and the Problem of Paternalism: When is Humanity Sufficient?

Hume states that if a group of powerless, rational creatures lived amongst human beings, then humans would be required to treat this species with humanity but not with justice. Michael Ridge has argued that this implies humans would be required to engage in a morally dubious form of paternalism toward this imagined species. I argue that a proper understanding of why this imagined species is excluded from the scope of justice shows Hume has a plausible moral reason for requiring paternalism in this instance. The reason the imagined species is excluded is that they are incapable of feeling what I term “the pain of dependence,” or unease arising from complete dependence upon those who are more powerful. Those capable of the pain of dependence will have reason to resent exclusion from the scope of justice (and the accompanying susceptibility to paternalism). However, I contend that Hume did not think that the imagined species was capable of feeling the pain of dependence. This means that the imagined species would not consider themselves wronged when subject to paternalistic treatment, and, consequently, there is good reason to think the sort of paternalism that Hume's theory allows is not morally objectionable.     

Children and the Limits of Paternalism

Philosophers disagree about what precisely makes an act paternalistic, and about whether, when, and why paternalistic acts are morally objectionable. Despite these disagreements, it might seem uncontroversial to think that it is permissible to paternalize children. When paternalism seems morally objectionable, that is usually because an adult has been treated in a way that seems appropriate only for children. But, we might think, there can be nothing morally objectionable about treating children as children. In this paper, however, I argue that there are limits to how we may permissibly paternalize children. I begin in Section 1 by describing and endorsing Jonathan Quong’s account of paternalism, which defines paternalistic acts as those that involve particular kinds of judgments that the paternalizer makes about the capacities of the paternalizee. In Section 2, I identify a distinction between two kinds of paternalism: ‘compensatory’ paternalism, and ‘non-compensatory’ paternalism. In Section 3, I argue that compensatory paternalism is usually permissible in the case of children. In section 4, I argue that non-compensatory paternalism is much harder to justify than compensatory paternalism, and because of this, it is sometimes impermissible even when directed at children.     

Professional Paternalism

This article points out how far-reaching the changes in our public life would actually have to be if we wanted to avoid paternalism altogether. For example, the widespread view that only a physician with training at a recognized institution should be allowed to perform surgery or that only an educated lawyer may provide legal council is clearly paternalistic. In fact, many professional regulations, not just in medicine and law, but also in engineering and many other areas of expertise, have a strongly paternalistic function. Moreover, this problem is located in a sphere that is neither clearly private, nor seems to be part of a state-legislated public sphere. Professional organizations are neither governments, nor necessarily democratic, but they are often state-certified and produce binding regulations for issues of public interest. The author bites the bullet and accepts professional paternalism, while insisting that special care should be placed on how to design an appropriate professional code of conduct.     

Subject‐Relative Reasons for Love

Can love be an appropriate response to a person? In this paper, I argue that it can. First, I discuss the reasons why we might think this question should be answered in the negative. This will help us clarify the question itself. Then I argue that, even though extant accounts of reasons for love are inadequate, there remains the suspicion that there must be something about people which make our love for them appropriate. Being lovable, I contend, is what makes our love for them appropriate, just as being fearsome is what makes our fear of certain situations appropriate. I finally propose a general account of this property which avoids the major problems facing the extant accounts of reasons for love.     

Knowing and Not‐Knowing For Your Own Good: The Limits of Epistemic Paternalism

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

The Justification of Paternalistic Actions in Psychotherapy

This article defines the nature of paternalistic interventions in psychotherapy and discusses reasons why the client's right to consent to treatment is important. We describe a reasoning process developed by Culver and Gert (1982) that can be used to determine when paternalistic actions are and are not ethically justifiable in mental health practice. We demonstrate how this procedure may be applied to psychotherapy by using a number of case illustrations.     

Bioethics reformation style

The Hippocratic model is inadequate because it is too paternalistic, argues Rebecca D. Pentz in her response to Cameron. Instead, we would do well to think of the patient/doctor relationship in Reformation terms, using the pastor/congregation relationship as a model. Rejecting Hippocratic paternalism is not tantamount to an assertion of absolute autonomy; it entails patient responsibility, shared with the physician.     

Who Benefits?— Why personal identity does not matter in a moral evaluation of germ-line gene therapy

Recently it has been argued that some instances of germ-line gene therapy will change the identity of the person who receives the benefit of therapy, and that in these instances there is no good moral reason to conduct germ-line gene therapy. Against this we argue that even if gene therapy should have an effect on the identity of the resulting person, this would not diminish the urgency of the therapy. Not only would impersonal moral reasons speak in favour of such radical gene therapy, there would also be person-affecting reasons to perform it.     

Sinking Cohen's Flagship — or Why People with Expensive Tastes Should not be Compensated

G. A. Cohen argues that egalitarians should compensate for expensive tastes or for the fact that they are expensive. Ronald Dworkin, by contrast, regards most expensive tastes as unworthy of compensation — only if a person disidentifies with his own such tastes (i.e. wishes he did not have them) is compensation appropriate. Dworkinians appeal, inter alia, to the so‐called ‘first‐person’ or ‘continuity’ test. According to the continuity test, an appropriate standard of interpersonal comparison reflects people's own assessment of their relative standing: Person A can only legitimately demand compensation from person B if he regards himself as worse off, all things considered, than B. The typical bearer of expensive tastes does not regard herself as being worse off than others with less expensive tastes. Hence, in the typical case, pace Cohen, compensation for expensive tastes is inappropriate. The article scrutinizes this rationale for not compensating for expensive tastes. Especially, we try to bolster the continuity test by relating it to Dworkin's distinction between integrated and detached values, pointing out that an argument for the continuity test can be built on the assumption that equality has integrated value. In brief, the point is that a metric of equality should be assessed, partly, in virtue of its consequences for related ideals. One of these is the kind of justificatory community promoted by the continuity test. We defend this view against an objection to the effect that equality is a detached value. We conclude that the continuity test constitutes a strong foothold for the resourcist egalitarian reluctance to compensate people for their expensive tastes.     

Vicarious action preparation does not result in sensory attenuation of auditory action effects

The perception of sensory effects generated by one’s own actions is typically attenuated compared to the same effects generated externally. However, it is unclear whether this specifically relates to self-generation. Recent studies showed that sensory attenuation mainly relies on action preparation, not actual action execution. Hence, an attenuation of sensory effects generated by another person might occur if these actions can be anticipated and thus be prepared for.Here, we compared the perceived loudness of sounds generated by one’s own actions and actions of another person that either could or could not be anticipated. We found an attenuation of the perceived loudness for self- as compared to other-generated sounds. This difference was independent of whether the sound-eliciting actions of the other person could be anticipated or not. Thus, sensory attenuation seems to be specifically tied to self-generation instead of being a secondary effect of agent-independent preparation for an upcoming action.     

Following the law because it’s the law: obedience,bootstrapping, and practical reason

Voluntarists in the early modern period speak of an agent’s following the law because she was ordered to do so or because it’s the law. Contemporary philosophers tend either to ignore or to dismiss the possibility of justified obedience of this sort – that is, they ignore or dismiss the possibility that something’s being the law could in itself constitute a good reason to act. In this paper, I suggest that this view isn’t taken seriously because of certain widespread beliefs about practical reason – in particular, it’s due to the belief that it’s impossible for reasons to be “bootstrapped” into existence. I argue, though, that a plausible account of practical reasoning should allow that reasons can be bootstrapped into existence, and so there’s no reason to be suspicious about the possibility of a person’s being justified in following the law because it’s the law. I end by suggesting that this conclusion opens up important new avenues of inquiry for philosophers working on topics related to legal obedience.     

The justification of paternalistic actions in psychotherapy

This article defines the nature of paternalistic interventions in psychotherapy and discusses reasons why the client's right to consent to treatment is important. We describe a reasoning process developed by Culver and Gert (1982) that can be used to determine when paternalistic actions are and are not ethically justifiable in mental health practice. We demonstrate how this procedure may be applied to psychotherapy by using a number of case illustrations.     

Morality,choice and inwardness

The present paper tries to analyse the way in which Judge William, in Sören Kierkegaard's work Either/Or, distinguishes between the aesthetic and the ethical way of life. Basically his distinctions seem to be that the ethicist is a seriously committed person (has inwardness) whereas the aestheticist is indifferent, and that the former accepts universal rules whereas the latter makes an exception for himself. — In order to come from the aesthetic to the ethical stage one must, according to Judge William, make a choice of oneself. We try to show that such a choice is only one among several factors implicit in his reasoning and that he does not at all consider it as a ‘leap’, but as based upon reasons, though his reasons are mostly of an aesthetic nature. Far from seeing the Judge as a champion of choice, we maintain that the book primarily contains a plea for a certain personality ideal. This probably has to do with the fact that he does not seem to be in doubt as to what one ought to do, only as to how to become a person who does what he ought to do. We shall also argue that a choice of oneself, as a matter of fact, is neither necessary nor sufficient in order to bring a person within the ethical stage, as described by the Judge. — A person who lives ethically does not, according to Judge William, necessarily act rightly, but his actions are either right or wrong, as opposed to the actions of the aestheticist which fall outside the domain of the ethical. In order to obtain a tenable distinction within his philosophy between ‘being within the ethical stage’ and ‘acting ethically rightly’ the first concept should be defined in terms of inwardness (serious commitment), the latter as inward conformity with certain universal rules. — This idea of inwardness, probably the most original and fruitful contribution of ‘Equilibrium’, seems to be based, however, like most of his ethical reasoning, on certain controversial assumptions about human nature.