Beyond Mental Competence

Justification for psychiatric paternalism is most easily established where mental illness renders the person mentally incompetent, depriving him of the capacity for rational agency and for autonomy, hence undermining the basis for liberal rights against paternalism. But some philosophers, and no doubt some doctors, have been deeply concerned by the inadequacy of the concept of mental incompetence to encapsulate some apparently appealing cases for psychiatric paternalism. We ought to view mental incompetence as just one subset of a broader justification for psychiatric paternalism. The very basis of liberal limitations on psychiatric paternalism, whether described in terms of rights to autonomy or as respect for differences in values and lifestyles, presupposes a sense of moral persistence, and hence some sufficiently persistent self. Paternalistic intervention is warranted when we are unable to govern our lives in a manner consistent with the goals and values that comprise that ‘self’. One way that can occur is when we lack the mental capacities required for autonomy, such that we are unable to interpret and interact with our environment in order to meaningfully pursue our goals, i.e. mental incompetence. But it can also occur when we are subject to impositions that alter our goals without altering our capacity to pursue them — i.e. when it is our ‘self’ that is impaired rather than our competence.     

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.     

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.     

Informed consent in mental health treatment: A sociological perspective

The rise in the mental health movement coincides with a decline in prestige and importance of criminal law. While this may, in part, reflect the greater effectiveness of mental health treatment in dealing with overlapping problems, it also reflects certain problems that criminal law has with the individualistic values of modern society and the value-attractiveness of the mental health professions' commitment to helping the individual. However, many of the same value problems inherent in criminal punishment also apply to some aspects of mental health treatment, especially the paternalism of the doctor-patient relationship and involuntary treatment. Informed consent can be seen as a response to these value conflicts as well as part of the general extension of citizenship rights to the less privileged members of the society. This paper analyzes some of the conflicts inherent in the application of informed consent to mental health treatment from the above perspective.     

The Normative Core Of Paternalism

The philosophical debate on paternalism is conducted as if the property of being paternalistic should be attributed to actions. Actions are typically deemed to be paternalistic if they amount to some kind of interference with a person and if the rationale for the action is the good of the person interfered with. This focus on actions obscures the normative issues involved. In particular, it makes it hard to provide an analysis of the traditional liberal resistance to paternalism. Given the fact that actions most often have mixed rationales, it is not clear how we should categorize and evaluate interfering actions for which only part of the rationale is the good of the person. The preferable solution is to attribute the property of being paternalistic not to actions, but to compounds of reasons and actions. The framework of action–reasons provides the tools for distinguishing where exactly paternalism lies in the complex web of reasons and actions.     

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.     

Why Nudges Coerce: Experimental Evidence on the Architecture of Regulation

Critics frequently argue that nudges are more covert, less transparent, and more difficult to monitor than traditional regulatory tools. Edward Glaeser, for example, argues that “[p]ublic monitoring of soft paternalism is much more difficult than public monitoring of hard paternalism”. As one of the leading proponents of soft paternalism, Cass Sunstein, acknowledges, while “[m]andates and commands are highly visible”, soft paternalism, “and some nudges in particular[,] may be invisible”. In response to this challenge, proponents of nudging argue that invisibility for any given individual in a particular choice environment is compatible with “careful public scrutiny” of the nudge. This paper offers the first of its kind experimental evidence that tests whether nudges are, in fact, compatible with “careful public scrutiny”. Using three sets of experiments, the paper argues that, even when entirely visible, nudges attract less scrutiny than their “hard law” counterparts.     

Islamic religious education in Belgian state schools: a post-secular perspective

Abstract

Based on Habermas’ normative theory of religion in post-secular society, this article elaborates on the organisation of Islamic religious education (RE) in state schools. Hereto, a brief sketch of the Habermasian concepts of reflexive religion and complementary learning processes will be given. Subsequently, the author addresses the role of RE in post-secular society and applies these Habermasian concepts to confessional RE, with particular attention to Islamic RE in Belgium, where this subject is included as an optional subject in the state school curriculum since 1975, but where it is also criticised today, in particular with regard to content, teacher-training, textbooks, and inspection. These deficiencies will lead us to one of the main problems of Islamic RE and of confessional RE in general: the absence of state control. Based on Habermas’ ideas, the author concludes that it is up to the state to elucidate under which conditions confessional RE can be part of the regular curriculum, and to facilitate these conditions, by funding and co-organising teacher training, reviewing curricula and textbooks, formulating a ‘core curriculum’ and controlling teachers, for example. If these conditions have not been met, confessional RE should not be a part of the regular curriculum in a liberal state.     

Children,Paternalism and the Development of Autonomy

This paper addresses the issue of paternalism in child-rearing. Since the parent–child relationship seems to be the linguistic source of the concept, one may be tempted to assume that raising a child represents a particularly appropriate sphere for paternalism. The parent–child relationship is generally understood as a relationship that is supposed to promote the development and autonomy-formation of the child, so that the apparent source of the concept is a form of autonomy-oriented paternalism. Far from taking paternalism to be overtly unproblematic in such paradigmatic, pedagogical settings, this article analyzes how an effort should be made to understand a child’s capacities and which standards parents should be held to when deciding whether interference truly serves the child’s interests.     

Reviving Ulysses contracts

Ulysses contracts have faced paternalism objections since they first were proposed. Since the contracts are designed to override a present request from a legally competent patient in favor of a past request made by that patient, enforcement of these contracts was argued to be unjustifiable strong paternalism. Recent legal developments and new theories of practical reasoning suggest that the discussion of Ulysses contracts should be revived. This paper argues that with a proper understanding of the future-directed planning embodied in Ulysses contracts, the charge of strong paternalism can be answered, and the enforcement of some Ulysses contracts may be justified under the rubric of weak paternalism.     

Applying Principles to Cases and the Problem of Judgment

We sometimes decide what to do by applying moral principles to cases, but this is harder than it looks. Principles are more general than cases, and sometimes it is hard to tell whether and how a principle applies to a given case. Sometimes two conflicting principles seem to apply to the same case. To handle these problems, we use a kind of judgment to ascertain whether and how a principle applies to a given case, or which principle to follow when two principles seem to conflict. But what do we discern when we make such judgments—that is, what makes such judgments correct? The obvious answer is that they are made correct by whatever makes other moral judgments correct. However, that cannot be right, for a principle can be inconsistent with morality yet still apply in a particular way to a given case. If the principle is inconsistent with morality, then morality cannot be what we discern when we judge whether and how that principle applies to a given case. I offer an alternative account of what makes such judgments correct.     

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.     

Autonomy and coercion in disease prevention and health promotion

Most of the attention regarding the balance between autonomy and paternalism has been focused on the therapeutic relation. Much less attention has been devoted to the problem of autonomy in the application of medical knowledge for preventive purposes. Here, because the good to be achieved is social as well as individual, an unavoidable dilemma ensues. Effective preventive measures of benefit to all must necessarily limit autonomy and involve some coercion. I argue that there are principles which can be established to guide society in a moral use of coercion. The question of employing medical knowledge is not, as it is in therapeutic medicine, to preserve or enhance autonomy. Rather its aim is to enhance voluntary co-operation. Principles for moral use of coercion must thereby be derived from health as a moral value.     

Paternalism and the Ill-Informed Agent

Most anti-paternalists claim that informed and competent self-regarding choices are protected by autonomy, while ill-informed or impaired self-regarding choices are not. Joel Feinberg, among many others, argues that we can in this way distinguish impermissible ??hard?? paternalism from permissible ??soft?? paternalism. I argue that this view confronts two related problems in its treatment of ill-informed decision-makers. First, it faces a dilemma when applied to decision-makers who are responsible for their ignorance: it either permits too much, or else too little, intervention to satisfy its proponents. Second, the most promising rationales in favor of the view ignore the distinction between an agent??s voluntarily bringing about some state of affairs, on the one hand, and an agent??s voluntarily assuming a risk, on the other. I conclude that a decision-maker??s ignorance is irrelevant to the permissibility of intervention on her behalf. If it is permissible to intervene in a given ill-informed choice, it would be permissible to intervene in an otherwise similar but informed choice, at least provided that intervention would produce similar benefits in both cases. This shows that we should sometimes accept straightforwardly paternalistic rationales.     

Relational Autonomy and the Social Dynamics of Paternalism

In this paper I look at various ways that interpersonal and social relations can be seen as required for autonomy. I then consider cases where those dynamics might play out or not in potentially paternalistic situations. In particular, I consider cases of especially vulnerable persons who are attempting to reconstruct a sense of practical identity required for their autonomy and need the potential paternalist’s aid in doing so. I then draw out the implications for standard liberal principles of (anti-) paternalism, specifically in clinical or therapeutic situations. The picture of potential paternalism that emerges here is much more of a dynamic, interpersonal scenario rather than a case of two separate individuals making decisions independent of each other.     

A Puzzle About Proportionality

The paper addresses a puzzle about the proportionality requirement on self-defense due to L. Alexander. Indirectly the puzzle is also relevant to the proportionality requirement on punishment, insofar as the right to punish is derived from the right to self-defense. Alexander argues that there is no proportionality requirement on either self-defense or punishment, as long as the aggressor/offender has been forewarned of the risk of a disproportional response. To support his position Alexander appeals to some puzzle cases, challenging us to explain why the requirement applies in some of them when it clearly does not in others. The paper responds to his challenge by answering two questions: why does the proportionality requirement exist in the first place, and when does it apply? The paper argues that the requirement holds because of our need to protect our rights from violation, and that it applies to cases where the person defending his rights counts as having imposed a cost on one of the offender’s options. An account is offered of when such cost imposition occurs.

     

A method of matrix analysis of group structure

Matrix methods may be applied to the analysis of experimental data concerning group structure when these data indicate relationships which can be depicted by line diagrams such as sociograms. One may introduce two concepts,n-chain and clique, which have simple relationships to the powers of certain matrices. Using them it is possible to determine the group structure by methods which are both faster and more certain than less systematic methods. This paper describes such a matrix method and applies it to the analysis of practical examples. At several points some unsolved problems in this field are indicated.     

A Problem with Societal Desirability as a Component of Responsible Research and Innovation: the “If we don’t somebody else will” Argument

The implementation of Responsible Research and Innovation (RRI) is not without its challenges, and one of these is raised when societal desirability is included amongst the RRI principles. We will argue that societal desirability is problematic even though it appears to fit well with the overall ideal. This discord occurs partly because the idea of societal desirability is inherently ambiguous, but more importantly because its scope is unclear. This paper asks: is societal desirability in the spirit of RRI? On von Schomberg’s account, it seems clear that it is, but societal desirability can easily clash with what is ethically permissible; for example, when what is desirable in a particular society is bad for the global community. If that society chose not to do what was desirable for it, the world would be better off than if they did it. Yet our concern here is with a more complex situation, where there is a clash with ethical acceptability, but where the world would not be better off if the society chose not do what was societally desirable for itself. This is the situation where it is argued that someone else will do it if we do not. The first section of the paper gives an outline of what we take technology to be, and the second is a discussion of which criteria should be the basis for choosing research and innovation projects. This will draw on the account of technology outlined in the first section. This will be followed by an examination of a common argument, “If we don’t do it, others will”. This argument is important because it appears to justify acting in morally dubious ways. Finally, it will be argued that societal desirability gives support to the “If we don’t…” argument and that this raises some difficulties for RRI.     

A State to Call Their Own: Insurrection, Intervention, and the Communal Integrity Thesis

Many reasons have been given as to why humanitarian intervention might not be justified even where rebellion with similar aims would be a morally legitimate option. One of them is that intervention involves the imposition of alien values on the target society. Michael Walzer formulates this objection in terms of a people's right to a state that 'expresses their inherited culture' and that they can truly 'call their own'. I argue that this right can plausibly be said to extend sovereignty to at least some illiberal governments, and therefore to impose at least some moral constraints on humanitarian intervention. The problem for Walzer is that this right cannot form the basis of a constraint that applies to foreign intervention exclusively. Once the details of Walzer's argument are teased out, it becomes apparent that civil war and revolution must be equally restricted by this right. Hence a people's prerogative to be governed in accordance with familiar traditions cannot coherently be invoked to show that intervention is impermissible in cases where insurrection is taken to be justified.