Prescriptions: Autonomy,Humanism and the Purpose of Health Technology

My purpose is to examine two of the foundations of medical ethics: the principle of autonomy and the concept of the human. I also investigate the extent to which health technology makes autonomy and humanness possible. I begin by underlining Illich's point that the same health technology designed to promote health and autonomy also is pathogenic. I proceed to analyse the Kantian concept of autonomy, a concept which is closely associated with health and which continues to determine current ethical thinking. In so doing, I uncover an unexpected ontological function of health technology, a function described in Heidegger's work on technology. Based on this discovery, I suggest that calls for Kantian autonomy may often be self-defeating or even sometimes harmful. I conclude by calling for continued ethical vigilance, but also for a questioning of the hitherto virtually unquestionable concepts of ethics and humanness which may themselves play a role in our era's greatest problems.     

Ethical evaluation of "retainer fee" medical practice

This article examines the reasons that some physicians have recently opted to reduce the size of their practice rosters to allow more time for each patient in exchange for a retainer fee from patients. These physicians also offer supplementary, nonmedical amenities to patients as part of their service. Because physicians have reduced the size of their practice rosters and have increased the price tag for their services, some patients have lost access to their care. We have tried to assess the ethical propriety of such a change in the design of medical practices by weighing plausible, ethically relevant arguments favoring and opposing RFMP. Physicians are ethically obligated first and foremost to promote and protect the health of their patients. RFMP fulfills this duty directly by ensuring prompt and ample professional time for the care of patients. It does so indirectly by allowing time for physicians' continuing education, which in turn should upgrade the quality of care. It also advances the ethical goals of autonomy as it allows patients to choose their own physicians and to spend their money as they please. On the other hand, these ethical positives are offset by the cost of retainer fees that may exclude access of patients to their physicians' care. Even if ethical tradition obligates physicians primarily to patients under their specific care, as professionals and as private citizens, they also have a responsibility to support the health of the entire community. RFMP does little to advance this cause, except that by optimizing the conditions under which their own private patients receive healthcare, they call attention to shortcomings in prevailing public healthcare policies, which by comparison fall short of that standard. An assumption that health is not properly a market commodity, and that all people should receive healthcare on equal terms, would expose RFMP to moral reproof. From an ethical perspective, we find sufficient cause for concern and caution in this innovative style of practice. Nevertheless, the weight of arguments presented here does not seem to justify unequivocal moral condemnation of RFMP. As neither pro nor con views seem to have settled the ethical question, definitive moral judgment on RFMP will probably depend on the outcome of future experience and ongoing evaluation. The implications of RFMP for any future healthcare system are not clear, at least to us.     

Moral responsibility and respect for autonomy: meeting the communitarian challenge.

The principle of respect for autonomy has come under increasing attack both within health care ethics, specifically, and as part of the more general communitarian challenge to predominantly liberal values. This paper will demonstrate the importance of respect for autonomy for the social practice of assigning moral responsibility and for the development of moral responsibility as a virtue. Guided by this virtue, the responsible exercise of autonomy may provide a much-needed connection between the individual and the community.     

The Anarchist's Myth: Autonomy,Children, and State Legitimacy

Philosophical anarchists have made their living criticizing theories of state legitimacy and the duty to obey the law. The most prominent theories of state legitimacy have been called into doubt by the anarchists' insistence that citizens' lack of consent to the state renders the whole justificatory enterprise futile. Autonomy requires consent, they argue, and justification must respect autonomy. In this essay, I want to call into question the weight of consent in protecting our capacity for autonomy. I argue that if we care about all of the preconditions for autonomy, then we have good reasons to leave the state of nature. This leaves the philosophical anarchist with a dilemma. If she truly cares about autonomy, then she must welcome the state. But if she wants to deny the legitimacy of the state because of the value of consent, then she needs to downplay the moral significance of autonomy in people's lives. If autonomy matters, the state does too. If it doesn't, then consent doesn't. The philosophical anarchist can't have it both ways.     

Dianomy: understanding religious women's moral agency as creative conformity

This essay seeks to contribute to work on moral agency of religious women through the creative naming of a dynamic that is emerging in recent scholarship. Drawing on fieldwork in Iran in 2004, I argue that prominent models of agency based on autonomy, heteronomy, and theonomy are unable take into account both religious influence on and individual creativity of women's actions. I propose the neologism, "dianomy," meaning dual-sources of the moral law, to account for moral agency that relies neither exclusively upon the self as a source of moral authority nor exclusively upon religious traditions. Dianomy also attempts to comprehend creative ruptures in obedience to tradition, even when these innovations are unintentional. Such a concept is particularly important in order to correct past tendencies to ignore or even negate feminist politics that do not resist or strategically reform religious norms. With dianomy, tactical moves, actions that are not "freely chosen," and even happy accidents can be studied as productive within traditional religious communities. I call these types of actions, which confound the actions theorized by autonomy, heteronomy, and theonomy, "creative conformity."     

Empathy,Respect, and Vulnerability

ABSTRACT

This paper reconsiders Heather Battaly’s argument that empathy is not a virtue. Like Battaly, I argue that empathy is a disposition that includes elements of virtue acquisition, but is not in itself a virtue in the Aristotelian sense. Unlike Battaly, however, I propose a distinction between care and respect. Drawing on Darwall’s view of recognition respect as well as on phenomenologically inspired views of empathy, I argue that respect can be regarded as the moral feeling that is distinctive of empathy. In my view, the feeling of respect towards another’s situated experience grants epistemic dignity, which is the recognition of the intrinsic significance of subjective experience. By way of conclusion, I suggest that the relation between empathy and respect can be relevant for an account of vulnerability that is not opposed to autonomy.     

Ethical Issues in Counselling and Health in Primary Care

Primary care is the first contact with the health service for patients and is thus the meeting point for people with different perspectives on emotional and psychological issues. The counselling model needs to examine the moral problems posed by these difficulties, and its own differences from the standard health care model, where cure and symptomatic relief rather than personal growth may be the aim. Key situations and relationships are examined against a background of accepted ethical principles (respect for autonomy, the duty to care, minimising harm, and being fair) from the viewpoint of all involved in the encounter, with particular reference to conflicts, responsibilities, confidentiality, and methods of referral and joint working.     

Professional Autonomy in Belgium

The Belgian health care system has a few features that may havecontributed to the rising costs of health care: patients' freechoice of physicians, large clinical freedom of physicians, essentiallya fee-for-service remuneration for medical specialists in which the feesare agreed between insurance funds and physicians. The increased medicalconsumption and costs have prompted the state and insurance companies totake measures that limit the professional autonomy of the physicians.Access to medical education, free until 1997, is now restricted. Themedical profession is organized in the Order of Physicians that hasestablished a code of professional ethics that has moral but not legalforce. So far, there is no special legislation for thepatient–physician relationship, though laws on specific issueslike organ transplantation contain duties for physicians. In recentyears a debate is taking place on patients' rights, of which informedconsent is central and gaining importance in medico-legal publications.An analysis of (ethical and legal) regulations concerning thewithholding or withdrawal of treatment by physicians demonstrate thatthe profession still enjoys a large clinical autonomy, though duediscussion with the patient has become more explicitly required. Therespect for professional autonomy is not primarily due to any formalpower that the Order of Physicians would have, but is rather grounded inthe generally high quality of the patient–physician relationshipthat in ethical terms is considered essentially as a confidencerelationship rather than a contractual relationship.     

Ethics Beyond Moral Theory

I develop an anti‐theory view of ethics. Moral theory (Kantian, utilitarian, virtue ethical, etc.) is the dominant approach to ethics among academic philosophers. But moral theory's hunt for a single Master Factor (utility, universalisability, virtue . . .) is implausibly systematising and reductionist. Perhaps scientism drives the approach? But good science always insists on respect for the data, even messy data: I criticise Singer's remarks on infanticide as a clear instance of moral theory failing to respect the data of moral perceptions and moral intuitions. Moral theory also fails to provide a coherent basis for real‐world motivation, justification, explanation, and prediction of good and bad, right and wrong. Consider for instance the marginal place of love in moral theory, compared with its central place in people's actual ethical outlooks and decision making. Hence, moral theory typically fails to ground any adequate ethical outlook. I propose that it is the notion of an ethical outlook that philosophical ethicists should pursue, not the unfruitful and distorting notion of a moral theory.     

The value of dignity in and for bioethics: rethinking the terms of the debate

The discussion of the nature and value of dignity in and for bioethics concerns not only the importance of the concept but also the aims of bioethics itself. Here, I challenge the claim that the concept of dignity is useless by challenging the implicit conception of usefulness involved. I argue that the conception of usefulness that both opponents and proponents of dignity in bioethics adopt is rooted in a narrow understanding of the role of normative theory in practical ethical thinking. I then offer an alternate understanding of the nature and value of dignity. I begin by recognizing that claims that one’s dignity has been violated point to an important difference between “respect for autonomy” and “respect for persons.” I then suggest three different conceptions of how dignity can be normatively guiding for bioethics, and conclude that, ultimately, understanding dignity as the cornerstone of a reflective perspective that frames moral reflection and deliberation is valuable for doing bioethics well.     

Personal Identity, Autonomy and Advance Statements

abstract    Recent legal rulings concerning the status of advance statements have raised interest in the topic but failed to provide any definitive general guidelines for their enforcement. I examine arguments used to justify the moral authority of such statements. The fundamental ethical issue I am concerned with is how accounts of personal identity underpin our account of moral authority through the connection between personal identity and autonomy. I focus on how recent Animalist accounts of personal identity initially appear to provide a sound basis for extending the moral autonomy of an individual — and hence their autonomous wishes expressed through an advance statement — past the point of severe psychological decline. I argue that neither the traditional psychological account nor the more recent Animalist account of personal identity manage to provide a sufficient basis for extending our moral autonomy past the point of incapacity or incompetence. I briefly explore how analogies to similar areas in law designed to facilitate autonomous decision, such as wills and trusts, provide at best only very limited scope for an alternative justification for granting advance statements any legal or moral authority. I conclude that whilst advance statements play a useful role in formulating what treatment is in a patient's best interests, such statements do not ultimately have sufficient moral force to take precedence over paternalistic best interests judgements concerning an individual's care or treatment.     

Wonder and the clinical encounter

In terms of intervening in embodied experience, medical treatment is wonder-full in its ambition and its metaphysical presumption; yet, wonder’s role in clinical medicine has received little philosophical attention. In this paper, I propose, to doctors and others in routine clinical life, the value of an openness to wonder and to the sense of wonder. Key to this is the identity of the central ethical challenges facing most clinicians, which is not the high-tech drama of the popular conceptions of medical ethics but, rather, the routine of patients’ undramatic but unremitting demands for the clinician’s time and respectful attention. Wonder (conceived as an intense and transfiguring attentiveness) is a ubiquitous ethical source, an alternative to the more familiar respect for rational autonomy, a source of renewal galvanizing diagnostic imagination, and a timely recalling of the embodied agency of both patient and clinician.     

Ethical issues in managed care: a Catholic Christian perspective.

A Christian analysis of the moral conflicts that exist among physicians and health care institutions requires a detailed treatment of the ethical issues in managed care. To be viable, managed care, as with any system of health care, must be economically sound and morally defensible. While managed care is per se a morally neutral concept, as it is currently practiced in the United States, it is morally dubious at best, and in many instances is antithetical to a Catholic Christian ethics of health care. The moral status of any system of managed care ought to be judged with respect to its congruence with Gospel teachings about the care of the sick, Papal Encyclicals, and the documents of the Second Vatican Council. In this essay, I look at the important conceptual or definitional issues of managed care, assess these concerns over against the source and content of a Catholic ethic of health care, and outline the necessary moral requirements of any licit system of health care.     

Kant,Oppression, and the Possibility of Nonculpable Failures to Respect Oneself

I argue that Kant's ethical framework cannot countenance a certain kind of failure to respect oneself that can occur within oppressive social contexts. Kant's assumption that any person, qua rational being, has guaranteed epistemic access to the moral law as the standard of good action and the capacity to act upon this standard makes autonomy an achievement within the individual agent's power, but this is contrary to a feminist understanding of autonomy as a relational achievement that can be thwarted by the systematic attack on autonomy that occurs within oppressive social conditions. Insofar as Kant's negative duty of self‐respect is unable to accommodate the ways immersion in oppressive social environments can warp an individual's understanding of what she is owed and capable of as a moral agent, it perpetuates the cruelty of unjust social systems in the guise of respecting individual autonomy. I conclude by considering Carol Hay's argument that those who are oppressed have an obligation to themselves to resist their own oppression, in order to explore how this limitation in how Kant conceives of the duty to respect the self may reach expression in contemporary ethical theory inspired by Kant.     

Evolution and Free Will: A Defense of Darwinian Non–naturalism

In his recent book The Natural Selection of Autonomy , Bruce Waller defends a view that he calls "natural autonomy." This view holds that human beings possess a kind of autonomy that we share with nonhuman animals, a capacity to explore alternative courses of action, but an autonomy that cannot support moral responsibility. He also argues that this natural autonomy can provide support for the ethical principle of noninterference. I argue that to support the ethical principle of noninterference Waller needs either a libertarian or a compatibilist theory of autonomy. I then go on to argue that, contra Waller, the libertarian view is both compatible with Darwinism and able to make sense of how autonomous acts belong to the agents who perform them. Thus, I conclude that the libertarian position is a live option for Darwinians. If however, naturalism is taken to include a deterministic view of the universe (at least at the nonquantum level), as is often the case, then my article takes some strides in defending "Darwinian non–naturalism."     

A Narrative Approach to the Clinical Reasoning Process in Pediatric Intensive Care: The Story of Matthew

This paper offers a narrative approach to understanding the process of clinical reasoning in complex cases involving medical uncertainty, moral ambiguity, and futility. We describe a clinical encounter in which the pediatric health care team experienced a great deal of conflict and distrust as a result of an ineffective process of interpretation and communication. We propose a systematic method for analyzing the technical, ethical, behavioral, and existential dimensions of the clinical reasoning process, and introduce the Clinical Reasoning Discussion Tool—a dialogical and interpretive device aimed at improving communication, understanding, empathy, and moral deliberation in the clinical setting.     

Ethics in Long-Term Care: Are the Principles Different?

It has become common in medical ethics to discuss difficult cases in terms of the principles of respect for autonomy, beneficence, nonmaleficence, and justice. These moral concepts or principles serve as maxims that are suggestive of appropriate clinical behavior. Because this language evolved primarily in the acute care setting, I consider whether it is in need of supplementation in order to be useful in the long-term care setting. Through analysis of two typical cases involving residents of long-term care facilities, I argue for the additional principles of candor and responsibility for narrative integrity.     

Governing Humanity

In the United Kingdom, clinical governance has become a master narrative for health care over the last decade. While many see this political imperative as embodying both enlightening and humanistic goals, I argue that it has also become an apparatus for resuscitating a hypermodernist worldview which further conceals the political drivers of health care delivery. While resistance to clinical governance seems futile, insistence on the inclusion of historical analysis in understanding modern health care delivery may be profitable. Drawing from selected dramatic texts by Henrik Ibsen, an historical moment of clinical governance may be analysed showing the complex interplay of the personal, social, empirical and ethical dimensions of health care delivery.     

Dealing with the other between the ethical and the moral: albinism on the African continent

Albinism is a global public health issue but it assumes a peculiar nature in the African continent due, in part, to the social stigma faced by persons with albinism (PWAs) in Africa. I argue that there are two essential reasons for this precarious situation. First, in the African consciousness, albinism is an alterity or otherness. The PWA in Africa is not merely a physical other but also an ontological other in the African community of beings, which provides a hermeneutic for the stigmatising separateness or difference of the PWA. The second reason hinges on a distinction drawn by Jürgen Habermas between the ethical point of view and the moral point of view. While the former consists of the ethos, customs, or idea of the good shared by a group of persons with a shared tradition or way of life, the latter consists of what is good for all and transcends particular traditions or ways of life. Consequently, the African ethical point of view, the ethics of solidarity, justifies within the African worldview the established alterity and, by implication, stigmatization of PWAs. On this view, actions that promote harmony and prevent discord and disequilibrium among accepted beings in the African community are permissible. I further show that unless there is a change in the physical and ontological conception of PWAs and a leap from the ethical point of view to the moral point of view, the negative attitudes toward PWAs will not change. The leap to the moral point of view does not suggest an abandonment of the ethical point of view but only recommends that the two meet halfway in respect for universally accepted norms of human actions. To achieve this, I will show that much needs to be done in the areas of policy formulation, law, health care services, and education.