Doctors,Patients, and Nudging in the Clinical Context—Four Views on Nudging and Informed Consent

In an analysis of recent work on nudging we distinguish three positions on the relationship between nudging founded in libertarian paternalism and the protection of personal autonomy through informed consent. We argue that all three positions fail to provide adequate protection of personal autonomy in the clinical context. Acknowledging that nudging may be beneficial, we suggest a fourth position according to which nudging and informed consent are valuable in different domains of interaction.     

The Curious Case of the De-ICD: Negotiating the Dynamics of Autonomy and Paternalism in Complex Clinical Relationships

This article discusses the response of our ethics consultation service to an exceptional request by a patient to have his implantable cardioverter defibrillator (ICD) removed. Despite assurances that the device had saved his life on at least two occasions, and cautions that without it he would almost certainly suffer a potentially lethal cardiac event within 2 years, the patient would not be swayed. Although the patient was judged to be competent, our protracted consultation process lasted more than 8 months as we consulted, argued with, and otherwise cajoled him to change his mind, all to no avail. Justifying our at times aggressive paternalistic intervention helped us to reflect on the nature of autonomy and the dynamics of the legal, moral, and personal relationships in the clinical decision-making process.     

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.     

Two arguments against lying

Kant and Sidgwick are at opposite extremes on whether we may tell paternalistic lies. I trace the extremism to their views about ethical concepts. Sidgwick thinks fundamental ethical concepts must be precise. Common Sense morality says we may tell paternalistic lies to children but not to sane adults. Because the distinction between a child and an adult is imprecise, Sidgwick thinks this principle cannot be fundamental, and must be based on the (precise) principle of utility, which often mandates paternalistic lies to adults. Kant thinks that ethical concepts are ideals of reason, which do not fit the world precisely because the world is imperfect. We lie to children and the insane because they are irrational, but no one is perfectly rational. We must treat all persons with the respect due to rational agents, so the pressure of the theory is toward not lying to anyone. Decisions about where to draw the line must be made pragmatically and to some extent arbitrary. But fear of this is not a good reason to abandon ethical ideals for utilitarianism.     

WHOSE INTERESTS ARE THEY,ANYWAY?

This review both praises Richard Miller's book--a thoughtful, judicious, and comprehensive analysis of bioethics for the pediatric age group, notably the first effort worthy of the name--and points out the work still to be done in this area, work firmly based in and illuminated by Miller's ground-breaking thesis. Specifically, the book rightly compels us to recognize obligations of beneficence as primary and to refocus on the child's basic interests, rather than putative "best" interests. There remains much to be done in defining and discerning basic interests and in distinguishing whose interests are on the table when decisions are being made for seriously ill and dying children.     

In Defense of the Jurisdiction Theory of Rights

This essay critically examines three theories of moral rights, theBenefit, the Interest, and the Choice theories. The Interest andChoice theories attempt to explain how rights can be more robustthan seems possible on the Benefit theory. In particular, moralrights are supposed to be resistant to trade-offs to supportprincipled anti-paternalism, to constitute a distinct dimensionof morality, and to provide right holders with a range ofdiscretionary choice. I argue that these and other featuresare better yet provided by a fourth theory of moral rights, theJurisdiction theory.     

无效治疗的概念与道德的争论

现代教学治疗的有效、无效的争论越来越引起社会的关注。随之而引发对医患关系、资源分配、医患对话、自主、知情同意、家长主义等问题的大讨论。现重点对无效治疗判断的四个基本方面进行探讨：（１）建立在医学科学的基础上;（２）价值的判断和有效性的预测;（３）无用与有益的边界区域问题;（４）生理、心理的经济的负担。并就谁来决定和判断无效治疗进行讨论。     

In Defence of Luck Egalitarianism

This paper considers issues raised by Elizabeth Andersons recent critique of the position she terms luck egalitarianism. It is maintained that luck egalitarianism, once clarified and elaborated in certain regards, remains the strongest egalitarian stance. Andersons arguments that luck egalitarians abandon both the negligent and prudent dependent caretakers fails to account for the moderate positions open to luck egalitarians and overemphasizes their commitment to unregulated market choices. The claim that luck egalitarianism insults citizens by redistributing on the grounds of paternalistic beliefs, pity and envy, and by making intrusive and stigmatizing judgments of responsibility, fails accurately to characterize the luck egalitarians rationale for redistribution and relies upon luck egalitarians being insensitive to the danger of stigmatization (which they need not be). The luck egalitarian position is reinforced by the fact that Andersons favoured conception of equality, democratic equality, is counterintuitively indifferent to all unchosen inequalities, including intergenerational inequalities, once bare social minima are met.I am indebted to Catriona McKinnon and Hillel Steiner for their insightful comments on earlier versions of this article. An antecedent of the paper was presented at the Northern Political Theory Association Annual Conference at the University of St Andrews in August 2003. Research for this article was supported by the University of York Alumni Fund and the Arts and Humanities Research Board.     

Taking Law Seriously: Starting Points of the Hart/Devlin Debate*

The famous mid-20th century debate between Patrick Devlin and Herbert Hart about the relationship between law and morality addressed the limits of the criminal law in the context of a proposal by the Wolfenden Committee to decriminalize male homosexual activity in private. The original exchanges and subsequent contributions to the debate have been significantly constrained by the terms in which the debate was framed: a focus on criminal law in general and sexual offences in particular; a preoccupation with the so-called “harm principle,” a sharp delineation of the realms of law and morality, and a static conception of the relationship between them. This article explores the limitations imposed by these various starting-points and argues for a holistic and symbiotic understanding of the relationship between law and morality. * Thanks to Tony Connolly, Leighton McDonald and Niki Lacey for penetrating and suggestive comments on previous versions.     

Perfectionism for children,anti-perfectionism for adults

This paper explores the debate between perfectionists and anti-perfectionists in the context of children. It suggests that the most influential and compelling arguments in favour of anti-perfectionism are adult-centric. It does this by considering four leading reasons given in favour of anti-perfectionism and shows that none apply in the case of children. In so doing, the paper defends a perfectionist account of upbringing from the attacks made against perfectionism more generally. Furthermore, because the refutation of the various anti-perfectionist arguments are made exclusively dealing with children, the paper suggests that the perfectionist view of upbringing is compatible with anti-perfectionist restrictions on dealing with adults. This dual view combining perfectionism for children and anti-perfectionism for adults is referred to as restricted perfectionism.