Everyday Ethics

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Preparing for Ebola: Should the U.S. Close its Borders?

October 21st, 2014 by Elijah Weber · No Comments

Last week, I talked about some of the ethical issues that arise within the context of advanced screening for Ebola.  However, this is not the only ethical issue that Ebola preparedness raises.  Some people have suggested that one way, perhaps the best way, to protect ourselves against an outbreak of Ebola is to close our borders to international travelers.

There are a couple of ways that this “close our borders” strategy might be formulated.  First, we might simply prohibit entry into the country altogether, no matter where a person is trying to enter from.  This is probably not necessary–there’s no evidence that anyone with Ebola has been in South America, for example.  A more plausible scenario is to restrict entry into the U.S. for people coming from countries where Ebola is known to have occurred, or where it is especially prevalent.

There are at least two groups of individuals to whom this sort of restriction might apply.  First, it might apply to non-citizens who wish to enter the country to visit family, or perhaps vacation.  Here, a case can be made for the permissibility of restricting access.  Non-citizens don’t have any sort of right to enter a nation of which they are not a citizen.  Entry into a sovereign country can be restricted or limited for a variety of different reasons, and preventing an outbreak of a deadly virus seems like a pretty good reason for doing so.  So there’s no obvious rights-based argument against prohibiting non-citizens from entering the U.S. for this reason, and a fairly good argument for thinking this sort of policy is morally permissible.

Things get more complicated for American citizens seeking to return from Ebola-affected areas.  One might plausibly claim that a U.S. citizen has a right to re-enter their home country if they wish to do so, and that denying them access is a violation of this right.  For example, suppose that an American citizen is returning from a visit with family in Sierra Leone, one of the nations currently being most seriously affected by Ebola.  Does this person not have a right to come home, even though they may now be a carrier of the disease?

If you think that the answer to this question is no, it’s probably because you are concerned about the public health impact of allowing people coming from Ebola-affected nations to enter the U.S., whether they are American citizens or not.  But does concern for public health really outweigh something as significant as a right to access one’s home?

This issue, just as we saw in our earlier discussion about involuntary quarantine, again points to a difficult, more general ethical question–what sorts of individual interferences can be justified on grounds of public health?  On the one hand, we do think that public health is a serious consideration that sometimes does justify inconveniencing people in certain ways.  On the other hand, there’s a very real concern that one could attempt to justify extremely serious rights violations based on these same concerns.

We should, at least, be mindful of the possibility that in attempting to do only the former, we may end up doing the latter as well.

→ No CommentsTags: Applied Ethics · Political and Legal Philosophy · Social Ethics

Does Public Health Justify Involuntary Confinement? The Case of Ebola

October 18th, 2014 by Elijah Weber · No Comments

As public concern about a possible Ebola outbreak grows, health care institutions have had to start making some difficult decisions.  While some people think that the danger is being overblown, public health workers do not have the luxury of thinking this way.  If an Ebola outbreak were to occur in the U.S., it might be extremely serious, and because of the nature of the virus, it would be exceedingly difficult to provide certain treatments to Ebola patients without considerable risk to medical staff.

How to safely treat Ebola patients without undue risk to medical personnel is just one of the ethical questions that the possibility of an Ebola outbreak requires the medical community to cope with.  But there is another, and it’s already coming up within the context of advanced screening for Ebola.  Once someone is identified as a possible carrier of the virus, their carrier status must be confirmed, or refuted, via a blood test.  For the sake of certainty, this test is completed a second time.

However, the samples required to complete this screening must be sent to special labs that are equipped to deal with these sorts of samples.  As a result, it can take up to 48 hours for someone who is identified as a possible carrier to be confirmed as virus-free.  In the meantime, these individuals are held in isolation.

Recently, I asked a high-level hospital administrator what would happen if such a person decided that they wanted to go home.  I was told that, for reasons of public health, such a person can be held against their wishes.

On the face of it, this might seem like an obvious case of good sense.  Ebola is a potentially serious risk to public health.  Thus, it seems, we can justifiably hold someone, against their wishes, if we think that allowing them to leave would constitute a serious risk to others.  We can justifiably detain such a person, it seems, for the sake of preventing harm to others.

However, there are two reasons that this answer is actually somewhat surprising from an ethical perspective.  First, we don’t think that in general, individuals with infectious diseases can be justifiably detained, against their wishes, in order to protect others.  People with influenza, for example, are not subject to any sort of involuntary confinement.  But influenza kills far more people every year than Ebloa, and it’s much easier to transmit to others.  In some respects, it is a far more dangerous disease.

If risk of harm to others is sufficient to justify involuntary confinement in the case of Ebola, and influenza is a more dangerous disease than Ebola, then risk of harm to others is sufficient to justify involuntary confinement in the case of influenza.  But we don’t think involuntary confinement is justified for influenza patients, so perhaps we shouldn’t think that similar reasoning justifies involuntary confinement in the case of Ebola either.

There is another reason that the seeming acceptance of involuntary confinement for Ebola patients is surprising.  We seem to think that this practice is also acceptable when someone is merely a possible carrier of Ebola.  So it’s not just risk of harm to others, but merely possible risk of harm to others that is being appealed to as justification.

But we don’t generally think that the possibility that someone may put others at risk of harm is sufficient to justify their involuntary confinement.  If we did, bad drivers, career criminals, former spousal abusers, and people with anger management problems would all be justifiably subject to involuntary confinement, for a seemingly indefinite period of time.

In general, the reasons one is inclined to give as justification for the practice of involuntarily confining not only Ebola patients, but also individuals who are merely possible carriers of Ebola, are not generally thought to be good reasons to subject someone to involuntary confinement.

So what makes Ebola so different that these seemingly bad reasons suddenly become good reasons to confine someone against their wishes?

→ No CommentsTags: Applied Ethics · Bioethics

“No Means No” or “Yes Means Yes”? Weighing the Pros and Cons of Each

October 10th, 2014 by Elijah Weber · No Comments

Last week, I discussed California’s recent decision to alter the way that consent to sex is evaluated for sexual assault cases.  I noted that, while there are some good ethical reasons to move to a “Yes Means Yes” standard, and away from a “No Means No” standard, this shift does not alter the fundamental problem of uncertainty that plagues these sorts of cases.

Given the potential significance of this shift, especially if it becomes the new national standard for consent in sexual assault cases, it seems worthwhile to consider the pros and cons of both standards, and determine whether a definitive case can be made for either.

As we noted in an earlier post, the argument for the “Yes Means Yes” standard is twofold.  First, the idea that an absence of refusal amounts to consent fails to capture what consent is really about.  For example, informed consent in a medical setting requires that one understands what they are agreeing to, that they are not coerced, and that they are competent to make this sort of decision for themselves.  Simply failing to definitively refuse would not count as a legally-significant form of consent in any other context, so it’s difficult to see why it should count as such here.

In addition, the “Yes Means Yes” standard avoids the ethical problem of re-victimizing the victim.  Too often, legal investigations of sexual assaults have been unduly invasive, often resorting to tactics like questioning the sexual history and reliability of the victim, in an effort to cast doubt on the notion that they refused the advances of the accused.  So “Yes Means Yes” is an appealing standard, in part, because it protects victims of sexual assault from being further victimized by both law enforcement and defense attorneys.

However, there are also some significant costs to the “Yes Means Yes” standard.  As we noted previously, moving to a “Yes Means Yes” standard does little to alleviate the “he said–she said” nature of many sexual assault cases.  While “No Means No” makes it very difficult for victims to prove that they refused sex, “Yes Means Yes” makes it equally difficult for the accused to prove that consent was given.

Though the epistemic uncertainty associated with each standard might seem like a wash, the consequences of being unable to prove what one must prove in each case are not equivalent.  When a victim is unable to prove that they refused sex, it creates the possibility that a guilty person may go free.  Such persons may commit similar crimes in the future, and some victims will struggle with the lack of closure that this outcome creates.  This can have serious personal consequences for the victim.

However, when the accused is unable to prove that they received a consent, it creates the possibility that an innocent person may lose their freedom.  You might think, and the structure of our legal system supports this notion, that it’s preferable for guilty people to sometimes go free, rather than innocent people going to prison.

Both of these possibilities are terrible.  But which is worse?  The problem of how to evaluate consent to sex in sexual assault cases is something of a tragic dilemma, a situation where every available course of action is morally bad.  But like all tragic dilemmas, we must choose.

As a society, which of these undesirable consequences should we prefer, that the guilty sometimes go unpunished or that the innocent are sometimes imprisoned?  Typically, we’ve opted for the former, on the grounds that losing one’s freedom is the worst sort of injustice.  But do we still think this is true?  Is there something about sexual assault that should motivate us to think differently?  Share your thoughts below, and let’s try to work through this one together.

→ No CommentsTags: Applied Ethics · Political and Legal Philosophy · Sexual Ethics · Social Ethics

What Does it Mean to Respect the Dead?

October 7th, 2014 by Elijah Weber · No Comments

According to the National Funeral Directors Association (NFDA), its members have “an ethical obligation to care for each deceased person with the highest respect and dignity.” This principle is highly plausible, and its demands seem both clear and obvious, so much so that the NFDA saw little reason to provide specific guidance regarding how this obligation is to be met. Vague offerings like “show proper care during transport” and “the body shall be properly covered” are given as sufficient to guide the professional conduct of NFDA members. Morticians, it seems, have an intuitive understanding of what is required to show respect for the body of the deceased.

However, this principle is difficult to vindicate from a philosophical perspective.  Concepts like respect and dignity are easily applied to living humans, and can sometimes be plausibly extended to non-human animals and the natural environment.  However, neither of these accounts of respect tell us much about why a dead person’s body is also deserving of respect.  In many ways, a dead body is like any other non-living, inanimate object.

Most people hold one of two possible views on this topic.  Some claim that we should respect the body of the deceased because it’s a way of showing respect for the person who has died.  By showing respect for their corpse, it’s thought, we show respect for the person that once occupied this body.

While this view is intuitively plausible, it doesn’t explain why we are obligated, as the above principle claims, to show respect for the body of the deceased.  From the fact that we can show respect for a deceased person by treating their corpse with respect, it doesn’t follow that we must do so.  This explanation might account for why many people do treat the bodies of deceased persons with respect, but it doesn’t explain why this is something that we are obligated to do in every case.

Alternatively, one might claim that we ought to respect the body of the deceased because we have an obligation to their family or loved ones.  By showing respect for one’s corpse, it’s thought, we show respect for the living persons who have been left behind.

Again, this view is intuitively plausible, but it can’t be the whole story.  In some cases, the dead have no family or loved ones.  Thus, there is no living person to whom respect for the corpse is owed.  And yet, we think the corpse should still be treated with respect.  So while this explanation does capture why there sometimes can be obligations to respect the body of the deceased, it doesn’t explain why such an obligation obtains in every case.  And yet, that’s precisely what the above principle says.

In general, though we often do treat the bodies of the deceased with respect, it’s not clear that this is an obligation, nor that this is an obligation that obtains in every case.

One possibility, though some moral philosophers may not like this explanation, is that the obligation to respect the body of the deceased is a cultural norm, rather than a universal moral principle.  This view captures the notion that morticians have an obligation to respect corpses, and allows for historical and cross-cultural variation regarding the ways in which respect for corpses can be demonstrated. However, it also allows that there’s nothing immoral about cultures that fail to respect, or even actively disrespect, the bodies of deceased persons.

What do you think?  Is an obligation to respect the body of the deceased a universal moral norm?  If not, is it just a social norm based on cultural preferences?  If the former, on what grounds does this obligation rest?  If the latter, is this a problem for the claim that we ought to respect the bodies of deceased persons?

→ No CommentsTags: Applied Ethics · Medical Ethics

Should Murderabilia Be for Sale?

October 2nd, 2014 by Elijah Weber · 2 Comments

Last night, I watched an episode of Taboo, a television show on the National Geographic channel that focuses on “taboo” practices, traditions, and professions.  One such profession is the sale of “murderabilia,” items connected in some way to famous serial killers.  Murderabilia dealers sell everything that can plausibly be connected to a highly publicized murder, from artwork by Richard “The Nightstalker” Ramirez to dirt from a dump site used by the Craigslist killer.  If it’s connected to a famous serial killer, murderabilia dealers will try to sell it.

The sale and collection of murderabilia is taboo, to be sure, but is it morally problematic?  Murderabilia dealers claim that they are simply trying to make a living by meeting a market-based demand.  What they are doing does not, in most cases, violate any laws or regulations, and while some people think their profession is creepy, the fact that something is creepy doesn’t make it morally wrong.

Further, even if it were morally wrong to sell murderabilia, this wouldn’t necessarily show that the sale of murderabilia ought to be legally prohibited.  Opponents of the trade in murderabilia must explain why murderabilia is not only morally problematic, but sufficiently so that it ought to be legally prohibited

The opponents of murderabilia are not without arguments to this effect.  Some people see the sale of murderabilia as a re-victimization of the victims and their families, who may be deeply disturbed by the fact that the death of their loved one is being profited from in this way.  It’s especially troubling, they claim, that the killers themselves are sometimes compensated for providing murderabilia items to dealers.  And while the sale of murderabilia is not federally prohibited, eight states have outlawed the sale and purchase of murderabilia, and there are similar efforts underway elsewhere.

Here’s the question:  Should we allow people to sell murderabilia?

Some might be inclined to say yes, perhaps arguing that in free market societies, we should allow consumer demand to dictate the sorts of products that can be sold.  And while we don’t permit the sale of certain items that are especially dangerous or potentially harmful, it’s not clear that murderabilia is similar to those sorts of items.  Murderabilia is surely less harmful than alcohol or cigarettes, for example, and we readily allow the sale of these items.

In their forthcoming book, Markets without Limits:  Commercial Interests and Moral Virtues, philosophers Jason Brennan and Peter Jaworski offer a rationale that also seems to support permitting the sale of murderabilia.  Their analysis is driven by the claim, roughly stated, that if it’s permissible to give something away, it’s also permissible to sell it.  Thus, things like the sale of vital organs and prostitution ought to be permitted in a free market, because organs and sex are both things that can permissibly be given away, so to speak.

This claim also seems to support the permissibility of selling murderabilia.  Surely it’s permissible for letters or works of art to be given by famous serial killers, for example.  By Brennan and Jaworski’s principle, it would also be permissible to allow such items to be sold.

That said, there does seem to be something disturbing about the sale and collection of items made collectible by their connection to the killing of others.  But what is it about this activity that makes it so disturbing, and does this feature justify legal prohibition on the sale of murderabilia?

I confess that as of now, I don’t know the answer to this question.  But if you have something to say about this, post a comment below, and we’ll try to figure it out together.

 

 

 

→ 2 CommentsTags: Applied Ethics · Social Ethics

Is “Yes Means Yes” a Good Standard for Sexual Consent?

September 30th, 2014 by Elijah Weber · No Comments

Recently, my home state of California passed a measure that redefines the way consent to sexual activity is typically understood.  Typically, the standard for determining whether someone has given consent to sex is characterized as a “No Means No” standard.  This standard problematically places the burden of proof on victims of sexual assault, who must prove that they adequately expressed their refusal to consent.

The “Yes Means Yes” standard shifts the burden of proof away from the victim, and onto the alleged perpetrator.  Now, when someone is accused of sexual assault, they must prove that they were given consent.  The absence of a refusal is no longer regarded as consent.

On the face of it, you might think this is a really good thing.  After all, sexual assaults continue to be a serious problem in the United States, and part of the California legislature’s motivation was to put pressure on colleges and universities to do more about the especially serious problem of sexual assaults on our nation’s academic campuses.

Plus, surely the absence of a refusal isn’t akin to giving consent.  Imagine if during a medical examination, your physician discussed the benefits of receiving a flu shot, you nodded in agreement throughout the discussion, and your physician then gave you a flu shot without your consent, insisting that your lack of explicit refusal, plus your vigorous nodding, was adequate to justify their giving you the flu shot.

The “No Means No” standard has clearly created problems in the way that we treat victims of sexual assault, and it most likely makes it too easy to get away with these sorts of crimes.  However, part of the problem with the “No Means No” standard is that it’s incredibly difficult to determine whether someone has refused to consent to sex.  Whether a particular instance of sexual activity counts as sexual assault depends almost entirely on whether consent has been given, so this difficulty is a big part of what makes sexual assaults so difficult to prosecute.

While the motivation of the California legislature was clearly based on ethical concerns, the more difficult issue here is not an ethical concern, it’s an epistemological problem. Prosecuting sexual assaults requires that we know something that, in almost every case, it’s impossible to know with any degree of certainty or confidence.

The relevant question for determining whether a sexual assault has occurred is “did everyone consent?”.  Now, it seems clearly mistaken to think that the absence of a refusal counts as a consent, so in that regard, the shift to a “Yes Means Yes” standard is a positive step.  However, it’s not clear that it’s any easier to determine whether a positive consent occurred.  Either way, we’re mostly relying on the testimony of the involved parties, and occasionally a witness or two, to determine whether a consent was given.

Shifting to a “Yes Means Yes” standard has the positive feature of more closely tracking what’s relevant to consent, as well as the ethical benefit of minimizing the re-victimization of the victim that has become all-too-common in many sexual assault investigations.  However, “Yes Means Yes” does not resolve the deep epistemological problems associated with sexual assaults.  Whether “Yes Means Yes” or “No Means No,” determinations of guilt or innocence in sexual assault cases remain largely a matter of he said–she said.*

*I use the phrase “he said-she said” for rhetorical purposes, and to reflect the fact that most sexual assaults involve female victims of male assailants.  However, this should not be taken to imply that same-sex sexual assaults do not occur, or that they are any less serious.*

→ No CommentsTags: Applied Ethics · Sexual Ethics · Social Ethics

The NFL and Why There’s Nothing for Me to Talk About Here

September 22nd, 2014 by Elijah Weber · No Comments

Recently, my mother, who is also a frequent reader of this blog, asked me why I hadn’t written anything about the seemingly endless saga of abuse scandals involving current NFL players.  I wrote something about the initial 2 game suspension of Ray Rice, but from there, I’ve largely avoided the topic.  My mother’s question was a simple one:  you often write about ethics and sports, why aren’t you writing about this?

Here’s the simplest answer I could think of:  when it comes to things like domestic violence and child abuse, there’s really no ethical debate to be had.  These sorts of actions are morally reprehensible, and the people who commit them are deserving of our harshest criticism, along with whatever legal and professional consequences their conduct invites.  There’s no debating whether domestic violence victims might bear some degree of responsibility.  There’s no debate about when it’s okay to hit your children, or what sorts of corporal punishment are acceptable.

Ethically speaking, the discussion is over before it begins.  Domestic violence and child abuse are morally wrong, and people that do these things are bad people that deserve our scorn.  How could anyone genuinely disagree with that claim?

Now in some sense, that reply is a bit of an over-simplification.  There’s plenty to say, for example, about whether domestic abusers should be punished by their employers in addition to any legal ramifications of their actions.  There’s also a conversation to be had about the transparently self-interested nature of the response from the NFL, its owners, and their sponsors.  Finally, these incidents reveal the troubling nature of society’s relationship with violence, where we seem unable to differentiate between, say, two MMA fighters voluntarily pummeling each other and a grown man violently beating a toddler.  These incidents raise interesting ethical and social questions best considered from an interdisciplinary perspective.

But when it comes to the sorts of actions that people like Ray Rice, Greg Hardy, or Adrian Peterson are accused of committing, there’s really no moral debate.  Don’t hit women, and don’t hit children.  Period.  There are no exceptions, there’s no “unless,” there are no “time and place” considerations.

Domestic violence and child abuse are morally egregious actions for which there is no justification.  About this, there is no room for debate.

 

→ No CommentsTags: Applied Ethics · Social Ethics

Upcoming Presentation: Taking Moral Distress Seriously

September 11th, 2014 by Elijah Weber · 1 Comment

I want to take a moment and share an abstract of a paper that I’ll be presenting next week at the Western Michigan University Medical Humanities Conference.  The paper is entitled “Taking Moral Distress Seriously.”  If you’ll be in the Kalamazoo area next Thursday and Friday, this should be a really good conference, especially for anyone interested in bioethics.

Here’s the abstract.  Feel free to comment, or post any questions you might have about either the forthcoming paper or the upcoming conference where I’ll be presenting it.  Enjoy!

Taking Moral Distress Seriously

The problem of moral distress is an increasingly common, yet inadequately discussed phenomenon among health care practitioners. Consider the following example of moral distress. Suppose a patient with cystic fibrosis, currently hospitalized for complications related to her underlying condition, has repeatedly expressed that certain life-sustaining measures not be taken, should she come to need them. Despite this, her code status is not formally addressed, and she becomes unable to make decisions for herself. In the meantime, her surrogate decision-maker is asked about her code status, and he opts for full code. Thus, the patient’s code status obligates the medical team to provide interventions that they believe to be contrary to the patient’s wishes.

This is the sort of scenario that can lead to moral distress among health care practitioners. I define moral distress as a negative feeling state that one experiences whenever there is a disparity between what one takes oneself to be expected to do, and what one takes to be morally right. This suggests, among other things that moral distress may be a much more widespread phenomenon than is typically thought.  In this paper, I explain why we should adopt this account of moral distress, and identify several advantages this account has over other accounts of moral distress.

I then consider the ethical significance of moral distress for health care decision-making, and argue that given its ethical significance, the moral distress that a treatment decision may create for the health care practitioners involved ought to be factored into treatment decisions where moral distress is likely to occur. It is not enough to simply acknowledge or create outlets for the expression of moral distress.   The moral significance of moral distress demands that it be taken into account when treatment decisions are made. More specifically, the moral distress that an intervention creates for a medical team is a consideration that can count in favor of either providing or denying treatment. This is not to say that we ought to provide or deny treatment based solely or primarily on concerns about moral distress. Rather, it is to call for taking moral distress seriously, and treating it as comparable to other potential harms that a treatment decision may cause.

→ 1 CommentTags: Bioethics

When Does Rage Go Too Far?

September 8th, 2014 by Elijah Weber · No Comments

Rage is an emotion that is frequently depicted in the national and international news.  The civil unrest in Ferguson, Missouri and the ongoing conflict between Israel and Gaza are both recent examples.  Further, we seem to think that rage is a morally problematic emotion.  All things considered, the world would probably be a better place if no one ever felt or expressed rage.  Any emotion that tends toward such destructive violence is something that, in my view at least, we should be suspicious about.

Recently, philosopher Antti Kauppinen has challenged some of my thinking on rage.  You can check out his analysis, and some of our online discussion, here.  In the meantime, I want to take some of Antti’s analysis as a jumping-off point for further discussion.

Antti characterizes warranted (or rational) rage in the following way:

“I’ll say that rage is warranted (or, as some might say, rational) when one really is deprived of something important one is entitled to, particularly when a pseudo-reasonable justification is offered for it, and, due to machinations of those benefiting from such deprivation, one cannot change the situation without a significant cost to oneself or others.”

Let’s suppose for now that Antti is right about this.  Whatever moral concerns we might have about the violence that follows from our feelings of rage, let’s take for granted that it can be rational to experience rage at least some of the time.  My question is whether the rationality of rage has any sort of time-constraints, a kind of expiration date on warranted rage.  In other words, even if rage is sometimes warranted, can warranted rage become unwarranted when it drags on too long?

I ask this question, in part, because of my own reflections about the ongoing protests in Ferguson, Missouri.  I cannot pretend to relate to the kinds of feelings about law enforcement that protestors there are expressing.  However, I think we can rightly ask whether the violent protesting has carried on too long.

Even if rage was a warranted response to the shooting of Michael Brown, is rage still warranted today?

While I don’t yet have a good argument for this, I suspect that the answer to this question is no, and that an account of warranted rage should include a constraint on how long one can rationally be enraged about something.

On the other hand, perhaps my concerns about enduring or persistent rage are moral or prudential concerns, rather than concerns about rationality.  If this is correct, then we can still raise concerns about long-term or persistent rage, but they will not be rational concerns of the sort Antti and I have been discussing.

On this view, we can challenge the ongoing rage of protestors in places like Ferguson, but we must do so from moral and prudential points-of view.  For example, we might say “you’re right to be enraged about this, but the ongoing violence should stop because it’s causing undue harm to others” or “even if you’re rightly enraged, continuing to protest violently won’t serve your long-term goals.”

But that’s quite different from claiming “your rage is no longer rational, because it’s gone on too long.”  It’s one thing to say that an emotion is being immorally or imprudently expressed, and quite another to say that having the emotion is, itself, irrational.

I confess that I do not yet know the answer to this question.  However, the way that we answer it clearly bears on both the way we think about events like Ferguson, Missouri, and the sorts of deliberative strategies we pursue in trying to resolve the conflicts that produce them.  Thus, what seems like a theoretical problem in the philosophy of emotions turns out to have significant, real-world implications.  For philosopher and non-philosopher alike, this is a question worth pursuing.

 

→ No CommentsTags: Philosophy of the Emotions · Social Ethics

Autonomy in Medicine: Where Theory and Practice Part Ways

August 21st, 2014 by Elijah Weber · No Comments

Recently, I’ve been reviewing some medical ethics cases that involve patients who lack decisional capacity.  In these cases, the patient has been declared incompetent, and there is a question about whether a particular course of action is consistent with what they would have chosen for themselves.  What has been especially striking about these cases is that despite the finding that the patients involved are incompetent, they have expressed preferences about what sorts of medical interventions they do and do not want.

This is a great example of the way that theoretical and practical ethics can come apart.  When determining whether a patient is competent to make decisions for themselves, patients must demonstrate that their capacities exceed a certain threshold.  If they demonstrate that their capacities fall below this threshold, they are considered not competent to make decisions for themselves. Evaluations of competency treat autonomy as a threshold capacity.  If one performs below the requisite threshold, one is regarded as lacking the capacity for autonomy, and one’s expressed wishes are not taken to have moral authority.

However, most moral philosophers know that autonomy is not a threshold capacity.  Instead, the capacity for autonomy falls along a spectrum.  A ten year old, for example, has a greater capacity for autonomy than a newborn, even though neither would exceed the threshold for being competent to make their own medical decisions.  Young children, as well as persons with certain psychological impairments, can still assert and express their values, desires, and preferences, even where they do not meet the threshold for being competent to make their own decisions.

This distinction has significant, but not often recognized ethical implications for medical practice.  Even where a patient fails to meet the necessary threshold for autonomous decision-making, we shouldn’t thereby regard their expressed wishes as uninformative with regard to what they would have chosen for themselves.  It is one thing to declare a patient incapable of making their own decisions, and quite another to completely disregard what they now claim to want.

The expressed wishes of incompetent persons should not have the same moral authority as the expressed wishes of competent persons, but it doesn’t follow that they should have no moral authority at all.   The expressed wishes of incompetent persons can sometimes still tell us something about what the patient values, desires, and cares about, which is useful information when attempting to determine whether a particular medical intervention is contrary to what the patient would have chosen for themselves, were they able to do so.

This leaves medical practitioners with a very difficult problem.  If incompetent persons retain some measure of autonomy, despite their incompetence, to what extent should their expressed wishes be respected?  How can we respect patient autonomy without granting decision-making power? We’ll talk about how to deal with this problem next time.  Until then, feel free to leave a comment to get the discussion started.

→ No CommentsTags: Bioethics