Autonomy

Returning To Personhood: On The Ethical Significance Of Paradoxical Lucidity In Late-Stage Dementia

By David M Lyreskog

About Dementia

Dementia is a class of medical conditions which typically impair our cognitive abilities and significantly alter our emotional and personal lives. The absolute majority of dementia cases – approximately 70% – are caused by Alzheimer’s disease. Other causes include cardiovascular conditions, Lewy body disease, and Parkinson’s disease. In the UK alone, it is estimated that over 1 million people are currently living with dementia, and that care costs amount to approximately £38 billion a year. Globally, it is estimated that over 55 million people live with dementia in some form, with an expected 10 million increase per year, and the cost of care exceeds £1 trillion. As such, dementia is widely regarded as one of the main medical challenges of our time, along with cancer, and infectious diseases. As a response to this, large amounts of money have been put towards finding solutions over decades. The UK government alone spends over £75 million per year on the search for improved diagnostics, effective treatments, and cures. Yet, dementia remains a terrible enigma, and continues to elude our grasp.

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New Publication: ‘Overriding Adolescent Refusals of Treatment’

Written by Anthony Skelton, Lisa Forsberg, and Isra Black

Consider the following two cases:

Cynthia’s blood transfusion. Cynthia is 16 years of age. She is hit by a car on her way to school. She is rushed to hospital. She sustains serious, life-threatening injuries and loses a lot of blood. Her physicians conclude that she needs a blood transfusion in order to survive. Physicians ask for her consent to this course of treatment. Cynthia is intelligent and thoughtful. She considers, understands and appreciates her medical options. She is deemed to possess the capacity to decide on her medical treatment. She consents to the blood transfusion.

Nathan’s blood transfusion. Nathan is 16 years of age. He has Crohn’s disease. He is admitted to hospital with lower gastrointestinal bleeding. According to the physicians in charge of his care, the bleeding poses a significant threat to his health and to his life. His physicians conclude that a blood transfusion is his best medical option. Nathan is intelligent and thoughtful. He considers, understands and appreciates his medical options. He is deemed to possess the capacity to decide on his medical treatment. He refuses the blood transfusion.

Under English Law, Cynthia’s consent has the power to permit the blood transfusion offered by her physicians. Her consent is considered to be normatively (and legally) determinative. However, Nathan’s refusal is not normatively (or legally) determinative. Nathan’s refusal can be overridden by consent to the blood transfusion of either a parent or court. These parties share (with Nathan) the power to consent to his treatment and thereby make it lawful for his physicians to provide it.

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Compromising On the Right Not to Know?

Written by Ben Davies

Personal autonomy is the guiding light of contemporary clinical and research practice, at least in the UK. Whether someone is a potential participant in a research trial, or a patient being treated by a medical professional, the gold standard, violated only in extremis, is that they should decide for themselves whether to go ahead with a particular intervention, on the basis of as much relevant information as possible.

Roger Crisp recently discussed Professor Gopal Sreenivasan’s New Cross seminar, which argued against a requirement for informational disclosure in consenting to research participation. Sreenivasan’s argument was, at least in its first part, based on a straightforward appeal to autonomy: if autonomy is what matters most, I should have the right to autonomously refuse information.

I have previously outlined a related argument in a clinical context, in which I sought to undermine arguments against a putative ‘Right Not to Know’ that are themselves based in autonomy. In brief, my argument is, firstly, that a decision can itself be autonomous without promoting the agent’s future or overall autonomy and, second, that even if there is an autonomy-based moral duty to hear relevant information (as scholars such as Rosamond Rhodes argue), we can still have a right that people not force us to hear such information.

In a recent paper, Julian Savulescu and I go further into the details of the Right Not to Know, setting out the scope for a degree of compromise between the two central camps.

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‘Waiver or Understanding? A Dilemma for Autonomists about Informed Consent’

by Roger Crisp

At a recent New St Cross Ethics seminar, Gopal Sreenivasan, Crown University Distinguished Professor in Ethics at Duke University and currently visitor at Corpus Christi College and the Oxford Uehiro Centre, gave a fascinating lecture on whether valid informed consent requires that the consenter have understood the relevant information about what they are being asked to consent to. Gopal argued that it doesn’t. Continue reading

Consent Without Alternatives

Written by Ben Davies and Joshua Parker

“COVID-19: Do not resuscitate orders might have been put in place without consent, watchdog says”. This recent headline followed an investigation by the Care Quality Commission into Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) decisions early in the pandemic. In a recent post, Dominic Wilkinson highlights two misconceptions in the coverage of this report, one of which is the ‘consent misconception’.

Dominic’s view is that “there is no ethical requirement…to seek the agreement of patients not to offer or provide a treatment” which a medical professional judges inappropriate. Of course, his position is not that consultation and discussion around CPR is inappropriate, only that consent is not necessary. This is the standard view on consent in this context and, due in part to the Tracey judgment, reflects doctors’ practice. Thus, an important distinction emerges between consenting to the withholding of some treatment, and discussion of that decision. Doctors may be ethically required to discuss a decision without also having an obligation to seek the patient’s consent. The absence of consent, then, does not signal that the DNACPR was unethical, whereas a failure to consult probably will.

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The Right Not to Know and the Obligation to Know

By Ben Davies

Most people accept that patients have a strong claim (perhaps with some exceptions) to be told information that is relevant to their health and medical care. Patients have a Right to Know. More controversial is the claim that this control goes the other way, too. Some people claim, and others deny, that patients also have a Right Not to Know.

A number of considerations (harm to the patient; autonomy; privacy) have been marshalled on either side of this debate over the past few decades (e.g. Laurie 2004; Robertson and Savulescu 2001; Herring and Foster 2012; Takala 2019). In this post, I focus on a distinct argument and its apparently unassailable logic. This is the view that a comprehensive Right Not to Know cannot be justified because in many cases a patient’s ignorance will likely lead harm to third parties (Council of Europe 1997; Rhodes 1998; Harris and Keywood 2001).

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Diet, Changing Desires, and Dementia

Written by Ben Davies

Last week saw the launch of a campaign (run by the group Vegetarian For Life) that seeks to ensure that older people in care who have ethical commitments to a particular diet are not given food that violates those commitments. This is, as the campaign makes clear, a particularly pressing issue for those who have some form of dementia who may not be capable of expressing their commitment.

Those behind the campaign are quite right to note that people’s ethical beliefs should not be ignored simply because they are in care, or have a cognitive impairment (see a Twitter thread where I discuss this with a backer of the campaign). But the idea that one’s dietary ethics must be ‘for life’ got me thinking about a more well-established debate about Advance Directives. (I should stress that what I say here should not be taken to be imputing any particular motivation or philosophical commitments to those behind the campaign itself.)

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Moral Responsibility and Interventions

Written by Gabriel De Marco

Consider a story about Joe, Louie, and Dr. White. Joe is a gambling man and has been for much of his life. In his late twenties, Joe began to gamble occasionally and after a while, he decided that he would embrace this practice of gambling. Although Joe gambles fairly often, he has his limits, and can often resist the desire to gamble.

Louie, on the other hand, is a frugal family man. With his wife, he has been saving money over the last year so that they can take their kids to Disneyland. Dr. White, an evil neurosurgeon who detests the thought of children enjoying themselves at Disneyland, wants to stop this trip. So, Dr. White designs and executes a plan. One night, while Louie is sleeping, Dr. White uses his fancy neuroscientific methods to make Louie more like Joe. He implants in Louie a strong desire to gamble, as well as further attitudes that will help Louie embrace this desire, such that Louie, for example, now values the thrill of gambling, and he desires that his gambling desires are the ones that lead him to action. In order to increase chances of success, Dr. White also significantly weakens some of Louie’s competing attitudes, like some of his family values, or his attitudes towards frugality. When Joe wakes up the next morning, he feels this strong desire to gamble, and although he finds it strange that it has come out of the blue, he fully embraces it (as much as Joe embraces his own gambling desires), having recognized that it lines up with some of his other attitudes about his desires (which were also implanted). Later in the day, while he is “out running errands,” Louie swings by a casino, bets the money he has been saving for the trip, and loses it. “Great success” thinks Dr. White. Since his goal of preventing some children’s joy at Disneyland has been achieved, he turns Louie back into his old self after Louie goes to sleep.

This story is similar to stories sometimes found in the debate about freedom and moral responsibility, though I will focus on moral responsibility. Intuitively, Louie is not morally responsible for gambling away these savings; or, at the very least, he is significantly less responsible for doing so than someone like Joe would be for doing something similar. If we want to make sense of these different judgments about Louie and Joe’s responsibility, we are going to need to find some difference between them that can explain why Louie is, at least, less responsible than regular Joe.

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Video Interview: Richard Holton on Addiction

Is addiction within or beyond our control? What turns something into an addiction? What should we do (more of) to tackle addiction? In this interview with Dr Katrien Devolder (philosophy, Oxford), Professor Richard Holton (philosophy, Cambridge) discusses these questions.

 

Utilitarian Supervillains, Moral Enhancement, and Enforced Vegetarianism

By Hazem Zohny

 

Bad utilitarians make for great supervillains.

Take Thanos, the purple CGI nemesis the Avengers have to face this year in what feels like the gazillionth Marvel movie. In his sincere desire to reduce suffering, Thanos is trying to kill half of all life in the universe.

Like all utilitarian-type supervillains, he has presumably gotten his welfare-maximizing calculus very wrong. But it made me wonder what such a supervillain might look like if their calculus wasn’t so comically dim-witted. To that end, I’m going to discuss a character we can call Vegetarian Thanos.

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