Principlism

Part 1: Respect for Autonomy

Last Time

We discussed several arguments designed to undermine the following doctrine:

Passive euthanasia – but not active euthanasia – is sometimes morally permissible.

We ended with an argument based on the idea that withholding treatment is an action.

Withholding = Action

W1. Discontinuing treatment is an action.

WC. There is no such thing as letting die and hence no distinction between killing and letting die.

W2. If W1, then there is no such thing as letting die and hence no distinction between killing and letting die.

Withholding = Action

Would it be permissible to simply not feed a newborn and hence let it die?

Withholding = Action

Would it be permissible to simply not feed a newborn and hence let it die?

What makes such a case different from withholding treatment?

Withholding = Action

Would it be permissible to simply not feed a newborn and hence let it die?

What makes such a case different from refusing to treat an intestinal blockage?

What makes such a case different from withholding treatment?

Today

We are going to do a little work building a theoretical framework.

The big picture is called principlism.

Principlism identifies four basic principles that ought to guide decisions in biomedical research and practice: respect for autonomy, nonmaleficence, beneficence, and justice.

Today

We’re going to spend our time today thinking about the first of the four principles that make up principlism:

Respect for autonomy.

As the course continues, we will add further principles to our theoretical framework.

Autonomy

What is autonomy? At a very rough first pass, autonomy is self-governance. A person acts autonomously if she has liberty and agency.

Liberty in this sense is independence from (external) control.

Agency in this sense is the capacity to act intentionally.

Autonomy

The predicate “… is autonomous” is vague.

There are clear examples of acts (and persons) that are autonomous.

There are clear examples of acts (and persons) that are not autonomous.

And there are difficult cases in between.

Autonomy

What are some clear cases of autonomous action?

What are some clear cases of non-autonomous action?

What are some good examples of borderline cases?

Autonomy

Beauchamp and Childress consider two broad accounts of autonomous action:

Split-Level Theory & Three-Condition Theory

Autonomy

Split-Level Theory maintains that for a person to act autonomously, her first- and second-order desires must be properly aligned.

This is supposed to be a necessary condition. What are some challenges?

Autonomy

Three-Condition Theory maintains that a person acts autonomously when her act satisfies the following three conditions: Intentionality, Understanding, and Noncontrol.

Autonomy

An act is intentional when it is the result of representing a plan to oneself and then executing that plan.

First, I’m going to need a catapult.

Autonomy

An act is taken with understanding when one evaluates the decision to act on the basis of adequate information.

But what if the rock falls off, first?

Autonomy

Does the criterion of understanding include or entail competence? Abilities to …

1. Express preferences2. Recognize consequences3. Process relevant information4. Give (rational, cost/benefit) reasons5. Express a decision

Autonomy

An act satisfies the condition of noncontrolwhen it is sufficiently free of external or improper internal influence.

The act is non-deviantly caused by an appropriately formed intention.

Autonomy

What does it mean to respect autonomy?

Beauchamp and Childress think that maintaining privacy and confidentiality is part of respecting autonomy. What is the connection?

To what extent does respect for autonomy require promotion of autonomy?

Informed Consent

Perhaps the most widespread example of respect for autonomy is the requirement of informed consent.

1. Disclosure2. Understanding3. Voluntary Decision

Informed Consent

Three standards of disclosure:

1. Professional Practice2. Reasonable Person3. Patient Determined (Subjective)

Informed Consent

Is it unethical for a physician to prescribe a therapeutic placebo?

Informed Consent

Is informed consent impossible in virtue of the fact that patients do not themselves have extensive medical knowledge?

Informed Consent

What should we say or do in response to refusal of treatment? If the patient has …

A broken bone.An operable cancer.A severe panic disorder.Severe schizophrenia.An STI / STD.A pandemic virus.

Next Time

We will be talking about non-consensual treatment. You should provide an argument summary for EITHER Epright’s argument (804-805) that non-consensual treatment is justified when it promotes future patient autonomy ORCherry’s argument (729-730) that non-consensual treatment is not justified in virtue of promoting future patient autonomy.

Irrelevant Grounds

A further argument involves the claim that lives are sometimes ended with an irrelevant justificatory patina.

The real, rational ground is different.

Irrelevant Grounds (1)

IG1. Withholding treatment for fatal condition X is justified iff the patient also has condition Y.

IGC. The decision should not be made on that basis.

IG2. Actively killing an otherwise healthy patient with condition Y is not justified.

IG3. If the life-threatening condition is an irrelevant ground, then the decision should not be made on that basis.

Irrelevant Grounds (2)

IG4. If The Principle leads to decisions made on irrelevant grounds, then The Principle should be rejected.

IGC2. The Principle should be rejected.

IG5. If IGC, then The Principle leads to decisions made on irrelevant grounds.