Civil Discourse

We live in a fractious age in which people are often rude to those who hold views opposed to their own. Indeed on some social platforms such as Twitter it would seem that being rude is necessary in order to be noticed. In this posting I don’t want to consider the nature or the causes of rudeness. In the philosophy of rudeness I argued that whilst rudeness isn’t immoral that nonetheless it damages discourse and as a result is on the road to immorality. In this posting I want to consider ways in which discourse can be improved with those who hold views which are radically opposed to our own. I will consider how we should talk to our opponents. This isn’t an easy task for as Amy Olberding points out people often enjoy being rude to one another for by being rude they escape from the constraints of politeness. They excuse their escape by believing that they are being true to themselves, being authentic. She suggests such excuses are usually poor excuses and almost all rudeness is unjustified. Moreover if rudeness is ever justified then we should feel regret when doing so rather than smug satisfaction. Olberding also points out that sometimes people are unaware that they are being rude. She advocates that in order to improve civility and reduce rudeness we should respect our opponents by adopting a well-mannered approach. In doing so she is echoing the ancient Chinese philosophy of Confucius and Mengzi. Let us agree with Olberding that being well mannered is a pre-condition for engaging in any meaningful discourse which questions some the views of our opponents. According to Olberding any well-mannered discourse must be pro social and involve respect, consideration and toleration. Perhaps if rudeness damages meaningful discourse civility fosters it. However even if the tone of our discourse is polite what we talk about matters. Even if our arguments are good ones telling people why they are wrong and why we are right is unlikely to be effective. In this posting my arguments will not be primarily about the tone of what we talk to our opponents about but the methods we employ when discussing the issues involved. I will suggest three ways which might make a discourse more meaningful. Firstly I will argue that we should simply and politely explain our own views together with our reasons for holding them. I will then counter argue that such an approach is unlikely to succeed in changing many minds. Secondly I will argue that in certain cases we should simply ask our opponents to confirm their views which we find objectionable, “do you really mean that”. Lastly I will argue that we should politely but firmly press our opponents about what justifies their views. My comments are meant to apply to face to face conversations and those on social media.

Let us briefly examine the first approach. We might try to convince our opponents that our values are sensible values and that the force of our politely expressed arguments will challenge them into changing their own views. We hope that the force of our argument alone will bring about change and that we shouldn’t challenge or directly attempt to discredit our opponents’ views. The hope being that good arguments win out in the long term. For instance, we might challenge opponents of gay marriage by pointing out that gay people have the same rights as other people in most areas of life and suggest that these rights ought to be extended to marriage. We might then hope that the logic of our argument will mean the opponents of gay marriage change their minds. Such a suggestion seems to be hopelessly naive and I am unconvinced that such an approach would be either right or successful. We may be polite to our opponents but we aren’t really trying to improve discourse, indeed it might be questioned whether we are really attempting any sort of meaningful discourse at all because we aren’t paying any attention to the views of our opponents. It might be suggested that we are really doing is preaching and that we aren’t being particularly polite to our opponents by ignoring their views. I would suggest what we wrong our opponents because by not considering their views we fail to respect them as persons. Moreover such an approach is unlikely to be successful because even if we supply good arguments supporting our views we aren’t giving our opponents any reasons to reject their own views. If someone has no reason to reject her current views then she is unlikely to do so. Good arguments don’t alone change minds they must be shown to be better arguments.

A second approach which we might adopt in any discourse questioning the views of our opponents we find objectionable would be simply to ask them to confirm these views, “do you really mean that”. Perhaps we should repeat their views in our own words to ensure clarity. This approach at least has the merit of being directed at their views which our first approach didn’t do. Such an approach seems to morally justifiable because we are being respectful, considerate and tolerant towards our opponents. Unfortunately such an approach seems unlikely to be successful in changing the views of people who are strongly committed to their views. Nonetheless sometimes people express views which reflect underlying unconscious biases. These biases can sometimes come out inadvertently in sexist or racist remarks. If we simply ask the agent “do you really mean that” then this might combat some more mild biases by doing two things. Firstly we are asking the agent to examine her views. If the these views are unconscious views which conflict with her more reflective ones then our question might lead her to reflect more fully on her views by bringing them into focus. Secondly we are expressing our disapproval in a polite manner. If we accept that one form of shame is fear of social disapproval then if the agent feels some shame this might once again cause her to question her views.

However simply asking our opponents to confirm their views which we find objectionable is unlikely to make the majority of them seriously question these views. How then might we more effectively question these views in a polite non-confrontational manner? One approach might be to adopt the position of Socrates and politely ask our opponents why they hold these views, to ask for justification, rather than telling them directly why these views are wrong. Perhaps this approach might be used in conjunction  with the one outlined above of asking out our opponents whether they really mean that. One benefit of such a composite approach is that we are talking with our opponents rather than preaching to them. If someone is asked to provide an explanation in order to help us understand some of her views then the explanation she provides must also offer some sort of justification which she believes supports her views. It might be thought such questioning is a simple task but such a thought would be premature. Our task isn’t simply to listen impatiently and then move on to our own agenda. Out task is to understand our opponent’s views and understanding requires paying attention and listening to her justification with a certain degree of humility. Such a discourse is likely to be a slow one because after listening we must only think of our response after listening. Once again our approach seems to be morally justifiable because it treats our opponents with respect, consideration and toleration. Returning to my example of gay marriage an opponent of gay marriage might justify her views by explaining to us that the purpose of marriage is to provide a safe environment for the creation and rearing of children. We must listen carefully and understand that her opposition to gay marriage is based on a particular view about the purpose of marriage. We might then ask her how this purpose justifies marriage for couples whose children have grown up or are childless. However I would suggest that such an approach is unlikely to change the minds of those who hold strongly held views for three reasons. Firstly the confirmation bias means those such as fervent Brexiteers or Trump supporters instead of changing their minds will seek alternative justifications for their views. Secondly someone’s strongly held views help make someone who she is, help in defining her, and relinquishing them involves a loss of pride. Nonetheless our questioning might help to erode some of our opponent’s most extreme views which would be a useful thing to do. Lastly some people have strongly held views which seem to be based on faith and don’t require justification. This last group is particularly hard to engage in civil discourse because there appears to be no place for the discourse to start. Some might argue that because this approach is unlikely to change many minds that we should adopt a much more aggressive approach towards our opponents in the hope of at least changing a few minds. Perhaps, instead of simply asking our opponents to justify their views, we should robustly tell them why we think these views are unjustifiable. Unfortunately such an approach means we end up simply “talking at” or preaching to our opponents rather than talking with them. Once again such an approach seems to be wrong because we fail to respect our opponents. Moreover the confirmation bias makes it unlikely that it will be successful in changing many minds. However a more strident approach might help convince those who are yet to form a settled view.

What are the consequences of adopting the above approach? One consequence of accepting the above is that we must be prepared to provide justifications for our own views when asked to do so. Moreover, if the justifications we provide seems on reflection to be inadequate ones then we must be prepared to exchange our defective views for more defensible ones. Secondly because we mustn’t simply listen to the justifications of our opponents views but try to understand them then if we find these justifications convincing we must be prepared to accept their views or at the very least amend our own.

1. Amy Olberding, 2019, The Wrongness of Rudeness, Oxford University Press

The Doctrine of Informed Consent and Respect for Autonomy

In this posting I want to examine the relationship, if any, between the doctrine of informed consent and respect for autonomy. In doing so I will try to answer three important questions. Firstly is the doctrine of informed consent based on respecting autonomy or is it a sui generis doctrine? The fact we talk about a doctrine of informed consent seems to suggest the latter. Secondly if informed consent isn’t based on respecting autonomy should it be so based? Lastly if informed consent is based on respecting autonomy what type autonomy should that be?

Is informed consent based on respecting patient autonomy? According to Charles Foster the doctrine of informed consent is in a mess.

“Informed consent, in practice, is a bad joke. It’s a notion created by lawyers, and like many such notions it bears little relationship to the concerns that real humans have when they’re left to themselves, but it creates many artificial, lucrative, and expensive concerns.” Practical Ethics

Let us accept that the principles underlying informed consent are unclear. Let us try to start understanding these underlying principles by examining the process of informed consent in practice. When taking informed consent a patient’s doctors propose some form of treatment and provide the patient with the information he needs in order to make a good decision. The patient then agrees or refuses to agree to this treatment. What is the purpose of this process? The purpose of the agreement part of this process seems clear. The agreement part prevents the patient being treated against his will and his doctors from being accused of assault. The purpose of the information part is different. The purpose of this part is to enable patients to make good decisions. What exactly do we mean by a good decision? A decision which is in the patient’s best interests or an autonomous decision? In a medical setting a decision which is in a patient’s best interests is one which minimises harm to the patient,  maintains or improves his physiological health. The amputation of a patient’s gangrenous leg would be an example of acting in a patient’s best interests by minimising harm. The provision of drugs to control a patient’s blood pressure would be an example of acting in a patient’s best interests by maintaining his physical health. A kidney transplant would be an example of improving a patient’s health. Autonomy is concerned with self-government and very roughly speaking an autonomous decision is one by which someone governs himself. However self-government is simply governing oneself and need not always be good government. We can govern ourselves badly. Let us assume that a patient simply wants to accept his doctors’ judgement about his treatment and doesn’t want to receive any additional information. Intuitively such a decision can be seen as a decision by which he governs himself and as a result is an autonomous decision for after all we can simply choose to follow our lawyer’s advice and most would regard such a decision as autonomous. However under The General Medical Council’s proposed guidelines such a decision might not be seen as a valid informed consent decision.

“If, after discussion, a patient insists that they don’t want even this basic information, you must explain the potential consequences of them not having it. This might include being unable to proceed if you are not confident that their consent would be valid, or if you are not confident that the proposed course of action would be beneficial to the patient overall.” (1)

In the light of the above it would appear that The General Medical Council’s guidelines are not really based on respecting autonomy and the purpose of providing information when taking informed consent is to enable patients make decisions which are in their best interests.

It might be objected that I have only briefly sketched a certain account of autonomy and that a different account might mean that the doctrine of informed consent could be based on respect for autonomy. After all in my brief account the patient in my example above who fully trusted his doctors to make a decision on his behalf might wake up to unexpectedly find himself with only one leg. It might be suggested such a decision isn’t an autonomous one and that we should adopt a more substantive account. For the sake of argument let us assume an autonomous decision must be one that concurs with some generally accepted set of norms. If these norms are to be generally accepted then they must concern what is good for people. Autonomous decisions become linked to good decisions. An autonomous decision must be a good decision and a bad decision cannot be an autonomous one. I now want to argue against accepting such a substantive account of autonomy. If an autonomous decision must be a good decision because it must concur with some accepted norms then it might be questioned whether such an account of autonomy is really doing any useful work. A substantive account of autonomy puts itself out of business because we only need to consider good and bad decisions. We don’t need to consider autonomous decisions at all. Using a substantive account of autonomy an autonomous decision must of necessity be a good decision according to some accepted norms whilst on a content neutral account of autonomy an autonomous decision can be a bad decision. Of course it is preferable that an autonomous decision, using a content neutral account of autonomy, is a good decision which benefits the decision maker but the purpose of respecting autonomy remains simply to respect the decision maker as a person and the actual decision doesn’t of necessity need to be a good one. If we accept the above then we have two options. Firstly we could abandon the pretence that underlying the doctrine of informed consent is respect for autonomy or secondly we could accept that underlying the doctrine of informed consent is respect for a content neutral or primitive account of autonomy and modify the doctrine accordingly.

If we accept the above then there is not only a difference in complexity between substantive and primitive accounts of autonomy but more importantly these different accounts have a different focus. A substantive account focusses on respecting good decisions, a primitive account focusses respecting persons by simply accepting their decisions. Adopting a primitive account requires adopting a certain degree of humility. Let us accept that if the concept of autonomy is to remain a relevant one that it must be a primitive or content neutral concept based on respecting persons. Such a concept might be classed as a Millian concept. In the rest of this posting ‘autonomy’ will refer to such a concept. Let us also accept the first of the above options that the doctrine of informed consent is a doctrine in its own right and isn’t based on respect for autonomy. The informed consent process starts with a patient’s doctors proposing a course of treatment which they believe to be in his best interests, the patient then consents or refuses to consent to the proposed treatment. I argued above that the purpose of informed consent is to get a patient to consent to treatment which his doctors believe to be in his best interests. In almost all cases the patient simply consents and no problems arise. What is interesting are cases in which the patient refuses to consent. In these cases according to the doctrine of informed consent a patient’s doctors must be sure, or take steps to ensure, that the patient knows the consequences of his actions. However let us assume that the patient maintains his refusal of consent. By what standards is his competence to refuse treatment measured by and how is it assessed? If someone takes a driving test his competence to drive is based on his actual driving. This is not true when assessing someone’s ability to give informed consent. Someone’s competence to give informed consent isn’t based on his actual decisions. His decision might of course trigger a competence assessment but his competence isn’t dependent on his actual decision. Someone’s competence to give informed consent is based on his ability to make good decisions based on his best interests. I would suggest that someone who has the ability to make good decisions based on his best interests is self-governing, is autonomous.

As mentioned above the purpose of a driving test is to measure someone’s competence to drive and the criteria by which his competence is measured is by his actual driving. The same isn’t true of informed consent. I have argued above that the purpose of informed consent is to enable patients to make good decisions. I have further argued above that the way in which a patient’s competence to make good decisions is assessed is by his ability to make autonomous decisions. Such a mismatch creates problems and perhaps is one of the reasons why the doctrine of informed consent is in a mess. Two solutions might be suggested to remedy this mismatch. First the purpose of informed consent should be to enable a patient to make a good decision in particular circumstances and the patient’s competence should be assessed by his ability to make a good decision in these circumstances. Secondly the purpose of informed consent is to enable a patient to make an autonomous decisions and his competence to do so should be assessed by his ability to make an autonomous decision.

Let us consider the first of these options. Let us accept that a good decision is one that is in the decision maker’s best interests and that a decision is a competent one only if the decision is in the decision maker’s best interests. Clearly if someone makes a decision to do something which he believes isn’t in his best interests then he isn’t making a good decision. If a patient’s competence depends on him making a good decision then he is incompetent. Perhaps he is paralysed by fear. However in practice most people make decisions which they believe to be in their best interests. Moreover in a medical setting there is usually agreement between the patient and his doctors about what these best interests are. Unfortunately in a few cases in which there might be disagreement about what is in a patient’s best interests. Let us accept that a patient who makes a decision which he believes to be in his best interests, but which is generally believed not to be in his medical interests by his doctors, is making an incompetent decision. In practice if a child or cognitively challenged adult makes a decision which others believe isn’t in his best interests his competence might be questioned and he might be treated against his will. Unfortunately if a competent decision must be a good decision then the same considerations would seem to apply to all patients. Accepting the above would mean that if any patient makes a decision which is generally regarded as not being his best interests then his decision is an incompetent one. In these circumstances the patient’s doctors might be accused of paternalism or even epistemic arrogance. Fortunately in most cases a patient’s medical best interests and what the patient believes are his overall best interests concur. However this isn’t true in all cases. In cases in which these interests don’t concur do we insist that a competent decision is based on a patient’s best medical interests or what he believes to be in his overall best interests? Practical considerations and the need to avoid the charge of paternalism suggest that we should choose the second option. However if we accept that a patient is making a competent decision when it concurs with what he believes are in his overall best interests we are back to assessing a patient’s competence to make a good decision by assessing his ability to make an autonomous one and the above mismatch remains unresolved.

The above difficulties suggest that we should choose the second option. The purpose of informed consent should be to enable patients to make autonomous decisions about their treatment and that any competence assessment should be based on their ability to make autonomous decisions. This provides an answer to the second of my three initial questions. Informed consent should be based on respect for patient autonomy. Moreover if a substantive account of autonomy makes itself redundant as I have argued above the type of autonomy underlying informed consent must be a primitive or Milliian account. This answers the third of my three initial questions. Accepting this option has consequences for the amount of information which needs to be supplied to patients when taking informed consent. In the past under the doctrine of informed consent a patient’s doctors determined what risks the patient should be made aware of. However the Montgomery ruling Montgomery ruling stated that a patient’s doctors must ensure that the patient is aware of any and all the risks involved. If patients are to make informed consent decisions based on respect for autonomy they don’t always need to be aware of any and all the risks and the Montgomery ruling seems to suggest that informed consent shouldn’t be based on respect for a primitive account of autonomy. However if we accept that if an account of autonomy is to remain a meaningful account that it must be a primitive account then if informed consent is based on respect for autonomy  it must be based on a primitive account. Accepting the above means that a patient’s doctors should have a dialogue with him about any suggested medical procedure. How this dialogue proceeds shouldn’t be preordained by some doctrine but driven by the patient’s needs. In most cases this will include informing him about any major risks and life changes he faces. However some patients might need less or more information in order to make an autonomous decision. As mentioned above an autonomous agent can make an autonomous decision to trust the advice of his lawyer or financial advisor. If someone is non-autonomous someone else might be given power of attorney to act on his behalf. Are doctors any less trustworthy than lawyers or financial advisors? It would seem to me they aren’t. Does then the context in which informed consent takes place differ from other contexts such as the law and finance in respect of an agent’s ability to make autonomous decisions? Provided the patient isn’t incapacitated by fear it isn’t. It follows if informed consent is based on respect for autonomy that a patient should be able to make a competent decision simply to take his doctors’ advice. Other patients might need more information than is usually supplied in order to make an autonomous consent decision. Doctors should make it clear that they are willing to supply more information when this is requested. For instance it might matter greatly to a Jehovah’s witness whether there would be any possibility of a blood transfusion however remote this possibility might be.

It might be objected that I have already introduced an example which shows that it would be absurd to base the doctrine of informed consent on a non-substantive or Millian account of autonomy. Let us agree that if we accept such an account that a patient can make a competent decision simply to trust his doctor. Let us recall the patient with the gangrenous leg. Let us assume that this patient simply wants to trust his doctor and refuses to listen to any information provided. He wakes up and unexpectedly finds he has only one leg. Such a scenario seems absurd. Perhaps then the basis of informed consent should be a substantive account or the doctrine of informed consent should be a self-contained doctrine. Let us assume the patient still wants to simply trust his doctors and refuses to listen to any information concerning his procedure. Should he should be forced to listen to brief details connected to his proposed treatment? Do doctors really want to force someone to listen? Is it possible to force someone to listen and digest information? Should he be left to die? In this situation it seems more likely that the patient would be judged as incompetent. He would then be treated in accordance with his best interests and his leg removed. He wakes up with only one leg. In this case adopting a substantive account of autonomy or considering the doctrine of informed consent as a sui generis doctrine changes nothing. It follows that whilst adopting a non-substantive might lead to some highly undesirable consequences in a few rare cases that it doesn’t lead absurd ones.

1. Supporting patient choices about health and care: Draft Guidance for consultation, GMC, 2019, [33]-[35]

Lying and Autonomy

  

We live in a world surrounded by fake news and lies. According to Terry Pratchett in the Truth “A lie can run round the world before the truth has got its boots on.” However even if lies sometimes spread more easily than the truth, perhaps in part because they are more palatable and we want to believe them, in the long term the truth matters because the truth has persistence which lies don’t. Perhaps the dwindling number of climate change deniers supports the above. Are there any circumstances in which lying is beneficial? Stephen Rainey writing in practicalethics  suggests that some lies “can also be a kindness, when the truth might serve no good”. Let us accept that in most circumstances lying damages both individuals by depriving them of the truth and trust. Nonetheless is Rainey correct when he suggests some lies might be beneficial in some circumstance? For instance might a government be acting beneficently if it lied about the harm done by the coronavirus to prevent panic? The fact that lying hasn’t been eliminated from human culture over time suggests it isn’t harmful in all circumstances. In this posting I want to examine what these circumstances might be. It might be thought that this is merely an interesting rather than important question, however in seeking to answer this question raises a further question about the balance between acting beneficently and respecting autonomy. I will argue that if I lie to someone and even if my lie benefits him that I also fail to respect him by failing to respect his autonomy.

Most people have no problems with defining a lie. The definition I shall adopt here is that of Sam Harris

“To lie is to intentionally mislead others when they expect honest communication.” lying

Lies so defined can explicit when liars intentionally give someone false information. Lies can also be acts of omission when the liar intentionally withholds information others expect him to provide. Perhaps passive aggression can be a form of lying if it involves withholding information. Liars can be practised by individuals, institutions or even governments.

Let us now consider whether it is ever acceptable to lie for beneficent reasons. Because lying is so prevalent our intuitions suggest that it is. Everyday examples seem to confirm our intuitions. For instance the mother who lies to her child by saying she has no money left when her child demands a second ice cream. Someone who lies to his partner about a surprise party. A government which lies to its citizens about the seriousness of some disease outbreak, such as that caused by the coronavirus, in order to prevent mass panic. Nonetheless as Harris points out we need to be extremely cautious about our intuitions. Firstly we must be sure about our motives being really beneficent. Is the mother above really worried about her child becoming obese or simply taking an easy option? Secondly we must be careful not to damage trust. The government above might avert mass panic but in the future its pronouncements on health matters might not be so readily trusted. If a lie cannot be maintained then it is better not to lie at all in order to retain trust. The Chinese government’s attempt to suppress the full extent of the coronavirus outbreak in Wuhan seems to support the above. However let us accept that there are at least some cases in which we might lie for beneficent reasons in which our motives are clear and we don’t damage trust. For instance it would be perfectly acceptable to lie to a stalker carrying a knife about the whereabouts of his ex-girlfriend.

Let us accept that in certain circumstances we can act beneficently by lying, telling white lies. Let us further accept that in some of these circumstances trust isn’t damaged. In such circumstances is Rainey correct when he suggests that lying might be an act of kindness? It certainly seems that because we are behaving beneficently that our actions might be classed as acts of kindness. However I now want to argue even if our lies serve a beneficent purpose and can be classed as acts of kindness that nonetheless it is almost always wrong to lie. Most pet owners are kind to their pets and act beneficently towards them but most people don’t want to be treated in the same way as pets however kindly. They want to be recognised as the sort of creatures who can make their own decisions. To be autonomous. Autonomous people govern themselves and this requires making decisions that matter to them. To make decisions that matters to someone requires information and lying deprives him of some of that information. It follows if we lie to someone we fail to respect his autonomy. Moreover if someone becomes aware of being lied to this lack of respect is a form of rudeness see the philosophy of rudeness.html or form of contempt. It further follows if we believe it is right to respect someone’s autonomy that we shouldn’t lie. It further follows if a government lies to or intentionally misleads the electorate over some issue such as Brexit that it not only deprives the electorate of some of the information needed to make a good decision it also shows a lack of respect for the electorate and perhaps even democracy itself. This lack of respect is similar to the lack of respect many colonialists showed for native people even if their motives were beneficent.

I now want to consider two objections to accepting the above conclusion. My first argument will be based on respecting autonomous persons and my second on respecting autonomous decisions. Firstly it might be objected that we should give precedence to acting beneficently over respecting autonomy and that sometimes lying is the only effective way to act in someone’s best interests. I now want to present two counter arguments against accepting the above. Let us accept that if we need to lie to someone in order to act in what we believe to be their best interests that there must be a clash between what we believe to be in their best interests and what they perceive to be in their best interests. It would appear that we believe we know better than the agent about what is in his best interests or should be in his best interests. In this situation we might be accused of epistemic arrogance. Secondly I would argue if we accept the above objection we don’t really understand what respect means. We can sometimes act beneficently towards someone but part time respect isn’t respect we can’t respect someone only some of the time. We can of course respect someone’s courage but not her wit. However when we respect her as a person we can’t respect her only some of the time. Part time respect just isn’t respect at all. It follows if we lie to someone in order to act beneficently we are not giving precedence to acting beneficently over respecting autonomy we are in reality failing to respect autonomy at all.

Now let us consider respecting autonomous decisions. Let accept to respect an autonomous decision means to accept it. It might be objected that any difference between respecting someone’s autonomous decisions and acting beneficently towards him is largely illusory. This objection depends on accepting a substantive account of autonomy in which autonomous decisions must concur with some accepted norms, autonomous decisions must be good decisions. Accepting such an account means that if we lie to someone, who is making a bad decision, in order to act beneficently towards him we are still respecting his autonomy. Bad decisions just aren’t autonomous decisions. However I am reluctant to accept a substantive account of autonomy. A substantive account has become more prominent recently largely in order to make respecting autonomy concur better with the doctrine of informed consent. Unfortunately as I have argued elsewhere a substantive account of autonomy puts itself out of business, see autonomy and toleration . If autonomous decisions must be good decisions in accord with some accepted norms then we can just consider good decisions and autonomy becomes a redundant concept. Of course if someone is to make an autonomous decision he mustn’t be misled or coerced but it follows that if autonomy is to remain a meaningful concept that we should adopt a primitive or Millian account. It further follows if autonomous decisions needn’t be good decisions that if we lie to a mature adult in order to protect him from a bad decision that we are failing to respect his autonomy. I would suggest accepting the above has implications for apology. Insincere apology is a form of lying. Perhaps in most circumstance apologising without really mean it is a form of white lying. Nonetheless such apologising just compounds any wrong by showing a lack of any real respect to the one lied to.

I have argued that it is always wrong to lie if this means we fail to respect someone’s autonomy even this is done for beneficent reasons. The question now arises is lying ever acceptable? If the mother of a young child who pesters her to buy another ice cream lies then her lie can be justified. The child isn’t autonomous yet and having two ice creams isn’t in her best interests. However caution is needed if we accept a primitive account of autonomy as I suggested above then slightly older children who are capable of making autonomous decisions and lying to them fails to respect their autonomy. Sam Harris uses an extreme example and asks should we lie even if with “Nazis at the door and Anne Frank is in the attic”. Of course we should lie. We should lie to protect Anne Frank and her autonomy. Lying to someone who is infringing someone else’s autonomy is perfectly acceptable, lying to protect autonomy is lying to respect autonomy.

What conclusions can be drawn from the above? Firstly we should never lie if this means failing to respect autonomy even if our lies might be in what we consider to be someone’s best interests. Even white lies are wrong. Secondly if autonomy is to remain a meaningful concept we must always give precedence to respecting autonomy over acting beneficently. Lastly lying to autonomous agents can never be kind.

Different Degrees or Different Types of Rape?

Rape is an offence which can vary greatly in the degree of its seriousness. Unlawful killing is split into two different offences, manslaughter and murder. In this posting I want to examine whether it might also be beneficial to split rape into two different offences or continue to accept a single definition. If we continue with the later course then because the seriousness of the rape can vary greatly this variability might lead to some less serious cases not being prosecuted. Perhaps if we allow for different types of rape these less serious cases might become more likely to be prosecuted. Perhaps also if we define different types of rape it might be clearer to some potential rapists that cases which might be considered as borderline cases under a single definition are indeed forms of rape.

I want to start my examination by considering four examples which are all very different. These differences suggest that our concept of rape is really an umbrella one. These examples highlight the differences involved. The first case was used by Mike LaBossierre.

“They’d now decided — mutually, she thought — just to be friends. When he ended up falling asleep on her bed, she changed into pyjamas and climbed in next to him. Soon, he was putting his arm around her and taking off her clothes. ‘I basically said, “No, I don’t want to have sex with you.” And then he said, “OK, that’s fine” and stopped. . . . And then he started again a few minutes later, taking off my panties, taking off his boxers. I just kind of laid there and didn’t do anything — I had already said no. I was just tired and wanted to go to bed. I let him finish. I pulled my panties back on and went to sleep.” talking philosophy

My second example is that of 78 year old man who had sex with his wife who was suffering from Alzheimer, see Hastings Center  . She didn’t resist his advances but was incapable of giving any form of consent. My third example is of someone who is violently raped by a stranger. My last example is that of a paedophile having sex with an underage child.

Do these examples suggest any ways in which how different types of rape might be defined? Firstly it might be suggested that different types of rape might be differentiated by the amount of violence is involved. If we accept the above suggestion then my first two examples would be considered as a less serious type of rape and my third example a more serious type. Unfortunately my fourth example shows any such a suggestion to be unsound. Consider a paedophile having sex with a child who is neither forced nor unwilling. If we accept that rape can be differentiated by whether violence is involved then this case might be classed as a less serious type of rape. However this seems to be a clear example of extremely serious rape. It follows that different types of rape cannot be differentiated by the use of violence.

Next it might be suggested that different types of rape might be differentiated not simply by the violence involved but by the actual harm inflicted. Let us accept that not all the harm involved in rape need be physical harm. Accepting the above would mean that my example of the paedophile need not be considered as a less serious type of rape. Let us now consider this suggestion using my other examples. In my third example the victim would suffer physical harm and great psychological trauma. However the victims in my first two examples wouldn’t suffer the same degree of harm. The student in my first example suffered no physical harm and only believed she was raped in retrospect and so any psychological trauma would seem to be slight whilst in my second example we are even unable to say if any trauma took place at all. In spite of the above I would be reluctant to accept that different types of rape might be differentiated by the harm involved for two reasons. Firstly theft is not split into different types based on how much the thief steals, theft is theft, and I can see no obvious reason why rape should be different in this respect. Secondly the old man having sex with his demented wife might not be considered as a less serious form of rape but not an example of rape at all.

Lastly might different types of rape might be defined by differences in the refusal of consent. In what follows I will assume that a refusal of consent can not only be verbal but take the form of active resistance to sexual intercourse. According to the Oxford English Dictionary rape is,

“Typically committed by a man, of forcing another person to have sexual intercourse with the offender against their will.”

Let us consider my first and third examples. Let us assume in my third example that the victim fought back and maintained her refusal of consent provided she wasn’t prevented from doing so. In my first example the victim refused to consent but it might be questioned whether her actions maintained that refusal. She wasn’t prevented from maintaining her refusal to consent but didn’t do so. It might be suggested that type one rape should be defined as one in which the victim refuses consent and that whilst undergoing sexual intercourse maintained her refusal or is prevented from doing so. Type two rape might be defined as one in which the victim refuses consent but whilst undergoing sexual intercourse but fails to maintain her refusal whilst remaining capable of doing so. This division of rape into two different types might appear attractive because by allowing these two different types might mean some cases of rape might be prosecuted as type two rapes which wouldn’t have been prosecuted if we retain a unified concept of rape. However these are incomplete definitions because they fail to deal with cases in which the possibility of consent doesn’t exist such as in my second and fourth examples. It might be suggested that this difficultly might be avoided if we define type one rape as one in which the victim is unable to give valid consent or if she is able give consent refuses to so and whilst undergoing sexual intercourse maintains her refusal or is prevented from doing so. Initially his suggestion seems to be an attractive for one for in most cases in which sexual intercourse taking place without the possibility of consent are serious cases. Sex with children or adults unable to give consent due learning difficulties are serious offences. Unfortunately my second example gives us a reason to question adopting this approach provided we accept that the old man having sex with his demented wife was a form of rape. Intuitively it seems wrong to class his rape as the same type of a rape as that of a violent rapist for whilst we might still blame the old man for his actions we can also pity him. We would have no such pity for the violent rapist. Perhaps then we should include cases in which consent is impossible with type two rapes. Type two rape might now be defined as rape defined cases in which the victim is unable give valid consent or if she is able do so refuses to consent and her refusal of consent is not maintained whilst undergoing sexual intercourse when it is possible for her to do so. Unfortunately my fourth example shows the difficulties with adopting this approach. It would seem to be wrong to put a paedophile having activity with a child in the same class of rape as that of someone having activity with a victim who only comes to realise that she has been raped in retrospect. At this point it might be objected that my first example isn’t a less serious type of rape, it isn’t a type of rape at all. Underlying my definition of both types rape is the idea that consent can sometimes be implicit rather than explicit. It might be argued that the student in my first example by not maintaining her refusal of consent was in practice giving implicit consent. Perhaps if the student in question hadn’t initially refused consent then her actions might be construed as giving implicit consent. I would suggest that explicit and implicit consent cannot be mixed up and that an explicit refusal of consent can only be changed by the explicit giving of consent. Explicit consent is stronger than implicit consent. It follows the student was indeed raped. Her failure to maintain her refusal of consent doesn’t show she wasn’t raped but I would suggest it does show her rape was a less serious type of rape than some others. It also illustrates why the idea of type two rape could be a useful concept.

In the light of the above it seems my initial intention to split rape into two types fails. It fails because of difficulties in accommodating cases in which no consent is involved within either of these two types. When I started writing this posting my intention was to show that rape should be split into two types, the above shows that in philosophy one must always be prepared to change one’s mind. Can anything be salvaged from the above discussion? Perhaps if we want to prosecute an increased number of rape cases then rapes might be split into three types. Category one rape might be defined as one in which the victim refuses consent and whilst undergoing sexual intercourse maintains her refusal of consent or is prevented from maintaining her refusal. Category two rape might be defined as one in which the victim refuses consent but whilst undergoing sexual intercourse fails to maintain her refusal of consent whilst remaining able to do so. Category three rape might defined as any form of sexual intercourse in which the victim is unable to consent. What might be the consequences of adopting these three different types? One consequence might be a greater number of prosecutions for rape. Cases such as the student in my first example might be prosecuted whilst he might not have been prosecuted using the current definition. Splitting rape into three types would have an effect on sentencing. The sentencing of rapists guilty of category one rapes would remain unchanged. The sentencing of rapists guilty of category two rapes might be best dealt with by restorative justice. It might be objected that restorative justice doesn’t deal with the serious of the crime. In response I would point out restorative justice is not easy for the offender. The offender doesn’t simply have something done to him but has to seriously address behaviour, doing so means confronting the sort of person he is and learning to make changes. One of the aims of restorative justice is not just to make the offender feel he has done wrong but also feel the wrongness itself. I would also point out that whilst category two rape isn’t a trivial offence it is a much serious offence than category one and should be considered as such. I have suggested that the severity of sentencing for category one and two rapes should have a fairly tight domain the same isn’t true of category three. A paedophile might attract expect a severe sentence whilst the old man having sex with his demented wife is to be pitied and simply needs to learn his actions were wrong.

What conclusion can be drawn from the above? Clearly splitting rape into three different types is a messy business. However life is sometimes a messy business and this messiness might be a price worth paying if it leads to the prosecution of some cases which might not otherwise be prosecuted and a clearer understanding of what it means to rape someone. Should we do so? I’m not sure

The Logic of Relieving Suffering and Voluntary Euthanasia

Recently a seventeen year old Dutch girl, who had been repeatedly raped as a child and who suffered from post-traumatic stress disorder, anorexia and depression, starved herself to death. This was widely reported as an example of euthanasia, see BioEdge . Simply starving oneself to death isn’t euthanasia. It was unclear in this case whether her doctors helped to control her suffering. In this posting I want to explore whether doctors who relieve the suffering of a patient who starves himself to death should be regarded as assisting in suicide. In order to make my argument I will first explore what can be considered as the legitimate use of medical skills. Let us start with the premise that the decreasing of someone’s suffering is a legitimate use of medical skills. However accepting this premise is too simplistic. Surgery might actually increase someone’s suffering in the short term and surgery is clearly a legitimate use of medical skills. Let us revise the premise so that decreasing someone’s overall suffering is always a legitimate use of medical skills when this is possible.

Let us now agree that decreasing someone’s suffering is usually a legitimate use of medical skills but is it always so? I now want to examine two arguments suggesting it isn’t. Firstly it might be argued that some people deserve to suffer and that it would be wrong to alleviate their suffering due to dessert. Consider a convicted rapist who became infected with HIV when committing his crime. Let us assume that he is now serving his sentence in relative isolation due to the hideous nature of this crime and as a result is unable to infect others. Would treating him for his HIV would be an illegitimate use of medical skills? What reason could be advanced for illegitimacy of treatment in this case? It might possibly be argued that in this case the rapist deserves to be HIV positive and that as a result treating him for this state should be an illegitimate use of medical skills. This extreme example might concur with many people’s intuitions but seems to run counter to the caring ethos of medicine. I would argue linking the legitimacy of the use of medical skills to dessert is problematic in all circumstances. Accepting that it is illegitimate to treat some people whilst it is legitimate to treat others because of dessert appears to imply that it is legitimate to use medical skills to achieve dessert. The domain in which the employment of legitimate medical skills is extended from simply treating suffering to treating suffering and ensuring just dessert. We might link suffering and dessert together but nonetheless they remain independent conditions. Someone can suffer without deserving to do so and someone may deserve to suffer without actually doing so. If we accept that the legitimate use of medical skills is linked to dessert in addition to suffering then provided a death sentence could be considered as just it would be a legitimate use of medical skills to carry out this sentence. An interesting account of the death penalty and the proper ends of medicine is to be found can Silver (1).

Secondly it might be argued that medical professionals have no duty to alleviate suffering when this is caused by self-harm and the sufferer is fully aware his behaviour is the cause of his suffering. In practice accepting this argument might mean that there is less of a duty to treat conditions when these conditions are caused by alcoholism, obesity and anorexia. Clearly alcoholics, the obese and anorexics suffer even if this suffering is caused by their own behaviour. What reason could be advanced as to why treating them would be regarded as an illegitimate use of medicals skills? One reason might be that because their suffering is self-imposed they can simply stop the suffering by changing their behaviour and there is no need to employ medical skills. I’m doubtful whether the eating habits of anorexics or the obese can simply change their behaviour and alcoholism is an addiction.  However let us assume that someone’s suffering is self-imposed and that can change his behaviour and he will cease to suffer. In this context is the use of medical skills to alleviate his is an illegitimate use? It might be suggested he deserves to suffer because his suffering is self-imposed. However if we accept this suggestion it would re-introduce all the problems of dessert outlined above. Both of the above arguments as to why medical professionals don’t always have a duty to alleviate suffering when this is possible appear to be unsound. It follows that we should accept the premise that the decreasing someone’s overall suffering is always a legitimate use of medical skills when this is possible. It is of course possible that there are other legitimate uses of medical skills, see Cosmetic Surgery, Enhancement and the Aims of Medicine . 

I now want to consider the relationship between the relief of suffering and voluntary euthanasia. In particular I want to focus on the relief of suffering of those people who voluntary stop eating and drinking (VSED). Most people who adopt VSED do so because they have a terminal illness but this isn’t true in all cases as the Dutch girl shows. Let us assume that the relief of someone’s suffering caused by VSED is assisting in voluntary euthanasia. I have argued above that decreasing someone’s overall suffering is always a legitimate use of medical skills. It follows relief of someone’s suffering caused by VSED is a legitimate use of medical skills. It further follows that assisting in voluntary euthanasia is a legitimate use of medical skills. Some might be unhappy to accept these conclusions but being unhappy about these conclusions has nothing to do with the logic of the argument or the validity of the conclusions. 

Lastly let us assume that the relief of someone’s suffering caused by VSED isn’t assisting in voluntary euthanasia. If this is the case then there would seem to be no reason to be unhappy about the deployment of medical skills to alleviate someone’s suffering caused by VSED. However I find hard to see how alleviating someone’s suffering, when this suffering is caused by a desire to die, shouldn't be regarded as a case of physician assisted suicide without using the principle of double effect.

1. Silver D, (2003) Lethal Injection, Autonomy and the proper ends of Medicine, Bioethics 17(2), pp. 205-211.

Redesigning People

In China a scientist has created two gene edited babies using CRISPR-cas9 in order to prevent HIV infection. These babies are usually referred to as designer babies. In this posting I will use the term redesign rather than design because people have already been designed by their genes and this design is shaped by nature and evolution. I will consider whether we should attempt to improve on that design by redesigning people and in what circumstances it would be permissible to do so. If we redesign a kettle we hope the redesigned kettle will be an improvement on the previous one. Intuitively it might be thought if we redesign a person the result will automatically be an improved person. However we must be wary of our intuitions and whilst it might be pointless to redesign a kettle which isn’t an improved kettle the same does not hold for persons. A kettle is designed for a single task persons aren’t. Someone might redesign a person to serve a specific purpose and such a redesigned person needn’t necessarily be an improved person when considered more broadly. Perhaps a person might be redesigned to be a better soldier such a redesigned person need only be a better soldier not a better person. Prior to considering specific wrongs which might arise if we redesign persons I want to consider the different ways in which redesigning might be wrong.

Redesigning persons might be wrong in three circumstances. Firstly we aren’t competent to redesign persons. Persons unlike kettles are highly complex and perhaps we just don’t have the expertise to carry out such redesign. If we accept the above then it would be unacceptable to redesign persons unfortunately in these circumstances we should be open to the rather unpalatable option that others such as aliens or even some advanced AI might be able to redesign us even if we can't do so. Secondly it might be suggested that whilst we don’t have the expertise to redesign persons now that we might acquire such expertise in the future. If we accept this option then whilst it would be unacceptable to redesign persons now it might become acceptable in the future and it would be sensible to debate the consequences of doing so now. Lastly it might be suggested that the act of redesign must always damage the redesigned person. Danaher explores two objections raised by Jurgen Habermas to redesigning persons in which the act of redesign damages the designee. Habermas argues redesigning a person would of necessity damage her because it would compromise her autonomy and status of equality. I will now consider the specific ways in which redesigning persons might be damaging. Firstly I will briefly consider how redesigning persons might cause damage to both persons and society by creating inequality. Secondly I will consider how redesigning a person might damage that person by compromising her autonomy.

Let us accept that Kant was right to insist that treating someone simply as a means and not an end in herself is morally wrong. It follows that if we accept that creating someone to serve our ends is equivalent to using someone to serve our ends then redesigning a person to serve the ends of another is wrong. It also follows that if someone redesigns another to serve her ends that there is a lack of equality between the designer and the designee. The choice of available ends to the designer and the designee are unequal. However why should we want to redesign a person to serve our needs? It seems probable that if our technology becomes advanced enough to redesign persons that it would also become advanced enough to design robots which aren’t, as yet, persons to serve the same needs. In this situation if we want an improved soldier, a robotic soldier would seem to be a better option than a redesigned person. Personhood would be an unnecessary extravagance and might even make the soldier less effective. The same seems true of most servants with one possible exception. Currently there is some interest in sex robots (1). However is sex with a robot genuine intercourse? I have argued that sex isn’t simply friction and as a result sex with a robot is really only an enhanced form of masturbation sex with robots . It is possible that in this situation someone might want to redesign a person to serve her sexual desires. It follows that it is conceivable that in some limited circumstances someone might want to redesign a person to serve her own ends. Such redesigning creates a person designed for the ends of another making her less equal. It follows redesigning someone to serve the ends of another is morally wrong because it creates inequalities between persons. Now let us consider whether redesigning someone in order to benefit that person might also create inequalities in society. Any society which contains both enhanced and unenhanced persons is likely to be an unequal one. It follows that we might have reason not redesign persons based on the potential damage it might do to society. How strong these reasons are will depend on the cost and availability of redesign. It is possible that redesigning persons won’t damage society. I now want to consider other reasons why redesigning persons might be wrong.

In what follows it will be accepted that to design a person in order to serve the needs of another is wrong. It will also be accepted that redesigning persons might be wrong if it creates unacceptable inequalities in society. It will also be assumed that if we redesign someone that we do so in order to benefit her. If we redesign someone in order to benefit her then this redesign is a form of enhancement. I now want examine whether redesigning someone in order to enhance her might damage her personally? Let us start our examination by considering a specific example. Some potential mothers suffer from mitochondrial disease and these mothers will normally have babies who will suffer from the same disease. Using IVF an egg taken from such a mother might be fertilised. The nucleus of this egg is then transferred to an egg with its nucleus removed which has been donated by another woman from which the nucleus has been removed creating a three parent baby. This is a clear case of redesign and it is hard to see in this case how being designed damages the designee. It also seems to answer one of the questions raised above as to whether we can effectively redesign someone, the answer is that we can at least in some cases. If we accept the above then redesigning persons is both possible and doesn’t always damage the persons involved. However are there some circumstances in which designing a person damages the designed person?

Let us recall we have excluded cases in which we redesign someone in order to serve the purposes of another and are only considering redesign in circumstances in which the redesign is intended to benefit the redesigned person. Such a redesign is a form of enhancement. Let us first consider the possibility that we can enhance only one capability and leave the rest of the designed persons capabilities unchanged. Perhaps someone might be redesigned to be stronger or have a better memory. Human beings are animals and it is hard to see from the viewpoint of an animal how such enhancement might damage the animal involved. Being stronger or remembering the hiding places of predators should give any animal an evolutionary advantage. Let us accept that enhancing a single instrumental capability whilst leaving the rest of some designed person’s capabilities unchanged doesn’t damage her physically. Much the same reasoning can be applied to enhancing several capabilities provided the remaining capabilities are unchanged. However human beings aren’t simply animals they are potential persons. Does the fact that some capacity or capacities have been chosen by another for enhancement damage her as a person? I now want to consider whether the redesigning of a person in order to enhance her damages her autonomy.

Let us return to my example in which we redesign someone to be stronger. How can being stronger damage someone’s autonomy even if this choice was made for her by another? It might be suggested that by making someone stronger we are enhancing her capacity for athletic prowess. It might then be further suggested that by enhancing her athletic prowess she becomes more likely to choose an athletic career and as a result we have limited her choices and compromised her autonomy. The same argument could be applied to redesigning someone in order to enhance other skills such as an improved memory. It might be suggested that such redesign is analogous to parents who encourage a child’s athletic prowess and that they too damage her ability to choose and as a result compromise her autonomy. In practice we accept parents who encourage their children’s athletic prowess.  After all what can be wrong with encouraging prowess in something which is beneficial? It might then be further argued that if we are prepared to accept encouraging parents who encourage athletic prowess that we should be prepared to accept parents who seek to increase this prowess by redesign. It seems to me that this argument is unsound because the analogy is not a close one as children can reject parental encouragement but they can’t reject redesign.

I have suggested that parents who encourage their children to excel in some activity don’t damage their children’s autonomy because their children can reject their parent’s choices whilst parents who redesign their children to excel in some activity might do so because their children can’t reject the enhancement. I would be unhappy to accept this suggestion for two reasons. Firstly I accept that whilst most parents who encourage their children to excel don’t damage their children’s autonomy some might. Parenting is about guidance and some parents try to direct rather than guide their children, such parents do some harm to their children’s autonomy, see parenting and excessive guidance . Secondly my objector is suggesting that the enhancement of certain capacities of someone makes it more likely that she will choose some option and that this increased probability damages her autonomy. I accept that enhancing someone’s capacity might make her more inclined to make certain choices but I want to argue this doesn’t damage her autonomy in all circumstances. Let us return to my example of parents who enhance their child so that she has greater strength. These parents have no specific life plan for their child in mind and only want their child to be stronger. Let us assume that the child decides to become a gymnast. Let us accept that her increased strength makes it both easier and more probable that she will choose this option. Does the fact that some option has been made both easier to choose and more probable to be chosen by someone due to her enhancement by others mean that her autonomy has been damaged? I would suggest that in these circumstances it doesn’t. In these circumstances our potential gymnast hasn’t been coerced and it is difficult to see how her greater strength could possibly alter her capabilities to make an autonomous choice. Making it easier for someone to choose some option isn’t the same as making her choose that option. It follows redesigning a child so she has greater strength doesn’t damage her autonomy. I would now suggest that the same argument could be applied to all her instrumental capacities including cognitive abilities such as an improved memory or quicker reasoning. The fact that someone else has chosen which capacities to enhance seems irrelevant in these circumstances as far as enhanced person’s autonomy is concerned. Accepting the above leads a the conclusion that redesigning someone so that she has certain enhanced instrumental cognitive or physical capacities which were chosen by others and these capacities make it more likely that she will choose a particular option doesn’t damage her autonomy in circumstance in which this redesign doesn’t affect her remaining capacities and should be permissible. If this wasn’t so then any educational establishment which offered a bursary to a student, which might make it more likely she would pursue an academic career could be said to be damaging her autonomy.

I have argued that any enhancement in circumstances which only enhances some of someone’s instrumental capacities whilst leaving her remaining capacities unchanged doesn’t damage her autonomy and that such a redesign should be permissible. However it is possible to enhance someone’s non-instrumental capacities. I now want to consider whether enhancing these capacities might damage someone’s autonomy. Ingmar Persson and Julian Savulescu have argued that there is a need for widespread moral enhancement in order to counter the existential dangers which our modern world poses (2). Perhaps in order to counter these dangers we should redesign persons so that they have an increased capacity for empathy.  Would such a redesign damage someone’s capacity for autonomy? It might be argued that if we increase someone’s capacity for empathy that this increased capacity would lead to an increased desire to help others which in turn might lead to a decrease in her ability to fully exercise her cognitive abilities. Her increased empathy overwhelms her ability to make autonomous decisions to some degree. If we accept the above then enhancing someone’s capacity for empathy might damage her capacity to make autonomous decisions. What is important in these circumstances is not simply that someone has chosen which capacity to enhance but that by choosing she has altered the relationship between the enhanced person’s capacities to choose or damaged one of them. If we accept the above then it might be concluded that if enhancing some of someone’s capacities alters her remaining capacities to choose or damages them then this enhancement damages her autonomy and this redesign should be impermissible.

Whether we should accept the above conclusion depends on the account of autonomy employed. There are many different accounts of autonomy and I will only consider two accounts here because most other accounts fall somewhere between these accounts for our purposes here even if the details differ. First an autonomous decision might be regarded as a good decision based on what the agent cares about together with some widely accepted norms. If we accept this account then if someone’s enhanced capacity for empathy compromises her ability to accept certain norms then her autonomy is damaged. If we accept this account of autonomy then we might limit any damage to someone’s autonomy by employing a dual enhancement that enhances both empathy and cognition which might lead to increased empathy across a wider domain, see widespread moral enhancement. Secondly an autonomous decision might be regarded as simply as one which accords with what an agent cares about. Clearly if we accept this account and redesign someone in order to increase her empathy we won’t damage her autonomy. I have argued elsewhere that we should adopt this second primitive account of autonomy because if we don’t autonomous decisions simply become good decisions and that we have no need for a separate account of autonomy. If we accept this second account of autonomy then we have no reason based on damaging someone’s autonomy not to enhance her capacity for empathy even if her enhanced empathy overwhelms some of her cognitive capabilities. However in these circumstances doing so would still damage her as a person. Persons have some capacity for reasoning and if we overwhelm this capacity we damage the person involved.

I have summarised the main conclusions which can be drawn from the above below.

·       It should be unacceptable to redesign a person to serve the needs of another.

·       Redesigning persons might create unwarranted inequalities in society. Whether these inequalities mean redesign should be impermissible will depend on the cost and availability of the redesign.

·       Redesigning persons in order to enhance one or more of their capacities whilst leaving the remaining capacities the same does not compromise their capacity for autonomy and should be permissible. Making some option easier to choose is not the same as damaging someone’s capacity to make autonomous decisions.

·       Redesigning persons in order to enhance one or more of their capacities when this enhancement means altering the relationship between her capacities involved in decision making might damage her as a person even if it doesn’t damage her capacity to make autonomous decisions and should be impermissible.

1. Danaher, Mcarthur, and Migotti, 2017 Robot Sex: Social and Ethical Implications, MIT Press
2. Ingmar Persson & Julian Savulescu, 2012, UNFIT FOR THE FUTURE, Oxford University Press.

A right to anaesthesia, a right to physician euthanasia?

In an editorial in Anaesthesia Julian Savulescu and Janet Radcliffe‐Richards suggest that many people who are against the deliberate killing of terminally ill patients who wish to die should have no objection to what is known as terminal sedation, bringing about unconsciousness for terminally ill patients until their natural death, see Anaesthesia . I agree with Savulescu and Radcliffe‐Richards that most people would accept that sedation for terminally ill patients is not wrong when death is imminent. In France in 2016 a law came into effect granting terminally ill patients the right to anaesthesia until death. Sinmyee et al go further and argue that a right to anaesthesia should be available to all patients who choose to end their life by starvation or dehydration, see Sinmyee . Would most people accept that sedation for terminally ill patients is not wrong when death is inevitable but not imminent? Perhaps a patient has a prognosis that he has only six months to live. Secondly would most people accept that sedation for terminally ill patients is not wrong when used to relieve suffering which they cause themselves by a refusal to eat or to drink? I’m not sure what most people would find acceptable in either of these scenarios. In this posting I will firstly briefly summarise the argument why it isn’t morally wrong to sedate terminally ill patients even if their current suffering is due caused by a refusal to eat or drink. I will then consider what implications accepting this argument has for accepting physician assisted suicide and voluntary euthanasia.

Let us accept that any competent person has right to refuse to take food and water. It might be objected that in some cases the person in question is unlikely to be competent due to eating disorders such as anorexia. However clearly this objection doesn’t carry much weight when considering terminally ill patients. Let us also accept that relieving pain is a legitimate end of medicine even when this lessens a patient’s life span. Let us still further accept that relieving pain remains a legitimate end of medicine even when this pain is due to self-harm. We treat drug users for their addiction. Lastly let us accept that if pain cannot be controlled by any other means that it can be controlled by deep sedation. It appears to follow that deeply sedating a patient suffering from a terminal illness, even if his immediate suffering is caused by his refusal to eat or drink, is a legitimate end of medicine. It follows that in these circumstances deep sedation would not be morally wrong.

Let us now consider how permanent deep sedation differs from death. For a dead person conscious life is over. Conscious life is also over anyone who will be deeply sedated until he dies. Of course for someone who is deeply sedated some important unconscious physiological processes such as breathing will continue. The same is not true of the dead. But do these unconscious physiological processes matter if someone will never resume consciousness or take part in life again? If they do matter who do they matter to? These unconscious physiological processes certainly don’t matter to the sedated person. If they doesn’t matter to the person involved why should they matter morally to others? It would appear to follow that there is no significant moral difference between being dead and being deeply sedated until death. If this is so is there any moral difference between a doctor deeply sedating someone until he dies and helping him die a good death if he requests help to do so? If dying and being deeply sedated until death are equivalent for moral concerns then we should be prepared to conclude that if we are prepared to accept deep sedation until death that we should be prepared to accept physician assisted suicide PAS.

It might be objected that deep sedation involves no suffering whilst helping a patient to die might do so. However even if we accept this objection the above question might be reframed. Is there any moral difference between a doctor deeply sedating someone until he dies and deeply sedating someone prior to carry out his previously expressed wishes for voluntary euthanasia? If there isn’t any difference then we should be prepared to conclude that if we are prepared to accept deep sedation until death that we should be prepared to accept voluntary euthanasia, which might require prior sedation, when requested by a terminally ill patient.

I now want to examine two major objections to the above conclusion. Firstly it might be objected that the above argument depends on the concept of a person and that when considering deep sedation and voluntary euthanasia we should consider human beings instead. My objector might argue that that matters is not whether a person continues to exist bur whether a human being continues to exist. What does it mean for a human being to continue existing? Is someone who will never regain consciousness but for whom unconscious physiological processes such as breathing continue still a human being? My objector might conclude the answer is obvious and is affirmative. However if we consider the concept of brain death commonly used in transplant medicine the answer is not obvious. Someone is brain dead if he has a permanent absence of cerebral and brainstem functions, however mechanical ventilators and other advanced critical care services can maintain unconscious physiological processes such as breathing for some time. Whether someone who is brain dead remains a human being is far from obvious for we can use his organs for transplant subject to consent. Why does brain death matter? It matters not simply because of a loss of cerebral and brainstem functions but because the implications of these losses. These losses lead to a permanent loss of consciousness. If the above is accepted then substituting human for persons doesn’t affect my original argument.

I now want to consider a second objection to my argument that if we are prepared to accept deep sedation of the terminally ill patients until death that we should also be prepared to voluntary euthanasia for such patients. It might be objected that I have slipped too easily from considering PAS to considering voluntary euthanasia and that the two aren’t equivalent. PAS is self-administered whilst voluntary euthanasia is carried out by a physician. I made this move because it has been suggested that PAS might involve suffering by the terminally ill patient. As a philosopher I am unable to say much about whether PAS might involve suffering. However I can say something about the possible scenarios. Firstly if PAS doesn’t necessarily involve suffering then my original conclusion stands. Next let us assume that PAS involves some limited suffering. In this scenario it might be questioned whether a terminally ill patient needs to be fully anaesthetised for PAS to take place? Perhaps a patient’s pain might be alleviated without affecting his cognitive abilities allowing him to carry out PAS. Once again my original conclusion stands. Lastly let us assume that PAS involves suffering that cannot be fully alleviated without full anaesthesia. In this scenario PAS isn’t possible with full pain relief. In this scenario the question changes and becomes, if we are prepared to accept deep sedation until death then why shouldn’t we be prepared to accept voluntary euthanasia?

In order to answer the above question I want to consider two further scenarios. In both scenarios I will assume the patient is fully competent. In the first I will assume that the patient is capable of initiating the start of his anaesthesia before his physician takes over and delivers a fatal dose. In this scenario why is the patient initiating his own anaesthesia? I would suggest he isn’t only initiating a form of pain relief. He is only initiating pain relief in order to die. In this scenario the patient’s actions resemble those of a patient undergoing PAS.  However the two are not identical. In PAS the physician only supplies the means and need not be present at the time of death whilst in the above scenario the physician must not only be present but also deliver the lethal dose. Let us accept that the physician’s presence or lack of it is not relevant morally. However we must ask ourselves whether the fact that the physician supplies the means of dying differs in a morally significant way from the physician applying the lethal dose. It might be suggested that this a case in which we could use the principle of double effect to explain the difference. I would be reluctant to accept this suggestion. When supplying the means to die the physician involved in PAS has the intention of allowing the patient to kill himself, it isn’t a foreseen consequence of something else. The physician’s intention is the same whether he is involved in PAS or voluntary euthanasia as described in the above scenario. It seems provided the patient involved is able to initiate his own anaesthesia that there is no morally significant difference between voluntary euthanasia in these circumstances and PAS. Let us now consider a second scenario in which the patient is unable to initiate his own anaesthesia. I would suggest that there are no morally significant differences between a physician carrying out voluntary euthanasia on a terminally ill patient in this scenario and a physician suppling him with the means to carry out PAS provided the degree of voluntariness is the same in both cases. However is the degree of voluntariness the same in both cases? In the case of PAS the patient’s intentions seem to be clear because he initiates the dying process. If a patient can initiate his own anaesthesia I have argued he is initiating his death and once again his intentions seem clear cut. However if a patient is unable to initiate his own anaesthesia his intentions aren’t quite so clear cut. Perhaps this situation can be remedied by a rigorous consent process and a clear last directive. None the less differences remain between this scenario and the one in which the patient initiates his own anaesthesia and for this reason I would be reluctant to conclude that the scenario in which the patient is unable to initiate his own anaesthesia is equivalent to PAS. The above suggests some consequences for the process of deep sedation. Let us accept that the deep sedation of terminally ill patients who are unable to initiate their own sedation and voluntary are equivalent. It follows if we aren’t prepared to accept voluntary euthanasia we shouldn’t be prepared to accept deep sedation if the patient is unable to initiate his own anaesthesia.

In this posting I have argued that the deep sedation of terminally ill patients should be morally acceptable. I further argued such sedation was a legitimate use of medical skills. I have also assumed that most people would find such sedation acceptable and less contentious than either PAS or voluntary euthanasia. If most people find PA and voluntary euthanasia unacceptable and deep sedation is a legitimate use of medical skills then such sedation should be an option for the terminally ill. I then examined the moral implications of accepting deep sedation. The main implications of this acceptance are summarised below.

1. If we are prepared to accept deep sedation for terminally ill patients until death then we should be prepared to accept PAS when this process does not involve suffering.
2. If we are prepared to accept deep sedation until death and PAS involves some suffering then we should accept PAS provided that this suffering can be controlled without anaesthesia.
3. If we are prepared to accept deep sedation until death and a patient is able to initiate his own anaesthesia then in these circumstances we should be prepared to accept voluntary euthanasia.
4. If we are not prepared to accept voluntary euthanasia then we should not be prepared to accept deep sedation until death when a patient is unable to initiate his own anaesthesia.