Cryonic Preservation and Physician Assisted Suicide

Recently a terminally ill teenager won the right to have her body preserved by cryonics in the hope that she might live again at some future date. Such a hope comforted her. The case was really a case of whether she had the right to determine how her body was disposed of when she died, see bbc news . Cryonic preservation is not a form of treatment at the present time, cryonic preservation is simply a form of bodily disposal tinged with hope and as a result does not presently appear to pose any major ethical problems. However, let us imagine a scenario in the future when cures become available for some diseases which are currently terminal and that those preserved by cryonics can be brought back to life. This scenario raises ethical concerns and this posting I want to examine these concerns.

At the present time cryonic preservation might be defined as the preservation by freezing of a dead body in the hope that a cure for the disease that body died from becomes available in the future and that the body can then be resuscitated and cured. The case of the teenager above was an example of this type of cryonic preservation. However, an alternative form of cryonic preservation seems possible. Let us consider someone suffering from a terminal illness who finds his present life not worth living. He might consider physician assisted suicide PAS, such an option is available in several countries and some states in the USA. On reflection he might think a better option might be open to him. He wants his body frozen whilst he is still alive and preserved in the hope that a cure for the disease he suffers from becomes available in the future in the hope that he may be resuscitated and cured. For the rest of this post cryonic preservation will be referred to by CP. These alternative types of CP will be defined as follows.

• Type 1 CP will be defined as the preservation by freezing of a dead body in the hope that a cure for the disease that body died from becomes available in the future in the hope that he may be resuscitated and cured.
• Type 2 CP will be defined as the preservation by freezing of someone’s body whilst he is alive in the hope that a cure for the disease he suffers from becomes available in the future in the hope that he may be resuscitated and cured.

Type 1 CP is extremely fanciful because not only do cures need to be found and bodies unfrozen but also dead bodies need to be brought back to life. I will deal with type 2 CP first because there is more realistic opportunity of it being realised. There seems to be some possibility that in the future it might become possible to freeze and preserve someone’s living body and unfreeze it after a substantial period of time permitting him to resume his life. Such a scenario remains fanciful but is by no means impossible. Let us assume studies have frozen and stored large living animals and that after a substantial period of time have thawed them permitting them to resume their lives. I am assuming here that studies on rats or mice might not be applicable to humans. Let us assume someone is aware of this fact and learns he is starting to suffer from Alzheimer’s disease. I have previously argued it would not be irrational or wrong for such a person to commit suicide if he so desired and moreover it would not wrong to help him do so, see alzheimers and suicide . In this scenario it might be argued by analogy it would neither be irrational nor wrong for such a person to choose type 2 CP. Indeed, it might be argued as I have suggested above it is a more rational option than suicide. I now want to examine the ethical concerns raised by type 2 CP.

If we preserve someone using type 2 CP are we doing something which is wrong? To answer this question, we must first ask what are we doing if we preserve someone using type 2 CP? The company providing the service is simply storing a living body and this seems to raise no ethical concerns. But what are the doctors who prepare the body for storage doing? It is uncertain whether a cure might be found for Alzheimers. In this scenario how we describe these doctors’ actions in preparing him for preservation raise different ethical concerns. Are they killing him now, preserving him to die in the future or helping him commit suicide? The first possibility is clearly wrong. Is the second possibility also wrong? Delaying death is an accepted part of medical practice. But would it be right to delay death if there is no conscious life between the start of the delaying process and death? Intuitively though such an action harms no one and might not be wrong it seems pointless. If we accept physician assisted suicide, then we must accept the third option isn’t wrong. In the case of the teenager what was being decided was how a body might be disposed of. Let us now consider a variation of this case. Let us assume that a relatively young person who is competent to give informed consent is suffering from terminal cancer wishes to have his body preserved by type 2 CP. He wants his body preserved whilst he is still alive. Let us also assume using type 2 CP it is possible to preserve a body for a hundred years and then resuscitate it. It seems possible that a cure, or at least an ability to manage cancer, might well come about in the next hundred years. In this case if his doctors prepare his body for type 2 CP, what are they doing? In this scenario it seems wrong to say they are killing him, delaying his death or helping commit suicide. If the techniques involved in type 2 CP are proved to be safe and a cure for cancer is a genuine possibility then I would suggest his doctors are treating his disease, they are treating him a patient and there are no ethical objections to doctors treating patients. In might be objected that doctors only treat patients so they can recover from their illnesses. In response I would point out doctors treat patients when they manage cancers they can’t cure by providing palliative care. Let us assume it is possible to preserve a body for a hundred years and then resuscitate it. In the light of the above it might be concluded that it would not to be wrong for doctors to prepare a relatively young competent person for type 2 CP provided he or those close to him could pay for the service. The above conclusion is subject to two conditions. First there must be a reasonable prospect that the condition he suffers from will become curable or manageable in the future and secondly that it has proved to be possible freeze and store large living animals and after a substantial period of time these can be unfrozen permitting them to resume their lives.

Let us accept the above conclusion that it is not wrong to provide type 2 CP to relatively young competent patients when there is a realistic possibility that their illness can be cured in the future. But would it be wrong to provide such treatment to older or even incompetent patients. I will deal with someone who is incompetent first. If someone is incompetent to give consent to treatment then a surrogate decision maker, such as the courts or his parents, acts on what is in his best interests. Intuitively it might be objected deciding to use type 2CP is not deciding about treatment. However, I have argued for a relatively young competent person type 2 CP can be seen as a form of treatment. Moreover, I would suggest treatment doesn’t become non-treatment simply because someone is unable to give competent consent. Accepting the above raises many practical problems. Should type 2 CP be carried out if someone who is incompetent resists such treatment? I would suggest it should not but will not offer any arguments here to support my suggestion. Should type 2 CP be carried out if someone who is incompetent but is prepared to accept such treatment? I would suggest it should. If we believe it shouldn’t then mustn’t we also believe the lives of the incompetent have less value than those of the competent whilst at the same time remembering that young children are incompetent. Moreover, if we accept the above aren’t we are encouraging eugenics by the backdoor? It might be concluded that it would not wrong to provide type 2 CP to relatively young incompetent patients, provided they are prepared to accept treatment and those close to them are prepared to pay for the service. This conclusion is subject to the same conditions required for the relatively young competent patients outlined above.

Is it wrong to offer type 2 CP to older persons? It seems to me in world of infinite resources it would not. Resources in this scenario are not a problem and it would appear that if someone believes it would wrong to offer type 2 CP to older persons that it should be up to him to justify his belief. It can again be concluded it would not be wrong to offer type 2 CP to older persons, subject to the same conditions outlined in the other two cases.

I now want to consider a different question. If type 2 CP could be regarded as treatment would we have a duty to provide this treatment? This question is at the moment completely hypothetical. However, if studies froze and stored large living animals and then after a substantial period of time thawed them permitting them to resume their lives, then this question would cease to be a hypothetical one. Indeed, if there was also the possibility of several new cures for previously incurable diseases an answer to this question becomes important. Usually whether someone should be offered treatment depends on the quality added life years, QUALYs, expected from the treatment in question. It might be concluded that it would not be wrong to offer type 2 CP to older persons when the number of expected QUALYs is similar to the expected QUALYs offered by other accepted treatments subject to two provisions. First, the number of expected QUALYs should not include the years spent in frozen state. Secondly it possible that the freezing process might reduce the number QUALYs and this should be taken into account.

I have argued that it would not be wrong to provide type 2 CP to people who can finance this service themselves. I have also argued that it is possible that in the future type 2 CP might be regarded as treatment. It seems that the same arguments I used regarding type 2CP can be applied to type 1 CP concerning its permissibility. However, in some circumstance type 2 CP might be seen as a form of treatment, it is difficult to see how type 1 CP might be regarded as a form of treatment. Philosophy should not only be concerned with what should be permitted but also with what helps people flourish, philosophy should make recommendations about how to live. Let us assume one or both types of CP prove to be effective. Should we recommend that someone facing terminal or life changing illness try CP? Several reasons might be advanced as to why we should not. First, a long suspension might mean they awake to an alien world making it hard for them to cope. Secondly a long suspension might mean they awaken to find their friends, spouse and even children have died. Whether someone would want to undergo CP would depend not only on their imagined future but also on their current circumstances. A single lonely person might find CP attractive whilst someone whose life centres on family might not. The young might find CP more attractive than the old because CP offers them the possibility of a longer life extension. Personally as a relatively old man I do not find the idea of CP attractive, however returning to our starting point if I was fourteen I might well do so.

Nussbaum, Transitional Anger and Unconditional Forgiveness

Charles Griswold argues that forgiveness is a kind of transaction and as a result there are certain conditions attached to the transaction which mean that one cannot truly forgive without fulfilling these conditions (1). In response it might be pointed out that conditional love is inferior to unconditional love. It might then be argued by analogy that conditional forgiveness, transactional forgiveness, is inferior to unconditional forgiveness. In this posting I will argue this doesn’t hold and that transactional forgiveness is morally more desirable than unconditional forgiveness because of the message it sends to the offender.

Martha Nussbaum rejects the idea of transactional forgiveness as suggested by Griswold and goes further by arguing that there are also problems with unconditional forgiveness. The problem with all sorts of forgiveness according to Nussbaum is that it is essentially backward looking and attached ideas of payback. She argues rather than forgiving we should engage with offenders in a spirit of active love (2). In response to such arguments Griswold suggests that for a victim just to give unconditional forgiveness means she lacks self-respect and that others will also fail to respect her. Intuitively if someone who has been wronged and the offender exhibits no remorse or indeed continues offending, holds no resentment, then the victim lacks self-respect. Intuitively it also seems morally wrong, not just hard, for someone who has been sexually assaulted to unconditionally forgive her assailant.

In this posting I don’t want to examine a lack of respect. Instead I want examine two different objections to unconditional forgiveness. First, I will argue that in some circumstances unconditional forgiveness means the victim far from having too little self-respect, means she actually has too much and is over proud. Secondly I will argue unconditional forgiveness by the victim harms the offender. Let it be accepted that all forgiveness whether unconditional or transactional means letting go of resentment. Intuitively this appears to be true for it seems impossible to believe a victim truly forgives her transgressor if she still bears resentment towards him. For the sake of argument let us assume Sue has been morally harmed by John and that she has unconditionally forgiven him. In this context because Sue’s forgiveness is unconditional it is possible that John might remain quite happy with the fact that he has morally harmed Sue and would be fully prepared to do so again.

Let us examine Sue’s motives in unconditionally forgiving John. According to Nussbaum sometimes,

“the person who purports to forgive unconditionally may assume the moral high ground in a superior and condescending way.” (3)

If we accept Nussbaum view, then it is possible that Sue’s underlying motive in unconditionally forgiving John is to feel good in a superior way. Sue’s motive displays a certain moral arrogance. Such a motive does not justify unconditional forgiveness. However, let us assume that Sue’s motive is not to feel superior but simply a desire to act in a moral manner.

Let us examine the above assumption. I now want to present two arguments why even in this context Sue’s unconditional forgiveness might be flawed. Both arguments will be based on Sue’s focus. Firstly, I will argue that by unconditionally forgiving John to satisfy her desire to act in moral manner Sue might still be exhibiting an excessive moral pride. Before proceeding I must make it clear I am not attacking limited moral pride, moreover I believe that some limited moral pride is a good thing. How then can Sue exhibit excessive moral pride by unconditionally forgiving John? It seems possible to me that Sue’s motives for forgiving John might have nothing actually to do with John. Let us assume Sue’s unconditional forgiveness is due to her focus on acting morally and isn’t a case of moral grandstanding. Her focus might be flawed if it focusses exclusively on Sue’s behaviour because her focus is too narrow. If Sue focusses exclusively on her own behaviour, focusses on herself, then she seems to be exhibiting excessive pride. Nussbaum for instance might argue such a limited focus is unhealthy because it contains a narcissistic element. It follows that if underlying Sue’s unconditional forgiveness is an excessive pride that her motive for this forgiveness is flawed, indeed it might be argued that by excessive cherishing of herself she damages herself. However, it does not automatically follow that her unconditional forgiveness of John cannot be justified by other reasons just because Sue’s motivation is flawed.

Let us assume Sue’s motive for her unconditional forgiveness is simply focussed on acting morally and has nothing to do with excessive pride. This brings us to the second of my two arguments. I want to argue that whilst Sue’s simple desire to act morally is admirable the way she enacts this desire is flawed. I will base my argument once again on Sue’s narrow focus. In order to act in a true moral way people must consider all moral agents and not just a select few, a particular morality is a partial morality. Any non-partial system of morality must include those who harm us. I would suggest that Sue’s narrow focus on unconditionally forgiving John means she fails to genuinely consider his moral needs. Sue is only considering herself morally and disregarding the moral needs of John. By withdrawing her resentment Sue is withdrawing something that might help John become a better person. Resentment at wrongdoing is not simply something the victim feels; resentment also sends a signal to the offender that he is causing moral harm. It seems to me that by unconditionally forgiving John Sue is denying John this signal which might help him become a better person. Agnes Callard makes a similar argument with respect to revenge when she argues that “revenge is how we hold one another morally responsible” (4). It follows Sue’s unconditional forgiveness of John whilst admirable in some ways is nonetheless flawed because she ignores John’s moral needs or is mistaken about what will help John become a better person.

I have argued that conditional is superior to unconditional forgiveness however it might be argued by some that my conclusion is unsound. They might point out that unconditional forgiveness seems to set an excellent example of how to love others and this reason for supporting unconditional forgiveness outweighs the reasons against I have advanced above. In response I would argue the recognition of others as moral agents is even of even more fundamental importance to morality than any possible demonstration of love. Without this basic recognition no system of morality can even get started. In my example it seems to me if Sue unconditionally forgives John then she is acting in a way she believes is best for John and by so doing she is failing to recognise him as a fully moral agent.

Does accepting that unconditional forgiveness might be harmful mean we must accept the type of transactional forgiveness favoured by Griswold? Nussbaum sets out the long list conditions necessary for Griswold’s conditions for transactional forgiveness to take place (5). She argues that going through such a process is a humiliating one smacking of payback, I am inclined to agree. Griswold’s transactional forgiveness makes sense if we accept a traditional view of anger which includes payback. However, Nussbaum argues ideas of anger involving payback doesn’t make sense. Once we see traditional anger doesn’t make sense we can transmute it into action according to Nussbaum. Traditional anger,

“quickly puts itself out of business, in that even the residual focus on punishing the offender is soon seen as part of a set of projects for improving both offenders and society.” (6)

I am again inclined to agree with Nussbaum that anger should be transmuted into something useful. I am inclined to agree because I believe like Michael Brady that emotions, including anger, act in a way analogous to alarms focussing our attention on the need to do something (7). Alarms are meant to be attended to, an unattended car alarm is annoying, unattended anger can be damaging. However, even if unattended anger is harmful this doesn’t mean anger is harmful. Unattended alarms are annoying but alarms are useful. Unattended anger may be harmful but anger is useful, anger draws attention on the need to do something. According to Nussbaum anger should “focuses on future welfare from the start. Saying ‘Something should be done about this”. (8) If we accept that anger should be attended to, be transmuted, then it seems to me Griswold’s transactional idea of forgiveness is in trouble because the transactions involve payback which seem to me to be related to un-transmuted anger.

If we forgive someone and we do not adopt Griswold’s ideas on transactional forgiveness are we forced somewhat reluctantly to conclude that our forgiveness should be unconditional? I don’t believe it does. What does it mean to forgive? If we define forgiveness as simply as relinquishing anger and its associated desire for revenge, then a commitment to transitional anger also means commitment to unconditional forgiveness. It means even if John remains quite happy with the fact that he has morally harmed Sue and remains prepared to do so again that if Sue translates her anger that she forgives him unconditionally. However, forgiving someone might mean also be defined as the normalisation of relations between the forgiver and the forgiven. Translating anger in this context doesn’t simply mean moving on. Transitional anger means looking to the future, moving on. Transitional anger also means looking back to the past, past wrongdoing cannot be ignored after all it is the reason why we must look to the future. This approach doesn’t of necessity involve a formal transactional process involving payback. It does however mean that certain minimum conditions not involving payback must be met. Relations cannot be normalised if a wrongdoer disputes the facts or wrongness of his action. In this situation victims are entitled to protect themselves by withholding trust. Trust is an essential part of normal human relations if someone is always wary of another their relationship cannot said to be a normal one. Protecting oneself doesn’t need involving payback. It follows forgiveness requires that the wrongdoer must accept responsibility for the act and acknowledge its wrongness for normal relations to be met. It further follows if someone accepts transitional anger that his acceptance does not commit her to unconditional forgiveness which might harm the wrongdoing.

1.    Charles Griswold, 2007, Forgiveness, Cambridge University Press.
2.    Martha Nussbaum, 2016, Anger and Forgiveness, Oxford University Press, Chapter 3.
3.    Nussbaum, chapter 3.

4.    Agnes Callard, 2020, On Anger, Boston Review Forum, page 15
5.    List of Griswold’s conditions as outlined by Nussbaum.
·       Acknowledge she was the responsible agent.
·       Repudiate her deed (by acknowledging it. Express regret to the injured at having caused this particular injury to her
·        Commit to becoming a better short of person who does not commit injury and show this commitment through deeds as well as words.
·       Show how she understands from the injured person’s perspective the damage done by the injury. Offer a narrative of accounting for how she came to do the wrong, how the wrongdoing does not express the totality of the person and how she became worthy of approbation.
·       Acknowledge she was the responsible agent. Repudiate her deed (by acknowledging its wrongness) and herself as the cause.
·       Express regret to the injured at having caused this particular injury to her.
·       Commit to becoming a better short of person who does not commit injury and show this commitment through deeds as well as words. 
·       Show how she understands from the injured person’s perspective the damage done by the injury. Offer a narrative of accounting for how she came to do the wrong, how the wrongdoing does not express the totality of the person and how she became worthy of approbation.
 
6.    MARTHA C. NUSSBAUM, 2015, Transitional Anger. Journal of the American Philosophical Association, page 51.
7.    Michael S. Brady, 2013, Emotional Insight; The Epistemic Role of Emotional Experience, Oxford University Press
8.    MARTHA C. NUSSBAUM, 2015, Transitional Anger. Journal of the American Philosophical Association, page 54.

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Montgomery and the Information needed for Valid Informed Consent

In the light of Montgomery case  the Royal College of Surgeons  has warned the NHS that failure to fully implement informed consent rules opens the way to more litigation. In this case the court held that doctors must ensure patients are fully aware of any and all risks that an individual patient, not mainstream medical practice, might consider significant. This judgement appears contrary to the judgement given in the Bolam case which held the information necessary for consent to be considered valid was the information most doctors would consider necessary. In other words, the medical profession could act in a paternalistic manner with regard to the amount of information it provided.

I have some sympathy for the Montgomery decision because I believe that patients rather than their doctors should decide how much information they need to make informed consent decisions. Nonetheless I also believe there is now a clear danger of some patients being over informed making it hard for them make informed consent decisions. There is a difference between doctors simply acting paternalistically and acting paternalisticlly if asked to do so. In this posting I will argue it is possible to over inform some patients and that it is possible to give adequate consent on limited information.

 In making by argument I will use an example provided by Steve Clarke.

“Consider the case of ‘Squeamish John’. Squeamish John cannot bear to hear the details of medical procedures; hearing these make him feel weak at the knees and dramatically diminishes his capacity to make sensible decisions. Nevertheless he does not wish to abrogate responsibility for his decision about whether or not to undergo an operation. Squeamish John wishes to participate in a restricted informed consent process in order to make his decision. He wishes to make a decision based only on the disclosure of the risks and benefits of the operation couched in cold, impersonal, statistical language. He does not wish to have any significant details of the procedure described to him.” (1).

In addition, let us assume John is lying in hospital bed suffering from type2 diabetes and needing a leg amputation. Let us assume John gives consent in the restricted way outlined by Clarke and he regains consciousness minus one leg. Intuitively such a situation seems very wrong. Nonetheless I would argue it is possible for John to make an autonomous decision based on restricted information. John is making a decision to trust his doctor and it is possible to make an autonomous decision based solely on trusting the advice of another. If I trust the advice of my lawyer or financial advisor I am making an autonomous decision I can identify myself with. Are then doctors any less trustworthy than lawyers or financial advisors? It seems obvious to me that they are not. 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? Once again I would suggest it does not. It follows if squeamish John is permitted to make a decision in the way he prefers it would be an autonomous decision.

However, let us put questions of autonomy to one side. Let us assume John’s doctors follow the Royal College of Surgeons advice and do not allow him make his informed decision based on restricted information. Let us further assume John refuses to listen to or read most of the information they provide. In this situation it seems to me that John’s doctors have two available options. First, they might discharge him simply because he won’t listen knowing that his discharge will probably lead to death. In less life threatening cases than that of John this would be the probable outcome. It seems wrong to condemn summon to die because he simply won’t listen. Secondly they might decide his refusal to listen to all the details of his projected operation makes him incompetent to give consent. This decision would have to be validated by the courts. Let us assume this decision is validated and a decision on John’s treatment is made by a surrogate. This surrogate should make a decision based on John’s best interests, his best interests will be decided by his doctors. The outcome would be identical to that if it was accepted that John could make a valid informed consent decision based on trusting his doctors.

I accept my example is an extreme one but I believe it nonetheless raises some interesting questions. First, the Montgomery case seems to show that informed consent is not simply based on respect for autonomy. I have argued it is perfectly possible to make an autonomous decision based on trusting the advice of another person. Some patients at a very stressful time might want to make extremely complicated decisions and would prefer to make simple autonomous decisions. The Montgomery decision seems to deny them the possibility of making such decisions. The Montgomery judgement seems to require that much more information needs to be provided in order to make a valid informed consent decision as opposed to an autonomous decision. Secondly if doctors must ensure that patients are fully aware of any and all risks involved in their procedure, must doctors ensure they understand these risks including the probabilities involved or only have the capacity to understand. Must doctors ensure that their patients listen intently or fully read the information provided? Lastly even if doctors can be sure that patients understand the information should they also insist patients actually use it when making decisions? In conclusion I believe there are problems connected to the Montgomery case’s requirement that patients must aware of any and all risks involved their procedures. I also believe patients must have the possibility of becoming aware of any and all risks involved their procedures but that this awareness should be driven by patients’ needs. It seems this awareness is at moment being driven by fear of litigation rather than any genuine concern for patients’ real needs.

1. Steve Clarke, 2001, Informed Consent in Medicine in Comparison with Consent with Consent in Other Areas of Human Activity, The Southern Journal of Philosophy, 39, page 177

A Duty to permit Assisted Suicide?

In previous postings I have argued that we should accept that terminally ill people have a right to die and that we should respect that right by accepting assisted suicide. My arguments were based on respecting autonomy and of course respecting autonomy involves duties. However in this posting I want to focus more directly on duties. I will argue that we have a duty not to cause terminally ill people who are suffering to continue to existing against their will. We have a duty not to force innocent people endure pain in order to protect the vulnerable, surely the vulnerable can be protected in better ways.My argument will be based on the premise that we have a duty not to bring into existence any being which would find its life not worth living.


Let us accept the above premise without argument. I now want to suggest that the duty not to bring into existence any being we think would not find its life worth living is analogous to a proposed duty not to cause any being to continue to exist against its will if its life is not living. Accepting this analogy would have implications for using animals in medical research but in the following discussion I will limit my argument to assisted suicide. It might be objected that my suggested analogy fails for two reasons. First, it might we objected that by refusing to grant the right to assisted suicide to these people we do not cause them to lead lives which are not worth living. Secondly it might be objected even if some people do experience lives which are not worth living this would be better rectified by changing the conditions of these lives rather than by making assisted suicide available to such people. I will deal with each of these objections in turn.

Let us accept that that we have a duty not to bring into existence any being we think would find its life not worth living. We have a duty not to cause the existence of such lives. My objector might accept this premise. We shouldn’t enslave or torture people for instance. But he might argue that we don’t cause terminally ill patients or prisoners serving life sentences to lead lives not worth living and as a result my analogy fails. The cause of their misfortune is due to disease or past crimes. He might then proceed further by suggesting even if we are a partial cause of the type of lives some people live that a partial cause doesn’t give rise to a duty. Let accept that my objector does accept that he has duty not cause a child to come into existence who wouldn’t have a life worth living. Let us assume this child wouldn’t have a life worth living due to some genetic defect. It follows anyone who permits such a child come into existence is only a partial cause of the child not having a life worth living. It would appear my objector must accept either that our partial causation of some event can incur duties or that there is nothing wrong with causing a child to exist when he will not have a life worth living due to genetic defects. In the light of the above example my initial premise might be amended as follows. We have a duty not to be the partial cause of the existence of any being which wouldn’t have a life worth living. If someone accepts my amended premise, then it might be argued by analogy that we also have a duty not to be the partial cause of someone continuing to live a life he doesn’t find worth living.


At this point my objector might raise a second objection to my analogy. He might point out that in my amended premise we only have a binary option of causing or not causing existence. He might proceed to further point out that for both those suffering from terminal illnesses and prisoners serving life sentences other options are available. For terminally ill patients we could improve palliative care and for prisoners serving life sentences we might improve penal conditions. I accept my objectors point and accept that provided other options are available which would allow both of these categories of people to live lives they would find worth living my analogy fails. I also accept that improvements in palliative care and prison conditions are desirable and should be carried out. However, I do not accept that such improvements always means we are not the cause of making someone live a live he finds not worth living. Simply removing pain from a terminally patient’s life doesn’t mean he has a life worth living. We can remove all pain from someone by putting him in an induced coma for the rest of his life. Would such a patient really be alive? I would argue if someone is unconscious and will never regain consciousness he is in a state equivalent to being dead, he is certainly not living any sort of live at all. Whether it is possible to remove almost all the pain from all conscious terminally ill patients so that pain by itself doesn’t mean they don’t have lives worth living is an empirical question. Personally I doubt whether this will be possible in all cases but I will not pursue the point here. However, even if we could reduce pain to acceptable levels for all terminally ill patients it does not follow that they have lives which they believe are worth living. A life worth living is not just a question of having a relatively pain free conscious existence. Is simply existing really living? A very limited lifespan together with vastly impaired capabilities might well mean some such people find their lives lacking all meaning, find their lives not worth living. I would suggest anyone who suggests otherwise might be accused of epistemic arrogance. It follows even if palliative care was much improved there would still be some terminally ill patients living lives which they would find to be not worth living. It might also be argued much improved prison conditions don’t automatically mean prisoners serving life sentences always find their lives worth living. Some such prisoners might suffer from remorse which makes their lives not worth living. Indeed, better penal conditions might increase such prisoners’ propensity to suffer remorse. Other such prisoners might find the impossibility of freedom makes their lives meaningless, not worth living. It again follows that improved penal conditions would not mean all prisoners serving life sentences would have lives they considered to be worth living.

In the light of the above it appears, if we accept the premise that we have a duty not to bring into existence any being which would find its life not worth living that we also have a duty not to cause people to continue to exist if they have lives not worth living. It follows we should permit assisted suicide to those suffering from terminal illness. Accepting the above might also mean some patients with a terminal diagnosis who find their lives worth living might better enjoy their lives if they had the reassurance that if these lives became unbearable they could be helped to end them removing their worries about how these lives might end.

Happiness and Consumerism

It is commonly asserted that people aren’t as happy as they used to be years ago due to the consumerist culture we live in. Usually very little evidence is produced to support this assertion. In this posting I will attempt to remedy this situation by providing an argument to support the above assertion. I will argue that our culture limits our ideas about what makes us happy and that this limitation limits the amount of happiness we experience. Previously I have argued that the way in which we are happy changes as we age and mature and I will use this argument as a starting point to support the current argument. My argument rests on two important premises both of which I will support by argument. Firstly, I will argue that our actual level of happiness depends on, at least to some degree, our ideas about what will make us happy. Secondly, I will argue that our culture helps define those ideas. I will conclude that we should try to broaden the focus of our culture particularly with regard to the way we work and the way we are educated.

Before proceeding with my argument I want to introduce two differing ideas, concepts, of happiness. Firstly, there are hedonistic concepts of happiness such as that outlined by Fred Feldman. Feldman believes someone is happy now “if when we consider all the propositions with which she is currently intrinsically attitudinally (dis)pleased with and we then consider the degree to which she is (dis)pleased with these propositions and find the sum to be positive” (1). This is a definition of momentary happiness but in this posting my concern will be with happy persons rather than momentary happiness. Feldman believes a happy person is simply one who over time is pleased to a greater degree than she is displeased. A different concept is that of Daniel Haybron. According to Haybron,

“To be happy then, is for one’s emotional condition to be broadly positive – involving stances of attunement, engagement and endorsement – with negative central affective states and mood propensities only to a minor extent.” (2)

 There is some overlap between these concepts but Haybron argues that happiness,

“has two components: a person’s central affective states and second, her mood propensity …. What brings these states together, I would suggest is their dispositionality.” (3)

I have previously argued that a disposition to be happy is an essential element of being a happy person and will briefly repeat my argument here, see Feldman, Haybron and happy-dispositions . There is a difference between a happy person and a person who is happy. It seems to me that Feldman and hedonists are interested in people who are happy rather than happy persons. A person who is happy is simply a person who is currently happy. The fact that a person is currently happy by itself gives me little reason to assume she will be happy tomorrow. I may of course believe she will be happy tomorrow because I know that tomorrow will be her birthday, but the fact she is happy currently, by itself, gives me little reason to predict her future happiness. However, if I believe someone to possess a happy disposition then I normally expect her to be happy tomorrow. For this reason, I believe Haybron better defines what it is to be a happy person and will use his definition unless stated otherwise.

If we accept Haybron’s definition, then it seems to me that the relative importance of the various elements within his definition change as we age, see does our concept of happiness change as we age . I will briefly outline my argument. Let us recall that that someone is happy if her emotional condition is broadly positive and that this involves her in general being attuned to, engaged with and endorsing her emotional condition. Haybron ranks the importance of attunement, engagement and endorsement in that order in relation to happiness. Haybron connects endorsement to feelings of joy or sadness (4). I suggested endorsement involves being satisfied with rather than any large scale feelings of joy or sadness. I did however suggest being satisfied with does involve some minimal positive emotion, slight joy? If the above is accepted, then being satisfied is an essential element of being happy. A further argument can be advanced as to why being satisfied is an essential element of happiness. Martin Seligman believes achievement is an essential element of happiness (5). It seems to me that achievement usually linked to being satisfied. If we accept that Seligman is correct and achievement is an important element of being happy then it follows so is being satisfied. Lastly I argued if we accept that satisfaction is an essential element of being happy then the way we are happy changes as we age because younger people give greater weight to hedonistic pleasures whilst older people give greater because to being satisfied. It would appear the way in which we are happy changes as we age.

Let us accept that the way in which we are happy changes as we age. I now want to argue that our ideas about what will make us happy affects the level of happiness we actually experience. Some might question if an idea about what will make us happy is needed if we are to be happy. They might suggest people are just happy or unhappy and don’t need any ideas about what will make them happy. To support this suggestion, they might point out animals and infants can be happy without any idea of what will make them happy. They might proceed to argue that apart from philosophers most people are simply happy or unhappy. However unlike animals or infants we aren’t simply happy, we actively pursue happiness. A pursuit is impossible without some goal. The pursuit of happiness implies that we must have some ideas about what will make us happy. Let us accept that people must have some ideas about the things which will make them happy however vague. However even if we accept the above it doesn’t automatically mean our ideas about the things will make us happy are related to the level of happiness we experience. We might be mistaken about what will make us happy. It might be suggested that such mistakes are of little importance because we naturally pursue the things that make us happy. I would reject such a suggestion. Let us accept that there can be a mismatch between the things we think will make us happy and the things that actually make us happy. Having mistaken ideas of what will make us happy can damage our actual happiness. We can pursue things that don’t really make us happy at the expense of not pursuing thigs that actually make us happy. Examples are easy to find. For instance, someone who desires meaning in his life but pursues hedonistic lifestyle because he believes living such a life will make him happy. Or perhaps someone who pursues a stoic way of life and rejects the demands of love. It follows that our ideas of what will make us happy can affect the actual level of happiness we experience.

I now want to argue that the culture someone lives in affects her idea of what will make her happy. Clearly someone’s culture affects the things that make her happy. For instance, some cultures value wealth whilst others value honour more than wealth. It might be argued that this difference is only a difference in what makes us happy but not in the way we are actually happy. For instance, someone might be a gourmet and value good food whilst someone else might be a libertine who values having sexual intercourse as often as possible. Two different sort of things make these people happy but both of these people have the same underlying idea about the way they will be happy. It might be concluded that our basic idea about the way we will be happy doesn’t change even if its focus does. I now want to argue such a conclusion would be mistaken because in certain cases the things we value helps determine the way we enjoy them. Let us consider someone who values honour. Haybron hints that if someone is happy there is a link between her happiness and the self. (7) I believe Haybron is correct and that there is indeed a connection between some forms of happiness and the self. Clearly this is not the case with hedonistic happiness. To enjoy a good meal or sexual intercourse no one needs a sense of self. This is not true of someone who values honour ‘cares about’ or loves her honour. Valuing honour is connected to her identity, her sense of self, see some of my previous postings. I would suggest such a person will be happy when she acts honourably and that her happiness depends on her satisfaction with acting as she believed she should. I would further suggest her satisfaction is linked to her sense of self by her cognition. The way she is happy is very different to the way someone is happy when enjoying a good meal or having sexual intercourse. Let us accept that people can be happy in different ways and that the pursuit of different ways of being happy requires different ideas about happiness. Let us also accept what we value determines the way we enjoy it, the way in which we are happy. Different cultures value different things. Some of the things we value are determined by the culture we live in. It follows culture helps to determine the way in which we are happy.

No culture is completely homogenous and our culture certainly isn’t. However, I now want to argue that a certain dominant idea within our current culture fosters ideas about what will make us happy which damage our actual happiness. In the western world our culture is dominated by the idea of the consumer. Advertising suggests we will be happier if we have the latest car, have a large modern house, have shinier hair, have brighter teeth, etc. Advertising suggests we will we happier if we have certain things, if we are consumers. Western culture sees us as consumers just as much as it sees us as citizens. The idea of a consumerism is widespread even extending into education. In school pupils are encouraged to learn in order to get good jobs rather than enjoy learning. In education more generally courses are becoming increasingly designed with employment in mind rather broadening students’ horizons. Education is in Yeats words becoming a matter of filling pails rather than lighting fires. I argued above culture helps determine the way we are happy. A culture with a dominant consumerist ethos supports a hedonistic ideas of happiness such as that of Feldman. I further argued that an account such as that of Feldman offers an incomplete concept of happiness because it offers an inadequate account of what it means to be a happy person. Lastly I argued that our ideas about what will make us happy affect the actual happiness we experience. It follows that someone holding an incomplete idea of what will make her happy might experience less actual happiness than if she had a more complete idea.

I now want to discuss four ways in which our overly consumerist culture damages our happiness by fostering an incomplete idea of happiness. First, I have argued above our consumerist culture fosters a hedonistic ideas of happiness. I argued above that such an account of happiness is an incomplete account. Let us recall that that according to Haybron someone is happy if his emotional state is positive and he is attuned, engaged and endorses that state to some degree. I have suggested endorsement is linked to satisfaction. Someone might be satisfied if she is eating a chocolate cake, with some state of affairs or past achievements. Being satisfied with eating a chocolate cake does not involve any cognitive abilities. However, if someone is satisfied with some state of affairs or past achievements she engages some of her cognitive abilities. A hedonistic account of happiness does not directly involve our cognitive abilities. It follows if culture fosters a hedonistic idea of happiness that this fostering might limit some peoples’ ideas about happiness by diminishing their desire to pursue some of the things which might add to their happiness, by limiting their desire to pursue things that satisfy them. Secondly I have argued that as people age the weights attached to the various elements which contribute to their happiness change. A culture which fosters a mostly hedonistic idea of happiness damages that change and as a result damages the happiness they experience. I have outlined this argument above and will not repeat it here. Again it follows that an overly consumerist society might limit our overall happiness especially for older people. Thirdly would argue that our consumerist culture encourages an attitude to work which limits the happiness we experience. Let us accept that some work can give our life meaning and that this meaning increases our happiness. There are two different definitions of work. Firstly, we might define work simply as labour undertaken for some economic reward or hope of such a reward, let us define this as working for something. Such work is instrumental and has no intrinsic value. Secondly someone might work at something. For instance, she might work at playing some musical instrument simply because she enjoys it. Someone playing a musical instrument might become fully immersed with her music losing any feeling of reflective self-consciousness.  According to Mihaly Czikszentmihalyi when someone is in such a flow state she experiences positive emotions. These emotions contribute to his happiness. Our consumerist culture encourages working for something at the expense of working at something and by so doing limits our ability to experience our ability to experience the positive emotions generated by flow. It again follows that an overly consumerist society damages our overall happiness. Lastly our consumerist culture emphasizes consuming things makes us happy. I don’t deny consumption might make us happy for a while. A consumerist culture places emphasis on momentary happiness. It seeks to make people happy, which in itself is laudable, but it is much less concerned with happy people and this lack of concern also limits our happiness. At this point I must it clear that when I speak about happy people I am concerned with people who have a disposition to be happy rather than people who are simply experiencing positive emotions. Our consumerist culture limits happiness because momentary happiness is fragile happiness whilst the happiness experienced by happy people is more robust than momentary happiness. It again follows that an overly consumerist society damages our overall happiness.

What conclusions can be drawn from the above? First our consumerist society damages our happiness and we should seek to broaden the focus of society. Our attempts to broaden the focus of society should concentrate on work and education. This expanded focus might be particularly important if automation leads to people working less. If work provides some meaning in life then it is important to change society’s focus from ‘working for’ to ‘working at’, see work, automation and happiness . An overly consumerist society might find such a change difficult. Secondly if it is hard to broaden society’s focus it becomes especially important to have an accurate idea of what makes us happy, our concept of happiness matters.

1. Fred Feldman, 2010, What is this thing called Happiness? Oxford, page 29.
2. Daniel Haybron, 2008, The Pursuit of Unhappiness, Oxford, page 147.
3. Haybron, page 138.
4. Haybron, page 113
5. Martin Seligman, 2011, Flourish, Nicholas Brealey Publishing, Chapter 1.
6. Haybron, page 130.

Sport, Motivational Enhancement and Authenticity

 

Heather Dyke writing in the conversation examines why doping in sport is wrong. In a previous posting I have argued that doping in sport is wrong for three main reasons, see sport performance and enhancing drugs . Firstly, I believe there should be a difference between sport and simple spectacle and that the use performance enhancing drugs by sportspersons erodes this difference. Secondly I argued that permitting performance enhancing drugs simply moves the goalposts. If we don’t permit the use of all drugs, including dangerous ones, we will still have to test whether any drugs used are permitted ones. Lastly I argued what we admire about sport is linked to the determination and effort required by sportspersons and that the use of performance enhancing drugs weakens this link. Determination and effort are linked to motivation, to character. I have previously argued that it would not be wrong to enhance our motivation, see effectiveness enhancement . It would appear that I hold two conflicting positions with regard to doping in sport. In this posting I want to examine this conflict.

Let me start my examination by making it clear the sort of doping I am opposed to. I believe any drug which enhances an athlete’s body damages sport for the three reasons outlined above. If some mediocre athlete could transform himself into an Olympic champion in a matter of weeks by taking some drug which vastly physically enhanced him would we really admire him? I would suggest we would not because we feel sporting excellence should require some effort. Now let us consider a second mediocre athlete who transforms himself into an Olympic champion over by taking some drug which enhances his motivation over a number of years. By transforming his motivation, he trains more determinedly and makes greater effort when training. This second athlete raises three interesting questions. Firstly, is there any real difference in a sporting context between an athlete taking a drug to enhance himself physically and enhance himself mentally? Secondly would we admire such an athlete? Lastly is the enhancement of someone’s motivation compatible with the ethos of sport?

I will now attempt to answer each of the above a questions in turn. Is there any real difference in a sporting context between an athlete taking a drug to enhance himself physically and enhance himself mentally? Clearly there is a difference in this case because an athlete who enhances himself physically with the use of drugs need make no effort to achieve his enhancement whilst a second athlete who physically enhances herself by mentally enhancing her motivation must still train hard. Does this difference matter? The answer this additional question is connected to our second original question. What do we admire about sportspeople? I would suggest we admire their dedication to the effort required for their sport, we admire their motivation for sport, we admire part of their character. Of course it follows we need not admire all of a sportsperson’s character. Let us accept that we admire a sportsperson’s motivation, effort and dedication. The question now would admire his motivation, effort and dedication if these were artificially enhanced?

It might be argued that if we obtain certain goods easily without any real determination that in so doing we devalue determination in general. Let us assume it is possible to artificially enhance our motivation by making us more determined. Let us accept that if an athlete enhances himself physically by the use of drugs, gene therapy or blood doping that he devalues the importance of motivation. Does the same apply if he enhances his motivation artificially? I would suggest it does not. There is an important difference between the enhancement of effectiveness and the enhancement of motivation. Enhancing our effectiveness devalues our motivation whilst it is hard to see how enhancing our motivation could possibly devalue motivation. Accepting the above means it might be possible to admire an athlete who artificially enhances his motivation whilst at the same time failing to admire an athlete who simply enhances himself physically.

At this point someone might object that whilst accepting someone who enhances his motivation does not devalue his motivation that nonetheless he devalues himself as a person. He does so by making himself less authentic. My objector might then argue someone shouldn’t enhance his motivation because being authentic is something we value. In response I would point out the things which make us authentic aren’t fixed from birth, babies aren’t authentic. People seek to change themselves by enhancing themselves by training or learning. I can see of no reason why people changing themselves by these means will render themselves inauthentic. I would suggest someone’s authenticity depends on him seeking goals he identifies with rather than the means he chooses to seek these goals. Someone’s authenticity is determined by what he loves or cares about. I would further suggest that a truly authentic person must always choose those means which are most effective in promoting the goals he identifies herself with. It follows if these means include enhancing his motivation that this enhancement isn’t inauthentic. Indeed, it appears that if someone doesn’t use the most effective means to promote those goals he identifies with that his authenticity is weakened. Sometimes those most effective means might include motivational enhancement and it follows someone does not use motivational enhancement that his authenticity is weakened

What conclusions can be drawn from the above. Firstly, physical enhancement by artificial means devalues sport.  Secondly motivational enhancement by artificial means does not seem to conflict with the ethos of sport provided it is accepted this ethos is connected to the sportsperson’s character. I accept some people might be reluctant to accept this second conclusion and might believe I am wrong to separate so completely the goals someone identifies with and the means he uses to achieves his goals. 

Outsourcing Ethical Decision Making and Authenticity

In a previous posting I questioned whether algorithmic assisted moral decision making is possible. Let us assume for the sake of argument that AAMD is possible. Using such a system might be considered as an example of algorithmic outsourcing of our moral decision making. Such outsourcing according to John Danaher means taking away the cognitive and emotional burden associated with certain activities, see Danaher . Intuitively outsourced moral decisions are inauthentic decisions. In this posting I will argue that under certain conditions outsourced ethical decisions using AAMD could be authentic ones.

Before proceeding I must make it clear what I mean by algorithmic assisted moral decision making, outsourcing and authenticity. Any moral decision simply made by an algorithm is not an authentic decision. In my previous posting I suggested when initialising an AAMD system we should first use a top down approach and install simple human values such as avoiding harm. However once initialised such a system should be fine-tuned by the user from the bottom up by adding his personal weights to the installed values. This primitive system might then be further modified from the bottom up using of two feedback loops. Firstly, the user of a system must inform the system whether she accepts any proposed decision. If the user accepts the proposed decision, then this decision can form a basis for similar future decisions in much the same way as in the legal judgements set precedents for further judgements. If the user doesn’t accept a particular decision, then the system must make it clear to the user the weights which are attached to the values it used in making this decision and any previous decisions employed. The user might then further refine the system either by altering these weights or highlighting differences between the current decision and any previous decisions the system employed. According to Danaher outsourcing can take two forms. Cognitive outsourcing means someone using a device to perform cognitive tasks that she would otherwise have to perform himself. Affective outsourcing means someone using a device to perform an affective task that she would otherwise have to perform himself. I will assume here that an authentic decision is a decision that the decision maker identifies herself with or cares about.

According to Danaher taking responsibility for certain outcomes is an important social and personal virtue. Further, someone only takes responsibility for certain decisions if he voluntary wills his chosen outcomes of these decisions. Authenticity is an important social and personal virtue. Getting an app to automatically send flowers to someone’s partner on her birthday doesn’t seem to be an authentic action because the sender doesn’t cause the action. However, here I am only interested in outsourcing our ethical decisions, does outsourcing such decisions damage their authenticity?

I will now argue the answer to the above question depends not on outsourcing, per se, but on the manner of the outsourcing. Let us assume that in the future there exists a computer which makes decisions based on a set of values built into it by a committee of philosophers. Let us consider someone who outsources his moral decisions to this computer. I would suggest that if she implements a moral decision made in this way that his decision is an inauthentic one. It is hard to see how someone in this situation could either identify with the decision or consider herself to be responsible for the outcome. Let us now consider someone who outsources her moral decision making to a AAMD system which is finely tuned by the user as outlined above, are her decisions also inauthentic? I would suggest someone who makes a moral decision in this way is acting authentically because she can identify with his decision. She is able to identify with the systems decisions because, once initialised, the system is built from the bottom up. Her weights are attached to the incorporated values and her past decisions are built into its database.

I suggested that some who uses such a system must accept or reject its decisions. Someone might object that someone who simply accepts the systems decisions without reflection is not acting authentically. In response I would point in virtue ethics someone can simply act and still be regarded as acting authentically. My objector might respond by pointing out Christine Korsgaard pictures the simply virtuous human as a sort of Good Dog (1). Perhaps someone who simply accepts the results of an AADM system might also be pictured as behaving as a good dog with the system replacing the dog’s owner. Surely such a person cannot be regarded as acting authentically. In response I would suggest what matters is that the agent identified himself with the system’s decision. To identify with a decision someone has to be satisfied with that decision. What does it mean to be satisfied with a decision? According to Frankfurt satisfaction entails,

“an absence of restlessness or resistance. A satisfied person may be willing to accept a change in his condition, but he has no active interest in bringing about a change.” (2)

I’m not sure that an absence of restlessness or resistance with a decision is sufficient to guarantee its authenticity. I would suggest authentic decisions are ones that flow from our true self. I have argued our true self is defined by what we are proud or ashamed of, see  true selves do they exist . Let consider someone who accepts the recommendation of an AAMD system without feeling any shame, is her acceptance an authentic one or simply not an inauthentic one? I have argued that there are two types of shame . Type one shame is anxiety about social disqualification. Type two shame is someone’s anxiety about harming the things she cares about, loves and identifies with. Let us accept someone must feel type two shame when she acts in a way which harms the things she cares about, loves and identifies with. In the above situation if someone simply accepts the recommendation of an AAMD system without feeling any type two shame then he is acting in accordance with what he loves and identifies with and is acting authentically.

What conclusions can be drawn from the above. If someone outsources some of his moral decision making to a computer, she may not be acting authentically. However, if she outsources such decision making to an AAMD system designed using a bottom up approach as outlined above it is at least conceivable that she is acting authentically.

1. Christine Korsgaard, 2009, Self-Constitution, Oxford University Press, page 3. 
2. Frankfurt, 1999, Necessity, Volition, and Love. Cambridge University Press, page 103.

Cosmetic Surgery, Enhancement and the Aims of Medicine

  

Jessica Laimann wonders whether we should prohibit breast implants (1). She proceeds to argue that we shouldn’t prohibit breast implant surgery but then suggests we might compensate individuals who decide not to have such surgery. She seems to be uneasy with the idea that breast implant surgery could be a legitimate aim of medicine, I agree with Laimann that we shouldn’t prohibit breast surgery and would and suggest that the skills of medical practitioners might be better employed elsewhere. However, there is a difference between what could be a legitimate aim of medicine and what we should prohibit. Let us assume that in the future medical practitioners can satisfy all the now commonly accepted aims of medicine, in these circumstances could breast implant surgery become a legitimate aim of medicine? In these circumstances could human enhancement become a legitimate aim of medicine? In this posting I want to examine these questions.

In order to examine these questions, I must first examine what the aims of medicine should be. The aims I am concerned with a list of aims, such as repairing heart valves, treating cancer and so on but with aims common to all medical procedures. It might be suggested that aim of all medicine is obvious, to make people better. But what do we mean by better? William Mayo expressed the traditionally held view that “the aim of medicine is to prevent disease and prolong life, the ideal of medicine is to eliminate the need of a physician.” Mayo’s definition might be extended to include the treatment of injury and disability. According to the traditional view medicine makes us better by the treatment of disease, injury, disability and the prolongation of life. If we accept this definition then cosmetic surgery, assisted reproduction and any enhancement, with the possible exception of life extension, wouldn’t be things that make us better. A slightly different definition of the aims of medicine is given by Silver.

“The proper ends of medicine are to use medical skills and training to maintain or improve the position of the person involved, subject to her autonomous consent.” (2)

If we accept Silver’s definition then cosmetic surgery and some forms of enhancement might be considered as making us better. How can we decide which of the above definitions to accept? Let us accept that medicine is a caring profession. Let us also accept that medical practitioners should exercise their skills to serve those interests of patients which can only be served by medical means.

Unfortunately accepting the above doesn’t automatically help us in deciding which of these different aims of medicine to accept. Firstly, what is better for a patient might simply be defined as her medical interests as defined by her doctors. Secondly, what is better for her might be partly defined by what she sees to be her interests, her subjective interests. Let us accept that doctors should respect a patient’s autonomy. I have previously argued that a purely Millian account of autonomy is an incomplete account, see autonomy and beneficence revisited . I argued that a more complete account means that respecting someone’s autonomy requires that one must sometimes act beneficently towards her by attempting to satisfy her desires provided so doing does not harm her on balance and does not cause me significant inconvenience. Autonomy and some forms of beneficence are linked. If the above argument is accepted, then it seems to me that we should accept that a patient’s interests must include her subjective interests provided her general health interests can be easily satisfied. Such satisfaction is difficult now but might be more easily achieved in the future. If we accept the above it might be concluded that we should accept Silver’s definition, such a conclusion would be premature.

Let us assume that breast implants might be in the subjective interests of some individuals. However, it does not automatically follow that breast implantation surgery should be a legitimate aim of medicine. Breast implantation might damage society by sending a damaging picture of what it means to be a woman to both to some men and vulnerable young women. In this situation should we give greater weight to the interests of individual women or to the interests of society? I now want to argue that the above is a false dichotomy and that by respecting individual rights we benefit rather than damage society. Let us accept that breast implantation does some damage to society by projecting a damaged picture of what it means to be a woman. I now want to argue that a ban on breast implantation surgery would cause even greater damage to society. If we fail to respect the right of individuals to make their own decisions, then we fail to see them as the kind of people who can make their own decisions. This failure has two bad consequences, first we fail to truly respect those individuals and secondly we might be accused of moral arrogance. Even more importantly in this failure is the implicit belief that society should shape its members’ decisions. I believe such a belief is dangerous because it is too simplistic. Let us accept that when individual members of a society make decisions that those decisions are partly shaped by the society they live in. However, society both shapes and is shaped by the decisions of its individual members. A flourishing society resembles a living entity that evolves and changes over time. This change is in part shaped by the decisions of its individual members. In order for this shaping to take place such a society must be prepared to accept these decisions. Mill makes much the same point when he suggests that the human race is damaged by silencing the expression of an opinion.

What conclusions can be drawn from the above? Firstly, that Silver is right and that the aim of medicine should be to use medical skills are both to maintain or improve the position of the person involved, subject to her autonomous consent. Let us also accept that in achieving this aim precedence should be maintaining rather than improving the position of the person involved if resources are scarce. Secondly provided resources aren’t scarce then cosmetic surgery and assisted reproduction can and should be a legitimate aim of medical practice. Lastly the above suggests that we have some reason to accept that other forms of enhancement, of those who autonomously desire enhancement, should be a legitimate aim of medical practice unless compelling reasons can be advanced as to why such enhancement causes greater damage to society than the satisfaction these autonomous desires.

  

1. Jessica Laimann, 2015, Should we Prohibit Breast Implants? Journal of Practical Ethics 3(2)
2. Silver M, 2003, Lethal injection, autonomy and the proper ends of medicine, Bioethics 17(2).