Locking Down the Elderly

Julian Savulescu and James Cameron argue that a policy which locked down the elderly whilst allowing greater freedom to younger people during the covid-19 pandemic wouldn’t be ageist, see practical ethics . The purpose of such a policy would be to protect health services from being overwhelmed. They further argue if such a policy isn’t ageist that it isn’t wrong. In this posting I will accept their argument but suggest that an alternative policy would be preferable. Before proceeding I must make it clear that I am over seventy and one of the elderly however I hope this doesn’t affect the validity of my argument. In the rest of this posting I will use the term ‘older persons’ rather than elderly as this better reflects that the elderly remain persons.

Before making my argument I will briefly outline that of Savulescu and Cameron. They base their argument on Aristotle’s principle of equality. This requires that we treat like cases alike, unless there is a morally relevant difference. They use two examples to illustrate the principle. Firstly if men were allowed to vote and women weren’t this would be sexist and wrong because differences in sex don’t make any difference to the capacity to vote. Secondly government investment in screening women for breast cancer whilst not doing the same for men who sometimes also develop breast cancer isn’t sexist or wrong because men are far less likely to develop this cancer. Let us turn to Savulescu and Cameron’s argument that it wouldn’t be ageist to lockdown older persons whilst allowing younger people greater freedom. They point out that because the cost of the lockdown is massive it is desirable to lift the lockdown. Unfortunately lifting the lockdown might result in health services being overwhelmed. They further point that older persons are much more likely to require health services due to covid-19 than younger ones. They proceed to argue that because that older persons are much more likely to require health care that it wouldn’t be ageist or wrong to require older persons to remain lockdown whilst lifting the lockdown for others due to Aristotle’s principle of equality. When considering the need for health services due to covid-19 outbreak there is a significant difference between older persons and others. It follows that it wouldn’t be ageist to follow a policy which discriminates against older persons in this way.

Let us accept that the above is a perfectly good argument. However it would appear that BAME people are dying at twice the rate of others in the UK. If we accept Savulescu and Cameron’s argument about lockdown for the elderly then the same argument could be applied to BAME people. If it isn’t ageist to lockdown older persons then it shouldn’t be racist to lockdown BAME people. Most would be uneasy about accepting such a conclusion. Let us now consider a different policy which achieves the same ends and which might alleviate our unease. Let us assume that older persons are warned prior the lockdown being lifted, that if this leads to an increase in covid-19 cases which threaten to overwhelm the health services, that they might receive a lower standard of care compared to others. This lower standard is justified because of the disproportionate burden they place on these services. This policy means that older persons might be denied places in ICU and just receive palliative care. Older persons would face a choice of whether to self-isolate or not in order to protect themselves. Let us further assume that the lockdown is lifted and this leads to an increase in covid-19 cases which threaten to overwhelm the health services and as a result older persons start receiving a lower standard of care. Should this policy be regarded as ageist? Let us consider Aristotle’s principle of equality in this scenario. Clearly older persons are treated differently to others but are there any reasons which might justify this difference? I would suggest that there are two reasons which might justify treating older people differently. Firstly older persons are much less likely to survive treatment in ICU. Secondly if treatment in ICU has to be rationed then saving a younger patients at the expense of the elderly means saving patients who will usually live longer and can be justified by utilitarian principles. It would appear that if we accept Aristotle’s principle of equality then a policy which discriminates against older persons in this way wouldn’t be ageist.

I’m self-isolating and believe it is sensible for most older persons to remain in lockdown even if the lockdown were to be partially lifted. I have outlined two policies to protect our health services from becoming overwhelmed in both of which it wouldn’t be ageist to discriminate against older persons. Let us assume that each of these policies would be equally effective in preventing the health from being overwhelmed. Which of these policies should we choose if we accept that it isn’t a question of whether to discriminate but rather when to discriminate.

Let us accept that we have good reasons why we should adopt the first policy as proposed by Savulescu and Cameron. It might be argued that following such policy would protect older persons better than the second. It might be pointed out that if the second policy was adopted that older persons would have to protect themselves. In response it might be pointed out if the first policy is introduced that older persons would still have to protect themselves by remaining compliant. Nonetheless let us accept that we have good reason to adopt the first policy. However it is important to note that the reason to prefer the first policy over the second has nothing to do with protecting our health services from being overwhelmed, both policies do this adequately, the reason for preferring the first policy is to do with caring for older persons. If we choose the first policy then we are also acting beneficently.

Do we have any reasons to choose the second policy instead?  I would suggest that we have two. Firstly adopting the second policy might be more effective as it might be difficult to ensure that older persons remained in long term lockdown under the first policy. I won’t consider this reason further here. Secondly it might be argued that preferring the second policy protects autonomy better. Adopting the first policy serves the interests of all by protecting the health services but it doesn’t respect the autonomy of older individuals. It might then be argued that if the second policy adequately protects health services and respects autonomy that we have reason to prefer this policy. Two objections might be raised to the above argument. Firstly it might be objected that the first policy does respect autonomy. Secondly it might be objected that in times of extreme crisis such as this we should give preference to acting beneficently over respecting autonomy. I will now consider both objections.

What it means to respect autonomy depends on the concept of autonomy used. It might be suggested that an autonomous decision is one that is rationally made to concur with the agent’s best interests and is freely made. If we accept a substantive account of autonomy then these best interests include generally accepted interests such as safety and good health. If we accept a substantive account of autonomy then it might be argued that adopting the first policy is compatible with respecting the autonomy of older persons. Older people, if given the choice, would make an autonomous decision to remain in lockdown because it is in their best interests to stay safe and protect their health. I myself would make such a choice. However let us consider an elderly widow who lives alone and who is suffering from terminal cancer. Let us assume that she is still able to visit her family. If the first policy was adopted she would have to remain in lockdown whilst the rest of her family were free to socialise. I would suggest that if such a person could make an autonomous decision whether to remain in lockdown or not she would choose to socialise with her family. When she considers her best interests she might prioritise family life over staying safely in lockdown. It follows that in this case adopting the first policy wouldn’t respect her autonomy. It might be objected that I have used an extreme example and that we should still prefer the first policy.  I am prepared to accept that I have used an extreme example to illustrate my point but I still want to argue that if we prefer the first policy that we fail to respect the autonomy of older persons. Older persons in general have less future time to look forward to than younger people and many might make an autonomous decision, if they were able to do so, to prioritise family life over staying safe.

Let us accept that if we prefer the first policy then we must be prepared to accept either that acting beneficently is more important than respecting autonomy or that we can respect autonomy whilst acting beneficently. If we accept the second option then we must also accept a substantive account of autonomy. I have argued elsewhere that if we accept a substantive account of autonomy that autonomous decisions must be good decisions, see wooler.scottus . An autonomous decision cannot be a bad decision, it must concur with what is generally accepted to be in the maker’s best interests. However if autonomous decisions must be good decisions then the entire idea of autonomous decision making becomes redundant. We just need to consider good decisions. It follows that if we accept that autonomy is to remain a meaningful concept that we must be prepared to accept a content neutral account. It further follows that if we don’t accept that acting beneficently should be given priority over respecting autonomy that we should prefer the second policy.

However it might be argued that in times like these that acting beneficently is more important than respecting autonomy. Two objections might be raised to the above. Firstly if we prefer the first policy are we really acting beneficently towards older persons? An older person might well believe that leading a social life is in her best interests rather than remaining safe for her last few years. If we disagree we might be accused of epistemic arrogance. Secondly if we give precedence to acting beneficently we are taking acting beneficently to mean ‘caring for’ rather than ‘caring about’. People don’t want to be ‘cared for’ in much the same way as pets are they want to be ‘cared about’ as persons and this means taking their interests into account. It follows if we want to act truly beneficently that we should prefer the second policy.

Charlie Gard and Experimental Treatment for Children

Until recently I assumed without much reflection that it would be best if Charlie Gard was allowed to die peacefully. After some reflection I still believe this would be the most sensible option. However, after this reflection it seems to me that this case raises an important philosophical issue. What should form the basis of our decision making when deciding whether some experimental treatment might be appropriate for children. In this posting I will examine this issue. I have previously argued that autonomous adults with life threatening conditions have a right to try experimental treatments provided these treatments are privately financed, see wooler.scottus . I would argue that this right to try applies to all potential experimental treatments even when the chances of a cure are slim and possibilities of adverse side effects high. If the above is accepted, then it might appear to automatically follow that children’s parents have a right to try experimental treatment to combat their children’s life threatening conditions. I will argue this appearance is unsound and that the issues are more complicated when children are involved.

Let us accept a Millian account of autonomy is correct.  Let us accept that someone’s “own good, either physical or moral, is not a sufficient warrant” to preventing her from exercising her will provided this exercise does not harm to others. This acceptance implies that we must accept that autonomous adults have the right to try experimental treatments, subject to certain conditions, even when the results might be harmful. The same right does not extend to children. Parents must consider the physical, mental and moral good of their children. If parents fail to do so, then a court must decide what is in the child’s best interests. If we accept the above then it doesn’t mean children should never receive experimental treatment. However, it does mean the situation is more complicated than that in the case of adults.

It is generally accepted that parents should act in their children’s best interests and that if they fail the do a court has the right to intervene in order to protect these interests. Let us consider a case in which an experimental treatment becomes available to treat a gravely ill child. How should the child’s parents decide on whether she should undergo the treatment? Intuitively we might assume that they should decide whether the proposed treatment is in the child’s best interests. For any experimental treatment what is in the child’s best interests is a question of probability. Medical probabilities are complicated and parents and courts should usually take the advice of medical experts.

Does accepting the above mean parents should never accept any experimental treatment for a child who is gravely if this treatment is not recommended by the majority of medical experts and carries a low probability of success? Surely any treatment with a low probability of success cannot be in a child’s best interests. However, the above is not always true. In a few cases, experimental treatment might well be in a child’s best interests even if in the majority of cases it isn’t and in these cases might even be harmful. The philosophical issue I want to raise is on what basis should parents and courts use when deciding whether experimental treatment should be accepted. Most would suggest that the decision should be based on what is in the child’s best interests even if the probabilities attached to these interests are extremely hard to determine. I now want to argue such a suggestion is mistaken and that the decision should instead be based on the probability of whether any experimental treatment is likely to harm the child concerned.

Medical ethics is concerned with beneficence, non-maleficence and respect for patient autonomy. Usually parents or in some cases the courts decide whether experimental treatment is appropriate on the basis of what is in the child’s best interests. They apply the principle of beneficence. I appears that acting on the principle of beneficence excludes considerations of autonomy. I argued elsewhere that this assumption might not hold in the case of competent adults, see autonomy and beneficence . I have suggested above that in the case of a young child and experimental treatment that is sometimes impossible to ascertain what is in her best interests making it impossible to apply the principle of beneficence. Kant argued ought implies can. Let us accept Kant was right. It follows if we cannot ascertain what is in a child’s best interests that we ought not apply the principle of best interests. I would suggest that in this situation we should adopt the principle of non-maleficence. Adopting the principle of non-maleficence when considering the acceptability of using an experimental treatment for a child has two important consequences. First it means we need consider harm to the child. In the case of terminally ill children the harm of most concern must be the child’s suffering. Whether someone is suffering should be easier to determine than what is in her best interests. Secondly adopting the principle of non-maleficence brings respect for autonomy back into play. If the autonomous wishes of a sick child’s parents will not harm her then then these wishes matter.

What does accepting the above mean in practice? It might be objected that in practice it is just as difficult to act in a non-maleficent manner as it is to act beneficently. I would suggest such an objection carries little weight provided we ask and can answer three important questions concerning harm. First, we must ask whether the proposed treatment will cause any additional suffering to the child. Second, we must ask whether such treatment would extend the duration of her suffering. Thirdly, we must ask whether moving a child to receive such treatment will cause her further suffering. These questions remain difficult to answer. However, some further more practical questions might be asked to help us answer to answer the first three. I’m a philosopher and for this reason I will only tentatively outline some of these more practical questions. Is the child currently in pain? Will any experimental treatment lead to extra pain? Could any extra pain be controlled? Will the treatment cause nausea? These are clear cut questions and for this reason should be easier to answer than deciding if some treatment is in the child’s best interests. It follows that provided some experimental treatment will not cause a terminally ill child any further suffering, that from a non-maleficent basis, that there is no reason why that child should be denied such treatment provided it is privately financed. At this point I want to emphasise that I am only saying that experimental treatment should be acceptable according to the principle of non-maleficence, I’m not saying such a decision is a good decision.

What are the implications of the above in the case of Charlie Gard?  Should the wishes of his parents matter? When a court decides on what is in the welfare of a child the decision is based on what is in the child’s best interests. Accepting the above means that the wishes of Charlie Gard’s parents should play no part in the court’s decision. However, I have suggested that in cases such as that of Charlie Gard it is sometimes impossible to reach a decision based on best interests. Courts are concerned with practical matters and must make decisions. If a court cannot make a genuine decision based on beneficence then it might make a decision based on the futility of treatment in the belief that this equates with best interests. The two are not identical. Perhaps in these circumstances it would better not to fudge any decision and instead rely on the older principle of non-maleficence. It might even be argued that in these circumstances that a court deciding in a non-maleficent manner to limit a child’s suffering is also acting in a manner which might be loosely described as beneficent. I believe it would be more credible in these circumstances to simply admit acting on the principle of non-maleficence. If we accept the above, then certain questions need to be asked. Is Charlie suffering? Would any proposed experimental treatment cause him further suffering? Would moving him to receive any proposed experimental treatment cause him to suffer? Let us assume that Charlie is suffering then we must now ask whether any proposed experimental treatment likely to reduce or eliminate his suffering. If the answer is negative Charlie should be allowed to die peacefully. Let us assume Charlie isn’t suffering. It seems to me provided that the second and third questions above can be answered negatively that the wishes of his parents should matter and they should be free to seek experimental treatment provided it is privately funded. Accepting the above does not imply seeking such treatment is wise or desirable but only that it should be permissible.

In the light of the above discussion when dealing with difficult treatment options for seriously ill children we should ask the following questions when considering whether we should and if we should how to apply the principle of non-maleficence.

1. Is it possible to ascertain what is in a child’s best interests? Not just what we want to believe is in the child’s best interests. If the answer is no we can move on to apply the principle of non-maleficence.
2. Is the child suffering? If no we can move onto 4
3. Can this suffering be relieved? If yes we can go onto 4.
4. Will this proposed treatment cause further suffering which cannot be relieved. If no then such treatment is permissible according to the principle of non-maleficence even if others believe it to be futile

Autonomy and Beneficence Revisited

I have previously argued that if someone asks me to buy him cigarettes and I was not going to be significantly inconvenienced that I have reason to do so. I assumed that he was an adult fully aware of the dangers of smoking. I am a non-smoker and believe smoking is harmful. However I also believe in giving precedence to respecting autonomy over acting beneficently. Recently a posting by Michael Cook in bioedge has caused me to question my position. Cook considers the case of a North Carolina woman called Jewel Shuping. Ms Shuping wasn’t born blind but was convinced that she was meant to be blind.  According to her doctors she had Body Integrity Identity Disorder. A psychologist gave her some counselling and after this failed gave her some eye-numbing drops before washing her pupils with drain cleaner. Cook asks was the psychologist right to destroy his patient’s eyesight even if she freely requested him to do so and was happy with the result of this treatment? The case of Shuping is an extreme one, however let us assume I am a carer for someone who becomes housebound and unable to buy the cigarettes he had previously enjoyed. Let us further assume that I buy these for him for a number of years and that eventually he develops lung cancer. In this situation am I partly to blame for his condition or have I only been respecting his autonomy? In this posting I want to examine the way in which we should respect someone’s autonomy. This examination is important for as Cook points out it has wider implications in difficult contexts for informed consent such as gender reassignment surgery and euthanasia.

Why did I argue that if it didn’t inconvenience me that I should buy a smoker a packet of cigarettes when he asked me provided he was an adult and fully aware of the dangers involved? I argued by doing so I was respecting his autonomy. Most people would object that my buying someone cigarettes has nothing to do with respecting autonomy. Respecting someone’s autonomy to most people simply means not interfering with someone doing something he cares about provided that by so doing he doesn’t harm others. If this is all it means to respect autonomy then respecting a smoker’s autonomy gives me no reason to buy him cigarettes when he asks me to do so. Let us accept informed consent is based on respect for patient autonomy. It then also follows that Shuping’s informed consent gave her psychologist no reason to acquiesce to her wishes. He might of course thought he was acting beneficently.

I now want to argue that the account of autonomy outlined above is an incomplete one. I will argue that a more complete account means that someone’s autonomous wishes must carry some weight for me. Let us suppose someone asks me to do him a favour and that doing so would not significantly inconvenience me. If I respect him I must feel it would be better to satisfy these wishes, provided by doing so I do no harm. If this was not so I would be indifferent towards him. Being indifferent to someone is not compatible with showing respect. At this point it might be argued that satisfying someone’s wishes has more to do with acting beneficently towards him than respecting his autonomy. However I would reject such an argument. I can act beneficently towards my dog by satisfying his needs but this doesn’t mean I respect him. I may of course love my dog but love differs from respect. Respecting someone as a person means accepting him as the sort of creature that can determine his own future. Respecting someone as a person means accepting what he determines to be his wishes must have some sort of weight for me. If I see someone as the sort of creature who can determine his own future but give no weight to his wishes then I am indifferent towards him rather than respectful. It does not of course automatically follow on from giving weight to his wishes that I have to satisfy them. Doing so might may harm others or cause me significant inconvenience. However it does follow that if I respect someone as a person and can satisfy those of his wishes which do no harm others without any significant inconvenience that I have reason do so. It further follows a more complete account of autonomy requires satisfying someone’s autonomous wishes provided these wishes do no harm to others or cause significant inconvenience.

Let us accept this more complete account of autonomy. If we accept that informed consent is based on respect for autonomy then I would suggest Shuping’s psychologist did have reason to acquiesce to her demands. It might be objected even if Shuping’s desire did have some weight him that her psychologist should not have acted as he did due the harm caused. Cook poses the question,

“Was the psychologist right to destroy his patient’s eyesight if she freely requested it, was happy with the treatment, and was living in psychological torment because she could see.”

Let us assume that Shuping would have been satisfied if the psychologist had blinded her but that he didn’t do so. Perhaps he believed his refusal to act was in her best interests. However if he did this he might be accused of epistemic arrogance. Moreover he might be accused of failing to respect her autonomy because he is failing to see her as the sort of creature who could make her own decisions. If the above is accepted then when respecting someone else’s autonomy requires that ‘the doing no harm condition’ should be replaced by ‘doing no harm on balance’. At this point it might be objected that such a concept of autonomy is far too demanding as people cannot always decide what on balance does no harm and we should retain the simpler condition of doing no harm.

I now want to argue we should accept the condition of ‘doing no harm on balance’. Let us assume that embedded within our thicker account of respecting autonomy is the simpler Millian account. Let us assume our smoker makes an autonomous decision to buy cigarettes. It follows that if I respect his autonomy that I should not act to stop him buying cigarettes by hiding his wallet according to the Millian account. Now let us now assume that he has broken his leg and that it would not inconvenience me to buy him the cigarettes. However I believe the cigarettes will cause him harm and refuse. In both scenarios I can prevent this harm by refusing to buy cigarettes when he has broken his leg and by hiding his wallet when he hasn’t. In both of these scenarios the outcome doesn’t change. If I hide someone’s wallet then I am acting to block him from exercising his autonomy. And if I refuse to buy him cigarettes I am omitting to act. A discussion of autonomy is an unusual place for the act’s/omissions controversy to occur. Does the difference between acts and omissions apply in this context? Indeed is there any real difference between acts and omissions in practical deliberation, see Julian Savulescu’s posting in practicalethics . In both of the above scenarios we are aware of the effects of our choice of behaviour. Christine Korsgaard argues that “choosing not to act makes not acting a kind of acting, makes it something that you do.” (1) I would suggest provided Korsgaard is correct then if someone chooses to act or chooses to omit to act that there is no meaningful difference between acts and omissions. It is still possible that acts and omissions might differ provided ones actions are ones he is fully conscious of and are omissions are unconscious choices. However is such a difference one between acts and omissions or a difference between degrees of consciousness concerning our behaviour? The above suggests to me that when it comes to respecting autonomy there is no meaningful difference between acts and omissions. It follows if I believe smoking will harm the smoker but refrain from hiding his wallet but refuse to buy him cigarettes I am acting inconsistently.

What conclusions can be drawn from the above? Firstly that a purely Millian account of autonomy is an incomplete account. A more complete account means that respecting someone’s autonomy requires that one must sometimes act beneficently towards him by attempting to satisfy his desires provided so doing does not harm him on balance and does not cause significant inconvenience. Autonomy and some forms of beneficence are linked. Of course I accept that someone might have other reasons to act beneficently which are independent of respecting autonomy. Secondly it follows I should buy the smoker his cigarettes. Lastly it would seem Shuping’s psychologist acted correctly. I am somewhat reluctant to accept this conclusion. Perhaps in cases in which the stakes are so high there must be some doubt as to whether one is in fact causing no harm on balance and the precautionary principle should be applied. Nonetheless in spite of my reluctance I am forced to conclude that provided he was sure he was causing no harm that on balance Shuping’s psychologist was acting correctly.

1. Christine Korsgaard, 2009, Self-Constitution, Oxford University Press, page 1.

More Autonomy

In Melbourne Australia Harry Kakavas lost $20.5 million to a casino. He sued the casino arguing it should have known he was a pathological gambler and as a result not taken his money. He lost his case in the Australian High Court. The Court ruled that Kakavas did not show that he suffered from a disability, special to him, which was exploited by the casino. What sort of disability is relevant in such a case? It would seem in this particular case that Kakavas did not have the ability to make meaningful decisions, decisions which were in his own interests, whilst gambling. Gambling affected his autonomy. The Kakavas case raises questions about the nature and extent of autonomous decisions. In this posting I will examine both of these questions. I addition I will consider when we have a duty to intervene when someone makes a non-autonomous decision; provided of course we have the power to do so as the casino involved with Kakavas did,

Which of the decisions we make are autonomous? It might be thought that these decisions must be important decisions which we make only after careful consideration. A patient giving informed consent might be seen a paradigmatic example of such an autonomous decision. If this is so someone making a decision without appropriate reflection might be said to be making a non-autonomous decision. It might then be argued we can safely ignore her decision because it does not represent her ‘real self’, see Berlin (1). It is not a decision she would have made if he had more adequately reflected on it. I would suggest such an attitude is one of moral arrogance.

I now want to argue almost all of the decisions we make are autonomous. A common theme throughout all my postings is that someone’s autonomy depends on what she ‘cares about’. Caring about in this context means not merely wanting something; it means someone’s identity, her ‘real self’, is dependent on what she cares about. Moreover I have argued in previous postings what someone ‘cares about’ is defined by what she is satisfied with. Satisfaction in this context simply means no resistance to a decision, no restlessness with that decision (2). There is no desire to change the decision. It is important here to be clear satisfaction with a decision does not equate with being happy about a decision. As I have argued before someone with a terminal illness may decide to commit suicide and be completely satisfied with her decision but nonetheless her satisfaction does not imply she is happy about it. Accepting the above means if someone is satisfied with some decision and has no inclination to change her decision that her decision is an autonomous one. I would suggest that people are satisfied, as defined above, with almost all of their decisions. The above leads to the tentative conclusion that almost all of the decisions we make are autonomous.

At this point an objector might be prepared to accept that for a decision to be autonomous it must be based on what we care about. However she might be unwilling to concede that it naturally follows that almost all of our decisions are autonomous. My objector might argue we can only know what we care about after adequate reflection. She might then further argue that because most of our decisions are non-reflective that most of our decisions are non-autonomous. If my objector’s argument is to carry any weight then she must accept one of two options. Firstly someone may make an autonomous decision based on what she cares about and be dissatisfied with her decision. Or secondly she must accept that being satisfied with a decision is a necessary condition for that decision to be an autonomous decision based on what the agent cares about but argue it is not a sufficient condition. Let us examine the first option. An agent can make an autonomous decision and be dissatisfied with it. I accept an agent can make an autonomous decision she’s not happy with, see above, but I can’t accept she can make an autonomous decision she’s not satisfied with. Let us accept satisfaction with a decision does not simply mean the agent has some smug feeling but means she has no resistance to her decision, no restlessness to change it. It follows if an agent is dissatisfied with a decision that she either resists the decision or seeks to change it. She is ambivalent about her decision. I don’t accept that any decision someone is ambivalent about and seeks to change can be an autonomous decision. It follows an agent cannot make an autonomous decision she is dissatisfied with.

Let us consider my objectors second option that being satisfied with a decision is a necessary condition for that decision to be an autonomous one based on what the agent cares about but that it is not a sufficient one. My objector might suggest that for a decision to be an autonomous one not only must the agent be satisfied with it but that she must have reflected on it. This suggestion would mean most decisions we make are non-autonomous. Of course for many of the decisions we make this doesn’t matter. No one is really concerned whether someone’s decision to have an ice cream is an autonomous one or not. However let us consider a family on a summer’s day sitting on the bank of a fast flowing river eating ice cream. Let us assume one of the children falls into the river and without any thought the mother jumps in and saves the child. Was this a non-autonomous decision? I would argue it was an autonomous decision. Indeed the mother might feel hurt if someone suggested afterwards her actions were mindless. She might say she minded very much, she loved her child, and that she couldn’t act any other way, reflection was pointless. The above suggests for a decision to be autonomous all that matters is that the agent cares about it. It suggests that caring about a decision is both a necessary and a sufficient condition for that decision to be autonomous in conditions in which the agent has been neither coerced nor deceived. Of course sometimes an agent may have to reflect on what he cares about but it is caring about rather than reflection that guarantees a decision is autonomous. Indeed it might be argued the fact that an agent feels a need to reflect on a decision make the autonomy of the decision less certain.

My objector might accept that for a decision to be an autonomous one the agent must care about her decision but suggest we don’t really care about many of our decisions. For instance she might point out my decision to buy an ice cream on a sudden whim is not based on what I really care about in the way we have been using the term. We only care about important decisions and only these decisions can be autonomous or non autonomous, mere whims don’t count. I believe this might be the position Frankfurt would adopt, see (3). I however would adopt a slightly different position. I would suggest an autonomous decision need not be one an agent cares about but any decision he makes which is not discordant with what he cares about. If my suggestion is accepted then most of the decisions we make, including my whim to buy ice cream, would be autonomous. At this point my objector might point out my suggestion seems to weaken the connection between autonomy and personal identity. Frankfurt argues our identity is linked to what we care about.

“Caring is important to us for its own sake, insofar as it is the indispensably activity through which provide continuity and coherence to our volitional lives. Regardless of whether its objects are appropriate, our caring about things possesses for us an inherent value by virtue of its essential role in making us the distinctive kind of creatures that we are.” (4).

I agree our identity is connected to what we care about. It might appear that because identity and autonomy are connected that autonomous decisions must be decisions we care about. I believe appearance is unjustified. I have suggested above that autonomous decisions are connected to what we care about, our identity, by being decisions which are not discordant with what we care about, our identity. Of course when making most decisions we don’t reflect about our identity. Nonetheless I would suggest our identity is always present even if only in the background. I would further suggest this presence gives continuity and coherence to our lives. If autonomous decisions are any decisions which are not discordant with what we care about then not all autonomous decisions play an equal part in defining our identity. Indeed some like my decision to have an ice cream may play no part. Nonetheless if I continually buy ice cream I may be said to be someone who likes ice cream and this plays a small part of my identity. In the light of the above it appears an agent caring about her decision is not necessary for her decision to be an autonomous one. Moreover someone’s being satisfied with her decision is both a necessary and sufficient condition for the decision to be an autonomous one in circumstances in which she has not been deceived or coerced.

I have argued that most of the decisions we make are autonomous decisions. In addition I believe we should always accept an autonomous decision even if this decision harms the decision maker provided of course the decision does not harm others. I believe we must give precedence to respecting autonomy over acting beneficently. It seems to me someone’s identity is tied to her autonomy, tied to what she finds appropriate, what satisfies her. If we fail to respect someone’s autonomy we fail to respect her. Let us consider an example. Personally I detest is smoking. Moreover smoking harms smokers. Let us assume I one of my friends is a smoker who on hearing I am going to a shop asks me to buy her some cigarettes. As I am going to the shop anyway I will not be inconvenienced if I buy her cigarettes. Let us also assume she is completely satisfied with her decision, she will not smoke in my presence or that of other non-smoker and that she fully understands the dangers of smoking and is not deceiving herself. Let us further assume I refuse to buy her cigarettes because I believe these will harm her. I am helping her to prevent harming herself by not respecting her autonomous request even though satisfying her request would not inconvenience me. I am giving priority to acting beneficently over respecting her autonomy. I would suggest in this example I am merely paying lip service to respecting her as a person. Perhaps I might console myself that I am respecting her real self, but this real self is really an ideal self created by me. In this example I believe I could justly be accused of some sort of arrogance.

If we accept we should respect autonomy over acting beneficently and most decisions we make are autonomous in the sense used above then we have to accept a large number of decisions which are unwise or even foolhardy. Kakavas’ decision to gamble in the casino was certainly an unwise one but was it also a non-autonomous one? If it was an autonomous one then the casino should respect his decision however unwise it was. In theory it seems there might be completely satisfied gamblers. However in practice most gamblers feel guilty about their gambling and have some resistance to their compulsion to gamble. It follows most gamblers’ decisions to gamble are non-autonomous decisions. It seems probable that Kakavas’ decision to gamble was a non-autonomous one. It follows the casino could not justify, allowing Kakavas to continue gambling, on respect for his autonomy.

In normal life we generally accept peoples’ decisions, even if many of these are not autonomous decisions, provided we have no reason to suspect that these decisions will harm the decision maker. Kakavas’ gambling clearly harmed him. How could a casino possibly justify allowing Kakavas to gamble if his gambling was both non-autonomous and harmed him? One possible justification concerns the nature of the harm involved. Kakavas’ gambling harmed him financially but it might have done only limited harm to his capacity to make autonomous decisions. Kakavas’ capacity to make autonomous decisions was impaired whilst gambling but perhaps it remained unimpaired at other times. He could have made an autonomous decision not to go to the casino in much the same way a recovering alcoholic makes a decision not to go to a bar. The casino might argue even if Kakavas was harmed it was respecting his autonomous decision to go gambling and it was justified in respecting this decision because respecting autonomy should take precedence over acting beneficently. I would accept the above argument. However I would be some what sceptical about a gamblers ability to make a decision she knows will make her feel guilty without any resistance to her decision.