Organ transplant shortages are ubiquitous in healthcare systems around the world. In response, se... more Organ transplant shortages are ubiquitous in healthcare systems around the world. In response, several commentators have argued for the adoption of an opt-out policy for organ transplantation, whereby individuals would by default be registered as organ donors unless they informed authorities of their desire to opt-out. This may potentially lead to an increase in donation rates. An opt-out system, however, presumes consent even when it is evident that a significant minority are resistant to organ donation. In this article, we defend a mandated choice framework for consent to deceased organ donation. A mandated choice framework, coupled with good public education, would likely increase donation rates. More importantly, however, a mandated choice framework would respect the autonomous preferences of people who do not wish to donate. We focus in particular on the Australian healthcare context, and consider how a mandated choice system could function as an ethical means to increase the o...
Conscience is an idea that has significant currency in liberal democratic societies. Yet contempo... more Conscience is an idea that has significant currency in liberal democratic societies. Yet contemporary moral philosophical scholarship on conscience is surprisingly sparse. This paper seeks to offer a rigorous philosophical account of the role of conscience in moral life with a view to informing debates about the ethics of conscientious objection in medicine. I argue that conscience is concerned with a commitment to moral integrity and that restrictions on freedom of conscience prevent agents from living a moral life. In section one I argue that conscience is a principle of moral awareness in rational agents, and that it yields an awareness of the personal nature of moral obligation. Conscience also monitors the coherence between an agent’s identity-conferring beliefs and intentions and their practical actions. In section two I consider how human beings are harmed when they are forced to violate their conscience. Restrictions on the exercise of conscience prevent people from living i...
Respect for patient autonomy is a central principle of medical ethics. However, there are importa... more Respect for patient autonomy is a central principle of medical ethics. However, there are important unresolved questions about the characteristics of an autonomous decision, and whether some autonomous preferences should be subject to more scrutiny than others.In this paper, we consider whether inappropriately adaptive preferences—preferences that are based on and that may perpetuate social injustice—should be categorised as autonomous in a way that gives them normative authority. Some philosophers have argued that inappropriately adaptive preferences do not have normative authority, because they are only a reflection of a person’s social context and not of their true self. Under this view, medical professionals who refuse to carry out actions which are based on inappropriately adaptive preferences are not in fact violating their patient’s autonomy. However, we argue that it is very difficult to articulate a systematic and principled distinction between normal autonomous preferences...
This thesis considers how we should allocate scarce, lifesaving healthcare interventions among pe... more This thesis considers how we should allocate scarce, lifesaving healthcare interventions among persons in need. In some situations, clinicians must choose how to allocate scarce lifesaving interventions among their patients, and public health administrators must choose how to allocate scarce prophylaxis among population groups. Not everyone's needs can be met. It is apposite to consider, therefore, how the State should adjudicate between the competing claims that people make on healthcare resources. In discussing this issue, I take as my point of departure the bioethical principle of respect for persons. Respect for persons is understood by many to be synonymous with the need to obtain informed consent from persons who receive medical treatment or participate in biomedical research. This thesis, however, advances an alternative account of respect based on an ethic of mutual accountability and a concern to take moral claims seriously (Darwall 2006). This conception of respect is ...
ence and, indeed, expertise. Medical uncertainty is often a reason to call for greater caution ra... more ence and, indeed, expertise. Medical uncertainty is often a reason to call for greater caution rather than offering more indiscriminate services. It is not clear why doctors ought to adopt a somewhat consumerist approach to trans medicine: aiming to give customers access to any medical interventions they ask for, despite the absence of robust evidence of benefit or clear conception of what is being treated. What would be the right moral course of action when it comes to adhering to good medical practice? On whose authority, when and why should doctors intervene when it comes to altering someone’s body based on how the patient identifies? There are tensions between how a clinician in trans medicine should meet the expectations of patients seeking medical interventions, and the norms of the medical profession itself: securing a diagnosis, treating that which is pathological not physiological, and seeking to minimize iatrogenic harm. More broadly, to what extent would medics risk reinforcing sex-linked social norms and stereotypes of behaviour, expectations and appearance – both when they deny such demands and when they agree to proceed? For example, cosmetic surgeons offering breast enlargements for females might be criticized for marketing and entrenching the idea that women should aspire to medically alter their secondary sex characteristics or unhappiness will ensue. If cosmetic surgery then becomes a social norm and many women elect to undergo surgical breast implantations, this can put pressure on others to follow suit. Yet, in trans medicine the same medical intervention of chest enhancement may be advertised to males who identify as women, meaning similar questions must arise around possible medical collusion with the social expectations of women and men. What is the proper role of medicine in this complicated space? One hopes Trans Medicine will inspire further work that explores such questions in closer detail.
Background Viral pandemics present a range of ethical challenges for policy makers, not the least... more Background Viral pandemics present a range of ethical challenges for policy makers, not the least among which are difficult decisions about how to allocate scarce healthcare resources. One important question is whether healthcare workers (HCWs) should receive priority access to a vaccine in the event that an effective vaccine becomes available. This question is especially relevant in the coronavirus pandemic with governments and health authorities currently facing questions of distribution of COVID-19 vaccines. Main text In this article, we critically evaluate the most common ethical arguments for granting healthcare workers priority access to a vaccine. We review the existing literature on this topic, and analyse both deontological and utilitarian arguments in favour of HCW prioritisation. For illustrative purposes, we focus in particular on the distribution of a COVID-19 vaccine. We also explore some practical complexities attendant on arguments in favour of HCW prioritisation. Co...
Many ethicists argue that we should respect persons when we distribute resources. Yet it is uncle... more Many ethicists argue that we should respect persons when we distribute resources. Yet it is unclear what this means in practice. For some, the idea of respect for persons is synonymous with the idea of respect for autonomy. Yet a principle of respect for autonomy provides limited guidance for how we should distribute scarce medical interventions. In this article, however, I sketch an alternative conception of respect for persons-one that is based on an ethic of mutual accountability. I draw in particular upon Stephen Darwall's writings on respect and the second-person standpoint. I consider the implications of this conception of respect for the distribution of scarce, lifesaving healthcare resources. A second-personal account of respect rules out aggregative approaches to distribution, and instead requires that we give individual consideration to the claims that persons in need make on the resources in our control. The principles that we use to govern our allocation of resources, furthermore, should be principles that are acceptable to all reasonable agents. Building on this insight, the final section of this paper considers how a principle of need can be used as a means to make decisions about the allocation of lifesaving resources.
Much ink has been spilled in recent years over the controversial topic of conscientious objection... more Much ink has been spilled in recent years over the controversial topic of conscientious objection in health care. In particular, commentators have proposed various ways with which we might distinguish legitimate conscience claims from those that are poorly reasoned or based on prejudice. The aim of this chapter is to argue in favor of the “reasonableness” approach to conscientious objection, viz., the view that we should develop an account of “reasonableness” and “reasonable disagreement” and use this as a way of distinguishing licit and illicit conscience claims. The author discusses Rawls’ account of “reasonableness” and “reasonable disagreement,” and consider how this might guide us in regulating conscientious objection in health care. The author analyzes the “public reason” account offered in Card (2007, 2014), and argue that we should modify Card’s account to include a consensus among regulators about what counts as “basic medical care.” The author suggests that Medical Conscie...
In most jurisdictions where euthanasia is legal, patients seeking euthanasia need to seek out the... more In most jurisdictions where euthanasia is legal, patients seeking euthanasia need to seek out the approval of their request from two clinicians (one of who is a psychiatrist). These doctors are required to assess whether euthanasia is ‘appropriate’ for the patient in question. In this paper I claim that doctors qua doctors are not qualified (or, at least, not typically) to evaluate suffering of an existential kind, and consequently they are not qualified to 'evaluate' the requests of patients seeking euthanasia. Importantly, this argument is only focused on patients who are seeking euthanasia on account of acute suffering. To defend my central thesis, I discuss the limits of the professional expertise of clinicians, in addition to considering the nature of suffering experienced by patients requesting euthanasia (which is, typically, a combination of physiological, psychological and existential suffering). This article is available in Solidarity: The Journal of Catholic Socia...
One prominent view in recent literature on resource allocation is Persad, Emanuel and Wertheimer’... more One prominent view in recent literature on resource allocation is Persad, Emanuel and Wertheimer’s complete lives framework for the rationing of lifesaving healthcare interventions (CLF). CLF states that we should prioritise the needs of individuals who have had less opportunity to experience the events that characterise a complete life. Persad et al argue that their system is the product of a successful process of reflective equilibrium—a philosophical methodology whereby theories, principles and considered judgements are balanced with each other and revised until we achieve an acceptable coherence between our various beliefs. Yet I argue that many of the principles and intuitions underpinning CLF conflict with each other, and that Persad et al have failed to achieve an acceptable coherence between them. I focus on three tensions in particular: the conflict between the youngest first principle and Persad et al’s investment refinement; the conflict between current medical need and a...
As Catholic healthcare organizations form a substantive part of healthcare delivery in the USA an... more As Catholic healthcare organizations form a substantive part of healthcare delivery in the USA and Australia, ethical standards for Catholic health care were developed to guide practice. This study examined junior staff's understanding of Catholic ethics. Using a qualitative descriptive design, we recruited 22 medical and nursing staff to interviews/focus groups. Though Catholic ethics seldom informed ethical approaches, the principles were acknowledged as being useful to support development of confident and respectful care approaches. Findings provide early insights into challenges faced in considering implementation of ethical codes across both secular and religious healthcare organizations, suggesting that a more creative and pastoral approach to dialoguing and implementing Catholic ethics is required.
Nigel Biggar (2015) argues that religion deserves a place in secular medicine. Biggar suggests we... more Nigel Biggar (2015) argues that religion deserves a place in secular medicine. Biggar suggests we abandon the standard rationalistic conception of the secular realm and see it rather as "a forum for the negotiation of rival reasonings". Religious reasoning is one among a number of ways of thinking that must vie for acceptance. Medical ethics, says Biggar, is characterised by "spiritual and moral mixture and ambiguity". We acknowledge this uncertainty by recognising rival viewpoints and agreeing to provisional compromises.In this response, I object to Biggar's characterisation of medical ethics as "morally ambiguous" and "provisional". I argue that Biggar has failed to provide adequate support for his conception of ethics as a "forum for negotiation and compromise". I criticise Biggar's attempt to 'pluralise' rationality, and assert that if religion is to play a role in secular medicine, it must be ready to defend itself against a universal standard of reason. In the second section of my response, I argue that 'theistic natural law' gives us the resources to defend using reason alone ostensibly faith-based positions in healthcare ethics. In doing so, we retain a univocal conception of rationality, while at the same time leaving space for 'theism' in healthcare ethics.
Several ethicists have defended the use of responsibility-based criteria in healthcare rationing.... more Several ethicists have defended the use of responsibility-based criteria in healthcare rationing. Yet in this article we outline two challenges to the implementation of responsibility-based healthcare rationing policies. These two challenges are, namely, that responsibility for past behavior can diminish as an agent changes, and that blame can come apart from responsibility. These challenges suggest that it is more difficult to hold someone responsible for health related actions than proponents of responsibility-sensitive healthcare policies suggest. We close by discussing public health policies that could function as an alternative to contentious, responsibility-sensitive rationing policies.
Organ transplant shortages are ubiquitous in healthcare systems around the world. In response, se... more Organ transplant shortages are ubiquitous in healthcare systems around the world. In response, several commentators have argued for the adoption of an opt-out policy for organ transplantation, whereby individuals would by default be registered as organ donors unless they informed authorities of their desire to opt-out. This may potentially lead to an increase in donation rates. An opt-out system, however, presumes consent even when it is evident that a significant minority are resistant to organ donation. In this article, we defend a mandated choice framework for consent to deceased organ donation. A mandated choice framework, coupled with good public education, would likely increase donation rates. More importantly, however, a mandated choice framework would respect the autonomous preferences of people who do not wish to donate. We focus in particular on the Australian healthcare context, and consider how a mandated choice system could function as an ethical means to increase the o...
Conscience is an idea that has significant currency in liberal democratic societies. Yet contempo... more Conscience is an idea that has significant currency in liberal democratic societies. Yet contemporary moral philosophical scholarship on conscience is surprisingly sparse. This paper seeks to offer a rigorous philosophical account of the role of conscience in moral life with a view to informing debates about the ethics of conscientious objection in medicine. I argue that conscience is concerned with a commitment to moral integrity and that restrictions on freedom of conscience prevent agents from living a moral life. In section one I argue that conscience is a principle of moral awareness in rational agents, and that it yields an awareness of the personal nature of moral obligation. Conscience also monitors the coherence between an agent’s identity-conferring beliefs and intentions and their practical actions. In section two I consider how human beings are harmed when they are forced to violate their conscience. Restrictions on the exercise of conscience prevent people from living i...
Respect for patient autonomy is a central principle of medical ethics. However, there are importa... more Respect for patient autonomy is a central principle of medical ethics. However, there are important unresolved questions about the characteristics of an autonomous decision, and whether some autonomous preferences should be subject to more scrutiny than others.In this paper, we consider whether inappropriately adaptive preferences—preferences that are based on and that may perpetuate social injustice—should be categorised as autonomous in a way that gives them normative authority. Some philosophers have argued that inappropriately adaptive preferences do not have normative authority, because they are only a reflection of a person’s social context and not of their true self. Under this view, medical professionals who refuse to carry out actions which are based on inappropriately adaptive preferences are not in fact violating their patient’s autonomy. However, we argue that it is very difficult to articulate a systematic and principled distinction between normal autonomous preferences...
This thesis considers how we should allocate scarce, lifesaving healthcare interventions among pe... more This thesis considers how we should allocate scarce, lifesaving healthcare interventions among persons in need. In some situations, clinicians must choose how to allocate scarce lifesaving interventions among their patients, and public health administrators must choose how to allocate scarce prophylaxis among population groups. Not everyone's needs can be met. It is apposite to consider, therefore, how the State should adjudicate between the competing claims that people make on healthcare resources. In discussing this issue, I take as my point of departure the bioethical principle of respect for persons. Respect for persons is understood by many to be synonymous with the need to obtain informed consent from persons who receive medical treatment or participate in biomedical research. This thesis, however, advances an alternative account of respect based on an ethic of mutual accountability and a concern to take moral claims seriously (Darwall 2006). This conception of respect is ...
ence and, indeed, expertise. Medical uncertainty is often a reason to call for greater caution ra... more ence and, indeed, expertise. Medical uncertainty is often a reason to call for greater caution rather than offering more indiscriminate services. It is not clear why doctors ought to adopt a somewhat consumerist approach to trans medicine: aiming to give customers access to any medical interventions they ask for, despite the absence of robust evidence of benefit or clear conception of what is being treated. What would be the right moral course of action when it comes to adhering to good medical practice? On whose authority, when and why should doctors intervene when it comes to altering someone’s body based on how the patient identifies? There are tensions between how a clinician in trans medicine should meet the expectations of patients seeking medical interventions, and the norms of the medical profession itself: securing a diagnosis, treating that which is pathological not physiological, and seeking to minimize iatrogenic harm. More broadly, to what extent would medics risk reinforcing sex-linked social norms and stereotypes of behaviour, expectations and appearance – both when they deny such demands and when they agree to proceed? For example, cosmetic surgeons offering breast enlargements for females might be criticized for marketing and entrenching the idea that women should aspire to medically alter their secondary sex characteristics or unhappiness will ensue. If cosmetic surgery then becomes a social norm and many women elect to undergo surgical breast implantations, this can put pressure on others to follow suit. Yet, in trans medicine the same medical intervention of chest enhancement may be advertised to males who identify as women, meaning similar questions must arise around possible medical collusion with the social expectations of women and men. What is the proper role of medicine in this complicated space? One hopes Trans Medicine will inspire further work that explores such questions in closer detail.
Background Viral pandemics present a range of ethical challenges for policy makers, not the least... more Background Viral pandemics present a range of ethical challenges for policy makers, not the least among which are difficult decisions about how to allocate scarce healthcare resources. One important question is whether healthcare workers (HCWs) should receive priority access to a vaccine in the event that an effective vaccine becomes available. This question is especially relevant in the coronavirus pandemic with governments and health authorities currently facing questions of distribution of COVID-19 vaccines. Main text In this article, we critically evaluate the most common ethical arguments for granting healthcare workers priority access to a vaccine. We review the existing literature on this topic, and analyse both deontological and utilitarian arguments in favour of HCW prioritisation. For illustrative purposes, we focus in particular on the distribution of a COVID-19 vaccine. We also explore some practical complexities attendant on arguments in favour of HCW prioritisation. Co...
Many ethicists argue that we should respect persons when we distribute resources. Yet it is uncle... more Many ethicists argue that we should respect persons when we distribute resources. Yet it is unclear what this means in practice. For some, the idea of respect for persons is synonymous with the idea of respect for autonomy. Yet a principle of respect for autonomy provides limited guidance for how we should distribute scarce medical interventions. In this article, however, I sketch an alternative conception of respect for persons-one that is based on an ethic of mutual accountability. I draw in particular upon Stephen Darwall's writings on respect and the second-person standpoint. I consider the implications of this conception of respect for the distribution of scarce, lifesaving healthcare resources. A second-personal account of respect rules out aggregative approaches to distribution, and instead requires that we give individual consideration to the claims that persons in need make on the resources in our control. The principles that we use to govern our allocation of resources, furthermore, should be principles that are acceptable to all reasonable agents. Building on this insight, the final section of this paper considers how a principle of need can be used as a means to make decisions about the allocation of lifesaving resources.
Much ink has been spilled in recent years over the controversial topic of conscientious objection... more Much ink has been spilled in recent years over the controversial topic of conscientious objection in health care. In particular, commentators have proposed various ways with which we might distinguish legitimate conscience claims from those that are poorly reasoned or based on prejudice. The aim of this chapter is to argue in favor of the “reasonableness” approach to conscientious objection, viz., the view that we should develop an account of “reasonableness” and “reasonable disagreement” and use this as a way of distinguishing licit and illicit conscience claims. The author discusses Rawls’ account of “reasonableness” and “reasonable disagreement,” and consider how this might guide us in regulating conscientious objection in health care. The author analyzes the “public reason” account offered in Card (2007, 2014), and argue that we should modify Card’s account to include a consensus among regulators about what counts as “basic medical care.” The author suggests that Medical Conscie...
In most jurisdictions where euthanasia is legal, patients seeking euthanasia need to seek out the... more In most jurisdictions where euthanasia is legal, patients seeking euthanasia need to seek out the approval of their request from two clinicians (one of who is a psychiatrist). These doctors are required to assess whether euthanasia is ‘appropriate’ for the patient in question. In this paper I claim that doctors qua doctors are not qualified (or, at least, not typically) to evaluate suffering of an existential kind, and consequently they are not qualified to 'evaluate' the requests of patients seeking euthanasia. Importantly, this argument is only focused on patients who are seeking euthanasia on account of acute suffering. To defend my central thesis, I discuss the limits of the professional expertise of clinicians, in addition to considering the nature of suffering experienced by patients requesting euthanasia (which is, typically, a combination of physiological, psychological and existential suffering). This article is available in Solidarity: The Journal of Catholic Socia...
One prominent view in recent literature on resource allocation is Persad, Emanuel and Wertheimer’... more One prominent view in recent literature on resource allocation is Persad, Emanuel and Wertheimer’s complete lives framework for the rationing of lifesaving healthcare interventions (CLF). CLF states that we should prioritise the needs of individuals who have had less opportunity to experience the events that characterise a complete life. Persad et al argue that their system is the product of a successful process of reflective equilibrium—a philosophical methodology whereby theories, principles and considered judgements are balanced with each other and revised until we achieve an acceptable coherence between our various beliefs. Yet I argue that many of the principles and intuitions underpinning CLF conflict with each other, and that Persad et al have failed to achieve an acceptable coherence between them. I focus on three tensions in particular: the conflict between the youngest first principle and Persad et al’s investment refinement; the conflict between current medical need and a...
As Catholic healthcare organizations form a substantive part of healthcare delivery in the USA an... more As Catholic healthcare organizations form a substantive part of healthcare delivery in the USA and Australia, ethical standards for Catholic health care were developed to guide practice. This study examined junior staff's understanding of Catholic ethics. Using a qualitative descriptive design, we recruited 22 medical and nursing staff to interviews/focus groups. Though Catholic ethics seldom informed ethical approaches, the principles were acknowledged as being useful to support development of confident and respectful care approaches. Findings provide early insights into challenges faced in considering implementation of ethical codes across both secular and religious healthcare organizations, suggesting that a more creative and pastoral approach to dialoguing and implementing Catholic ethics is required.
Nigel Biggar (2015) argues that religion deserves a place in secular medicine. Biggar suggests we... more Nigel Biggar (2015) argues that religion deserves a place in secular medicine. Biggar suggests we abandon the standard rationalistic conception of the secular realm and see it rather as "a forum for the negotiation of rival reasonings". Religious reasoning is one among a number of ways of thinking that must vie for acceptance. Medical ethics, says Biggar, is characterised by "spiritual and moral mixture and ambiguity". We acknowledge this uncertainty by recognising rival viewpoints and agreeing to provisional compromises.In this response, I object to Biggar's characterisation of medical ethics as "morally ambiguous" and "provisional". I argue that Biggar has failed to provide adequate support for his conception of ethics as a "forum for negotiation and compromise". I criticise Biggar's attempt to 'pluralise' rationality, and assert that if religion is to play a role in secular medicine, it must be ready to defend itself against a universal standard of reason. In the second section of my response, I argue that 'theistic natural law' gives us the resources to defend using reason alone ostensibly faith-based positions in healthcare ethics. In doing so, we retain a univocal conception of rationality, while at the same time leaving space for 'theism' in healthcare ethics.
Several ethicists have defended the use of responsibility-based criteria in healthcare rationing.... more Several ethicists have defended the use of responsibility-based criteria in healthcare rationing. Yet in this article we outline two challenges to the implementation of responsibility-based healthcare rationing policies. These two challenges are, namely, that responsibility for past behavior can diminish as an agent changes, and that blame can come apart from responsibility. These challenges suggest that it is more difficult to hold someone responsible for health related actions than proponents of responsibility-sensitive healthcare policies suggest. We close by discussing public health policies that could function as an alternative to contentious, responsibility-sensitive rationing policies.
In this paper I review the ethics and law of the 14 day embryo experimentation rule. I suggest th... more In this paper I review the ethics and law of the 14 day embryo experimentation rule. I suggest that there is need for widespread and extended consultation with professionals involved in healthcare -- as well as ethicists, legal experts and the general public -- prior to any legislative change.
In this article I discuss the nature of suffering, and specifically the nature of the suffering e... more In this article I discuss the nature of suffering, and specifically the nature of the suffering experienced by patients who request euthanasia. I begin by considering the difficulties encountered when trying to define suffering. I then discuss suffering specifically in the context of euthanasia. I argue that the kind of suffering experienced by patients requesting euthanasia is far more complex than mere physiological pain and distress. In the final section of this paper I argue that the sort of suffering experienced by patients desiring euthanasia falls outside the area of expertise of clinicians; I assert that clinicians are acting beyond their professional capacity when they make a judgment about the appropriateness of euthanasia for an individual.
Peter Singer has claimed that Shelly Kagan’s notion of ‘modal personism’ is reducible to a versio... more Peter Singer has claimed that Shelly Kagan’s notion of ‘modal personism’ is reducible to a version of the New Natural Law (NNL) ‘potentialities’ argument against abortion and euthanasia. As such, Singer believes the two positions can be critiqued as one. Singer’s claim, however, seems to ignore a number of significant metaethical differences between Kagan’s view and the NNL account. In this article I will discuss the main differences between the two positions, and consider how such differences impact on the kinds of objections that can be made against the views.
In this paper I will argue that an individual can, in one and the same mental act, have both conc... more In this paper I will argue that an individual can, in one and the same mental act, have both conceptual and perceptual data in consciousness. Specifically, I will argue that in perception we can be conscious of objectual data given us by the senses, and at the same time certain abstract entities – what I will call ‘type-concepts’. By type-concept I am referring to a general concept that captures the essential features of an object in the world and allows a perceiver to form beliefs about it. By objectual data I am referring sense perceptual information that has as its content non-conceptualised objects (as opposed to, say, syntactical propositions or states of affairs). In discussing the union of concept and percept in perception, I want to suggest that in mental acts like perception consciousness is undivided.
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Papers by Xavier Symons