A large proportion of the ethical standards for healthcare professionals are based on and framed within the context of the principle of respect for autonomy. The principle is an instrument that is used to protect a patient’s right to refuse or choose treatment, and to allow patients to act based on their personal values and beliefs. It is also used to justify the professional obligation to be truthful, to not deceive or coerce, and to justify the protection of privacy.
Despite the central importance of the principle, there is, however, little agreement on its content and scope. What does respect for patient autonomy involve? How can a patient’s autonomy be supported or enhanced? When is autonomy absent or undermined? How should the value of autonomy be balanced with competing values such as solidarity, security, and welfare? The aim of this workshop is to bring together theorists and healthcare professionals to discuss the scope and limits of autonomy in healthcare decision-making.
The workshop is open for everyone. No registration is required.
Thursday 12 December
Chair: Kristine Bærøe (University of Bergen)
09:10-09:15 Welcome and coffee/tea.
09:15-10:15 Interactive Influences on Will Formation in Psychiatric Practice
Thomas Schramme (University of Liverpool)
10:15- 11:15 Autonomy, Rationality, and Psychiatric Disorder
Edmund Henden (Oslo Metropolitan University)
11:15-11:30 Coffee break
11:30-12:30 Conceptualising ‘Undue Influence’ in Decision-Making Support for People with Mental Disabilities
Jillian Craigie (Kings College London)
12:30-13:45 Lunch Break
Chair: Edmund Henden (Oslo Metropolitan University)
13:45-14:45 Trust, Nudging and Manipulation – Is the health Care Context Special?
Søren Holm (University of Manchester)
14:45-15:45 Autonomy Lost. Autonomy Regained?
Bjørn Hofmann (NTNU and University of Oslo)
15:45-16:00 Coffee break
16:00-17:00 Nudging in Nursing - Leading the Patient Towards Health and Dignity
Anne Helene Mortensen (Oslo Metropolitan University)
Friday 13 December
Chair: Torbjørn Gundersen (Oslo Metropolitan University)
09:15-10:15 Autonomy in Medicine and the Victorian Marriage
Anna Smajdor (University of Oslo)
10:15- 11:15 Empowerment and Autonomy in Evidence-Based Nursing Care
Marita Nordhaug (Oslo Metropolitan University).
11:15-11:30 Coffee break
11:30-12:30 Ethical accountability of decisions-makers in health: Readdressing power, risk and autonomy
Kristine Bærøe (University of Bergen)
12:30-13:45 Lunch Break
Afternoon Session - Due to illness the afternoon session is cancelled
Trust, Nudging and Manipulation – Is the Health Care Context Special?
Søren Holm, Centre for Social Ethics and Policy, University of Manchester
In this paper I will analyse arguments for and against the permissibility of communicative nudging and manipulation in the health care context. The paper will take its point of departure from Thaler and Sunstein’s original account of the requirements for nudging to be permissible, but will argue that this account is incomplete because it a) does not distinguish adequately between trusted and non-trusted* communicators, and b) does not distinguish between contexts of interpersonal, direct communication and contexts of non-personal communication.
It will be argued that the area of ‘health care’ does not in itself demarcate a context in which nudging is non-permissible, but that nudging and a fortiori other forms of communicative manipulation is more problematic and probably illegitimate when it occurs within an established health care professional – patient relationship.
* ‘non-trusted’ here simply means a communicator with whom the person in question does not have a positive trust relationship, it does not imply active mistrust
Conceptualising ‘Undue Influence’ in Decision-Making Support for People with Mental Disabilities
Jillian Craigie, Centre of Medical Law and Ethics, Kings College London
In the world of mental health and disability law there is currently much interest in the idea of frameworks to enable a shift in practice from substituted decision-making to supported decision-making. One of the concerns to be addressed in the development of law and policy in this area, is the risk that a supporter may unduly influence the decisions of the supported person.
This talk will examine the question of how ‘undue influence’ should be understood in this context, through an analysis of policy documents from advocacy organisations, the UN Convention on the Rights of Persons with Disabilities, and relevant law in England and Wales. Five broad models for conceptualising undue influence will be identified and the normative implications of each, explored.
Autonomy, Rationality, and Psychiatric Disorder
Edmund Henden, Centre for the Study of Professions, Oslo Metropolitan University
Personal autonomy is tightly linked, in moral theory, to the notion of rationality. Individuals who make decisions based on their own subjective reasons and long-term goals and attitudes (or set of values) are usually assumed to be autonomous decision-makers. One difficulty with this view is that some psychiatric patients appear to make decisions based on their own subjective reasons and long-term goals and attitudes. Yet there seems to be good reason for doubting that their decisions are made fully autonomously.
In this talk I will use the example of so-called “rational addicts” to explore this difficulty. I will argue that reflecting upon rational addiction reveals important deficiencies in some of the standard conceptions of autonomy. I will also suggest in what way psychiatric conditions (such as severe addiction) can prevent individuals from governing the process by which they make decisions, so impairing their autonomy, even if their decision-making processes satisfy standard conditions of rationality.
Interactive Influences on Will Formation in Psychiatric Practice
Thomas Schramme, Department of Philosophy, University of Liverpool
I will discuss different forms of influences on the will formation of people. I intend to illustrate these general considerations with examples from psychiatric practice. The context of health care is special, because many patients have a precarious will which is arguably more vulnerable to modifying influences.
I will use Harry Frankfurt's well-known model of autonomy as acting of one's own will as a starting-point and develop it to include dynamic elements regarding will formation. This will offer new insights, especially on the possible manipulation of patients in virtue of alienating them from their practical commitments. My aim is mainly conceptual, but I will say something about the normative assessment of certain health care practices as well.
Autonomy in Medicine and the Victorian Marriage
Anna Smajdor, Department of Philosophy, Classics, History of Art and Ideas, University of Oslo
It is widely accepted that the doctor-patient relationship is unequal. Faced with power imbalances, we can a) try to ensure that the powerful are morally excellent; or b) challenge systemic inequalities themselves. The focus on autonomy in medical ethics is an instance of the former. It implies that inequality is a necessary and immutable part of medical practice. There are parallels here between the inequality between a man and his wife in the days prior to women's emancipation.
Authors such as Anthony Trollope and many others considered this a reason to require husbands to give special moral consideration to their wives' autonomy. Their focus was improving men's moral sensitivity, rather than challenging the power imbalance itself. I will suggest the focus on autonomy in medicine may likewise deflect attention from a moral critique of the systemic power imbalance in medicine.
Autonomy Lost. Autonomy Regained? Unconsciously Influenced, Autonomous, and Proud!
Bjørn Hofmann, NTNU Gjøvik and Center for Medical Ethics, University of Oslo
There is a growing literature in psychology and behavioral economics criticizing the conception of individual autonomy arguing that we are unable to decide rationally according to standard conceptions of autonomy. Unconscious influence is a threat to autonomy.
Hence, the camp of “autonomy pessimists” has gained traction. Against this, there is a steady camp of firm “autonomy optimists.” Some of them may be so because they defy or ignore the arguments from the pessimists. Others acknowledge the arguments, but look for alternative conceptions of autonomy to address the challenges. Feminists and others have developed models of relational autonomy and dialogical conceptions of autonomy. Others have worked on conservational or value-based theories of autonomy. One key issue of the debate is whether persons under unconscious influence can be autonomous agents.
In this presentation I will investigate one approach where it is claimed that we can be autonomous and rational even though we are nudged or under unconscious influence, i.e., that of Neil Levy. Levy claims that biases and heuristics (e.g., in nudging) can work as other reasoning mechanisms: “The intuitive mechanisms to which nudges are addressed are reasoning mechanisms: they are disposed to respond as they do because they are attuned to features of the context of choice in just the way such mechanisms are supposed to be. Nudges may subvert autonomy, but that fact doesn’t distinguish them from the presentation of explicit reasons. When they subvert autonomy, they do so for the same reasons as bad arguments do.” (Levy, N. 2019. Nudge, Nudge, Wink, Wink: Nudging is Giving Reasons. Ergo 6 (10)).
Empowerment and Autonomy in Evidence-Based Nursing Care
Marita Nordhaug, Department of Nursing and Health Promotion, Oslo Metropolitan University
Empowerment and evidence-based practice represent two influential principles in nursing care: that decision concerning treatment and care should be based upon the patient’s autonomous choice, and the most up-to-date research findings, respectively.
Nurses’ obligations to care for patients in accordance with principles of empowerment, and evidence-based practice, set off some difficult issues in cases of conflicts between different knowledge bases, and values such as respecting a patient’s autonomy, as well as the nurse’s own professional autonomy. In this talk, I sketch out some possible normative conflicts these principles may give rise to in nursing care.
Mandatory Childhood Vaccination: Should Norway follow?
Carl Tollef Solberg (with Espen Gamlund, Karl Erik Müller, Kathrine Knarvik Paquet), Department of Global Public Health and Primary Care, University of Bergen
Systematic public vaccination constitutes a tremendous health success, perhaps the greatest achievement of biomedicine so far. But there is still room for improvement. Each year, 1.5 million deaths worldwide could be avoided with enhanced vaccine coverage. Several countries have introduced mandatory childhood vaccination programmes in an attempt to avoid deaths, but the Norwegian childhood vaccination programme has remained voluntary.
Our programme covers protection for twelve infectious diseases, and Norwegian children are systematically immunised from six weeks to sixteen years of age. The aim of the article is to systematically discuss whether it is morally justified to introduce a mandatory childhood vaccination programme in Norway.
Our discussion proceeds as follows: We examine what we consider to be the most central arguments against mandatory childhood vaccination: parental rights, bodily integrity, naturalness and mistrust. After that, we discuss the most central arguments in favour: the harm principle, herd immunity, and a precautionary strategy. We conclude that there are convincing moral arguments in favour of adopting a policy of mandatory childhood vaccination in Norway.
Ethical Accountability of Decisions-Makers in Health: Readdressing Power, Risk and Autonomy
Kristine Bærøe and Inger-Lise Teig, Department of Global Public Health and Primary Care, University of Bergen
How should the role of autonomy in bioethics be considered in light of real world, non-ideal relations of power? In this paper, we further H. Grimen's discussion of the nexus of trust, power and risk in clinical healthcare by arguing that this nexus should be addressed not only at the micro-level, but at the macro-level of decision-making, as well.
To exemplify, we identify inherent power structures involved in priority-setting decisions and academic initiatives. From Luke’s conceptualisation of power, we draw implications for how to hold decisions-makers accountable in a way that accommodates trust despite the inherent, power imbalances and the risks decision-makers maintain on part of the less powerful.
Finally, based on non-idealised, real world perspectives on decision-makers’ power and patients' and stakeholders' autonomy, we propose an overarching framework for ethical accountability of clinical and political decision-makers.
Nudging in Nursing - Leading the Patient Towards Health and Dignity
Anne Helene Mortensen, Department of Nursing and Health Promotion, Oslo Metropolitan University
In the lecture, I will present preliminary findings from three focus group interviews with nursing home staff and elucidate the following statements: Nudging safeguards patients’ dignity and may contribute to prevention of coercion in nursing homes. Healthcare personnel in nursing homes apply nudging even though they are not familiar with the notion or the theory behind it.
Yes, Both (Autonomy and Paternalism), as Winnie the Pooh Would Have Said
Dag Willy Tallaksen, Department of Nursing and Health Promotion, Oslo Metropolitan University
Suicide is an act quite different from other actions. A suicide cannot be reversed. It is a definitive act. Death is something unknown to us, and it stirs up anger and shame on the part of those involved. For those who are considering taking their lives, I hardly think the action appears to be a choice even if it is referred to as such. They see no other solution. Of course, I hope it will benefit from appealing to their willingness to live on, but sometimes society must intervene to prevent a non-reversible act, i.e., death.
- Kristine Bærøe (Department of Global Public Health and Primary Care, University of Bergen).
- Jillian Craigie (Department of Philosophy, Kings College, London).
- Edmund Henden (Centre for the Study of Professions, Oslo Metropolitan University).
- Bjørn Hofmann (Centre for Medical Ethics, University of Oslo).
- Søren Holm (Center for Social Ethics and Policy, University of Manchester).
- Anne Helene Mortensen (Department of Nursing and Health Promotion, Oslo Metropolitan University).
- Marita Nordhaug (Department of Nursing and Health Promotion, Oslo Metropolitan University).
- Thomas Schramme (Department of Philosophy, University of Liverpool).
- Anna Smajdor (Department of Philosophy, University of Oslo).
- Carl Tollef Solberg (Department of Global Public Health and Primary Care, University of Bergen).
- Dag Willy Tallaksen (Department of Nursing and Health Promotion, Oslo Metropolitan University).
- Edmund Henden (Centre for the Study of Profession, Oslomet).
- Marita Nordhaug (Department of Nursing and Health Promotion, Oslomet).
- Kristine Bærøe (Department of Global Public Health and Primary Care, University of Bergen).