Anthony Wrigley

Proxy consent: moral authority misconceived

The Mental Capacity Act 2005 has provided unified scope in the British medical system for proxy consent with regard to medical decisions, in the form of a lasting power of attorney. While the intentions are to increase the autonomous decision making powers of those unable to consent, the author of this paper argues that the whole notion of proxy consent collapses into a paternalistic judgement regarding the other person’s best interests and that the new legislation introduces only an advisor, not a proxy with the moral authority to make treatment decisions on behalf of another. The criticism is threefold. First, there is good empirical evidence that people are poor proxy decision makers as regards accurately representing other people’s desires and wishes, and this is therefore a pragmatically inadequate method of gaining consent. Second, philosophical theory explaining how we represent other people’s thought processes indicates that we are unlikely ever to achieve accurate simulations of others’ wishes in making a proxy decision. Third, even if we could accurately simulate other people’s beliefs and wishes, the current construction of proxy consent in the Mental Capacity Act means that it has no significant ethical authority to match that of autonomous decision making. Instead, it is governed by a professional, paternalistic, best-interests judgement that undermines the intended role of a proxy decision maker. The author argues in favour of clearly adopting the paternalistic best-interests option and viewing the proxy as solely an advisor to the professional medical team in helping make best-interests judgements.

Mitochondrial Replacement: Ethics and Identity.

Abstract Mitochondrial replacement techniques (MRTs) have the potential to allow prospective parents who are at risk of passing on debilitating or even life‐threatening mitochondrial disorders to have healthy children to whom they are genetically related. Ethical concerns have however been raised about these techniques. This article focuses on one aspect of the ethical debate, the question of whether there is any moral difference between the two types of MRT proposed: Pronuclear Transfer (PNT) and Maternal Spindle Transfer (MST). It examines how questions of identity impact on the ethical evaluation of each technique and argues that there is an important difference between the two. PNT, it is argued, is a form of therapy based on embryo modification while MST is, instead, an instance of selective reproduction. The articles main ethical conclusion is that, in some circumstances, there is a stronger obligation to use PNT than MST.

Hope and Terminal Illness: false hope versus absolute hope

Sustaining hope in patients is an important element of health care, allowing improvement in patient welfare and quality of life. However in the palliative care context, with patients who are terminally ill, it might seem that in order to maintain hope the palliative care practitioner would sometimes have to deceive the patient about the full nature or prospects of their condition by providing a ‘false hope’. This possibility creates an ethical tension in palliative practice, where the beneficent desire to improve patient welfare through sustaining hope appears to be in conflict with an autonomy-based requirement not to deceive patients about their condition. In order to resolve this ethical tension, we provide an analysis of the concept of hope and argue that there is at least one conception – the ‘absolute’ conception of hope – which when properly understood allows practitioners to foster hope in terminally-ill patients while avoiding any need to deceive them about their condition. Practitioners therefore do not need to shy away from using the language of hope in the palliative setting, as on this understanding of hope it can be used in a way that both promotes patient welfare and respects patient autonomy.

Ethics and end of life care: the Liverpool Care Pathway and the Neuberger Review

The Liverpool Care Pathway for the Dying has recently been the topic of substantial media interest and also been subject to the independent Neuberger Review. This review has identified clear failings in some areas of care and recommended the Liverpool Care Pathway be phased out. I argue that while the evidence gathered of poor incidences of practice by the Review is of genuine concern for end of life care, the inferences drawn from this evidence are inconsistent with the causes for the concern. Seeking to end an approach that is widely seen as best practice and which can genuinely deliver high quality care because of negative impressions that have been formed from failing to implement it properly is not a good basis for radically overhauling our approach to end of life care. I conclude that improvements in training, communication and ethical decision-making, without the added demand to end the Liverpool Care Pathway, would have resulted in a genuine advance in end of life care.

An Eliminativist Approach to Vulnerability

The concept of vulnerability has been subject to numerous different interpretations but accounts are still beset with significant problems as to their adequacy, such as their contentious application or the lack of genuine explanatory role for the concept. The constant failure to provide a compelling conceptual analysis and satisfactory definition leaves the concept open to an eliminativist move whereby we can question whether we need the concept at all. I highlight problems with various kinds of approach and explain why a satisfactory account of vulnerability is unlikely ever to be offered if we wish the concept to play a genuinely explanatory role in bioethical contexts. I outline why an eliminativist position should be taken with regard to this concept in light of these concerns but mitigate some of the severity of this position by arguing that we can still make sense of retaining our widespread use of the term by viewing it as nothing more than a useful pragmatic linguistic device that acts as a marker to draw attention to certain kinds of issue. These issues will be entirely governed by other, better understood ethical concepts and theories.

A Dead Proposal: Levi and Green on Advance Directives

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Ethical and legal issues in mitochondrial transfer

The US National Academies of Science, Engineering and Medicine recently provided conditional endorsement for mitochondrial transfer. While its approach is more conservative in some respects than that of the United Kingdom (which passed its own regulations in 2015), it marks a significant policy development for a potentially large implementer of this emerging intervention. In this perspective, we consider some of the ethical and legal aspects of these policy responses.

Vulnerability and Marginalized Populations

Public health practitioners attempt to identify and then remove, or at least reduce, threats of harm. However, harm does not affect everyone in the same way. Some people and communities are resilient, whereas others are more susceptible to potential harm. Much public health work is carried out by, or on behalf of, governments. Where people or communities are at great risk of harm, government has a clear and firm responsibility to protect its citizens. One way of describing a potential source of such a risk of harm is to focus on the idea of vulnerability. This introduction explores the concept of ‘vulnerability’ and the role that it may play in public health.

Rethinking Moral Expertise

Abstract We argue that the way in which the concept of expertise is understood and invoked has prevented progress in the debate as to whether moral philosophers can be said to be ‘moral experts’. We offer an account of expertise that draws on the role of tacit knowledge in order to provide a basis upon which the debate can progress. Our analysis consists of three parts. In the first part we highlight two specific problems in the way that the concept of expertise has been invoked in the moral expertise debate, namely the understanding of expertise as an exclusive concept and the conflation of expertise with the idea of ‘authority’. In the second part we suggest an alternative way of approaching the concept of expertise. This is based on Collins and Evans’ sociological theory of expertises. This theory provides a valuable analytical framework for thinking about claims to expertise and for drawing the kinds of distinctions which allow for different kinds of moral expertises and competencies. In the final part, we show how the application of this theory helps to avoid some of the problematic conclusions which theorists have arrived at to date and provides a common platform for debate. Ultimately, it permits the argument to be made that moral philosophers could be considered specialist members of an expert community of moral decision-makers.

Realism and Anti-Realism about Mental Illness

Abstract In this paper I provide an account of the metaphysical foundations of mental illness in terms of a realism debate. I motivate the importance of such metaphysical analysis as a means of avoiding some intractable problems that beset discussion of the concept of mental illness. I apply aspects of the framework developed by Crispin Wright for realism debates in order to examine the ontological commitments to mental illness as a property that humans may exhibit and to examine the various arguments that realists and anti-realists can use to defend their position on mental illness. I pay particular attention to characterising Szaszs account of mental illness as that of an anti-realist error-theory and present ways in which a realist may counter such a position. Ultimately I argue that in order to hold a realist position on mental illness one would have to adopt some form of realism towards values, such as moral realism.