Christopher Cowley

Expertise, Wisdom and Moral Philosophers: A Response to Gesang

In a recent issue of Bioethics, Bernard Gesang asks whether a moral philosopher possesses greater moral expertise than a non-philosopher, and his answer is a qualified yes, based not so much on his infallible access to the truth, but on the quality of his theoretically-informed moral justifications. I reject Gesangs claim that there is such a thing as moral expertise, although the moral philosopher may well make a valid contribution to the ethics committee as a concerned and educated citizen. I suggest that wisdom is a lot more interesting to examine than moral expertise. Again, however, moral philosophers have no monopoly on wisdom, and the study of philosophy may even impede its cultivation.

Conscientious objection and healthcare in the UK: why tribunals are not the answer

A recent issue of the journal Bioethics discussed whether conscientious objectors within the healthcare context should be required to give their reasons to a specially convened tribunal, who would have the power to reject the objection. This is modeled on the context of military conscription. Advocates for such a tribunal offer two different justifications, one based on determining the genuineness of the applicants beliefs, the other based on determining their reasonableness. I limit my discussion to a doctors objection to abortion in the UK, and argue against both justifications: I thereby defend the status quo, where such doctors are not formally required to defend their beliefs. My argument has to do with the particular nature of the abortion debate in the UK, and the more general nature of ethical disagreement.

Commentary on ‘Treatment-resistant major depressive disorder and assisted dying’

Schuklenk and van de Vathorst (henceforth “the authors”) make the following starting assumption, which I will accept: that it is ethically permissible for doctors to assist suicide and it is permissible for those competent patients with terminal somatic diseases (such as inoperable stage IV cancer) or non-terminal but untreatable debilitating diseases (such as motor neuron disease, MND) to be assisted in their suicide.1 Given these assumptions, there is a question about whether treatment-resistant major depressive disorder (henceforth ‘clinical depression’) is sufficiently similar to MND to qualify for assisted suicide: the authors think yes, I think no. The first and most obvious problem concerns competence. With cancer and MND that do not affect the brain, the disease does not directly undermine competence. With depression, there is always an initial question about competence and about authenticity. Does the disease distort their judgement about the world, about the future and about themselves in that world? Are the depressed persons wishes authentic in expressing their long and deeply-held beliefs and desires about the world and about themselves? The authors claim that the data is ambiguous, and therefore, clinically depressed patients should be presumed competent and their suicidal request should be granted. I would draw exactly the opposite conclusion: …

The Ethics of Forgiveness: A Collection of Essays

Forgiveness has seen a relatively narrow but sustained interest among moral philosophers for almost forty years now. The most important recent publication was Charles Griswold’s book Forgiveness (Cambridge: Cambridge University Press, 2007), his book was the basis for a conference in Norway a year later, and that conference generated the papers which make up this anthology. Although Griswold himself did not contribute to the anthology, most of the contributors engage with him and make use of his conceptual frameworks. There are three main philosophical questions running through most of this anthology. The first is about whether genuine forgiveness should be unconditional, in the sense that popular Christianity endorses, or whether an ethically legitimate forgiveness would have to be conditional on the offender’s apology and repentance. Perhaps the most famous secular defence of the unconditional account is that of Eve Garrard and David McNaughton (‘In Defence of Unconditional Forgiveness’, Proceedings of the Aristotelian Society, 103 (2003), pp. 39–60), and the pair have updated their arguments for this volume in response to Griswold’s criticism. In contrast, the most famous conditional accounts are those of Jeffrie Murphy (Getting Even: Forgiveness and Its Limits (Oxford: Oxford University Press 2003); J. Murphy and J. Hampton, Forgiveness and Mercy (Cambridge, Cambridge University Press 1988)) and of Griswold himself. In this volume, the articles by Ilaria Ramelli, Jerome Neu and Arne Johan Vetlesen all defend a conditional account. But the conditionality question is relevant to almost all the remaining pieces as well. The second main question, and also building on Griswold’s relevant chapter, concerns the nature of self-forgiveness. It is tempting to reject the notion as either incoherent or morally dubious, but the contributions by Garry Hagberg, Peter Goldie and to a lesser extent of Vetlesen and Espen Gamlund, reveal much more interesting possibilities. The third main question, less important than the first two, is what Griswold calls the problem of ‘political’ forgiveness, usually by one group of another International Journal of Philosophical Studies Vol. 20(2), 289–313

Conscientious objection in healthcare and the duty to refer

Although some healthcare professionals have the legal right to conscientiously object to authorise or perform certain lawful medical services, they have an associated duty to provide the patient with enough information to seek out another professional willing to authorise or provide the service (the ‘duty to refer’). Does the duty to refer morally undermine the professionals conscientious objection (CO)? I narrow my discussion to the National Health Service in Britain, and the case of a general practitioner (GP) being asked by a pregnant woman to authorise an abortion. I will be careful not to enter the debate about whether abortion should be legalised, or the debate about whether CO should be permitted—I will take both as given. I defend the objecting GPs duty to refer against those I call the ‘conscience absolutists’, who would claim that if a state is serious enough in permitting the GPs objection in the first place (as is the UK), then it has to recognise the right to withhold any information about abortion.

Euthanasia in psychiatry can never be justified. A reply to Wijsbek

In a recent article, Henri Wijsbek discusses the 1991 Chabot “psychiatric euthanasia” case in the Netherlands, and argues that Chabot was justified in helping his patient to die. Dutch legislation at the time permitted physician assisted suicide when the patient’s condition is severe, hopeless, and unbearable. The Dutch Supreme Court agreed with Chabot that the patient met these criteria because of her justified depression, even though she was somatically healthy. Wijsbek argues that in this case, the patient’s integrity had been undermined by recent events, and that this is the basis for taking her request seriously; it was unreasonable to expect that she could start again. In this paper, I do not challenge the Dutch euthanasia criteria in the case of somatic illness, but I argue that both Chabot and Wijsbek are wrong because we can never be sufficiently confident in cases of severe exogenous depression to assist the patient in her irreversible act. This is partly because of the essential difference between somatic and mental illness, and because of the possibility of therapy and other help. In addition, I argue that Wijsbek’s concept of integrity cannot do the work that he expects of it. Finally, I consider a 2011 position paper from the Royal Dutch Medical Association on euthanasia, and the implications it might have for Chabot-style cases in the future.

Justifying terminal care by ‘retrospective quality-adjusted life-years’

A lot of medical procedures can be justified in terms of the number of quality-adjusted life-years (QALYs) they can be expected to generate; that is, the number of extra years that the procedure will provide, with the quality of life during those extra years factored in. QALYs are a crude tool, but good enough for many decisions. Notoriously, however, they cannot justify spending any money on terminal care (and indeed on older people in general). In this paper I suggest a different way of construing ‘quality’ (as meaningfulness rather than physical comfort) and ‘life’ (as both backward-looking and forward-looking), so that the terminal patients efforts to find meaning in his life could in principle generate plenty of ‘retrospective QALYs’ to justify funding.

Dementia, identity and the role of friends

Ronald Dworkin (1993) introduced the example of Margo, who was so severely demented that she could not recognise any family or friends, and could not remember anything of her life. At the same time, however, she seemed full of childish delight. Dworkin also imagines that, before her dementia, Margo signed an advance refusal of life-saving treatment. Now severely demented, she develops pneumonia, easy to treat, but lethal if untreated. Dworkin argues that the advance refusal ought to be heeded and Margo be allowed to die of that pneumonia, on the basis that the prior refusal expresses her true wishes (her ‘critical interests’). In this paper I want to challenge Dworkin’s understanding of identity and his conclusion about advance refusals, and I develop my argument in two directions. First, I argue that the demented Margo is not some ‘lesser’ version of the ‘true’ Margo, but instead that the present Margo’s wishes should take precedence over those of the past Margo, on the grounds that all of us are entitled to change our minds. Second, I argue for a stronger role for friends and family members in sustaining the demented Margo’s identity through her years of decline. Based on this, I argue for a presumption against the advance refusal, but I allow that in extreme cases (which I describe), a friend might have the authority to demand that it be heeded.

Regret, Remorse and the Twilight Perspective

ABSTRACT I examine the ‘momentous’ choices that one makes early in life – about career or spouse, for example – and I ask what it means to regret such choices at the end of one’s life (in one’s twilight). I argue that such regrets are almost meaningless because of the difficulty of imaginatively accessing a much earlier self. I then contrast long-term regret to remorse, and argue that the two are qualitatively different experiences because remorse involves another person as victim.

Conscientious objection and the limits of dialogue

In Kimberly Brownlee’s book, Conscience and Conviction, she argues that Thomas More’s paradigmatic ‘personal objection’ successfully meets the 4 conditions of her ‘Communicative Principle’ (2012: 29). In this article I want to challenge Brownlee’s ‘universality’ condition and the ‘dialogical’ condition by focusing on a counter-example of a British GP conscientiously objecting to authorizing an abortion. I argue that such an objection can be morally admirable, even though the GP is not politically active, even though she is not open-minded to the possibility that she might be wrong, and even if she refuses to condemn her non-objecting colleagues. I suggest that this particular counter-example can tell us more general things about the nature of ethical disagreement and ethical incomprehension.