Transitional Paternalism: How Shared Normative Powers Give Rise to the Asymmetry of Adolescent Consent and Refusal

In many jurisdictions, adolescents acquire the right to consent to treatment; but in some cases their refusals – e.g. of life‐saving treatment – may not be respected. This asymmetry of adolescent consent and refusal seems puzzling, even incoherent. The aim here is to offer an original explanation, and a justification, of this asymmetry. Rather than trying to explain the asymmetry in terms of a variable standard of competence – where the adolescent is competent to consent to, but not refuse, certain interventions – the account offered here focuses more closely on the normative power to render actions permissible. Where normative powers are shared they can readily give rise to an asymmetry between consent and refusal. We then turn to why it is justifiable that normative powers be shared in adolescence. Transitional paternalism holds that the acquisition of normative powers by competent adolescents should not be an instant one, achieved in a single step, but that there should be a transitional period where paternalistic protection is rolled back, but not entirely withdrawn until a later date. Transitional paternalism could be implemented without generating the asymmetry between consent and refusal but, it is argued, the asymmetric version of transitional paternalism is to be preferred insofar as it offers a greater respect for the adolescent's decisions than the symmetrical alternative.     

Are Bans on Kidney Sales Unjustifiably Paternalistic?

This paper challenges the view that bans on kidney sales are unjustifiably paternalistic, that is, that they unduly deny people the freedom to make decisions about their own bodies in order to protect them from harm. I argue that not even principled anti‐paternalists need to reject such bans. This is because their rationale is not hard paternalism, which anti‐paternalists repudiate, but soft paternalism, which they in principle accept. More precisely, I suggest that their rationale is what Franklin Miller and Alan Wertheimer call ‘group soft paternalism’. Group soft paternalistic policies restrict the freedom of autonomous individuals, not for their own good (hard paternalism), but as an unavoidable consequence of seeking to protect other, non‐autonomous individuals from harms that they have not voluntarily chosen (soft paternalism). Group soft paternalism supports prohibiting kidney sales on three conditions: (1) that such sales are potentially harmful to vendors, (2) that many vendors would suffer impaired autonomy, and (3) that distinguishing between autonomous and non‐autonomous vendors and interfering only with the latter is unfeasible. I provide reasons for thinking that these conditions will often hold.     

Aboriginal ‘Difference’ and ‘Autonomy’ Then and Now: Four Decades of Change in a Western Desert Society

In just a few decades, Aboriginal people living near Australia's Western Desert fringe have experienced an extraordinarily intense trajectory of change: from a highly autonomous nomadic existence, through ‘first contacts’, the pastoral and mission frontiers, the devastating impacts of alcohol and of Western lifestyle diseases, the outstation movement, resource exploration and mining, a long but largely successful struggle for native title, and much else. In this paper, notions of ‘difference’ and ‘autonomy’ are used to explore these transformations. The situation among the Mardu is here linked to the gulf between government policies and lived Aboriginal experience. If the self‐management thrust of 1970s policies achieved partial restoration of Aboriginal autonomy, recent Federal Government policies are intent on intervention to reduce difference and claw back some of that autonomy. Their determination to force Aboriginal people out of their ‘dysfunctional’ ‘cultural museums’ (homeland settlements) and into greater economic engagement ignores the crucial underpinnings of security and identity among remote Aborigines. The retention of difference, albeit at considerable social cost and entrenched disadvantage, is still strongly preferred by Mardu to the kinds of engagement with the dominant society that not only assault their sense of self but also threaten to overwhelm whatever autonomy remains to them.     

Pilot study to assess the validity of the single assessment process as a screening tool for dental treatment needs in older people

Objective: To assess the feasibility of using a questionnaire‐based needs assessment tool (D‐E‐N‐T‐A‐L) to screen for dental treatment need as part of the single assessment process (SAP) for older people in Sheffield. Materials and methods: Test validation study comparing questionnaire‐assessed and normative need in two consecutive samples of older adults: 48 living at home in the transition phase of older age and 29 frail older adults living in care homes. Each answered the six D‐E‐N‐T‐A‐L questions as part of SAP and a dental examination was carried out within 2 weeks in participants’ homes. Question‐defined need was then compared to the normative need. Results: Questionnaire‐defined and normative need were high in both the transitional group (83% and 90% respectively) and the frail group (83% and 62%). These high levels of need meant that the sensitivity and positive predictive values of D‐E‐N‐T‐A‐L were high, but the specificity and negative predictive values were low. Conclusion: The high levels of need in these patient groups suggests that preliminary questionnaire‐based screening is an unnecessary step. A clinical examination of all older people undergoing SAP may be necessary. Further research may be warranted on the use of questionnaires to assess dental treatment needs among people with different attendance patterns.     

‘Rules that apply in times of crisis’: time,agency, and norm‐remaking during Nepal's People's War

This article explores how people in the former Maoist heartland of Nepal adopted previously transgressive norms and practices during the decade of the People's War (1996‐2006). By examining the rise in practices of beef‐eating and inter‐caste commensality, this article suggests that the temporal dimension of wartime ‘when different rules apply’ was crucial in making people accept new ideas and break established norms on a scale atypical for the ‘normal’ times of peace. Analysing the agency of Maoist activists, who self‐consciously tried to implement a project of radical social transformation, and those people who were caught in the midst of the Maoist transformative endeavour, this article argues that the contours of the ‘new society’ emerged not only due to revolutionaries’ intentional actions but also because of the ‘exceptional’ nature of wartime, which forced people to radically re‐create their daily lives. By transgressing social norms, ‘ordinary’ people did not deliberately undermine the normative order, but rather responded to the constraints of wartime, when people's agency and ethical choices were mostly driven by the need to secure the survival of their families and ensure the continuity of life itself.     

Assessing the difference between sociodental and normative approaches to assessing prosthetic dental treatment needs in dentate older people

Objective: To illustrate differences in assessed need using normative and sociodental approaches to assess prosthetic treatment needs of dentate older people. Design: A cross‐sectional study using non‐random sample. Setting: Metropolitan area of Chiang Mai, Thailand. Subjects: 707 older individuals, 549 of the total sample were dentate, living independently, aged 60 to 74 years. Results: The dentate population examined consisted of 289 classified as ‘normal health’ and 44 with a nutritional problem. Of the total population, 60% (333) had a normative need for partial dentures. Excluding the 44 with a nutritional problem, 50% (146) of the NTM group had ‘impact‐related treatment need’ and of the latter 146, 69% (102) had a high propensity for health behaviour. 41% of the 102 who had ‘impact‐related’ and ‘propensity related treatment need’ had ‘accessible treatment need’. That is 14.5 per 100 of those with normative need. The gap between normative and ‘accessible need’ was greater among those with ‘general health related treatment need’ due to underweight. Of the 44 with a NTM and had a health problem, 45% (20) had a “propensity related treatment need”. 40% of the group with a ‘propensity related treatment need’ had ‘accessible treatment need’. Overall of the 44 older people with a normative need for a prosthesis and who had a health problem, only 2.4% had ‘accessible treatment need’ mainly due to lack of finance. If the treatment were subsidised then 45% of those with ‘propensity related treatment need’ would be eligible for treatment. Conclusion: Large differences of estimated treatment need were found between a socio‐dental and a normative approach to assess prosthetic dental treatment needs of older Thai people.     

Pollen tube growth in the self‐compatible sweet cherry genotype, ‘Cristobalina’, is slowed down after self‐pollination

Sweet cherry is a self‐incompatible fruit tree species in the Rosaceae. As other species in the family, sweet cherry exhibits S‐RNase‐based gametophytic self‐incompatibility. This mechanism is genetically determined by the S‐locus that encodes the pollen and pistil determinants, SFB and S‐RNase, respectively. Several self‐compatible sweet cherry genotypes have been described and most of them have mutations at the S‐locus leading to self‐compatibility. However, ‘Cristobalina’ sweet cherry is self‐compatible due to a mutation in a pollen function modifier that is not linked to the S‐locus. To investigate the physiology of self‐compatibility in this cultivar, S‐locus segregation in crosses involving ‘Cristobalina’ pollen, and pollen tube growth in self‐ and cross‐pollinations, were studied. In the crosses with genotypes sharing only one S‐haplotype, the non‐self S‐haplotype was inherited more frequently than the self S‐haplotype. Pollen tube growth studies revealed that the time to travel the whole length of the style was longer for self‐pollen tubes than for cross‐pollen tubes. Together, these results suggest that ‘Cristobalina’ pollen tube growth is slower after self‐pollination than after cross‐pollination. This reproductive strategy would allow self‐fertilisation in the absence of compatible pollen but would promote cross‐fertilisation if cross‐compatible pollen is available, a possible case of cryptic self‐incompatibility. This bet‐hedging strategy might be advantageous for an ecotype that is native to the mountains of the Spanish Mediterranean coast, in the geographical limits of the distribution of this species. ‘Cristobalina’ blooming takes place very early in the season when mating possibilities are scarce and, consequently, self‐compatibility may be the only possibility for this genotype to produce offspring.     

Aspects of the semantics of emotions and feelings in Dalabon (South‐Western Arnhem Land,Australia)

This article describes two of the principal roots allowing the expression of emotions and feelings in Dalabon, an endangered language of South‐Western Arnhem Land. The first root, kangu, ‘belly’, is depicted linguistically as the location of emotions induced by interpersonal relationships. The belly is thus presented as the locus of good and bad moods generally and of conflict more specifically. Furthermore, the material properties of the belly—its fluidity in particular—impact on one’s temper and ability to deal with others in an ideologically prescribed manner. Speakers describe ritual manipulations undertaken on the belly of young infants in order to shape their temper. Kangu‐no may thus be described as a malleable interface between the person and the outside world, principally other people. The second root, yolh, may at first sight translate as ‘feelings’, either good or bad, but also means ‘appetite’, ‘drive’, ‘pep’. Yolh‐no is associated with the most intimate part of the person, one’s own aspirations that are independent of interactions with others. Although yolh‐no connotes the core self and kangu‐no, the belly, connotes relatedness to others, they are conceived as physiologically connected, so that material properties of the belly impact on the self. Thus, the semantic analysis of Dalabon, along with related anthropological observations, unveils an explicit conceptual and cultural attention to the distinction between emotions and feelings (as respectively defined in the article) and to the autonomy of the person within a constraining social framework. The article shows how this concern echoes and challenges both anthropological and philosophical considerations.     

Ambiguities and Asymmetries in Consent and Refusal: Reply to Manson

John Harris claims that is it ‘palpable nonsense’ to suggest that ‘a child (or anyone) might competently consent to a treatment but not be competent to refuse it.’ In ‘Transitional Paternalism: How Shared Normative Powers Give Rise to the Asymmetry of Adolescent Consent and Refusal’ Neil Manson aims to explain away the apparent oddness of this asymmetry of consent and refusal, by appealing to the idea of shared normative powers, presenting joint bank accounts as an example. In this article, I will argue that Manson's account fails to explain away the oddness. Rather, I will argue that there are ambiguities to which Manson has not paid sufficient attention. In fact, as odd as it may sound, I argue that Manson actually agrees with Harris (at least in relation to the asymmetry of competence). He fails to recognize that he agrees with Harris because he is not careful enough to distinguish between different asymmetries, which I have labelled the asymmetries of choice, permissibility and competence.     

PRENATAL GENETIC TESTING KITS SOLD AT YOUR LOCAL PHARMACY: PROMOTING AUTONOMY OR PROMOTING CONFUSION?

Research groups around the world are developing non‐invasive methods of prenatal genetic diagnosis, in which foetal cells are obtained by maternal blood test. Meanwhile, an increasing number of genetic tests are sold directly to the public. I extrapolate from these developments to consider a scenario in which PNGD self‐testing kits are sold directly to the public. Given the opposition to over‐the‐counter genetic tests and the continuing controversy surrounding PNGD, it is reasonable to expect objections to PNGD self‐testing kits. I focus on one potential objection, that PNGD self‐testing kits would undermine the autonomy of potential test subjects. More specifically, that ‘direct to the public’ PNGD would fail to ensure that consumers exercise autonomy in the following PNGD‐related choices:

• ? Should I use PNGD?
• ? Based on the results of the PNGD test, should I continue or terminate my pregnancy?

Under the current system, PNGD is provided by health care practitioners, who are required to counsel women both before and after the test. In contrast, ‘direct to the public’ PNGD would allow women to make their PNGD‐related decisions outside the context of the health care system. I compare these two decision‐making contexts, arguing that the health care system is not unequivocally better at promoting the autonomy of potential test subjects. Therefore the promotion of autonomy does not constitute a strong argument against such test kits. Other objections may be more persuasive, so I do not offer an overall assessment of the acceptability of ‘direct to the public’ PNGD.     

Facilitation among plants can accelerate density‐dependent mortality and steepen self‐thinning lines in stressful environments

The speed and slope of plant self‐thinning are all affected by plant–plant interactions across environmental gradients. Possible mechanisms driving the self‐thinning dynamics include the relative strength of root versus shoot competition, and the interplay between competition and facilitation. Although these mechanisms often act in concert, their relative importance has not yet been fully explored. We used both a one‐layer and a two‐layer zone‐of‐influence (ZOI) model to examine how competition and facilitation drive self‐thinning across stress gradients. As a development of the traditional ZOI model, the two‐layer version explicitly models shoot and root growth and neighbor interactions, and thus the overall size‐symmetry of competition is regulated by the relative strength of root versus shoot competition. One‐layer model simulations revealed that increasingly asymmetric competition accelerated thinning, and steepened (slope ranged from about –1 to –4/3) and lowered self‐thinning lines. Stress slowed down density‐dependent mortality considerably when competition was not completely symmetric. Stress significantly decreased the self‐thinning intercept, while facilitation simply counteracted stress effects. Both stress and facilitation showed little effect on the slope. In the two‐layer model, both stress and facilitation affected mortality in the same way as in the one‐layer version when competition was not completely symmetric. Different from the one‐layer model, the two‐layer version showed that the effects of stress and facilitation on the self‐thinning slope were mediated by the asymmetry of competition. As stress increased, the overall asymmetry of competition shifted from asymmetric to symmetric due to increased relative strength of root competition. High stress thus dramatically flattened self‐thinning lines, whereas the inclusion of facilitation counteracted stress and led to steeper self‐thinning lines. Our two‐layer model is based on the current knowledge of plant–plant interactions, and better represents ecological realities. It can help elaborate experiments for testing the role of competition and facilitation in driving plant population dynamics.     

Relational autonomy,care, and Jehovah's Witnesses in Germany

Drawing from an ethics of care, relational approaches to autonomy have recently emerged in bioethics. Unlike individual autonomy with its emphasis on patients’ rights, choice, and self‐determination which has been the hallmark of bioethics consistent with the ideology of individualism in neoliberal democracies in Western countries, relational autonomy highlights the relatedness, interdependency, and social embeddedness of patients. By examining the mediating role that male Hospital Liaison Committee members in Germany play in facilitating care that supports Jehovah's Witnesses’ refusal of blood transfusions, this article moves beyond ‘dyadic relations’ and contexts of caregiving. It also contributes to a deeper understanding of care and relational conceptualizations of Witness patients’ autonomy globally.     

Self‐Euthanasia,the Dutch Experience: In Search for the Meaning of a Good Death or Eu Thanatos

My main purpose in this article is to establish the meaning of a ‘good death’ when death is self‐chosen. I will take as my point of departure the new notion of ‘self‐euthanasia’ and the corresponding practice that has evolved in the Netherlands in recent years. Both physician‐euthanasia and self‐euthanasia refer to an ideal process of a good death, the first being ultimately the physician's responsibility, while the second is definitely the responsibility of the individual choosing to die. However, if we also accept the existence of a fundamental moral difference between ending another person's life and ending your own life, and if we accept this moral difference to be also relevant to the normatively laden good death, then this difference represents a strong reason for preferring self‐euthanasia to physician‐euthanasia.     

Counterparts: Clothing,Value and the Sites of Otherness in Panapompom Ethnographic Encounters

Panapompom people living in the western Louisiade Archipelago of Milne Bay Province, Papua New Guinea, see their clothes as indices of their perceived poverty. ‘Development’ as a valued form of social life appears as images that attach only loosely to the people employing them. They nevertheless hold Panapompom people to account as subjects to a voice and gaze that is located in the imagery they strive to present: their clothes. This predicament strains anthropological approaches to the study of Melanesia that subsist on strict alterity, because native self‐judgments are located ‘at home’ for the ethnographer. In this article, I develop the notion of the counterpart as a means to explore these forms of postcolonial oppression and their implications for the ethnographic encounter.     

The construction of ‘Asian American’: Reflections on intermarriage and ethnic identity among second‐generation Chinese and Korean Americans

This article explores the ethnic self‐identification of second‐generation children whose immigrant parents came to the United States from Latin America. The focus of the analysis is the adoption of the pan‐ethnic label, ‘Hispanic’, in contrast to national designators and non‐hyphenated American identities. Using data from a recent large survey of children of immigrants in south Florida and southern California, the analysis explores the determinants of ethnic self‐identities and the potential consequences of the adoption of one of these symbolic labels on children's self‐esteem, educational expectations and perceptions of discrimination. Contrary to the commonly‐held assumption that the label ‘Hispanic’ denotes greater assimilation into the mainstream of US society, our findings indicate that children who adopt the Hispanic label are the least well assimilated: they report poorer English skills, lower self‐esteem and higher rates of poverty than their counterparts who identify themselves as Americans or as hyphenated Americans. Theoretical and policy implications of findings as they bear on prospects for successful adaptation of second‐generation youth are discussed.     

The logic of asymmetric contests

A theoretical analysis is made of the evolution of behavioural strategies in contest situations. It is assumed that behaviour will evolve so as to maximize individual fitness. If so, a population will evolve an ‘evolutionarily stable strategy’, or ESS, which can be defined as a strategy such that, if all members of a population adopt it, no ‘mutant’ strategy can do better. A number of simple models of contest situations are analysed from this point of view. It is concluded that in ‘symmetric’ contests the ESS is likely to be a ‘mixed’ strategy; that is, either the population will be genetically polymorphic or individuals will be behaviourally variable. Most real contests are probably asymmetric, either in pay-off to the contestants, or in size or weapons, or in some ‘uncorrelated’ fashion; i.e. in a fashion which does not substantially bias either the pay-offs or the likely outcome of an escalated contest. An example of an uncorrelated asymmetry is that between the ‘discoverer’ of a resource and a ‘late-comer’. It is shown that the ESS in asymmetric contests will usually be to permit the asymmetric cue to settle the contest without escalation. Escalated contests will, however, occur if information to the contestants about the asymmetry is imperfect.     

The Consequences of Being a Gift

The issues of dislocated identity are epitomised in Mary's story. Brought from Papua New Guinea to Australia at a very young age as a ‘gift’, she grew up in a series of foster homes in Adelaide, South Australia. Now, as a teenager, Mary constitutes her identity through her body, emphasising her distinctive physical features, through idealised memories and through representations—photographs, cultural icons and people who ‘look like me’. The self she creates in this way sits uneasily along side another self; the Western adolescent self in trouble with the law, the self who struggles to be ‘one of the boys’ on the streets, one who ‘runs amuck’. This paper explores the process of ‘self-making’, the ‘serious play’ that Mary has employed to constitute her identity through her juggling of and reappropriation of cultural symbols. As a participant in a wider ethnographic study into Australian youth and representation, Mary portrayed the complexities of her growing up between worlds, embedded in neither and desperate to belong to her past.     

Kombinowanie: agency,informality, and the poetics of self in Highland Poland

This article asks what role local models of agency and subjectivity play in the structure and interpretation of informal economic practices, and how this influences the ways in which people narrate their behaviour to others. Exploring the use of a common Polish idiom for informal activities – kombinowanie – amongst villagers in the Carpathian Highlands, it argues that the term acts as a ‘master‐trope’ for local identity, providing villagers with a narrative model for asserting and broadcasting their social agency to peers. Furthermore, it shows how in this particular ethnographic context, the retelling of instances of informal or illegal activity as kombinowanie can be seen as part of a Highlander ‘poetics of self’, in that each manifestation of the term carries with it a series of implicit sociohistorical and normative meanings that relate to notions of ‘typical’ Górale (Highland) behaviour. By characterizing kombinowanie as a type of tactics, I open up the term for comparative analysis with other local conceptions of agency which value insubordination.     

Reconsidering counselling and consent

In the current era patient autonomy is enormously important. However, recently there has also been some movement back to ensure that trust in the doctor's skill, knowledge and virtue is not excluded in the process. These new nuances of informed consent have been referred to by terms such as beneficent paternalism, experience‐based paternalism and we would add virtuous paternalism. The purpose of this paper is to consider the history and current problematic nature of counselling and consent. Starting with the tradition founded by Hippocrates we trace and seek to understand how relevant aspects of the patient‐doctor relationship have evolved under the influences of subsequent moral theories. Finally we tentatively endorse certain modes of counselling in the current era in order to promote morally sound, good clinical practice.     

Trubs,but no trianas: filled and empty regions of angiosperm stem length‐diameter‐mechanics space

Discrete plant habit categories such as ‘tree’, ‘shrub’, and ‘liana’ belie continuous variation in nature. To study the evolution of this continuous variation, we gathered data on stem length, diameter and tissue mechanical stiffness across a highly morphologically diverse highland xerophytic scrub on a lava flow in central Mexico. With stem allometric and mechanical data from 1216 segments from 50 species, we examined relationships between stem length–diameter proportions and tissue mechanical stiffness using linear mixed‐effects models. Rather than a series of discrete clouds in stem length–diameter–tissue stiffness space, corresponding to traditional habit categories, the plants of this xerophytic scrub formed a single continuous one. Within this cloud, self‐supporting plants had stems that became predictably longer and tissues that became stiffer for a given diameter increase, and there was no paucity of intermediates between trees and shrubs (‘trubs’). Non self‐supporting plants had a steeper stem length–diameter slope and their tissues did not increase in stiffness with stem size. The area between self‐ and non self‐supporting plants was sparsely occupied as stem size increased. We predict that this ‘empty’ space between lianas and trees is developmentally accessible but of low fitness, meaning that there should be few ‘trianas’ in nature. © 2015 The Linnean Society of London, Botanical Journal of the Linnean Society, 2015, 179 , 361–373.