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.     

Reconsidering paternalism in clinical research

The ethical standards that regulate clinical research have multiple rationales. Among them is the need to protect potential subjects from making imprudent decisions, which extends beyond the soft paternalistic concern to protect people from making uninformed decisions to participate in trials. This article argues that a plausible risk/benefit restriction on clinical trials is presumptively justified by hard paternalism, which in turn is supported by a deeper fairness‐based rationale. This presumptive case for hard paternalism in research is not defeated by the alleged right to participate in clinical trials, by concerns about insult or status, by the need to conduct early phase trials that promise little to no benefit to participants, or by the recognition that some potential subjects are altruistically motivated.     

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.     

The new paternalism

The author argues that the belief that patient autonomy has great moral value has justified a new form of medical paternalism which can have effects similar to those of the old rejected form. He cites the argument that "all illness represents a state of diminished autonomy" and that therefore autonomy is not overridden when physicians make all decisions. Another view is that, in some situations, withholding information may prevent patient deterioration and loss of autonomy. Abridgement of present autonomy, then, is permissible if it promotes future autonomy. Strasser also rejects physician decision making based on patients' previously communicated values or on the theory that patient values are important but not decisive. He concludes that if we "allow paternalistic practices, then we should admit that we are denying autonomy in light of some other good rather than claim that, somehow, we are respecting autonomy by abridging it."     

Paternalism and certitude

When paternalism is deemed morally justified, weak paternalism—which restricts itself to assisting the target of paternalism realize his own preferences—is the preferred (less problematic) alternative. In determining the appropriateness of weak paternalism, the level of certitude of the paternalist regarding the correctness of her assessment of the true preferences of the one-paternalized is obviously a crucial factor. Yet in the ethics of paternalism this parameter has escaped systematic treatment. This paper aims to initiate discussion on this indispensable consideration for weak paternalism. Analysing a real-life dilemma of paternalism in healthcare, the paper focuses on the theoretical question of how the paternalist can optimize her certitude by combining personal knowledge of the individual patient with population data on treatment refusal/consent of patients facing similar decisions. The paper presents an outline of a decision-making scheme that can be valuable in medical ethics and beyond.     

Bystanders,risks, and consent

This paper considers the moral status of bystanders affected by medical research trials. Recent proposals advocate a very low threshold of permissible risk imposition upon bystanders that is insensitive to the prospective benefits of the trial, in part because we typically lack bystanders' consent. I argue that the correct threshold of permissible risk will be sensitive to the prospective gains of the trial. I further argue that one does not always need a person's consent to expose her to significant risks of even serious harm for the sake of others. That we typically need the consent of participants is explained by the fact that trials risk harmfully using participants, which is very hard to justify without consent. Bystanders, in contrast, are harmed as a side-effect, which is easier to justify. I then consider whether the degree of risk that a trial may impose on a bystander is sensitive to whether she is a prospective beneficiary of that trial.     

Was bioethics founded on historical and conceptual mistakes about medical paternalism?

Bioethics has a founding story in which medical paternalism, the interference with the autonomy of patients for their own clinical benefit, was an accepted ethical norm in the history of Western medical ethics and was widespread in clinical practice until bioethics changed the ethical norms and practice of medicine. In this paper I show that the founding story of bioethics misreads major texts in the history of Western medical ethics. I also show that a major source for empirical claims about the widespread practice of medical paternalism has been misread. I then show that that bioethics based on its founding story deprofessionalizes medical ethics. The result leaves the sick exposed to the predatory power of medical practitioners and healthcare organizations with only their autonomy-based rights to non-interference, expressed in contracts, to protect them. The sick are stripped of the protection afforded by a professional, fiduciary relationship of physicians to their patients. Bioethics based on its founding story reverts to the older model of a contractual relationship between the sick and medical practitioners not worthy of intellectual or moral trust (because such trust cannot be generated by what I call 'deprofessionalizing bioethics'). On closer examination, bioethics based on its founding story, ironically, eliminates paternalism as a moral category in bioethics, thus causing bioethics to collapse on itself because it denies one of the necessary conditions for medical paternalism. Bioethics based on its founding story should be abandoned.     

Developing Autonomy and Transitional Paternalism

Adolescents, in many jurisdictions, have the power to consent to life saving treatment but not necessarily the power to refuse it. A recent defence of this asymmetry is Neil Manson's theory of ‘transitional paternalism’. Transitional paternalism holds that such asymmetries are by‐products of sharing normative powers. However, sharing normative powers by itself does not entail an asymmetry because transitional paternalism can be implemented in two ways. Manson defends the asymmetry‐generating version of transitional paternalism in the clinical context, arguing that it maximizes respect for adolescent autonomy. This article offers an alternative argument in favour of the asymmetry‐generating form of transitional paternalism, one that makes appeal to obligations that individuals have to develop self‐governance in others. We should share normative powers asymmetrically in the clinical context for three reasons. First, the asymmetric version of transitional paternalism takes seriously duties to support adolescents’ developing autonomy, alongside other duties that adults have to young people. It does so by enabling young people to be involved in important decisions that they would otherwise be excluded from. This is of value because participation of this sort is central to the cultivation of their self‐governance. Second, only the asymmetric version gives young people a voice in respect of all clinical actions, and only the asymmetric version leaves open the possibility that the coarse lines of legislation might be ‘fine‐tuned’ in individual cases. Third, the asymmetric sharing of normative powers is consistent with the kind of social arrangements that best support autonomy.     

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.     

HARD PATERNALISM,FAIRNESS AND CLINICAL RESEARCH: WHY NOT?

Jansen and Wall suggest a new way of defending hard paternalism in clinical research. They argue that non‐therapeutic research exposing people to more than minimal risk should be banned on egalitarian grounds: in preventing poor decision‐makers from making bad decisions, we will promote equality of welfare. We argue that their proposal is flawed for four reasons. First, the idea of poor decision‐makers is much more problematic than Jansen and Wall allow. Second, pace Jansen and Wall, it may be practicable for regulators to uncover the values that a potential research participant holds when agreeing to enter a research project, so their claim that we must ban such research projects for all if we are to ban them for poor decision‐makers looks to be unmotivated. Third, there seem to be cases where the liberty to enter the sort of research project Jansen and Wall discuss is morally weighty, and arguably should outweigh concerns of egalitarian distribution. Fourth, banning certain types of research, which seem on the face of it to offer an unfavourable risk‐benefit ratio, would have unwelcome consequences for all clinical research, which Jansen and Wall do not recognize.     

Paternalism and fairness in clinical research

In this paper, we defend the ethics of clinical research against the charge of paternalism. We do so not by denying that the ethics of clinical research is paternalistic, but rather by defending the legitimacy of paternalism in this context. Our aim is not to defend any particular set of paternalistic restrictions, but rather to make a general case for the permissibility of paternalistic restrictions in this context. Specifically, we argue that there is no basic liberty-right to participate in clinical research and that considerations of distributive fairness justify some paternalistic protections of research subjects.     

Recycled

Both three-taxon analysis (3ta) and conventional parsimony analysis (CPA) fall within the cladistic framework. Attempts to exclude 3ta from the general cladistic framework so far seem to amount to declaring CPA as the only permissible analytic technique within cladistics. Critics of 3ta have failed to fully implement it in examples; as a result this criticism is faulty and does not support the claims made. Ultimately, the relative merit of 3ta will be resolved empirically, by comparison of classifications produced from it with classifications using other methods.     

Kin selection and parasite evolution: higher and lower virulence with hard and soft selection

Conventional models predict that low genetic relatedness among parasites that coinfect the same host leads to the evolution of high parasite virulence. Such models assume adaptive responses to hard selection only. We show that if soft selection is allowed to operate, low relatedness leads instead to the evolution of low virulence. With both hard and soft selection, low relatedness increases the conflict among coinfecting parasites. Although parasites can only respond to hard selection by evolving higher virulence and overexploiting their host, they can respond to soft selection by evolving other adaptations, such as interference, that prevent overexploitation. Because interference can entail a cost, the host may actually be underexploited, and virulence will decrease as a result of soft selection. Our analysis also shows that responses to soft selection can have a much stronger effect than responses to hard selection. After hard selection has raised virulence to a level that is an evolutionarily stable strategy, the population, as expected, cannot be invaded by more virulent phenotypes that respond only to hard selection. The population remains susceptible to invasion by a less virulent phenotype that responds to soft selection, however. Thus, hard and soft selection are not just alternatives. Rather, soft selection is expected to prevail and often thwart the evolution of virulence in parasites. We review evidence from several parasite systems and find support for soft selection. Most of the examples involve interference mechanisms that indirectly prevent the evolution of higher virulence. We recognize that hard selection for virulence is more difficult to document, but we take our results to suggest that a kin selection model with soft selection may have general applicability.     

Fundamental aspects: mechanisms of carcinogenesis and dose-effect relationship

Oncogenesis is a multistep process, which is the outcome of the accumulation in a single cell of genetic and epigenetic events. The events alter proto-oncogenes, which are converted into oncogenes with gain of function and tumor suppressor genes with loss of function. Cellular mechanisms (e.g. apoptosis) protect tissues against the malignant transformation of cells and limit, for each tissue, the combinations of efficient genetic alterations. The number of genetic events required for conversion to malignancy is still debated, but, at least in the case of many solid tumors (e.g. colon carcinomas), this number may be as high as seven to eight, which implies that a genetic instability occurs during cancer progression. In most cancers the probability of occurrence of oncogenic genetic events is increased by exposure to behavioural and environmental factors. In the case of chemical carcinogens, the dose-effect relationship is strongly affected by their effects on cellular proliferation, which should be taken account into when the experimental data of animal experiments are extrapolated to human exposures. When non-genotoxic carcinogens are considered, a threshold in the dose-effect relationship is generally observed. For genotoxic carcinogens, it is hard to prove experimentally that a threshold exists and linear no-threshold relationships are generally used to evaluate permissible levels of human exposures.     

Market Liberalism in Health Care: A Dysfunctional View of Respecting “Consumer” Autonomy

The unfortunately vast history of paternalism in both medicine and clinical research has resulted in perpetually increasing respect for patient autonomy and free choice in Western health care systems. Beginning with the negative right to informed consent, the principle of respect for autonomy has for many patients evolved into a positive right to request treatments and expect accommodation. This evolution of patient autonomy has mirrored a more general social attitude of market liberalism where increasing numbers of patients have come to embody the role of the “consumer.” This paper explores this transformation and critiques the current way in which respect for patient autonomy is put into practice. Ultimately, this paper concludes that the consumer view of patient autonomy is dysfunctional. Moreover, this paper argues that, based on the inherent goals of medicine, some form of paternalism is required in any meaningfully therapeutic relationship.     

Habitat Differences in Marine Invasions of Central California

We carried out a two-part investigation that revealed habitat differences in marine invertebrate invasions. First, we compared invasion levels of hard vs soft substrata in Elkhorn Slough, an estuary in Central California, by comparing abundance and richness of native vs exotic species in quantitative samples from each habitat type. Our results revealed that the hard substrata were much more heavily invaded than the soft substrata. Nearly all the hard substrata in Elkhorn Slough, as in most estuaries along the Pacific coast of North America, are artificial (jetties, rip-rap, docks). Some exotic species may by chance be better adapted to this novel habitat type than are natives. Two major vectors responsible for marine introductions, oyster culturing and ship-hull fouling, are also more likely to transport species associated with hard vs soft substrata. Secondly, we compared estuarine and open coast invasion rates. We examined species richness in Elkhorn Slough and adjacent rocky intertidal habitats along the Central California coast. The absolute number of exotic species in the estuary was an order of magnitude higher than along the open coast (58 vs 8 species), as was the percentage of the invertebrate fauna that was exotic (11% vs 1%). Estuaries on this coast are geologically young, heavily altered by humans, and subject to numerous transport vectors bringing invasive propagules: all these factors may explain why they are strikingly more invaded than the open coast. The finding that the more species rich habitat – the open coast – is less invaded is in contrast to many terrestrial examples, where native and exotic species richness appear to be positively correlated at a broad geographic scale.     

Protein folding in the cell: challenges and progress

It is hard to imagine a more extreme contrast than that between the dilute solutions used for in vitro studies of protein folding and the crowded, compartmentalized, sticky, spatially inhomogeneous interior of a cell. This review highlights recent research exploring protein folding in the cell with a focus on issues that are generally not relevant to in vitro studies of protein folding, such as macromolecular crowding, hindered diffusion, cotranslational folding, molecular chaperones, and evolutionary pressures. The technical obstacles that must be overcome to characterize protein folding in the cell are driving methodological advances, and we draw attention to several examples, such as fluorescence imaging of folding in cells and genetic screens for in-cell stability.     

Commodification and Human Interests

In Markets Without Limits and a series of related papers, Jason Brennan and Peter Jaworski argue that it is morally permissible to buy and sell anything that it is morally permissible to possess and exchange outside of the market. Accordingly, we should (Brennan and Jaworski argue) open markets in “contested commodities” including blood, gametes, surrogacy services, and transplantable organs. This paper clarifies some important aspects of the case for market boundaries and in so doing shows why there are in fact moral limits to the market. I argue that the case for restricting the scope of the market does not (as Brennan and Jaworski assume) turn on the idea that some things are constitutively non-market goods; it turns instead on the idea that treating some things according to market norms would threaten the realization of particular kinds of human interests.