Why physicians have authority over patients.

In this article, we argue that physicians have normative authority over patients. First we elaborate on the nature of normative authority. We then examine and critique Arthur Isak Applbaum's view that physicians lack authority over patients. Our argument appeals to four cases that demonstrate physicians' authority.

Should Employment Division v Smith Be Overturned?

Health professionals seeking religious exemption from caring for some patients or providing some interventions receive robust legal protection. Similarly, religiously affiliated organizations have great latitude in deciding which services to offer. These protections could soon become stronger, as the US Supreme Court considers 2 cases that revisit constraints on exemption claims established in Employment Division, Department of Human Resources of Oregon v Smith (1990). This article contends that overturning this case's precedent might result in clinicians claiming more religious exemptions, which, barring acts of US Congress, would erode the rule of law and increase risk of harm to patients.

In Defence of Forgetting Evil: A Reply to Pilkington on Conscientious Objection.

In a recent article for this journal, Bryan Pilkington (2019) makes a number of critical observations about one of our arguments for non-traditional medical conscientious objectors' duty to refer. Non-traditional conscientious objectors are those professionals who object to indirectly performing actions-like, say, referring to a physician who will perform an abortion. In our response here, we discuss his central objection and clarify our position on the role of value conflicts in non-traditional conscientious objection.

Surrogates and Artificial Intelligence: Why AI Trumps Family.

The increasing accuracy of algorithms to predict values and preferences raises the possibility that artificial intelligence technology will be able to serve as a surrogate decision-maker for incapacitated patients. Following Camillo Lamanna and Lauren Byrne, we call this technology the autonomy algorithm (AA). Such an algorithm would mine medical research, health records, and social media data to predict patient treatment preferences. The possibility of developing the AA raises the ethical question of whether the AA or a relative ought to serve as surrogate decision-maker in cases where the patient has not issued a medical power of attorney. We argue that in such cases, and against the standard practice of vesting familial surrogates with decision making authority, the AA should have sole decision-making authority. This is because the AA will likely be better at predicting what treatment option the patient would have chosen. It would also be better at avoiding bias and, therefore, choosing in a more patient-centered manner. Furthermore, we argue that these considerations override any moral weight of the patient's special relationship with their relatives.

Responding to religious patients: why physicians have no business doing theology.

A survey of the recent literature suggests that physicians should engage religious patients on religious grounds when the patient cites religious considerations for a medical decision. We offer two arguments that physicians ought to avoid engaging patients in this manner. The first is the Public Reason Argument. We explain why physicians are relevantly akin to public officials. This suggests that it is not the physician's proper role to engage in religious deliberation. This is because the public character of a physician's role binds him/her to public reason, which precludes the use of religious considerations. The second argument is the Fiduciary Argument. We show that the patient-physician relationship is a fiduciary relationship, which suggests that the patient has the clinical expectation that physicians limit themselves to medical considerations. Since engaging in religious deliberations lies outside this set of considerations, such engagement undermines trust and therefore damages the patient-physician relationship.

Parental Decision Making: The Best Interest Principle, Child Autonomy, and Reasonableness.

On what basis should we judge whether a parent's medical decision for their child is morally acceptable? In a recent article, Johan Bester attempts to answer this question by defending a version of the Best Interest Standard (BIS) for parental decision making. The purpose of this paper is to identify a number of problems faced by Bester's version of BIS and to suggest ways to redress these problems. Accordingly, we intend to advance the project of formulating a method for guiding parents' medical decision making for their children. We argue that Bester's standard fails to accommodate the autonomy of the child and that his criteria for assessing the reasonableness of the parents' argument for their decision is too weak. We conclude that properly addressing these worries renders his test otiose and that it ought to be replaced with the three commonly held principles of bioethics-the principles of autonomy, beneficence, non-maleficence-and a standard of reasonableness.

The common rule's 'reasonable person' standard for informed consent.

Laura Odwazny and Benjamin Berkman have raised several challenges regarding the new reasonable person standard in the revised Common Rule, which states that informed consent requires potential research subjects be provided with information a reasonable person would want to know to make an informed decision on whether to participate in a study. Our aim is to offer a response to the challenges Odwazny and Berkman raise, which include the need for a reasonable person standard that can be applied consistently across institutional review boards and that does not stigmatize marginal groups. In response, we argue that the standard ought to be based in an ordinary rather than ideal person conception of reasonable person and that the standard ought to employ what we call a liberal constraint: the reasonability standard must be malleable enough such that a wide variety of individuals with different, unique value systems would endorse it. We conclude by suggesting some of the likely consequences our view would have, if adopted.

Forget Evil: Autonomy, the Physician-Patient Relationship, and the Duty to Refer.

Aulisio and Arora argue that the moral significance of value imposition explains the moral distinction between traditional conscientious objection and non-traditional conscientious objection. The former objects to directly performing actions, whereas the latter objects to indirectly assisting actions on the grounds that indirectly assisting makes the actor morally complicit. Examples of non-traditional conscientious objection include objections to the duty to refer. Typically, we expect physicians who object to a practice to refer, but the non-traditional conscientious objector physician refuses to refer. Aulisio and Arora argue that physicians have a duty to refer because refusing to do so violates the patient's values. While we agree with Aulisio and Arora's conclusions, we argue value imposition cannot adequately explain the moral difference between traditional conscientious objection and non-traditional conscientious objection. Treating autonomy as the freedom to live in accordance with one's values, as Aulisio and Arora do, is a departure from traditional liberal conceptions of autonomy and consequently fails to explain the moral difference between the two kinds of objection. We outline how a traditional liberal understanding of autonomy would help in this regard, and we make two additional arguments-one that maintains that non-traditional conscientious objection undermines society's autonomy, and another that maintains that it undermines the physician-patient relationship-to establish why physicians have a duty to refer.

Public reason and the limited right to conscientious objection: a response to Magelssen.

In a recent article for this journal, Morten Magelssen argues that the right to conscientious objection in healthcare is grounded in the moral integrity of healthcare professionals, a good for both professionals and society. In this paper, I argue that there is no right to conscientious objection in healthcare, at least as Magelssen conceives of it. Magelssen's conception of the right to conscientious objection is too expansive in nature. Although I will assume that there is a right to conscientious objection, it does not extend to objections that are purely religious in nature. i Thus, this right is considerably more restricted than Magelssen thinks. In making my case, I draw on John Rawls's later work in arguing for the claim that conscientious objection based on purely religious considerations fails to benefit society in the appropriate way.