In current American medical practice, autonomy is assumed to be more valuable than human life: if a patient autonomously refuses lifesaving treatment, the doctors are supposed to let him die. In this paper we discuss two values that might be at stake in such clinical contexts. Usually, we hear only of autonomy and best interests. However, here, autonomy is ambiguous between two concepts-concepts that are tied to different values and to different philosophical traditions. In some cases, the two values (that of agency and that of authenticity) entail different outcomes. We argue that the comparative value of these values needs to be assessed.
In this essay, I raise the question of whether some degree of noncoercive state support for religious conceptions(broadly understood) should be left to the majoritarian branch of government. I argue that the reason not to do so is that such state support would alienate many citizens. However, to take this as a sufficient reason to constrain the majoritarian branch is to accept the thesis that not being alienated from one’s polity is a significant part of the human good. Those who would prohibit even a small amount of noncoercive support of religious conceptions must appeal either to pragmatic considerations (the worry that noncoercive will lead to coercive support, i.e., to tyranny) or to a conception of the good that puts great value on the agent’s sense of connectedness to the polity. And the latter is something that reasonable citizens in a modern democracy could reasonably reject.
When does behavior trigger a lesser claim to medical resources? When does chronic drinking, for example, mean that one has a lesser claim to a liver transplant? Only when one's behavior becomes a callous indifference to others' needs—when one knows the consequences of heavy drinking and knows that by drinking one may end up depriving someone else of a liver.
The question that surrogate decision-makers are expected to ask themselves, as they try to decide on the appropriate course of treatment, is the wrong question. That question is, what would the patient choose? The appropriate question is, what could the patient choose, given her commitments?
A patient has a specific kind of moral right to make her own medical decisions. A surrogate has no analogous moral right to decide for someone else. We want the surrogate to make the decision because we believe that she has a relevant epistemological advantage over anyone else on the scene. If and when she has no such advantage or if she refuses or is unable to use it, then there might not be sufficient reason to let her be the decision-maker.
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