Compulsory vaccination protects autonomy.

In a recent article in this journal, Kowalik argues that compulsory vaccination unjustifiably infringes on the autonomy of vaccine refusers. While accepting Kowalik's central premises, we argue that, when appropriately expanded in scope, autonomy considerations do not undermine the justifiability of compulsory vaccination. Vulnerable individuals-including the very old, the very young and those with compromised immune systems-face an omnipresent risk of contracting a potentially fatal vaccine-preventable illness and are thus prevented from accessing public goods by coercive pressure. Consequently, when we consider an appropriately broad scope of autonomy constraints, autonomy considerations do not undermine the case for mandating vaccination.

Why Intellectual Disability Poses a Challenge to the Received View of Capacity and a Potential Response.

While copious quantities of ink have been spilled on the topic of autonomy in the context of health care, little has been written about autonomy in relation to intellectual disability. After presenting the received account of capacity, we argue that it cannot account for the moral permissibility of limiting an individual with intellectual disability's access to diet soda. In cases of preventative medicine and intellectual disability, the philosophical motivation for the received account of capacity is incompatible with the actions it recommends. We consider and reject several potential solutions; then, drawing on applied behavior analysis and the phenomenon of automatic reinforcement, we propose our own solution. The article concludes by considering the broader implications of our discussion.

Justifying risk-related standards of capacity via autonomy alone.

The debate over risk-related standards of decisional capacity remains one of the most important and unresolved challenges to our understanding of the demands of informed consent. On one hand, risk-related standards benefit from significant intuitive support. On the other hand, risk-related standards appear to be committed to asymmetrical capacity-a conceptual incoherence. This latter objection can be avoided by holding that risk-related standards are the result of evidential considerations introduced by (i) the reasonable person standard and (ii) the standing assumption that patients have capacity. This evidential approach to justifying risk-related standards of capacity avoids the most significant challenges faced by extant views while grounding risk-related standards in two fairly uncontroversial views in biomedical ethics.

Proxy Consent by a Physician When a Patient's Capacity Is Equivocal: Respecting a Patient's Autonomy by Overriding the Patient's Ostensible Treatment Preferences.

Respect for patients' autonomy has taken a central place in the practice of medicine. Received wisdom holds that respect for autonomy allows overriding a patient's treatment preferences only if the patient has been found to lack capacity. This understanding of respect for autonomy requires a dichotomous approach to assessing capacity, whereby a patient must be found either to have full capacity to make some particular treatment decision or must be found to lack capacity to make that decision. However, clinical reality is more complicated, and, in borderline cases, different physicians may arrive at disparate judgments of capacity. In such cases, when capacity-determination protocols fail to achieve consensus, physicians would benefit from guidance regarding the clinical decision-making process necessary to elucidate the most ethically sound course of action. This article considers one such case and argues that, in a limited number of cases, respect for autonomy may require overriding a patient's stated treatment preference when a capacity determination is equivocal, even though the patient has not clearly demonstrated a lack of capacity.

Autism, intellectual disability, and a challenge to our understanding of proxy consent.

This paper focuses on a hypothetical case that represents an intervention request familiar to those who work with individuals with intellectual disability. Stacy has autism and moderate intellectual disability. Her parents have requested treatment for her hand flapping. Stacy is not competent to make her own treatment decisions; proxy consent is required. There are three primary justifications for proxy consent: the right to an open future, substituted judgment, and the best interest standard. The right to an open future justifies proxy consent on the assumption of future autonomy whereas substituted judgment justifies proxy consent via reference to past autonomy. Neither applies. Stacy has not been, nor will she be, competent to make her own treatment decisions. The best interest standard justifies proxy consent on the grounds of beneficence. It is unlikely that hand flapping harms Stacy. None of the three primary means of justifying proxy consent apply to Stacy's case.

The Case for Enrolling High-Cost Patients in an ACO.

Though accountable care organizations (ACOs) are increasingly important to American healthcare, ethical inquiry into ACOs remains in its nascent stages. Several articles have raised the concern that ACOs have an incentive to avoid enrolling high-cost patients and, thereby, have an incentive to deny care to those who need it the most. This concern is borne out by the reports of consultants working with newly formed ACOs. This paper argues that, contra initial appearances, there is no financial incentive for ACOs to avoid enrolling high-cost patients.

Ethical Practice Under Accountable Care.

Accountable Care Organizations (ACOs) are a key mechanism of the Patient Protection and Affordable Care Act (PPACA). ACOs will influence incentives for providers, who must understand these changes to make well-considered treatment decisions. Our paper defines an ethical framework for physician decisions and action within ACOs. Emerging ethical pressures providers will face as members of an ACO were classified under major headings representing three of the four principles of bioethics: autonomy, beneficence, and justice (no novel conflicts with non-maleficence were identified). Conflicts include a bias against transient populations, a motive to undertreat conditions lacking performance measures, and the mandate to improve population health incentivizing life intrusions. After introducing and explaining each conflict, recommendations are offered for how providers ought to precede in the face of novel ethical choices. Our description of novel ethical choices will help providers know what to expect and our recommendations can guide providers in choosing well.

Informed Consent, Deaf Culture, and Cochlear Implants.

While cochlear implantation is now considered routine in many parts of the world, the debate over how to ethically implement this technology continues. One's stance on implantation often hinges on one's understanding of deafness. On one end of the spectrum are those who see cochlear implants as a much needed cure for an otherwise intractable disability. On the other end of the spectrum are those who view the Deaf as members of a thriving culture and see the cochlear implant as an attempt to eliminate this culture. Rather than take a stance in this debate, we will argue that the informed consent process for cochlear implantation must include access to Deaf perspectives. Deaf individuals know best what it is like to be a member of the Deaf community; the reasonable person would put significant weight on the testimony of Deaf individuals when considering whether to undergo cochlear implantation. The reasonable person standard determines what information careproviders must present as part of the informed consent process; thus, informed consent for cochlear implantation requires access to the testimony of Deaf individuals.

Tourette Syndrome: A Catalyst for Operationalizing Neurodiversity.

Our goal, taking Tourette syndrome as a case example, is to introduce neurologists to, and motivate discussion on, the neurodiversity paradigm. This philosophical construct considers some neurologic conditions in diversity, instead of simply disease. Moving from philosophical idea to empirical construct draws from patient and family perspectives on (1) quality of life and discrimination, (2) disability pride, and (3) unique profiles of different patient cohorts. Listening to patient voices, attending to family, advocacy group, and societal views on neurologic disorders can strengthen precision neurology practice. Dialogs on neurodiversity, including antitherapy sentiments, offer to enhance neurologic care, patient agency, and autonomy; encourage respectful communications with patients who challenge the idea their condition is pathologic; and to set the stage for future empirical investigations and practice guidelines.

Clinical Informed Consent and ABA.

The practice of clinical informed consent in America is governed by over 100 years of case law. Although predominant ethics resources for behavior analysts offer some guidance regarding the provision of clinical informed consent, such guidance remains limited. The goal of this article is thus to expand the contemporary literature on clinical informed consent in behavior analysis by providing a historical and contemporary guide to relevant case law. The article will highlight seminal moments in the history of case law regarding clinical informed consent, discuss their applicability to the process of clinical informed consent in behavior analysis, and provide an enhanced understanding of the ethical and legal obligations related to informed consent in the therapeutic context. Supplementary Information: The online version contains supplementary material available at 10.1007/s40617-023-00902-0.

Internet-based crowdsourcing and research ethics: the case for IRB review.

The recent success of Foldit in determining the structure of the Mason-Pfizer monkey virus (M-PMV) retroviral protease is suggestive of the power-solving potential of internet-facilitated game-like crowdsourcing. This research model is highly novel, however, and thus, deserves careful consideration of potential ethical issues. In this paper, we will demonstrate that the crowdsourcing model of research has the potential to cause harm to participants, manipulates the participant into continued participation, and uses participants as experimental subjects. We conclude that protocols relying on this model require institutional review board (IRB) scrutiny.

Applied Behavior Analysis and the Abolitionist Neurodiversity Critique: An Ethical Analysis.

The behavior analytic literature on neurodiversity remains limited. This article aims to begin filling the lacuna. We will introduce the neurodiversity perspective and demonstrate an important congruence between the behavior analytic and neurodiversity perspectives on autism. Despite this congruence, applied behavior analysis is often targeted for criticism by proponents of the neurodiversity perspective. A central concern raises questions about the aims of behavior analytic interventions for clients with autism. Is it appropriate to teach clients with autism to behave as if they were neurotypical? Concerns about the aims of behavior analytic interventions mirror concerns that have been raised about the aims of language education in schools. Drawing on the literature regarding linguistically diverse classrooms, we will critically evaluate the abolitionist neurodiversity critique of ABA. We conclude by considering both concrete and theoretical implications for the ethics of behavior analytic work with autistic clients.

Black, white or green: 'race', gender and avatars within the therapeutic space.

Personal identity is critical to provider--patient interactions. Patients and doctors tend to self-select, ideally forming therapeutic units that maximise the patients' benefit. Recently, however, 'reality' has changed. The internet and virtual worlds such as Second Life (http://www.secondlife.com/) allow models of identity and provider--patient interactions that go beyond the limits of mainstream personal identity. In this paper some of the ethical implications of virtual patient--provider interactions, especially those that have to do with personal identity, are explored.

Get your paws off of my pixels: personal identity and avatars as self.

There is an astounding silence in the peer-reviewed literature regarding what rights a person ought to expect to retain when being represented by an avatar rather than a biological body. Before one can have meaningful ethical discussions about informed consent in virtual worlds, avatar bodily integrity, and so on, the status of avatars vis-à-vis the self must first be decided. We argue that as another manifestation of the individual, an individual's avatar should have rights analogous to those of a biological body. Our strategy will be to show that (1) possessing a physical body is not a necessary condition for possessing rights; (2) rights are already extended to representations of a person to which no biological consciousness is attached; and (3) when imbued with intentionality, some prostheses become "self." We will then argue that avatars meet all of the conditions necessary to be protected by rights similar to those enjoyed by a biological body. The structure of our argument will take the form of a conditional. We will argue that if a user considers an avatar an extension of the self, then the avatar has rights analogous to the rights of the user. Finally, we will discuss and resolve some of the objections to our position including conflicts that may arise when more than one individual considers an avatar to be part of the self.

The Promise of Accountable Care Organizations: "The Code," Reimbursement, and an Ethical No-Win Situation for Behavior Analysts.

Clinical ethics, with its emphasis on the actions of clinicians, risks overlooking the ways in which broader health-care structures influence the behavior of health-care providers. Analysis of a factual case study demonstrates that status quo reimbursement practices may place behavior analysts in a position where, no matter how they act, they risk acting unethically. By contrast, the reimbursement model set by accountable care organizations (ACOs), part of the Patient Protection and Affordable Care Act (also known as Obamacare), may offer a solution. However, making good on the promise of ACOs will require more resources than any individual behavior analyst possesses. In order to encourage institutional structures that facilitate ethical practice, behavior analysts' professional organizations should engage in contemporary political discussions about the state of American health care.

The Unique Challenge of Articulating the Behavior Analysts' Ethical Obligations and the Case of Punishment.

There is a long-standing debate about the place for technical versus colloquial language in applied behavior analysis; however, this debate has yet to be considered within the context of a professional code of ethics for applied behavior analysts. In this article we discuss the limitations of technical language in articulating the applied behavior analyst's ethical commitments, illustrating this point by considering the use of the term punishment in the Professional and Ethical Compliance Code for Behavior Analysts (Behavior Analyst Certification Board, 2016). The ethical concerns regarding the use of punishment may be more accurately stated in terms of the need to avoid techniques that cause pain or discomfort rather than techniques that meet the technical definition of punishment. In summary, more consideration should be given to the use of subjective terminology in behavior analysts' ethical discussions.