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					                                                  TABLE OF CONTENTS

Table of Contents ............................................................................................................ i

Summary ......................................................................................................................... xii

Statement of Originality .................................................................................................. xiv

Acknowledgements ......................................................................................................... xiv

INTRODUCTION .............................................................................................................. xv

                                                The Case of Mrs L. Burmester .................................... xv

                                                Setting the Stage .......................................................... xvi

                                                The Medical Context ................................................... xvii

                                                The President's Commission........................................ xix

                                                Terminology ................................................................ xxi

PART I: TREATMENT LIMITATION AND RESPECT FOR AUTONOMY .......................... 1

            Chapter 1. The Nature of Being Autonomous .............................................. 1

                        1.1 Some Requirements of Autonomy .................................................. 1

                                    1.11 Being Autonomous Entails Making Evaluations ............ 1

                                                1.111 Autonomy and Rational Desiring ..................... 3

                                    1.12 An Argument for Rational Evaluation ............................ 4

                                                1.121        Logic and the Facts, Relevant and
                                                Available ..................................................................... 4

                                                1.122 Vivid Imagination ............................................. 8

                                                            1.1221 Uncertainty and the Unknown ........... 10

                                                            1.1222         Surprise, Impulsiveness and
                                                            Choosing to Ignore Available Facts ............... 12

                                                            1.1223 Actual Experience.............................. 14
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                     1.123 A Reasonable Range of Alternatives ................ 15

                                 1.1231 What Ought to Be Possible ................ 17

                     1.124 A Reasonable Range of Consequences ............ 18

                                 1.1241 The Improbable but Significant ......... 20

         1.13 Rational desires: Actual or Hypothetical? ....................... 21

         1.14 Autonomy Is a Dispositional Concept............................. 23

                     1.141 Autonomy and Valuing .................................... 25

         1.15 The Objects of Rational Evaluation ................................ 30

1.2 The Concept of Obstructive Desire ................................................ 31

         1.21 Two Objections ............................................................... 33

         1.22 Relevance to Health Care ................................................ 33

1.3 Objections to a Rational Desire Account of Autonomy ................. 35

         1.31 The Problem of Manipulation and the Infinite
         Regress ..................................................................................... 35

                     1.311       One Response to the Incompleteness
                     Problem ....................................................................... 37

                     1.312             Christman's            Solution          to      the
                     Incompleteness Problem .............................................. 40

                                 1.3121 Sleight of Hand .................................. 40

                                 1.3122 The Significance of Personal
                                 History ............................................................ 41

                     1.313 Relevance to Health Care ................................. 42

         1.32 Berlin's Critique of Positive Liberty ................................ 43

                     1.321 Berlin's Argument against the Splitting
                     of the Self. ................................................................... 43

                                 1.3211             Problems          with       Berlin's
                                 Objection ........................................................ 45

                                             1.32111 Conflating Values and
                                             Desires ............................................... 45

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                                                   1.32112 Failing to Distinguish
                                                   Hypothetical             and        Actual
                                                   Rational Desire Theories ................... 46

                                        1.3212         Why Does Berlin Fail to
                                        Accord Importance to Positive Liberty? ......... 46

                             1.322 The Argument from Sour Grapes ..................... 48

                                        1.3221        Two Responses to Berlin's
                                        Objection ........................................................ 50

                             1.323 The Argument Against Rationalism ................. 52

         1.4 Practical Issues: Determining What a Person Values..................... 56

                  1.41 Respect Only Expressed Desires ..................................... 56

                  1.42 Direct Report ................................................................... 57

                  1.43       Determining a Person's Values From That
                  Person's Behaviour and Desires ............................................... 59

                             1.431        Conditions Under Which Rational
                             Desires Are Likely to Be Revealed ............................. 61

                                        1.4311 Past and Present Experience .............. 61

                             1.432 Potential for Error and Abuse ........................... 63

                  1.44 Change in Rational desire................................................ 64

         1.5 Summary: Some Necessary Requirements for Autonomy ............. 66

Chapter 2. Autonomously Desiring to Die: "No Man Ever Threw
Away Life, While It Was Worth Keeping." ................................................... 68

         2.1 Disability, Suffering and Obstructive Desire ................................. 69

                  2.11 Adaptation to Disability .................................................. 70

                             2.111 One Example of Adaptation: Deafness ............ 73

                  2.12 Hurdles to Rational Evaluation ....................................... 74

                             2.121 Contrast ............................................................ 74

                                        2.1211 The Coding of Experience ................. 75

                             2.122 Loss Aversion ................................................... 75

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                                              2.123 Framing Effects ................................................ 77

                                                          2.1231          Modes of Presentation of
                                                          Information ..................................................... 79

                                              2.124 Comparison to Norms........................................ 81

                                                          2.1241 What Is a Norm? ................................ 81

                                                          2.1242 The Norm for Paraplegia ................... 82

                                                          2.1243 When the Use of Norms Goes
                                                          Wrong ............................................................. 83

                                              2.125 Subjective Probability Estimations................... 88

                                              2.126 Endowment. ....................................................... 90

                                              2.127 Bias to the Present and Near Future .................. 90

                                  2.13 Conclusion: The Challenge to Be Rational ..................... 91

                      2.2 Practical Applications .................................................................... 94

                                  2.21 Limitation of Treatment of Previously Competent,
                                  Now Incompetent Patients........................................................ 94

                                  2.22 Limitation of Treatment of Competent Patients .............. 98

                                  2.23      One Practical Objection: Autonomy and False
                                  Beliefs....................................................................................... 100

                                              2.231 Instrumental Irrationality ................................... 100

                                              2.232 Instrumentally Valuable False Beliefs ............... 101

                                              2.323 Descriptive and Non-Descriptive Beliefs .......... 102

                                  2.24 Conclusion and Recommendations ................................. 104

PART II: TREATMENT LIMITATION AND PROMOTION OF

BEST INTERESTS ............................................................................................................ 108

           Chapter 3. The Nature of a Human Being's Best Interests ......................... 108

                                              Interests and the President's Commission .................... 109

                      3.1 Three Theories of Well-Being........................................................ 110

                                  3.11 Desire-Fulfilment Theories ............................................. 110


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           3.111 Which Desires? ................................................. 110

           3.112 Choosing One's Own Lesser Good and
           The "Implied Objective Standard" .............................. 112

           3.113 Ideal Desire Theories ........................................ 114

                      3.1131 Ideal Desire Theories Fail to
                      Meet the Implied Objective Standard of
                      Prudence ......................................................... 116

                      3.1132         A Stand-Off: Desiredness,
                      Ideal Desiredness and Desirability ................. 119

           3.114       Other Reasons for Seeking a More
           Objective Account of Well-Being ............................... 121

                      3.1141          The Difference Between
                      Respect for Autonomy and Promoting a
                      Person's Interests............................................. 121

                      3.1142 The Collapse of Prudence and
                      Self-Sacrifice .................................................. 122

3.12 Hedonistic Theories......................................................... 123

           3.121 Pluralism ........................................................... 124

           3.122 Objections ......................................................... 125

                      3.1221 Non-Experiential Goods .................... 125

3.13 Objective List Theories ................................................... 127

           3.131 Objections ......................................................... 128

                      3.1311          Mackie's Argument from
                      Queerness........................................................ 128

                      3.1312 The Comparability Problem .............. 132

                      3.1313 Totalitarianism ................................... 134

                      3.1314 The Importance of Pleasure ............... 135

3.14 A Synthesis ...................................................................... 135

           3.141 Plato's Conception of Well-Being .................... 135


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                   3.142 Parfit's Composite Conception of Well-
                   Being ........................................................................... 136

                   3.143 Refining the Composite Conception of
                   Well-Being .................................................................. 139

                              3.1431 A Minor Refinement: How Is
                              Pleasure to Be Construed within the
                              Composite Conception of Well-Being? .......... 139

                              3.1432 A Major Refinement: Meeting
                              the Requirement for Uplifting ........................ 139

                              3.1433          Autonomy as a Prudential
                              Value ............................................................... 142

                                          3.14331 The Extended List vs
                                          the Composite Conception of
                                          Well-Being ......................................... 144

                   3.144 Summary: An Account of Well-Being ............. 145

3.2 What Is Objectively Good in Life? ................................................ 146

         3.21 "Touching the Void" ....................................................... 146

                   3.211 Intimacy ............................................................ 151

                   3.212 Achievement ..................................................... 155

                   3.213 The Importance of a Plan ................................. 155

                   3.214 The Importance of Routine to the Plan ............. 156

                   3.215 Self-Understanding ........................................... 157

                   3.216 Having a Personal History ................................ 157

                   3.217 Richness of Experience .................................... 158

                   3.218 Vividness of Experience ................................... 159

                   3.219 Harmony ........................................................... 160

         3.22 Richness and Repetition, Empathy and Boredom ........... 162

                   3.221 The Makropulos Case ....................................... 162

                   3.222 The Fallacy of Solipsism .................................. 163


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                                               3.2221 Gossip and Television ....................... 164

                       3.23 Having A Reason to Live ................................................ 166

                                   3.231 Good Categorical Reasons ................................ 166

                                   3.232 Facing Death and Having a Reason to
                                   Live .............................................................................. 168

                                   3.233 Three Examples ................................................. 171

Chapter 4. Practical Applications: When Is Death in a Human
Being's Interests? ............................................................................................. 175

           4.1     Intrinsically versus Instrumentally Valuable Goods and
           Bads ....................................................................................................... 175

                       4.11 Narrowly Construed Medical Interests versus Best
                       Interests .................................................................................... 176

                                   4.111 Measuring Quality of Life ................................ 177

                       4.12 Pain .................................................................................. 181

                                   4.121 What Is Pain?.................................................... 182

                                   4.122 The Badness of Pain ......................................... 183

                                   4.123 The Goodness of Pain ....................................... 185

                       4.13 How Bad Is Paraplegia? .................................................. 189

                                   4.131 Loss of Other Goods ......................................... 190

                                   4.132 Loss of Capacity ............................................... 191

                                               4.1321 When Being a Paraplegic Is the
                                               Best Life Possible ........................................... 191

                                               4.1322             Counterfactuals             and       the
                                               Badness of Paraplegia ..................................... 192

                                   4.133 Trading Goods ................................................... 193

                                   4.134          A Comparison with Poverty and
                                   Wisdom ....................................................................... 193

           4.2      Best Interests and the Limitation of Life-Sustaining
           Treatment .............................................................................................. 196


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4.21        Best Interests and the Reasonableness of
Autonomous Choice: The Role of Education........................... 196

           4.211 A Final Note on Mrs L. Burmester ................... 198

4.22      Best Interests as a Determinant of Treatment
Limitation ................................................................................. 200

           4.221 The Nature of Well-Being ................................ 200

                       4.2211 The Case of Baby R: Mental
                       Retardation, Dependence and Life Not
                       Worth Living .................................................. 200

                                   4.22111 What Matters Most ............. 202

                                   4.22112         What Matters Less:
                                   Mental           Retardation              and
                                   Dependence........................................ 203

                                   4.22113             Conflating          Two
                                   Perspectives ....................................... 206

                                   4.22114 A Qualification ................... 207

           4.222 Amount of Well-Being ..................................... 209

                       4.2221         Life Is Worth Living as a
                       Function Purely of the Good in Life ............... 209

                                   4.22211 One Answer ........................ 210

                       4.2222        Life Not Worth Living as a
                       Function of the Bad in Life............................. 212

                       4.2223 Life Not Worth Living as a Mix
                       of the Good and Bad in Life ........................... 213

           4.223 Distribution of Well-Being ............................... 214

                       4.2231 Spreading a Good Too Thin .............. 214

                       4.2232 Spreading a Good Too Thick,
                       Too Soon ........................................................ 215

                       4.2233 Other Distributions ............................ 215

                       4.2234 Pure Timing of the Good ................... 216

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                                      4.224 Pre-Existing Level of Well-Being .................... 218

                                      4.225       The Uncertainty of Achieving Well-
                                      Being ........................................................................... 219

                                      4.226 The Good of Future Autonomy ........................ 221

                                                 4.2261            Future        Autonomy           as     a
                                                 Barometer of the Worth of Life Now ............. 222

                                                 4.2262          Autonomy as a Prudential
                                                 Good ............................................................... 223

                                                 4.2263                Autonomy              and         the
                                                 Construction of Meaning: the Case of
                                                 Ms P ................................................................ 224

                           4.23 Conclusion ....................................................................... 226

PART III. RATIONAL CHOICE: SUBJECTIVE OR OBJECTIVE? ................................... 228

        Chapter 5. What a Person Has Most Reason to Do ..................................... 228

                5.1 Background .................................................................................... 230

                           5.11 The Bon Vivant ............................................................... 230

                           5.12 The Time Frame of Preferences. ..................................... 230

                           5.13 Which Preferences Provide Reasons for Action? ............ 231

                           5.14 Temporal Neutrality ........................................................ 232

                           5.15 Parfit's Present-aim Theory ............................................. 233

                           5.16 The Strategy: A War of Five Battles ............................... 234

                5.2 Battle 1: Psubjective vs Ssubjective ............................................... 237

                           5.21 Cross-Temporal Desires .................................................. 237

                                      5.211        The Importance of Present Cross-
                                      Temporal Desires......................................................... 238

                                                 5.2111 Now-For-Then Preferences ............... 238

                                                 5.2112                      Now-For-Back-Then
                                                 Preferences...................................................... 240

                           5.22 Past (Back-then-for-back-then) Desires .......................... 240

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          5.23 Future (Then-For-Then) Desires ..................................... 243

                     5.231 Inconsistent Prescriptions ................................. 243

                     5.232 Why the Present Matters .................................. 246

                                 5.2321 Ground Projects ................................. 246

                                 5.2322 Internal and External Reasons ........... 252

                     5.233 Values and Desires ........................................... 255

                                 5.2331         Responding Now to Future
                                 Desires ............................................................ 256

          5.24 Two Problems for P......................................................... 257

                     5.241 Wills of the Dead .............................................. 257

                     5.242 Precommitment Contracts ................................ 258

          5.25 Conclusion ....................................................................... 259

5.3 Psubjective vs Pobjective ............................................................... 261

          5.31 The Drug-Taking Bon Vivant ......................................... 261

          5.32       The Instrumental, Deliberative and Critical
          Versions of P ............................................................................ 261

          5.33       Are There Any Intrinsically Irrational and
          Rationally Required Desires? ................................................... 263

                     5.331 "Intrinsically Irrational" and "Rationally
                     Required" Desires Accepted by DP ............................. 264

                                 5.3311          Intransitive or Inconsistent
                                 Preferences...................................................... 264

                                 5.3312           Desires for a Particular
                                 Instance of a Desired General Kind ................ 264

                                 5.3313                  Rationally            Required
                                 Instrumental Desires ....................................... 265

                     5.332          Other Intrinsically Irrational and
                     Rationally Required Desires Suggested by
                     Parfit ............................................................................ 266


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                                                         5.3321 Arbitrary Concern .............................. 266

                                                         5.3322         The Desire to Jump from a
                                                         Cliff................................................................. 269

                                                         5.3323 Time Bias ........................................... 270

                                                         5.3324                What          Constitutes           a
                                                         "Desirability-Characterization"? ..................... 271

                                  5.34 How Much Weight Ought to Be Accorded to the
                                  Satisfaction of Subjectively Rational Desires?......................... 273

                                             5.341 Non-Rational Beings ........................................ 276

                                             5.342 Rational Beings ................................................ 277

                                             5.343 The Drug-Taking Bon Vivant and Grass-
                                             Counter Revisited ........................................................ 279

                      5.4 The Argument from Intuitions about Achievement ....................... 281

                                  5.41 Battle 2: Pobjective vs Sobjective ................................... 281

                                  5.42 Battle 3: Psubjective vs Sobjective ................................. 287

                                             5.421 Which Version of P Wins? ............................... 289

                                                         5.4211           Changing One's Rational
                                                         Desires ............................................................ 290

                      5.5 Conclusion ..................................................................................... 294

                      5.6 A Reductionist Challenge to the Importance of Subjective
                      Reasons ................................................................................................. 297

                                  5.61 Parfit's Reductionist Conception of Identity ................... 297

                                  5.62 The Immorality of Imprudence ....................................... 298

                                  5.63 Should One's Future Self Be Treated As If It
                                  Were Another Person?.............................................................. 300

                                  5.64 Conclusion ....................................................................... 307

           Chapter 6. Final Conclusion .......................................................................... 308
BIBLIOGRAPHY .............................................................................................................. 311




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