Ralf Stoecker

Im Rahmen psychiatrischer Behandlungen ergeben sich immer wieder Situationen, in denen ärztliche Interventionen zwar dringend erforderlich sind, die Patientinnen und Patienten aber krankheitsbedingt nicht aufgeklärt in die Behandlung einwilligen können oder sie sogar ablehnen. In dem Beitrag soll erstens gezeigt werden, dass es sich bei derartigen Situationen tatsächlich um moralische Dilemmata handelt. Das liegt daran, dass das medizinethische Prinzip, Behandlungen nur nach aufgeklärter Einwilligung durchzuführen, nicht nur auf dem Recht auf Selbstbestimmung beruht, sondern auch auf dem Recht auf Integrität des Körpers und der Intimsphäre sowie dem Recht, keinem Zwang ausgesetzt zu werden. Alle drei Rechte sind wiederum eng mit dem Schutz der Würde der Patienten verbunden. Zweitens soll gezeigt werden, dass der Abschluss von Behandlungsvereinbarungen einen ethisch attraktiven Ausweg aus derartigen Dilemmata bieten kann, weil Behandlungsvereinbarungen eine Unterform sogenannter Odysseus-Verträge sind, die dazu geeignet sind, auch im Rahmen von Zwangsmaßnahmen die Würde der Patientinnen und Patienten zu wahren.

The topic of this article is the dependency or, maybe, the interdependency of rationality and self-knowledge. Here two questions may be distinguished, viz. whether being rational is a necessary condition for a creature to have self-knowledge, and whether having self-knowledge is a necessary condition for a creature to be rational. After a brief explication of what I mean by self-knowledge, I deal with the first question. There I defend the Davidsonian position, according to which rationality is, indeed, a necessary condition for self-knowledge. In addition, I distinguish two aspects of rationality which I call basic and local rationality. After that I concentrate on the second question for the remaining larger part of this article. Here I proceed in two stages: first I examine whether self-knowledge is necessary for basic rationality, and then whether it is necessary for local rationality.

Under the new heading “Philosophie aktuell” topics which are relevant in terms of public, moral, and political discourse will be discussed from a philosophical vantage point. By way of example, the explanatory capacity of philosophical reflection and critique will be demonstrated. The present issue puts the reform of the Transplantation Law under philosophical investigation. Concepts of life and death, in particular that of cerebral death, will be scrutinized. It will be asked whether these concepts are descriptive in nature or prescriptive, normatively charged ones. Are cerebrally dead persons still alive or already dead?

Das deutsche Gesundheitswesen steht durch die schnell steigende Anzahl an CO- VID-19-Erkrankten vor erheblichen Herausforderungen. In dieser Krisensituation sind alle Beteiligten mit ethischen Fragen konfrontiert, beispielsweise nach gerech- ten Verteilungskriterien bei begrenzten Ressourcen und dem gesundheitlichen Schutz des Personals angesichts einer bisher nicht therapierbaren Erkrankung. Daher werden schon jetzt klinische und ambulante Ethikberatungsangebote verstärkt mit Anfragen nach Unterstützung konfrontiert. Wie können Ethikberater*innen Entscheidungen in der Krankenversorgung im Rahmen der COVID-19-Pandemie unterstützen? Welche Grenzen von Ethikberatung sind zu beachten? Bislang liegen hierzu noch wenige praktische Erfahrungen vor. Angesichts der dynamischen Entwicklung erscheint es der Akademie für Ethik in der Medizin (AEM) wichtig, einen Diskurs über die angemessene Rolle der Ethikberatung bei der Bewältigung der vielfachen Heraus- forderungen durch die COVID-19-Pandemie zu führen und professionelle Hinweise zu geben. Mit dem vorliegenden Diskussionspapier möchte die AEM einen Beitrag zur Beantwortung wesentlicher Fragen leisten, die sich für die Ethikberatung in den verschiedenen Bereichen des Gesundheitswesens stellen. Sie regt an, diesen Dis- kurs weiter zu führen und hat ein Online-Forum (s. unten) eingerichtet, in dem Ethikberater*innen ihre Erfahrungen teilen und die professionelle Selbstreflexion der Ethikberatung in Pandemiezeiten mit Anregungen fördern können.

Die Würde des Menschen ist unantastbar. – Trotz ihrer prominenten Rolle im Grundgesetz und in vielen anderen Dokumenten nach dem Zweiten Weltkrieg hat sich die moderne Philosophie lange Zeit nur wenig um die Menschenwürde gekümmert. Erst als um die Jahrtausendwende herum die Würde von Embryonen zur Diskussion stand, zeigte es sich, wie spannend und schwierig es ist, ein angemessenes philosophisches Verständnis der Menschenwürde zu finden. Dieses Buch basiert auf drei Grundgedanken: dass die Menschenwürde aus ihren Verletzungen heraus verstanden werden muss, dass wir sie in ihrem historischen Kontext betrachten sollten und dass es vor allen Dingen wichtig ist, ihre vielfältige Verwendung in unterschiedlichen Feldern der Angewandten Ethik zu untersuchen. Entsprechend vereint das Buch theoretische philosophische Überlegungen mit konkreten Untersuchungen zu öffentlich vieldiskutierten Themen wie Hirntod, assistiertem Suizid, Todesstrafe und Ehrenmord. Reflexionen zur Würde des Kindes, des Alters und des Sterbens bilden den Abschluss des Buches. Dabei erweist es sich, dass der Menschenwürde eine unverzichtbare Rolle in der Ethik zukommt, weil sie die Bedeutung eines für jedermann geltenden Schutzes vor Erniedrigungen ausdrückt, und damit für uns alle einen – vielleicht sogar den – Kern unseres moralischen Status formuliert.

Ethische Fragen betreffen alle Gesellschaftsbereiche. Sie stellen sich bei Themen wie sozialer Gerechtigkeit sowie in politischen oder ökologischen Debatten. Das Handbuch erfasst die Angewandte Ethik systematisch und historisch, beschreibt ihre rechtliche und institutionelle Situation sowie die relevanten Teilbereiche, wie z.B. Forschungs-, Wirtschafts- und Bioethik. Im Zentrum stehen konkrete Fragen aus dem Privat- und Sozialleben des Menschen, der medizinischen Ethik sowie der Umwelt- und Tierethik.

The developement of intensive care and transplantation medicine gave rise to ethical problems of the proper treatment of dying patients: How long should they be upheld and from which point on could their organs be removed? Brain oriented concepts of death promised to ease these problems, but on closer look turn out to be untenable. Hence, an alternative attitude towards death and the morally proper treatment of the dying is urgently needed. In former times, before intensive care was developed, death always had comprised various different changes, usually losses, which do not necessarily or conceptually belong to death, but which none the less were responsible for the moral weight we still attach to death. Modern medicine cut the joints between these losses, and hence dissolved the traditional, morally weighty concept of death. This leaves medical ethics with the task to inquire, one by one, into the ethical consequences of these different losses. Die Entwicklung der Intensiv- und Transplantationsmedizin hat eine Reihe neuartiger medizinethischer Probleme entstehen lassen: die Fragen, bis wann man einen Menschen mit allen Mitteln am Leben erhalten und ab wann man ihm lebensnotwendige Organe entnehmen darf. Die Identifikation des menschlichen Todes mit dem Hirntod bot eine attraktive Auflösung dieser Schwierigkeiten, ist aber in den letzten Jahren zunehmend in die Kritik geraten, weil die begrifflich/weltanschaulichen Argumente, die für diese Gleichsetzung angeführt werden, einer Überprüfung nicht standhalten. Es gilt anzuerkennen, daß die medizinische Entwicklung nicht etwa eine Neudefinition des Todes erforderlich, sondern jede derartige Definition müßig gemacht hat, weil die Auffächerung der Sterbeprozesse in der Intensivmedizin die herkömmliche Annahme, daß mit dem Tod ein plötzlicher Umschwung im moralischen Status eines Menschen verbunden ist, ihrer Legitimation beraubt. An ihre Stelle tritt die Anerkennung einer ganzen Reihe verschiedener moralisch folgenreicher Veränderungen , die ein Mensch im Laufe seines Sterbens durchmacht. Es ist die Aufgabe der medizinischen Ethik, die Auswirkungen dieser Veränderungen auf die Patienten-Arzt-Beziehung zu erforschen.

The main topic of Rudiger Bittner's book 'Doing Things for Reasons' is action theory. We learn what it is to have reasons for action and how acting in response to reasons should be construed; we learn to what extent these reasons are elements of our mental life (and in particular that they aren't mental at all). Almost at the end of the book, however, in chap. 12, all of a sudden we learn something more. We receive an answer to the very core question of anthropology: who we are, as men and women, and what is so special about us - or rather that there is nothing special about us. It is this last part of the book, easily overlooked, that I want to concentrate on in my contribution.

Do we sometimes know what will happen in the future? There are two intuitively plausible answers. The prognostic thesis says that we frequently know what will happen, the agnostic thesis says that we never do. Examining the question in the light of different conditions of knowledge supports the prognostic thesis. Yet there is still room for the agnostic intuition, as an expression of oUf necessarily suboptimal epistemic situation with respect to the future, but also of our freedom, in principle, to shape the world as we like to.

Is self-respect a necessary condition for human dignity ? On the one hand, if it were a necessary condition, we could neither respect nor violate the human dignity of small children, severely mentally disabled and unconscious persons, which would certainly be an absurd consequence. On the other hand, it seems to be characteristic for violations of human dignity that they are humiliating for the victim, and humiliation usually is construed as a violation of self-respect. The dilemma is solved when we realize that self-respect is a disposition to take care of one’s personal dignity, and that human dignity basically consists in having the opportunity of maintaining one’s personal dignity. Since personal dignity does not disappear when a person looses her ability to take care of it, respecting human dignity may consist in taking care of someone’s personal dignity who has lost self-respect. Therefore, self-respect is not necessary for human dignity

I offer a justification for the received view that the characteristic feature of agents is to be found in the particular way their behaviour is explainable. Agents are people who have acquired three skills: (i) to act in accordance with inner or public deliberation; (ii) to do many things almost as if they had deliberated; and (iii) to recognize situations where it is worthwhile to switch from the second to the first skill. We can therefore assume that agents behave as if they were accompanying their behaviour by constant thinking although they don't actually deliberate all the time. This view allows for some attractive solutions for notorious problems in action theory but has the surprising ontological consequence that, although there are agents in action, there are no actions.

Given the many marvelous things animals can do and moreover the success we have in employing the intentional stance towards animals, it seems to be almost unthinkable to say that animals could not act at all. Nonetheless, this is exactly what I argue for. I claim that strictly speaking there is no animal action, only behaviour. I defend this claim in three steps. Firstly, I recapitulate some of the weighty grounds that speak in favour of animal agency. Secondly, I explain why I still doubt that animals act. The argument is that the account of agency that I take to be the most attractive one entails that animals can't act. Since this account of agency is non-standard, I spend the bulk of the paper with providing a sketch of what, according to it, actions are. Finally, I explain why it is still so natural and promising to regard animals as agents, although in fact they aren't. As one might put it: of course they act, only strictly speaking they don't

There is a widely accepted view in action theory (most prominently defended by Donald Davidson) according to which (1) actions are events, (2) reasons are intentional attitudes of the agent (pairs of beliefs and desires), and (3) acting for a reason entails that the reason rationalizes as well as causes the action. In the first part of my contribution I list seventeen difficulties for this standard account; in the second part I give an outline of how a more plausible conception of reasons and actions could look like. According to this conception, which is based on Gilbert Ryle’s criticism of a mechanistic understanding of psychological concepts, agency is due to a special kind of disposition of the agent, namely the disposition to behave as if the agent were permanently deliberating about what to do. The conception has surprising consequences for the ontological status of intentional attitudes and actions and for the relationship between action and responsibility.

Mental causation comes in different shapes, but certainly one of the most conspicuous instances of mental causation is intentional action – when we do something because we want to do it. At least, most action theorists and philosophers of mind take it for granted that intentional action is an instance of mental causation, since they assume first that desires are mental and second that doing something because one wants to do it is to be accounted for causally. Yet, these philosophers face a well-known problem: it may happen that our desires cause what is wanted without that being an instance of our intentionally doing what is wanted. Prima facie, what is wrong in these cases is that the causal path leading from desires to actions goes ‘wayward’ instead of taking the right track, apt for intentional action. Hence, action theorists have tried to specify the right tracks of action causation. But since this turned out to be an awfully tricky task, the idea came up that the whole enterprise may have been ill-advised from the beginning. As I shall argue, this suspicion is correct. Although the two assumptions leading to the problem of waywardness are true (if understood in the right way), the idea of causal paths connecting desires with actions is wrong and should be replaced by a quite different picture of the causal role of desires in agency: desires and other intentional attitudes are causal powers which are actualized in intentional agency. This alternative picture not only has the advantage of accounting for the notorious cases of waywardness, it also relieves some doubts concerning the conceivability of a causal influence of desires in a world of material causes. However, I shall confine myself to the problem of waywardness. My contribution has twelve sections. In section 1, I sketch a standard story about the way we influence the world, and I mention two well known problems discussed in the theory of action. Sections 2 and 3 present three cases of wayward causal chains that pose a third problem for the standard picture. I shall go on to discuss mainly two of them, cases of so-called basic versus non-basic waywardness (section 4) . To understand what is wayward in these cases one needs to understand the special function of ‘by’-sentences (section 5) and the causal role of intentional attitudes (sections 6-8). Sections 9-11 explain the idea that intentional attitudes are causal powers of agents. As it turns out, this accounts smoothly for the two prime examples, but leaves unaddressed a third kind of wayward causal chains. Section 12 closes with an attempt to extend the account to those cases, too, thereby connecting human agency with freedom.