By Shadi “Sophie” Heidarifar
When a patient requests a procedure shaped under constraints, including oppressive ones, we tend to evaluate the preference itself: whether it is autonomous, whether it reflects internalized norms, whether it has been formed under coercive conditions. This framing presumes that the central bioethical question concerns the status of a preference. In my paper, I argue that the difficulty lies elsewhere, not in assessing an isolated health-related adaptive preference (HRAP), but in examining how a subject comes to inhabit a world in which certain HRAPs become possible at all.
Much of the literature on adaptive preferences examines whether a given preference reflects internalized oppression or unjust social conditioning. The central question becomes whether the preference should be accepted at face value, resisted, or regarded with caution in light of the constraints under which it was formed. This framing directs normative attention to the status of the preference itself. The evaluative task then is to determine whether that preference is distorted, compromised, or otherwise morally suspect.
What remains largely unexamined is the prior formation of the subject who holds it. Adaptive preferences do not arise within a ready-made chooser; they emerge within a formed orientation in which certain possibilities appear viable, necessary, or unavoidable, while others fail to appear as options at all. The question, then, is not only whether a preference is compromised by constraint, but how constraint structures the field of intelligible health-related possibilities from which an HRAP is drawn.
In my paper, I develop what I call a subjectivity-first approach. The proposal is straightforward: before asking whether an HRAP is morally permissible, we should ask how a subject came to experience that preference as intelligible, viable, or necessary within the world they inhabit.
To be specific, an HRAP does not emerge in a vacuum. It takes shape within a world already organized by expectations, risks, and material limits that determine which responses to constraint are realistically livable. Evaluating the preference alone leaves that organization intact.
A subjectivity-first approach therefore shifts the level of analysis. Rather than beginning with the evaluation of a preference, it begins with the formation of the subject for whom that preference has become a live option.
Without this shift, clinical responses to HRAPS tend to oscillate between two familiar poles. On one side lies the impulse to override the preference in the name of welfare, treating it as the product of distortion or constraint and therefore in need of correction. On the other lies the impulse to accept the preference at face value, treating its lived coherence for the patient as sufficient for endorsement.
Both responses take the preference as the primary object of evaluation. The disagreement concerns how to classify it, not whether it is the right unit of analysis.
A subjectivity-first approach alters the terrain. It relocates normative attention from the isolated preference to the formative conditions that rendered it compelling in the first place. In doing so, it reframes the ethical task to how to understand and, where possible, reshape the conditions that made an HRAP appear necessary.
Rather than asking simply whether an HRAP should be accepted at face value or refused, a subjectivity-first approach directs attention to three prior questions:
- How did this preference come to make sense within the subject’s circumstances?
- Within that same practical domain, are meaningful alternatives realistically available?
- If such alternatives are absent, what would need to change for other options to become livable?
These questions do not yield a single determinate outcome. They instead widen the bioethical lens. They move analysis beyond the isolated preference toward the structured conditions that define what counts, for this subject, as viable at all.
The distinctive contribution of this framework is thus not a new theory of autonomy, nor a rejection of existing accounts of adaptive preference. It is a shift in level of analysis: from evaluating HRAPs to examining the formation of subject for whom an HRAP becomes intelligible in the first place.
If medicine confines itself to judging preferences, it risks misidentifying the locus of the ethical difficulty. The more fundamental question concerns how certain options came to appear as the most viable responses within the constraints a subject inhabits.
Author: Shadi “Sophie” Heidarifar
Affiliation: Roseman University College of Medicine
Competing Interests: None to declare