The Reporting of Suicide

The topic in this posting is the reporting of suicide. My starting point is a posting in bio edge . A leading Australian newspaper recently ran some articles chronicling Beverly Broadbent’s decision to commit suicide, see The Age. It appears at the time Beverly was relatively healthy. I will not consider whether Beverly was right to commit suicide here. However at this point I must make it clear I believe some people have the right to commit suicide and in the right circumstances may justify their decision if they do so. The post’s author clearly believes the journalist involved, Julia Medew, acted in an irresponsible way. He points out,

“A journalist is first of all a human being. Didn’t Medew have a moral obligation to dissuade a relatively healthy woman from committing suicide?”

However even if Medew ought to have attempted to dissuade Beverly this does not mean she ought not to have reported the suicide. In this posting I will argue the reporting of suicide is necessary for a better understanding of suicide.

What is wrong with Medew’s story? It might be objected that either the story should not have been reported in the way it was or it should not have been reported at all. I will deal with the latter objection first. An objector might argue such stories should not be reported due to the harm they cause. She might point to evidence that suggests the reporting of suicide leads to copy cat attempts, see for instance Gould, Jamieson and Romer . Because of the harm these copy cat suicides cause she might conclude suicide should simply not be reported at all. In reply I could point out much the same argument could be applied to school massacres and terrorist bombings. Prima facie it would be inconsistent to report these and not report suicides. Moreover it would seem to be absurd not to report events such as the Boston bombings for fear of contagion so why should Medew not report on Beverly’s suicide. My objector might respond that my analogy is flawed. She might point out the Boston bombings are a major story that cannot be ignored whilst Beverly’s suicide was a minor one and as a result could be. In reply I accept that Beverly’s particular suicide was not a major story but suicide in general is an important concern to society. If this were not so why should the World Health Organisation offer guidelines to journalists ?

However let us assume that my objector is correct and that in practice it is impossible to ignore terrorist bombings, such as those in Boston, whilst suicides can safely be ignored. Now provided she believes suicides should not be reported, due to the danger of copy cat cases, does this mean she also believes terrorist bombings should not be reported provided this was possible, as the same dangers of copycat attacks seem to apply. Perhaps the only reason why we ought not to attempt to ban the reporting of terrorist bombings is that we cannot. I will now argue that for terrorism such censorship is wrong even if this is possible. The Provisional IRA carried out a program of terror in Northern Ireland during the troubles. Both the British and Irish governments attempted censorship in the reporting of the troubles. However in Ed Moloney’s view,

“Censorship probably extended the life of the Troubles by as much as a third and that people died unnecessarily because of it. I say this because what censorship did was prevent the media from explaining events fully. One result was that public and government understanding was less than it should have been”, see Irish Censorship .

At this point my objector might point out that the reporting of terrorist bombings is not the same as journalists talking to Sinn Fein. In response I would point out a failure to report on Sinn Fein lead to a lack of understanding. I would then argue failing to fully report terrorist bombings might lead both the public and governments failing to grasp the full importance of these events. I would then suggest this diminished importance would lead to diminished understanding. If we fail to grasp the full importance of something we are less likely to reflect on it fully. Suicide is a problem for society and it is the biggest killer of young men in the UK, see The Guardian . If society is to understand and tackle this problem then it must be aware of the importance of the problem. I would suggest a failure to debate suicide, in an order to obtain a more adequate understanding of its causes, merely perpetuates suicide at its present levels. I would further suggest even if press coverage of suicide increases the cases of copy cat suicide in the short term that in the long term a more adequate understanding of the causes of suicide will lead to a decrease in the suicide rate. If this is so then the harm caused by copy cat suicides due to the reporting of suicide should be more than counterbalanced by a long term drop in the suicide rate.

I have argued it was not wrong for Medew to report on Beverly’s suicide. This brings us back to the first reason for the possible wrongness of her reporting, perhaps she was not wrong to report Beverly’s suicide but she did so in the wrong way. A report usually involves, what happened, the details of how it happened and why it happened. I have argued above if something that happens is not fully reported then we can fail to grasp how important that something is. This failure can lead to an inadequate understanding of the problem. Nonetheless it seems to me the mechanics of how someone commits suicide is not usually necessary to the understanding suicide and hence should not usually be reported. However if we are to understand the reasons for suicide we must understand an individual’s reasons for committing suicide and these should be reported. I would suggest the reporting of these reasons should not be emotive. There should be a separation of news and comment and comment need not be emotive free. If we understand the reasons why someone wishes to or actually commits suicide we might be in a better position to deal with the underlying causes of these reasons. Let us consider the case of the Verbessem brothers mentioned in my previous posting. I accept it is possible that the reporting of the brother’s case might lead to an increase in the number of the deaf blind wanting euthanasia in Belgium. However reporting the reasons why the brothers wanted to die might also lead to more or better centres for the deaf-blind. It follows reporting the brother’s case might well lead to an increase of options available to the deaf-blind, which in turn might lead to a reduction in the number of deaf-blind people seeking to end their lives.

So far I have argued that someone’s suicide should be reported and the reasons for her suicide should also be reported. However it would be a mistake to think all individuals who commit suicide can give reasons for doing so. Some individuals might commit suicide simply because they have a lack of reasons to go on living. Harry Frankfurt would class such persons as wantons (1). I have previously suggested such a person suffers from the unbearable lightness of simply being, see riots and the unbearable lightness of simply being. A wanton is someone moved by mere impulse and inclination and someone to whom nothing much matters. Such a person may well be prone to commit suicide. They may also be prone to becoming terrorists and other violence, see self respect and love. The reporting of suicides could well lead to such persons committing copy cat suicides. Moreover in such cases the reporting of suicides will not lead to any long term decrease in suicide committed by such people. Such people give us reason not to report suicide, or at least to do so in a very limited way.

In the above I have argued that, when someone has a reason to commit suicide, the reporting of her suicide and her attendant reasons, even if it leads to some copy cat suicides, is in the long term beneficial. However I have also suggested that for a certain class of suicidal persons such reporting is harmful. Should then suicide be fully reported? On balance I believe it should, I am however open to persuasion and comments are most welcome.

1. Frankfurt, 1999, Necessity, Volition, and Love. Cambridge University Press, page 106.

Assisted Suicide and the Verbessem Brothers

Belgian twins, Eddie and Marc Verbessem, were euthanized at Brussels University Hospital last December. The brothers had been deaf since birth and had been recently diagnosed with a genetic form of glaucoma that would leave them blind. William Pearce comments that this case appears to mean the following holds in Belgian,

“Death is a logical and reasonable option if a person will become deaf-blind. By logical extension there are some disabilities that are a fate worse than death. One does not need to be terminally ill to be euthanized”, see Hastings Center Bioethics Forum .

In this posting I will argue even if death is a reasonable option it does not mean some disabilities that are worse than death. I will then examine if death is a reasonable option when, if ever, it is permissible to help someone die.

Pearce seems to believe that all voluntary euthanasia is wrong. In the rest of this posting I will assume voluntary euthanasia is roughly equivalent to assisted suicide and only use the latter term. There are of course some differences between voluntary euthanasia and assisted suicide but don’t I believe these differences significantly affect my arguments. Pearce suggests two reasons for the wrongness of assisted suicide. Firstly he points to research in Oregon where assisted suicide is legal which shows most people who chose to end their lives this way did so because of the loss of autonomy or dignity rather than unbearable pain. The implication of the above is he seems to believe loss of autonomy or dignity is not a good enough reason to justify assisted suicide. I agree loss of autonomy is not a reason that can be used to justify assisted suicide. However it is important to be clear what losing autonomy means. Losing the ability to participate in activities that made someone’s life enjoyable or a loss of her dignity is not the same as losing her autonomy. Losing autonomy means someone losing the ability to make decisions based on what she cares about. Secondly Pearce seems to believe that many of the conditions given as reasons for permitting assisted suicide can be alleviated and hence are not reasons that can be justified. For instance in the Verbessem case he points to the lack of skill centres devoted to the deaf blind. In response I would suggest one cannot say someone ought to do something on the basis of something that ought to be. The Verbessem brothers had to decide what to do on the basis of the circumstances that actually prevailed, not on the circumstances that ought to have prevailed. I of course accept it is possible a reason that is now used to justify assisted suicide may cease to be a reason if and when circumstances change.

It might be suggested that the Verbessem brother’s case implies that living with certain disabilities is worse than dying but this is not so. Clearly some people who are deaf-blind want to continue living and do not see this disability as a fate worse than death. Equally clearly some people would like to live as long as possible regardless of any disability or any disease they may be suffering from. It follows that any condition however bad or painful cannot be the sole reason to justify assisted suicide. What matters is someone’s attitude to her condition. For instance someone suffering from painful terminal cancer might just wish to die whilst someone else suffering from the same cancer might wish to continue living, perhaps for religious reasons. It would appear to follow what matters is someone’s attitude to her condition caused by disease or disability. It further follows assisted suicide is really being justified by someone’s preferences. However because, we do not have a reason simply to satisfy all of someone’s preferences, satisfying her preferences cannot be used to justify assisted suicide. It still further follows that Pearce is correct and neither loss of autonomy nor any condition, however awful someone suffers from, can be used to justify assisted suicide.

It seems to be if we can justify suicide that we should be able to justify assisted suicide. Clearly we have the capacity for rational agency. Joseph Raz argues we also have a duty to respect the exercise of this capacity by others within certain bounds because we value this capacity. Moreover he believes this exercise includes the option to determine when and how to end one’s life and that others may help us implement this option (1). I now want to consider two objections to Raz’s position. Firstly someone might object that euthanasia is not part of a rational person living her life. Raz might reply a rational person might nonetheless value she has the option to end her life, if it became meaningless and full of pain, whilst living her life. He might point out if someone values a right and the exercise of this right does not significantly harm others that we should respect her right. This could be classed as Mill’s position.

I now want to examine what is meant by significant harm in more detail. Firstly the fact that someone is offended, simply by another’s decision to commit assisted suicide, is not a great enough harm for her to fail to respect the other’s decision. The fact that someone is offended by another’s political views should not mean she fails to respect the other’s capacity to express these views. Nonetheless there are certain harms that would sometimes make the exercise of assisted suicide wrong. For instance it would seem wrong for a mother with dependent children to be able to be assisted to commit suicide. Or an aged parent who enjoys life but in spite of this enjoyment chooses to end her life solely to ensure her estate passes to her children rather than being dissipated on her care. However such examples don’t show assisted suicide is always wrong. They merely show, as Raz suggests, there are bounds as to when assisted suicide is permissible.

Should assisted suicide always be impermissible because of the harm it may inflict? In what follows I will argue assisted suicide should only be impermissible in specific cases due to specific harm relevant to the case in question. Let us accept that a complete ban on assisted suicide would prevent harming people such as those in the above examples. However I would suggest a complete ban on assisted suicide would also harm other people. For instance if someone who is terminally ill and in great pain, has no relatives, wishes to commit assisted suicide is prevented from doing so she is harmed. She is harmed not by the failure of society to permit others to help release her from the pain, someone else might well want to continue living even with the same degree of pain. She is harmed in two ways. Firstly she is harmed because society prevents her attaining something she values. Secondly and more importantly in my view she is harmed by the failure of society to recognise her as an agent. In this case she values something, which harms no specific person, but is nonetheless prevented from seeking what she values. It follows a complete ban on assisted suicide would harm some people. It further follows some assisted suicide is permissible.

The above suggests if all assisted suicide is impermissible some people would be harmed and if all assisted suicide is permissible others would be harmed. How is society to decide on which cases are permissible and which are not? I would suggest this decision should firstly be based on harm to others. I would further suggest this harm must be to those who depend on the person who wishes to commit assisted suicide, basically family members. However not all harms to family members make assisted suicide impermissible. Consider an aged woman, suffering from a painful terminal condition, who only has weeks to live. She wants to be assisted to commit suicide. In addition she is also a much loved mother and her adult children do not want her to commit suicide. However her children are not dependent on her any more and even if they will be harmed by her death I would suggest such harm is not so great to make her assisted suicide is impermissible.

Let us assume it is permissible for an autonomous person to commit suicide. If suicide is permissible for an autonomous person why should it be impermissible for someone to aid her to do so in some cases? In order to answer this question I will first consider what means to make an autonomous decision. An autonomous decision is not simply a rational decision. The rationality of a decision depends on how well it achieves the agent’s goals. In this blog I take a position similar to that of Harry Frankfurt. Autonomous decisions are decisions based on what an agent ‘cares about’. Caring about and autonomy are central to being a person.

“Can something to whom its own condition and activities do not matter in the slightest properly be regarded as a person at all. Perhaps nothing that is entirely indifferent to itself is really a person, regardless of how intelligent or emotional or in other respects similar to persons it may be” (2).

However sometimes someone may not be fully aware of what she cares about. She might make a decision based on what she believes she cares about but when she comes to implement her decision finds she cannot. Sometimes what someone cares about is shown more by her actions rather than her decisions. Accepting the above provides a reason as to why even if it is permissible for someone to commit suicide it is sometimes impermissible for others to aid her do so. Someone may make a decision to commit suicide but be unable to implement her decision. Accepting the above suggests if assisted suicide is ever permissible it is only permissible if someone makes an autonomous decision to commit suicide and is unable to implement her decision by herself. It further suggests if voluntary euthanasia is ever permissible it must be so only under the above conditions,

Does the greater certainty that someone’s actions are autonomous compared to her decisions mean we can never justify assisted suicide even for someone who makes, what we believe to be autonomous decision to commit suicide, but lacks the capabilities to implement her decision by herself. I accept that the conditions in which assisted suicide might be permissible are far ideal. Nonetheless even if these conditions are far from ideal I believe assisted suicide is permissible if someone makes a decision to commit suicide and is unable to implement her decision. My belief is based on centrality of autonomy to our lives, of seeing ourselves as capable of determining our own future. I would assume anyone who believes we should not permit assisted suicide does so for beneficent reasons. She believes in acting beneficently has priority over respecting autonomy, at least in this scenario. Some proponents of assisted suicide argue that, because we would not let animal suffer as we do some persons in some cases, we should permit assisted suicide. I have argued above that suffering alone does not provide a basis to justify assisted suicide. Nevertheless in much the same way I would suggest those who place greater emphasis on acting beneficently over respecting autonomy see persons in much the same way as they see animals. They fail to see, or only pay lip service to seeing, others as creatures who can determine their own future, see respecting autonomy and a flourishing society .

Accepting the above has three important practical consequences. Firstly, because our certainty about autonomous decisions is less than our certainty about autonomous actions, we must be extremely careful about assessing autonomous decisions. Unfortunately if autonomy is essentially a matter of someone’s will rather than her rationality this is far from easy to do. I have previously suggested this involves assessing someone’s satisfaction with her decision, see valid consent . Secondly it seems to me Brussels University Hospital can justify offering the Verbessem brothers assisted suicide. Provided the Verbessem brothers had made an autonomous decision to commit suicide which they could not implement. I am assuming in the above that anyone who is both blind and deaf would have difficulty in committing suicide. I do not deny that had there been more skills centres for the death blind might available to the brothers that they might have made a different decision. Unfortunately as I have argued above they had to make their decision in the light of circumstances in their case. Lastly and perhaps even more controversially assisted suicide might be offered to a broader domain of people than just the terminally ill. I have suggested myself that assisted suicide might be permissible for prisoners serving life sentences, see prisoners serving life sentences .

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1. Joseph Raz, 2013, Death in Our Life, Journal of Applied Philosophy, 30(1).
2. Frankfurt, 1999, Necessity, Volition, and Love, Cambridge University Press. Page 90.

Self Respect and Love

Kristjan Kristjansson argues too much attention is paid to promoting an individual’s self esteem and not enough to promoting his self respect. Kristjansson is referring to global self esteem, how good we feel about ourselves in general, rather than domain based self esteem, how we feel about our performance in a particular domain. The problem with Kristjansson’s argument is that in practice our ideas of self esteem and self respect easily get confused. In spite of this reservation I agree with Kristjansson that an over inflated ego based on high global self esteem is not useful to someone and may even be harmful. Kristjansson also argues that domain based self esteem is good for someone, once again I agree. Indeed if someone is a good athlete a failure to recognise this fact is a failure to recognise the truth. I further agree self respect is a useful for someone. However if we are to encourage self respect we must be clear about what we should be encouraging. In this posting I want to examine the basis of self respect.

Kristjansson believes we have a real emotionally based self rather than just a self construct. He believes self respect may be defined roughly as a disposition not to act or feel in a way that is unworthy of oneself. In Hamlet Polonius advises Laertes as follows, “This above all: to thy own self be true”. Perhaps this advice reflects what it means for someone to respect himself, to be authentic. However if someone is to be true to himself or to be authentic he must understand the nature of his self.  Kristjansson argues there are two incompatible understandings of what it means for someone to respect himself based two different concepts of a real self. One concept is Kantian and the other Aristotelian. Kristjansson favours adopting an Aristotelian concept (1). Using this concept means what really matters is that someone has certain virtues such as justice, generosity and courage. That he can feel appropriate pride and shame. Lastly he must have the courage of his convictions, he must not be easily swayed from his chosen path, and that his beliefs and convictions must have some persistence. Being true to such a self, respecting oneself, means someone must act virtuously based on his deeply held beliefs and convictions. Perhaps this is what Shakespeare meant by being true to oneself. However someone’s ability to choose his own beliefs and convictions, his autonomy, seems only to have a peripheral importance according to an Aristotelian concept of self. Perhaps then we should adopt a Kantian concept of the self. However if we adopt a Kantian concept of the self we find a self with very little substance except for the ability to choose. Such a self can choose but his self seems an unsubstantial thing giving him very little basis on which to base any choices he makes. To respect such a self we need only accept his right to choose and respect his choices provided these choices do not harm others. However even if we have reason to respect such a self it does not follow we have reason to admire such an insubstantial self.

Kristjansson believes we must choose either an Aristotelian or Kantian concept of the self. Intuitively neither of these concepts completely captures our idea of self. I would suggest that there is a concept of self which combines the idea of an autonomous and substantial self. I would suggest someone’s self is based on what he loves. A self based on what someone loves is not an insubstantial self. Moreover I would further suggest a self that makes choices based on what he loves is an autonomous self, see Frankfurt (2). Indeed if someone doesn’t love anything at all it is hard to see how he can make any meaningful decisions. Anyone who fails to love has no boundaries and has no basis on which to make decisions. He is amorphous with no fixed shape or identity, see Frankfurt (3). Of course I accept someone’s identity can change over time but his identity must have some persistence. I would also suggest that anyone who doesn’t love himself at least to some degree cannot love anything else. To love something according to Frankfurt is simply to be satisfied with what one loves. Satisfaction means someone has an absence of restlessness and has a resistance to change his relation to his beloved (4). If we accept Frankfurt’s definition loving defined by satisfaction then loving something need not involve pride. It further follows someone cannot love himself excessively, cannot respect himself excessively. Pride it seems to me is connected to self esteem rather than self respect. It be suggested at this point self respect need only involve love of self. I would reject such a suggestion. If someone only loves himself he has no substantial self to love. He is trying to love something amorphous with no fixed shape or identity. However an objector might point out that I have suggested someone who does not love himself cannot love anything else and that someone who does not love anything else cannot love himself. My objector might then suggest love so defined is impossible. My response would be that coming to love is a natural process and that when someone comes to love something he comes at the same time to love himself.

I must make it clear that Kristjansson rejects such a concept of the self (5). Personally I believe the concept of a self defined by what he loves need not differ radically from an Aristotelian conception. A self defined by what he loves cannot choose anything his choices are constrained not by others but by what he loves. Moreover it is perfectly possible for a self that is defined by what he loves to acquire some of the virtues by education provided he endorses these virtues by loving them. Such a self might be regarded as an Aristotelian self. What is the relationship between an Aristotelian self and the virtues? Does he simply possess them or love them? I would argue if loving is based on satisfaction then a virtuous person must love any virtues he possesses. It follows if an Aristotelian self must love the virtues then he might also be regarded as a self based on love. However the concept of a self defined by what he loves is a broader concept than an Aristotelian concept. A self defined by what he loves of course need not of necessity love the virtues even if a virtuous person must love the virtues.

What does self respect mean if the self is defined by what someone loves? I have argued above it does not mean someone takes pride in himself. It simply means someone is satisfied with himself. To be satisfied with something someone’s satisfaction must be both persistent and consistent. Let us agree with Kristjansson that self respect is good for someone and that it should be encouraged. Unfortunately if we also accept someone’s self respect depends on his loving something including himself then we cannot directly encourage self respect. Someone cannot decide to love something simply because he decides loving is good for him. Similarly someone cannot decide to respect himself because self respect is good for him. We can however indirectly encourage self respect by creating the conditions in which self respect can flourish. This means allowing someone the freedom to love the things that matter to him, means loving and caring about things ourselves and it the case of children suggesting, but no more than suggesting, that it is good for them to love certain things.

To conclude I want to make some more speculative comments about the importance of self respect especially if it is based on love or “caring about”. These comments are of more speculative nature because I am a philosopher not a psychologist. Many of the perpetrators of murderous massacres such as the dreadful killings in Newtown Connecticut do not seem to be mad. I would however speculate that none of these perpetrators is satisfied with themselves. None of these perpetrators has self respect. Of course it would be simplistic to suggest the reason of such massacres is just a lack of self respect. Nonetheless I would speculate such a lack is one reason for these massacres even if it is a minor one. This is one reason why it is so disappointing that we cannot directly encourage self respect. Nonetheless if directly encouraging self respect is impossible, no matter how disappointing this may be, we should not attempt to do so but instead concentrate our efforts on trying to create the conditions in which self can flourish, see my posting on Riots and the Unbearable Lightness of Simply Being . Secondly I would speculate if self respect is based loving that the search for self respect can also lead to dreadful crimes. Some people in a desperate search for self respect, for identity, for something to love may come to love something in inappropriate ways. I would suggest suicide bombers are such people, see my posting on Terrorism, Love and Self Delusion ; see also Kristjansson (6).

1. Kristjansson, K. (2010) The Self and Its Emotions. Cambridge University Press, page, 154.
2. Frankfurt, H. (1999) Necessity, Volition, and Love. Cambridge University Press, page, 135.
3. Frankfurt, page 114.
4. Frankfurt, page 103.
5. Kristjansson, pages 89 90.
6. Kristjansson page 197.

Happiness and Satisfaction

In my previous posting I considered happiness in the light of Feldman and Haybron’s concepts. Both concepts differ, but both accept that someone’s affective states play an essential part of any meaningful concept of happiness. Intuitively the affective states concerned seem to those of joy or pleasure. In this posting I accept if someone is happy then he must have some feeling of joy or pleasure. Both Feldman and Haybron agree that one cannot simply equate happiness with satisfaction. Once again I accept their position. Nonetheless satisfaction is an important element in someone’s life. In this posting I want to examine the relative importance of happiness and satisfaction in life.

Before proceeding with my examination I want to show that being satisfied in life is not the same as being happy even though the two terms are often used interchangeably. For instance Mill seems to have used the terms interchangeably. In Utilitarianism Mill argued actions are right if they promote happiness and wrong if they promote unhappiness he then proceeded to argue “it is better to be a human being dissatisfied than a pig satisfied; better to be Socrates dissatisfied than a fool satisfied”. Psychologists also sometimes equate satisfaction with happiness. Daniel Nettle for instance suggests that there are three levels to happiness. First there are momentary emotions such as joy or pleasure. Secondly there are judgements about feelings such as satisfaction and lastly the quality of someone’s life over time. Nettle for the most part seems to equate happiness with satisfaction (1). However it seems to me someone could be completely satisfied with some decision or state of affairs but still not be considered to be happy. Let us consider someone suffering from a painful terminal illness. Such a person might well consider going to the Dignitas Clinic in Zurich to end his life. It seems to me such a person could be satisfied with his decision. However it also seems to me it would be wrong to describe such a person as happy. It follows being satisfied with some event, decision or even state of affairs does not equate to being happy. My terminally ill patient is unlikely to feel any joy or pleasure emanating from his decision.

In the rest of this posting I will assume that being happy must involve the emotions of joy or pleasure. Happiness that includes these elements, regardless of how this inclusion is done, is important to our lives. Satisfaction is also important to our lives. I have argued above that happiness and satisfaction are not identical. I now want to examine the relative importance of being satisfied with our lives and being happy. I will conclude that at the least a little happiness and an ability to be satisfied are essential to our identity as persons. I will also conclude that we ought to give greater priority in our lives to seeking satisfaction rather than seeking happiness.

Is satisfaction more important in our lives than happiness? The first possible reason as to why satisfaction might matter more than happiness is that it might be argued that someone cannot be happy if he isn’t satisfied. Accepting the above would mean being satisfied is a necessary condition for being happy even if it is not a sufficient one. What exactly does it mean for someone to be satisfied? According to Frankfurt a satisfied person simply has an absence of restlessness or resistance to change. He may be willing to accept a change in his condition, but he has no active interest in bringing about a change (2). It follows if someone is not satisfied he is restless or resists his current state of affairs. It might then be argued this restlessness or resistance means he cannot be happy and as a result satisfaction is a necessary condition for happiness. Such an argument would be mistaken. I have accepted that being happy must involve the emotions of joy or pleasure. However being happy is compatible with someone feeling pain or sorrow. To be happy someone’s joys or pleasures must simply outweigh his pains and sorrows. It is therefore conceivable that someone, who may be restless and resist his current state of affairs, is nonetheless happy provided his joys or pleasures outweigh this restlessness and resistance.

The second possible reason as to why satisfaction might matter more than happiness in our lives is that satisfaction is more central to us as persons than happiness is. Frankfurt argues caring about oneself is essential to being a person and that there couldn’t be a person of no importance to himself (3). If we accept Frankfurt then it follows that anyone who cares about himself must seek to satisfy some of his desires. Anyone who doesn’t care about anything has no basis to make any decisions. Anyone who has no basis to make any decisions can hardly be regarded as a person at all. It follows satisfaction, or at the very least attempted satisfaction, is central to our lives as persons. Someone might accept the above but suggest satisfaction is a positive emotion. He might then suggest positive emotions must involve joy, or at the very least some pleasure, and so satisfaction involves happiness. Satisfaction is a sufficient condition for happiness. He might then conclude if satisfaction is central to us as persons then so is happiness. If the above is accepted then we must also accept that my terminally ill patient who decides to go to Dignitas in order to commit assisted suicide is not only satisfied with his decision but also happy with this decision. It seems to me that in this situation the patient’s satisfaction is not a positive emotion but a response he finds appropriate. Appropriate to him as the person he sees himself to be. Satisfaction if it is viewed as an appropriate response can be seen as a matter of fit or congruence rather than a positive emotion. Accepting the above means it does not follow that happiness must be central to our lives just because satisfaction is.

Nevertheless happiness may be central to our lives for reasons which have nothing to do with satisfaction. Let us accept that happiness is an important element of our lives. But is happiness central to our lives? Someone might argue even if happiness is an important element of our lives that it is not as central to our lives as satisfaction is because happiness does not endure in the way satisfaction does. If Frankfurt is correct in believing that satisfaction entails an absence of restlessness or resistance to a state of affairs then as long as this state of affairs endures then satisfaction endures. The same is not true for happiness. If some situation increases our happiness then as time progresses we adapt to this new situation and our happiness returns to its former level (4). It would appear then that happiness does not endure as satisfaction does. Perhaps the reason for this that evolution developed joy and pleasure to drive us towards certain goals. Once these goals are attained the need for joy or pleasure ceases, see (5). It might appear because happiness does not endure in our lives the way satisfaction does it is less central to our lives than satisfaction is.

I have reservations about accepting the above; just because happiness doesn’t endure doesn’t mean it isn’t central to our lives. Can there be a person who isn’t happy and who never has been happy about anything. Of course there can be a person who is deeply unhappy because he has a great deal more to be unhappy about than happy about. Of course it makes sense to talk about an unhappy person. But can we really imagine a person who is not and never has been happy about anything at all? Even my terminally ill patient may have been happy in the past and perhaps his memories still give him some happiness even if he is unhappy now. Someone might suggest it is possible for a person to act purely for moral reasons and that such a person need never be happy about anything. Personally I am doubtful whether such a person can exist but I am even more doubtful that if a person acted purely on moral grounds that he would never take even the slightest pleasure in his actions. I’m not sure how to answer the question as whether there could ever be a person who isn’t happy and who never has been happy about anything. My inclination is to say there cannot be such a person. If my inclination is correct then it follows that being happy, at least to some small degree, is essential to being a person. Having some happiness and caring are both central to our identity as a person.

However I would suggest that even if some minimal level happiness and an ability to care both play an essential part in making us the persons we are it does not follow that we should give the same weight to increasing our happiness as to satisfying our desires. It is possible to achieve modest improvements in our happiness, see Seligman . Moreover it seems to me that provided we have realistic expectations that it is easier to increase our overall satisfaction in life by paying more attention to the things we care about rather than increase our happiness. It follows we should give greater weight to increasing our satisfaction rather than increasing our happiness provided of course that we cannot do both.

1. Daniel Nettle, 2005, Happiness; The Science Behind Your Smile, Oxford, page 8.
2. Harry Frankfurt, 1999, Necessity, Volition, and Love. Cambridge University Press, page 103.
3. Frankfurt, page 90.
4. Jonathan Haidt, 2006, The Happiness Hypothesis, Heinemann, page 86.
5. Nettle, chapter 7.

Guilt, Shame and Society

According to Max Wind-Cowie shame should be liberated rather than legislated for. By this I take Wind-Cowie to mean that shame should play a greater part in regulating our society and this regulation should replace the need for some legislation. In my posting "me and my values"  I suggested the balance between pride and shame has shifted in most people’s psyche and that this shift damages them as persons. I believe shame is important to us as persons but I also believe shame is important to society. It follows that I broadly agree with Wind-Cowie’s aim. However in what follows I will argue that whilst this aim is desirable it is by no means easy to achieve.

Wind-Cowie suggests that for “a myriad of pressing, modern problems - from tax avoidance to obesity - society needs to judge more and legislate less”. Exactly how is a more judgemental attitude linked to shame? It seems Wind-Cowie’s argument runs roughly as follows. If society was more judgemental then more people would feel shame when contemplating actions society finds unacceptable. This shame would stop them from undertaking these actions. If the above argument is sound it follows in the context of a more judgemental society there would be less need for legislation. Wind-Cowie then uses, the example of Jimmy Carr’s use of an apparently legal tax avoidance scheme and his subsequent change of heart after others judged this scheme to be morally wrong, to support his argument, see the Guardian . I have two important reservations about society becoming more judgemental even though I accept that shame should be liberated.

My first reservation is that, even if it is accepted our society needs to be more judgemental, these judgements might be carried too far. For instance in my previous posting I suggested that in the past some gay people were ashamed of their homosexuality and this unjustified shame led them to lead inauthentic lives. They were ashamed because society judged their homosexuality to be wrong. My first worry is certainly not an insubstantial one because in the past some people such as Alan Turing may have committed suicide partly in response to such judgements. Perhaps society should only be judgemental about matters that harm society rather than harm individuals. I would suggest one of the things that harms society most is unfairness. Tax avoidance even if legal is unfair. Unfortunately judgements about what harms society and what harms individuals are not always as easy to make as in the case of tax avoidance. For instance obesity harms individuals. But it might be argued the obese place an unfair burden on the non-obese if the latter are required to support them through taxes. It follows obesity also harms society. Should then society become more judgemental about obesity?

Let us accept making society more judgemental carries dangers as well as benefits. My second reservation is whether Wind-Cowie’s argument outlined above is a sound one. For surely it would be wrong to encourage a more judgemental society, if its judgements were not effective in solving society’s problems, due to the problems outlined above. Clearly society’s judgement was effective in the case of Jimmy Carr. But is society’s judgement always just as effective? For instance, if the judgement of the majority of society condemns some action but a sizeable subsection of that society condones the same action then the majority’s condemnation seems likely to be ineffective. Consider the traders working for Barclays Bank who tried to manipulate the Libor rate in order to benefit the bank. The majority of people would have condemned such an action. However these traders were not rogue traders and it seems possible that their colleagues and traders in other banks might well have condoned their actions. It further seems possible that despite society’s condemnation these traders might have felt no shame. They might have felt no shame because their actions were just the actions of any average bank trader.

Nevertheless even if these traders did not feel ashamed of their actions it seems probable that they did feel some negative emotions with regard to these actions for after all they kept them secret. In everyday usage the terms guilt and shame are often treated as interchangeable. At this point I want to try and differentiate between these terms. I must make it clear I am only interested in guilt as an emotion. David Velleman defines guilt as anxiety about being in an indefensible position that might warrant one’s being cut off from social interaction (1). Let us accept this definition. The traders who attempted to manipulate the Libor rate may well have felt no shame but I would suggest that they might well have worried about damaging their social interactions. Of course they would not have worried about damaging their social interactions with fellow traders nor would they have worried about being cut off totally from social interaction. Nevertheless they might have worried that their actions, if fully public, would have damaged their social interactions with the majority of the population. I would suggest such a worry is a form of guilt. Velleman also suggests guilt might be connected to the loss of love of one’s conscience (2). Guilt may well be tied to one’s conscience but I don’t believe it is tied to loss of love of one’s conscience. Shame however may be tied to loss of love of one’s conscience. Bennett Helm links pride and shame to our identity as a person (3). Let us accept that someone must love himself at least to some degree to be considered a person at all. Someone who feels absolutely no love for himself has no reason to act and so becomes a wanton. It might then be argued that for someone, who feels shame and as a result comes to love himself less, his shame acts a guardian of his identity. I would suggest shame can be partly defined as someone’s worry about the loss, at least in part, of his identity. I would further suggest the traders who attempted to manipulate the Libor were not worried about their identity and that any negative emotions they felt as a result should be characterised as guilt rather than shame.

I have attempted to differentiate between guilt and shame by claiming that guilt is a worry about social exclusion whilst shame is a worry about someone’s identity. If my claim is accepted then the following would seem to hold; because guilt is a worry about social exclusion whether we feel guilt depends on society’s judgements whilst because shame is worry about our identity shame is not. It follows if society becomes more judgemental it will liberate guilt rather then shame. Personally I see no reason why guilt should not be liberated in some contexts. For instance liberating guilt about tax avoidance would be acceptable whilst fostering guilt about someone’s homosexuality or obesity would be wrong. How then are we to differentiate between contexts in which liberating guilt is desirable and those in which it is not? It might be suggested that our politically correct society places restraints on our natural inclination to criticise and all that is needed is to remove these restraints. Unfortunately our natural inclination to criticise in a social setting usually applies to all those who don’t observe society’s norms. These norms may well include sexual orientation.  Nonetheless I still believe it would benefit society to remove some of the restraints society places on people in order to make society more judgemental and by so doing liberate guilt. An unfair society is an unjust society. It should always be perfectly acceptable in society to criticise unfairness.

My argument suggests that a more judgemental society would rely on guilt rather than shame. Nonetheless I still believe shame is important to society and that society should foster shame. What basis do I have for believing society should foster shame? I would argue the quality of any society depends in part on the qualities of the individuals who make up that society. A society composed mostly of rogues is likely to be a very limited poor quality society. I have previously argued shame makes people better people it follows fostering shame makes for better society. I would further suggest a society that is regulated for the most part by individual morality is a better one than one mostly governed by legislation. How then may society foster shame if society becoming more judgemental cannot be do this? To answer this question we must first ask why people feel shame. Let it be accepted the ability to feel shame makes someone a better person. Why is this so? I would suggest that shame like pride is essential in helping someone maintain his identity. I have frequently argued in this blog that someone’s identity is linked to Frankfurt’s ideas on loving or ‘caring about’. Frankfurt believes when someone cares about something he,

“identifies himself with what he cares about in the sense that he makes himself vulnerable to losses and susceptible to benefits depending upon whether what he cares about is diminished or enhanced.” (4)

In what follows I will follow Frankfurt is assuming that ‘caring about’ as defined above is equivalent to loving. Loving so defined differs from erotic love and the beloved may be for instance a person, a place or even an ideal. I would suggest that one of the ways someone who causes losses or damages to what he loves, becomes vulnerable, is because he feels shame. I would further suggest anyone who doesn’t love anything cannot feel shame. It follows if we want to foster shame we must foster a society in which people come to love things.

Someone might object it can’t be that simple and fostering a society in which people come to love things need not be any better than a society in which people don’t. She might suggest someone could come to love, identify himself with, getting rich and feel shame if he failed to do so. I have two responses to this objection. Firstly I doubt if someone can actually feel shame at his failure to become rich. I don’t deny someone may feel shame at his failure to support his family but this is different from becoming rich. It is easy to see how someone might identify himself with supporting his family but I would question whether someone can identify himself with becoming rich. This is an empirical question and it seems to me an experimental philosopher could do some useful work on shame. My second response is that if we foster a society in which people love things that help them to flourish. Becoming rich is not one of these things.

How do we foster people coming to love certain things that help them flourish? The certain things in this context being ideals or virtues. We teach them. My objector might respond you can’t teach people to love something. She might point out that love has an affective element and cannot be taught like arithmetic or even philosophy. In reply I would argue even if we can’t teach someone in a conventional sense to come to love something we can nevertheless help or foster him to learn to love something. For instance we may point out the things we love. We may encourage someone to persist in some activity in the hope he later learns to love it. We must make it clear what we love in the hope someone may emulate us. By so doing we are not becoming judgemental about someone else’s actions as Wind-Cowie would have us do but we are being judgemental about what we love and demonstrating this judgement. Lastly we may simply introduce someone to what we love in the hope he will come to love much the same sort of thing.

I believe fostering shame would benefit society as Wind-Cowie hopes. Unfortunately as I have argued fostering shame cannot be achieved by society becoming more judgemental even if by so doing we liberate guilt. Fostering shame is difficult. Indeed fostering a genuine sense of shame is best achieved in children by helping them become virtuous. It follows fostering a sense of shame is a long term process. Shame is related to our identities and should be fostered by fostering our identities by fostering our loving in ways I have suggested above. Because fostering shame is a long term process and society’s problems are pressing it might be argued that these problems are better addressed by liberating guilt or government legislation. In reply I would suggest many of society’s problems are related to personal problems and as such are best solved by helping people come to love or value certain things. For instance it seems to me that the problem of obesity is mostly a personal problem better dealt with by shame about what people ‘care about’ rather than making fat people feel guilty or forcing legislation onto reluctant food manufacturers as some sort of bandage. I would further suggest many of the problems facing society are not the kind that are amenable to quick fixes and can only be dealt with in the long term.

1. David Velleman 2009, How We Get Along, Cambridge University Press, page 99.
2. Velleman, page 101
3.  Bennett Helm, 2010, Love, Friendship & the Self, Oxford, page 109
4. Frankfurt, H. (1988) The Importance of What We Care About. Cambridge University Press page 83.

Me and My Values

There is a tendency in philosophy to believe we define ourselves. That we define ourselves by our values or what we ‘care about’, see for instance Helm and Frankfurt.

“I have claimed that one’s identity is fundamentally a matter of the kind of life worth living and that this is determined largely by one’s personal priorities and values; ….Thus when asked who I am I do not say a 6-4 –inch former soccer player who likes chocolate and is susceptible to the gambler’s fallacy … I respond by saying that I am a philosophy professor, father of three, etc.” (1)

“It is in the nature of a lover’s concern that he is invested in his beloved. That is, he is benefited when his beloved flourishes; and he suffers when it is harmed. Another way of putting it is that the lover identifies himself with what he loves. This consists of accepting the interests of his beloved as his own.” (2)

In this posting I do not want to deny we partly define ourselves by our values or what we ‘care about’. However I will suggest there is a tendency to overstate this self-definition. Moreover I believe this overstatement applies to the importance of values and what someone ‘cares about’ and ignores other things that help define her.

Helm when asked who he is does not say he was a soccer player or that he likes chocolate and is susceptible to the gambler’s fallacy but replies by choosing certain things he values. Helm is identifying himself with his values and seems to assume others will identify him in a similar way. However there are problems with this approach. Firstly someone may be unaware of some of the values she possesses. Secondly we must be careful about the idea of choice. As I noted in my previous posting what someone values need not be identical with the values she explicitly identifies with. She can be mistaken about some of her values. Our values are determined just a much by what someone actually does as by what she thinks she should do. I believe Helm would accept this point as he argues someone sometimes discovers her values.

However even if someone is unaware of some of her values, does she sometimes choose her values and in so doing is she creating her identity like some existential hero? Personally I am unhappy with such a position. Recent research in experimental philosophy has shown that sometimes someone’s choices are influenced less by her character and more by the situation she finds herself in; see for instance Appiah (3). It follows someone’s choices may sometimes be determined less by her character and more by her situation. It further follows some of someone’s values might well be determined by the circumstances she finds herself in. Helm holds our identity is determined by our values. It still further follows if we accept Helm’s position that in practice someone’s identity is not simply chosen by her. Accepting the above is one of the reasons I rather like Helm’s idea of someone discovering her values; discovering her identity. In spite of the above I do not want to completely downplay the role someone’s explicit choices about value play in creating her identity, I only want argue such choices do not play as big a part as we might assume. The fact someone has some value may in many cases be partly be due to the fact she made a choice. But even if someone has genuinely chosen something as a value does not guarantee it is in fact value. She must also be able to live up to her choice. In some cases she may discover she cannot, see Frankfurt discussion of Sartre’s young man (4). It might be objected there is some circularity in the above arguments concerning character, value and identity. I will not pursue this objection here but believe it can be overcome, see (5).

Helm and Frankfurt hold that our identity depends on what we value or ‘care about’. However I would suggest the fact that we often appear to discover our identity means other factors play a part in determining this identity. In my posting of 12/12/11 I argued that the fact someone suffers from Asperger’s syndrome partly determines her identity. Asperger’s syndrome affects someone’s neural development and hence the way she thinks, she chooses. I would go even further than this and suggest factors independent of our neural makeup also affect our identity. Consider someone born without legs and as a result of this is confined to a wheelchair. I would argue this fact affects the choices open to her and hence her identity. She may not for instance become a mountaineer like her parents. An objector to the above might use my wheelchair example to argue against me. She might argue if a soldier who loses his legs in Afghanistan and becomes confined to a wheelchair that this does not change his identity. Our intuitions about the mountaineer’s daughter and the wounded soldier seem to lead us to a paradox. I believe this paradox can be resolved. I accept soldier’s identity is not changed at the time of his injury but I would argue his identity will be changed over time. Let us assume prior to his injury the soldier identified himself with being a soldier leading his men into battle. This option is now closed to him. Let us further assume that post his injury he becomes a Para-Olympian and identifies himself with sport. It would appear then that over time the fact he has become a wheelchair user has in some ways affected his identity.

I have argued that in practice someone’s identity is not simply chosen by her but is also determined by her physical body and the circumstances she finds herself in. Part of these circumstances is the way other people see her. It follows our identity is linked to the way others see us. Let us return to a soldier example. Let us assume our soldier is a paramedic who does not see herself as brave. Let us further assume one day she tends to a wounded colleague under enemy fire. Her colleagues see her as brave and because of this she discovers herself to be brave. Of course she was brave before her discovery but her bravery was unreflective whilst after her discovery her bravery came to play a more central part in her life, in her identity and this centrality would not have happened had not others seen her as brave.

1.      Bennett Helm, 2010, Love, Friendship & the Self, Oxford University Press, page 130.

2.      Harry Frankfurt 2006, Taking Ourselves Seriously, Stanford University Press, Page 41.

3.      Kwame Appiah, 2008, Experiments in Ethics, Harvard University Press, chapter 2.

4.      Frankfurt, 1988, The Importance of What We Care About. Cambridge University Press, page 84.

5.      Helm, page 140.

Valid Consent, Good Consent and Asymmetric Competence

In this posting I want to consider the topic of informed consent. Eric Chwang is interested in the difference between the standard needed for consent to be considered valid for normal clinical patients and the standard necessary for valid consent from research subjects (1). In this posting my sole concern is with normal patients. Chwang takes as his starting point the judgement in Canterbury v Spence, see Canterbury v Spence . This Judgement has two main strands. First the information a doctor must give a patient should be determined by the patient’s needs. The second condition places a restriction on these needs. Chwang calls the second condition the pragmatic criterion and expresses it as follows,

 “in order for consent to be valid, whether some piece of information needs to be disclosed depends on whether it might affect the patient’s (subject’s) decision whether to consent.” (2

)

The pragmatic condition seems to reflect the judgement in the Montgomery case . In this case the court held that doctors must ensure patients are fully aware of any and all risks that an individual patient, not just the risks mainstream medical practice, might consider significant. It is the consequences of accepting the information requirements of this judgement I want to explore in this posting.

The pragmatic criterion gives us some guidance as to how much information a patient should be supplied with in order to make a competent decision. Unfortunately, this guidance seems to be at odds with the idea of informed consent being based on respect for patient autonomy. Suppose a patient simply understands he is likely to die without treatment and makes a decision on solely this basis, if any additional information will not alter his decision then according to the pragmatic criterion it is unnecessary to disclose any additional information. Chwang writes,

“Suppose that the only way to save my life is by amputation. To get consent for ‘life saving treatment’, but without also mentioning that the treatment in question is amputation, would be grossly inappropriate” (3).

The question I will now discuss is what is inappropriate about obtaining consent in this way? In order to help in this discussion I will use an example provided by Steve Clarke.

“Consider the case of ‘Squeamish John’. Squeamish John cannot bear to hear the details of medical procedures; hearing these make him feel weak at the knees and dramatically diminishes his capacity to make sensible decisions. Nevertheless he does not wish to abrogate responsibility for his decision about whether or not to undergo an operation. Squeamish John wishes to participate in a restricted informed consent process in order to make his decision. He wishes to make a decision based only on the disclosure of the risks and benefits of the operation couched in cold, impersonal, statistical language. He does not wish to have any significant details of the procedure described to him.” (4).

Let us assume John gives consent in manner outlined by Clarke and he wakes minus one leg. Chwang would find this situation grossly inappropriate and according to the Montgomery judgement John’s would have given inadequate consent. I now want to consider is inappropriate or inadequate about such a decision. I will now argue what is inappropriate or inadequate about such a decision is not that it is an non autonomous one. Let it be accepted an autonomous decision is simply a decision with which the agent identifies himself and ‘cares about’; in this context I am using ‘cares about’ in the same way as it is used by Harry Frankfurt (5). If autonomy is defined in such a manner John’s decision appears to be autonomous. However, some objector might argue for any decision to be autonomous it must be made using practical reason. Even if this objection is accepted it might be argued that practical reason is closely tied to an agent’s identity and what he cares about. David Velleman for instance believes practical reason is defined by the self-understanding someone gains by playing himself (6). This understanding depends on him doing what makes sense or seems appropriate to him; he must identify with and care about such actions. However, my objector might respond further by arguing this isn’t normally how we use the term practical reason. She might argue that anyone using practical reason to make a decision should objectively weigh up all of her available options connected to this decision. Any decision made this way would satisfy the Montgomery judgement.

For the sake of argument let us assume that assume practical reason does involve some objective weighing up of all the relevant costs and benefits and that for a decision to be autonomous it must utilise practical reason as so defined. However, if we accept the above it follows that squeamish John’s cannot make an autonomous decision. In this situation John’s squeamishness means his preferred way of making his consent decision is the only possible way he can make a decision. In everyday life outside a medical context all of us sometimes delegate important decisions to experts of our choice, such as lawyers or financial advisors, without others questioning our autonomy. Are then doctors any less trustworthy than lawyers or financial advisors? It seems obvious to me that they are not. Does then the context in which informed consent takes place differ from other contexts such as the law and finance in respect of an agent’s ability to make autonomous decisions? I would suggest it does not. It follows if squeamish John is permitted to make a decision in the way he prefers it would be an autonomous decision. It further follows what Chwang finds inappropriate, or the Montgomery judgement finds inadequate, about such a decision is not that it is a non-autonomous one.

I have argued squeamish John’s proposed decision would be an autonomous one. I would suggest what Chwang finds grossly inappropriate or the Montgomery judgement inadequate about such a decision is either that it is not a good decision or a good way to make such a decision. I would argue we should not equate autonomous decisions with good decisions. Autonomous decisions are simply autonomous decision and not autonomous decisions plus another requirement. Autonomous decisions as defined above need not of necessity good decisions. None the less autonomous decisions cannot simply be made at random, by the throw of a dice for instance. Autonomous decisions must be made on the basis of some information. If it is accepted that autonomous decisions need not of necessity be good decisions then the amount of information necessary to make an autonomous decision may not always be identical with the amount of information needed to make a good decision. The above raises the question about how much information is needed to make an autonomous decision?

In order to answer the above question, we must first be clear about an agent’s purpose when making an autonomous decision. I have suggested above an autonomous decision is one which the agent ‘cares about’ and with he identifies with. This type of decision is one the agent is wholehearted about. Frankfurt argues a wholehearted decision is one with which the agent is satisfied with. He further argues satisfaction involves an absence of restlessness and any desire for change (7). It is of course true that many agents would not be satisfied with any decision they regarded as sub optimal. However, it would appear a decision need not be an optimal decision for it to be an autonomous one according to Frankfurt. All that is necessary for a decision to be autonomous is that the agent is satisfied with his decision. I accept such a position. My objector might again point out such decisions need not be rational ones and that any decision lacking rationality should not be regarded as a fully autonomous one. In reply I would question exactly what is meant by rational. I will assume in the context of giving consent rationality refers to practical rationality. If this is so I would once reiterate that some philosophers such as Velleman would regard decisions with which the agent is satisfied with as defined above or finds appropriate as practically rational. In addition, I would argue such decisions are examples of satisficing or bounded rationality. The term satisficing was introduced by Herbert Simon in 1956. Satisficing does not require an agent maximise his good. Satisficing only requires that an agent brings about an outcome that he considers good enough by some standard. My objector might now point an autonomous agent needs only to be satisfied with his decision and does not set some standard by which any option must be judged. She might then argue any such decisions are not examples of bounded rationality. In reply I would suggest satisfaction as defined above must at the very least involve some unconscious bounds and that autonomous decisions implicitly involve bounded rationality. It follows the amount of information needed for an agent to make an autonomous decision is the amount of information that would satisfy agent.

I have used the example of squeamish John to show in certain contexts, provided the only way to save someone’s life is by amputation and consent is obtained without mentioning this fact, that none the less the patient’s consent might be autonomous. Chwang believes such consent would be grossly inappropriate. Chwang’s belief seems to be based on the idea that the patient has been inadequately informed. I believe Chwang is correct in most contexts but not all. Good quality consent should be an aim of the informed consent process, see GMC guidance for consent . However, the taking of consent like medical interventions does not always occur under ideal conditions and in some contexts good quality consent may be impossible. The General Medical Council’s guidelines on consent of 1998 specifically stated that the purpose of consent was to respect patient autonomy. The current guidelines mentioned above do not explicitly base informed consent on respect for autonomy but none the less implicitly require this respect. If respect for autonomy is the sole principle on which informed consent is based then we must simply respect all autonomous decisions. My objector might point the purpose of medicine is to act beneficently towards patients. She might then use this fact to argue basing informed consent solely on respect for autonomy is simplistic. She might then suggest the purpose of informed consent should be to respect patient autonomy and enable them to make good decisions. I accept the above is the ideal which informed consent should aim for. However, in some contexts acting beneficently might clash with respecting patient autonomy. Such a clash must be resolved. I have previously suggested we cannot act truly beneficently if we fail to respect autonomy. We must give priority to respecting autonomy over acting beneficently when these values clash, see Autonomy and acting Beneficently. Accepting the above means we must in some situations accept less than ideal decisions provided these decisions are autonomous and that Chwang is mistaken to regard such decisions as inappropriate in these situations.

Lastly I want to consider whether a consequence of accepting the pragmatic criterion is accepting the concept of asymmetric competence. This concept is defined by Wilks as follows.

“If we consider a safe, routine treatment for an acute and dangerous condition (as with an appendectomy for appendicitis), it is clear that the risk in accepting the treatment is small, the benefit great, while the risk in refusing it is great and the benefit in most cases non existent. This means that one confronted with this choice would require a higher level of competence to say no than to say yes, with, indeed, a very pronounced difference between the levels” (8)

Intuitively the pragmatic criterion supports Wilks’ position. In the situation such as that envisioned by Wilks above if a patient consents a great deal of information is unlikely to alter his decision. However, were he to refuse to consent some additional information might well alter his decision. Before considering the question of asymmetric competence I will examine two related concepts. I will examine the asymmetric triggering of competence assessments and the asymmetry in information needed to give competent consent and to give a competent refusal. I will firstly argue that for pragmatic reasons there should be asymmetric triggering of competence assessments. Indeed, it seems unlikely any patient’s competence will be questioned provided his consent is sought and he consents. I would support this failure to assess competence only in situations in which there is universal agreement among health professionals that some particular treatment is in a patient’s best interests. I have argued the most important purpose of patient consent is to protect patient autonomy. The reason why competence is sometimes assessed is to ensure non-autonomous patients receive beneficent care. In the light of the above assessing a patient’s competence if he consents seems unnecessary. Provided the patient is competent his autonomous decision should be respected. However, if he was assessed as incompetent and a surrogate decision maker made a decision on his behalf then any treatment would identical with the treatment he had previously consented to. It follows no useful purpose is served by assessing a patient’s competence provided he consents to some treatment when the health benefits are clear and the risks of non-treatment great.

I will now argue there is an asymmetry in the information needed for a patient to make a competent decision when he consents and when he refuses to consent. Let it be accepted as I have argued above any autonomous decision must count as a competent decision. Let us consider squeamish John once again. John consents to treatment and is satisfied with his decision. It might be suggested the reason why John is satisfied is that he finds the decision is appropriate to him because he can justify it to himself. John can justify his decision by trusting his doctors to do what is in his best interests. The minimal amount of information John receives also satisfies the pragmatic criterion as any additional information will not alter his autonomous decision. It follows as I have argued above John can make a competent decision, even if less than an ideal one, based on the minimal information provided. Now let us consider a situation in which a patient refuses to consent and insists on only being supplied with the same minimal information available to John. In this situation, provided the patient’s condition is non-life threatening, the procedure would simply be cancelled and the patient’s competence would remain unquestioned. For example a patient who refuses to consent to a hip replacement. However, let us assume the patient’s condition is life threatening. In this situation I would argue such a patient cannot make an autonomous decision and hence is not competent to give consent. There might be one exception to the above. A suicidal patient may well have enough information to make an autonomous decision. Needless to say medicine is not in the business of helping patients commit suicide with the possible exception of those who are terminally ill. The reason why such a patient cannot make an autonomous decision is he does not have enough information to make a decision with which he can be satisfied; a decision that he can justify to himself. In addition any additional information may well alter the patient’s decision meaning the information provided in this situation does not satisfy the pragmatic criterion. It follows if we accept either that a competent decision must be autonomous one or one requiring that a competent patient has enough information to satisfy the pragmatic criterion that a patient in this situation cannot make a competent decision. It further follows there is sometimes an asymmetry in the information a patient needs to make a competent decision if he consents and the information he needs if he refuses to consent.

Let it be accepted asymmetry between the information a patient needs when he consents and refuses consent. It is then possible for a patient to be asymmetrically competent. If a patient can understand the information needed to consent but fails to understand the additional information needed to refuse consent then he is asymmetrically competent. In practice I believe this situation is unlikely to occur as it seems to me most patients will be capable of understanding the additional information.

1. Eric Chwang, 2010, A Puzzle about Consent, Journal of Applied Philosophy, 27(3).
2. Chwang, page 262.
3. Chwang, page 265.
4. Steve Clarke, 2001, Informed Consent in Medicine in Comparison with Consent with Consent in Other Areas of Human Activity, The Southern Journal of Philosophy, 39, page 177
5. Harry Frankfurt, 1999, Necessity, Volition, and Love, Cambridge University Press
6. David Vellman, 2009, How We Get Along, Cambridge University Press, page 18.
7. Frankfurt, 1999, page 103.
8. Wilks, 1997, The debate over Risk-related Standards of competence, Bioethics 11(5), page 417., 2010, A Puzzle about Consent, Journal of Applied Philosophy, 27(3)..