Living Wills

In this posting I want to explore a familiar theme of this blog respect for autonomy. In previous postings I have stressed the importance of respect for autonomy. However I will now argue in the specific context of living wills respect for a patient’s autonomy is usually misplaced and that as a result the circumstances in which a patient’s living will should be respected are extremely limited.

A legal will states how someone’s goods are to be distributed after her death. A living will states someone’s preferences as to how she wishes be treated if she ceases to able to give fully informed consent for herself. The terms ‘living will’ and ‘last directive’ have the same meaning. In this posting I will use the term ‘living will’ as I believe this term best reflects our intuitive ideas. In the U.K. the validity of living wills is recognised by The Mental Health Act of 2005 and The Department of Health’s ‘Reference Guide to Consent for Examination or Treatment’ page 10. A living will is only valid if it refers to the treatment proposed and the will maker was competent at the time she made her will. If a patient is competent this usually means she meets the requirements of the so called C test (Re C, [1994] 1 All ER 819). However in practice there seems to be no way to assess whether a will maker actually meet the standards laid down by the C test at the time she made her will. When considering a patient’s living will it seems she would be regarded as competent when she made her ‘living will’ provided she was autonomous at the time.

It does not automatically follow from the fact that, we should respect someone’s current autonomous decisions, that we should also respect her past autonomous decisions. Consider the following scenario. Suppose someone is autonomous and signs and gets witnessed a document specifying how her vote should be cast in any future general election if she suffers from dementia at the time. It might be assumed for the sake of argument that this person has always supported only one party. At the date of a future general election such a document would be meaningless even if the person involved actually did suffer from dementia. However such a document seems in some ways to be analogous to a living will. This example suggests that perhaps we need not respect all living wills in all circumstances. I will consider whether we should respect a patient’s will in two sets of circumstances.

1. When a patient has permanently lost her capacity for autonomy. In these circumstances I will argue there are no reasons to respect her living will.
2. When a non-autonomous patient is expected to regain her capacity to make autonomous decisions but has permanently lost her capacity to implement these decisions. In these circumstances I will argue her living will need only be respected when the treatment or non-treatment specified in her will is irreversible.

Consider an elderly patient with dementia who catches pneumonia. Let it be assumed that this patient’s dementia means she has permanently lost her capacity to make or implement autonomous decisions. Clearly such a patient cannot give valid informed consent. Let it be further assumed her doctors believe provided she is placed on a ventilator for a short time she will recover and be able to live in the state she was in immediately prior to catching pneumonia. Let it be still further assumed that prior to her becoming demented this patient made a living will specifying that in these precise circumstances she was not to be placed on a ventilator in order to prolong her life. Lastly let it be assumed that this patient, prior to catching pneumonia, enjoyed simple pleasures such as sitting in the garden even if prior to becoming demented she hated gardens and enjoyed mountaineering. Under current legislation and medical guidelines it would seem such a patient should not be placed on the ventilator even though she had a reasonable quality of life.

I wish to question whether respecting the living will of such a patient is really connected to respecting her autonomy in circumstances when she will never be autonomous again? In what follows accepting or respecting someone’s decisions refers to decisions that do not harm others unless stated otherwise. Let it be accepted the reason why we respect someone’s living will is in order to respect her informed consent decision. Let it be further accepted the reason why we should respect someone’s informed consent decision is in order to respect her autonomy. I have previously argued that making autonomous decisions does not require any great intellect and that autonomous decisions need not of necessity be good decisions, see my posting of 01/07/08. It follows before a doctor thinks about respecting a living will she must first be totally sure the patient is non-autonomous. However let it be assumed our patient is clearly non-autonomous. Does respecting this patient’s living will respect her autonomy? Clearly it does not respect any autonomy she now possesses because she is non-autonomous. Does then respecting her living will respect her previous status as an autonomous person? The answer to this second question is yes. However the answer to this second question suggests a third question. If it is accepted that we should respect someone’s status as an autonomous person does this mean we should also respect her previous status as an autonomous person? In order to answer this third question we should consider a fourth question; why do we respect someone’s status as an autonomous person?

We do not respect someone’s status as an autonomous person on a mere whim but because we believe autonomy has value. Autonomy has both instrumental and intrinsic value. However in the case of a patient who is non-autonomous it is hard to see how her previous status as an autonomous person could possibly have any instrumental value to her now. It follows in the context of living wills if we respect autonomy we do so because of the intrinsic value of someone’s autonomy in the past. I have previously argued the intrinsic value of someone’s autonomy depends upon the recognition of her as the kind of person capable of making her own decisions, see my posting of 23/03/08. It follows respecting the intrinsic value of someone’s autonomy means accepting her decisions that do not harm others. Now that we are clear about why we might respect autonomous decisions, in the context of living wills, we are in a position to tackle the question as to whether we should respect someone’s previous status as an autonomous person. Consider someone who has previously made an autonomous decision to prefer x to y. Let it be assumed she changes her mind and makes a further autonomous decision preferring y to x. Clearly we do not respect her autonomy if we fail to accept her current autonomous decision preferring y to x because we feel we should respect her previous autonomous decision preferring x to y. One reason why we fail to respect her autonomy in this case is that we fail to recognise that she is the kind of person capable of making her own decisions. The above suggests we can only respect the intrinsic value of someone’s autonomy at the time she exercises this autonomy. If my suggestion is correct then there are no reasons based on respect for the intrinsic value of autonomy as to why we should respect someone’s past autonomous decisions. It can then be concluded if respect for living wills is based on respect for the intrinsic value of autonomy there is no reason to respect someone’s living will in circumstances in which she has permanently lost her capacity to make autonomous decisions. It can be further concluded in these circumstances the patient’s doctor should make a decision on her behalf based on what is in the patient’s best interests after consulting her relatives.

I now wish to consider whether we should respect living wills in circumstances in which treatment, or lack of treatment, means the non-autonomous patient is expected to regain her capacity to make autonomous decisions whilst at the same time losing her capacity to implement her decisions. Once again I will use an example. The example I will use will be the case of Ms B (Re B, [2002] All ER 449). Ms B suffered from a cavernous haegmangioma. She recovered but the angioma recurred and she became tetraplegic and was placed on ventilator. Prior to being placed on the ventilator she made a living will stating she wished treatment to be withdrawn if she was suffering from a life threatening condition or permanent mental disability or unconsciousness. Ms B regained consciousness and wished to have her ventilator switched off. The hospital trust in question refused. Eventually The High Court agreed that Ms B had a right to have the ventilator switched off and awarded her a small amount in damages for trespass. I now only consider the question as to whether her doctors were correct in ignoring the wishes she expressed in her living will. I will argue the answer to this question is not as straightforward as it might appear.

Let it be assumed Ms B was fully autonomous when she made her living will. Let it also be assumed after being placed on the ventilator Ms B could again make autonomous decisions but that she could not implement these decisions. I believe whether Ms B’s doctors were correct in ignoring, the wishes expressed in her living will depend on whether the effects of her treatment could be reversed. I will argue in contexts in which the effects of a patient’s treatment can be reversed that even if some treatment is undertaken, which runs contrary to the wishes expressed the patient’s living will, the patient’s autonomy might still respected. When treatment is undertaken, which runs contrary to the wishes expressed the patient’s living will, her doctors cannot ask her if she is sure about these wishes. However once the patient becomes capable again of expressing her autonomous wishes her doctors may ask her if her views are unchanged. Moreover in this context if her views are unchanged her doctors can reverse the treatment. The above position is partly analogous to the position in many other fields. In these fields we can still respect someone’s autonomous decision even if we ask her to think again. Once she has thought again we respect her autonomy by simply accepting her decision regardless of whether she has changed her mind or not. How good this analogy is depends on what is meant by being able to reverse the treatment.

It might be assumed that in the case of Ms B the effects of her treatment could be reversed by simply switching off the ventilator. In practice this would have caused Ms B to suffer. Her ventilation should have been reduced slowly whilst at the same time giving her painkillers. It follows reversing some treatments might mean doctors having to employ their medical skills in assisting this reversal. It follows in practice treatment is only reversible if the following three conditions can be satisfied.

1. It is possible to reverse the treatment and leave the patient in a similar condition to that she was in prior to the commencement of treatment. In most circumstances reversing treatment will mean stopping treatment.
2. It is not illegal to reverse the treatment.
3. Any doctors prepared override a patient’s wishes expressed in a valid living will and treat the patient must also be prepared reverse this treatment. This reversal of treatment might involve taking measures to ensure the reversal does not cause the patient unnecessary suffering once she regains the power to make autonomous decisions.

In the case of Ms B I believe her medical team acted correctly by placing her on a ventilator. However her medical team failed to respect her autonomy because they were not prepared to stop the treatment once she regained the power to make autonomous decisions. It can be concluded there is no reason, based on respect for autonomy for doctors to respect a patient’s living will, in circumstances when she is expected to regain her capacity to make autonomous decision provided the proposed treatment is reversible subject to the three conditions outlined above.

I have argued there are no good reasons based on respect for autonomy to respect the majority of living wills. However there are some circumstances in which living wills should be respected provided respect for living wills is based on respect for patient autonomy. Living wills should be respected in all cases in which a patient is expected to be able to regain the ability to make autonomous decisions and in which the effects of her treatment cannot be reversed. Accepting the above would mean non-autonomous patients who state in their living wills that in certain circumstances they should not be resuscitated and who once are expected to regain the capacity to make autonomous decisions again should have their wishes respected. Further examples might include limb amputation and perhaps, though I write this reluctantly, blood transfusion.

GM CROPS, AUTONOMY AND SATISFICING

In this posting examine the issue of GM crops. In it I will not examine the issues directly concerned with growing of these crops. Instead I will examine the different methods used in evaluating whether GM crops should be grown. Proponents of GM crops hold that the production of these crops would give us greater yields produced in a more efficient and environmentally-friendly way. Opponents of GM crops argue the potential risks associated with these crops to health and the environment mean the growing of GM crops should not be permitted. It seems clear opponents and proponents of GM crops stress the importance of different factors in the debate as to whether these crops should be grown. It seems to me this different stress results from using different methods to address the question of whether GM crops should be grown.


Proponents of the growing of GM crops are concerned with choosing the best available option; their opponents are concerned with choosing a safe option. The opponents of the growing of GM crops appear to be using a satisficing strategy, see satisficing, when making their decision. This satisficing strategy may not be explicit but it is implicit in the way the decision is made. Hebert Simon developed the idea of satisficing due to difficulties associated with maximising utility. One of these difficulties was that people find it hard to assign probabilities to various utilities. This same difficulty seems to apply to the debate concerning the growing of GM crops. In this posting I want to ignore more recent concepts of satisficing, such as those of Slote and Pettit, and concentrate on Simon’s original concept. Simon argued that when making a decision we should choose an option which satisfies two conditions. Firstly all the possible outcomes of the chosen option should satisfy us. Secondly we should choose the first option which satisfies the first condition. For example if it is decided the growing of GM crops should be permitted, one outcome of this decision might be increased yields which would to satisfy me, whilst another possible outcome might be environmental damage which would fail to satisfy me. If it is decided not to grow GM crops then one outcome would be no environmental damage associated with these crops which would satisfy me, whilst another outcome would be no associated increase in yields which might also satisfy me. Remember satisficing deals only with satisfaction. In practice I might have preferred an increase in yield associated with the growing of GM crops. Nonetheless I might still be satisfied with retaining present yields.



Proponents of the growing of GM crops sometimes argue the debate concerning GM crops should be a rational debate and that their opponents often raise false or exaggerated fears. Proponents usually assume if this debate was conducted in a more rational manner that they would win the debate. However I have shown what is at issue is not really about the rationality of any decision concerning the growing of GM crops but the manner in which people decide on this issue. Moreover it seems using a satisficing strategy in some circumstances may be completely rational. The real question that must be addressed is this, should we respect the conclusions people reach, if they adopt a satisficing criterion as opposed to a criterion which maximises utility in order to reach these conclusions? Let it be accepted that we should respect autonomous decisions. I will now argue any decision made using a satisficing methodology is an autonomous decision. Autonomy is sometimes simply defined as the second-order capacity of persons to reflect critically on their first-order desires and the capacity to accept or attempt to change these in the light of higher-order preferences and values (1) An autonomous decision might then be defined as any decision made using this capacity. Consider someone who uses this capacity to decide if he is in favour of permitting the growing of GM crops. Let it be assumed due to the complexities involved he makes a decision but that he remains unhappy with his decision. Using the above definition of an autonomous decision such a decision is an autonomous decision, however intuitively such a decision is not an autonomous decision. The reason being if someone is unhappy with his decision it seems it would be hard for him to identify this decision. It might be objected in reality there are no such thing as autonomous decisions, there is only a capacity for autonomy, meaning this situation couldn’t arise. However accepting this objection would make nonsense of the modern world which relies on autonomous decision-making.



Let it be accepted that in practice there are autonomous decisions and that autonomy does not simply mean a capacity for autonomy. Accepting the above does not automatically mean we must accept our intuitive idea that an agent must identify with his autonomous decision. However autonomous decision-making is about self-government and it is again hard to see in practice how any decision the agent doesn’t care about can be part of his self-governance. It follows the idea of an autonomous decision making seems meaningless if the agent doesn’t care about his decisions. Frankfurt argues if someone cares about something he identifies himself with what he cares about (2). It might be argued Frankfurt sees autonomy as a hybrid concept, a cross between reflection and caring about. He further argues that to identify with something an agent must be wholehearted. He defines wholeheartedness as follows:

In what does his wholeheartedness with respect to these physic elements consist? It consists in his being fully satisfied that they, rather than others that inherently (i.e., non contingently) conflict with them, should be among the causes and considerations that determine his cognitive, affective, attitudinal and behavioral processes (3)

Frankfurt then proceeds to define satisfaction as follows.

What satisfaction does entail is an absence of restlessness or resistance. A satisfied person may be willing to accept a change in his condition, but he has no active interest in bringing about a change.

It seems to me provided someone is satisfied with his choice in the way Frankfurt defines above that he must be satisfied with all the outcomes of his choice. Any agent who was not satisfied with all the outcomes of some choice he makes would surely encounter some lingering desire to alter his choice. Moreover the agent’s choice must the first one he makes for he has no active interest in choosing again. It follows any decision meeting Frankfurt’s criteria for being wholehearted also meets Simon’s satisfying criteria. In the light of the above it might be suggested that any decision made using a satisfying criteria also meets Frankfurt’s criteria for being autonomous. Such a suggestion would be false. It seems it would be perfectly possible for me to make a decision to buy an ice cream using a satisficing strategy. However Frankfurt would argue such a decision was not an autonomous decision. He argues “the notion of caring, implies a certain consistency or steadiness of behaviour, and this presupposes some degree of persistence” (4). A desire for an ice cream usually has no persistence. If I fail to buy one I move on and my desire for ice cream simply fades. It follows any decision meeting Simon’s satisfying criteria does not automatically meet Frankfurt’s criteria for being autonomous. However a persistent decision meeting Simon’s satisfying criteria would also meet Frankfurt’s criteria for being autonomous. It has been accepted above that we should respect autonomous decisions. It can therefore be concluded that should we respect the persistent conclusions of people reach by adopting a satisficing attitude. It can be further concluded that in any debate about the growing of GM crops that it is perfectly legitimate for someone to use a satisficing strategy in order to make his decision even if this means he does not maximise utility.

What lessons can be learned from the above discussion? I myself believe the opponents of the growing GM crops greatly exaggerate the dangers involved. Nonetheless if the proponents of GM crops wish to win the debate their main emphasis in this debate should not be on the benefits of these crops. The proponents of these crops must concentrate on issues directly concerning the safety of growing GM crops. They must concentrate on their opponent’s ground. Moreover the same is true of any advance which the public finds hard to understand the issues, such as the future of nuclear power or human genetic enhancement, see my previous postings.

1. Dworkin, 1988, The Theory and Practice of Autonomy. Cambridge University Press.1988, page 20.
2. Harry Frankfurt, 1988, The Importance of What We Care About. Cambridge University Press, page 83.
3. Frankfurt, 1999, Necessity, Volition, and Love. Cambridge University Press., page 103.
4. Frankfurt, 1988, page 84.

Autonomy and Caring Revisited

In this posting I want to examine whether an ethics based on empathic caring is possible and the relationship between empathic caring and Frankfurt’s ideas of ‘caring about’. Mackenzie and Leach Scully make the following two assumptions (1).

1.      There are no mental events without bodies.

2.      Imaginative prospective is based on personal experience.

I accept both of these assumptions. Mackenzie and Leach Scully then proceed to question whether because any system of morality, based on empathic or sympathetic caring, is possible because our empathic or sympathetic concerns are based on our own bodily experience. Intuitively Mackenzie and Leach seem to be correct for prima facie it seems hard for someone who is healthy and not disabled to imagine the prospective of someone who is in a wheelchair or suffers from dementia.

“The epistemic obstacles to imaging being another are so significant as to make this mode of imaginative engagement highly implausible as a basis for our capacity to morally engage with others.”(2)

They then proceed to argue due to these obstacles we should adopt an attitude of asymmetrical reciprocity towards others. They define asymmetrical reciprocity as the recognition of the other as a person, with distinctive point of view shaped by that person’s history, social situation, life experiences and relationships with others. I accept these obstacles do indeed present significant barriers to a caring morality based on empathy or sympathy. Nonetheless I will argue even if we adopt an attitude of asymmetrical reciprocity towards others that a caring morality is possible. However I will firstly argue these obstacles mean we must give greater importance to autonomy than some people who propose a caring morality, such as Gilligan and Slote, would favour.

Adopting an attitude of asymmetrical reciprocity towards others means we must adopt an attitude of epistemic humility towards others according to Mackenzie and Leach Scully. This attitude means we cannot merely imagine ourselves in someone else’s shoes when trying to understand her attitudes towards events in her life. I will now argue if we adopt this attitude towards someone then we must respect her autonomous decisions. Adopting an attitude of asymmetrical reciprocity towards someone is not the same as uncritically accepting her views for these views may be the result of coercion or delusion. Let it be assumed that the views of someone are not the product of delusion or coercion. Let it be further assumed we recognise these views but see no need to accept any actions that flow from these views even if these actions do not harm others. It seems clear that in this situation we do not have an attitude of epistemic humility. Indeed our attitude might be classed as arrogant. Moreover if we do not have an attitude of epistemic humility towards someone in these circumstances, which involves accepting her views and actions provided her actions do not harm others, then adopting an attitude of asymmetrical reciprocity seems to serve no useful purpose. It follows if an attitude of asymmetrical reciprocity is serve any useful purpose that provided an agent is un-deluded and is un-coerced we should adopt an attitude of epistemic humility towards her views and accept any actions that flow from these views that do not harm others. It follows if we do adopt an attitude of epistemic humility towards someone which involves accepting her views and the actions that flow from them that we of necessity must respect her autonomy.

In a previous posting I argued if I care about an adult in a purely empathic way I must care about what she cares about, rather than what I think might be in her best interests, see caring based solely on empathy . In what follows an adult means an un-deluded and un-coerced adult unless stated otherwise. Caring about such an adult in this way means I have adopted an attitude of epistemic humility towards her. I argued adopting an attitude of empathic caring has two important conditions for respecting someone’s autonomy. It follows these conditions also apply if I have an attitude of epistemic humility towards someone. Firstly even if I believe her best interests clash with her autonomy I must give precedence to respecting her autonomy over acting beneficently towards her. Secondly I must respect someone’s actual decisions rather than just her capacity for autonomy.

Many feminist and other philosophers who favour a caring ethic would find accepting these two conditions difficult. They would argue respecting autonomy does not automatically mean giving preference accepting autonomous decisions over acting in a caring manner, acting beneficently. A philosopher who favours a caring ethic might argue it is still possible to respect autonomy whilst not respecting all autonomous decisions. She might for instance argue one should respect someone’s capacity for autonomy rather than respecting all his autonomous decisions. This might involve helping people to develop the specific capacities needed for good reflective decision making and creating the conditions in which this type of decision-making can flourish. Michael Slote argues that respecting autonomy is like this and somewhat analogous to helping children to become fully independent (2). Let it be accepted that autonomy is simply defined as someone’s second-order capacity to reflect on her desires and to accept or change these desires in the light of her goals and values. Accepting such a definition means it might be possible to respect autonomy whilst not respecting all autonomous decisions. The trouble with accepting such a simple definition of autonomy is that there seems to be very little to differentiate autonomy from an individual’s capacity for practical reason. Using this definition means an autonomous action might be simply defined as the product of extra careful practical reasoning. It can be concluded such a concept of autonomy would be wholly instrumental.

It is usually accepted that autonomy has both intrinsic and instrumental value. I will now argue that to respect autonomy means one must respect the intrinsic value of autonomy and that this cannot be achieved by simply respecting someone’s capacity for autonomy. Harry Frankfurt believes the intrinsic value autonomy depends the recognition of us by others as the distinctive kind of creatures who can determine their own futures (3). It follows respecting the intrinsic value of someone’s autonomy might be defined as us accepting that she is the kind of creature capable of determining her own future. Let the above definition of respecting the intrinsic value of autonomy be accepted. Let it also be accepted that some of an agent’s autonomous decisions are respected and some are not. It follows that the agent is not recognised as someone who is capable of determining her own future and the intrinsic value of her autonomy is not respected. It might be objected that even if this argument is valid the first premise should be amended as follows. The intrinsic value of autonomy might be defined as accepting that someone is the kind of creature capable of only partially determining her own future. It might then be argued even if not all of an agent’s autonomous decisions are respected that nonetheless the intrinsic value of her autonomy might still be respected. However there are two problems with accepting this revised definition. Clearly if none of someone’s autonomous decisions are accepted then her autonomy is not the respected. This raises the practical problem about which of her decisions must be respected. Secondly children can partially determine their own future and are not recognised as fully autonomous creatures. For these reasons it seems the amended definition should be rejected and the original definition accepted. It follows that if an agent is not recognised as someone who is capable of determining her own future that the intrinsic value of her autonomy is not respected.

However feminist and other philosophers, who favour a caring ethic and find giving precedence to respecting someone’s autonomy over acting beneficently towards her, might argue we should only respect the instrumental value of her autonomy. This means helping people to develop the capacities needed for good decision-making and helping create the conditions in which this type of decision-making can flourish. I believe respecting autonomy cannot be simply reduced to respecting the instrumental value of autonomy for three reasons. Firstly someone who does not have her autonomous decisions respected might intuitively feel her autonomy was not being respected. Secondly Mackenzie and Leach Scully suggest we adopt an attitude of asymmetrical reciprocity towards others. It would seem impossible to adopt such an attitude if we fail to recognise the autonomous decisions of others. Indeed by not respecting someone’s autonomous decisions we might be classed as being exhibiting epistemic over-confidence rather than epistemic humility for instead of listening to the needs of others as perceived by them we substitute the needs we perceive them to need. Lastly if we only respect the instrumental value of autonomy it might be questioned if the concept of autonomy plays any useful part in determining our actions for as I argued above respecting our instrumental autonomy seems to differ little from respecting practical rationality. It follows if we regard autonomy simply as instrumental autonomy that we have no use for the concept of autonomy.

I have argued if we adopt an attitude of epistemic humility towards others we must respect their autonomous decisions. It might then be further argued that adopting an attitude of epistemic humility towards others means we are unable to act beneficently towards them. This second argument depends on the assumption that because we cannot imagine ourselves in someone else’s shoes we cannot understand her true interests. Accepting this second argument would of course mean any caring ethic is meaningless. Moreover because someone’s interests are unrecognisable to us respecting her autonomy might also become impossible. In order to examine this second argument we must consider the assumption that because we cannot imagine ourselves in someone else’s shoes we cannot understand her interests. Let us examine a particular case. Consider a soldier who has been returned from the war in Afghanistan after losing both his legs. It seems to me that adopting an attitude of epistemic humility towards him does not mean we cannot understand most of his interests. We can understand his sense of grief at the loss of a friend or at a more mundane level his hunger. It might then be questioned if we understand his needs whether an attitude of epistemic humility is indeed the correct attitude to adopt towards such a soldier. I believe an attitude of epistemic humility is the correct attitude to adopt because even if, we can understand most of his interests, we cannot understand the priorities he gives to these interests. For instance if I was a colleague of this soldier we both may have given a high priority to physical fitness and a low priority to learning in the past. However the soldier’s priorities may now have now changed due to the loss of his legs whilst mine remain the same. It seems possible to conclude using this example that the epistemic obstacles to imaging being another are not that we are unable to understand another’s interests but rather that we are unable to understand the priorities she gives these interests. Accepting the above conclusion means adopting an attitude of epistemic humility towards others does not mean we are unable to act beneficently towards them. It can be further concluded the obstacles raised by adopting an attitude of epistemic humility towards others do not present significant barriers to a caring morality based on empathy or sympathy.

1.      Mackenzie, Leach, Scully, 2007,Moral imagination, Disability and Embodiment; Journal of Applied Philosophy, 24(4)

2.      Michael Slote, 2007, The Ethics of Care and Empathy, Routledge, page 60.

3.      Harry Frankfurt, 1999, Necessity, Volition, and Love, Cambridge University Press, page 163.

Moral Insanity

In this posting I want to examine the moral implications raised by the behaviour of the Austrian man Josef Fritzl who imprisoned and sexually abused his daughter for 24 years. The idea for this posting is “The stain of moral insanity” by A C Grayling and found in the New Scientist of 17/05/08. Grayling suggests evil simply means a great deal of wrong. Moreover he suggests evil is not a useful term and acts as a full stop on our understanding. It follows he argues describing someone as evil does not capture the moral implications his behaviour. He argues it might be better to regard people such as Fritzl as morally insane rather than simply mad or evil. I will use Grayling’s definition of moral insanity to give two further consistent definitions. I will also briefly examine the implications of these two definitions.

Insanity is not now usually regarded as a medical term. Legally insanity means an agent suffers from a mental disease or defect and does not possess the capacity to appreciate the requirements of the law. Moral insanity is defined by Grayling as follows
“Moral insanity is the refusal to act according to important moral dictates the agent fully understands.”
Grayling’s definition makes no mention of mental illness or defect. It follows Grayling’s concept of moral insanity appears to be unattached to the legal concept. This appearance does not of course mean his concept is not useful in examining the moral implications of the behaviour of people such as Fritzl.

It might be Grayling wants to connect the idea of moral insanity to our intuitive ideas of insanity. Intuitively insanity might be simply said to be acting without any regard for rationality. However it is hard to see how any requirement of rationality, other than understanding what society regards as a moral dictate, is needed by Grayling’s definition. Consider the behaviour of someone like Fritzl with regard to Grayling’s definition. Let it be assumed this person fully understands the moral dictates of society. Let it be further assumed that for someone to act rationally simply means to act in such a way as is likely to satisfy his desires and help him attain his goals. It appears to follow such a person may fully understand these moral dictates but have no reasons, other than prudential reasons, to obey them. Grayling argues the elaborate steps Fritzl took to conceal his behaviour showed he believed what was doing was wrong. It seems reasonable to assume Fritzl was aware society would punish him on account of his actions should these be discovered. It follows it is possible to give a different interpretation of Fritzl’s behaviour. Fritzl had good reasons to conceal his behaviour for his prudential interests. It then follows the steps he took were quite rational based purely on serving these prudential interests. It might then be concluded, provided the two above assumptions are accepted, that Fritzl’s behaviour might be better described as a failure to accept generally accepted moral standards rather than acting irrationally.

However it might be possible to connect rationality with moral insanity if Grayling’s definition is slightly amended. His definition might be amended as follows to give my first definition of moral insanity.

Moral insanity is the refusal to act according to important moral dictates the agent fully accepts.

Prima facie using this definition of moral insanity Fritzl’s actions would be irrational provided he fully accepted these important moral dictates. It is important to be clear about what ‘fully accepts’ means in this definition. Fully accepting something in this amended definition doesn’t simply mean that the agent accepts that some moral dictates are society’s moral dictates but rather that these dictates are his dictates. He identifies himself with these dictates. Moreover if someone identifies himself with a course of action in line with these dictates then rationally he should undertake this action in circumstances in which he is able to do so. Using this amended definition it might be useful to class someone, who acts contrary to moral principles he accepts, as morally insane due to his lack of rationality. However in practice such clear cut circumstances are rare. As a consequence it seems doubtful if my first definition of moral insanity would apply in many cases. Moreover whilst it is possible to check if someone acts logically it would seem to be difficult to assess whether someone’s actions are instrumentally rational. It follows in such cases it might be more useful to question whether the perpetrator is autonomous rather than morally insane.

I suggested above that intuitively insanity might be simply defined as someone acting without regard for rationality. I then assumed an agent acts rationally if he acts in such a way as is likely to satisfy his desires and help him attain his goals. However if this assumption is rejected might it be possible to connect an agent’s refusal to act according to important moral dictates with our intuitive ideas of insanity in a more meaningful way? Let it be assumed the above assumption is incorrect by assuming Kant is correct in believing that morality is based on the rational recognition of universal moral norms. It follows Fritzl is defective because he is unable to correctly apply universal rationality. It further follows Fritzl’s actions might be intuitively considered as insane due to this inability to recognise rational moral norms. It still further follows if morality is based on universal rationality that the idea of moral insanity based on rationality might indeed be a useful concept. However the rational recognition of universal moral norms would seem to be something few, if any, could achieve in practice. It follows that in normal circumstances if we question someone’s ability to act rationally we assess his ability to use practical rationality. Let it be accepted if we question someone like Fritzl’s ability to act rationally we should use the same standard as we use to assess the rationality of others. It can then be concluded if we question someone like Fritzl’s ability to act rationally we should assess his ability to use practical rationality.

I have argued someone like Fritzl and sociopaths in general seem perfectly able to use practical rationality. It follows it would be wrong to class such persons as insane, or morally insane, provided they are capable of using practical rationality. However it still seems to me that the idea of moral insanity might be useful. Legal ideas on insanity mean that an insane person suffers from mental disease or defect and does not possess the capacity to appreciate the requirements of the law. I have argued that sociopaths do not usually have a defect of rationality. However sociopaths may be defective in other ways. Sociopaths may be defective because they lack sympathy and empathy for others. Slote argues actions are morally wrong and contrary to moral obligation, if and only if, they reflect or exhibit or express an absence of a fully developed empathic concern for others on behalf of the agent, see previous postings. Provided Slote’s argument is accepted then someone such as Fritzl and sociopaths in general are morally defective because they are unable to feel empathy for others. It follows the whole idea of morality makes no sense to such persons. It is now possible to give a second definition of moral insanity based on an inability to feel empathy for others.

Someone is morally insane if he acts contrary to accepted moral dictates he understands due to his inability to feel empathic concern for others.

It is important to be aware of two important properties of this definition. Firstly this definition makes no mention of rationality. Secondly this definition differs significantly from the legal definition of insanity. Legally in order to be considered insane someone must not only have some mental defect, in our case no capacity to feel empathy, but also not understand what the law requires. A sociopath might well understand the requirements of the law and have a defect in empathy, but is this defect a mental defect? It follows a sociopath might be considered as morally insane but as legally sane, depending on whether we regard an inability to feel empathy as a mental defect or not.

I will now consider the practical implications of accepting this second definition of moral insanity. Firstly it seems to me if we accept this definition then we have a duty to see the circumstances in which moral insanity arises are minimised. In practice this means trying to foster circumstances in which children grow up to be able to empathise with others. To do this we must address social problems such as struggling single parents, social isolation and poverty. Secondly accepting this definition carries certain dangers. If we regard someone as defective because he is incapable of empathic caring then we might also regard him as different from others in a particularly important way. If I lose a leg I am defective with regard to walking but I am not defective with regard to being essentially human. The same does not seem to be true of a sociopath. Furthermore if morality is in some way based on empathy, the fact a sociopath is defective with regard to empathising, might mean we would find it difficult to include him within our sphere of moral concern. See Slote and empathising with an alien, mentioned in an earlier posting. Returning to Grayling’s concerns the term sociopath might indeed act as a full stop on our understanding. Perhaps if evil is also seen as a full stop on our understanding it would be right to describe sociopaths as evil. The dangers of labelling people as evil are all too well illustrated by considering Nazi Germany. The dangers of seeing people as evil and beyond our moral understanding are real and present a challenge to those of us who see morality as based on empathic caring. In this case all that can be done is to admit sociopaths may indeed be evil, beyond our moral understanding, but we should never the less include them in our moral concerns. After all we may be morally concerned about the environment even if the environment has no moral concerns.

Justified Anger and Empathy

This posting is concerned with justified anger. It is partly a response to Chapter 5 of Nancy Sherman’s “Stoic Warriors” (1). It is all too easy to become angry. However it is much more difficult to switch anger off. Indeed it might be argued being angry is like being on a slippery slope. We are unable to control anger in the same way an alcoholic cannot control her drinking. Just as an alcoholic damages both herself and others so an angry person damages both herself and others. According to the ancient stoic philosophers the response of a wise person to her potential anger should be an attempt to eliminate this anger. The question this posting addresses is this, are the stoics correct and should we also attempt to eliminate anger in our lives?

Anger is usually aroused by some negative event occurring in our lives. I will argue that due to the various causes of negative events some anger may be justified and some anger may not. In the vintage TV series Fawlty Towers the hotel’s proprietor Basil beats his car in anger with a stick when it breaks down. Intuitively such anger seems to be inappropriate. Sherman considers the anger of Hugh Thompson in response to the massacre at My Lai during the Vietnam War. Thompson’s anger helped him to courageously save others from being massacred. Clearly Thompson’s anger was not inappropriate. However the question might be asked was his anger necessary to help stop the massacre? Might not a calm rational moral person also have helped to stop the massacre? I will argue not. I will argue Thompson’s anger was not only an appropriate reaction to the massacre but was also a necessary condition needed by him in order to help stop the slaughter.

In order to fully understand whether anger is justified we must examine the circumstances in which negative events occur in our lives. Basically there seem to be two types of negative events which cause anger. Firstly events which we regard as morally wrong, for example the My Lai massacre. And secondly events which frustrate our desires or ambitions, for example Basil Fawlty’s car breaking down so frustrating his desire to drive from A to B.

I will consider first whether our anger is justified at events which we regard as morally wrong. I will now argue briefly that both a consequentialist and a deontologist would agree anger serves no useful purpose in reacting to events which they regard as morally wrong. I will then further argue any morality based on empathic caring would regard anger at such events not only as justified but also a necessary condition the agent needs in order to act well. Consequentialist ethics believes in maximising some good in the world. This good might be happiness, satisfied lives, the choices available to people and so forth. What form this actual good takes need not concern this discussion. Whatever good consequentialistism seeks to maximise, someone’s actual choice, about how to maximise this good, is a purely rational decision. It follows an agent’s anger plays no part in making her decision. It further follows anger is not a necessary condition in order to act well. If morality is conceived of as simply comprised of rights and relevant duties then someone’s anger again plays no part in her actual decision. She simply sees her duty and acts upon it. It might of course be true that her anger acts as a catalyst making doing her duty easier. It follows in any deontological system of morality being angry is also not a necessary condition for an agent to act well. It might be argued by not expressing anger at such events might damage the agent and that by not expressing anger she does not express her true self. It seems to me that because under any consequentialist or deontological system of morality the expression of anger does no useful work any such expression is not only unnecessary but might also be considered as mere posturing.

In previous postings I have suggested that intuitively morality is based on acting in accordance with our empathic concerns as outlined by Slote. Let it be accepted that morality is indeed based on empathy for others. It follows,

“Actions are morally wrong and contrary to moral obligation if, and only if, they reflect or exhibit or express an absence (or lack) of a fully developed empathic concern for (caring about) others on behalf of the agent.” (2)

The question that must now be addressed is this, is it possible to have a fully developed empathic concern for others when these others are being wronged and not have some anger? Empathic concern for others is clearly not based on rationality. Empathic concern for others is based on the ability to experience the feelings of others. Let it be accepted if some person is wronged she must feel some emotion. If the above is not accepted then the whole idea of basing morality on empathic caring becomes nonsense. Someone who is wronged may feel various emotions such as pain, grief and sorrow but must she also feel anger? Let anger be defined as a sense of displeasure at some perceived wrong. It might be objected this definition is too weak and anger should be defined as a strong sense of displeasure at some perceived wrong. However anger can vary from mild anger, annoyance, to extreme anger, uncontrollable rage. It follows anger can be defined as having some sense of displeasure at some perceived wrong. I fully accept such a definition is an incomplete definition in the case of extreme anger such as rage. I suggested above it would be impossible for someone who has been wronged to feel no emotion. This emotion must be a negative emotion giving her a sense of displeasure. It follows if someone has been wronged that she must feel some anger. It further follows from the definition of empathy, if I have empathic concern for someone who has been wronged then I must feel some anger. Let it be accepted morality is based on empathic caring It can be concluded if an agent is to act morally in response to some moral violation then it is a necessary condition for her action that she feels some anger with regard to the violation. It can be further concluded Hugh Thompson’s anger was not only an appropriate reaction to the massacre at My Lai but was also necessary condition for him to help stop the massacre.

Finally I will consider whether anger caused by events which merely frustrate our desires or ambitions can be justified. It seems to me the answer to this question simply depends on whether our anger is useful in helping us satisfy our desires or achieve our ambitions. Basil Fawlty seemed to have no justification for beating his car with a stick. Such behaviour did not aid him in furthering his desire to go from A to B. Indeed such behaviour might have frustrated this desire. However someone’s anger at being passed over for promotion may be justified. She might use her anger as encouragement to work harder and achieve promotion at a later date. In these circumstances someone’s anger can be justified provided she is able control her anger. If however she is unable to control her anger, like the alcoholic who is unable to control her drinking, she should attempt to eliminate this anger.

1. Nancy Sherman, 2005 Stoic Warriors, Oxford.
2. Michael Slote, 2007, The Ethics of Caring and Empathy, Routledge. 

Genetic Enhancement and the bondage of future people by present people

In chapter 8 of “Enhancing Evolution” Harris considers the view of Habernas that the use of genetically enhancing technologies might involve the bondage of future people by present people. This is an example of good rhetoric, but what does in mean if anything. In this posting I will examine exactly what is meant by “the bondage of future people”. I will assume the bondage of future people must affect their ability to make autonomous decisions. It follows I must consider how genetic enhancement might affect autonomy. Autonomy might be affected in two possible ways.
1. Genetic enhancement might mean the choices available to some future agent are curtailed.
2. Genetic enhancement means a future agent’s capacity to make autonomous decisions is damaged.

In this posting I will not consider the second of these possibilities. The reason being I believe any genetic manipulation which damages someone’s capacity to make autonomous decisions cannot be a genuine enhancement. Prima facie it might seem, provided genetic enhancement does not damage a future agent’s capacity to make autonomous decisions, that genetic enhancement does not affect his autonomy. Consider the possible genetic enhancements mentioned by Harris such as an increased resistance to the development of cancer or life extension. Clearly if such enhancements do not directly affect an agent’s mental status they do not affect his capacity to make autonomous decisions. Moreover it would still possible for an agent to jeopardise his enhanced status by engaging in dangerous pastimes such as motor racing.
It might of course be argued the fact an agent has an increased resistance to cancer and the prospect of greater longevity means he doesn’t see the prospect of engaging in dangerous pastimes as a sensible option. It might then be concluded that because genetic enhancement might cut down on an agent’s available options, even if his capacity for autonomy is unaltered, his ability to make autonomous decisions is slightly damaged. Harris argues future agents would gladly accept such a slight limitation on their ability to make autonomous decisions in exchange for the benefits of enhancement. He further argues vaccination of children against childhood diseases may slightly limit their ability to make future choices, but that no one seriously questions such vaccination. Indeed it might be argued limiting someone’s future choices does not damage their ability to make autonomous decisions. Someone may wantonly choose among a large array of options; yet few would argue such decisions are autonomous, see Frankfurt (1999, Necessity, Volition, and Love, Cambridge University Press, page 106). It might then be further argued for an agent to retain the ability to act autonomously he does not need a large number of options, he only needs options he can care about. According to this view for an agent to act autonomously simply means he is able to do what he wants. If this simple view of autonomy is accepted then even if genetic enhancement limits the options available to an agent it does not necessarily limit his ability to make autonomous decisions provided he has options he can identify with. It is very easy to imagine future agents identifying with living longer and not getting cancer! It can be concluded even genetic enhancements limit the options available to an agent that this might not affect his ability to make autonomous decisions.
I believe such a conclusion depends on a simplistic view of autonomy. Autonomy is a hybrid concept. This concept includes identifying with one’s choices, caring about something, and making a reflective choice. Furthermore whilst autonomy clearly has instrumental value it also has intrinsic value. To me the intrinsic value of autonomy lies in being recognised as the kind of person who has the right to make his own decisions. Moreover it seems to me if people now take decisions on behalf people in the future they are failing to recognise the intrinsic value of their autonomy. As has been noted above Harris assumes future persons would gladly give up some autonomy in order to benefit from enhancements. It seems to me there are two objections to this assumption.
1. Provided we are recognised as the kind of person who has the right to determine his own future then any attempt to determine our future fails to recognise the intrinsic value of our autonomy.
2. Harris automatically assumes future people would want to be enhanced even if this limits their autonomy. Such an assumption is dangerous for as was pointed out by Berlin (1969, Four essays on liberty, The Clarendon Press, page 132) this assumption seems to be based on what some idealised future person would choose rather than an actual person.

Harris would doubtless reply to my objections by arguing many of the things parents do for their children affect their future autonomy; education for example. He might further argue that by doing so parents do not damage their children’s future status as the kind of persons who have the right to make their own decisions. It would follow not all attempts to benefit someone damages the intrinsic value of his autonomy. I accept parents do not usually damage the intrinsic value of their children’s autonomy. However I am not at all sure it can then be argued by analogy that some genetic enhancements also do not damage the intrinsic value of autonomy. It seems to me the analogy fails to work because the usual benefits parents confer to their children differ in a significant way from genetic enhancement. The usual benefits parents confer to their children may be rejected by these children later in life. For instance someone may reject the benefits of his education and lead a slothful or purely hedonistic life. It seems non genetic benefits may be accepted or rejected. This ability to accept or reject these non genetic benefits means the intrinsic value of an agent’s autonomy is not damaged in this context. However it might be impossible for an agent to reject a genetic enhancement. It follows even if a particular genetic enhancement does not greatly damage the intrinsic value of someone’s autonomy the cumulative effect of many enhancements might. It might then be concluded Habernas is correct in his belief that the use of genetically enhancing technologies might involve the bondage of future people by present people.
In the light of the above discussion some might possibly conclude that genetic enhancement should not be permitted. I believe such a conclusion would be premature and that genetic enhancement should be permitted subject to safeguards. I argued above the way some parents attempt benefit their children might seem to partly determine their future. I further argued in practice such attempts do not damage these children’s autonomy because these benefits may be accepted or rejected. These benefits may be seen as gifts. It seems to me provided genetic enhancements can also be seen as gifts that these enhancements should be permitted. It follows Habernas’ belief may be wrong and that genetic enhancements do not bind future generations, provided these enhancements can be seen as a gift. However the idea of genetic enhancement as a gift must be explored a little further. It must be asked if a genetic enhancement is a gift to who is the gift intended. There seem to be two possible answers to this question.
1. The enhancement is a gift to those people who are enhanced.
2. The enhancement is a gift to future generations.

A gift it something the recipient can reject. You cannot force someone to accept a gift. It may of course be bad manners to reject a gift. Let it be assumed that some genetic enhancement is seen as a gift to future generations. It follows if a genetic enhancement is a gift then it must be possible to undo this enhancement for these future generations; even if the enhancement cannot be undone for particular individuals. I suggest in this context no genetic enhancement should be permitted until it is possible to undo this enhancement for future generations. Let it be assumed that some genetic enhancement is seen as a gift to those people who are enhanced. It follows the enhanced person must be able to see his genetic enhancement as a gift which he must be able to decide to use or not use. I suggest in this context any enhancements someone must use should not be permissible.

Cognition Enhancing Drugs

John Harris argues it would not be wrong to use cognition enhancing drugs such as Ritalin in order to obtain good grades in examinations (1). Prima facie it would appear the taking of such drugs, provided these drugs have no adverse side effects, would be an enhancement to the drug user as they appear to increase his cognitive abilities. It seems to me in practice the question as to whether it would be wrong to use cognition enhancing drugs in the context of examinations is not as straightforward as Harris believes. Let it be accepted that the use of cognition enhancing drugs to enhance someone’s cognition will allow him to obtain a better grade in an examination. I now want to question whether such an enhancement should be permissible.

Let it be accepted that an enhancement should not be permissible if it denies to others the goods they are rightfully entitled to. Does the fact that some candidate might improve his grade in an examination by the use of cognition enhancing drugs, whilst others do not take these drugs, potentially deny these others some goods they are entitled to? In order to answer this question we must first consider the purpose of an examination. This purpose is not simply to assess someone’s ability to pass an examination. The purpose of an examination might be defined as an attempt to assess someone’s proficiency in some subject which depends on his cognitive abilities in much the same way as a driving test tests someone’s proficiency to drive a car. An examination might be defined as a test of someone’s knowledge and cognitive abilities. The above definition still needs some further refinement. In an examination the attempt to assess someone’s proficiency takes place at time T. However the purpose of this assessment is not simply to gauge a candidate’s proficiency at time T. The purpose of an examination might be defined as an attempt to assess someone’s proficiency over an ongoing period of time. Examinations would clearly be pointless if candidates immediately lost all proficiency in the subject examined after the examination. Consider two candidates A and B taking some examination. Let it be assumed A takes cognition enhancing drugs in an attempt to improve his grade whilst B doesn’t. Let it be further assumed A is successful in obtaining a better grade in the examination than B and as a result obtains a better position than B. Let it be still further assumed that A’s stops taking the cognitive enhancing drugs after the examination and that his proficiency drops to below that of B. Prima facie it appears B has been deprived of some good he is entitled to. It follows that the possibility of using of cognition enhancing drugs in examinations might deny candidates who do not take these drugs the goods they are entitled to.

The above conclusion seems to depend on two factors. Firstly A’s use of cognition enhancing drugs in the examination does not enhance his proficiency in the subject examined in an ongoing way. Secondly his use similarly fails to enhance his cognitive abilities. Both these factors seem plausible. Taking aspirin after all only relieves pain for a limited period. Moreover it also seems reasonable to assume if someone stops taking cognitive enhancing drugs his cognitive abilities fall. If his abilities did not fall then it might be questioned whether the drugs concerned were really cognitive enhancing.

However even if both of these factors are true it does not automatically mean A’s use of cognition enhancing drugs denies B some goods he might be entitled to in all circumstances. Firstly A might continue to take cognition enhancing drugs after passing the examination. In these circumstances the fact he took these drugs in order to do well in the examination does deprive B of any goods he is rightfully entitled to. Furthermore provided someone’s continuing taking of these drugs has no long term adverse effects it again seems plausible A will continue to do so. After all some people after all continue to take a daily aspirin in order to reduce the possibility of heart attacks and strokes. It would seem in these circumstances the use of cognition enhancing drugs becomes a genuine enhancement and not one limited to the context of passing examinations. Secondly the taking of cognition enhancing drugs for a short period leads to cognition enhancement in the long term. I find this possibility unlikely. It follows that the use of cognition enhancing drugs in examinations ought to be permissible provided one or both of the two following conditions holds.

1. The short term use of cognition enhancing drugs by a candidate in an examination either increases his proficiency in the subject examined or his cognitive abilities in an ongoing way.
2.  Any candidate using cognition enhancing drugs in an examination must continue to use these drugs.

It might be objected that in practice the first condition is unlikely to hold. I accept this objection. It is also possible to object to my second condition. My objector might argue that it would seem to be impossible to ascertain whether someone would continue taking cognitive enhancing drugs after his examination. If someone fails to continue taking these drugs then the results of the examination will provide an inaccurate assessment of someone’s proficiency over an ongoing period of time. My objector might then conclude if cognition enhancing drugs are permitted in examinations that the value of examinations is devalued. However I would suggest that subject to the condition that the use of a cognition enhancing drug has no adverse side effects, it seems probable that anyone who benefits from this drug would continue to take it. To stop doing something which benefits someone and which does him no harm would seem to be illogical. It follows the second condition listed above should normally hold. It further follows Harris is correct to argue it should be permissible for someone to use cognition enhancing drugs in an examination provided those drugs benefit the users if taken in the long term and doing them no harm.

1. John Harris, 2007, Enhancing Evolution, Princeton University Press