Hobbs and Heroes

At the BBC radio 3’s free thinking festival at The Sage in Gateshead Angie Hobbs posed the question do we need heroes? In her discussion Hobbs used a working definition of a hero as “someone who does something of outstanding and recognised benefit to society or culture which most people would find impossible to perform”. The Cambridge online dictionary defines a hero as someone “who is admired for having done something very brave or having achieved something great”, the italics are mine. It would appear Hobbs’ definition and that of the dictionary roughly concur. In this posting I will argue such definitions are incomplete.

 

Hobbs used a thought experiment to tease out our intuitive ideas of who is a hero. She imagined someone standing on a swollen river bank. A child falls into the river and the person jumps in to save the child. She then refined this situation to explore further our intuitive ideas about who counts as a hero. For instance is the potential rescuer a hero if she cannot swim and has only a minimal chance of saving the child? Is she a hero if her desire for heroism means standing around on riverbanks for hours hoping to rescue someone? Or is she a hero if her desire for heroism means she pushes someone who is a much better swimmer out of the way so she can rescue the child? In the light of Hobbs’ examples I want to question if the person standing on the riverbank who rescued the child was Superman whether we would consider his action as heroic. Someone might object that my question is simply a no-brainer arguing because Superman is a superhero it automatically follows his action is heroic. However I would suggest the fact that Superman is regarded as a ‘superhero’ rather than simply as a hero gives us some grounds to question his heroism.

 

Is a superhero just someone who is super at being a hero or someone who differs from normal heroes in a more significant way? It seems to me it is difficult for someone with super powers to be a hero, it's hard for superman to be a hero I now want to argue that Superman’s action in saving the child lacks an essential element needed for his action to be regarded as heroic. Superman when he rescues the child is fully confident he is going to succeed. I would suggest Superman is only doing his duty and that heroes are people who go beyond the call of duty. Let it be assumed I am standing on the side of a pond into which I can wade with no danger to myself. Let it be further assumed this pond is deep enough to drown a small child. Into this pond falls such a child. In this situation I would suggest because someone has a need for my services, the child, services which I could provide at very little cost to myself, getting wet, that intuitively I have a duty to provide these services. Furthermore I would suggest there is something drastically wrong with me as a person if I fail to feel some empathy for the drowning child. If we accept a caring ethic and I fail to save the child because my actions fail to reflect or exhibit or express an absence of empathic concern for the child then I am acting wrongly. I am also failing to do my duty from a consequentialist and deontological viewpoint. For these reasons I would argue in the above situation I should be blamed if I did not rescue the child and that whilst the child’s mother may be grateful for my actions that nonetheless these actions do not merit praise because I only doing my duty. I would further argue superman’s position on the riverbank is analogous to mine on the side of the pond. If superman fails to rescue the child at relatively little cost to himself then intuitively he fails to do his duty. Moreover any failure on his part to rescue the child reflects an absence of empathic concern and also means he fails to do his duty. I would suggest in the light of the above that a more complete definition of a hero is as follows. A hero is someone who chooses to recognisably benefit someone else or society in ways most people could not, in addition her actions must be beyond the call of duty and must involve some real sacrifice on her part. Accepting the above raises some interesting questions. Could the ‘someone’ in the above definitions be a young child be a hero or even some sorts of animals? Clearly very young children or animals cannot knowingly benefit society. However young children and perhaps animals can love someone else. If a child concurs his fears and goes into the street knowing it is dangerous to seek help for his unconscious mother who has fallen down stairs a hero? I would suggest young children can be heroes. Is a sniffer dog who fearfully enters a building only because he loves his handler brave and perhaps a kind of hero? The answer to this question depends on whether love can be a reason to be heroic.

 

Accepting the above definition means we have no reason to regard football stars as heroes even if they are capable of doing things on the football field we would find impossible to perform. In practice it seems we already do this by referring to sportsmen and women as ‘sporting heroes’ rather than simply as heroes. It also follows we have no reason to regard most soldiers fighting in Afghanistan against the Taliban as heroes. These soldiers are brave but it is part of a soldier’s duty to be brave and bravery need not of necessity involve sacrifice. However the question might still be posed must a more meaningful definition of a hero include the fact that she does something brave? It is certainly true that in the ancient world a hero had to be brave because the domain of heroes was restricted to soldiers prepared to sacrifice themselves for their country. However over time the domain of heroes has expanded to include all men, women, and children. Does this expansion mean that a hero must still be brave? I would suggest it does but that the domain of what is a brave action also needs expanding. To be brave someone must be prepared to do something that makes her vulnerable, she must be prepared to sacrifice herself for some commonly perceived good.

The Roots of Cruelty

Paul Bloom writing in the New Scientist of 16/10/10 states the following “It is no surprise that modern humans can be selfish and cruel, but this kindness poses a deep puzzle.” Personally I am not puzzled by human kindness nor am I surprised by selfishness or cruelty. However even if I am not surprised by cruelty I am puzzled by this phenomena and it is this puzzlement I wish to explore in this posting.

The reason for my puzzlement lies in the fact that whilst it seems possible to give evolutionary reasons for the roots of empathy and in certain contexts selfishness, I can see no evolutionary reasons for the roots for cruelty. Cruelty can be defined as cruel behaviour or actions. The Cambridge online dictionary defines such actions as extremely unkind and unpleasant causing pain to people or animals intentionally. The way we define and use words is important as our definitions partially determine our reactions and for this reason I want to be more precise about the above definition. It is quite common to talk of nature or animals being cruel, but we never speak of nature or animals being unkind or unpleasant. In what follows I will regard being unpleasant as a mild form of unkindness. Perhaps being unkind is not an essential element of cruelty. In practice we censure cruel people but don’t censure animals. In addition we don’t censure surgeons who intentionally cause us pain. It follows we have two different concepts of cruelty. The first concept does not involve unkindness and for that reason is philosophically uninteresting. In what follows I will only consider the second concept.

If I am going to be unkind to someone I must understand him to some degree. I must have a theory of mind. Accepting the above means cruelty cannot have a long evolutionary history. It follows most animals, with a few possible exceptions such as chimpanzees, cannot be cruel in my second sense. Nevertheless natural selection does select for some features which only have a short evolutionary history. For instance it seems clear natural selection would favour creatures possessing a theory of mind. A theory of mind appears to have a short evolutionary history. A theory of mind appears to be a precondition for a capacity to feel empathy. Someone might object to the above by suggesting dogs feel empathy for their owners and argue dogs do not have a theory of mind. I would question whether dogs feel genuine empathy and would suggest dogs merely react their owner’s feelings in an appropriate way. It therefore seems probable that the capacities for feeling empathy and acting cruelly only became possible at around the same time in our evolutionary history. It is now becoming generally accepted that natural selection favours creatures with a disposition to feel empathy. A disposition for empathy appears to clash with a cruel disposition. Someone might now argue because of this clash natural selection cannot favour creatures with a capacity for empathy and also favour or be indifferent to creatures with a disposition for cruelty. A moment’s reflection shows his argument to be unsound. Consider a peacock. A peacock’s tail feathers clash with his survival but are nonetheless selected for by natural selection because of their usefulness in attracting mates. It follows even if natural selection favours creatures with a capacity for empathy it is still possible that it might also favour or be indifferent to creatures with a capacity for cruelty.

However until very recently in human history I see no obvious reason why natural selection should select for cruelty. Indeed until the emergence of large societies it is possible to argue natural selection would select against a trait for cruelty. Before the emergence of large societies people lived as hunter gathers. Research has shown these societies were largely non hierarchical and had an egalitarian structure, see http://en.wikipedia.org/wiki/Hunter-gatherer . In such societies being cruel to gain power or amass wealth would be pointless. Prima facie in such societies cruelty appears to offer no advantages to individuals. Indeed being cruel would appear to be a disadvantage. In the light of the above it is far from obvious that cruelty is deep rooted in us due to natural selection. In practice of course no one can deny cruelty exists and perhaps given the society we live in I should not be puzzled by this. However my argument suggests the roots of this cruelty lie in our society and not our nature. Moreover if we do not have a natural inclination for cruelty I see no reason why our society must of necessity have a Hobbesian or Machiavellian nature. Accepting my suggestion permits the comforting belief that the roots of cruelty are shallow and we need not accept cruelty as inevitable.

The Obese, Muggers and NICE

The National Institute for Health and Clinical Excellence's citizens' council thinks it might be right to offer grossly unhealthy people financial incentives to mend their ways provided these incentives proves less expensive to the state in the long-run than their continued ill health. In the following discussion the only grossly unhealthy people I will consider will be the obese. However I believe all my comments are to some degree applicable to all grossly unhealthy people such as smokers, alcoholics and drug users. Someone might protest if NICE’s citizens' council’s idea is accepted that we must also accept it would be right to pay muggers to mend their ways provided these payments cost the state less than their continued mugging. My protestor might argue such a policy would save the money on policing muggings, the trials of muggers and the imprisonment of offenders. He might further argue some members of the public would be saved the trauma of mugging whilst the rest of us might feel safer on the streets. If we are to reject my protestor’s arguments we must show there is a significant difference between paying such incentives to the grossly obese and muggers. This is easily achieved by simply noting paying incentives to all potential muggers is in reality paying blackmail.

Let us firmly reject the idea of paying blackmail to all potential muggers. However my protestor might refine his argument. He might accept we should not pay all potential muggers. He might now argue if it can be shown giving a small cash incentive to convicted muggers reduces mugging and this incentive is cost effective that we should do so. In the following ‘muggers’ will be taken to mean convicted muggers. It might be objected such an incentive remains a form of blackmail. I believe my protestor can effectively reject this objection. He might point out in this context the incentive is freely offered and not demanded by the convicted muggers. The question I wish to consider is whether, in this revised context, it is possible to show there is a significant difference between giving a small incentive to the grossly obese either to slim or go to a gym and giving muggers a similar incentive to desist from mugging.

If we adopt a purely consequentialist viewpoint of morality it is by no means clear we can find a meaningful difference. From a very simple consequentialist viewpoint based on purely avoiding harm to individuals it might be concluded there is indeed no difference. The harm an obese person does to himself can be equated with the harm a mugger does to his victims. From such a viewpoint all that matters is harm and the fact that an obese person harms himself whilst a mugger harms others is irrelevant. However such a viewpoint involves a too simplistic idea of harm. Mugging damages society and hence indirectly damages others as well as the mugger’s victims. It might be suggested this extra harm means giving incentives to muggers should be given priority over giving incentives to the obese. Clearly such a suggestion seems ridiculous. The reason being it is based on the same simplistic idea of harm. It seems to me the harm done to society must somehow include the wrongness of mugging and that the payment of cash incentives to muggers pays no attention to any such wrongness. Nevertheless even if this wrongness can be weighted into a consequentialist viewpoint, which I personally doubt, it still remains doubtful whether such a viewpoint can pinpoint a significant difference between the payment of a small cash sum to enable someone who is grossly obese go to a gym and giving a similar sum to a mugger to help him desist from mugging.

One of the problems of any consequentialist account of morality is how to deal with dessert. Is it possible to find a significant difference based on dessert? In considering this question I will rely on our intuitive ideas of dessert and will not consider any theory of dessert. Intuitively if someone deserves something he must undertake some action that makes him worthy of this dessert. Intuitively convicted muggers don’t do anything that makes them worthy of the proposed cash incentives. Unfortunately it is far from obvious that the grossly obese do anything that make them worthy of these incentives either. Intuitively it might be argued provided their obesity is self inflicted the obese merit our approbation rather than any ‘deserved’ cash incentives.

If it is impossible to find a significant difference from either a consequentialist viewpoint or that of dessert then perhaps it may be possible to find a difference based on need? The obese need to lose weight muggers don’t need to stop mugging, muggers should stop mugging. It is clear then there is a significant difference between paying a small incentive to the grossly obese in order to help them slim and paying a similar incentive to convicted muggers to encourage them desist from mugging from the viewpoint of need. However even if we accept the above and that we should satisfy needs when possible it does not automatically follow we should incentivise the obese to lose weight. People have many needs and limited resources mean we cannot satisfy the needs of all. Consider a father is grossly obese due to lack of exercise and a diet of jam doughnuts. Let it be assumed his gross obesity means he is a poor father. Let us also consider a good father who eats sensibly and works very hard to support his family. Let it be further assumed this second father is stressed due to his hard work. A small cash incentive could help the first father slim by going to a gym. However the same small cash incentive could also help the second father relieve his stress by going to the same gym. Both fathers have needs but if we can only satisfy the needs of one intuitively we might feel we should satisfy the needs of the second father. The reason for our intuitive feelings seems to be based on dessert.

None of the above means it would be wrong to give the obese some small cash incentive if it can be shown this incentive will help them lose weight and hence improve their health. Indeed I would suggest it would be wrong not to care about the obese. I would agree with Michael Slote when he argues an action is wrong if it exhibits or expresses a lack of caring motivation based on a lack of empathy, see (2007, The Ethics of Care and Empathy, Routledge). However even if we must care about the obese it does not follow we must offer them financial incentives to lose weight even if these incentives are effective. First as noted above if resources are scarce we may feel others are more deserving of these resources. Secondly even if resources are more readily available it might be argued offering the obese incentives to lose weight, when others can do so under their own volition, means we are not treating the obese with the same respect as we do most people. I will not pursue this argument here. It follows whether we should incentivise the obese lose weight in order to improve their health when resources to do so are freely available remains undecided.

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)..

The Decriminalisation of Drugs

Ian Gilmore, former president of the Royal College of Physicians, and one of the UK's leading doctors has argued that the government should consider the decriminalisation of drugs, see http://www.guardian.co.uk/politics/2010/aug/16/drugs-decriminalisation-doctor-ian-gilmore. He bases his argument on the fact that the ban on drug appears to have failed to either cut crime or improve health. His argument is squarely based on utilitarian principles. A similar argument is expressed by Dominic Wilkinson who suggests that when considering the decriminalisation of drugs we should ask – which is more harmful – regulated access or prohibition? See http://www.practicalethicsnews.com/practicalethics/2010/08/demedicalising-and-decriminalising-drugs.html#more . In what follows I will take a different approach as arguments such as the above use a blanket approach to harm. I will attempt to differentiate between various classes of people who are harmed by drug use.

I will take as the starting point of my argument Mill’s contention “that the only purpose for which power can be rightfully exercised over any member of a civilised community against his will, is to prevent harm to others. His own good, either physical or moral, is not sufficient” (1974, On Liberty and Other Essays. Oxford University Press (Oxfords Worlds Classics, page 69). Mill goes on to contend “each is the proper guardian of his own health, whether bodily or mental and spiritual. Mankind are greater gainers by suffering each to live as seems good to themselves, than by compelling each to live as seems good to the rest” (page 72). Mill would clearly have regarded any harm drug users do to themselves as something that should not be included in any of considerations of whether the government should decriminalise the use of drugs. I accept Mill is correct in his contention that each one of us is the proper guardian of our own health and the harm drugs do to the drug user should not be the concern of others. It follows the harm drug users do to themselves should not concern us when considering whether to decriminalise drug use. However drugs users not only harm themselves but harm others. I will now restrict my examination to the harm drug use does to others whilst ignoring any harm drug use does to the drug user. These others can be split into two classes. Firstly drug users harm people they do not personally know. I will class this harm as harm to society. Secondly they harm people they personally know, people they are in some relationship with. I will firstly consider the harm the drug users do to society and secondly the harm they do to those in a relationship with them.

Clearly drug use harms society. Muggings and robberies to finance drug taking and gangland turf wars do real harm. However the majority of this harm to society seems to occur because drugs are illegal. It follows if we were only to consider the harm done to society that we should decriminalise drug use in order to minimise this harm. Someone might argue that, besides harming society, drug users really only harm themselves. She might suggest drug users are lonely people who take drugs alone or in conjunction other drug users who they do not significantly harm due to their existing drug use. However her argument is unsound because such idealised drug users seldom exist in practice. Most drugs users live in some sort of relationship with others and one only has to consider wrecked relationships and blighted childhoods in order to see the harm drug use inflicts on others. It follows even if we accept Mill’s contention that “the only purpose for which power can be rightfully exercised over any member of a civilised community against his will, is to prevent harm to others” that in our considerations of whether to decriminalise the use of drugs we must consider the harm done to those in some sort of personal relationship with drug user.

Mill in formulating his argument believed the harm to others must be substantial to justifying curtailing someone’s liberty. For instance the harm others suffer because they don’t like drug takers taking drugs is not a substantial enough harm to count as a reason against the drug use. The question that must be answered is this. Is the harm done by drug users to those in some sort of relationship with them substantial enough to justify the continuing criminalisation of drugs? This is a difficult question to answer and I will try to address this problem by differentiating between two classes of people in a personal relationship with drug users. I will suggest provided it is possible for someone to end a relationship and with it any harm her partner’s actions inflict on her then we have no reason based on this harm to curtail his actions. Of course she may have good reasons to remonstrate, reason with or attempt to persuade him his actions are wrong, see Mill page 68. Consider for instance the situation in which the only harm a drug user’s habit does is to his partner. His partner may scold and berate him due to the harm his drug use does both to himself and her, I will assume she loves him, but she could always end the relationship and end the harm he does to her. My argument depends only on the fact that it is possible for the drug user’s partner to leave him and end the harm; it does not require that she must leave him and end the harm. Indeed in this context if she does not leave him she appears to be accepting the harm caused by her partner and this harm might be regarded to some degree as self inflicted. I have argued it is the criminalisation of drug use rather than drug use itself that damages society and that any harm done by the drug user to himself does not justify prohibiting drug use. I have further argued that any harm done to someone in a personal relationship with a drug user should not count against the decriminalisation of drugs provided she can end this relationship. However an objector whilst accepting the above might point out the domain in which my arguments are applicable is too small. She might point out that I must also consider personal relationships which the injured party cannot simply end.

The objector’s point is a sensible one and I accept it. If a drug user’s use harms people, who he is in a personal relationship with and this is a relationship which the injured parties cannot end in order to end the harm caused, does this mean we have a right to prohibit his drug use? I accept we do. My objector might now argue if I accept the above that I must also accept we should not decriminalise the use of drugs. She might point out the damage drug using parents do to their children to support her argument. I do not accept her argument. Alcohol is a drug. Drunken parents harm their children yet we do not criminalise the use of alcohol. It seems to me that, provided there is no major difference between the effects of alcohol and other drugs, we should either criminalise the use of alcohol or decriminalise the use of other drugs if our reasoning is to remain consistent. Let us assume there is no major difference between the excessive consumption of drugs and alcohol. If we were to prohibit the use of alcohol, to protect people who are in relationships which they cannot end, with abusive alcoholics we would deny many drinkers the right to drink who do no harm or if they do harm only harm themselves. At this point a utilitarian would do a calculation to maximise preferences, pleasure or some other perceived good in order to decide whether to criminalise the use of alcohol or decriminalise the use of other drugs. As I am considering theses issue by considering the idea of personal liberty such a position is not open to me. However at present drunks who abuse or neglect their children can be held accountable. They can be accused of child neglect or cruelty rather than alcohol addiction. It follows there is no need to prohibit alcohol use no need to criminalise the use of alcohol to protect the people who are in a personal relationship with an alcoholic even this is a relationship these people cannot end in order to end the harm caused. Moreover this same legislation helps protects people who are in a personal relationship with a drug user. It further follows the decriminalisation of drugs should not harm these people.

The above discussion leads me to two conclusions. Firstly if we accept Mill’s liberty principle then we should decriminalise the use of drugs. Perhaps if we do so we should also take extra special care to see vulnerable people are not abused or neglected, children in particular. The second conclusion which is more tentative and perhaps more interesting concerns the harm condition in Mill’s concept of liberty. Usually this harm condition is just taken to mean substantial harm but does not specify how substantial this harm must be to curtail liberty. I have suggested this harm condition does not apply to society in general. Mill believed it could not apply to society because he believed liberty could only benefit society. I suggested above the liberty of someone could only be restricted by the harm done to others in some sort of personal relationship with him. I then loosened this restriction. The above leads me to conclude secondly that someone’s liberty of action can only be restricted by the harm his action does to others in some sort of personal relationship with him and these others cannot end the relationship in order to end this harm.

Velleman, Guilt and Love

David Velleman defines guilt as anxiety about being in an indefensible position which means one might be cut off from social interaction. In this posting I will examine this definition. Freud says guilt is anxiety about being punished by the superego. Velleman thinks Freud is on roughly the right lines and seems to suggest that guilt might be connected to the loss of love of one’s conscience (1). I accept guilt is connected to the loss of love but will argue it is not connected to the loss of love of one’s conscience but rather to an inability to love oneself.

Velleman’s definition of guilt, as anxiety about social exclusion, means guilt is not necessarily concerned with morality. Intuitively guilt is not solely concerned with moral matters. If we accept the above it becomes difficult to differentiate between Velleman’s concepts of guilt and shame. Moreover accepting Velleman’s definition would mean excluding guilt from some situations in which we would intuitively feel the feeling of guilt would be appropriate. Because Velleman’s definition does not include these situations I will argue his definition is an inadequate one. My argument is much the same one as the one I employed in discussing his concept of shame; see Velleman and Shame 11/05/10. Let us consider someone on diet who secretly eats a lot of chocolates. Intuitively we feel such a person might feel guilty. Indeed it would seem be completely natural for us to say she has a guilty secret. However she need have no anxiety about social exclusion on account of her guilty secret. If it is accepted our dieter does indeed have cause to feel guilty then because Velleman’s definition of guilt fails to account for this his definition is an inadequate definition.

Even if our dieter is not in the danger of social exclusion due to her secret chocolate eating none the less I would suggest her position seems in some way to be indefensible. I would further suggest it might seem indefensible to her. What is indefensible in this context? Does Velleman’s suggestion that guilt is connected the loss of love of one’s conscience help us to understand what our dieter finds indefensible? In my previous posting I suggested shame might be simply seen as an unease or dissatisfaction with our sense of self as moral persons. My example of our dieter shows guilt is not simply restricted to moral matters. I believe Velleman is correct in connecting love and guilt. However I would not connect guilt to the loss of the love of one’s conscience as Velleman does. I would connect guilt to not loving oneself. As in previous postings I will accept Frankfurt’s position that love is ‘caring about’ when caring about is defined as someone persistently making herself vulnerable to losses and susceptible to benefits depending upon whether what she ‘cares about’ is diminished or enhanced (2). I will also accept Frankfurt is correct when he argues that here could not be a person whose self is of no importance to her (3). If something is important to me I must ‘care about’ it, I must love it, it follows if someone must be important to herself she must care about, love, herself to some degree. It is of course true persons need not totally care about themselves, indeed some people often talk of hating themselves, never the less I contend all persons must care about themselves to some degree. If the above is accepted guilt might be defined not as anxiety about social exclusion but rather as anxiety about being unable to truly love oneself. Such a definition might explain the secret chocolate eater’s guilt and as a result is a more complete definition than that of Velleman.

However even if we reject Velleman’s concept of guilt and accept my definition it does not follow that anxiety about being in an indefensible position with regard to society is unimportant. Such anxiety might explain why the secret chocolate eater worries about being unable to love herself. This anxiety might be explained in two ways. Firstly her anxiety may be due to the breaking some accepted social norms even if this breaking is unobservable and done in private. This anxiety might arise because she is breaking social norms which she personally accepts. Secondly her anxiety might arise as her actions are contrary to her image of herself and as a consequence of this image how she should act. This image would I suggest must be partly based on society’s expectations.

1. David Velleman, 2009, How We Get Along, Cambridge University Press, page 101)
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 90.

Prisoners serving Life Sentences and Assisted Suicide

In his posting on practical ethics Shlomit Harrosh connects the rights of death row inmates in certain states of the USA to choose the method of their execution and those of terminally ill patients choosing when to die, see Harrosh . Harrosh believes some personal autonomy is important even in the difficult circumstances of death row and that by choosing how to die a prisoner is to some limited degree choosing how to live as an expression of who he is and what he values as an autonomous agent.

“Like the choice of a last meal, the choice of method of execution is a final exercise in personal autonomy. Within limits, it gives prisoners the opportunity to choose the final experiences of their lives and express their values and preferences.”

Harrosh goes on to suggest that by choosing when to die terminally ill patients are making a similar choice.

“Terminally ill patients who choose voluntary euthanasia are similarly choosing how to live. The choice to hasten death is simply a means to an end: ensuring that their remaining time is lived according to their standards of a worthwhile life, expressing their values and preferences.”

Harrosh believes both of these rights have the same basis. He concludes if the right of death row inmates to choose between methods of their execution is permissible it follows that terminally ill patients have the right to choose when to die. I agree with Harrosh’s conclusion even though some might argue choosing when to die is not the same as choosing how to die.

The public at large appears to believe if some murderer, paedophile, terrorist or mass rapist attempts to commit suicide whilst in prison that no attempt should be made to prevent him doing so. In this posting I want to subject this common belief to some philosophical scrutiny. I will initially restrict my consideration to offenders who have committed terrible crimes which mean they will never be released from custody. In what follows offenders will specifically refer to those offenders who never be released from custody unless I specify otherwise. Harrosh makes a connection between the right of prisoners on death row to choose the method of their execution and the right of the terminally ill to choose when to die. I want to connect the right of terminally ill patients to choose when to die and a right of offenders to choose when to die. In what follows I will propose if terminally ill patients possess a right, to choose when to die, then so should these offenders. At the outset I must make it clear this is not an argument in support of capital punishment and that I personally do not believe in such punishment.

Do terminally ill patients have the right to choose when to die? Most people working in applied philosophy would accept this right and as a consequence I will only present a brief argument to support the right. Harrosh believes terminally ill patients have this right because they have the right to choose how to live their lives. I agree with Harrosh and would further argue these patients have the latter right because we should see such patients as the same sort of creatures as ourselves. Harry Frankfurt believes the intrinsic value of our autonomy is connected to the recognition of us by others as the kind of creature capable of determining its own destiny (1). Christine Korsgaard believes that by choosing we determine our identity (2).  If we accept that Frankfurt and Korsgaard’s views are correct then were we to deny terminally ill patients the right to choose when to die then we appear to be failing to accept these patients as the same sort of persons as ourselves. Someone might object this appearance is false and that we do see these patients as the same sort of persons as ourselves even if we deny them the right to choose when to die. He might argue we see ourselves as the sort of persons who can normally choose how to live our own lives but whom, if we became terminally ill, would have this choice restricted. I would counter argue due to our identity being so closely tied to our ability to choose if someone becomes terminally ill and his health is damaged and as a result his choices are restricted then even though he remains a person he is treated as a damaged person. I would suggest damaged health should not automatically mean a damaged person.  My objector might now argue my argument carries little weight because I have failed to adequately specify what I mean by a damaged person. I accept his argument. I suggested above our identity as persons is closely tied to our ability to choose. I would now suggest this ability to choose is not just the ability to make any choice but an ability to make an autonomous choice. The above means a damaged person might be defined as one whose capacity to make autonomous decisions has been damaged. I see no reason why most diseases or injuries must of necessity damage someone’s autonomy, diseases of or injuries to the brain might be exceptions. It follows even if disease or injury damages someone’s health that it does automatically damage him as a person and that we should continue treating him as such. Let it be accepted without any further argument that terminally ill patients do have the right to choose when to die because they have the right to choose how to live their lives. However, it is certainly not true that offenders have the same rights as the rest of us. My objector might now argue even if not all terminally ill patients are damaged persons all offenders are. I would reject such an argument as I have defined damaged persons as people whose capacity to make autonomous decisions has been damaged. I would suggest for the most part these offenders are damaged moral persons rather than damaged persons. Korsgaard would disagree with my suggestion. However I must accept some offenders are damaged persons unable to make autonomous decisions due to physiological or psychological conditions. I believe such offenders should be in secure mental health institutions such as Broadmoor rather than normal prisons. In the light of the above I will limit my discussion further to offenders in a normal prison who will never be released. I believe we should see such offenders as basically the same sort of people as ourselves, autonomous persons. Indeed history teaches us that evil is not usually perpetrated by people who are vastly different from ourselves. The Milligram Experiment further supports this point, see my previous posting. It follows even though these offenders have committed some terrible crimes they are not damaged as autonomous persons. The recognition of such offenders as undamaged autonomous persons means we should accept that they retain some choice about how to live their lives provided these choices will not harm others. For instance they may have the choice of attending religious services, which library books they choose or attending literacy classes. Should these limited choices include the right to choose to die? 

The answer to the above question depends on why we send offenders to prison. We send offenders to prison for three reasons; firstly to protect ourselves, secondly to punish the offender and lastly to rehabilitate him before he is released. We can disregard the last reason in this discussion. Prima facie if we should treat offenders as persons like ourselves then these offenders should retain all choices about how to live their lives provided these choices don’t endanger the public at large or detract from any punishment involved. Clearly giving offenders, who will never be released from prison, the right to choose when to die will not endanger us. The only question that remains to be answered is whether giving such offenders the right to choose to die detracts from their punishment? The answer to this question is not clear cut. Let it be accepted our sense of common humanity, our sense of seeing others as persons rather than monsters, does not permit us the option of cruel punishments such as simply putting an offender in a cell and metaphorically throwing away the key. It follows we must give offenders some quality of life including limited choices about how to live their lives. Provided prisoners must have some quality of life and enjoy certain limited choices it seems to me giving offenders the right to choose to die does not detract from their punishment. In the light of the above it might be concluded because the terminally ill have a right to choose when to die then so do offenders who will never be released from prison. 

I will now consider four objections to the above conclusion. This Blog is concerned with applied philosophy and someone might object it is pointless to give rights to people who will never use them. In particular it might be argued even if such offenders are the given the right to end their lives that in practice they will never avail themselves of this right. However there is some empirical evidence to show that at least some such offenders desire to die. Consider for instance consider the cases of Fred West the Gloucestershire builder who murdered 12 people and Harold Shipman who had 215 murders ascribed to him who both committed suicide in prison. Further evidence is provided by the need to place some prisoners on suicide watch.

Our objector might advance a second objection. He might point out there are a lot of mentally unstable people in prison and invariably among these people there will be some offenders who will never be released. Some of this mental instability may be due to depression. He then might argue if we give these offenders the right to choose to die rather than face life long imprisonment that some of those who exercise this option will not have made an autonomous choice due to depression. Indeed he might still further argue that if this option is made available some of offenders might feel they are being pressurised into taking it. If offenders are simply offered this choice then I believe this is a perfectly good argument. However I believe the argument loses its validity provided some safeguards are introduced. These safeguards must ensure that only offenders capable of making an autonomous decision are offered this choice. Our objector might now introduce a counter argument. He might argue these safeguards would involve counselling the offenders to ensure they can make an autonomous decision and that counselling is expensive. He might then proceed by arguing such offenders do not merit such expense and hence conclude these safeguards should not be introduced. In reply to this counter argument I would make two points. Firstly I would point out keeping people in prison for a lifetime is very expensive. If an offender who will never be released chooses to die his choice saves the taxpayer a great deal of money even if this choice includes expensive counselling. Secondly and I believe more importantly I would question whether these safeguards really need to include expensive counselling. For I would suggest all that is needed for a decision to be autonomous is that it is wholehearted and un-ambivalent. I would suggest if an offender expresses a constant un-ambivalent desire to die over a period of a few months, then his decision is an autonomous one and as such ought to be respected. Our objector might respond that my suggestion means a severally depressed offender might choose to die. In reply I would simply point out being depressed may well be the natural state of affairs for such an offender and suggest his depression does not preclude him from making an autonomous decision to die.

I have argued the reason why we should allow such offenders the right to die is based on their autonomy. I further argued that the basis of autonomy is seeing others as basically the same sort of persons as ourselves. However our objector might mount a third objection. He might argue if we allow these offenders the right to die then we are sending them a message that even at this basic level they are not the same sort of persons as ourselves. He might point out if we saw someone about to jump from a high building we would try and talk him down rather than simply pass by or tell him it’s his choice whether to jump or not. Indeed our objector might accuse us of double standards. The same objection might also be made if we allow terminally ill patients to choose when to die. I would reject his objection by arguing the difference in our attitudes is due to a difference in circumstances rather than a supposed difference in persons. An offender may be depressed and as I have suggested this depression may be both natural and normal considering his circumstances. His depression may be natural because his ongoing circumstances will not significantly change.  Someone about to jump from a building may also be depressed but his depression may not be natural and certainly need not be ongoing as his circumstances might change. These different circumstances mean the offender’s decision, subject to certain safeguards, is an autonomous one whilst the decision of the man about to jump from a high building may not be. An autonomous decision is a constant un-ambivalent decision. If we permit an offender to die we can be fairly certain his decision is an autonomous one because the prison authorities would require that he had expressed an un-ambivalent desire to die over a period of some months. The same requirement cannot be applied to someone about to commit suicide by jumping from a high building.

Our objector might now point out, offenders do not have a handy means of suicide readily available, and that if my conclusion is accepted the means of suicide would have to be approved of and brought into prison by the relevant authorities under strictly controlled conditions. I accept the objectors point. He might then use this point to raise a fourth objection to my conclusion. He might argue accepting my conclusion reintroduces capital punishment by the back door and once again accuse me of double standards due to my stated opposition to capital punishment. In reply I would reject his argument by firstly pointing out capital punishment is imposed and not simply optional. Secondly I am not proposing that the prison authorities kill these offenders even with the offender’s approval. I am proposing that the prison authorities make the means of suicide available to such offenders in controlled circumstances. These circumstances might be the much the same as those in the Dignitas clinic in Geneva. The person committing suicide in this clinic takes an anti sickness drug followed half an hour later by the overdose that kills him. In similar circumstances the offender would not have the drugs administered to him but would have them provided for him to take them himself. The fact that these drugs would be self administered would be an important additional safeguard of the offender’ autonomy, for often someone may believe he should take some course of action but when he tries to implement this action finds he cannot. For as Frankfurt points out someone’s decision only show what he intends to will and that when he attempts implement his decision he might be surprised to find out his decision does not in practice represent his will (3). In the above circumstances it would be hard to characterise the assisted suicide of an offender as capital punishment. Recently in Belgium Frank Van Den Bleeken who is serving a life sentence for rape and murder has been allowed by a court to undergo euthanasia, see bioedge . However I agree with Frankfurt that someone’s decision only show what he intends to will and in practice his decision may not always truly represent his will. For this reason whilst I believe offenders should have the right to commit suicide I would be doubtful whether this right should extend to euthanasia. 

In conclusion it appears all my imagined objector’s objections remain unconvincing. Finally I wish to consider an additional reason to that of the offender’s limited autonomy to support my position. Harrosh suggests if a prisoner on death row chooses a method of execution involving greater suffering that his choice can be a form of atonement. I would extend Harrosh’s suggestion further by suggesting if an offender chooses to die this might also be a form of atonement. In practice I don’t believe the need for atonement would be a major factor in decision making of most these offenders’ decisions to die. Rather it would be a desire to escape from life long imprisonment. None the less I believe it might be a factor in some such cases. Such atonement should be accepted not only because it is an expression of an offender’s limited autonomy but also because the acceptance of responsibility by the offender for his offences is something which may benefit the victim or victim’s relatives.

 

1. Harry Frankfurt, 1999, Necessity, Volition, and Love, Cambridge University Press, page 163.
2. Christine Korsgaard,  2009, Self-Constitution, Oxford University Press.
3. Frankfurt 1988, The Importance of What We Care About, Cambridge University Press, page 84