Soldiers and Beta Blockers

A large number of soldiers returning from active service in Iraq and Afghanistan suffer from PTSD (post traumatic stress disorder) and the military is interested in using beta blockers to help in alleviating this disorder. Beta blockers are drugs commonly used to treat some heart conditions such as angina. Elisa Hurley is concerned that the use of these drugs may have at least one bad consequence (1). In this posting I want examine whether we should share her concern.

Before I start my examination I must briefly summarise Hurley’s argument. Let it be accepted that post battle beta blockers help prevent the formation of painful emotional memories (PEM) in soldiers. Clearly soldiers are required to kill enemy combatants in battle. Equally clearly civilians are required to not kill others. If they do so they may be charged with murder. Hurley suggests this killing in battle separates soldiers from the normal moral community. Some might reject her suggestion but I will accept it here for the sake of argument. She proceeds to argue that after battle soldiers need to be integrated back into the moral community. She then further argues coming to terms with PEM is necessary for this re-integration. She then concludes a bad consequence, of beta blockers preventing the formation of PEM, is that they also prevent this re-integration. Hurley’s argument it seems to me depends on two implicit assumptions. Firstly any normal moral community depends on emotions to some degree. Secondly a moral community must be integrated. I will question these assumptions.

Not all moral systems have an affective component. Some believe that morality is objective and that our moral behaviour should be based on norms. Clearly if we accept a non-affective moral system PEM are not necessary for a soldier to successfully himself re-integrate into such a community. However in practice I would argue that the problems autistic people and sociopaths have in forming moral judgements strongly suggests that morality must include an affective element, see for instance Nichols (2). In what follows I will accept the first of Hurley’s implicit assumptions.

I will now turn to the second of Hurley’s implicit assumptions. It seems clear to me if Hurley assumes a soldier can be reintegrated into a moral community she must also implicitly assume that this community is in some way integrated. I will now give three reasons why I find the idea of such a fully integrated moral society improbable. Firstly I would simply point out we live in a multi-cultural society and that some of the norms people live by differ. I of course accept in any society people must share some norms. Secondly I would argue a fully integrated moral society might become something akin to an exclusive club. For instance a fully integrated society might exclude some people such as schizophrenics from membership. Intuitively provided schizophrenics take drugs to control their condition they ought to be full members of moral society. This intuition is supported in practice. Society holds schizophrenics responsible for their actions provided their schizophrenia is controlled. A further example might be provided by convicted prisoners who by their actions don’t seem to be fully integrated into moral society but whom nonetheless I would argue should nevertheless be regarded as members of moral society to some degree. These examples suggest that we live in a moral society which is not fully integrated. Lastly I would argue to talk too much of integration with respect to any moral society which includes an affective element would be a mistake because we experience emotions to a varying degree. For example Michael Slote believes it might be possible to base our moral society on empathic concern for others (3) . In such society women might be better at dealing with moral problems because of their greater capacity for empathy. It seems to me that such a society would not be fully integrated. It should of course be fully inclusive. For these reasons I would reject Hurley’s second implicit assumption that we live in an integrated moral society. I would suggest it would do better to consider the ability of people to be members of, to function, in a moral society rather than integration.

Hurley posed the question does the taking of beta blockers damage a soldier’s reintegration into society after battle. I have suggested above there is no such thing as a fully integrated moral society. I have further suggested that it would do better to consider the ability of people to function in a moral society than integration. If my suggestions are accepted then Hurley’s question needs to be refined. Her original question might be refined as follows; does the prescription of beta blockers to soldiers affect their ability to function in society? It seems clear many ex-soldiers find it hard to function in our everyday society. According to James Treadwell a lecturer in criminology at the University of Birmingham statistics suggest that between 3% and 10% of the British prison population are ex-forces personnel. Former soldiers the highest occupational culture claimed by prisoners, see Howard League for Penal Reform . This situation might be partly explained by the experience of soldiers witnessing or being party to traumatic events while in the services, and then later developing Post Traumatic Stress Disorder.

At one time most schizophrenics found it hard to function in society and many were confined to asylums. Recently advances in drugs have allowed most schizophrenics to function in society. The taking of these drugs does not damage a schizophrenic’s ability to function in society, indeed it makes it possible. Let it be accepted PEM prevents soldiers from fully functioning in society. Let it be further accepted beta blockers dampen a soldier’s PEM after battle and that this helps prevent PTSD. It might then be argued by analogy beta blockers do not damage soldiers’ ability to function in society but instead enhance it. For these reasons it might be thought that I am in favour of soldiers taking beta blockers provided these prevent PTSD. In practice I share Hurley’s concern about the use of these drugs

My concern is not about the successful re-integration of soldiers back into society after battle but rather the integration of a soldier’s life with his sense of self. Consider a non-swimmer who through no fault of his own fails to rescue a child from a swollen river. Let us assume the child drowns and this person is traumatised by memories of her screams. Let us further assume there is a drug which would erase all memories of this incident from this person’s mind and hence eliminate his trauma. Some might argue there is no problem here and that the trauma victim should take the drug. I am not so confident that there is no problem. If we accept there is no problem in the above case then perhaps we should also accept there would be no problem if we took the same drug every night when we are sleeping to erase all painful memories of the day before. Such a situation would be similar that which occurs in the film “Eternal Sunshine of the Spotless Mind”. In such a scenario some past events in a person’s life appear to have little effect on a person’s sense of self; the person loses some important connections to his personal history. I would suggest any disconnection between someone’s personal history and his sense of self is damaging for at least two reasons. Firstly anyone who has a sense of self with only a selective view of his history seems to have a diminished sense of self. I would further suggest such a diminished sense of self is damaging to the individual concerned. Secondly the idea of forgiveness can play an important part in our lives. For somebody to be forgiven he must accept responsibility for his actions. However if drugs dull or pervert his memories of his actions it is hard to see how he can genuinely accept such responsibility. The idea of forgiveness is particularly important in the context of war. After a war has ended there is often a need for a soldier to become reconciled with his former enemies. It would seem to me reconciliation is impossible without accurate recollection. For the above reasons I would suggest that the taking of beta blockers to dull a soldier’s painful memories post battle is damaging.

An objector might claim that nevertheless the damage done by PTSD to a soldier’s ability to function in society may well outweigh any damage to his sense of self or need for reconciliation. He might then use this claim to conclude that the use of beta blockers post battle is acceptable. I would reject such a claim. However even if the objectors claim is accepted I don’t think his conclusion automatically follows. It is clear that schizophrenics who take drugs to successfully control their condition can function in society. Indeed in most cases it seems probable that taking these drugs is the only way they can function in society. But the situation is different with regard to soldiers. Soldiers can be treated in different ways to relieve PTSD, cognitive therapy for instance. I would suggest, provided it is accepted that beta blockers damage the connection between a soldier’s sense of self and his history, that these drugs should not be used to treat PTSD.

1.  Elisa Hurley, 2010, Combat Trauma and the Moral Risks of Memory Manipulating Drugs, Journal of Applied Philosophy, 27(3)
2. ShaunNichols, 2004, Sentimental Rules, Oxford University Press.
3. Michael Slote, 2007, The Ethics of Care and Empathy, Routledge

What’s Wrong with Addiction to Video Games

In a posting on addiction Bennett Foddy points out whilst we universally regard addiction to tobacco as bad we are more ambivalent with regard to badness of addiction to video games, see http://blog.practicalethics.ox.ac.uk/. In this posting I want to examine what’s wrong with addiction to video games. Before I carry out this examination it is necessary to understand the different types of harm caused by addiction.

However if we are to understand the harm of addiction we must have a satisfactory definition of addiction which is both useful and captures our intuitions. Smoking is clearly addictive. Smoking is harmful because it damages our health. But overeating might also be regarded as harmful if it leads to obesity which damages our health. Yet we don’t regard all overeating as an addiction. I am of course not denying there are some cases of overeating which might be regarded as addiction. It follows physiological harm cannot be used in isolation to define addiction. Addiction might be defined as someone not having control over doing, taking or using something, to the point that it may be harmful, see www.nhs.uk/conditions/addictions .

Is the above definition a satisfactory definition? Let us assume someone is greedy and who because of his greed becomes obese damaging his health. Intuitively such a person need not be addicted to food, being a glutton is not the same as being an addict. However if we were to use the above definition a glutton would be classed as an addict. A glutton lacks control over food because he is greedy not because he is compelled to. Let us compare the case of a glutton with that of a smoker. In the case of a smoker as opposed to a glutton his lack of control is due to compulsion. A compulsion caused by nicotine. In the light of the above my initial definition of addiction might be modified as follows. Addiction is not having control due to some of compulsion over doing, taking or using something, to the point that it may be harmful. It is important at this point to be clear that not all compulsive behavior is a case of addiction. A mother may feel compelled to love her child, she may feel she can do no other, but nonetheless intuitively we would not regard her as addicted to either her child or love. It is of course possible for some people to become addicted to something that resembles love. However I believe it is impossible to become addicted to love for reasons I will give later.

Let us accept the above definition of addiction. There are two elements to this definition. Firstly the harm caused by the addiction and secondly the agent’s lack of control due to compulsion. I will examine the harm element first. The harm element of addiction might be physiological or psychological. I will now argue any physiological harm is not part of the harm peculiar to addiction. Let us once again consider our mother who feels naturally compelled to love her child. Let us assume this mother is a single mother who works long hours to enable her to care for her child to the best of her ability. As a result of these long hours she becomes overtired and harms her physiological health. As I have pointed out intuitively this mother is not an addict. Next let us consider two patients with damaged livers. Let us assume the physiological harm, the damage to the liver, is identical in both cases. Let us also assume that in the first case this damage is caused by disease and in the second by alcohol addiction. However it seems to me the harm caused to the alcoholic’s liver is not a peculiar type of harm connected to addiction. Viruses may cause identical damage to someone’s liver as that caused by alcohol abuse. We should of course try to eradicate addictions that cause physiological harm just as we should try and eradicate diseases which cause harm but the peculiar harm of addiction does not seem to be captured by the nature of any physiological harm.

I will now consider two forms of non-physiological harm that might be particular to addiction. Firstly a virtue ethicist might suggest that addiction damages someone’s ability to act as a moral agent. Traditionally the cardinal virtues are wisdom, justice, fortitude and temperance. Let us accept that an addict is not a temperate person. It follows provided you accept virtue ethics that someone’s addiction harms him by affecting his ability to act as a moral agent. However, even if one accepts virtue ethics, it does not seem to me that a lack of temperance is a peculiar harm to addicts. After all someone may be a temperate person before he suffers a stroke and become intemperate after.

I now want to consider a second non physiological harm that might be particular to addiction. I will now argue that addiction harms the addict by harming his status as an autonomous agent. Before making this argument I must make clear what I mean by autonomy. Autonomy is not just simply the ability to choose. A wanton may be free to choose whatsoever he wants but his will is anarchic, moved by mere impulse and inclination, see Frankfurt, 1999, Necessity, Volition and Love, Cambridge University Press. Intuitively someone whose will is moved simply by impulse and inclination is non-autonomous because autonomy involves self-government. Someone might argue that the exercise of autonomy involves an agent freely making rational choices rather than simply being free to choose. Adopting this definition means that because an addict’s choices are compelled by his addiction he cannot freely make rational choices. It then follows such an agent is unable to exercise his autonomy. Before we can decide whether we should accept either this definition or the conclusion that follows from it we must be sure about what is precisely meant by rational and freely. Firstly does rational mean logical or does rational simply mean the agent chooses what seems appropriate to him? I would suggest being autonomous means an agent must be free to choose what seems appropriate to him. Secondly does the freedom to choose involve freedom from both external and internal compulsions? I would suggest in this case being autonomous need only involve being free from external compulsions. For instance a devout Christian might feel compelled to profess his faith even if he is free from all external compulsions but few would regard his profession as non-autonomous. In the light of the above an autonomous decision might be more precisely defined as one in which is the agent’s decision is free from external compulsions and is one which feels appropriate to him. Clearly if this definition of autonomy is accepted it means any external compulsion such as drug addiction damages an agent’s ability to make autonomous choices.

Accepting the above definition means addiction damages an agent’s autonomy. Someone might now suggest that this definition is incomplete because it does not cover all forms of addiction. He might then point out the above definition appears to exclude some gamblers, compulsive consumer’s of pornography and many others as addicts. He might further point out that such intuitive addictions are caused by internal compulsions. I fully accept his point that some internal compulsions cause addiction. But I would reject his suggestion that the above definition is incomplete by arguing any agent would see such internal compulsions as inappropriate. A lover may feel compelled to love his beloved. However love is not an addiction because the lover identifies with his beloved and is satisfied by his compulsion. In other words he finds his love appropriate. On the other hand a compulsive consumer of pornography may feel compelled to consume pornography but is unlikely to totally identify himself with this consumption or be satisfied with it. He is in other words unlikely to feel his consumption is appropriate. It follows addictions caused by internal compulsions with which the agent fails to identify damage his ability to make autonomous choices. It does not follow my above definition of autonomy is incomplete. The damage addictions cause to an agent’s ability to make autonomous choices may vary. In some circumstances mild addiction may do very little damage to someone’s status as an autonomous agent. In others his addiction may mean he is unable to make decisions he identifies with and which satisfy him. In these circumstances he may suffer psychological harm and in extreme cases his sense of identity may be damaged.

I am now in a position to answer the question posed at the beginning of this posting, what is wrong with addiction to video games? I have argued the harm done by addiction may be physiological or psychological. The physiological damage of smoking is large and well documented. I have argued the psychological damage done to us by addiction is damage done to our autonomy. In the light of this I would suggest the psychological harm caused by addiction to tobacco is minimal. Smokers may prefer not to be a smoker but in all other respects they can exercise their autonomy in much the same way as non-smokers. The harm done by addiction to video games is different. The physiological damage done by addiction to video games would appear to be minimal in contrast to the damage smoking causes. However the psychological damage done to game’s addicts may be much larger than the minimal psychological damage caused by smoking. Games addicts may prefer to play these games less just as smokers may prefer not to smoke. However unlike smoking which causes minimal damage to the smoker’s autonomy the games addict’s ability to make autonomous decisions may also be limited by the time taken in the playing of these games. In addition some young children who become addicted to video games appear to become aggressive and this also may hinder their personal development and ability to make autonomous decisions, see for instance www.rcgd.isr.umich.edu/aggr/articles/... . Four conclusions follow from the above discussion. Firstly it might be concluded that the addictions of tobacco and video games cause different types of harm. Secondly the harm peculiar to addiction is harm to the agent as an autonomous agent. Thirdly the harm caused by addictive video games, though different, may be every bit as serious as that caused by smoking, perhaps even more serious. Lastly far from celebrating the addictiveness of certain games we should see this addictiveness as potentially very harmful.

Ecological Refugees

Cara Nine argues in that the Lockean proviso means a people who have their homeland destroyed, or made uninhabitable by ecological disaster, have a theoretical right to a new homeland. Global warming increases the probability of this happening. Nine argues that other states have a duty to provide for this homeland by ceding part of their sovereign territory (1). The Lockean proviso roughly means we have unlimited rights to any resource provided there is enough of this resource left for others. If however the resource becomes limited we must share this resource. For instance if people A have their water resources provided by river B and people X have equally good water resources provided by river Y then people A can have exclusive rights, to own, the water resources provided by river B. However according to the proviso if resources become scarce and river Y dries up people A cease to have exclusive rights to B and should share their water resources with people X. Does it follow from accepting the above that if people C lose their homeland due to ecological disaster that people D should cede part of their territory to people C? I will argue it does not.

Let it be accepted the Lockean proviso does mean other states should share some resources by offering food, shelter and a home to ecological refugees whose homeland has become uninhabitable. Does this sharing of resources extend to ceding the territory needed to permit these refugees to continue living in the same state albeit in a different place? Nine believes the Lockean proviso depends on a natural duty to promote the preservation of humankind (2). Let us assume these refugees come from a state which denies women equal rights and persecutes minorities. Allowing the creation of a similar state by ceding territory rather than simply aiding these refugees by offering food, shelter and a new home does not seem to promote the preservation of humankind. For instance should the territory of North Korea become uninhabitable due to radioactive fallout because of this regime’s nuclear policy it would be ridiculous for any country to cede land in order to allow the continuation of the current regime. It follows the Lockean proviso does not apply to all states. Nine argues provided we accept that if the people of current legitimate states have the right to self-determination then we should also accept the loss of a state’s territory does not destroy the right of its people to self-determination. In what follows I will only consider refugees who come from a legitimate state which permits self-determination. The question now becomes if a legitimate state which permits self-determination becomes uninhabitable due to ecological disaster then does the accepted sharing of resources required by the Lockean proviso extend to including the ceding of land by unaffected states to permit the refugees to live in the same state albeit in a different place?

I believe the answer to the above question is no for two reasons. Firstly if we are required to share water or food due to drought or famine then each of us as individuals should take a little less to help those suffering. However no such equitable solution is available if we were to try to resettle an entire state displaced by ecological disaster on new land. If we are to stick strictly to the Lockean proviso then all of the states unaffected by the disaster should cede a small part of their territory. In such a scenario it seems ridiculous to say the land ceded permits these refugees to live in the same state albeit in a different place. Clearly any state with a formerly unified territory which becomes split over a hundred far flung pieces of land is not the same state it was. If we accept the Lockean proviso must have an equitable solution then it cannot even theoretically apply states which are destroyed by ecological disaster.

Secondly let us assume that a more unified state might be created in one state from all the other states. I myself find the possibility of such a scenario as highly doubtful because of doubts as to whether the compensation could be equitable. However putting my doubts to one side and assuming we can equitably create such a state does the Lockean proviso give us a reason to create of such a state? I would argue in this revised scenario the Lockean proviso gives us no reason to do so. In her paper Nine assumes “that the loss of existing territorial domain due to ecological disaster does not eliminate this right of self-determination (3). I agree with Nine. However the loss of someone’s state and her subsequent resettlement in a different state which permits self-determination does not eliminate her right to self-determination. Nine’s argument seems to depend on a second assumption. Nine assumes the loss of someone’s state and her subsequent resettlement in a different state, albeit a state which permits self-determination, would damage her self-determination. Her argument seems to be based on the idea that the Lockean proviso requires that we must seek to repair this damage. This second assumption seems doubtful. It is of course true a refugee’s resettlement might alter the way her self-determination is expressed but alteration is not the same as damage. Indeed an altered way of self-determination may be an improvement. It seems the Lockean proviso only applies when resources are lost, become sparse or are damaged. The Lockean proviso does not apply to altered resources provided these resources are adequate. If the above is accepted then the Lockean proviso of course means accepting we have a duty to resettle ecological refugees. It does not follow from the above that this resettlement must include the ceding of territory by other states in order to permit these refugees to continue living in the same state albeit even if this state is in a different place. However even if Nine is mistaken about the need for states to cede territory a further important implication follows from the Lockean proviso. Provided the Lockean proviso involves restoring a right to self determination then a host state should grant full civic rights, such as the right to vote, to ecological refugees. Such a conclusion might be hard for many to accept in the Western world.

1. Cara Nine, 2010, Ecological Refugees, States Borders and the Lockean Proviso, Journal of Applied Philosophy; 27.
2. Nine, page 361.
3. Nine, page 359.

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)..