This blog is concerned with most topics in applied philosophy. In particular it is concerned with autonomy, love and other emotions. comments are most welcome
Monday, 23 March 2020
Stoicism, Covid-19 and Fortitude
Tuesday, 25 February 2020
Passive Aggression
In this posting I want to investigate the harm caused by
passive aggression. However there can also be some benefits of passive
aggression and these benefits must be weighed against any harm. In a previous
posting I argued that rudeness is harmful because it damages civil discourse. I
will attempt to show here that passive aggression is a form of rudeness and as
a result damages discourse. I will conclude that in most circumstance any
benefits of passive aggression are outweighed by the damage it does to civil
discourse. Before commencing my investigation I will examine what is meant by
passive aggression and the sort of circumstances in which it might be useful
and why.
What is meant by passive aggression? According to Rebecca
Roach passive aggression “is an expression of hostility,
resentment, contempt, etc, that are indirect.” Hostility, resentment and
contempt are all related to anger but it is important to note that acting with
passive aggression is not the same as expressing anger. Perhaps passive
aggression is a means of expressing repressed anger. Someone’s expression of
anger sometimes is also an attempt to elicit a response from those who have
angered him. Anger is connected to conflict. Passive aggression tries to avoid
conflict by limiting action. Pure anger is an emotion requiring no reflection
whilst the passive aggressor has to reflect on how he is going to react. Of
course passive aggression might be a manifestation of anger which is an emotion
but passive aggression remains a response to an emotion rather than the emotion
itself. Roach defines passive aggression as an expression of hostility,
resentment and contempt. It might then be argued that because hostility,
resentment and contempt are emotions that passive aggression is really a second
order emotion and that I am wrong to suggest otherwise. I would reject this
argument by suggesting even if hostility, resentment and contempt are emotion
passive aggression remains a reaction to these emotions rather than a higher
order emotion. Someone can be unemotional when reacting with passive
aggression. Lastly I will assume that passive aggression must be verbal because
otherwise sullenness could be regarded as a form of passive aggression. Some
might disagree with the last point but I won’t pursue it further here.
In what sort of circumstances is passive aggression usually
employed? I would suggest that these circumstances fall into two broad sets.
Firstly passive aggression is often employed when there is an asymmetry of
power making the expression of anger difficult.
For instance an office worker might employ passive aggression towards
his tyrannical boss. In these circumstances passive aggression is used because
civil discourse appears to be impossible. Secondly passive aggression might be
employed by someone who wishes to limit the damage full scale confrontation
might do to relationships but also wishes to register his displeasure about
someone else’s behaviour. These relationships are usually close relationships.
For instance Andrew’s partner Bernice fails to attend Andrew’s sister Clair’s
wedding due to some prior commitment. At a later date Clair says he can’t
attend the christening of Andrew and Bernice’s baby due to another prior
engagement. However had Bernice attended Clair’s wedding then Clair would have
been pleased to attend the christening. Clair wishes to register him
displeasure whilst at the same time avoiding a family row.
What harm does passive aggression cause? I will now argue
that passive aggression harms us in three ways. Firstly I have suggested above
that passive aggression is connected to hostility, resentment and contempt.
These are harmful emotions. By seeking to avoid conflict passive aggression
doesn’t address the issues underlying these emotions resulting in these issues
remaining unresolved and the associated harmful emotions retained to some
degree. It follows that passive aggression is harmful. Secondly it might be
argued that expressing anger sends a message to someone that something is
wrong. Repressed anger muddles the message. Expressing anger also focusses our
attention on addressing the wrong. Repressed would seem to be less effective in
doing so. However when there is an asymmetry of power even the expression
controlled anger is difficult. It might then be argued that in these
circumstance even if we can’t overtly express our anger that passive aggression
enables us to do so covertly. It follows that if passive aggression is the
covert expression of our underlying anger that expressing it might be of some
limited benefit to us by permitting some limited venting of our feelings. Thirdly
it might be argued that passive aggression might harm some people by causing a
sense of a loss of agency because they are unable to directly express
themselves. In response I would suggest that an asymmetry of power might causes
someone feel a loss of a sense of agency and that passive aggression might
benefit someone by restoring a limited sense of agency. Some sense of agency,
even a limited one, might benefit us more than simply adopting a sullen
attitude.
I have argued that passive aggression harms us because it
fails to address underlying issues which means we retain harmful emotions, it
fails to fully address the perceived wrong and damages agency. I then suggested
that the harm of passive aggression might be counterbalanced by allowing us to
covertly vent our anger leading to a reduction in the harmful emotions we are
experiencing and restore a limited sense of agency. It follows that on balance
passive aggression might benefit us. I now want to argue that passive
aggression harms us in another way by damaging civil discourse. First I will
argue that passive aggression is an indirect form of rudeness. Secondly I will
argue that rudeness damages discourse which causes harm.
What do we mean by rudeness? In a previous posting I
defined rudeness as someone knowingly not considering the needs, views and
wishes of another and at the time of this inconsideration the other being aware
of this inconsideration, see wooler.scottus
. If we adopt this definition then it isn’t immediately obvious than passive
aggression is a form of rudeness. After all passive aggression is triggered by
the views and wishes of others. However even if passive aggression is triggered
by the views and wishes of others it isn’t concerned with their needs. Passive
aggression is only concerned the views and wishes of others in a limited way,
it is only concerned with the perceived wrongness of these views. It follows
that someone expressing passive aggression fails to properly consider the
needs, views and wishes of the person the aggression is directed at. Must
someone at whom the aggression is aimed at be aware of the aggression? It might
be suggested that passive aggression is an indirect way of expressing
hostility, resentment and contempt those who the aggression is aimed need not
be aware of it. If this is so then passive aggression is simply a private
venting of feelings. I would reject the above suggestion as passive aggression
is only indirect aggression because the person expressing the aggression is
aware that the person at whom the aggression is aimed is aware of it. Passive
aggression is a way of making someone aware of your dissatisfaction with his
behaviour whilst at the same time trying to limit the damage done to your
relationship with him. In light of the above passive aggression seems to be a
form of rudeness.
I now want to briefly argue that rudeness harms someone by
damaging civil discourse. It might be argued that rudeness benefits the rude
person by enabling him to freely express his true feelings free from the
fetters of politeness. It might even be suggested that the free expression of
feelings means rudeness is connected to honesty, I would reject this second
suggestion because the focus of the rude person is partial and by knowingly
ignoring the views of others he might deprive himself of further knowledge of
the situation and increase the possibility of self-deception. However let us
accept that rudeness can benefit the rude person by simply allowing the
unfettered expression of his feelings. Unfortunately rudeness also involves an
inattention to the views of others and as a result damages discussion by
shifting the focus of our attention from the issues involved to the tone of the
discourse. Rudeness means we talk at each other rather than engage in a
meaningful civil discussion and fail to address the underlying long term
issues. Let us accept that civil discourse promotes the meaningful discussion
of difficult issues which benefits individuals. The pleasure of rudeness is
short lived whilst the resolution of difficult issues matters in the long term.
Issues that aren’t fully addressed can cause long term harm. It follows that
the short term pleasure of rudeness is outweighed by the long term damage it
does to individuals by a failure to address difficult issues. It further
follows that if passive aggression is a form of rudeness it harms us by
damaging discourse
It might be objected that in some circumstances civil
discourse isn’t possible. For instance if someone has a tyrannical employer
then he might be unable to engage in civil discourse about his grievances. In
other circumstances someone’s extreme sensitivity might make it difficult for
others to engage in meaningful discourse with him. In circumstances like these
the pleasure of passive aggression cannot be outweighed by the harm done to
civil discourse because civil discourse isn’t possible. Whilst being passively
aggressive makes no sense to the powerful it makes perfect sense to the
powerless. It follows that passive aggression might benefit some people in some
circumstances.
The above conclusion depends on the premise that in some
circumstances meaningful civil discourse is impossible. Let us accept this
premise. However even if we accept the premise if the above conclusion is to be
useful we must define these circumstance more rigidly. I argued above these
circumstances in which passive aggression might be useful fall into two broad
groups. Let us consider the first of these groups in which there is an
asymmetry of power. In a totalitarian regime such as Stalinist Russia discourse
about the regime’s policies is impossible and passive aggression might be
justified. Jokes at the regime’s expense might be regarded as a form of passive
aggression. However I would suggest that in most circumstances where there is
an asymmetry of power civil discourse isn’t impossible but merely difficult. I
would further suggest that just because civil discourse is difficult we
shouldn’t abandon it and fall back on passive aggression to relieve our
negative feelings. If we simply use passive aggression then we might be accused
of taking the easy option, mental laziness or being lacking in courage. We
might also be accused of failing to address the underlying issues which are the
cause our passive aggression. How might we engage in civil discourse when there
is an asymmetry of power? I would argue that this can be done in two ways.
Firstly we should ask those we are aggrieved with simply to confirm what we are
aggrieved about. This allows us to be sure our grievance is justified and may
also alert those who aggrieve us to the fact that we are aggrieved in a
non-confrontational way. Secondly we should ask those who aggrieve us why they
are acting this way. We ask them to justify their actions again in a
non-confrontational way. This might make those who aggrieve us reflect on their
actions. It might also give us reason to question our negative feelings. I have
argued elsewhere that such questioning can be repeated, see civil
discourse . However all conversations come to an end and if the
underlying issues cannot be resolved we should end the conversation by asking
the person who has aggrieved us does he really ‘mean that’. It follows in most
cases when there is an asymmetry of power civil discourse is possible even it
is difficult. It further follows that because passive aggression damages civil
discourse that we should try to avoid acting this way. Let us now consider the
second group of circumstances in which passive aggression is often employed.
These are when someone who wishes to limit the damage full scale confrontation
does to close relationships whilst at the same time registering him
displeasure. In these circumstances someone tries to limit the damage by
avoiding the full expression of his anger. However repressing anger doesn’t
eliminate it and it might manifest itself latter. I now want to argue that if
when we are aggrieved if we adopt the strategy outlined above of asking for
confirmation and then for further explanation then we shouldn’t do any greater
harm to relationships than we would by the use of passive aggression. Firstly
by simply asking someone to confirm something that aggrieves us might be
slightly annoying but doesn’t seem to be confrontational. Secondly asking
someone for an explanation might be confrontational to some degree but no more
so than employing passive aggression. It would appear that asking for
confirmation and explanation is no more confrontational than passive aggression
but has the additional benefit of addressing the underlying issues rather than
postponing discussion of them.
I have argued that passive aggression damages civil
discourse. I also argued that except in exceptional circumstances discourse is
possible when conducted carefully. I further argued that even if discourse is
difficult it is better to try and engage in meaningful discourse rather than
react with passive aggression because discourse helps resolve contentious
issues whilst passively aggressive merely postpones addressing them. Lastly I argued
that the use of passive aggression is a lazy way of dealing with contentious
issues. It follows that except in very limited circumstances we should avoid
the use of passive aggression.
Wednesday, 22 January 2020
Love me for a reason
Love is all around us, love matters to us and we value
loving and being loved, but why love matters so much to us isn’t immediately clear.
In this posting I want to offer a sketch of why love matters to us. Before
proceeding I must consider three question. Love has many variations, we can
have erotic love, parental love and affectionate love to name but a few. Are
these completely different types of love or have these variations all evolved
from a common basis or perhaps these apparently different types of love are in
reality different ways of expressing a general idea of love in different
domains?
According to Aristotle there are three types of love
erotic, philia and agape. If we accept Aristotle’s position then on first
appearance it would appear that there isn’t a single unified idea of love. According
to Aristotle erotic love is a passionate desire for another, usually a sexual
desire. Philia is more a fondness and appreciation of another and is important
in friendship. Agape refers to the love of God for man or man for God. However
it is still possible to argue that there is a unified concept of love. Firstly it
might be suggested that these types of love are in reality identical and that
the apparent differences in love might be due to the intensity of loving rather
than differences in type. Secondly it might be suggested that apparent differences
in love might be due to love being expressed differently in different domains.
It seems possible that a more modern version of agape might be that of
unconditional love of all. It follows that it is at least possible that there
is an underlying unified concept of love.
I now want to argue that there is indeed a unified
primitive concept of love. I will argue love isn’t just some concept that arose
recently or is limited to human beings. Let us that assume “caring about” is a
primitive form of loving. Animals can care about their offspring and if you
accept group selection, as Darwin did, then animals which care about their
offspring have an evolutionary advantage. It follows that a primitive type of love
has a very long history. However even if a plover’s behaviour when it pretends
to have a damaged wing in order to lure a predator away from its chicks is a
primitive form of love it isn’t what we usually mean by love. Perhaps Aristotle
was right after all and there are different types of love. I will now argue
that love has evolved some sort of structure rather than being differentiated
into different types. Let us accept us accept that many creatures including us
possess a primitive kind of love, the ability to “care about”. This basic form
of loving need have no affective or cognitive elements and might simply be
based on some on ancient neurochemical systems that evolved to serve our
ancestors' reproductive needs. It might be objected that such a basic system
isn’t what we mean by love. Love as we know it can’t be defined in such a basic
way. I accept my objectors point but my acceptance doesn’t mean we no longer
retain this basic system. Nature is parsimonious and doesn’t usually replace
ancient systems but adapts and modifies them to serve new purposes. It might
then be suggested that what we mean by love is this ancient primitive system of
“caring about” which has had its structure modified and built upon. It is hard
to see how such a simple structure could be modified so let us assume it has
been built upon. Firstly our primitive love has been expanded by our capacity
to feel empathy. Let us be clear what we mean by empathy. I don’t mean empathic
contagion such as that when one baby cries and another simply follows. I also don’t
mean the ability just to understand how another feels which can be exploited by
a sociopath. I mean having a disposition to feel as another feels. Secondly our
primitive love has been expanded by our increasing cognitive abilities. A bird
might only care for its chicks and perhaps its mate. Human beings increased
cognitive abilities enable them to see others as much the same as themselves
allowing them at the very least to question why they shouldn’t care about them
hence increasing love’s domain. Lastly our primitive love has been expanded by
the culture we live in. Let us accept that love can be regarded as an emotion.
According to Lisa Feldman Barrett,
“An emotion is your brain’s creation of what your bodily
sensations mean, in relation to what is going on around you in the world.” (1)
If we accept Feldman Barrett’s position then love depends
on concepts and our concepts are partly constructed by the culture we live in.
Her position can be supported by noticing that the dominant view of love in
culture has changed over the last hundred and fifty years from romantic love to
parental love. Let us accept that what we mean by love is our ancient capacity
to “care about” which has been built on and had its domain extended by our
capacity for empathy, our increased cognitive abilities and the culture we
inhabit.
Let us now consider why we value love as outlined above. We
can care about both loving and being loved. I now want to argue that loving is
more important than being loved. The above seems counterintuitive. However we
can imagine someone who isn’t loved but loves someone or something living a
meaningful even if somewhat unhappy life. We can’t imagine someone living a
meaningful life if she doesn’t care about anything at all. Let us assume that
we must “care about” our ideals. According to Frankfurt having ideals, “caring
about” or loving is essential to being a person.
“He can make whatever decision he likes and shape his will
as he pleases. This does not mean that his will is free. It only means that his
will is anarchic, moved by mere impulse and inclination. For a person without
ideals, there are no volitional laws he has bound himself to respect and to
which he unconditionally submits. He has no inviolable boundaries. Thus he is
amorphous with no fixed shape or identity.” (2)
If we accept the above then we should value loving firstly because
by loving we make ourselves into persons. Secondly what we love defines what
sort of persons we are. On a somewhat speculative note it might be suggested
children keep teddy for reasons of love. Teddy bears can’t love children so
perhaps children keep bears because of their need to love. I have also suggested
elsewhere that this need to love is one of the reasons some people keep pets,
see the philosopher's dog .
I have argued that it is more important to love than be loved.
Nonetheless to human beings and perhaps some other creatures such as dogs being
loved is also of major importance. To be loved means that a lover must care
about the interests of his loved one. Could someone be said to love another
person if he remained completely indifferent to the interests of that person?
It follows one reason we value being loved is because it advances our interests.
However our interests can be advanced by others acting from duty and doing so needn’t
involve love. Moreover even if most people want to be cared about they would nonetheless
regard simply being cared for as an incomplete form of love. Husbands, wives, romantic
partners, friends and children don’t want to be simply cared for in the way
someone cares about a pet, they want to be cared about because of the particular
people they are. It would appear that people want to be loved for a reason and
they want that reason to be based on the sort person they are, their
characteristics. Sven Nyholm expresses this want,
“Love is, in this way, a sort of confirmation that we are, as we might
put it, ‘lovable’ in the sense of being able to inspire or call forth such dispositions
in another (namely the lover).” (3)
A lover doesn’t love everyone but specific persons. What sort of specific qualities does a loved one need in order to create a disposition in his lover to love her? Prima Facie it might seem what creates such a disposition is the attributes the loved one possesses, for example someone might be loved because of her humour, tenacity and straight talking.
Unfortunately accepting the above raises three problems. First someone’s
loved one might be fungible. They can easily be replaced by someone else who
has the same attributes but to a greater degree or someone who has some
additional attributes. Using the above example above the loved one might be
replaced by someone who is funnier, has greater tenacity and whose conversation
is even more to the point. Or alternatively by someone who is just as funny, tenacious
and to the point but additionally is courageous. Nyholm seems to be suggesting
that someone want to be loveable because of certain attributes she possesses
but do we really love her or her attributes? If we love the attributes do we
really love the person at all? This echoes Platonic love with all its problems.
Of course it might be suggested that we
can’t separate a person from her attributes. A second problem arises if we love
someone for her attributes then we should also equally love someone else who
possesses identical attributes. Theoretically we could love a very large number
of people who possess these attributes. It might be argued that in practice we
don’t have the cognitive abilities to assess the attributes of a very large
number of people meaning that in practice we are only likely to love a subset of
the people who possess the same attributes. The number of people we can love
might also be limited by the Dunbar number. Nonetheless in practice we could
end up loving several people because they possess identical attributes. Of
course such a situation might be perfectly acceptable for the friends we go to
watch football with but does the same apply to romantic partners? Lastly do we
love our children because of their good qualities or simply because they are
our children? If we choose the first option then our love is conditional and I
would suggest that this would cause problems with childrearing.
Nonetheless in spite of the
above it is natural to see our children as possessing lovable qualities. However
more generally do we see these qualities as lovable prior to loving our loved
ones? If we don’t then perhaps we are labelling these qualities as lovable
partly in order to explain to ourselves why we love our loved ones. Our loved
ones don’t naturally possess lovable qualities we create them.
In the light of the above problems it might be suggested either that the
account of love I have outlined love above is an inadequate one and that it should
be replaced by a more adequate one or that there are different accounts of love
in different domains as proposed by Aristotle. I am reluctant to accept either
of these suggestions and will now give reasons for my reluctance. According to
Simon May love is an ancient emotion but that over the last hundred and fifty
years the dominant view of love has changed. Romantic love has been replaced by
love of our children, parental love (4). I have suggested above that far from
being a modern interpretation of what we mean by love that parental love forms
the basis of all other forms of love. Let us accept that parents caring about
their young offspring is a basic form of love. It is important to note caring
about isn’t equivalent to caring for, someone may care for another without
caring about him. Caring about means being vulnerable to the fate of the loved
one caring for doesn’t. I will now argue that this primitive form of love when
its domain is extended can account for our desire to be loved because of the specific
persons we are.
What are the reasons someone
has for loving us? It might be suggested that this question splits into two
further questions. First, what sort of reasons might someone have for coming to
love her loved one? Secondly what sort of reasons might have to continue loving
her loved one? It might be objected that the reasons are identical in both
situations. Accepting this objection means either that our original question
doesn’t really split into two as I have suggested or if it does the same
reasons satisfy both questions. Let us accept that the original question might
split into two. Someone might come to love her loved one because of his beauty
and years later continue loving him for another reason once this has faded. I
now want to argue that we need reasons to come to love someone but that once we
have done so we just continue loving her. We must have reason to come to love,
to bestow love, but that we don’t need reasons to continue loving. Once we come
to love someone we are simply satisfied with our love and we would need reasons
to come to stopping loving someone, becoming dissatisfied with our love. If we
accept the above then it is possible to explain why some people find it hard to
stop loving. For instance the mother of a paedophile might continue to love her
child in spite of the crimes he has committed. She came to love him because he
was her child and once her love was established she became satisfied with her
love.
What reasons do we have to
come to love someone? I would suggest one sort of reason is the relationship
between the lover and the loved one. A parent comes to love her child because
he is her child, a friend loves her friend because he is her friend and
romantic partners love each other because they are romantic partners. The fact
that parents love their own children rather than other children who are just as
cute, intelligent and charming seems to support the above. This suggestion is
based on Niko Kolodmy’s idea of love as a valuing relationship (5). These
reasons define the domain of love rather than love itself. It might be objected
that some prior relationship isn’t a necessary condition for coming to love a
loved one, one simply does it. Accepting the above raises the possibility of
love at first sight. It might be argued that the type of love I have outlined
above is unable to explain love at first sight. In response to this objection
it might be argued that love at first sight is illusory. However even if we
accept that love at first sight exists it can be explained by the type of love
outlined above. I have argued above that we have a need both to be loved and to
love. I argued above that we have a greater need to love than be loved. It
follows that the reason for love at first sight can be satisfied by our need to
love.
I have suggested that love was originally a simple emotion which has changed as we have evolved. It has been changed by our empathy, increased cognitive powers and we fact we live in a particular culture. I would now suggest that these changes have altered what we love, expanded the domain of our love, but haven’t changed how we love. I have also suggested that whilst we have reasons why we come to love someone we don’t have any reason to continue loving. Relationships give us reason to love someone but our love simply persists because we are satisfied with our love. If we accept the above what does this mean for Nyholm’s contention that we have a desire to be lovable. It certainly means we can’t be considered lovable because of some of the attributes we possess. But do we really want to be loved for our attributes? If we are wise and loved for our wisdom we would still want to be loved if we lost our wisdom. If we are loved for our caring we would still want to be loved when we become old have to be cared for rather than care for others. Perhaps we simply want to be loved rather than loved for some of our attributes. We simply want to be loved rather than loved for a reason. Accepting the above means there are reasons why we come to be loved but no reasons our continuing to be loved. We come to be loved because of we are the children of someone, the parent of a child or simply a friend. Accepting the above also helps explain why the parents of severely handicapped child love and regard him as irreplaceable even if he possesses few lovable properties. Perhaps we should be grateful for being loved and the benefits it brings.
- Barrett, Lisa Feldman, 2017, How Emotions Are Made: The Secret Life of the Brain, Pan Macmillan, page 30
- Harry Frankfurt, 1999 Necessity, Volition, and Love. Cambridge University Press. Page 114
- Sven Nyholm,‘Love troubles: Human attachment and biomedical enhancements’, Journal of Applied Philosophy, 32, 2 (2015): 190–2
- Simon May,2019, Love, a New Understanding of an Ancient Emotion, Oxford University Press, page 21[js1]
- Niko Kolodny, 2003, Love as Valuing a Relationship, The Philosophical
Review, Vol. 112(2).
Thursday, 28 November 2019
Civil Discourse
- Amy Olberding, 2019, The Wrongness of Rudeness, Oxford University Press
Wednesday, 23 October 2019
The Doctrine of Informed Consent and Respect for Autonomy
In this posting I want to examine the relationship, if any,
between the doctrine of informed consent and respect for autonomy. In doing so
I will try to answer three important questions. Firstly is the doctrine of
informed consent based on respecting autonomy or is it a sui generis doctrine? The
fact we talk about a doctrine of informed consent seems to suggest the latter. Secondly
if informed consent isn’t based on respecting autonomy should it be so based?
Lastly if informed consent is based on respecting autonomy what type autonomy
should that be?
Is informed consent based on respecting patient autonomy? According
to Charles Foster the doctrine of informed consent is in a mess.
“Informed consent, in practice, is a bad joke. It’s a
notion created by lawyers, and like many such notions it bears little
relationship to the concerns that real humans have when they’re left to
themselves, but it creates many artificial, lucrative, and expensive concerns.”
Practical
Ethics
Let us accept that the principles underlying informed
consent are unclear. Let us try to start understanding these underlying
principles by examining the process of informed consent in practice. When
taking informed consent a patient’s doctors propose some form of treatment and
provide the patient with the information he needs in order to make a good decision.
The patient then agrees or refuses to agree to this treatment. What is the
purpose of this process? The purpose of the agreement part of this process
seems clear. The agreement part prevents the patient being treated against his
will and his doctors from being accused of assault. The purpose of the
information part is different. The purpose of this part is to enable patients
to make good decisions. What exactly do we mean by a good decision? A decision
which is in the patient’s best interests or an autonomous decision? In a
medical setting a decision which is in a patient’s best interests is one which minimises
harm to the patient, maintains or
improves his physiological health. The amputation of a patient’s gangrenous leg
would be an example of acting in a patient’s best interests by minimising harm.
The provision of drugs to control a patient’s blood pressure would be an
example of acting in a patient’s best interests by maintaining his physical
health. A kidney transplant would be an example of improving a patient’s
health. Autonomy is concerned with self-government and very roughly speaking an
autonomous decision is one by which someone governs himself. However
self-government is simply governing oneself and need not always be good
government. We can govern ourselves badly. Let us assume that a patient simply
wants to accept his doctors’ judgement about his treatment and doesn’t want to
receive any additional information. Intuitively such a decision can be seen as
a decision by which he governs himself and as a result is an autonomous
decision for after all we can simply choose to follow our lawyer’s advice and
most would regard such a decision as autonomous. However under The General
Medical Council’s proposed guidelines such a decision might not be seen as a
valid informed consent decision.
“If, after discussion, a patient
insists that they don’t want even this basic information, you must explain the
potential consequences of them not having it. This might include being unable
to proceed if you are not confident that their consent would be valid, or if
you are not confident that the proposed course of action would be beneficial to
the patient overall.” (1)
In the light of the above it
would appear that The General Medical Council’s guidelines are not really based
on respecting autonomy and the purpose of providing information when taking
informed consent is to enable patients make decisions which are in their best
interests.
It might be objected that I have
only briefly sketched a certain account of autonomy and that a different
account might mean that the doctrine of informed consent could be based on respect
for autonomy. After all in my brief account the patient in my example above who
fully trusted his doctors to make a decision on his behalf might wake up to unexpectedly
find himself with only one leg. It might be suggested such a decision isn’t an
autonomous one and that we should adopt a more substantive account. For the
sake of argument let us assume an autonomous decision must be one that concurs
with some generally accepted set of norms. If these norms are to be generally
accepted then they must concern what is good for people. Autonomous decisions become
linked to good decisions. An autonomous decision must be a good
decision and a bad decision cannot be an autonomous one. I now want to argue against
accepting such a substantive account of autonomy. If an autonomous decision
must be a good decision because it must concur with some accepted norms then it
might be questioned whether such an account of autonomy is really doing any useful
work. A substantive account of autonomy puts itself out of business because we
only need to consider good and bad decisions. We don’t need to consider
autonomous decisions at all. Using a substantive account of autonomy an
autonomous decision must of necessity be a good decision according to some
accepted norms whilst on a content neutral account of autonomy an autonomous
decision can be a bad decision. Of course it is preferable that an autonomous
decision, using a content neutral account of autonomy, is a good decision which
benefits the decision maker but the purpose of respecting autonomy remains
simply to respect the decision maker as a person and the actual decision
doesn’t of necessity need to be a good one. If we accept the above then we have
two options. Firstly we could abandon the pretence that underlying the doctrine
of informed consent is respect for autonomy or secondly we could accept that underlying
the doctrine of informed consent is respect for a content neutral or primitive
account of autonomy and modify the doctrine accordingly.
If we accept the above then there is not only a difference
in complexity between substantive and primitive accounts of autonomy but more
importantly these different accounts have a different focus. A substantive
account focusses on respecting good decisions, a primitive account focusses
respecting persons by simply accepting their decisions. Adopting a primitive
account requires adopting a certain degree of humility. Let us accept that if
the concept of autonomy is to remain a relevant one that it must be a primitive
or content neutral concept based on respecting persons. Such a concept might be
classed as a Millian concept. In the rest of this posting ‘autonomy’ will refer
to such a concept. Let us also accept the first of the above options that the
doctrine of informed consent is a doctrine in its own right and isn’t based on
respect for autonomy. The informed consent process starts with a patient’s
doctors proposing a course of treatment which they believe to be in his best
interests, the patient then consents or refuses to consent to the proposed
treatment. I argued above that the purpose of informed consent is to get a patient
to consent to treatment which his doctors believe to be in his best interests.
In almost all cases the patient simply consents and no problems arise. What is
interesting are cases in which the patient refuses to consent. In these cases according
to the doctrine of informed consent a patient’s doctors must be sure, or take
steps to ensure, that the patient knows the consequences of his actions. However
let us assume that the patient maintains his refusal of consent. By what
standards is his competence to refuse treatment measured by and how is it assessed?
If someone takes a driving test his competence to drive is based on his actual
driving. This is not true when assessing someone’s ability to give informed
consent. Someone’s competence to give informed consent isn’t based on his
actual decisions. His decision might of course trigger a competence assessment
but his competence isn’t dependent on his actual decision. Someone’s
competence to give informed consent is based on his ability to make good
decisions based on his best interests. I would suggest that someone who has the
ability to make good decisions based on his best interests is self-governing,
is autonomous.
As mentioned above the purpose of a driving test is to
measure someone’s competence to drive and the criteria by which his competence
is measured is by his actual driving. The same isn’t true of informed consent.
I have argued above that the purpose of informed consent is to enable patients
to make good decisions. I have further argued above that the way in which a
patient’s competence to make good decisions is assessed is by his ability to
make autonomous decisions. Such a mismatch creates problems and perhaps is one
of the reasons why the doctrine of informed consent is in a mess. Two solutions
might be suggested to remedy this mismatch. First the purpose of informed
consent should be to enable a patient to make a good decision in particular
circumstances and the patient’s competence should be assessed by his ability to
make a good decision in these circumstances. Secondly the purpose of informed
consent is to enable a patient to make an autonomous decisions and his competence
to do so should be assessed by his ability to make an autonomous decision.
Let us consider the first of these options. Let us accept
that a good decision is one that is in the decision maker’s best interests and
that a decision is a competent one only if the decision is in the decision
maker’s best interests. Clearly if someone makes a decision to do something
which he believes isn’t in his best interests then he isn’t making a good
decision. If a patient’s competence depends on him making a good decision then
he is incompetent. Perhaps he is paralysed by fear. However in practice most
people make decisions which they believe to be in their best interests.
Moreover in a medical setting there is usually agreement between the patient
and his doctors about what these best interests are. Unfortunately in a few
cases in which there might be disagreement about what is in a patient’s best
interests. Let us accept that a patient who makes a decision which he believes
to be in his best interests, but which is generally believed not to be in his
medical interests by his doctors, is making an incompetent decision. In
practice if a child or cognitively challenged adult makes a decision which
others believe isn’t in his best interests his competence might be questioned
and he might be treated against his will. Unfortunately if a competent decision
must be a good decision then the same considerations would seem to apply to all
patients. Accepting the above would mean that if any patient makes a decision
which is generally regarded as not being his best interests then his decision
is an incompetent one. In these circumstances the patient’s doctors might be
accused of paternalism or even epistemic arrogance. Fortunately in most cases a
patient’s medical best interests and what the patient believes are his overall
best interests concur. However this isn’t true in all cases. In cases in which
these interests don’t concur do we insist that a competent decision is based on
a patient’s best medical interests or what he believes to be in his overall
best interests? Practical considerations and the need to avoid the charge of
paternalism suggest that we should choose the second option. However if we
accept that a patient is making a competent decision when it concurs with what
he believes are in his overall best interests we are back to assessing a
patient’s competence to make a good decision by assessing his ability to make
an autonomous one and the above mismatch remains unresolved.
The above difficulties suggest
that we should choose the second option. The purpose of informed consent should
be to enable patients to make autonomous decisions about their treatment and that
any competence assessment should be based on their ability to make autonomous
decisions. This provides an answer to the second of my three initial questions.
Informed consent should be based on respect for patient autonomy. Moreover if a
substantive account of autonomy makes itself redundant as I have argued above
the type of autonomy underlying informed consent must be a primitive or
Milliian account. This answers the third of my three initial questions. Accepting
this option has consequences for the amount of information which needs to be
supplied to patients when taking informed consent. In the past under the
doctrine of informed consent a patient’s doctors determined what risks the
patient should be made aware of. However the Montgomery ruling Montgomery
ruling stated that a patient’s doctors must ensure that the patient
is aware of any and all the risks involved. If patients are to make informed
consent decisions based on respect for autonomy they don’t always need to be
aware of any and all the risks and the Montgomery ruling seems to suggest that
informed consent shouldn’t be based on respect for a primitive account of
autonomy. However if we accept that if an account of autonomy is to remain a
meaningful account that it must be a primitive account then if informed consent
is based on respect for autonomy it must
be based on a primitive account. Accepting the above means that a patient’s
doctors should have a dialogue with him about any suggested medical procedure.
How this dialogue proceeds shouldn’t be preordained by some doctrine but driven
by the patient’s needs. In most cases this will include informing him about any
major risks and life changes he faces. However some patients might need less or
more information in order to make an autonomous decision. As mentioned above an
autonomous agent can make an autonomous decision to trust the advice of his lawyer or financial advisor.
If someone is non-autonomous someone else might be given power of attorney to
act on his behalf. Are doctors any less trustworthy than lawyers or financial
advisors? It would seem to me they aren’t. 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? Provided
the patient isn’t incapacitated by fear it isn’t. It follows if informed
consent is based on respect for autonomy that a patient should be able to make
a competent decision simply to take his doctors’ advice. Other patients might
need more information than is usually supplied in order to make an autonomous
consent decision. Doctors should make it clear that they are willing to supply
more information when this is requested. For instance it might matter greatly
to a Jehovah’s witness whether there would be any possibility of a blood transfusion
however remote this possibility might be.
It might be objected that I
have already introduced an example which shows that it would be absurd to base
the doctrine of informed consent on a non-substantive or Millian account of
autonomy. Let us agree that if we accept such an account that a patient can
make a competent decision simply to trust his doctor. Let us recall the patient
with the gangrenous leg. Let us assume that this patient simply wants to trust
his doctor and refuses to listen to any information provided. He wakes up and
unexpectedly finds he has only one leg. Such a scenario seems absurd. Perhaps
then the basis of informed consent should be a substantive account or the
doctrine of informed consent should be a self-contained doctrine. Let us assume
the patient still wants to simply trust his doctors and refuses to listen to
any information concerning his procedure. Should he should be forced to listen
to brief details connected to his proposed treatment? Do doctors really want to
force someone to listen? Is it possible to force someone to listen and digest
information? Should he be left to die? In this situation it seems more likely
that the patient would be judged as incompetent. He would then be treated in
accordance with his best interests and his leg removed. He wakes up with only
one leg. In this case adopting a substantive account of autonomy or considering
the doctrine of informed consent as a sui generis doctrine changes nothing. It
follows that whilst adopting a non-substantive might lead to some highly
undesirable consequences in a few rare cases that it doesn’t lead absurd ones.
- Supporting patient choices about health and
care: Draft Guidance for consultation, GMC, 2019, [33]-[35]
Thursday, 26 September 2019
Lying and Autonomy
We live in a world surrounded by fake news and lies. According to Terry Pratchett in the Truth “A lie can run round the world before the truth has got its boots on.” However even if lies sometimes spread more easily than the truth, perhaps in part because they are more palatable and we want to believe them, in the long term the truth matters because the truth has persistence which lies don’t. Perhaps the dwindling number of climate change deniers supports the above. Are there any circumstances in which lying is beneficial? Stephen Rainey writing in practicalethics suggests that some lies “can also be a kindness, when the truth might serve no good”. Let us accept that in most circumstances lying damages both individuals by depriving them of the truth and trust. Nonetheless is Rainey correct when he suggests some lies might be beneficial in some circumstance? For instance might a government be acting beneficently if it lied about the harm done by the coronavirus to prevent panic? The fact that lying hasn’t been eliminated from human culture over time suggests it isn’t harmful in all circumstances. In this posting I want to examine what these circumstances might be. It might be thought that this is merely an interesting rather than important question, however in seeking to answer this question raises a further question about the balance between acting beneficently and respecting autonomy. I will argue that if I lie to someone and even if my lie benefits him that I also fail to respect him by failing to respect his autonomy.
Most people have no problems with defining a lie. The definition I
shall adopt here is that of Sam Harris
“To lie is to intentionally mislead others when they expect honest
communication.” lying
Lies so defined can explicit when liars intentionally give someone false information. Lies can also be acts of omission when the liar intentionally withholds information others expect him to provide. Perhaps passive aggression can be a form of lying if it involves withholding information. Liars can be practised by individuals, institutions or even governments.
Let us now consider whether it is ever acceptable to lie for beneficent reasons. Because lying is so prevalent our intuitions suggest that it is. Everyday examples seem to confirm our intuitions. For instance the mother who lies to her child by saying she has no money left when her child demands a second ice cream. Someone who lies to his partner about a surprise party. A government which lies to its citizens about the seriousness of some disease outbreak, such as that caused by the coronavirus, in order to prevent mass panic. Nonetheless as Harris points out we need to be extremely cautious about our intuitions. Firstly we must be sure about our motives being really beneficent. Is the mother above really worried about her child becoming obese or simply taking an easy option? Secondly we must be careful not to damage trust. The government above might avert mass panic but in the future its pronouncements on health matters might not be so readily trusted. If a lie cannot be maintained then it is better not to lie at all in order to retain trust. The Chinese government’s attempt to suppress the full extent of the coronavirus outbreak in Wuhan seems to support the above. However let us accept that there are at least some cases in which we might lie for beneficent reasons in which our motives are clear and we don’t damage trust. For instance it would be perfectly acceptable to lie to a stalker carrying a knife about the whereabouts of his ex-girlfriend.
Let us accept that in certain circumstances we can act beneficently by lying, telling white lies. Let us further accept that in some of these circumstances trust isn’t damaged. In such circumstances is Rainey correct when he suggests that lying might be an act of kindness? It certainly seems that because we are behaving beneficently that our actions might be classed as acts of kindness. However I now want to argue even if our lies serve a beneficent purpose and can be classed as acts of kindness that nonetheless it is almost always wrong to lie. Most pet owners are kind to their pets and act beneficently towards them but most people don’t want to be treated in the same way as pets however kindly. They want to be recognised as the sort of creatures who can make their own decisions. To be autonomous. Autonomous people govern themselves and this requires making decisions that matter to them. To make decisions that matters to someone requires information and lying deprives him of some of that information. It follows if we lie to someone we fail to respect his autonomy. Moreover if someone becomes aware of being lied to this lack of respect is a form of rudeness see the philosophy of rudeness.html or form of contempt. It further follows if we believe it is right to respect someone’s autonomy that we shouldn’t lie. It further follows if a government lies to or intentionally misleads the electorate over some issue such as Brexit that it not only deprives the electorate of some of the information needed to make a good decision it also shows a lack of respect for the electorate and perhaps even democracy itself. This lack of respect is similar to the lack of respect many colonialists showed for native people even if their motives were beneficent.
I now want to consider two objections to accepting the above conclusion. My first argument will be based on respecting autonomous persons and my second on respecting autonomous decisions. Firstly it might be objected that we should give precedence to acting beneficently over respecting autonomy and that sometimes lying is the only effective way to act in someone’s best interests. I now want to present two counter arguments against accepting the above. Let us accept that if we need to lie to someone in order to act in what we believe to be their best interests that there must be a clash between what we believe to be in their best interests and what they perceive to be in their best interests. It would appear that we believe we know better than the agent about what is in his best interests or should be in his best interests. In this situation we might be accused of epistemic arrogance. Secondly I would argue if we accept the above objection we don’t really understand what respect means. We can sometimes act beneficently towards someone but part time respect isn’t respect we can’t respect someone only some of the time. We can of course respect someone’s courage but not her wit. However when we respect her as a person we can’t respect her only some of the time. Part time respect just isn’t respect at all. It follows if we lie to someone in order to act beneficently we are not giving precedence to acting beneficently over respecting autonomy we are in reality failing to respect autonomy at all.
Now let us consider respecting autonomous decisions. Let accept to respect an autonomous decision means to accept it. It might be objected that any difference between respecting someone’s autonomous decisions and acting beneficently towards him is largely illusory. This objection depends on accepting a substantive account of autonomy in which autonomous decisions must concur with some accepted norms, autonomous decisions must be good decisions. Accepting such an account means that if we lie to someone, who is making a bad decision, in order to act beneficently towards him we are still respecting his autonomy. Bad decisions just aren’t autonomous decisions. However I am reluctant to accept a substantive account of autonomy. A substantive account has become more prominent recently largely in order to make respecting autonomy concur better with the doctrine of informed consent. Unfortunately as I have argued elsewhere a substantive account of autonomy puts itself out of business, see autonomy and toleration . If autonomous decisions must be good decisions in accord with some accepted norms then we can just consider good decisions and autonomy becomes a redundant concept. Of course if someone is to make an autonomous decision he mustn’t be misled or coerced but it follows that if autonomy is to remain a meaningful concept that we should adopt a primitive or Millian account. It further follows if autonomous decisions needn’t be good decisions that if we lie to a mature adult in order to protect him from a bad decision that we are failing to respect his autonomy. I would suggest accepting the above has implications for apology. Insincere apology is a form of lying. Perhaps in most circumstance apologising without really mean it is a form of white lying. Nonetheless such apologising just compounds any wrong by showing a lack of any real respect to the one lied to.
I have argued that it is always wrong to lie if this means we fail to respect someone’s autonomy even this is done for beneficent reasons. The question now arises is lying ever acceptable? If the mother of a young child who pesters her to buy another ice cream lies then her lie can be justified. The child isn’t autonomous yet and having two ice creams isn’t in her best interests. However caution is needed if we accept a primitive account of autonomy as I suggested above then slightly older children who are capable of making autonomous decisions and lying to them fails to respect their autonomy. Sam Harris uses an extreme example and asks should we lie even if with “Nazis at the door and Anne Frank is in the attic”. Of course we should lie. We should lie to protect Anne Frank and her autonomy. Lying to someone who is infringing someone else’s autonomy is perfectly acceptable, lying to protect autonomy is lying to respect autonomy.
What conclusions can be drawn from the above? Firstly we should never
lie if this means failing to respect autonomy even if our lies might be in what
we consider to be someone’s best interests. Even white lies are wrong. Secondly
if autonomy is to remain a meaningful concept we must always give precedence to
respecting autonomy over acting beneficently. Lastly lying to autonomous agents
can never be kind.
Wednesday, 21 August 2019
Different Degrees or Different Types of Rape?
Engaging with Robots
In an interesting paper Sven Nyholm considers some of the implications of controlling robots. I use the idea of control to ask a different...
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In his posting on practical ethics Shlomit Harrosh connects the rights of death row inmates in certain states of the USA to choose the met...
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According to Max Wind-Cowie shame should be liberated rather than legislated for. By this I take Wind-Cowie to mean that shame should pl...
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Kristjan Kristjansson argues too much attention is paid to promoting an individual’s self esteem and not enough to promoting his self res...