New Article on the Ethics, Philosophy and Practice of Person-centred Care and Shared Decision-making

One topic that's been part of my research activities for some years now is the ethical and philosophical implications of movements to transform health care practices towards more of what's often called a "patient-" or "person-centred" perspective, sharing clinical decisions with patients to a larger extent. I've been lucky to publish a few analytical works in this area in collaboration with, e.g., Lars Sandman and Daniela Cutas, which have attracted quite some attention, partly as an outcome of an ongoing research collaboration with the pediatric diabetes centre at the Sahlgrenska University Hospital, involving medicine, psychology, organisation, communication, care and human factors risk research, besides philosophy and ethics. Now I'm happy to announce the first of a number of planned articles coming out of empirical and multi-disciplinary investigations of communicative aspects of adolescent diabetes care undertaken in this project, authored by Anders Herlitz, myself, Marianne Törner and Gun Forsander. This article uses outtakes from a video-study of continuous doctor-patient consultation sessions forming the bulk of adolescent diabetes inpatient care (the rest is self-care performed by the younsters themselves) to question received assumptions in standard notion of what person-centredness and shared decision-making should involve, basing our arguments in received results from behavioural science and moral psychology. Instead, we advocates a new approach for patients who are at risk of suffering from weak decision capacities when performing self-care, while being in need of significant portions of such care. We also argue, that this new model exposes an hitherto ignored ethical tension within the person-centredness and shared decision-making advocacy, which needs to be adressed and managed for care to be defensible.

The article is entitled "The Counselling, Self-care, Adherence Approach to Person-centred Care and Shared Decision-making: Moral Psychology, Executive Autonomy and Ethics in Multi-dimensional Care Decisions", and has been accepted for publication in the journal Health Communication, to appear shortly. Meanwhile, interested parties may sample our final draft after the critical review that lead to acceptance (a so-called postprint), which has been made available here. In the pipeline are at least two more works based on this study, one of which on the role of parents and family in adolescent care, and one on conrete strategies to promote what in the article promoted here is called "robust decision capacity". In the future lingers further yet undecided things, as I am part of a group that has just received a nice bit of funding for continuing working on this topic.

There Is A Question of What We Should Say To Each Other, But It Has Nothing To Do With Limits To Freedom Of Speech

Following recent bloody events in Copenhagen and Paris, with two very similar coordinated deadly attacks against symbolic targets of freedom of speech and religion, there has ensued a completely confused public discussion on the limits of freedom of speech, not seldom implicitly suggesting that maybe the cartoonists at Chalie Hebdo and Lars Vilks (the Swedish artist who co-organised the debate on blasphemy and freedom of speech that was one of the targets of the Copenhagen shooting) had it coming to them. I note that the other two targets in both cases where symbols of Jewish religious practice – a kosher store and a synagogue, respectively – so, I suppose this regards these two as well (?).

The problem with these debates, however, is that they consistently confuse two completely separate normative issues about public communication of information and expressions:

1. What should one publicly communicate / express?

2. What should one be allowed to publicly communicate / express?

Somehow, it seems that almost all of the debaters who have found reason to raise the issue about what the butchered cartoonists in Charlie Hebdo have expressed with this or that picture (mostly in total ignorance of French satirical tradition and using heavily biased selections of images) and Lars Vilks' various actions as an artist and debater (especially the latter is far from nice, aligning himself with semi-fascist groupings, such as Dispatch International), think that this somehow actualises a question of the limits of the freedom of speech. Of course it does not. Not in any way whatsoever.

Freedom of speech is a legal institutional arrangement, whereby the state takes upon itself not to prosecute public communications / expressions (and to protect people from other people's attempts to prevent or punish such acts with unlawful means). All liberal democratic states have limits to these arrangements, but as a rule, these limits are only about independently defined crimes, such as libel or unlawful harassment or threat, or endangering public order, instigating riots, violence or other criminal acts of others. The issue of whether or not a public communication / expression is morally OK has nothing to do with it. Of course, these limits mean that all people enjoying this type of right have a reason to moderate their behaviour. Moreover, if they want to have as wide license as possible, they have reason to act in their public communication in ways not approaching the legal limits, e.g., in line with the classic example of J.S. Mill, avoiding inflammatory tones and biases in front of large masses of angry people in order not to stir up a riot, while still expressing criticism of some person of phenomenon. However, the issue of whether or not this expression is morally warranted or not is of no consequence at all for determining such limits of free speech.

Having said that, there is, of course, a moral question of how we, as individuals, should behave towards each other. We may have reasons to be considerate and to moderate our ways of communicating our opinions and feelings. In general, we have reason not to harm each other in any way, unless there are good reasons for it. This includes things such as upsetting others, making them feel disrespected and so on. In other words, when communicating publicly we all owe consideration to each other, in a way no different from other kinds of actions. And, of course, it holds equally for all agents (in proportion to the good and the damage they may do) – e.g., religious clerics, political campaigners, journalists, and so on. But, of course, this reason may be balanced by other ones, such as the value of undermining the authority of oppressing institutions and practices, of having victims of such institutions experiencing public support and so on, of promoting worthy causes, and so on. But, and here we are, none of this has anything at all to do with the limits of the freedom of speech. To demonstrate that beyond all doubt, we may only reflect on the simple fact that the moral considerations just described hold entirely independent of whether or not a state enforces freedom of speech or not. We would owe each other consideration also under the most oppressing of tyrannies.

So, in light of the obvious fact that the recent attacks are deliberately directed against the institution of the freedom of speech – they tell us: if you keep this freedom, we will murder you for using it – in light of this, raising the moral issue is completely out of place. Its only fathomable function can be to muddle the water as to the weight and importance of standing up for the freedom of speech. In effect, it unwittingly (I hope!) sides with the attackers. For, to side with the victims of the murders – to declare "Je Suis Charlie!" or whatever other expression of solidarity is – of course! – not to condone them as morally splendid people, but to take stand for the freedom of speech. The same holds, of course, for the victims of the attacks against religious Jewish targets – to side with their right to practice their religion without being murdered is not to side with or even like Judaism, or religion at all for that matter.

Brian Leiter: from Online Harrassment and Ridiculous Legal Threats to Simple False Flag Bullying

You thought it was over, but of course it was not. Like a dung beetle will eventually find its way to a suitable habitat, where it can enjoy itself royally, University of Chicago philosopher and law professor Brian Leiter is now finally finding his way home, resorting to slander and bullying, pure and simple rural redneck style. You may inform yourself about foregone events regarding professor Leiter's manners and manoeuvres here and through the links there provided.

Then move on to read the latest tidings on how the dear professor tries to get back at one of his self-perceived nemesis, Leigh Johnson: Here and here. Given the increasingly sorry figure Brian Leiter is in these ways making of himself, you may ask yourself if you might commit the mistake of the Black Mamba / Beatrix Kiddo judging the motivational features of Bill:

... and whether the dear professor commits that of Bill misjudging "Kiddo", of course.

As for myself, wise from my own experience of anonymous comments on matters Leiter (see first link above), there is at least no mystery with regard to the identity of "AnonUntenured", an observation of which I'm far from alone.

An Addendum Re Existential Risk Arguments: A Comment and A Fresh Application at Cern with Hawking and de Grass Tyson at the Centre

Related to my latest blog post on the existential risk argument and Pascal's Wager , there's a nice comment by Karim Jebari over at his otherwise mostly Swedish blog - illustrating, with reference to Sven Ove Hansson, how there are certainly openings for taking such risks seriously without basing one's reasoning on the simplistic (alternatively trivial) existential risk argument, and that one may thus avoid exposing oneself to the wager analogy (in full at least). This at the cost of the conclusion being less obvious and straightforward, such as the typical existential risk argument advocates otherwise seem to like them to be. Since in the original post I referred to exactly that being done – however mostly outside the devoted existential risk argument advocacy circles – in bioethics, environmental ethics and research ethics for a rather long time already, and since I have myself developed a rather complicated theory to exactly that effect, I'm of course more than happy to welcome such solutions, although it remains unclear what the devoted existential risk argument advocates (to which I do not count Karim or Sven Ove) would say about such more developed approaches to the area.

I'm even less certain if I should count cosmologist Stephen Hawking and astrophysicist Neil de Grass Tyson among the lot who embrace such willingness to nuance and complication. This due to their recent airings of Star Gate- and Armageddon-related worries due to the coming CERN reopening of the Large Hadron Collider (LHC) to perform an experiment to simulate – some say "recreate" – Big Bang.

Read it all here, and judge for yourself.

On a personal note, I do have to confess that, as I'm happy to have just been invited to talk about the existential risk matter at the Swedish Institute for Future Studies in April, and the experiments at CERN are scheduled to start in March, I rather hope they're wrong.

Why Aren't Existential Risk / Ultimate Harm Argument Advocates All Attending Mass?

An increasingly popular genre in the sort of applied philosophy and ethics of technology, which does not so much engage with actual technological development as more or less wild phantasies about possibly forthcoming ones is the notions of "existential risks" or "ultimate harms", or similar expressions. The theme is currently inspiring several research environments at world-leading universities, such as this one and this one (where you can find many links to other sources, articles, blog posts, and so on), and given quite a bit of space in recent scholarly literature on a topic often referred to as the ethics of emerging technology. Now, personally and academically, as it has actually proceeded, I have found much of this development being to a large extent a case of the emperor's new clothes. The fact that there are possible threats to human civilizations, the existence of humanity, life on earth or, at least, extended human well-being, is not exactly news, is it? Neither is there any kind of new insight that some of these are created by humans themselves. Also, it is not any sort of recent revelation that established moral ideas, or theories of rational decision making, may provide reason for avoiding or mitigating such threats. Rather, both these theses follow rather trivially from a great many well-established ethical and philosophical theories, and are well-known to do so since hundreds of years. Still, piece after piece is being produced in the existential risk genre making this out as some sort of recent finding, and exposing grand gestures at proving the point against more or less clearly defined straw-men.

At the same time, quite a bit of what is currently written on the topic strikes me as philosophically shallow. For instance, the notion that the eradication of the human species has to be a bad thing seems to be far from obvious from a philosophical point of view - this would depend on such things as the source of the value of specifically human existence, the manner of the imagined extinction (it certainly does not have to involve any sort of carnage or catastrophe), and what might possibly come instead of humanity or currently known life when extinct and how that is to be valued. Similarly, it is a very common step in the typical existential risk line to jump rather immediately from the proposition of such a risk to the suggestion that substantial (indeed, massive) resources should be spent on its prevention, mitigation or management. This goes for everything from imagined large scale geo-engineering solutions to environmental problems, dreams of outer space migration, to so-called human enhancement to adapt people to be able to handle otherwise massive threats in a better way. At the same time, the advocates of the existential risk line of thought also urges caution in the application of new hitherto unexplored technology, such as synthetic biology or (if it ever comes to appear) "real" A.I. and android technology. However, also there, the angle of analysis is often restricted to this very call, typically ignoring the already since long ongoing debates in the ethics of technology, bioethics, environmental ethics, et cetera, where the issue of how much of and what sort of such caution may be warranted in light of various good aspects of different the technologies considered. And, to be frank, this simplification seems to be the only thing that is special with the existential risk argument advocacy: the idea that the mere possibility of a catastrophic scenario justifies substantial sacrifices, without having to complicate things by pondering alternative uses of resources.

Now, this kind of argument, is (or should be) well-known to anyone with a philosophical education, since it seems to share the basic form of the philosophical classic known as Pascal's Wager. In this argument, French enlightenment philosopher and mathematician, Blaise Pascal offered a "proof" of the rationality of believing in God (the sort of God found in abrahamitic monotheistic religion, that is), based on the possible consequences of belief or non-belief, given the truth or falsity of the belief. You can explore the details of Pascal's argument, but the basic idea is that in the face of the immense consequences of belief and non-belief if God exists (eternal salvation vs. eternal damnation), it is rational to bet on the existence of God, no matter what theoretical or other evidence for the truth of this belief exists and no matter the probability of this truth. It seems to me that the typical existential risk argument advocacy subscribes to a very similar logic. For instance, the standard line to defend that resources should be spent on probing and (maybe) facilitating), e.g., possible extraterrestial migration for humanity, seems to have the following form:

1) Technology T might possibly prevent/mitigate existential risk, E

2) It would be really, really, very, very bad if E was to be actualised

3) Therefore: If E was otherwise to be actualised, it would be really, really, very, very good if E was prevented

4) Therefore: If E was otherwise to be actualised, it would be really, really, very, very good if we had access to a workable T

5) Therefore: there are good reasons to spend substantial resources on probing and (maybe, if that turns out to be possible) facilitating a workable T

That is, what drives the argument is the (mere) possibility of a massively significant outcome, and the (mere) possibility of a way to prevent that particular outcome, thus doing masses of good. Now, I'm sure that everyone can see that this argument is far from obviously valid, even if we ignore the question of whether or not premise 2 is true, and this goes for Pascal's Wager too in parallel ways. For instance, the existential risk argument above seems to ignore that there seems to be an innumerable amount of thus (merely) possible existential risk scenarios, as well as innumerable (merely) possibly workable technologies that might help to prevent or mitigate each of these, and it is unlikely (to say the least) that we have resources to bet substantially on them all, unless we spread them so thin that this action becomes meaningless. Similarly, there are innumerable possible versions of the god that lures you with threats and promises of damnation and salvation, and what that particular god may demand in return, often implying a ban on meeting a competing deity's demands, so the wager doesn't seem to tell you to try to start believing in any particular of all these (merely) possible gods. Likewise, the argument above ignores completely the (rather high) likelihood that the mobilised resources will be mostly wasted, and that, therefore, there are substantial opportunity costs attached to not using these resources to use better proven strategies with better identified threats and problems (say, preventing global poverty) - albeit maybe not as massive as the outcomes in the existential risk scenarios. Similarly, Pascal's Wager completely ignores all the good things one needs to give up to meet the demands of the god promising eternal salvation in return (for instance, spending your Sundays working for the allieviation of global poverty). None of that is worth any consideration, the idea seems to be, in light of the massive stakes of the existential risk / religious belief or non-belief scenarios.  

Now, I will not pick any quarrel with the existential risk argument as such on these grounds, although I do think that more developed ways to analyse risk-scenarios and the ethical implications of these already in existence and used in the fields I referred above will mean lots of troubles for the simplistic aspects already mentioned. What I do want to point to, however, is this: If you're impressed by the existential risk argument, you should be equally impressed by Pascal's Wager. Thus, in accordance with Pascal's recommendation that authentic religious belief can be gradually installed via the practice of rituals, you should – as should indeed the existential risk argument advocates themselves – spend your Sundays celebrating mass (or any other sort ritual demanded by the God you bet on). I very much doubt, however, that you (or they) in fact do that, or even accept the conclusion that you (or they) should be doing that.

Why on earth is that?