PAPERS
Titles and abstracts of my recent work are shown below (in order of acceptance, not publication). Please contact me if you would like to see the most recent draft of a paper in preparation.
CONTRIBUTORY INJUSTICE IN PSYCHIATRY
2019 Journal of Medical Ethics (45:2): available here
I explain the notion of contributory injustice, a kind of epistemic injustice, and argue that it occurs regularly within psychiatric services; in particular, I argue that it affects those who experience auditory hallucinations of voices. I argue that abstract effort on the part of clinicians to avoid perpetrating this injustice is an insufficient response to the problem; mitigating the injustice will require open and meaningful dialogue between clinicians and service user organisations, as well as individuals. I suggest that clinicians must become familiar with and take seriously concepts and frameworks for understanding mental distress developed in service user communities, such as Hearing Voices Network, and by individual service users. This is especially necessary when these concepts and frameworks explicitly conflict with medical or technical understandings of users’ experiences. Further, I defend this proposal against the claim that it might produce conflict with clinicians’ responsibility to inform service users of all medically pertinent information prior to obtaining consent for treatment.
A PREDICTIVE PROCESSING THEORY OF MOTIVATION
2021 Synthese (198): available here
In this paper I propose minimal criteria for a successful theory of the mechanisms of motivation (i.e. how motivational mental states perform their characteristic function), and argue that extant philosophical accounts fail to meet them. Further, I argue that a Predictive Processing (PP) framework gives us the theoretical power to meet these criteria, and thus ought to be preferred over existing theories.
The argument proceeds as follows – motivational mental states are generally understood as mental states with the power to initiate, guide, and control action, though few existing theories of motivation explicitly detail how they are meant to explain these functions. I survey two contemporary theories of motivational mental states, due to Wayne Wu and Bence Nanay, and argue that they fail to satisfactorily explain one or more of these functions. Nevertheless, I argue that together, they are capable of giving a strong account of the control function, which competing theories ought to preserve (all else being equal).
I then go on to argue that what I call the ‘predictive theory’ of motivational mental states, which makes use of the notion of active inference, is able to explain all three of the key functions and preserves the central insights of Wu and Nanay on control. It thus represents a significant step forward in the contemporary debate.
ANHEDONIA AND THE AFFECTIVELY SCAFFOLDED MIND
2019 Ergo (6:23): available here
Anhedonia, roughly defined as the diminishment or absence of the capacity to experience pleasure or joy in the performance of daily activities, is a core symptom of Major Depressive Disorder, as well as other psychiatric illnesses. I argue that the two major psychological theories of anhedonia are committed to the view that anhedonia cannot, in the general case, be explained with reference only to neurobiological states and processes. This is despite the overwhelming explanatory focus on neurobiological factors in the existing literature. Instead, it is to be understood as the breakdown in the function of what Colombetti & Krueger (2015) term a subject's affective niche. Since affective niches are composed of elements of a person's natural and social environments, including artefacts, activities, and other people, anhedonia turns out to be a phenomenon deeply integrated into a subject's environment, inscrutable within the boundaries of skin and skull. I briefly discuss ramifications of this view for diagnosis and treatment.
NARRATIVE COHERENCE AND MENTAL CAPACITY IN ANOREXIA NERVOSA
2020 American Journal of Bioethics: Neuroscience (11:1): available here
I comment on Goldberg's proposal to add a narrative coherence requirement to capacity assessments, in order to better handle 'hard cases' (2020). I argue that many service users with Severe and Enduring Anorexia Nervosa will still meet this enhanced criterion for capacity. This provides additional evidence for the view that such service users are often capacitous to refuse nutrition and hydration, despite the ill-founded conviction of many ethicists and clinicians to the contrary. I briefly discuss the ramifications of this view.
ON GROUNDS, ANCHORS, AND DISEASES: A REPLY TO GLACKIN
(with Tom Davies, 2020 The Philosophical Quarterly (71:2): available here
Shane Glackin’s 2019 Philosophical Quarterly article aims to (a) offer a framework for understanding the philosophical debate about the nature of disease and (b) utilise this framework to reply to several standard objections to normativist (particularly social constructivist) theories of disease. Specifically, Glackin claims his model avoids three central challenges to normativism, which we term the ‘Flippancy Problem’ (which charges that normativism implies diseases can be cured by adjusting our attitudes towards them), ‘Repugnancy Problem’ (which charges that normativism implies we must endorse repugnant historical views regarding ‘conditions’ like Drapetomania as ‘genuine diseases in their day’), and the ‘Explanatory Problem’ (which charges that normativism cannot explain why diseases warrant certain kinds of medical intervention without lapsing into vicious circularity). Although we find Glackin’s framework helpful in clarifying the terrain of the debate, we argue these three challenges continue to afflict his preferred construal of the normativist/social constructivist position.
RETHINKING THE ETHICS OF PANDEMIC RATIONING: EGALITARIANISM AND AVOIDING WRONGS
2022 Cambridge Quarterly of Healthcare Ethics (31:2): available here
I argue in this paper that we ought to rethink the harm reduction prioritisation strategy that has shaped early responses to acute resource scarcity (particularly of ICU beds) during the COVID-19 pandemic. While some authors have claimed that “[t]here are no egalitarians in a pandemic”, I note that, to the contrary, many observers and commentators (myself included) have been deeply concerned about how prioritisation policies that proceed on the basis of criteria such as survival probability or capacity to benefit quickly may unjustly distribute the burden of mortality and morbidity, even while reducing overall numbers of deaths. I further argue that there is a general case in favour of a broadly egalitarian approach to resource rationing, even in a state of acute emergency – egalitarian approaches to resource rationing minimise wrongs, and wrongful harm. I defend this claim against a prima facie objection and go on to explain why we should consider the possibility that avoiding wrongful harm is more important than avoiding harm simpliciter.
PRESUMED INCAPACITY IN ANOREXIA IS NEVER PERMISSIBLE: A REPLY TO IP
2021 Bioethics (35:6): available here
In a recent article, Eric C. Ip argues that, if their capacity to refuse life-saving nutrition is impugned, patients with anorexia nervosa should be assumed to be incapacitous with respect to such decisions, with the service user having to meet a “high standard of proof" in order to overturn this assumption.
I argue that this proposal should be rejected on two grounds. Firstly, we have good reason to believe that it would a) cause significant avoidable distress to a vulnerable group of service users and b) lead them to have worse clinical outcomes than they currently do. These harms, in my view, are far more significant than those involved in continuing to (defeasibly) presume capacity in such cases. Secondly, I argue that, in any case, Ip does not provide adequate reason to think that service users presenting with long-term anorexia nervosa typically lack capacity to refuse life-sustaining nutrition (though many will, of course). This means that his proposal, if enacted, will predictably deny liberty to, and forcefully impose treatment on, a large number of capacitous service users
UNWEIGHTED LOTTERIES & COMPOUNDING INJUSTICE: REPLY TO SCHMIDT ET AL
2021 Journal of Medical Ethics (48): available here.
[This paper is a short reply to this paper, which should be read first to understand what is going on.]
I argue that Schmidt, Roberts & Eneanya, while correctly diagnosing the serious racial inequity in current ventilator rationing procedures, misidentify a corresponding racial inequity issue in alternative ‘unweighted lottery’ procedures. Unweighted lottery procedures do not ‘compound’ (in the relevant sense) prior structural injustices. However, Schmidt, Roberts & Eneanya do gesture towards a real problem with unweighted lotteries that previous advocates of lottery-based allocation procedures, myself included, have previously overlooked. On the basis that there are independent reasons to prefer lottery-based allocation of scarce lifesaving healthcare resources, I develop this idea, arguing that unweighted lottery procedures fail to satisfy healthcare providers’ duty to prevent unjust health outcomes, and thus that lotteries weighted in favour of Black individuals (and others who experience serious health injustice) are to be preferred.
AFFORDANCE SENSITIVITY IN DEPRESSION
In Progress
There is good and increasing evidence that our ability to act effectively on and in our immediate environments depends on our sensitivity to environmental affordances – opportunities to act that our environment offers us. For instance, chairs afford sitting-on, clothes afford getting dressed, and mugs of coffee afford grasping and drinking-from. Sensitivity to affordances consists in two sub-capacities; affordance perception and potentiation. I argue that a pathological failure of affordance perception and potentiation underwrite agential pathology – a core symptom of depressive disorders whereby individuals struggle and fail to undertake day-to-day activities absent any organic motor abnormality. What I call the affordance insensitivity hypothesis gains much of its plausibility from its ability to satisfyingly explain four aspects of the phenomenology of agential pathology that extant theories struggle to deal with all at once, alongside explaining the functional outcome of action failure. This illustrates the importance of paying close attention to the phenomenology of psychiatric conditions and ensuring that candidate explanations are phenomenologically adequate.
UNJUST SILENCING IN THE PSYCHIATRIC ENCOUNTER
In Progress
Status-based statutes (e.g. the Mental Health Act 2007 in the UK) that permit the involuntary detention and treatment of otherwise legally competent psychiatric service users are common worldwide. This makes seeking psychiatric care in crisis a risky enterprise; an individual with mental health difficulties is at significantly greater risk of the harms involved in detention and compulsion than someone presenting to primary care with a physical ailment. Since many service users are keen to avoid such outcomes, they are motivated to downplay the severity of their symptoms, especially if these include suicidal ideation, completed or intended self-harm, or psychosis.
There is, however, a further source of risk in psychiatric encounters which pulls in the other direction. If individuals do not receive any help, then they are liable to experience extreme distress, perhaps engage in serious acts of self-injury, or even attempt or complete suicide. Service users who wish to avoid these outcomes in an era of grossly under-resourced mental health services must make it clear that their situation requires urgent prioritisation.
In this paper, I argue that the phenomena above amount to various forms of unjust silencing and coerced speech, which in turn often amount to violations of a patient’s right to autonomy, their right to healthcare provision, and the physician’s duty of non-maleficence. Since self-report is a necessary precursor to effective psychiatric care, this means that suffering serious wrongs is a common, indeed typical, precondition of receiving psychiatric care. I survey various proposals to remedy this situation, concluding that the problem cannot be solved at the clinical level; it requires significant legal reform of mental health systems to reduce or eliminate compulsion.