Research
Research
I work on a range of issues in ethics and political philosophy, mostly to do with health and medicine. In the past this has included responsibility, sufficiency, professional ethics, autonomy and paternalism, public health (especially related to infant feeding advice), and discrimination, especially related to age and disability. At the moment I'm thinking a bit more about responsibility, as well as about the idea of making the health care system more "democratic". I am also interested in animal ethics.
Edited collections
Edited with Gabriel De Marco, Neil Levy and Julian Savulescu. Responsibility and Healthcare. Oxford University Press (Open access)
Edited collection with chapters on a range of topics related to responsibility and health care, including the responsibilities of institutions, medical professionals and patients.
Book chapters
with Gabriel De Marco, Neil Levy and Julian Savulescu. Responsibility and Healthcare: An Overview (substantive chapter than goes beyond the standard edited collection introduction).
with Joshua Parker. Physician, heal thyself? Do doctors have a responsibility to practice self-care? In Responsibility and Healthcare.
A common response to burnout among medical professionals, especially in the NHS, has been to emphasise strategies of self-care, focusing on what the individual can do to avoid burnout and the impact of burnout on their professional responsibilities. Argues this is ethically exploitative and pragmatically self-defeating.
with Tom Douglas. Learning to Discriminate: The Perfect Proxy Problem in Artificially Intelligent Criminal Sentencing. In Sentencing and Artificial Intelligence. OUP.
Machine learning tools used for criminal sentencing can seemingly avoid direct racial discrimination by having race excluded from their training data. However, ML tools might learn associations between other factors and recidivism that form a proxy, perhaps even a perfect proxy, for race; this might be, for instance, because of associations between race and factors such as social deprivation, and further links between social deprivation and recidivism. Explores what this means on several prominent theories of the wrongness of discrimination.
Journal articles
What do 'humans' need? Sufficiency and pluralism. Ethics, Policy & Environment. (Open access)
Sufficientarians face a problem of arbitrariness: why place a sufficiency threshold at any particular point? One response is to seek universal goods to justify a threshold. After criticising this approach as importantly incomplete, considers another individualised threshold: ‘tolerability’. Responds to some traditional challenges to individualistic approaches to justice - ‘expensive’ tastes, and adaptive preferences - and outlines how this approach might be made relevant to policy.
with Thomas Schramme. Health capital and its significance for health justice. Public Health Ethics
Outlines a novel framing of the normative significance of health through the idea of ‘health capital’. Health capital is a set of health-related assets of individuals that enable them to pursue their interests and to collaborate with others. Establishes the notion of health capital beyond a metaphorical idea and explores its repercussions for health justice. Proposes a sufficientarian approach to health capital justice.
with Joshua Parker. Deference or critical engagement: How should healthcare practitioners use Clinical Ethics Guidance? Monash Bioethics Review
Considers two ways healthcare practitioners could approach ethics guidance. Outlines the idea of deference to ethics guidance, showing how it raises three key problems: moral value; moral understanding; and moral error. Sdvocates an alternative framing of ethics guidance as a form of moral testimony by colleagues, and suggests that a more promising attitude to ethics guidance is ‘critical engagement’.
with Jin Park. Rationing, responsibility, and vaccination during COVID-19: A conceptual map. American Journal of Bioethics. (Open access)
A critical overview of arguments around whether vaccination status is a legitimate consideration in emergency pandemic triage. Discusses arguments framed around responsibility, reciprocity, and background justice.
My response to some commentaries on the article is here.
with Clare Moriarty. Feeding infants: Choice-specific considerations, parental obligation, and pragmatic satisficing. Ethical Theory and Moral Practice. (Open access)
Building on work by Fiona Woollard, considers whether moderate views of parental duties can support an obligation for parents to follow standard health guidelines around feeding infants by adopting "Exclusive Breastfeeding on Demand" (EBFoD). Argues that on any reasonable view (i) there can be no general duty to EBFoD, (ii) its polar opposite, Exclusive Formula Feeding, is often the right choice, and (iii) given the complexity of interests involved, the decision is best left to families to decide, and it is permissible to engage in pragmatic satisficing rather than spend too much time worrying about what is 'best'.
A new paradox for welfare subjectivism. Analysis. (Open access)
Outlines a paradox for subjectivist theories of welfare which is based on the 'paradox of desire', but applies to a broader range of theories.
Disability discrimination in emergencies: The return of Taurek? ethic@ (Open access)
Surprisingly little engagement has taken place between literature on whether the numbers count in rescue cases, and the practical question of whether certain facts about patients are eligible for consideration in real-world prioritisation. Suggests that a position close to Taurek’s maps onto real-world arguments by groups representing disabled individuals. Whereas Taurek is focused on equalising survival chances, some disability rights activists and scholars appear to argue in favour of equalising selection chances. Considers the promise of this approach by appealing to the idea of “opacity respect”, and suggests a sufficientarian alternative.
Medical need and health need. Clinical Ethics. (Open access)
Introduces a distinction between 'health need' and 'medical need', and raises several questions about their interaction.
Healthcare priorities: The 'young' and the 'old'. Cambridge Quarterly of Healthcare Ethics (Open access)
Argues that while considerations of equity cannot justify giving ‘old’ patients low priority, there could be a limited role for age-based prioritisation in the context of infant and childhood death, since those who die young are necessarily among the worst off.
with Hazem Zohny and Dominic Wilkinson. Affirmative action in healthcare resource allocation: Vaccines, ventilators and race. Bioethics. (Open access).
Considers arguments for and against Affirmative Action (AA) in the context of two pandemic-related healthcare resources: vaccinations and ventillators.
with Julian Savulescu. Institutional Responsibility is Prior to Personal Responsibility in a Pandemic. The Journal of Value Inquiry (Open access).
Develops a theory of pandemic responsibility, particularly focusing on the decision-making of the UK government during Covid. Argues that failures of institutional responsibility constrain, but do not fully eliminate, personal responsibility of individual citizens.
with Joshua Parker. Doctors as appointed fiduciaries: A supplemental model for medical decision-making Cambridge Quarterly of Healthcare Ethics. (Open access).
Existing models of the doctor-patient relationship either fail to cater for patients who do not want the responsibility of medical decision-making, or place too much control in doctors' hands as a default. Outlines an alternative where patients are offered the chance of a formal, but limited, transfer of decision-making responsibility to their doctor.
Responsibility and the recursion problem. Ratio (Open access)
Outlines a two–way relationship between health and other social goods: deficits in health typically undermine one's abilities to secure advantage in other areas, which in turn often have further negative effects on health. This relationship exacerbates an existing problem for proponents of responsibilisation (the ‘harshness objection’) in ways that standard responses to this objection cannot address.
'Personal Health Surveillance': The use of mHealth in Healthcare Responsibilisation Public Health Ethics. (Open access)
Critiques the idea that mHealth technologies could solve problems of fairness and trust in holding patients responsible. Suggests a more plausible model of using personal health surveillance as a 'last resort' for patients who would otherwise independently qualify for responsibility-based penalties. But notes remaining ethical and practical problems that such a policy would need to overcome.
with Julian Savulescu. The Right Not to Know: some steps towards a compromise Ethical Theory and Moral Practice. (Open access).
Opponents and proponents of the 'right not to know' (see paper 12 below) tend to fall into two opposing camps with respect to autonomy. Proponents typically defend a 'liberty' conception, where autonomy involves freedom to act as one wishes; opponents often advocate a 'duty' conception, where autonomy involves the duty to become informed. Suggests that neither position is tenable in its extreme version, and suggests a compromise.
with Julian Savulescu. From sufficient health to sufficient responsibility. Journal of Bioethical Inquiry. (Open access).
Outlines a 'responsibility-sensitive' sufficientarian view for healthcare: responsibility can be taken into account, but only (i) between individuals who are in similar positions with respect to sufficiency, and (ii) when they have shown sufficient responsibility.
with Joshua Parker. No blame, no gain? From a No Blame culture to a responsibility culture in medicine Journal of Applied Philosophy. (Open access)
Many health systems adopt a 'no blame culture' in response to medical errors, which eschews individual blame in favour of a focus on systems. Outlines an alternative approach which keeps the positives of (mostly) avoiding blame without ignoring individual responsibility.
We also wrote a related post on the blog Justice Everywhere.
Responsibility and the limits of patient choice Bioethics (Open access).
Discusses how we should determine limits on the choices patients are able to make with respect to their treatment, and considers how we should respond to patients who nonetheless persist with treatments outside this range, or who refuse institutionally-accepted forms of care.
The right not to know and the obligation to know (open access). Journal of Medical Ethics (Open access).
Extends an existing argument, based on the burdens placed on others by exercising the right not to know, that suggests that in many cases patients have a moral obligation to receive health-relevant information. However, notes that - contrary to the dominant treatment of this issue by Rosamond Rhodes and others - this does not mean that patients lack a right not to know.
JME Feature Article, commentaries from Benjamin Berkman, Aisha Deslandes, Lisa Dive and Ainsley Newson, and John Harris. (See 'Replies and commentaries' below for my response).
with Julian Savulescu. Solidarity and responsibility in health care Public Health Ethics. (Open access)
Argues that healthcare services founded in solidarity can, in some cases, hold patients substantively responsible.
Reply to Nick Beckstead and Toby Ord's 'Bubbles under the wallpaper'. Beckstead and Ord argue that even if QALYs are discriminatory against disabled people, our only alternative is to abandon a more fundamental commitment. Shows that the tensions they use to ground this view occur even without a commitment to avoiding discrimination.
Health(care) and the temporal subject The Ethics Forum.
Defends “momentary sufficientarianism,” as an important element of healthcare justice: it is a fundamental demand of justice that people are sufficiently well off not across their lives, but at all moments in their lives. Also considers how a pluralist approach, which engages both with people’s lives as a whole and with their states at particular moments, can reconcile potentially competing claims.
Ageing and terminal illness: Problems for Rawlsian justice Journal of Applied Philosophy.
A strict application of the difference principle in the case of health care leads to extreme conclusions, given the existence of very young patients whose situation cannot be improved. Prudential calculations on which one of these views - Hugh Lazenby's - relies are not warranted from within the Rawlsian framework. Age and terminal illness are significant problems for any Rawlsian account of health justice.
Paternalism and evaluative shift Moral Philosophy and Politics
In cases where we can predict an agent will undergo a significant alteration in their evaluative outlook - an 'evaluative shift' - many otherwise persuasive objections to paternalism lose their force.
Enhancement and the conservative bias Philosophy and Technology
Critically examines Nicholas Agar’s view that we should avoid 'radical' enhancement in relation to two kinds of radical enhancement: cognitive and anti-ageing. Agar's worries have some plausibility with respect to cognitive enhancement, they fail against radical anti-ageing enhancement.
with Giulia Felappi. Publish or perish Metaphilosophy
Offers a systematic review of the problems involved in reliance on publication numbers in contemporary academic philosophy. Argues the situation is bad not just for individual philosophers, but philosophy itself. Suggests potential solutions.
Utilitarianism and animal cruelty De Ethica. (Open access)
Adds further considerations in support of a tension between utilitarianism and concern for animal welfare. Utilitarianism: a) opposes animal cruelty only when it offers an inefficient ratio of pleasure to pain; b) faces the problem of the inefficacy of individual decisions; c) ignores various pleasures humans get from a superior status that exploitation confers.
Fair innings and time-relative claims Bioethics
Greg Bognar offers a prioritarian justification for ‘fair innings’ distributive principles that ration healthcare by age. Argues this position is incomplete because of ‘time-relative’ egalitarian principles that could complement the kind of lifetime view Bognar adopts.
Replies and commentaries
Grow the pie, or the resource shuffle? Journal of Medical Ethics
Invited commentary on an article by Christian Munthe, Davide Fumagalli and Erik Malmqvist.
The right not to know and the obligation to know, response to commentaries. Journal of Medical Ethics
Other publications
John Rawls and the 'Veil of Ignorance' in (Noah Levin, ed.) Introduction to Ethics: An Open Educational Resource
A short chapter in an open-access textbook on Rawls's use of the 'Veil of Ignorance'.
John Rawls' 'A Theory of Justice 1000-Word Philosophy
A brief overview of some central themes in John Rawls' book, A Theory of Justice, intended as a study and teaching aid.
Book reviews
War on All Fronts: A Theory of Health Security Justice by Nicholas G. Evans. Bioethics.
Thinking Through Utilitarianism by Andrew T. Forcehimes and Luke Semrau. Teaching Philosophy
Justice Between the Young and the Old by Dennis McKerlie. Czech Sociological Review
Against the idea that using patient responsibility in healthcare is a form of 'moralisation'
Should we practice 'affirmative action' in healthcare allocation?
The idea of 'unbearable suffering' - with Marina Moreno
The state of the public debate on infant feeding - with Clare Moriarty
Whether we should always 'treat like cases alike'.
The role of 'basic needs' in health care.
Older drafts with no current home
Comments are very welcome on drafts where these are available.
Bringing the myth to life: Three prima facie cases of optional war
War is a morally serious undertaking, and hence requires the threat of severe harm to justify it. Kieran Oberman uses this fact to argue that wars cannot be morally 'optional' (morally permissible, but not required). Oberman considers two traditional grounds of war's optionality (a humanitarian war that will impose great costs on the war-going nation's people; and a self-defensive war that can be refused on the grounds of self-determination) and argues convincingly against them. In particular, the humanitarian case is rejected on the grounds of what Oberman calls the 'Cost Principle': if citizens do not have a humanitarian duty to bear a cost to resolve a humanitarian crisis, the state may not permissibly impose that cost on them. However, I suggest that even if Oberman's arguments are sound, they do not prove that the optional war is a "myth" as he claims. Using humanitarian wars as my focus, I suggest three scenarios that might be grounds for optional war: a state's obligation to incentivise its citizens towards privately supporting a war ('The Private War'); a scenario where it is uncertain whether the war will exceed the principle established by the Cost Principle ('The Forever War'); and a scenario where a state faces two or more interventions, which would individually fall below the threshold, but which collectively exceeds it ('The Multi-War'). While there are ways to resist these conclusions, they require significantly more argument or assumption than Oberman provides.
Some people think that the logic behind veganism implies an obligation to eat certain kinds of meat - different authors have defended this claim with regard to animals as complex as cows, to as simple as insects and shellfish. I take cows, crickets and clams to stand for three different animal categories: animals that can definitely suffer; animals that might be able to suffer, and animals who are as likely to suffer as are plants. I then note that the primary principle behind defences of 'vegan' meat-eating depend on the 'least harm' principle (LHP). But LHP is implausible, and not the only possible motivator for veganism. I consider the implications of the primary alternative to LHP - a deontological theory of rights - for the alleged obligation(s) to eat certain kinds of meat.
Evolutionary debunking accounts claim that the evolutionary origins of our moral beliefs provide a problem for moral realists because evolutionary explanations of our moral beliefs have more plausibility than realist accounts. A certain kind of response, which I term ‘rationalist’ offers a dual response to evolutionary debunking. First, they offer a supposedly plausible account of how we acquire objective moral knowledge through use of our rationality. Second, they claim that certain moral beliefs are not amenable to evolutionary explanation. I argue that neither of these putative advantages survives further scrutiny. An appeal to ‘rational insight’, although it makes reference to a somewhat familiar faculty, gives no useful explanation of how we come to know moral facts. Moreover, the supposedly problematic moral beliefs are in fact amenable to evolutionary explanation. As such, rationalist accounts are, like other realist accounts, on the wrong side of the balance of justification against evolutionary debunking.