Research

Current

I am a Lecturer in Political Philosophy at the University of Sheffield. Until recently, I was working on issues related to the idea of sufficiency in healthcare decision-making, funded by a Wellcome Research Fellowship on the project 'From best interests to sufficient benefit: The ethics of hard decisions in healthcare'. 

My central research focus outside this project is inter-generational justice in health care: this includes thinking about how the passage of time affects our justice-related entitlements, and has in the past included work - including my PhD - on anti-ageing enhancement. You can hear me talk about some of the issues involved as part of KCL's Health & Society podcast series (2016) here. I also have interests in broader issues of justice in healthcare (particularly related to discrimination and democracy). 

Other than this, my research interests are in:

(1) animal ethics, particularly deontological constraints on our relationships with animals;

(2) professional ethics, especially in healthcare;  

(3) autonomy, paternalism and prudence.

Publications

Edited collections

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

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. This chapter explores what this means on several prominent theories of the wrongness of discrimination. One conclusion is that avoiding the wrongness of discrimination is likely not to be as simple a matter as excluding some material from explicit training data. 

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. This chapter critiques this individualist and instrumentalist focus, arguing that it is both ethically exploitative, and pragmatically self-defeating. 

Journal articles

John Taurek famously held the view that, when deciding whom to rescue, the numbers don’t count: we should instead give everyone the same chance of surviving. Surprisingly little engagement has taken place between the detailed and rich 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, e.g., in emergency triage during a pandemic. I suggest that a position close to Taurek’s maps on to 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. I consider the philosophical promise of this approach by appealing to the idea of “opacity respect”, and suggest a sufficientarian alternative.

Considers two ways healthcare practitioners could approach ethics guidance. Outlines the idea of deference to ethics guidance, showing how an attitude of deference raises three key problems: moral value; moral understanding; and moral error. Then advocates 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’. 

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. 

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. 

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 both child-centred views and views which allow consideration of parental interests, (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 that it is permissible to engage in pragmatic satisficing rather than spend too much time worrying about what is 'best'. 

Outlines a paradox for subjectivist theories of welfare which is based on the 'paradox of desire', but applies to a broader range of theories. 

Introduces a distinction between 'health need' and 'medical need', and raises several questions about their interaction. Health needs relate directly to our health condition. Medical needs bear some relation to medical institutions or processes. Suggests that whether medical insurance or public care should cover medical needs, health needs, or only needs which fit both categories is a political question that cannot be resolved definitionally. Argues against an overly strict definition of medical need.


Some people argue for using age as an priority-setting criterion in healthcare by appealing to claims about equity. For instance, ‘old’ patients are claimed to have had more of a relevant good than ‘young’ people, or enough, and so their claims to treatment are weaker. But discussions of 'egalitarian ageism' focusing are sometimes ambiguous between two claims which are not equivalent: that 'old' patients should have lower priority than everyone else, and that 'young' patients should have higher priority than everyone else. I argue 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. 

Considers arguments for and against Affirmative Action (AA) in the context of two pandemic-related healthcare resources: vaccinations and ventillators, and ways in which an AA in this area - Affirmative Action in healthcare Resource Allocation (AARA) - could be implemented, and considers some challenges for AARA. 

Reply to Hun Chung's article, 'Prospect utilitarianism: A better alternative to sufficientarianism. Chung argues that sufficientarianism faces fatal problems in giving inappropriate answers to 'lifeboat cases', and in failing to respect the axiom of continuity. He proposes a novel view - 'prospect utilitarianism' - which retains sufficientarianism's advantages while avoiding its problems, and which draws support from empirical work. I argue that sufficientarianism has the conceptual resources to avoid Chung's criticisms, and raise problems for prospect utilitarianism, including its supposed empirical support. 

​Preprint

Develops a theory of pandemic responsibility in light of the Covid pandemic, particularly focusing on the decision-making of the UK government. Argues that failures of institutional responsibility constrain, but do not fully eliminate, personal responsibility of individual citizens. 

Existing models of the doctor-patient relationship either fail to cater well for patients who do not want the responsibility of medical decision-making, or place too much control in doctors' hands as a default. We outline an alternative model, where patients are offered the chance of a formal, but limited, transfer of decision-making responsibility to their doctor. 

Debates around using responsibility as an allocation criterion in healthcare tend to focus on one-off decisions, and narrowly on impacts on people's health. But there is 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. Placing significant conditions on healthcare access because of a person's prior responsibility risks trapping them in, or worsening, negative cycles where poor health and associated lack of opportunity reinforce one another, making further poor yet ultimately responsible choices more likely. 

'mHealth' or mobile health technologies allow patients to self-monitor behaviours and outcomes in new ways. Some may see mHealth as offering a solution to problems which plague attempts to hold patients responsible for their own health: fairness of burdens and reliance on self-reporting. After noting that these would only really be solved by unacceptably comprehensive forms of personal health surveillance, I suggest a more plausible model is to use personal health surveillance as a 'last resort' for patients who would otherwise independently qualify for responsibility-based penalties. However, I note that there are still a number of ethical and practical problems that such a policy would need to overcome. The prospects of mHealth enabling a fair, genuinely cost-saving policy of patient responsibility are slim.

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. We suggest that neither position is tenable in its extreme version, and offer some suggestions for compromise. While the two positions remain distinct, this paper tries to point towards a middle ground. 

While many sufficientarians see the threshold of sufficiency as marking a point below which responsibility cannot be taken into account, this paper 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. 

Many health systems adopt a 'no blame culture' in response to medical errors, which eschews individual blame in favour of a focus on systems. We argue that the no blame culture fails to distinguish between blame and responsibility, and outline an approach which keeps the positives of (mostly) avoiding blame without ignoring individual responsibility altogether. 

We also wrote a related post on the blog Justice Everywhere. 

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' is a putative right in healthcare for patients to refuse medically relevant information. I extend 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 know. However, I note that - contrary to the dominant treatment of this issue by Rosamond Rhodes - this does not mean that patients lack a right not to know. Patients can have the right to do what is morally wrong, and it is important to have an institutional protection of patient control over access to information even if some patients will fail moral obligations in exercising this right. 

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). 

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 people with disabilities, our only alternative is to abandon a more fundamental commitment. I show that the tensions they use to ground this view occur even without a commitment to avoiding disability discrimination. 

Defends “momentary sufficientarianism,” as being 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 the potentially competing claims in healthcare that emerge from these two perspectives.

Preprint

Critical appraisal of two prominent extensions of John Rawls's theory of justice to health care. 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. I also show that the 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. 

Preprint

Suggests a justification of paternalism that avoids the suggestion that the target of paternalistic interference has made some mistake about what is in her interests. In cases where we can predict that an agent will undergo a significant alteration in their evaluative outlook - an 'evaluative shift' - many otherwise persuasive objections to paternalism lose their force. 

Preprint

Explores Nicholas Agar’s view that we should avoid 'radical' enhancement in relation to two kinds of radical enhancement: cognitive and anti-ageing. While Agar's worries have some plausibility with respect to radical cognitive enhancement, it is not plausible for radical anti-ageing enhancement.

​Preprint

Offers a systematic review of the problems involved in reliance on publication numbers in contemporary academic philosophy, and argue that the resulting situation is bad not just for individual philosophers, but for philosophy itself. Suggests potential solutions, including a professional code of conduct for philosophers.

Adds further considerations in support of a tension between utilitarianism and concern for animal welfare. Suggests three ways in which utilitarianism comes significantly apart from mainstream concerns with animal welfare. a) It opposes animal cruelty only when it offers an inefficient ratio of pleasure to pain, which is not obviously true of abuses not related to food consumption; b) it faces the problem of the inefficacy of individual decisions; c) the it ignores various pleasures that humans may get from the superior status that a structure supporting exploitation confers.

​​Greg Bognar offers a prioritarian justification for ‘fair innings’ distributive principles that ration healthcare by age. This article argues that this position is incomplete because of the possibility of ‘time-relative’ egalitarian principles that could complement the kind of lifetime egalitarianism that Bognar adopts. 

Preprint

Replies and commentaries

Invited commentary on an article by Christian Munthe, Davide Fumagalli and Erik Malmqvist.

Preprint

​Other publications

2019 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'. 

2018 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

2020 Thinking Through Utilitarianism by Andrew T. Forcehimes and Luke Semrau. Teaching Philosophy 

2015 Justice Between the Young and the Old by Dennis McKerlie. Czech Sociological Review 

Work in progress​

 Older drafts with no current home

Comments are very welcome on drafts where these are available. 

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.