Research assignment

We shall focus on some foundational issues that affect all attitude-sensitive theories of wellbeing, prudence, and morality and are thus relevant for the three general research questions of the project. According to an attitude-sensitive theory, whether something has a certain value, or a certain normative status, depends at least in part on attitudes.

1. Q1. How do we determine what is better for a person who is affected by a transformative choice (TC)?

One of the biggest challenges here is to find a stable standard of wellbeing. TCs can radically change people’s preferences so that they switch from preferring one state to dispreferring it. The main question here is

1. How do we determine the well-being of a person when her preferences are not stable across states (times or lives)?

Another challenge is managing epistemic transformations. The main question here is:

1. How can one state be better for a person than another if she can only grasp one of the states and thus only have an attitude towards one of the states?

One hypothesis we will explore is that the value of a certain state for a person is determined by the attitudes they would have towards this state were they to be in it. This provides a stable standard of wellbeing and enables us to compare states even when the person cannot grasp the state she is not in.

1. Q2. How can we make prudential choices when they are transformative?

If we let the answer to the wellbeing question be unstable, so that a state A can be worse than another B if A is realized but better than B if A is not realized, then we end up with normative dilemmas: no matter which state we realize, we will be doing something imprudent, since the outcome will be worse for the person. Even if this can be solved, there are still challenges about undefined wellbeing in cases of radical epistemic transformations and incomparability of wellbeing when the attitudes cannot be compared across states. A complete theory of prudence for TCs must address all these problems. The issue here is also how to act rationally (prudentially) when one suspects that the outcome of one’s choice could be something of which one is currently unaware or cannot grasp. It may therefore be fruitful to apply criteria of rationality under growing awareness.

1. Q3. What does morality require for TCs?

We need an ethics for both self-regarding and other-regarding TCs. The latter are more complex. They present a double-challenging decision-making context where one makes a choice on behalf of another without knowing how her preferences or attitudes will be affected. Though many other-regarding TCs are potentially beneficial, they remain undertheorized. Since any plausible ethics will consider wellbeing, we can use the results from the sections above and feed them into a well-being sensitive morality. But attitudes can have moral significance that goes beyond their role for wellbeing. A common liberal idea is to evaluate interventions in people’s lives in terms of autonomy. One option for evaluating other-regarding TCs is to ask people whether they approve of an intervention. Giving this authority to people might respect their autonomy and not just promote their welfare. The challenge again is that for certain TCs, approval is not stable. A person can initially consent to an intervention, but then come to disapprove of it once it has been implemented. And a person might initially disapprove of a decision, but after making it they would come to approve it. Is it ethical to choose these interventions for a person, if they are unable to make the decision themselves? (Paul & Sunstein 2021)?

Assume transformative experience (TE) involves a single person undergoing a transformation from one state to another. But if the transformation is radical, as it might be in severe cases of dementia, the person beforehand and the person afterward may not be identical (Mosquera 2022). This will be so if we assume a psychological theory of personal identity, according to which the continued existence of a person over time and in different possible worlds requires, or depends on, some kind of psychological similarity (Parfit 1984; Shoemaker 2008; Campbell 2000; Campbell & McMahan 2010). On psychological theories, non-identity cases include ones in which a single embryo will give rise to one of two very different psychological lives depending on our choice. For example, the possibility for embryonic gene editing to add or remove a disability (such as deafness or Down Syndrome) may in the future give rise to a non-identity case rather than a case in which one individual is affected for better or worse (Mosquera 2022). It should be noted that what appear to be non-identity cases may be cases of indeterminate identity, in which the number of people whose well-being we need to consider is indeterminate (Campbell 2021). Unlike the question of rational choice under uncertainty, questions of rational and ethical decision-making under this kind of indeterminacy have hardly been explored at all.

References

• Campbell, T. (2021) “Personal Identity and Impersonal Ethics,” in McMahan, J. et al. (eds.), Principles and Persons: The Legacy of Derek Parfit,Oxford University Press: 55-84.

• Campbell, T. & McMahan, J. (2010) “Animalism and the varieties of conjoined twinning,” Theoretical Medicine and Bioethics 31(4): 285–301.

• Campbell, S. (2000) “Could your life have been different?” American Philosophical Quarterly 37(1): 37–50.

• Mosquera, J. (2022) “Disability and Population Ethics,” in Arrhenius, G. et al. (eds.), The Oxford Handbook of PopulationEthics, Oxford University Press: 158–173.

• Parfit, D. (1984) Reasons and Persons, Oxford University Press.

• Shoemaker, S. (2008) “Persons, Animals and Identity,” Synthese 162: 313–324.

To approach these pressing normative questions about TCs in a fruitful way, we need the right theoretical tools. The project will develop a theoretical framework, suitable for assessing changing attitudes, that will make it clear what exactly is at stake in these concrete cases and help us keep track of the following complexities involved in TCs.

1. Attitude change. TCs can change attitudes both across time and across alternative life-options.

2. Object of attitudes. We can have attitudes at one time towards other times, and attitudes in one life-option towards other alternative life-options.

3. Attitude Polarity. Our attitudes are not just comparative, as when we prefer one state over another, they also come with a certain polarity: pro-attitudes, con-attitudes, and neutral attitudes.

4. Attitude Strength. Our attitudes often come with a certain strength; one can favour something to a certain degree.

5. Attitude Incomparability. It is not always possible to compare the strength of different attitudes, especially when they are of very different kinds. For example, it might not be possible to say that one admires something more than one enjoys something else.

6. Unconceptualizable states. TCs can be epistemically transformative. In your present state you might be unable to conceptualize a different state, and thus not be able to form an attitude towards it. This is the predicament in many of the standard cases of TCs such as whether to receive a cochlear implant, since as a person born deaf, you cannot conceptualize being hearing. But you might also lose your ability to conceptualize a state when you enter it, a possibility that is often neglected. This holds for becoming unconscious, severely demented, severely disabled, or psychotic. You can conceptualize a state of this kind only while you are not in it, and thus you can only form an attitude towards it when you are not in it.

We will develop an Attitude Matrix Framework that presents information about preference change across both time and lives in a way that is easily accessible and captures all the complexities involved in TCs explained above.

Awareness Growth

TE involves awareness growth, that is, an agent becoming aware of possibilities of which she was previously unaware. Therefore, the literature on decision-making when one predicts awareness growth can be fruitfully applied to TCs. It has been argued there are ways to assess the probability and utility of not-yet-conceptualised possibilities (Steele & Stefánsson 2021); therefore, if TCs are instances of choices under unawareness, such choices can be rational (contrary to what Paul suggests). In this project we will apply the theory of Steele & Stefánsson (2021) to TCs, thus carrying out a suggestion made (but not spelled out) by Carr (2015), Bykvist 2019) and Steele & Stefánsson (2022). In addition, we will continue foundational work on how to make decisions when one suspects that one’s choices may result in awareness growth. One of our hypotheses is that the Awareness Growth Framework of Gilboa & Schmidler (2001) – which contains a rigorous treatment of the notion of similarity between decision-situations – can be developed further so that it can be used to estimate upper and lower bounds on the probability and utility of possibilities of which one is currently unaware; for instance, when that of which one is unaware is an outcome of a TC. Another hypothesis is that the principle of Awareness Reflection (Steele & Stefánsson 2021, 2022) can be applied to TCs. Informally, this principle says that when faced with the possibility of awareness growth, one should defer to the attitudes that one expects one’s more aware self would have.

References

• Carr, J. (2015) “Epistemic Expansions,” Res Philosophica 92(2): 217–236.

• Bykvist, K. (2019) “Paul’s Reconfiguration of Decision-problems in the Light of Transformative Experiences,” Symposium on LA Paul’s Transformative Experience, Dellantonio, S. (ed.), Rivista Internazionale di Filosofia e Psicologia, 10(3): 346–356.

• Gilboa, I., & Schmeidler, D. (2001) A Theory of Case-Based Decisions, Cambridge University Press.

• Steele, K., & Stefánsson, H. O. (2021) Beyond Uncertainty: Reasoning with Unknown Possibilities, Cambridge University Press.

• Steele, K., & Stefánsson, H. O. (2022) “Transformative Experience, Awareness Growth, and the Limits of Rational Planning,” Philosophy of Science 89(5): 939–948.

Transitioning from one health state to another can change your attitudes toward the states, but also enable, or prevent you from grasping, both states fully (Menzel et al. 2002). For example, a deaf person might change her attitude towards hearing once she has become hearing, and this might in part be due to a gain of perceptual information that was inaccessible when she was deaf (Barnes 2009). By becoming deaf, one acquires a unique way of functioning and may become part of a rich culture (sign language; strong representation in disability rights movement). Some disability theorists also see deafness as a disability with non-negative value (Barnes 2014, 2016). Consequently, some deaf parents choose reproductive material to even ensure a deaf baby, leading to a debate on the permissibility of genetically selecting for disability (Savulescu 2002; Levy 2002; Mand et al. 2009). Having a disability removed can also be a TE. By receiving a cochlear implant, one acquires a new sensory ability that changes the way one relates to the world and one’s self-identity (Paul 2014).

The overall aim of part III of the project is to develop an account of the value of health that takes the challenge of TEs and TCs seriously, and provides a plausible foundation for a transformative ethics that can be applied to health care decisions.

1. Adaptive preferences. People who have lived with a disability or health condition tend to judge their state more positively than the general public judges these states. A common explanation for this attitude divergence is adaptation. Adaptation might be a response to cognitive denial, to having forgotten what being in full health enables one to do, or to an abrupt change in personal taste and judgements about final ends to avoid disappointment (‘sour grapes phenomenon’). Adaptive preferences cast doubt on the reliability of current patients’ attitudes towards their condition. Some disabilities might be worse than what people with them report. Trusting the self-reports might then lead to under-attending to these disabilities (Amundson 2010). Some have proposed mixed accounts that combine elements from first-person and other-person methods (Eyal 2021).
   However, it is complicated to build measures that provide the right weights to the judgments of each relevant party, and it has been shown that some existing proposals end up violating basic adequacy conditions for a measure of this sort (Mosquera 2021; 2023). However, completely discarding first person health state judgements has been criticised as “epistemic injustice”, which occurs when someone is not given due credence typically because she belongs to a certain disenfranchised group (Fricker 2007). Trusting any judgements other than the current, first-personal one about one’s state, critics claim, unjustly disregards the capability of the person to correctly judge her own state (Barnes 2013; Marsh 2020). We aim to solve the problem of adaptive preferences by taking into account both first-person reports and the more objective value of health states.

2. Indeterminate identity. As noted in section I, some TCs are so radical that it is indeterminate whether the person persists through the transformation. Can advanced directives be relevant for the value of the transformed person’s health when it is indeterminate whether the person who gave the directives are identical to the transformed person? We aim to answer this question by looking at severe cases of dementia.

3. Ungraspable health states. When a person suffers from severe dementia or is severely intellectually disabled, she cannot (fully) grasp her health state. So we might not have any first-person report to take into considerations. Is the health value undefined for the person, or is there some other way to determine this value? If it is undefined, we will have incomparabilities in health value. We shall explore what implications this would have for health care decisions.

4. Incomparable attitudes. A related challenge is incomparability of attitude strengths. Sometimes it seem unrealistic that we can compare attitude degrees across states. For example, it can be difficult to trade-off mobility limitations against experiential aspects. The question is then what we should say about the comparisons of the value of different health states. One possibility is that we can’t compare value across such states at all. Another is that we can make imprecise comparisons. The question is then how to make health care decisions under partial incomparability.

References

• Amundson, R. (2010) “Quality of Life, Disability, and Hedonic Psychology”, Journal for the Theory of Social Behaviour 40: 374-392.

• Barnes, E. (2009) “Disability and Adaptive Preferences”, Philosophical Perspectives 23: 1–22.

• Barnes, E (2014) “Valuing Disability, Causing Disability”, Ethics 125(1): 88–113.

• Barnes, E. (2016) The Minority Body: A Theory of Disability, Studies in Feminist Philosophy, Oxford University Press.

• Eyal, N. (2020) “Measuring Health-State Utility via Cured Patients”, in Cohen, G.I. et al. (eds.), Disability, Health, Law, and Bioethics: 274–277.

• Fricker, M. (2007) Epistemic Injustice, Oxford, Oxford University Press.

• Levy, N. (2002) “Deafness, culture, and choice,” Journal of Medical Ethics, 28: 284–285.

• Mand, C. et al. (2009) “Genetic selection for deafness: the views of hearing children of deaf adults,” Journal of Medical Ethics 35(12): 722–728.

• Marsh, J. (2020) “What’s wrong with ‘you say you’re happy, but…’ reasoning?”, in Wasserman, D.T. & Cureton, A. (eds.), The Oxford Handbook of Philosophy and Disability: 310-325.

• Mentzel, P., Dolan, P., Richardson, J., & Olsen, J. A. (2002) “The role of adaption to disability in health state valuation: A preliminary normative analysis,” Social Science and Medicine 55: 2149–2158.

• Mosquera, J. (2021) “The Bias of Adapted Patients in Practice,” Journal of Law and the Biosciences 8(2): 1–10.

• Mosquera, J. (2023) “QALYs, Disability Discrimination, and the Role of Adaptation in the Capacity to Recover: The Patient-Sensitive Health-Related Quality of Life Account,” Cambridge Quarterly of Healthcare Ethics 32(2): 154–162.

• Paul, L. A. (2014) Transformative Experience, Oxford University Press.

• Savulescu, J. (2002) “Deaf lesbians, ‘designer disability,’ and the future of medicine,” The British Medical Journal 325: 771–773.