Tuesday, 29 September 2020

Cognitive Transformation, Dementia, and the Moral Weight of Advance Directives

Today's post is by Em Walsh (McGill University).



Em Walsh



The following is a real-life case study of a woman referred to as Mrs Black (Sokolowski 2018, 45-83). Mrs Black received a diagnosis of mid-stage dementia at the age of eighty-five. Mrs Black’s dementia impacted her ability to recall both the names and faces of her family members. Nevertheless, Mrs Black was noted by nurses who cared for her as always being an exceptionally happy woman, who took great pleasure in her daily activities in the residential care home in which she lived. Whilst in care, however, Mrs Black developed a serious bacterial infection, which posed a risk to her life if left untreated. Mrs Black’s primary caregivers wanted to treat the infection, but Mrs Black’s son noted that she had an advance directive stipulating that if she ever developed a condition which resulted in her inability to recognize her family members, she would not wish to receive any medical treatment to prolong her life. Her advance directive was implemented, and Mrs Black died shortly thereafter, leaving the medical team who cared for her devastated (Sokolowski 2018).

The dominant view in the philosophical literature suggests that advance directives, documents which allow individuals to set out directions for their future medical care in the eventuality that they lose decisional capacity (de Boer et al 2010, 202), ought to hold decisive moral weight. Thus, defenders of this view such as, Ronald Dworkin (1994), Jeff McMahan (2005), and Govind Persad (2019) would maintain that the decision made in the case of Mrs Black was the correct one. The reason for this is that such views suggest documents such as advance directives reflect an individual’s judgements about their own lives and should therefore be given significant moral weight, even when the price of so doing is the life of the individual in question.

In my paper, "Cognitive Transformation, Dementia, and the Moral Weight of Advance Directives", I suggest that the dominant philosophical view does not best align with current clinical practice. In current clinical practice, clinician’s show great reluctance to implement advance directives which undermine the dementia patient’s overall well-being. I put forward a philosophical defence of current clinical practice which gives moral weight to the preferences of dementia patients after the onset of their disease. In particular, I use L.A. Paul’s transformative experience framework [Paul 2016] to argue that having dementia is a cognitive transformative experience and that preference changes which arise from this are legitimate and ought to be given moral-weight in medical decision-making.


This paper has been responded to by various bioethicists, clinicians, lawyers, and psychologists. These responses have also been published in the American Journal of Bioethics, and so too has my own response to these open peer commentaries. I invite those interested in the debate to email me if they have any comments or questions, as I would love to continue the dialogue on this issue further.

Tuesday, 22 September 2020

Intellectual Humility and Prejudice

Today's post is by Matteo Colombo, Kevin Strangmann, Lieke Houkes, Zhasmina Kostadinova and Mark J. Brandt.

Matteo
Matteo

How does intellectual humility relate to prejudice? If I am more intellectually humble than you are, will I also be less prejudiced? Some would say yes. In much of the early monastic Christian tradition, for example, humility is understood as a virtuous form of abasement grounded in self-knowledge and self-appraisal. In his Demonstrations, Aphrahat the Persian Sage—a Syriac Christian author of the third-fourth century—writes that “humility is the dwelling place of righteousness. Instruction is found with the humble, and their lips pour forth knowledge. Humility brings forth wisdom and understanding.” Aphrahat’s suggestion that intellectual humility is the antidote to vanity, pride, and prejudice, is representative of one traditional way of understanding this character trait.


Mark
Mark

Some would say no. The idea is that the self-abnegation and abasement constituting humility are not virtuous, since they can reinforce existing structures of oppression and self-denigration. In Section IX of An Enquiry Concerning the Principles of Morals, David Hume, for example, includes humility in his list of “monkish virtues,” which “stupefy the understanding and harden the heart, obscure the fancy and sour the temper.” According to Hume’s view, being intellectually humble is generally a vice, which need not weaken one’s pride and prejudices against others. Contributing to the recent boom of philosophical and psychological work on intellectual humility, our paper “Intellectually Humble, but Prejudiced People. A Paradox of Intellectual Virtue” presents four empirical studies that clarify the relationship between intellectual humility and prejudice. We find support for three conclusions.

First, people are prejudiced towards groups perceived as dissimilar. If I perceive you belong to a group very different from the type of human I happen to be, then I will probably dislike you, even if I know nothing about you.


Lieke
Lieke

Second, intellectual humility weakens the association between perceived dissimilarity and prejudice. This suggests that intellectual humility helps break the link (or at least weaken the link) between seeing a group as dissimilar and prejudice. Aphrahat could use such a finding as an empirical basis for his account of humility.

Third, and paradoxically, more intellectual humility is associated with more prejudice overall. When looking across groups who are perceived as most similar to most dissimilar people with more intellectual humility express more prejudice towards these groups than people with less intellectual humility. Intellectual humility might make prejudice more severe! Such a finding might help Hume ground his view empirically.


Kevin
Kevin

When juxtaposed, these three conclusions suggest that we should not think about Aphrahat vs. Hume, but rather Aphrahat and Hume. Both are identifying some truth of intellectual humility. From our studies, we believe that whether and how intellectual humility emerges and a virtue or a vice likely depends on the situation or the target of judgment.

Evaluating when and to what extent intellectual humility promotes (or hinders) the attainment of certain epistemic goods requires we clarify its mechanism, its causal relationships with other beliefs, attitudes and traits, and the functions it performs across different situations.


Zhasmina
Zhasmina

Tuesday, 15 September 2020

Belief's Minimal Rationality

Today's post is by Marianna Bergamaschi Ganapini who talks about a recently published article in Philosophical Studies.




In this paper, I defend the claim that a mental attitude is a belief if it shows at least a minimal degree of doxastic rationality. More specifically, beliefs are minimally rational in the sense that they respond to perceived irrationality by re-establishing internal coherence (or at least by clearly attempting to do so).

A traditional view in philosophy is that it is a necessary condition for being a belief that an attitude behaves largely in a rational way (I call this view “Traditionalism”). That it, belief is typically (i) an attitude sensitive to the relevant evidence. It is also (ii) inferentially connected with other beliefs and other mental attitudes (e.g. emotions), and (iii) it typically causes actions when linked to a relevant desire.

Contrary to this view, there is now strong empirical evidence that that some of the attitudes that we comfortably call ‘beliefs’ show signs of doxastic irrationality: they are at times behaviorally inert, immune to counter-evidence, or inferentially compartmentalized. The Traditionalist approach would definitely exclude these attitudes from the category ‘belief’.

This has led some philosophers to reject Traditionalism and propose a much more lenient approach (Bortolotti, 2010). On this “Revisionist” view, for attitude A to be a belief, it suffices that A is expressed through a sincere assertion. That means that for the Revisionist, it is not expected that beliefs will behave in a mostly rational way: some beliefs show the same immunity to evidence and behavioral inertness we see with other attitudes such as imagination and acceptance.

Unfortunately, using sincere assertion as the mark of belief, is not the enough to uniquely individuate beliefs: people sincerely assert that p even when they mistakenly take themselves to believe that p. The Revisionist proposal is thus at risk of inflating the category ‘belief’ to include attitudes that are not in fact beliefs.

 

The view I propose in the paper is a midway position between Traditionalism and Revisionism.

On this view, irrational, inert, and patchy beliefs are possible, but belief’s key marker is exemplified in its reaction to irrationality. This reaction shows that belief is at least minimally rational in the following ways. One: minimal rational constrains will aim at establishing internal coherence (e.g. by eliminating one of the conflicting attitudes). Second: this kind of rational constrains will be applied when doxastic irrationality is detected.

In the paper, I refer to empirical evidence supporting my view while also showing that it is compatible with different kinds of mental architectures. This approach also offers a plausible picture of what makes belief unique: when belief’s fragmentation and irrationality are revealed, there will be a contrary push for coherence.

In contrast, attitudes such as imagination are governed by a decoupling mechanism that allows our imaginative episodes to be compartmentalized (Bayne 2010; Leslie 1987). Compartmentalization in the case of imagination (supposition, or acceptance) allows us to engage in complicated hypothetical reasoning by keeping track of multiple possible scenarios at the same time. In contrast, belief’s push for coherence applies across the board and tries to prevent the kind of fragmentation we see with imagination and the rest (Currie & Ravenscroft 2002).

Tuesday, 8 September 2020

Delusion Formation as an Inevitable Consequence of a Radical Alteration in Lived Experience

This post is by Rachel Gunn summarising an article co-authored with Michael Larkin and published in Psychosis. The article is based on Rachel's PhD work at Birmingham. The research findings and conclusions, framed in terms of the Enactive Approach, are a move towards a need for understanding the phenomenology of a person’s experience in terms of sense-making within a person-environment system.


Rachel Gunn


A person ordinarily understands and negotiates the world based on familiar patterns derived from her cultural and historical experience. She is born into a family, the family consists of particular relationships and the family lives within a relatively circumscribed culture. Humans are flexible and adaptive. The difference between the lived experience of a hunter-gatherer in the Amazon Rainforest and an investment banker in the City of London highlights this flexibility. 

 There might be circumstances under which an alteration in a person’s lived experience would be so radical that rapid adjustment is not possible (Parnas & Handest, 2003) and when someone becomes mentally ill, there are many factors that might contribute to this (see Bentall, 2016 for an extensive list of candidates). People are dynamic and complex, and in most cases, so are the factors that causally contribute to their psychological distress.


Drawing on interviews conducted with people experiencing clinically significant delusions and analysing the data using Interpretative Phenomenological Analysis (IPA), we show how this alteration in lived experience manifests as emotional, affective and/or perceptual anomalies. 

Writing about IPA Smith and colleagues use Heidegger’s notion of appearing and liken interpretation to a kind of detective work where the researcher is mining the material for possible meanings, thus allowing the phenomenon of interest to shine forth (Smith et al., 2009, p. 35). The double hermeneutic means that the researcher is always trying to make sense of the participant, who is in turn trying to make sense of what is happening in the context of her lifeworld as an embodied, situated person.

For example, one research participant (who I have called Andrew) was severely bullied at work and described it thus:

It’s that awful. You’ve seen the original ‘Planet of the Apes’… film, 1964 I think it is with Charlton Heston… and you know how he’s treated during it? Management treat you the… similar to that. That’s how it felt.

(In the film ‘Planet of the Apes’ human beings are treated like animals, used for slave labour, kept in cages and experiments are done on them.)

This constituted a radical alteration in his experience and his world-view. He had never experienced anything like this before and could not really understand what was happening or why it was happening to him. He went on to develop voice-hearing experiences which he described as God talking to him – these experiences assured him that justice would be done and perhaps prevented him from feeling utterly powerless in an impossibly difficult and distressing work situation.

The framework of the Enactive Approach posits that a person interacts with her environment in terms of sense-making and a vast array of factors (biological, psychological and environmental) are intermeshed to create a ‘person-environment system’. A person is not a discrete object; persons are comprised of bodies, stories, concepts, origins, commitments, connections, affordances - and so on - and are constantly reacting with their environment. 

Cognition emerges from the complex mereology of these many components. The mereology of the cognising (person-environment) system supposes that the parts (which include relational and environmental parts as well as bodily (person-level) parts) are arranged in a particular way, and that the relationship of the parts to each other is vital for the function of the whole (Varela et al., 1991).

From a clinical perspective, this demands an attempt to understand the phenomenology of the experience.

In this context the focus of treatment might then be directed towards affective, perceptual and emotional aspects of a person’s lived experience as well as environmental and relational factors. To think of delusion simply in terms of ‘false beliefs’ which are ‘firmly sustained despite… obvious proof or evidence to the contrary…’ (DSM-V, American Psychiatric Association, 2013, p. 819) is to limit them to cognitive anomalies, over-simplify the experience and deny the meaning an experience might hold for a given individual. 

There is a wide literature on the nature of stigma in mental illness (see for example Canadian Health Services Research Foundation, 2013; Mehta & Farina, 1997) and framing delusion formation in this way helps us to reduce stigma: how can a person who is doing her best to make sense of her world be ‘at fault’ or ‘bad’? 

We suggest that if the alteration in lived experience is sufficiently radical, then delusion formation is inevitable. A person strives for sense-making in whatever environment she finds herself. We are all susceptible to this possibility. 


Tuesday, 1 September 2020

Delusions as Hetero-Dynamic Property Clusters

Today's post is by Shelby Clipp. If you want to know more, check her thesis, "Delusions as Hetero-Dynamic Property Clusters."



The standard position about the nature of delusions is doxasticism, according to which delusions are best characterized as a type of belief. However, the features of clinical delusions often differ from those typically associated with belief. For example, delusions tend to be highly resistant to counterevidence; and unlike typical beliefs they tend to exhibit limited or inconsistent behavioral guidance.

The discrepancy between the features of delusions and ‘normal’ beliefs has inspired an ongoing debate between doxasticists: those who take delusions to be beliefs and non-doxasticists: those who take delusions to be instances of some other kind of state, such as imaginings or acceptances. In my thesis, “Delusions as Hetero-Dynamic Property Clusters,” I refer to this debate as the doxastic status debate. Despite efforts, the doxastic status debate remains unresolved.

I’ve argued that this is in part because as the debate stands, it fits the bill for what Chalmers’s (2011) has described as a largely verbal dispute -- a dispute in which two parties agree on all of the relevant facts about a domain in question yet disagree on whether a certain term applies to a particular object of that domain. I attempt to advance the debate into more substantive territory, by putting forward the hetero-dynamic property cluster (HDPC) model, a new descriptive model for characterizing delusions.

I develop the HDPC model against the background of Boyd’s (1991) homeostatic property cluster (HPC) approach to categories, according to which category membership is determined by a cluster of features which tend to mutually reinforce each other. On this view, states such as beliefs and imaginings are each HPCs. An example of such reinforcement is the way in which the responsiveness to evidence of beliefs tends to enable it to guide behavior productively.

However, on the HDPC model, delusions are best understood as mental states characterized by an odd and unstable cluster of features: Odd, insofar as unlike with attitudes such as beliefs and imaginings, the combinations of features characteristic of delusions tend to resist one another rather than reinforce. For instance, unlike with beliefs which tend to be revised in light of counterevidence, an individual with Capgras delusion might cling to the assertion that their spouse is an impostor despite ample counterevidence, and this resistance to counterevidence subsequently creates problems for letting that state guide behavior -- e.g., one won’t find their ‘actual’ wife by searching for her.

By not reinforcing one another, the features of delusions are unstable in that there’s nothing to hold them together as a cluster, so to speak. This instability essentially loosens restrictions on the mental state’s movement both within the property space of a particular attitude and among one property space to another, thereby allowing the features of an HDPC attitude to freely waver between distinct property clusters. To some extent then, delusion’s odd and unstable nature has served as a catalysis to the doxastic status debate in that it inexorably contributes to delusion’s failure to resolve neatly into any one kind of more familiar cognitive attitude.