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Pathologizing Values: When Should Patients Be Treated Against Their Will?

Many sufferers of anorexia nervosa — and similar eating disorders — intensely value thinness. They believe that thinness is of the utmost importance, more so than school, work, personal relationships, and their own physical health. Valuing thinness so strongly is harmful not only because of the malnutrition that follows but also because of how it undermines treatment. Treatment for anorexia leads (one way or another) to weight gain. Just as valuing thinness causes people with anorexia to lose weight, it can also cause them to refuse treatment that leads to weight gain.

How should clinicians respond when their patients refuse treatment? One possibility is to treat them against their will. In the case of anorexia, this involves detainment in in-patient facilities, which enforce strict protocols around feeding. In severe cases, it can also involve force-feeding through a tube. But is this ethical? On the one hand, such treatments can help sufferers to improve and prolong their lives. On the other hand, clinicians have a duty to respect their patients’ decision-making autonomy. This means respecting their decisions about what (if any) treatment they will receive — even decisions that seem irrational or harmful.

An illustrative example of the principle of decisional autonomy involves religion. Jehovah’s Witnesses often refuse blood transfusions due to their religious beliefs. That can result in death and could seem unreasonable from the perspective of those outside their faith. Nevertheless, such decisions are generally respected.

To exercise their decision-making autonomy, patients must be able to understand and appreciate the relevant medical facts. Many conditions, like psychosis or dementia, undermine this capacity. In such cases, patients are judged to lack decision-making competence, and coercive treatment is generally seen as warranted. Anorexia is a particularly perplexing case because those who suffer from the disorder often maintain their ability to understand and comprehend their treatment options. They are simply opposed to treatments that undermine their desire to be thin.

The philosopher and clinician Dr. Jacinta Tan advocates for one approach to justifying coercive treatment in the context of anorexia. She argues that the thinness values associated with anorexia are pathological — they belong to the disorder, not the individual. Because they are pathological, they can (and should) be distinguished from the agent’s authentic values, i.e. those that are genuinely her own. So, while someone with anorexia may be able to weigh their options and understand the relevant medical facts, they cannot freely decide on treatment because these (inauthentic) values get in the way.

The history of psychiatry suggests that we should tread carefully when it comes to pathologizing values. In the 1800s, drapetomonia was a supposed mental illness afflicting enslaved Africans. The central symptom was a strong desire to escape from captivity, leading to escape attempts. In trying to escape, these slaves were pursuing something they valued: freedom. But this value (according to certain psychiatrists from the Southern states) was pathological. The case of drapetomania illustrates an important principle: labeling values as pathological has serious consequences. We ought to, therefore, have a strong justification for the label.

Tan and her colleagues suggest basing such judgments on the co-occurrence between mental disorders and values. In the case of anorexia, intense thinness values occur (almost exclusively) in those diagnosed with the disorder, aren’t held before the disorder or after recovery, and their strength correlates with the strength of the disorder. According to Tan and colleagues, this strong co-occurrence between values and disorder justifies attributing thinness values to the disorder, not the person.

The cause of drapetomania illustrates the risk of this approach to pathologizing values. Escaping slaves who risked their lives to escape captivity did so because of their values — they valued freedom over a continued life in captivity, even one that brought (comparable) safety. However, having such a value system (and engaging in the escape behavior that follows from it) is precisely what attracted the ‘drapetomania’ label. Those values occur with drapetomania because having them is partly what it means to have drapetomania.

The same problem applies to anorexia. Intensely valuing thinness (and the resulting weight loss behavior) is deeply intertwined with diagnosis. Anyone who valued thinness with the intensity that anorexia sufferers do would engage in the same weight loss behaviors, therefore meeting the criteria for diagnosis. Co-occurrence tells us something about diagnostic categories but nothing about the authenticity of someone’s values. To dismiss thinness values as inauthentic, we cannot rely on co-occurrence alone.

One way to make progress on this issue is by better understanding the psychological factors that drive thinness values and how such factors relate to decision-making competence. Alternatively, ethicists might turn their attention to a different factor associated with anorexia.

Many sufferers of anorexia hold false beliefs about their body size. Experiments requiring patients to indicate their current size show that they consistently indicate body sizes much larger than their own. Indeed, sufferers of anorexia are often convinced that their bodies are larger than clinicians, family members, and friends insist.

Research suggests that these false beliefs are caused by misleading experiences of body size. Sufferers of anorexia genuinely perceive their bodies as larger than reality due to disturbances in the way their brain represents their body size. Their false beliefs are a natural response to these misleading experiences.

These false beliefs can, in some cases, undermine patients’ decisional competence. Consider an excerpt from an interview with a patient, recorded by Tan and colleagues:

Has the risk of death been mentioned? “Yeah.”

Do you believe these things you’ve been told? “No.”

About the risk of death, do you think it could happen? “Not to me.”

That’s the opinion of doctors, and I wonder why you don’t think it can happen to you. “Because you have to be really thin to die, and I’m fat, so it won’t happen to me.”

In this excerpt, the interviewee cannot understand that the relevant risks apply to them because of their beliefs about their own body size. This relates to an integral feature of decision-making competence. It isn’t enough that patients understand the relevant medical facts; they must also be able to appreciate how those facts apply to them. Some sufferers of anorexia are unable to do so because they don’t believe they are thin.

This illustrates how false beliefs about body size can undermine patients’ ability to reason about treatment, through a different route than what was proposed for thinness values. Tan and colleagues suggested that because thinness values are inauthentic, any treatment decisions that follow from them are similarly inauthentic. Body size beliefs, however, undermine decision-making competence not because they are inauthentic but because they distort sufferers’ reality. In doing so, they rob patients of the capacity to appreciate how medical risks apply to their situation.

It remains to be seen whether the thinness values associated with anorexia undermine sufferers’ decision-making competence and, if so, why. To solve that puzzle, we must understand more about the psychological factors that drive those values. But an equally important feature of anorexia related to decision-making competence is the body size beliefs involved. Such beliefs do not necessarily forfeit a patient’s right to choose their treatment. A clinician would need to probe the extent to which the beliefs are resistant to change and whether they are driving their patient’s treatment refusal. There is still much work needed to understand the relationship between body size beliefs and decision-making competence, but it represents a fruitful topic for future research.

The Scourge of Self-Confidence

photograph of boy cliff-jumping into sea

Our culture is in love with self-confidence — defined by Merriam-Webster as trust “in oneself and in one’s powers and abilities.” A Google search of the term yields top results with titles such as “Practical Ways to Improve Your Confidence (and Why You Should)” (The New York Times), “What is Self-Confidence? + 9 Ways to Increase It” (positivepsychology.com), and “How to Be More Confident” (verywellmind.com). Apparently, self-confidence is an especially valued trait in a romantic partner: a Google search for “self-confidence attractive” comes back with titles like “Why Confidence Is So Attractive” (medium.com), “4 Reasons Self-Confidence is Crazy Sexy” (meetmindful.com), and “6 Reasons Why Confidence Is The Most Attractive Quality A Person Can Possess” (elitedaily.com).

I will argue that self-confidence is vastly, perhaps even criminally, overrated. But first, a concession: clearly, some degree of self-confidence is required to think or act effectively. If a person has no faith in her ability to make judgments, she won’t make many of them. And without judgments, thinking and reasoning is hard to imagine, since judgments are the materials of thought. Similarly, if a person has no faith in her ability to take decisions, she won’t take many of them. And since decisions are necessary for much intentional action, such a person will often be paralyzed into inaction.

Nevertheless, the value that we place on self-confidence is entirely inappropriate. The first thing to note is that behavioral psychologists have gathered a mountain of evidence showing that people are significantly overconfident about their ability to make correct judgments or take good decisions. Representative of the scholarly consensus around this finding is a statement in a frequently-cited 2004 article published in the Journal of Research in Personality: “It has been consistently observed that people are generally overconfident when assessing their performance.” Or take this statement, from a 2006 article in the Journal of Marketing Research: “The phenomenon of overconfidence is one of the more robust findings in the decision and judgment literature.”

Furthermore, overconfidence is not a harmless trait: it has real-world effects, many of them decidedly negative. For example, a 2013 study found “strong statistical support” for the presence of overconfidence bias among investors in developed and emerging stock markets, which “contribut[ed] to the exceptional financial instability that erupted in 2008.” A 2015 paper suggested that overconfidence is a “substantively and statistically important predictor” of “ideological extremeness” and “partisan identification.” And in Overconfidence and War: The Havoc and Glory of Positive Illusions, published at the start of the second Iraq War, the Oxford political scientist Dominic Johnson argued that political leaders’ overconfidence in their own virtue and ability to predict and control the future significantly contributed to the disasters of World War I and the Vietnam War. And of course, the sages of both Athens and Jerusalem have long warned us about the dangers of pride.

To be sure, there is a difference between self-confidence and overconfidence. Drawing on the classical Aristotelian model of virtue, we might conceive of “self-confidence” as a sort of “golden mean” between the extremes of overconfidence and underconfidence. According to this model, self-confidence is warranted trust in one’s own powers and abilities, while overconfidence is an unwarranted excess of such trust. So why should the well-documented and baneful ubiquity of overconfidence make us think we overvalue self-confidence?

The answer is that valuing self-confidence to the extent that we do encourages overconfidence. The enormous cultural pressure to be and act more self-confident to achieve at work, attract a mate, or make friends is bound to lead to genuine overestimations of ability and more instances of people acting more self-confidently than they really are. Both outcomes risk bringing forth the rotten fruits of overconfidence.

At least in part because we value self-confidence so much, we have condemned ourselves to suffer the consequences of pervasive overconfidence. As I’ve already suggested, my proposed solution to this problem is not a Nietzschean “transvaluation” of self-confidence, a negative inversion of our current attitude. Instead, it’s a more classical call for moderation: our attitude towards self-confidence should still be one of approval, but approval tempered by an appreciation of the danger of encouraging overconfidence.

That being said, we know that we tend to err on the side of overconfidence, not underconfidence. Given this tendency, and assuming, as Aristotle claimed, that virtue is a mean “relative to us” — meaning that it varies according to a particular individual’s circumstances and dispositions — it follows that we probably ought to value what looks a lot like underconfidence to us. In this way, we can hope to encourage people to develop a proper degree of self-confidence — but no more than that.

Why Would Anyone Marry?

black and white photograph of "Just Married" in back window of vintage car

“Marriage is wonderful when it lasts forever, and I envy the old couples in When Harry Met Sally who reminisce tearfully about the day they met 50 years before. I no longer believe, however, that a marriage is a failure if it doesn’t last forever. It may be a tragedy, but it is not necessarily a failure. And when a marriage does last forever with love alive, it is a miracle.”

                                                                           —Peggy O’Mara, Mothering

On May 3rd, Bill and Melinda Gates announced their divorce, stating that after lots of “thought and a lot of work on our relationship, we have made the decision to end our marriage,” ending their twenty-seven year union. Whatever their reasons for divorce — the announcement being understandably vague — we should pause here to think about an important philosophical question, namely: why would anyone marry? Choosing to enter into a marriage is among the most consequential decisions one can make, affecting potential future children, well-being and happiness, and so on. A good marriage can be a major blessing, but a bad marriage can be hell.

Here’s a rough argument against marriage: no one wants a loveless marriage; it is something that, if we knew it would happen, would likely encourage us not to wed to begin with — to be stuck in a loveless marriage is a potential horror show. Often enough, the love couples feel for each other, entering a marriage, will fade and sometimes cease. To avoid this fate, we should be reticent prior to taking the vows. As the philosopher, Dan Moller, explains:

“Reduced to a crude sketch, the argument [against marriage] is simply that, (a) most of us view the prospect of being married in the absence of mutual love with something like horror or at least great antipathy; (b) the mutual love between us and our spouse existing at the inception of our marriage may very well fail to persist; and hence (c) when we marry we are putting ourselves in the position of quite possibly ending up in a loveless marriage of the sort we acknowledge to be undesirable.”

What’s partly hard about marrying is that emotions — an essential aspect of romantic love — have an autonomous element, not wholly governed by the will, even with the best of intentions. If romantic love is an essential aspect of marriage, how can marriage vows bind? When you cannot control something, you cannot be culpable for it — we don’t think people culpable for the ocean waves, by example.

Someone may object that marriage vows specify actions, not emotional states, and are thus under our control. As the philosopher, Justin McBrayer, argues:

“Notice how heavily [many generic marriage vows focus] on actions compared to emotions: support one’s partner, honor one’s partner, respect one’s partner, and so on. Even the emotional content is easily understood in a behavioral sense: to be a faithful partner in sickness and health clearly has a behavioral component. To see this, imagine the following thought-experiment. Suppose Landon makes the aforementioned promise to Hannah. Suppose next that he feels all the right things toward her (for example, he is in love with her), but that his behavior is wildly erratic – he sleeps around, is verbally abusive to Hannah, abandons her when she is ill, etc. Would anyone be willing to say that Landon has fulfilled his wedding vow? Surely not.”

There’s only one problem with this: it ignores the fact that emotions, like romantic love, are also essential to marriage. Of course it is clear that marriage vows, and marriage itself, includes the vow to do certain things — many married people expect their partner to be faithful to them, by example. However, it cannot be that actions and behavior is all there is to marriage — without an appropriate emotional component, it is not clear one would be in a marriage they would find fulfilling and satisfying. Imagine a different thought experiment: John treats his wife well, cares for her when ill, never cheats on her, and so forth, but simply doesn’t feel love for her at all. He is a good husband to fulfill his marriage vows because his nagging conscience won’t let him break them. We wouldn’t think though that this is a fulfilling marriage; it likely isn’t one John would have entered into had he known the result would be the death of love for his wife. Whether marriage vows include a behavior aspect is irrelevant — emotions seem a necessary part of marriage too.

So then we must wonder why people would marry — the people who marry usually do not want to end in a loveless marriage. There must be an upside then to marriage; benefits that contribute to our well-being. Likely they partly include the positive emotions many experience, especially in the early days of the marriage. However, there must be more to explain why so many people, despite the risk a bad marriage poses to living a good life, still choose to tie the knot.

It looks like, in addition to a romantic venture, marriage is a commitment device: by imposing costs on dissolving a marriage, the institution of marriage forces individuals to comprise and grow in a manner they wouldn’t if the cost of ‘walking away’ from a relationship were relatively low. And this can do several things: incentivize individuals in a marriage to work together, to engage in personal improvement for the sake of the union and family, provide a more stable environment for rearing kids, and make relationship-specific investments. Think of it like this: often time, but not always, couples will get along if forced to. Imagine, by example, you’re permanently handcuffed to someone — your fate and theirs are bound up. It would then make sense, assuming the other person is reasonable, to make the best of the situation by doing things like getting along and compromising.

This can, of course, be a bad thing if one of the partners is unreasonable; there are downsides to nearly anything. Our point isn’t to claim that marriage is always a good thing — we began the piece by thinking about why anyone would marry — but to highlight some marital benefits; whether the benefits outweigh the costs will likely vary from couple to couple. However, there are some downsides too if the cost of abandoning commitments is too low: it may be harder in some cases to find a long-term relationship if the cost of finding a new partner, whenever one is even remotely dissatisfied, is too low. To illustrate, consider a scene from Season 5, Episode 4 of Seinfeld, where Elaine has just dumped her partner:

JERRY: You’re out of your mind you know that.

ELAINE: What?

JERRY: It’s an exclamation point! It’s a line with a dot under it.

ELAINE: Well, I felt a call for one.

JERRY: A call for one, you know I thought I’ve heard everything. I’ve never heard a relationship being affected by a punctuation.

ELAINE: I found it very troubling that he didn’t use one.

We don’t want to be trapped in a loveless marriage, obviously; but we should worry too if the cost of abandoning our commitments is too low — the ramification of that would extend beyond marriage to, among other moral practices, promises more generally.

Waymo and the Morality of Self-Driving Cars

An image of a Waymo self-driving car.

What was once fiction is becoming a reality. In past decades, sci-fi novels and television have featured self-driving cars; this once-futuristic concept is finally coming to fruition. Will the result mirror the positive outcomes shown in fiction? Self-driving cars are intended to increase safety and efficiency in our society, but what are the moral implications and consequences that could come from such technology?

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