Demian Whiting

Standing up for an affective account of emotion

This paper constitutes a defence of an affective account of emotion. I begin by outlining the case for thinking that emotions are just feelings. I also suggest that emotional feelings are not reducible to other kinds of feelings, but rather form a distinct class of feeling state. I then consider a number of common objections that have been raised against affective accounts of emotion, including: (1) the objection that emotion cannot always consist only of feeling because some emotions—for example, indignation and regret—necessarily have a cognitive component (say, the perception of a lost opportunity in the case of regret); (2) the objection that emotion cannot consist only of feeling because in order to explain how emotions have intentional objects we will have to recognise that emotion consists of cognition; and (3) the objection that emotion cannot consist only of feeling because emotion, but not feeling, can be variously assessed or evaluated. However, I demonstrate how an affective account of emotion might be successfully defended against all of the objections that are cited.

The ethics of distress: Toward a framework for determining the ethical acceptability of distressing health promotion advertising

Distressing health promotion advertising involves the elicitation of negative emotion to increase the likelihood that health messages will stimulate audience members to adopt healthier behaviors. Irrespective of its effectiveness, distressing advertising risks harming audience members who do not consent to the intervention and are unable to withdraw from it. Further, the use of these approaches may increase the potential for unfairness or stigmatization toward those targeted, or be considered unacceptable by some sections of the public. We acknowledge and discuss these concerns, but, using the public health ethics literature as a guide, argue that distressing advertising can be ethically defensible if conditions of effectiveness, proportionality necessity, least infringement, and public accountability are satisfied. We do not take a broad view as to whether distressing advertising is ethical or unethical, because we see the evidence for both the effectiveness of distressing approaches and their potential to generate iatrogenic effects to be inconclusive. However, we believe it possible to use the current evidence base to make informed estimates of the likely consequences of specific message presentations. Messages can be pre-tested and monitored to identify and deal with potential problems. We discuss how advertisers can approach the problems of deciding on the appropriate intensity of ethical review, and evaluating prospective distressing advertising campaigns against the conditions outlined.

Qualitative analysis of how patients decide that they want risk-reducing mastectomy, and the implications for surgeons in responding to emotionally-motivated patient requests

Objective Contemporary approaches to medical decision-making advise that clinicians should respect patients’ decisions. However, patients’ decisions are often shaped by heuristics, such as being guided by emotion, rather than by objective risk and benefit. Risk-reducing mastectomy (RRM) decisions focus this dilemma sharply. RRM reduces breast cancer (BC) risk, but is invasive and can have iatrogenic consequences. Previous evidence suggests that emotion guides patients’ decision-making about RRM. We interviewed patients to better understand how they made decisions about RRM, using findings to consider how clinicians could ethically respond to their decisions. Methods Qualitative face-to-face interviews with 34 patients listed for RRM surgery and two who had decided against RRM. Results Patients generally did not use objective risk estimates or, indeed, consider risks and benefits of RRM. Instead emotions guided their decisions: they chose RRM because they feared BC and wanted to do ‘all they could’ to prevent it. Most therefore perceived RRM to be the ‘obvious’ option and made the decision easily. However, many recounted extensive post-decisional deliberation, generally directed towards justifying the original decision. A few patients deliberated before the decision because fears of surgery counterbalanced those of BC. Conclusion Patients seeking RRM were motivated by fear of BC, and the need to avoid potential regret for not doing all they could to prevent it. We suggest that choices such as that for RRM, which are made emotionally, can be respected as autonomous decisions, provided patients have considered risks and benefits. Drawing on psychological theory about how people do make decisions, as well as normative views of how they should, we propose that practitioners can guide consideration of risks and benefits even, where necessary, after patients have opted for surgery. This model of practice could be extended to other medical decisions that are influenced by patients’ emotions.

Abortion and referrals for abortion: is the law in need of change?

The Abortion Act 1967 provides doctors working in Great Britain (but not Northern Ireland which is governed by separate legislation [1]) the legal right to refuse to terminate pregnancies on grounds of conscience, exempting cases where a woman’s life or mental or physical health is at grave risk if pregnancy continues [2]. However, doctors who refuse to abort on grounds of conscience must refer the woman promptly to ‘a provider of primary medical services who does not have such conscientious objections’ if that is the woman’s wish [3]. In a paper published in this journal, Daniel Hill argues that the legal status quo is unacceptable and that the conscientious objection clause should extend to referrals for abortion [1]. This is because Hill believes that it is unsatisfactory for the law to allow doctors to refuse to terminate but not to refuse to refer given that many doctors who are opposed to non-emergency abortions will be opposed also to any action that aids or abets non-emergency abortion, including the action of referral for abortion. In Hill’s words: [It] is unsatisfactory to legislate that nobody may be legally obliged to participate in the treatment . . . for a nonemergency termination of pregnancy while simultaneously insisting that some may be legally obliged to refer people on for such a termination: many of those that have a conscientious objection to participating in a non-emergency abortion will also have a conscientious objection to referring on for such an abortion. ([1], p. 347) It should be emphasized that Hill’s argument is an argument about the rights of doctors and what protections should be afforded to doctors by law. It is in no way an argument about the protection that should be afforded to fetuses. Indeed, Hill’s argument, if successful, should be accepted by someone who believes that fetuses should be afforded no protection in law at all. This is an important point to bear in mind because it is crucial to avoid making claims about the moral status of fetuses in defence of the view that doctors should be allowed to refuse to refer on grounds of conscience (as, for instance, we would be doing if we stated that it is absolutely wrong for the law to require doctors to refer for abortion because referral is morally equivalent to sending people to an extermination camp). The issue is that of whether a doctor’s conscientious objection to what is otherwise required or allowed by law (namely to refer) should be protected, and not that of whether what is otherwise required or allowed by law itself needs changing (which would be the issue if someone resorted to making claims about the moral status of fetuses, for instance). For the purpose of this paper, I accept that many doctors who are opposed to abortion will also be opposed to referral for abortion (although it is not my view that all or even most doctors who are opposed morally to abortion will be opposed morally to referral, even if it is the case that morally speaking the two actions are on a par and therefore should both be morally opposed if they are to be opposed). I accept also that the objections that Hill considers in his paper to his position fail to overturn his position ([1], pp. 348–349). However, in this paper I raise a different objection to those considered by Hill. Hill assumes that the law should allow people to exercise moral consistency in their behaviours, but in his paper gives no positive argument for his position. This is a serious problem for Hill’s position because there is a very compelling alternative account of the law, one that is associated with John Stuart Mill [4], according to which it would not be acceptable for the law to always allow people to exercise moral consistency in their behaviours. And once the law is thought of in this alternative way, I think we will come to see that it is not at all obvious that it is wrong for the law to allow doctors to refuse to terminate on grounds of conscience but not to refuse to refer on conscientious grounds. The function of law account I have in mind can be traced to John Stuart Mill [4], but is to be found also in the works of more recent philosophers and legal theorists, including Joel Feinberg [5] and Journal of Evaluation in Clinical Practice ISSN 1365-2753

Serious professional misconduct and the need for an apology

In this paper I argue that doctors who are found guilty of serious professional misconduct should be required to apologize as a condition of their registration. I argue that such a requirement is to be justified on the basis of the need to protect patients, maintain public confidence in the profession, and declare and uphold proper standards of conduct and behaviour. I also answer an objection that might be made to the position I defend. Finally, I consider whether there should be any exceptions to the demand for an apology from doctors who have been found guilty of serious professional misconduct.

Should doctors ever be professionally required to change their attitudes

The General Medical Council instructs doctors not to allow their personal beliefs to interfere with their practice. But if attitudes can threaten to impact negatively on a doctors practice then the question arises: should doctors ever be professionally required to change their attitudes? In this paper I suggest that doctors should be required to amend their attitudes if two conditions are met, namely: (1) the doctor has an attitude that if neglected by the doctor will (or is very likely to) compromise his or her fitness to practise; and (2) the only way in which the doctor can prevent that attitude from compromising his or her fitness to practise is by changing the attitude. I also answer three objections that might be raised against the position that I advance.

Emotion as the categorical basis for moral thought

Abstract I offer and develop an original answer to the question of whether emotion plays an important role in the formation of moral thought. In a nutshell, my answer will be that if motivational internalism provides us with a correct description of the nature of moral thought, then emotion plays an important role because emotion is required to explain or ground the behavioral dispositions that are involved in moral thought.

Evaluating medico-legal decisional competency criteria.

In this paper I get clearer on the considerations that ought to inform the evaluation and development of medico-legal competency criteria—where this is taken to be a question regarding the abilities that ought to be needed for a patient to be found competent in medico-legal contexts. In the “Decisional Competency in Medico-Legal Contexts” section I explore how the question regarding the abilities that ought to be needed for decisional competence is to be interpreted. I begin by considering an interpretation that takes the question to be asking about the abilities needed to satisfy an idealized view of competent decision-making, according to which decisional competency is a matter of possessing those abilities or attributes that are needed to engage in good or effective or, perhaps, substantially autonomous or rational decision-making. The view has some plausibility—it accords with the way decisional competency is understood in a number of everyday contexts—but fails as an interpretation of the question regarding the abilities that should be needed for decisional competence in medico-legal contexts. Nevertheless, consideration of why it is mistaken suggests a more accurate interpretation and points the way in which the question regarding the evaluation of medico-legal competency criteria is to be answered. Building on other scholarly work in the area, I outline in the “Primary and Secondary Requirements” section several requirements that decisional competence criteria ought to satisfy. Then, in the “Applying the Framework” section, I say something about the extent to which medico-legal competency criteria, as well as some models of decisional competency proposed in the academic literature, fulfil those requirements.