Steve Matthews

Practitioners of person-centred care (PCC) for people living with dementia aspire to preserve and honour personhood through respect, relational care, and the promotion of agency and interests; yet its practical realisation often falters. This paper isolates an important moral-psychological element required for PCC’s fulfilment: the professional stance of compassionate understanding. Drawing upon philosophical analysis and empirical literature, the paper conceives this stance as a capacity combining enlightened compassion with four aspects of ethically informed care: forbearance, moral perception, skilled virtue, and empowerment. Compassionate understanding reconciles emotional attunement with the disciplined detachment required for professional endurance, thereby mitigating burnout while sustaining moral sensitivity and integrity. Grounded in an examination of dementia care practices, the paper argues that compassionate understanding constitutes an ethically desirable framework through which person-centred norms are realised.

The trauma and anguish professional people encounter in their work over time can lead to losses in competence and occupational burnout. However, the practice of detachment designed to avoid these outcomes can tip over into losses in the ability to connect with clients, and even to alienation from the professional role itself. Some have thought that the proper regulation of levels of empathic concern ensures a balance between these two poles. I argue against this and instead advocate for a stance I call compassionate understanding. I contend that this best achieves sustained professionalism while remaining morally attuned to the norms of one’s occupation. I focus on health care to illustrate what is at stake in compassionate understanding, though the position I defend has applications across a significant range of professions.

The trauma and anguish professional people encounter in their work over time can lead to losses in competence and occupational burnout. However, the practice of detachment designed to avoid these outcomes can tip over into losses in the ability to connect with clients, and even to alienation from the professional role itself. Some have thought that the proper regulation of levels of empathic concern ensures a balance between these two poles. I argue against this and instead advocate for a stance I call compassionate understanding. I contend that this best achieves sustained professionalism while remaining morally attuned to the norms of one’s occupation. I focus on health care to illustrate what is at stake in compassionate understanding, though the position I defend has applications across a significant range of professions.

Jennifer Blumenthal-Barby (2024) has called for bioethics to end talk about personhood, asserting that such talk has the tendency to confuse and offend. It will be argued that this has only limited application for (largely) private settings. However, in other settings, theorizing about personhood leaves a gap in which there is the risk that the offending concept will get uptake elsewhere, and so the problem Blumenthal-Barby nominates may not be completely avoided. In response to this risk, an argument is presented in support of the idea that the role of philosophers and bioethicists, far from ending talk of personhood, ought to be to clarify the concept, and to do so in nuanced ways, given its application for specific kinds of impairments. The case of dementia is used to illustrate this in the context of person-centered care. Ironically, given the stigma attached to dementia, far from the need to end talk of personhood, bioethicists are needed to rescue the concept and clarify its role.

According to a Kantian conception truthfulness is characterised as a requirement of respect for the agency of another. In lying we manipulate the other’s rational capacities to achieve ends we know or fear they may not share. This is paradigmatically a failure of respect. In this paper we argue that the importance of truthfulness also lies in significant part in the ways in which it supports our agential need to make sense of the world, other people, and ourselves. Since sense-making is something we do together, and that we can support or undermine, it generates norms of interaction that constitute a further, distinct, mode of recognition and respect for another’s agency. But the requirements of truthfulness and support for sense-making sometimes conflict. Through a series of cases, we analyze why and when a rigid insistence on truthfulness is disrespectful of the other and undermining of their agency.

We argue that contemporary conceptualizations of “persons” have failed to achieve the moral goals of “person-centred care” (PCC, a model of dementia care developed by Tom Kitwood) and that they are detrimental to those receiving care, their families, and practitioners of care. We draw a distinction between personhood and selfhood, pointing out that continuity or maintenance of the latter is what is really at stake in dementia care. We then demonstrate how our conceptualization, which is one that privileges the lived experiences of people with dementia, and understands selfhood as formed relationally in connection with carers and the care environment, best captures Kitwood’s original idea. This conceptualization is also flexible enough to be applicable to the practice of caring for people at different stages of their dementia. Application of this conceptualization into PCC will best promote the well-being of people with dementia, while also encouraging respect and dignity in the care environment.

The destruction and pollution of the natural environment poses two problems for philosophers. The first is political and pragmatic: which theory of the environment is best equipped to impact policymakers heading as we are toward a series of potential ecocatastrophes? The second is more central: On the environment philosophers tend to fall either side of an irreconcilable divide. Either our moral concerns are grounded directly in nature, or the appeal is made via an anthropocentric set of interests. The lack of a common ground is disturbing. In this paper I attempt to diagnose the reason for this lack. I shall agree that wild nature lacks features of intrinsic moral worth, and that leaves a puzzle: Why is it once we subtract the fact that there is such a lack, we are left with strong intuitions against the destruction and/or pollution of wild nature? Such intuitions can be grounded only in a strong sense of aesthetic concern combined with a common-sense regard for the interests of sentient life as it is indirectly affected by the quality of the environment. I suggest also that of the positions on offer, a hybrid theory of the environment is best suited to address our first problem, that of having an effective influence in the polity.

Soofi1 aims to develop an account of dignity in dementia care based on Nussbaum’s capabilities approach. He does this by drawing on the Kitwood and Bredin2 list of well-being indicators, in order to fill out her account of human flourishing to cover aspects such as practical reasoning that appear beyond the reach of those with relatively severe dementia. As Soofi points out, Nussbaum’s claim that such lost abilities can be compensated through guardianship measures is implausible. He asserts in response that his account of dignity is sufficient to address the desiderata he sets out at the start, including especially the problem of exclusionary implications any putative account should address. So far, so good, but an objection Soofi raises for his own account is that it seems unable to cover cases of severe late-stage dementia. His response is, > …that there is insufficient factual evidence to suggest that people at the very advanced stages of dementia lose all capabilities. But for the sake of argument, let’s suppose that this is true. This, however, still does not undermine the conceptual rigour of the modified version of Nussbaum’s account. This is because the list of the dementia-specific capabilities that I …

The decline in autobiographical memory function in people with Alzheimer’s dementia has been argued to cause a loss of self-identity. Prior research suggests that people perceive changes in moral traits and loss of memories with a “social-moral core” as most impactful to the maintenance of identity. However, such research has so far asked people to rate from a third-person perspective, considering the extent to which hypothetical others maintain their identity in the face of various impairments. In the current study, we examined the impact of perspective, comparing first- and third-person perspectives, as well as memory type. This online study asked 201 participants to consider hypothetical scenarios in which either themselves or another person experienced different types of memory failures associated with a diagnosis of AD. For each scenario, participants rated the degree to which the depicted individual remained the same person, and how impactful the impairment was. Social semantic memory failures – involving failures to recognise a loved one – were rated as most detrimental to self-continuity, and procedural memory failures the least. Averaged across all memory types, people considered their own and their partner’s self-continuity to be more resilient to memory failures than that of a parent or stranger. However, this pattern was reversed for some memory types: forgetting semantic or episodic information about close relationships was rated as more detrimental from a first-person than third-person perspective. Our findings suggest that perspective and type of memory impairment interact to impact judgements about the extent to which people maintain their identity when they experience dementia, and highlight the importance of social relationships to maintaining a sense of self.

BackgroundViral pandemics present a range of ethical challenges for policy makers, not the least among which are difficult decisions about how to allocate scarce healthcare resources. One important question is whether healthcare workers should receive priority access to a vaccine in the event that an effective vaccine becomes available. This question is especially relevant in the coronavirus pandemic with governments and health authorities currently facing questions of distribution of COVID-19 vaccines.Main textIn this article, we critically evaluate the most common ethical arguments for granting healthcare workers priority access to a vaccine. We review the existing literature on this topic, and analyse both deontological and utilitarian arguments in favour of HCW prioritisation. For illustrative purposes, we focus in particular on the distribution of a COVID-19 vaccine. We also explore some practical complexities attendant on arguments in favour of HCW prioritisation.ConclusionsWe argue that there are deontological and utilitarian cases for prioritising HCWs. Indeed, the widely held view that we should prioritise HCWs represents an example of ethical convergence. Complexities arise, however, when considering who should be included in the category of HCW, and who else should receive priority in addition to HCWs.

It is ordinarily thought that in Alzheimer's dementia, memory loss leads to a loss of the self. There is a familiar sense in which this is true given that there is, evidently, a close connection between episodic memory and personal identity. This view goes back to John Locke who argued that remembering our own experiences enabled the continuity of consciousness he thought constitutive of personal identity. Locke was also motivated by the idea—to be applied in "forensic" contexts—that continuity of consciousness was necessary in the appropriation of past actions as one's own. As we will see there is another type of connection between a person's psychology and morality—not involving questions of...

_ Source: _Page Count 22 Analysis of the concept of habit has been relatively neglected in the contemporary analytic literature. This paper is an attempt to rectify this lack. The strategy begins with a description of some paradigm cases of habit which are used to derive five features as the basis for an explicative definition. It is argued that habits are social, acquired through repetition, enduring, environmentally activated, and automatic. The enduring nature of habits is captured by their being dispositions of a certain sort. This is a realist account of habits insofar as the dispositions put forward must fit into some recognizable underlying system – in the case of humans a biological system – to fill the role as set out by the definition. This role is wide-ranging; in addition to the familiar cases of habitual behavior, habitual activities also include thinking, perceiving, feeling, and willing.

_ Source: _Page Count 22 Analysis of the concept of habit has been relatively neglected in the contemporary analytic literature. This paper is an attempt to rectify this lack. The strategy begins with a description of some paradigm cases of habit which are used to derive five features as the basis for an explicative definition. It is argued that habits are social, acquired through repetition, enduring, environmentally activated, and automatic. The enduring nature of habits is captured by their being dispositions of a certain sort. This is a realist account of habits insofar as the dispositions put forward must fit into some recognizable underlying system – in the case of humans a biological system – to fill the role as set out by the definition. This role is wide-ranging; in addition to the familiar cases of habitual behavior, habitual activities also include thinking, perceiving, feeling, and willing.

Addictions are commonly accompanied by a sense of shame or self-stigmatization. Self-stigmatization results from public stigmatization in a process leading to the internalization of the social opprobrium attaching to the negative stereotypes associated with addiction. We offer an account of how this process works in terms of a range of looping effects, and this leads to our main claim that for a significant range of cases public stigma figures in the social construction of addiction. This rests on a social constructivist account in which those affected by public stigmatization internalize its norms. Stigma figures as part-constituent of the dynamic process in which addiction is formed. Our thesis is partly theoretical, partly empirical, as we source our claims about the process of internalization from interviews with people in treatment for substance use problems.

Though famously Derek Parfit is known for his reductionism about persons, he does, in fact, also profess a form of realism about persons based on the way the language of persons and personal identity is used. We might say that Parfit is an ontological reductionist about persons but not a conceptual reductionist. In this discussion note I try to bring out a difficulty for this kind of hybrid view by showing that there are many ways – too many in fact – in which we use the language of persons and personal identity that cannot be reconciled with the core of Parfitian ontological reductionism. If it is true that the kind of reconciliation Parfit and his followers assent to is untenable, then a stark choice is presented between reductionism and a repudiation of most, if not all vestiges of realism. A genuine reductionist ought to choose against the latter.

In this article I argue that insanity defences such as M’Nagten should be abolished in favour of a defence of failed agency. It is not insanity per se, or any other empirical condition, which constitutes the moral reason for exculpation. Rather, we should first recognize the conditions for being a responsible moral agent. These include some capacity to direct and control one’s behavior, a non-delusional component, and the capacity to recognize that one’s behavior is expressive of what they have reason to be doing. When either of these fail in a case involving alleged criminal behavior the defence of failed agency may be appealed to. There may be many causes, including and besides insanity, that give rise to use of the defence of failed agency.

We will analyze the concept of anonymity, along with cognate notions, and their relation to privacy, with a view to developing an understanding of how we control our identity in public and why such control is important in developing and maintaining our social selves. We will take anonymity to be representative of a suite of techniques of nonidentifiability that persons use to manage and protect their privacy. At the core of these techniques is the aim of being untrackable; this means that others lack the information they would need either to intrude physically upon me or to discover some private facts about me. Anonymity often enough goes together with privacy, but not always. Consider a person walking down a foreign street. It is not a physically private situation but no one there knows who you are. On the other hand, when I cast a postal vote, this act is both private and anonymous. Privacy and anonymity seem to go together because of the way each protects something importantly personal, but their coming apart suggests a difference both in what they mean and in our purposes for securing them. A lot has been written about privacy, and deservedly so; there is reason to think anonymity, and its cognates, important as well

Dissociative Identity Disorder (DID) (formerly known as Multiple Personality Disorder) is a condition in which a person appears to possess more than one personality, and sometimes very many. Some recent criminal cases involving defendants with DID have resulted in "not guilty" verdicts, though the defense is not always successful in this regard. Walter Sinnott-Armstrong and Stephen Behnke have argued that we should excuse DID sufferers from responsibility, only if at the time of the act the person was insane (typically delusional); otherwise the presumption should be that persons with DID are indeed responsible for their actions. We find their interpretation of DID and of the way in which the requirements for criminal insanity relate to this condition worrying and likely to result in injustice to DID sufferers. Our thesis is that persons with DID cannot be responsible for their actions if the usual features of the condition are present. A person with DID is a single person in the grip of a very serious mental disorder. By focusing on the features of DID which have, as we argue, the effect of deluding the patient, we try to show that such a person is unable to fulfill the ordinary conditions of responsible agency (namely, autonomy and self-control).

Significant numbers of people believe that victims of violent crime are blameworthy in so far as they imprudently place themselves in dangerous situations. This belief is maintained and fuelled by ongoing social commentary. In this paper I describe a recent violent criminal case, as a foil against which I attempt to extract and refine the argument based on prudence that seems to support this belief. I then offer a moral critique of what goes wrong when this argument, continually repeated as social commentary, is left unchallenged. The effect of failing to challenge this repeated argument is the view, held by many, that the vulnerable are imprudent; indeed, they are believed negatively responsible (partly or wholly) for the violence wrought upon their person. My central claim is that public declarations of blame are morally problematic partly because they focus responsibility away from perpetrators, and partly because they harm vulnerable citizens who, as a result of internalising such public blame, suffer unnecessary constraints on their liberty

The quality of our public discourse – think of the climate change debate for instance – is never very high. A day spent observing it reveals a litany of misrepresentation and error, argumentative fallacy, and a general lack of good will. In this paper I focus on a microcosmic aspect of these practices: the use of two types of argument – the argumentum ad hominem and appeal to authority – and a way in which they are related. Public debate is so contaminated by the misuse of the ad hominem tactic that it is important to have an understanding of one of the ways in which its use may be legitimate. So readers who might have expected an analysis of the ad hominem fallacy will, on the contrary, be presented with an account of one of the places for its potential success. In ad hominem, arguers are viewed as legitimate constitutive targets for their own argument; in authority arguments, arguers provide a legitimate constitutive warrant for an argument they deploy. These types of argument are connected in so far as the identities of persons deploying them carry the cognitive weight of the argument. If authority arguments sometimes deserve to succeed, ad hominem attacks on them are potentially legitimate. An important motivation for this analysis is that in identifying the success conditions for one of the ad hominem types we attain some clarity in the evaluation of their use.

Stephen White (1989) suggests that current reductionist orthodoxy has been too restricted in its concern with psychological facts only. But once we widen the range of facts that we allow, including, for example, certain cultural or technological facts (the metapsychological facts), the boundaries we draw around persons will be determined by factors that cannot be fixed absolutely. Whether one survives or not won’t be a matter merely of psychological continuity between one’s different person-stages; inter alia, it will be a matter of what one’s society presupposes about such things as “personal identity, responsibility, and the unity and character of the self”. Such presuppositions differ across cultures and times. So, according to White, there are no universal facts about personal identity and survival; personal identity is a relative notion. In this paper I offer an alternative, and in so doing draw out some important morals for the methodology we apply in investigating questions of personal identity.

Marc Lewis argues that addiction is not a disease, it is instead a dysfunctional outcome of what plastic brains ordinarily do, given the adaptive processes of learning and development within environments where people are seeking happiness, or relief, or escape. They come to obsessively desire substances or activities that they believe will deliver happiness and so on, but this comes to corrupt the normal process of development when it escalates beyond a point of functionality. Such ‘deep learning’ emerges from consumptive habits, or ‘motivated repetition’, and although addiction is bad, it ferments out of the ordinary stuff underpinning any neural habit. Lewis gives us a convincing story about the process that leads from ordinary controlled consumption through to quite heavy addictive consumption, but I claim that in some extreme cases the eventual state of deep learning tips over into clinically significant impairment and disorder. Addiction is an elastic concept, and although it develops through mild and moderate forms, the impairment we see in severe cases needs to be acknowledged. This impairment, I argue, consists in the chronic automatic consumption present in late stage addiction. In this condition, the desiring self largely drops out the picture, as the addicted individual begins to mindlessly consume. This impairment is clinically significant because the machinery of motivated rationality has become corrupted. To bolster this claim I compare what is going on in these extreme cases with what goes on in people who dissociate in cases of depersonalization disorder.

Effective agency, according to contemporary Kantians, requires a unity of purpose both at a time, in order that we may eliminate conflict among our motives, and over time, because many of the things we do form part of longer-term projects and make sense only in the light of these projects and life plans. Call this the unity of agency thesis. This thesis can be regarded as a normative constraint on accounts of personal identity and indeed on accounts of what it is to have the life of a person in the broad, rather than narrowly biological sense. It is also a fundamental condition of social life that persons within society fulfill a range of longitudinal roles: parenthood is one such obvious example, as are teachers, health professionals, engineers, artists, and many others. The fulfillment of these and other valuable social roles requires that agents have the capacity to rationally conceive of themselves as engaged in these roles and subject to the demands of them. To be unable to fulfill any such longitudinal social roles is to have a life deficient in value. The unity of agency is thus, we argue, something we rationally strive for, and something to be morally promoted. Psychiatric states that undermine the unity of agency are morally and rationally disvaluable. Using the example of dissociation, we explain how one such state may have this undermining or disruptive effect on the unity of agency. The therapeutic ends for psychiatry in conditions involving such states are thus seen more globally as the restoration of effective agency, that is, unified agency.

In this essay I want to focus on a quality inherent in that range of feelings we associate with an experience described as ‘flow’. Csíkszentmihályi describes it as a state that arises in people involved in some skilled activity who become fully immersed in it; they reach a state of ‘intrinsic motivation’ and loss of self-awareness; their actions seem to occur spontaneously so that they seem to become simultaneously a passive witness to their own highly skilled agency. There are skilled movements and manoeuvres in sailing in which the equipment becomes, as we say, “an extension of oneself”. Under these conditions the sailor has usually reached such a level of proficiency that the state of flow just described may obtain. Moments of flow are relatively rare, and are highly prized by those who know what to look for. Losing oneself in the activity in this way is one of its highpoints, a point which makes it thereby significant and meaningful. Excellence in sailing confers a kind of fulfilment we rarely attain. It is, for this reason, an ideal worth striving for.