 is Professor Dan Broadney, who is the Professor in the Department of Philosophy and in the College at the University of Chicago. In addition, he's faculty in the McLean Center for Clinical Medical Ethics as well as the Divinity School. He has published scholarship in political philosophy, bioethics, and the philosophy of religion. He's been recipient of many awards and fellowships including the 2014 Quantrol Award for Excellence in Undergraduate Teaching. Today, Dr. Broadney is going to talk about practical reason at the bedside. Thank you, Dan. This is somebody else's? Is this yours? That's mine. As always, it's wonderful to be here. Thank you, Mark, for inviting me. I have two disclosures to make the first. This is not a pediatrics talk, despite the name of the panel. And the second is I'm keenly aware that I and the next speaker stand between you and lunch. So I will try and keep this brief. So I'm not a physician. I'm a philosopher professor. And what I tend to do when just observing how clinical decisions get made is I try to ask myself, are there philosophical presuppositions embedded in the model that's being used? And my work in this area has generally taken the form of trying to assume those presuppositions, sometimes suggesting that they can be changed, sometimes just saying, look at what we're doing. Today is sort of the latter kind of talk. Today I want to talk about, first of all, can you hear me? Everything okay? Yes, yes. About the standard for decisional capacity. It seems to me designed to do two things. It's designed to determine when the patient has a threshold level of rationality such that she has the capacity to make a rational decision and also determine when the patient ought to be permitted to make a treatment decision. A quick preliminary remark. To have a capacity and to exercise that capacity well are not in the least bit the same. A baseball player might have the capacity to hit a home run and yet sometimes often not exercise that capacity well. To have the capacity to make a threshold rational decision is not the same as actually making a threshold rational decision. It's perfectly intelligible to say of a patient that he does have a threshold level capacity for rationality and yet here and now he's making perhaps a wildly irrational decision. Most of us have a threshold level capacity for rationality. I suspect all of us have made occasional rational decisions. I know I've made some wildly irrational decisions. It's precisely because we have the capacity to make a rational decision that it makes sense sometimes to criticize us for not exercising that capacity well. Now one might think that the standard for having threshold rational capacity, whatever we think that amounts to, ought to be the same as the standard for letting someone make a decision. One might think that if some patient, Jack, falls below threshold rational capacity, he ought not to be permitted to make the treatment decision, especially an important decision. Fact my claim today is that in practice these two things, a standard for rationality and a standard for permitting the patient to decide sometimes come apart and sometimes ought to come apart. I don't think I'll be saying anything dramatically new. The underlying point has been made by Gareth Owen as well as by Adrian Martin, no doubt by others. My contribution will be to put a bit of old wine into a slightly new bottle. I'm going to cast the point in terms of the distinction between theoretical and practical reason. I'll be arguing that the current decision capacity model is conceptually suspect, but I don't think in the end I'm going to urge any reform in that model. My students here at the University of Chicago sometimes wear a t-shirt that has the following slogan on it. That's all well and good in practice, but how does it work in theory? That's the epigraph for today's talk. So let's start with a look at the standard for decisional capacity. I know that there's a lot of debate about this. I hope there's going to be acceptance of something like the four criteria proposed in the famous paper by Berg Applebaum and Grisso. First, the ability to communicate a choice. Second, the ability to understand relevant information. Third, the ability to appreciate the nature of the situation and its likely consequences. And fourth, the ability to manipulate information rationally. So where does the possession of reason, where does being rational come into this? Well, criterion two involves understanding information. Criterion four involves manipulating information rationally, and so the patient must be able to grasp the essential information about her medical condition, and she must be able to make rational use of it to think about possible courses of action. And this is tied to criterion three, the ability to appreciate the nature of the medical situation. So in all of these, the patient's reason seems to be in play. However, what I want to point out is that with the possible exception of the idea of appreciating the nature of the medical situation, something I'll come back to soon, many philosophers, take Aristotle, would think that criteria two, three, and four, the criteria that focus on celebration, involve the exercise of theoretical reason, not of practical reason. Theoretical reason tells us how things are. Practical reason tells us what to do. Criteria two, three, and four seem to involve reasoning about the way things are, not about what to do. No doubt this is a simplification, and I'll eventually add a little complexity, but I want to reflect a bit on this simplified picture. One might easily read into it a particular philosophical view of the scope of our rational capacities, of the scope of reason itself. In fact, it seems to fit rather well with the view of reason that one finds in the work, say, of the great 18th century Scottish philosopher David Hume. In his treatise of human nature, Hume famously declares, now quoting from Hume, it is not contrary to reason to prefer the destruction of the whole world to the scratching of my finger. It is not contrary to reason to prefer the destruction of the whole world to the scratching of my finger. Hume's claim here is that preferences and desires are not the sorts of things that are properly assessed in terms of being more or less rational. Preferences and desires, Hume thinks, are not candidates to be either rational or irrational. That I have desire D, Hume says, is no more rational or irrational than that I'm a certain height H. Each is merely a fact about me. Of course, Hume thinks that an action and desire can be an irrational action if it's also based on a false premise or an invalid inference. Suppose I want to slink my thirst. Here's a bottle of clear liquid. For anyone who took philosophy when I was, this is an absolutely standard example. I believe it's water, and so I desire to drink it. For Hume, the desire to drink in order to slink my thirst is neither rational nor irrational, but the desire to drink this clear liquid would be irrational if it turns out to be carbolic acid rather than water. To drink carbolic acid would be irrational as a means simply to slake my thirst. So Hume's claim is that as long as I understand all the facts, as well as all the cause-and-effect relationships, and then I make only valid inferences, that I have a desire to do any given thing cannot be either rational or irrational. It's simply a fact about me. Of course, Hume is not a moral skeptic. He does think that we can assess a desire along moral axes. The desire to help others is praiseworthy. The desire to harm others is blameworthy. But for Hume, neither desire counts as rational or irrational in itself. So the decisional capacity model looks to be humane. If the patient understands the medical facts and can make valid inferences from them, she's allowed to go with her preference, whatever that might be. The sheer rationality of her preference or desire as a preference or a desire is not in the picture. Now what I want to stress is that Hume's view about the scope of reason, about the relation of values to reason has not been the dominant picture, the dominant strain in the history of Western philosophical thought. Nor is it the dominant strain in current academic philosophical thought. Plato, going back to the ancients, thinks that a failure to know the nature of the good is a cognitive failure, a failure of reason. Some moderns, Kant comes to mind, might accept that a desire is not amenable to rational assessment. A little debate about that in the current literature, but that's the old view. But Kant would say that the decision to act upon a desire is thoroughly amenable to such assessment. As for current academic moral philosophers, both moral realists and moral constructivists, reject the Humean picture. Now I'm not saying that no philosophers have had or currently have a Humean style view about practical reason. My point is merely that it is very far from being the historical default view or the current default view. If the existing decisional capacity model assumes that all it takes to have capacity, where that means to possess a threshold level of rationality, is to have sufficient competence and theoretical reason, then that standard is relying on a highly disputable philosophical thesis about the nature of reason. But let's now add a little complexity. Back with Berg, Appelbaum, and Grissot's criterion three, the ability to appreciate the nature of the situation and its likely consequences. The term appreciate is ambiguous between the descriptive and the normative. It might mean simply that the patient fully grasps her medical condition and the likely consequences of going down pathway A versus going down pathway B. But to appreciate something might also suggest something normative. That the patient has a correct grasp of the values involved in going down pathway A versus pathway B. There is a little bit of literature that presses this point. The thought common to that literature is that at least in some cases and anorexia nervosa is the kind of case often cited, a condition of having decisional capacity is that one recognizes that if one is ill, where to do this involves having certain value-laden beliefs. Jules Holroyd puts it this way and now quoting, we tend to think that someone who weighs being thin or avoiding food over death or disability is not just endorsing a different set of values, rather they are making an evaluative mistake. Such a patient fails to see that she is in point of fact ill, but to get things right here to see that one is ill is to weigh values in a proper way to fail to see that one is ill is to weigh values in an improper way. So there is some complexity about all this in the literature. I don't think that makes much of a difference. In part it doesn't make much of a difference because the literature here about anorexia presses not only that the anorexic has irrational values but doesn't have decisional capacity. Sometimes the literature has another form and says that the anorexic's physical condition has so undermined her ability to engage in clear enough theoretical reasoning and it's for that reason that she is judged not to have capacity. However, the main reason to put aside such complexities is that, at least it's my impression and new clinicians will correct me if I'm wrong about this, is that these cases tend to be marginal. In these kinds of cases the level of practical reason needed to be judged to have decisional capacity is very modest. Many theories of practical reason would be much less modest. So even with a tweak to the current model I think it still remains substantially humane. So, my claim then is that the current standard for decision making capacity involves a commitment to a disputable philosophical thesis about the scope of practical reason. I don't have time to develop the point but I think that if one said instead that the capacity standard is supposed to pick out what it is to have something called autonomy one would end up more or less in the same situation. That is philosophers, surprise, surprise have many different views about what autonomy amounts to and on some views autonomy is effectively a procedural notion that's substantially value neutral. It does not require, so to speak that the agent who's autonomous track the good in doing so. On other views, depending upon the philosopher, either a condition for counting as autonomous or a condition for having autonomy to be worth caring about is that the actions of the autonomous agent do to some significant degree track what is good. So the same kind of issue would come up here if you were simply to say that the capacity model is trying to identify when we call a patient autonomous. That is you are inevitably going to be relying on a philosophical thesis that is in dispute and has been in dispute. So I began by remarking that the decisional capacity standard is supposed to do two things. Specific, specify when the patient has threshold rational capacity and specify when she should be allowed to make the treatment decision. Now, if a necessary condition for permitting the patient to make the treatment decision is that she does have threshold rational capacity then the philosophical debate about what that amounts to would have to be carried over to the question of whether the patient should be permitted to make the decision. The problem in theory would in fact entail a problem in practice. But I'm not ready to go with that entailment. That is I'm not recommending change in practice and certainly not the change required if one were to import a contentfully robust conception of practical reason into the decisional capacity standard. Rather, I'm proposing to separate a claim about when the patient has threshold rational capacity from a claim about when it's proper to let the patient make this treatment decision. And the reason to separate the two is simple. To my mind, no one has yet proposed a morally better standard for determining when the patient may make the decision. Writers in this area often say that the decisional capacity standard should be value neutral. One could aim at value neutrality either by relying on as I pointed out a disputable philosophical view about reason or one could aim at it by relying on certain practical considerations. The old-fashioned paternalism model assumed that the doctor was what Aristotle would have called a person of practical wisdom, a fronimous person who knew best. Few people accept that now, either about the physician or even really about the team as a whole. So if neither the physician nor the team has as it were is the repository of practical wisdom, the obvious question is who gets to make the decision. And there is a long and deeply dishonorable tradition of people in power denying the rationality of those without power of then overriding their preferences on the ground that one ought not to respect the preferences of people who are not sufficiently rational. So as a purely practical model, excuse me, it's a purely practical matter, I think it would be a great mistake to have much in the way of value be part of determining decisional capacity. So despite being problematic in theory in practice, things are more or less as they ought to be. Still, I think it matters how we describe things. It matters how things are in theory. We ought to be honest with ourselves about what we're doing. The very quick defense that I've just given of using a standard for decisional capacity that substantially value neutral is a purely practical defense. One could just subscribe to this defense while denying that practical reason is itself value neutral. So I want to leave some time for questions. I'm going to cut a couple of paragraphs. I want to end by making the point that if you take what I'm saying seriously, you would be willing to say in principle of some patient that she does not pass what you think is the proper philosophical standard for having a threshold level of reason. And yet she should be allowed to make the treatment decision. I actually think that that's probably, as I say, okay in practice, even if maybe a little worrisome in theory. Thank you. All right, I can't resist. Go for it. So I think that this is what we do in psychiatry all the time. And it's noteworthy that you raise the anorexia example, but what we do all the time is dance this dance of what is practical when our patients can decide and when they can't decide. And I think truthfully autonomy is often we're dancing the dance of what is the most practical application of what we can do. And so we're grateful to people like you who can give us philosophical grounding in what we're doing. But I'm not sure that the autonomy model is as we describe it now the right one. Thank you for that. As I say, I'm not prepared to say that things that practice should be changed. What I want to press is that if my analysis actually carries through there is this weird situation in which you're willing to say there's a sense and a real sense in which I don't think that this patient has the kind of level of reasoning ability of rational capacity, not just that she's not making a reasonable decision. We all do that all the time. But that she literally doesn't have capacity and yet the right thing to do is to let her decide. I think the best example of that is when we let somebody who is paranoid who wishes to be living outside but who's making that decision in the context of a Chicago summer versus a Chicago winter live outside. Thanks.