Publications
Smith, Jared N., Joanna Smolenski, Ben H. Lang, and Jennifer Blumenthal-Barby. “From Opioid Overdose to LVAD Refusals: Navigating the Spectrum of Decisional Autonomy.” The American Journal of Bioethics 24, no. 5 (2024): 8–10. doi:10.1080/15265161.2024.2329496.
Smith, Jared N., Natalie Dorfman, Meghan Hurley, Ilona Cenolli, Kristin Kostick-Quenet, Eric A. Storch, Gabriel Lázaro-Muñoz, and Jennifer Blumenthal-Barby. “Adolescent OCD Patient and Caregiver Perspectives on Identity, Authenticity, and Normalcy in Potential Deep Brain Stimulation Treatment.” Cambridge Quarterly of Healthcare Ethics, 2024, 1–14. https://doi.org/10.1017/S0963180124000203.
Kostick-Quenet, Kristin, Benjamin H. Lang, Jared Smith, Meghan Hurley, and Jennifer Blumenthal-Barby. 2023. “Trust Criteria for Artificial Intelligence in Health: Normative and Epistemic Considerations.” Journal of Medical Ethics, November. https://doi.org/10.1136/jme-2023-109338.
Dougherty, Ryan, Joanna Smolenski, and Jared N. Smith. “The Lived Realities of Chemical Restraint: Prioritizing Patient Experience.” AJOB Neuroscience 15, no. 1 (2024): 29–31. doi:10.1080/21507740.2023.2292506.
Smith, Jared N., Natalie Dorfman, Meghan Hurley, Ilona Cenolli, Kristin Kostick-Quenet, Gabriel Lazaro-Munoz, Eric A. Storch, and Jennifer Blumenthal-Barby. "Perspectives on informed assent and bodily integrity in prospective deep brain stimulation for youth with refractory obsessive-compulsive disorder." Clinical Ethics (2023): 14777509231201265.
Smith, Jared. "When uncertainty is a symptom: intolerance of uncertainty in OCD and ‘irrational’ preferences." Journal of Medical Ethics 49 (2023): 757-758.
Smith, Jared, and Jennifer Blumenthal-Barby. "Call for moral recognition as part of paediatric assent." Journal of Medical Ethics 49, no. 7 (2023): 481-482.
Hurley, Meghan E., Benjamin H. Lang, and Jared N. Smith. "Therapeutic Artificial Intelligence: Does Agential Status Matter?" The American Journal of Bioethics 23, no. 5 (2023): 33-35.
Other writing / public philosophy
Balancing Life and Ethics: The Debate over Normothermic Regional Perfusion in Organ Donation - Policywise (Baylor College of Medicine)
Interview with Dr. Keisha S. Ray on Anti-black Racism and Black Bioethics - BMJ Medical Humanities Blog
Is there hidden meaning in Madness? - Policywise (Baylor College of Medicine)
What could we owe the dead? - Policywise (Baylor College of Medicine)
Review of Green Light Ethics by Hallie Liberto - Philosophical Bioethics Hub
Dissertation: The Moral Psychology of Obsessive-Compulsive Disorder
My dissertation was supported by the Andrew Vincent White and Florence Wales White Scholarship for dissertations in the medical humanities, provided through the University of California Humanities Research Institute. The official page for this project can be found here, and the full text archived edition can be found here.
Imagine a person with a compulsive illness that leads her to frequently wash her hands. She will scrub her hands under all sorts of bizarre conditions, such as seeing a garbage truck drive down the road or hearing the word ‘trash’ on television. Sometimes her hands do need to be cleaned but this is usually a fortunate coincidence. This person does not have control over her behavior because she cannot help herself from washing her hands (unless dire consequences were to follow, such as the threat of imminent death, poisonous gassing of her children, and so on). Because she lacks control over her behavior, most people are inclined to think that she is not responsible for her compulsive washing or any harm that comes of it. We might even think that it is inappropriate to blame her if she cannot stop washing when she ought to. Importantly, the impact of her illness extends beyond the issues of responsibility and blame since it impacts the degree to which she is autonomous. After all, if she experiences extreme discomfort or alienation from her washing then it seems reasonable to suppose that her compulsive behavior does not truly represent her (or her deeper self).
This is the story that many philosophers of agency who have written about obsessive-compulsive disorder (OCD) tell. These theorists tend to depict those with OCD as lacking control over their behavior to such a degree that their moral responsibility and capacity for self-governance are impaired or obviated. So understood, people with OCD are of interest to philosophers of agency only insofar as they provide a colorful counterexample to one theory or another. But this story is false. In fact, it is really a caricature of the disorder that not only obscures its nature but, and more importantly, obscures the serious implications that OCD (properly understood) has for our understanding of core agential concepts, such as moral responsibility or identification with an attitude. In my dissertation I both correct this long-standing and entrenched misunderstanding of OCD in philosophical literature and work out the implications it carries for our understanding of human agency.
On my approach, an accurate understanding of OCD requires examining leading psychiatric literature on the disorder as well as consulting the words and experiences of people living with OCD. Although the disorder is formally defined in terms of experiencing thoughts, images, or impulses (obsessions) alongside rituals the person feels pressure to complete (compulsions), the thematic presentation of these symptoms can vary widely. For example, in Story of a Soul, St. Therese of Liseaux describes “a terrible disease of the scruples” that filled her with seemingly sinful thoughts, driving her to repeatedly pray and visit confession with little relief. In contrast, J. J. Keeler describes painful obsessions about unknowingly causing a fatal traffic collision, leading to hours spent retracing her route, scouring the news for reports of a hit-and-run, and so on. Yet despite this diversity, nearly all manifestations of OCD involve dysfunctional beliefs. These beliefs typically over-represent the chance of harm associated with an action and the person’s responsibility for preventing or causing harm. Consequently, they make those with OCD more likely to experience exaggeration of certain features of their environment or stimuli, skewing and disrupting their thinking and deliberation, leading them to engage in, as I argue, voluntary and intentional compulsive rituals aimed at averting harm and relieving anxiety. St. Therese’s sinful thoughts involve her dysfunctional beliefs about perfection, about what harms or helps her relationship with God, and about her responsibility for having those thoughts. She is driven to voluntarily pray as an attempt to relieve her anxiety and to make good with God. By comparison, Keeler obsesses that she may have caused or will cause a death and so checks her behavior on the road constantly and reduces ‘dangerous activities’ (such as driving on highways). In these memoirs we see that the pattern of beliefs at work in OCD can lead agents like Therese and Keeler to interpret certain acts as courting disaster when they are not especially risky, or certain thoughts and ideas as blasphemous when they are not representative of who that person is.
As noted, when philosophers discuss OCD in the context of moral responsibility, their depictions tend to stress a lack of control over one’s behavior. In reason-responsive theories, the person with OCD is thought to be unable to properly react to sufficient reasons for action even if she is able to recognize that they exist and have bearing. This is termed a failure of reason-reactivity. This is how one theorist, Michael Mckenna, frames his example of Handy the compulsive handwasher. Handy is a purported counterexample to Fischer & Ravizza’s reason-responsive theory (semicompatibilism) because Handy can recognize and react to at least one sufficient reason to refrain from washing his hands (despite ostensibly being a compelled agent). McKenna caricatures OCD by under-describing Handy’s mental states and over-emphasizing his limited ability to abstain from washing his hands in the presence of powerful countervailing considerations (e.g., to save the life of his child). McKenna’s example of Handy chiefly ignores the robust cognitive features of the disorder described above, specifically the agent’s beliefs about her own obsessions and compulsions and how they relate to the world around her. In contrast to this depiction of OCD, I argue that people with OCD are overly receptive to apparent reasons for action, seeing reasons where there are none or distorting the weight certain reasons have in deliberation. Furthermore, an accurate picture of OCD reveals that most people with the disorder do possess guidance control and are thus morally responsible. If we wish to argue that these agents are blameless, we must refine our understanding of what it means to ‘resist’ a compulsion. Instead, we must understand the difficulty associated with resisting the dysfunctional beliefs at the heart of OCD.
The fact that people with OCD are overly receptive to apparent reasons for action has implications not just for responsibility and freedom but also for other core concepts in agency like identification and autonomy. Identification generally refers to attitudes that ‘stand for’ an agent and so have the authority to represent her. Some philosophers argue that internal attitudes (those the agent identifies with) must be explicitly endorsed by the agent in some kind of reflective process, while others argue that more fundamental attitudes (such as our cares) are internal. Stretching back to Frankfurt’s first description of identification, obsessions have long been considered external to the agent, usually because obsessive thoughts are experienced as unwanted or upsetting. For example, Keeler’s thought that she has caused a fatal hit-and-run is distressing because the thought of having harmed someone so much is unbearable. Similarly, the rituals Keeler engages in, like checking the news for accident reports or searching the exterior of her car for blood, are upsetting to her even though they are aimed at relieving her distress. However, the same features of the disorder that lead people with OCD to become overwhelmed by reasons also appear to lead some to develop caring-like behaviors. For example, when Keeler experiences obsessions about the risk of hitting someone with her car, she becomes particularly attuned to situations in which she perceives her behavior as a threat to others on the road. In response Keeler takes serious steps to change her driving habits, including driving on surface roads rather than highways or traveling well under the speed limit. This behavior closely tracks the way agents behave when they care about something (whether it is a person, a value, an outcome). This means that, contrary to the way philosophers have hitherto understood clinical obsessions, obsessions can be internal to the agent and speak for her in a meaningful way. As I argue this is a feature and not a bug. In fact, it is a very significant, and from a therapeutic point of view, very worrying feature. This is because those cases of OCD that most resemble caring are also those in which the person lacks significant insight into her own disorder. The disorder is hidden from her own insight precisely because it is expressed in what she most cares about. Such individuals are often the most ill in terms of symptom severity and recovery trajectory. Reframing this behavior as dysfunctional caring explains why these obsessions take on ever greater significance to the agent and take up increasing space in her deliberative horizon. This finding, in turn, may indicate that therapies aimed at externalizing obsessions and removing them from one’s deliberative agenda could wear away at otherwise recalcitrant obsessions and compulsive rituals.
Mischaracterizations of OCD in philosophy of agency have driven a number of problematic depictions of the disorder, and the arguments built around such mischaracterizations are necessarily deficient. Depicting OCD as largely about control has yoked our discussions of the disorder’s symptoms to older, inaccurate conceptions of psychological compulsion as a kind of force. This has been to our theoretical detriment since it has concealed the degree to which compulsion in OCD is both voluntary and purposeful as well as driven significantly by dysfunctional beliefs. Recognizing these features of OCD and their impact on agency has significant implications for the way we theorize about concepts like responsibility and identification. For example, if people with OCD do possess guidance control then we must reassess our intuition that they are excused from blame, or else modify our understanding of what the relevant excusing conditions are. Similarly, understanding that seriously ill people with OCD may display caring-like behavior may inform our understanding of internality’s role in agency as well as potential treatment methods.