AMA Journal of Ethics^®

Abstract

This article draws on architectural analogies and popular culture to consider ethically and clinically important characterizations of causation and nonarbitrariness. This investigation also suggests similarities between intention and design.

Correlation and Causation

Did you know that sex could not be publicly discussed in the Soviet Union?¹

Me, neither. Without knowledge of this factoid, it’s hard to appreciate the cultural importance of what happened in 1987 when a television network in Finland broadcast the randy French series, Emmanuelle. Viewable in some areas¹ of Estonia (a Soviet state until 1991), episodes were allegedly so hot that “[n]ine months later the birth rate in Estonia spiked to an all-time high.”² Another more well-known source suggests that accounts of a “skyrocketed” birth rate were “probably exaggerated,”³ but it does not express much caution about mistaking correlation for causation. With Estonian independence foreseeable by some, though, many factors could have generated parental enthusiasm about raising a child in a country soon to be free from Soviet rule.

Design and Intention

As in this historical example about roles healthy doubt can play in rooting out logically tenuous causation claims, we can apply a similarly questioning stance to causation attributions in health care, especially when describing relationships between health care settings’ designs and patients’ outcomes. The architect Stefan Lundin has explored these relationships in psychiatric settings. In my view, his work has interesting and important ethical relevance because we tend to think about the moral psychological phenomenon of intention similarly to how we think about structural and spatial design of places we inhabit. One article by Lundin about safety among inpatients with mental illness poses that designs’ importance comes not only from what they cause or patient outcomes with which they are correlated, but from the fact that they are “not arbitrary.”⁴ What might this mean ethically in health care?

If there is an upshot from Lundin’s work that matters to health care ethics, one seems to be that designs thoughtful and well-considered enough to express a plurality of stakeholders’ interests promote safety among patients and caregivers in psychiatric units. Lundin states that a patient’s sense of control is key to keeping them safe.⁴ This is, he suggests, because making patients feel heard diminishes their stress. Patients’ stress reduction has design value not because it informs the physical or spatial architecture of a care setting, but because it influences how the care environment is inhabited by clinicians and patients. Inclusion is a lived ethical value intrinsic to how we intend our interactions with others to proceed. Intentions are moral psychological formations that express our motivations to act; they express how we design and define our characters over time in each action we are moved to do in each moment.

Yet our most fraught interactions illustrate that how we express our intentions must respond to external factors beyond our control and so, sometimes, only imperfectly influence our actions. Our intentions are not equally, perfectly, or completely expressible in our actions in all circumstances. Perhaps a contrast is helpful for explanation.

Our most fraught interactions illustrate that how we express our intentions must respond to external factors beyond our control and so, sometimes, only imperfectly influence our actions. 

In moral psychological terms, if an intention is arbitrary, it is not grounded in one’s perception of a reason to act. An action can still have ethical value (positive or negative) because of its consequences, but it has little-to-no value in expressing an agent’s character if it has no explanatory force about their intention or motivation. One might say this is one reason some criminal legal proceedings invest so much time in exploring what an action expresses, if anything, about the intention (mens rea in legal language) of the agent who committed the action. By contrast, ethically speaking, an intention is nonarbitrary if it has explanatory force about an action; even if that action does not go as planned, we might ask the agent, What did you mean? What were you thinking? What motivated you? In other words, even when an action does not carry out, or express, an agent’s intention well, an agent’s action can still have ethical value for the agent’s character if it expresses their intention, even if incompletely. (This is one reason why our expressions of regret or disappointment about an action that didn’t express an intention well can also have ethical significance; a statement like This isn’t what I wanted to happen, and this is what I mean to happen can matter ethically, particularly if you’re affected by the action that didn’t express the agent’s intention well.

Virtual Eye Contact

An example is from the world of video conferencing, in which moral psychological links between our intentions and our actions can be disrupted—by user errors, poor connection, poor reception, or accidents of context (eg, transmission delays)—if not severed completely. These external factors can make video call interactions more than just technically fraught, especially if someone on a video call is upset. If you’ve ever tried to make good on a humanitarian impulse to be empathic and emotionally intelligent with someone visibly upset on a video call, you might identify with what I found on video calls to be a confusing irony: you have to look at the camera on your device in order to create the impression for the person you’re trying to help that you’re looking at them. I’m not even sure whether virtual eye contact is possible. Yet, trying to do it for someone who would need eye contact in person somehow seems consistent with our “better angels”⁵ moral intuitions and, thus, seems to have ethical value.

Of course, looking directly at the camera on your device means you are not looking directly at the person’s image on your screen, which isn’t even really them, but a representation of them. Facilitating your interlocutor’s feeling that you are looking into their eyes—what many of us can do easily and quickly in person—to try to make them feel seen, heard, or understood requires diverting focus from their eyes in their image on your screen to the camera on your device. I don’t know whether this counts as virtual eye contact, but, even if it does, a source of trouble is that you can’t focus intently or simultaneously on both your device’s camera and on your interlocutor’s onscreen image, so your ability to modify your actions, expressions, and speech according to their affective cues is compromised by specific actions you need to perform in order to express your intention to connect with them.

In video calls in which you strive to keep virtual eye contact with an interlocutor you think might be helped by it, you simply have to live with the uncertainty that you might miss some key affective cues. If the affective clues you miss are critical ones, your actions might be received and perceived by your interlocutor very differently than you intend, and perhaps badly. Disjunctions between intention and action are always a risk, and this risk is exacerbated online. It doesn’t always make us feel better about the disjunctions between intentions and actions that external circumstances force us to navigate them. But, thankfully, intention and design need not be perfect in execution in order to have ethical and, according to Lundin, clinical value. They just need to be nonarbitrary to be important to who we want to be for ourselves and for each other.