DR MATTHEW BURCH

The Theory of Risk and the Practice of Care
Bridging the Gap
EARLY CAREER FELLOW: SEPTEMBER 2018 – AUGUST 2019

Matt Burch is a lecturer in the School of Philosophy and Art History at the University of Essex. He has a PhD in philosophy and an MSc in Behavioural Economics, and he works on issues at the intersection of phenomenology, action theory, and research in the cognitive and social sciences. At the moment, his research is focused in particular on the stance of objectivity in legal contexts, the breakdown of agency in everyday life, and, the topic of his ISRF grant, the issue of risk in the care professions. His research on risk is an outgrowth of his work on several projects with the Essex Autonomy Project (EAP), including an AHRC-funded project on the compliance of the Mental Capacity Act (2005) and the UN Convention on the Rights of Persons with Disabilities, and the Wellcome Trust-funded Mental Health and Justice project.

His ISRF project aims to bridge a gap between our theoretical tools for conceptualizing risk and the practical decisions about risk made in today’s care professions. The dominant paradigm in today’s discourse on risk stems from decision theory. This discipline has developed excellent mathematical tools for decision-making under risk. However, these tools, as any expert will attest, are only powerful predictors of risk under certain conditions—conditions almost never met in care work (Pecora et al. 2013). Care workers are not like insurance actuaries setting policy prices. They work collaboratively with individuals to solve specific, ethically complex problems in environments where the accurate statistical forecasting of risk is not a real possibility. Care workers thus need an approach to risk designed to fit their actual practice, and Matt’s project aims to develop such an approach. To do so, he will use the tools of philosophy to bring the discourse of risk back in touch with the human condition, and he will draw on social science methods to collaborate with care workers in order to develop an approach to risk fit-to-purpose for the care professions.

Abstract

Today’s dominant theories of risk offer decision-making guidance based on probabilistic reasoning. While extremely powerful in some domains, such theories offer little guidance for frontline care workers who make decisions about risk in an environment where the relevant probabilities are either unknown or too small to be useful. Unfortunately, this mismatch between the theory of risk and the practice of care is often overlooked, and institutions demand that care workers “manage risks” as if they were in a position to accurately forecast future outcomes. This creates practical and ethical problems on both sides of the care relationship. Care workers labor under near-constant anxiety due to unrealistic expectations about their ability to prevent negative outcomes; and service users frequently have their liberty curtailed in the name of risk, especially persons with disabilities who lack the ability to make decisions for themselves and/or the power to communicate those preferences forcefully. This project aims to mitigate these problems by highlighting this mismatch between theory and practice and developing a new approach to risk tailored to the needs of care workers. To develop this new approach, the project will bring the discourse of risk back in touch with the human condition by articulating a broad concept of risk as a fundamental aspect of life as an embodied, mortal, and social agent. With this broad concept in hand, I will then engage in collaborative work with care professionals to tailor this humanistic concept of risk to the realities of the care setting. The project will be intrinsically interdisciplinary from start to finish. It will draw on research from decision theory, philosophy, bioethics, the cognitive sciences, sociology, mental capacity law, and disability studies. And its methodology will reflect this interdisciplinary character.

The Research Idea

This project aims to bridge a gap between the theory of risk and the practice of care. The dominant paradigm in today’s discourse on risk stems from decision theory. This discipline, built on the seminal work of von Neumann & Morgenstern (1944), has developed excellent mathematical tools for decision-making under risk. However, these tools, as any expert will attest, are only powerful predictors of risk under certain conditions—conditions almost never met in care work (Pecora et al. 2013). Care workers are not like insurance actuaries setting policy prices. They work collaboratively with individuals to solve specific, ethically complex problems in environments where the accurate statistical forecasting of risk is not a real possibility. Unfortunately, this hasn’t prevented institutions from co-opting the language of decision theory, demanding that care workers ‘minimize’ risks, and punishing alleged failures to do so (Munro 2011).

Care workers need an approach to risk designed to fit their actual practice. This project will aim to develop such an approach. To clear the way for this work, I will first demonstrate the mismatch between current theories of risk and the practical and ethical demands of care work in order to better understand what a suitable theory should look like. Then I will endeavor to bring the discourse of risk back in touch with the human condition by articulating a broad concept of risk as a core feature of human experience. Finally, I will collaborate with care workers to tailor this broad concept to the practice of care.

Background

In recent history, the term risk has undergone a semantic shift so that it now encompasses many phenomena not previously considered risky (Beck 2009; Haslan 2016). Three factors behind this shift are increases in 1) media outlets amplifying risk anxiety (Kasperson et al. 1988), 2) digital technologies capturing ever more data, and 3) new tools to analyze this data. Together these factors promote the attitude that risks are ubiquitous, knowable, and manageable (Slovic et al. 1993; Kemshall 2010).

This shift has transformed the care profession. Indeed many care workers report that worries about risk have consumed their vocation (Barry 2007). But this transformation is unjustified. The attitude that risks are knowable and manageable is warranted only if one has access to aggregate data regarding risk factors known to correlate significantly with a target outcome. Otherwise, to use the language of decision theory, you aren’t making decisions under ‘risk’; rather, you’re working under conditions of ‘uncertainty’ or ‘ignorance’. This is precisely the case for most care work, where relevant probabilities are either unknown (Munro & Rumgay 2000) or too small to be useful (Szmukler 2003). This deflates not only the pretense that risks can be ‘managed’ in this domain but also the prospects of the trend promoting ‘debiasing’ (Carroll 2009). For the very idea of debiasing presupposes access to a normative standard against which bias is measured and corrected, which is what we lack when probabilities are unknown. The practice of care needs a fresh approach to the concept of risk.

The Focus

This project has real-world implications for care workers and service users. Due to the factors described above, today’s care workers are often held to unattainable standards when making decisions that involve significant risks. Moreover, when such decisions have bad outcomes, as some inevitably do, these workers can be disciplined, pilloried, and sacked for events they could not possibly have foreseen. And these punitive exercises in hindsight bias fuel anxiety and burnout throughout the profession (Webb 2006; Stanford 2009).

But it’s not only care workers who stand to benefit from a new approach to risk. Service users also face a unique set of harms in the name of risk management, most notably the curtailment of their liberty, freedom of movement, and preference satisfaction (Martin et al. 2014; Szmukler & Bach 2015). This is especially true for persons with disabilities who lack the capacity of make decisions for themselves (Burch 2016). Lacking this capacity, such persons cannot assume legal liability for decisions made on their behalf, which incentivizes care institutions to enforce risk-averse and paternalistic policies, further limiting what is often an already narrow range of life possibilities (Flynn & Arstein-Kerslake 2014).

This project will call for reform on theoretical and ethical grounds. It will argue that, at the theoretical level, the punitive and paternalistic measures described above often lack epistemic warrant. And when we deflate this theoretical pretension, the pressure put on care workers and the denial of recognition respect (Darwall 1977) to service users show up as illegitimate harms.

Theoretical Novelty

The principal theoretical contributions of this project are 1) a humanistic concept of risk and 2) a practical approach to risk tailor-made for the care professions. To achieve 1), this project will build on a line of thought from the philosophy of science that sees scientific models as abstractions derived from our experience in a shared ‘lifeworld’ (Husserl 1954; Cartwright 1983). Although there’s nothing inherently wrong with such abstractions, problems arise when we conflate them with the things they represent, which is precisely the problem in the case of risk. Decision theory’s models parsimoniously capture certain aspects of our experience of risk, and this mathematical elegance makes them powerful in some contexts. However, when we conflate these abstractions with the lifeworld phenomenon they only partially represent, we ignore resources for dealing with risk in other contexts – like the care setting – where such abstractions aren’t particularly useful. To remedy this, I plan to develop a humanistic lifeworld concept of risk as a fundamental aspect of the experience of embodied, mortal, and social agents. From the perspective of human life, risk is not an entirely negative phenomenon – as it’s often represented – but rather an ambiguous category of experience that opens up opportunities for growth and increased mastery while it also exposes agents to potential harms. With this humanistic concept of risk in view, I will set out to achieve 2) by working collaboratively with care professionals to adapt it to the practical and ethical demands of care practice.

Methodology

To articulate a humanistic concept of risk, I will rely on the method pioneered by Husserl (1954) and now widely used in the cognitive sciences (Gallagher and Zahavi 2008; Engel et al. 2016). Rather than capturing aspects of risk in a parsimonious model, this method will describe the phenomenon of risk as it is experienced and identify the features of human agency make that experience possible. This humanistic concept of risk will position me A) to demonstrate that the diverse vocabularies treating risk – from decision theory to sociological theories of ‘positive risk-taking’ (Zinn 2015) – share a common origin in the lifeworld, and B) to develop a new approach to risk for the care professions.

To accomplish B), I will rely on a collaborative method I have used in my work for the Essex Autonomy Project (EAP). In a session with 18 participants comprised of medics, social workers, and MCA (2005) Best Interests Assessors, I will present my findings from the first phase of the project. Participants will then break into small groups to discuss a set of vignettes designed to encourage them to reflect on their approach to risk decisions. I will record these conversations, and after six sessions I will study this data to identify procedures care workers use to make risk decisions in the field. After synthesizing these findings, I will review them in conjunction with my other research results to develop a “Risk Toolkit”—a set of best practices for risk decisions in a care setting.

Work Plan

The first phase of the project (months 1-3) will produce two research articles. One will clarify the mismatch between contemporary risk theories and the practice of care and identify the ethical grounds that count in favour of reform, focusing in particular on the unfair pressures and punitive measures faced by care workers and the unwarranted denials of recognition respect to service users, especially persons with disabilities. The second article will articulate a humanistic concept of risk and attempt to bring unity to the diverse discourse on risk by demonstrating that its different conceptual vocabularies share a common ground in this lifeworld phenomenon.

During phase two (months 4-7), I will run six collaborative research sessions, and I will use the data generated during these sessions in conjunction with my other findings to develop a new approach to risk tailor-made for the care setting. This work will lead to the publication of a third journal article that highlights the need for an approach to risk designed specifically for the care setting and offers one developed through collaborative research with care professionals.

The final phase (months 8-12) will lead to two practical and impactful outputs: 1) a freely available online video curriculum that presents the major findings of the project, and 2) the ‘Risk Toolkit’ described above. Both of these outputs will be used in the future to expand the module on risk that I developed for the EAP in 2013 and that has been a staple of their training curriculum ever since.

Outcome

The articles and practical tools for care workers mentioned above represent the first stage of a larger research program in the area of risk that I plan to execute in the next five years. In the year immediately following this project, I will 1) produce an in-depth four-hour training curriculum on risk based on the findings of this project that will become a permanent feature of the EAP’s training offer, and 2) apply for a larger multi-year grant that builds on the work done for this project.

This multi-year project will take the humanistic concept of risk developed for this project and extend it by taking a more in-depth look at how persons with disabilities experience risk. As stated above, the current project has implications for persons with disabilities, but I want to do further research based on direct interaction with members of this population to see whether, how, and to what extent the experience of risk varies across the neurologically diverse spectrum of the human condition. For the present project, I have easy access to a large pool of care workers thanks to the networks built over the years by my colleagues at the EAP, but for this larger project, I will have to expand this network to involve institutions that will enable me to work with persons with disabilities. A larger grant would make this possible and allow me to work with a co-investigator from another discipline to expand further the interdisciplinary reach of my work.