Our Editor’s Pick for December 2016 is Bertha A. Manninen’s paper, “Sustaining a Pregnant Cadaver for the Purpose of Gestating a Fetus: A Limited Defense.” Manninen argues that “there are times it is morally permissible to keep a brain-dead pregnant woman on life support” for the “sole purpose of allowing her fetus to gestate until it is able to be born as healthy as possible.” She then goes on to argue that this claim is compatible with a pro-choice perspective on abortion.
Dominic Wilkinson, a neonatal physician and medical ethicist, has written a searching, moving, and philosophically sophisticated book about the ethics of life and death decision making in the neonatal intensive care unit. Although I will devote much of this review to criticism, I want to say at the outset that Death or Disability represents interdisciplinary work at its very best. Wilkinson’s exposition is both rich in detail and uncompromising in its ethical analysis. He spares the reader none of the clinical, psychological, and moral complexities and uncertainties of the decisions made daily in the neonatal intensive care unit (NICU).
I especially recommend this book to moral philosophers and practical ethicists worried that their debates on issues like time-relative interests and non-identity are ingrown and academic. Wilkinson explains the relevance of these and other seemingly arcane issues to the real, wrenching decisions that parents, physicians, and the larger society must make about the treatment of newborns at risk of very severe impairment.
After briefly outlining the structure of the book and some of its complex arguments, I will focus on three of the few areas where Wilkinson’s thorough, painstaking analysis strikes me as incomplete: the role of impersonal considerations in decisions about continuing or ending the lives of impaired neonates; the implications of the time-relative interest account Wilkinson adopts for balancing potentially conflicting interests in the neonate’s survival; and the role of physicians in helping to make neonatal treatment decisions under the threshold framework Wilkinson proposes.
The book begins with two prologues about imagined visits to learn the fate of a sickly neonate: one to the Roman Temple of Carmentis in 30 AD, the other to The Carmentis Machine in 2030. These prologues are vivid and engaging, but a bit disorienting. They give the reader the impression that Wilkinson will be focused on the implications of prognostic technologies that enable physicians and parents to reliably predict a neonate’s development. But the book is not, or is much more than, an exercise in speculative bioethics. The second, longer half is devoted to decision making under the prognostic uncertainty that we will continue to face in the near future. Moreover, the first half focuses on (relative) certainty only about significant neonatal impairments – certainty that current physicians and parents can sometimes achieve. Wilkinson does not discuss the issues that would be raised by information about minor health conditions and nonmedical characteristics, which the Carmentis Machine would reveal. Those issues are interesting in their own right, but they would distract from his intense focus on the dilemmas posed by severely impaired neonates.
Wilkinson begins his analysis by explaining how the contemporary NICU forces painful decisions on parents and physicians: it keeps alive 23-28 week old neonates who would have previously died, but who face extremely severe physical and cognitive impairments once they leave the unit. He illustrates the difficulties with detailed accounts of real and composite cases, to which he refers back throughout the book. In chapter 2, he considers the prevailing standard for making those decisions: with reference to “the best interests of the child.” He questions how, or even whether, neonatal decision makers can assess those interests, or judge that a neonate will have a life “not worth living.” He argues that they make those judgments, albeit with an uncomfortable degree of speculation, by balancing the expected benefits and harms of the neonate’s continued life. But he departs from the best-interests standard in arguing that the interests of parents, siblings, and others should also be taken into account.
Chapter 3 argues that impersonal considerations, concerning the effect of a decision about neonatal treatment on aggregate well-being, do not have a significant role to play in making those decisions. This chapter raises a number of philosophically interesting claims that I discuss below. Chapter 4 concludes Part I with a richly detailed review of the potentially conflicting personal interests that are most directly implicated in neonatal treatment decisions: those of parents, siblings, and the child itself. Wilkinson defends the controversial claim that the neonate’s own interests should be discounted by its limited psychological continuity with its future self – a claim whose implications I discuss below.
Part II, starting with Chapter 5, introduces the manifold uncertainties that physicians and patients confront in the NICU, not all of which can be resolved by improved predictive technologies. I found this part of the book the most difficult, because it presents complex normative arguments that are resolved in part by the critical examination of empirical research. Chapter 5 reviews the evidence we have on the prognosis for severely impaired neonates. Wilkinson enumerates the factors that limit the inferences we can draw from existing data. For example, most studies count the deaths of infants for whom treatment was withdrawn, raising the acute problem of self-fulfilling prophecies. But counting only those neonates for whom treatment was extended may overrepresent the relatively healthy; those for whom treatment would have seemed more promising. Yet the sickest neonates also may be overrepresented in the leading studies, which come from specialized care centers. Some readers may find this methodological rigor daunting; there were times I struggled to see the forest for the trees. Perhaps the most accessible and important section of the chapter deals with the difficulties of quality-of-life assessment. These assessment blur medical prognosis with the normative evaluation of medically-challenged lives. Health professionals consistently give lower quality of life estimates than families (and much lower than those given by disabled individuals able to judge themselves); this may reflect their professional emphasis on health more than their superior knowledge.
Chapter 6 discusses ways of managing this uncertainty, focusing on the strategy of obtaining greater knowledge by prolonging treatment. This strategy raises a concern about the moral risk of extending treatment beyond the so-called “window of opportunity,” when the neonate’s survival is dependent on medical technology. Wilkinson argues for greater parental discretion on both ends: early withdrawal will often be justified given the evidence parents already have and the limited prognostic gain likely from continued treatment; parents may decide to let the child die past the “window” if the prognosis remains grim, by removing nutrition and hydration – a withdrawal that Wilkinson finds no more problematic in principle than removing a ventilator. Chapter 7 revisits the interests at stake in neonatal treatment decisions in light of these uncertainties. Its highlight is an original and highly sensitive account of the complex relationship between the interests of the neonate and its parents.
The book concludes with a careful proposal in chapter 8 for decision making under this prognostic and moral uncertainty. Wilkinson offers a two-threshold framework that carves out a space for parental discretion, between cases where the neonate’s dire prospects make continued life-support unacceptable and cases where its decent prospects make withdrawal unacceptable. He gives examples of cases that arguably fall within this “grey zone,” while acknowledging the daunting conceptual and practical problems in setting the thresholds. He finds grounds for optimism in the apparent consensus among an array of professional groups on guidelines. Less encouraging is his report of wide variability among individual physicians on specific cases, a finding that suggests that the consensus among groups may be largely verbal. In setting the thresholds, Wilkinson says very little about the impersonal considerations he discussed earlier, as well as the (ultimately personal) interests of the larger society in the cost of neonatal care. Although he has been criticized for his neglect of social costs (Foster 2013), that omission will be welcomed by those, like me, who deny that physicians, let alone parents, should engage in bedside rationing.
Wilkinson is particularly good at anticipating questions and objections; most of mine were thoughtfully addressed soon after they arose. There are, however, a few significant issues that could have benefited from further discussion:
1. In his analysis of the moral reasons for “replacing” a severely disabled neonate with a healthy child, Wilkinson does not deny that impersonal considerations have moral force; he merely argues that they provide only weak moral reasons for replacement, which can easily be outweighed even by fairly minor parental interests. His argument is, roughly, that 1) in most cases, the impersonal gain from replacing a less with a more healthy child will be smaller than the gain from having a more healthy child rather than none; 2) The gain in impersonal good from the latter is not enough to give parents a strong moral reason to have a healthy child; so 3) the moral reason parents have to replace a less with a more health child will be even weaker.
Although I doubt that impersonal considerations have any moral force, a proponent of replacement could respond by challenging a key assumption in Wilkinson’s argument: that if there is a moral reason to have a more rather than less healthy child, there is a moral reason to have a healthy child rather than no child. Johann Frick (2014) has recently argued that selection among possible children is a conditional duty, analogous to promise-keeping. One has no duty to make promises, only a duty to fulfill them if one has made them. Making a promise subjects the agent to a standard that would not otherwise apply to her. Similarly, one has no duty to have children. But, Frick contends, if one decides to have children, one has a duty to have the child with the happiest possible life; not only to make one’s child happy, but to select the child with the greatest potential for happiness. One needn’t accept this as the applicable standard for prospective parents – I emphatically don’t – to accept Frick’s more general point that whatever the correct standard is, it applies only conditionally.
In the context of procreation, Frick’s analysis challenges Wilkinson’s claim that it is inconsistent to acknowledge a moral reason to pick the happier or healthier child but not a moral reason to select either over no child. Even if this inference is blocked, however, Wilkinson could plausibly argue that the applicable standard is different for replacement than conception. It would be implausible to claim that parents had a strong moral reason to continue replacing neonates until they obtained the best one they could reasonably expect. But Wilkinson could not set a less demanding standard based on a comparison with the impersonal gains expected from conception – that comparison would simply be irrelevant.
More broadly, Wilkinson does not offer a decisive verdict on the scope, weight, and role of impersonal considerations. He shares the widely-held intuition that a world containing multitudes of people with lives just barely worth living would be worse than one with fewer, better-off people, even if the former had greater aggregate well-being. Moreover, he denies this this “repugnant conclusion” can be avoided by limiting impersonal considerations to “same number” choices, in which either choice will result in the same number of people ever existing. Wilkinson finds this limitation not only ad hoc but unhelpful, since replacement results in a different number of people ever existing. Yet at the same time, he recognizes the intuitive force of impersonal considerations in “substitution” cases, where prospective parents must choose between having a worse-off child now or waiting to have a better-off child later. Wilkinson, then, is unwilling to deny impersonal considerations some role in the NICU, even if he concludes that this role will usually be insubstantial. They remain as strangers at the neonates’ bedside, along with the personal interests of the neonate, parents, siblings, and others that Wilkinson so fully acknowledges.
2. The relevance and weight of impersonal considerations are left uncertain not only in replacement, but in treatment decisions where replacement is not at issue. Even if impersonal considerations lack great weight, they do not need much to serve as a thumb on the scales in close cases. This poses an especially significant challenge for Wilkinson, since he gives comparatively little weight to the interest of neonates in continued existence. According to Jeff McMahan’s Time-Relative Interest Account (TRIA) (2002), which Wilkinson adopts, a being’s interest in its future depends on the psychological connections it has with that future, connections that are very tenuous for a neonate. No matter how rich and rewarding its life is expected to be, a neonate’s time-relative interest in continuing it will be fairly slight. Wilkinson denies that this discounting will license treatment withdrawal in most cases, but his denial relies to an uncomfortable extent on the interests most parents have in the neonate’s survival, especially if its impairments are only moderate or mild. Not only are those interests highly contingent and variable, they may be outweighed in close cases by impersonal considerations – a prospect Wilkinson fails to address in his discussion of competing interests.
Even if parents are reluctant to withdraw support from an impaired neonate, an impersonal assessment of their interests may favor withdrawal. They may be significantly better-off in the long run without the expense and stress of raising a severely impaired child; they may be fully aware of this despite opposing withdrawal. (I agree with Wilkinson both that the challenges of raising a severely impaired child are often exaggerated, and that they can be oppressive or overwhelming for some parents.) Their willingness to sacrifice their own well-being arguably takes their personal interests off the scale, but it may have little or no relevance for the impersonal calculus. Even taking account of grief and guilt, their net well-being might be substantially increased if treatment is withdrawn. That gain in well-being counts impersonally, and it could easily outweigh the neonate’s highly discounted interest in survival. Allowing impersonal considerations any role in the NICU complicates, and arguably distorts, the formidable task of balancing the interests of actual persons– the child, parents, siblings, and the larger society.
3. I want to conclude by highlighting one of the difficulties in implementing the threshold framework that Wilkinson develops: the challenge to the physician’s traditional patient-centered role. Under that framework, it is not clear whether the physician can or should remain an advocate solely for the child’s interests. That role would require physicians to advocate withdrawal or continuation in the “grey zone,” depending on what they saw as in the neonate’s interest, against parents who had come to the opposite conclusion. Given the well-documented pessimism of physicians about prognosis and quality of life, their advocacy would likely reflect and reinforce the asymmetry between let-die and keep-alive decisions defended by Wilkinson, favoring withdrawal in close cases.
But there is a price for the clarity about potentially-conflicting interests promoted by such physician advocacy. Parents faced with agonizing decisions about whether to let-die or keep alive a very severely impaired neonate may often conflate their own interests with those of the child, a conflation facilitated by the extensive overlap in their interests. Clearly distinguishing the interests that do not overlap might improve the quality of parental decision making in some ways, but it might also have a substantial cost for parents who choose to withdraw support based in part on their non-overlapping interests. In cases where the physician believes it is in the child’s interest to continue living despite the heavy burdens for the parents, her well-intentioned advocacy to that effect will throw their “selfish” interests into sharp relief. I suspect it is much easier for parents to rationalize withdrawal decisions as made exclusively in the child’s interests than to acknowledge that their own interests tipped the balance. This may be self-deception, but it would be problematic for physicians to deny them this small mercy.
To conclude, this is an impressively serious, wise, and humane book. If there is a consequentialist aspect to Wilkinson’s analysis, it is not found in appeals to aggregate welfare or the impersonal good to resolve difficult questions. Rather, it is reflected in a deep, informed concern for all of the interests implicated in decisions about severely impaired neonates. Wilkinson’s perspective is encompassing, not impersonal; he comes close to the ideal of an empathic but unsentimental Impartial Observer, displaying a rare capacity to appreciate the multiplicity of interests and values that must be taken into account in making life-and-death decisions about severely impaired neonates.
Department of Bioethics
National Institutes of Health
Bethesda, MD, USA
Disclaimer: The views expressed are the author’s own. They do not represent the position or policy of the National Institutes of Health, U.S. Public Health Service, or the Department of Health and Human Services.
Foster, Charles. 2013. “Review of Death or Disability: The Carmentis Machine and Decision-Making for Critically Ill Children.” European Journal of Health Law 20: 532-539.
Frick, Johann David. 2014. “‘Making People Happy, Not Making Happy People’: A Defense of the Asymmetry Intuition in Population Ethics.” PhD diss., Harvard.
McMahan, Jeff. 2002. The Ethics of Killing: Problems at the Margins of Life. New York: Oxford University Press.
Professor Elizabeth Barnes has produced a tightly and carefully reasoned philosophical examination of the significance of disability. It provides a clear defense of certain core principles of the disability rights movement in contrast to the many professional philosophers (those which I will term ‘mainstream bioethicists’) who consider that movement to be ill-conceived. An example of this tradition can be seen in the volume From Choice to Chance: Genetics and Justice, coauthored by four of the most prominent bioethicists of the turn of the century (Buchanan, Brock, Daniels, & Wikler 2000). (For discussion see Amundson & Tresky 2007, 2008.) I confess to the prejudice implied by my label of ‘mainstream bioethicists’ as those beset by the prejudice of ableism. The late Adrienne Asch considered herself a mainstream bioethicist even though her progressive views of disability were rare among her colleagues.
Disability rights is a serious civil rights movement, equal in significance to gay rights, feminism, resistance against discrimination on the basis of ‘race,’ and a number of other such movements. Just as earlier generations of philosophers assumed the legitimacy of the social prejudices of their own times, mainstream bioethicists have assumed the correctness of prevailing assumptions about disability. In this tradition, disabilities are conceptualized as inimical to well-being, they essentially involve suffering, and any civic ameliorations of the problems of disability are seen to result only in slight improvements to the essentially low quality of a disabled life. Barnes argues the contrary. Disabilities should be conceived as mere differences, not bad differences. Her neutral model of disability comports with a great deal of testimony from disabled people themselves. But such testimony is vulnerable to principled dismissals from their philosophical critics (few of them disabled). Barnes proceeds to argue against those dismissals, concluding that they are cases of testimonial injustice. I will sketch aspects of these two conclusions: first her neutral model of disability, and second her defense of the contrary testimony of disabled individuals against dismissal.
The Value-Neutral Model. Barnes acknowledges that individual cases of disability often co-occur with lowered well-being. However she argues that it is a mistake to conclude that disability is itself the cause of lowered well-being. Arguments in favor of the conceptual linkage between disability and lowered life quality are common in the literature. For example: Disability is abnormal function, normal life opportunities require normal function, sub-normal life opportunities therefore imply reduced well-being, which proves that disability implies reduced well-being. (This argument is reconstructed from Buchanan et al. 2000.) How does Barnes refute this inference? She begins by distinguishing between local ‘bads’ and global ‘bads.’ Global bads are things that are bad for you on the whole, largely without respect to your situation. Local bads are bad for you only with respect to certain contexts or situations. This is nearly all she needs to reveal the value-neutrality of disability. Using a list of individual cases of ‘goods’ and ‘bads’ she shows (a) that many things that are highly valued by individuals also have serious ‘bads’ associated with them and (b) that many people who have significant disabilities also find important ‘goods’ associated with their disabling conditions. To weaken our assumptions of the bad-making properties of disabilities, Barnes cites some important examples of conditions that have recently been socially reclassified from ‘assumed to be bad-making’ to ‘assumed to be neutral.’ One of these is gayness. She reports gayness to be a neutral trait, even though it can surely be associated with very low well-being when it occurs in a social context that is heavily prejudiced against gayness. Our own society has only recently come to hold that gayness is a neutral trait. Not long ago, and certainly within my lifetime, gayness was classified as a psychiatric illness by medical authorities and deemed (by typical Americans) to cause very low well-being. We must notice that majority agreement with Barnes’s assessment that gayness is a neutral trait is not necessary for the strength of her argument. Even if her view about gayness (which I share) is not shared with the general public, it is surely shared among the majority of liberal, college educated Americans. (The recent election has shaken my confidence in guessing the opinions of my fellow countrypersons.) The important point is not that academics are correct in our views, but that we have changed our views with respect to gayness in recent decades. Barnes offers a corresponding argument with respect to biological sex, and claims that being a man is neutral with respect to well-being. This view was rejected not only by Aristotle, but by many others (predominantly men, the sex that dominates the historical record) well into the 20th century. (I was shaken by Barnes’s hypothetical discussion of how the lives of men might be assumed to be much lower in quality than those of women . I would have been more comfortable if she had stuck with social prejudices that matched my own.) Even if we liberals relinquish our claim to objective correctness, Barnes’s point stands. Earlier assumptions about how traits influence well-being have changed. The assumption about disability might change also. We must not assume the contrary, especially if evidence is against it.
Taking Their Word for It. What is the evidence that disability is neutral with respect to well-being? Some of it comes from questionnaires which clearly indicate that the average self-assessed well-being of disabled individuals is only slightly lower than that of non-disabled individuals. Published autobiographical reports often reflect similar valuation. One of Barnes’s many examples from this literature is Dostoevsky, who we learn had a serious form of epilepsy that strongly affected him throughout his adult life. Nevertheless, Dostoevsky valued his epilepsy highly because the special experiences that accompanied seizures, stating that “all you healthy people don’t even suspect what happiness is” (quoted in Barnes 2016, 109).
Nevertheless, mainstream bioethicists continue to believe that disabled people have a much lower level of well-being than nondisabled people. They do not change their opinions in the face of this apparent counterevidence. Instead they come up with reasons to dismiss the counterevidence. This is my second topic: Barnes’s discussion of the grounds on which mainstream bioethicists dismiss the disability-positive testimony of disabled people.
Disabled testimony is dismissed by likening it to cases like Stockholm Syndrome (in which hostages come to sympathize with their captors) or abused spouses who refuse to testify against their abusive partners out of a belief (that we presume to be irrational) that they are better off with the abuser than without him or her. The philosophical details of this problem are too complex to even summarize here, but Barnes does a fine job of explaining why dismissing the testimony of disabled people about their own well-being does not count as a liberation of victims from their delusions, as it would be for Stockholm Syndrome hostages or agreeable abused spouses. Instead it is an illegitimate dismissal of legitimate testimony. Barnes labels these dismissals as ‘testimonial injustice’ following philosopher Miranda Fricker (Fricker 2007). Disability studies authors (including your modest commentator) have rejected this kind of dismissal with similar purposes as Barnes. Unlike most other disability studies writers, Barnes has a close and detailed understanding of the theoretical background that underlies the dismissal. Her detailed discussion is welcome.
Overview. Barnes’s careful and concentrated philosophical discussions may not be attractive to some disability studies authors, who favor a more socially oriented approach to the problems of disability. She does little to position her writings in the context of other disability studies authors, except those that give autobiographical reports on their own well-being. A clearer acknowledgement of those relationships would have been useful. The book’s close philosophical focus will endear it neither to all disability rights advocates (it will seem curiously bloodless to some) nor, at first glance, to all philosophers (whose prejudices are being challenged). She reports that her entire book is aimed at providing a justification for the “disability pride” movement. I do not share that particular goal. It seems to me that the disability rights movement requires ‘pride’ only as a rhetorical flourish, as other ethnic movements have used it. But the arguments are especially valuable within the philosophical community. The neutral model of disability and other products of Barnes’s analysis are independently important. I was once told that one of my naïve efforts at explaining disability rights to philosophers was the first such published account (Amundson 1992). Since then the growth of interest in disability among philosophers has been impressive, though not overwhelming. It is time that close analytic attention was given to these problems, and Barnes’s book is a promising contribution.
University of Hawaii at Hilo
Hilo, HI, USA
Amundson, R. 1992. “Disability, handicap, and the environment.” Journal of Social Philosophy 23: 105-118.
Amundson, R., & Tresky, S. 2007. “On a bioethical challenge to disability rights.” Journal of Medicine and Philosophy 32: 541-561.
Amundson, R., & Tresky, S. 2008. “Bioethics and disability rights: conflicting values and perspectives.” Journal of Bioethical Inquiry 5: 111-123.
Buchanan, A. E., Brock, D. W., Daniels, N., & Wikler, D., eds. 2000. From chance to choice: genetics and justice. Cambridge: Cambridge University Press.
Fricker, M. Epistemic Injustice: power and the ethics of knowing. Oxford: Oxford University Press.
David Shoemaker’s highly innovative and intricately argued new book draws on much of his previous work together with substantial original material to form a detailed and cohesive treatment of responsibility. The book is engaging, crisp, and admirably clear. It is marvelously ambitious in its strategy and framework, engagement with multiple literatures, and decidedly novel approach to Strawsonian theory. Moral philosophers, psychologists, clinicians and practitioners, and anyone who has ever wondered about “marginal agents” – people with dementia, autism, (manic-)depression, OCD, and psychopaths – will find much to entice them in this thorough and accessible treatise.
Shoemaker’s starting point – the phenomenon he aims to explain – is the observation that many of us feel a certain ambivalence toward marginal agents of the sort mentioned above. When we interact with or read case studies of marginal agents, we feel a “profound unease,” which Shoemaker diagnoses as caused by the fact that “these agents seem worthy of some responsibility responses but not others, which suggests that they are responsible in some ways but not in others” (3). This is the foundational premise of the entire book. For Shoemaker, responsibility responses include but are not at all limited to the standard praise, blame, and resentment; admiration and contempt, approval and disapproval, pride and shame, anger and regret are all brought in under this unusually wide conception of responsibility responses (a point I’ll return to in my final remarks). The idea is that psychopaths may deserve contempt but not anger, patients with dementia may deserve admiration but not resentment, and so on and so forth.
Starting from responsibility responses puts Shoemaker squarely in the Strawsonian camp of moral responsibility theorists. Put in the simplest of nutshells, P.F. Strawson’s revolutionizing argument for sidestepping the free will problem in “Freedom and Resentment” was that we should stop thinking of responsibility responses as only justified by certain metaphysical facts, i.e., by the fact that we are agents with free will, and instead think of our responsibility responses as justified by their role in (unavoidably necessary but also intrinsically valuable) social practices of caring about and responding to others’ manifestations of goodwill or ill will toward us (Strawson 1962). In Part I, Shoemaker introduces three main modifications to Strawson’s view. The first is that Shoemaker draws a tripartite distinction amongst the “attitudes and intentions towards us” or the “quality of others’ wills towards us” that Strawson takes to be the object of reactive attitudes (Strawson 1962 48, 56); he distinguishes between the quality of others’ character, the quality of others’ judgment, and the quality of others’ regard for us. The second is an account of responsibility responses in terms of “sentiments” (along the lines of metaethical and aesthetic sentimentalism), where sentiments are dispositions to feel a special type of emotions that are culturally universal and recalcitrant to judgment. The third, following closely from the second, is slipped into an unobtrusive argument that if the appropriateness of our responsibility responses are not justified by metaphysical facts then “it must be a matter merely of how the responses somehow fit with their objects” (19). In other words, Shoemaker understands the justification of responsibility responses in terms of fittingness. Responsibility responses are justified when they are fitting to their objects, just as emotional and aesthetic responses are appropriate when they are fitting to their objects.
Shoemaker thus identifies three paradigmatic pairs of sentiments (and other related emotions) that correspond to the three different objects of our responsibility responses: agential disdain and admiration (along with contempt, abhorrence, awe, veneration, etc.) are the fitting positive and negative responses to good and bad character; agential regret and pride (etc.) are the fitting responses to good and bad judgment; and agential anger and gratitude (etc.) to good and bad regard. These correspond to what Shoemaker calls responsibility as attributability (directed at character), answerability (directed at judgment), and accountability (directed at regard). Part I of the book is devoted to laying out this theory and defending the distinctiveness of each of the three types of responsibility.
In Part II, Shoemaker shows how this tripartite account accommodates our ambivalent responses to marginal agents; in each case, he argues that the condition in question disrupts some of the capacities or psychic elements required for one form of responsibility, but leaves intact others required for other forms of responsibility. People with depression have mitigated attributability for their actions, because the depression has interfered with the cares and commitments that constitute a person’s character (or “deep self”), but they may still be capable of responding to reasons and experiencing empathy in the ways required for answerability and attributability. Psychopaths lack the capacities for experiencing empathy (or have severely mitigated capacities to do so) required to sustain properly moral regard for others, so they are exempt from accountability, but they still have the capacities for character and judgment that are required for attributability and answerability. And people with mild intellectual disabilities are exempt from (or have mitigated) answerability, because they lack the cognitive and adaptive capacities – reasoning, planning, learning – that are required for properly reasons-responsive evaluative judgment; but they may still have cares and commitments that constitute their distinctive selves and they may still be capable of empathy, especially for those with whom they have close relationships, in such a way as to preserve their attributability and accountability. Shoemaker provides similar accounts for people with mania, scrupulosity, high-functioning autism, dementia, and poor formative circumstances (i.e., morally deprived childhoods), demonstrating impressive mastery of the empirical literature around each of these marginal cases. The book really shines when Shoemaker draws on the resources of his tripartite theory to make illuminating proposals for further empirical and clinical investigation. He writes: “[O]nce we move beyond the deeply entrenched all-or-nothing model of responsibility, the tripartite theory opens us up to a new, nuanced set of tools for both those who treat and those who suffer from (at least some of) these disorders” (145). In short, a more fine-grained moral theory can help us better conceptualize complex psychological phenomena, while in the other direction, diving into real-life details prompts the development of more sophisticated moral theory.
In the remainder of this review, however, I will raise three worries for the project: one regarding the general strategy, and two regarding Shoemaker’s sentimentalist take on Strawsonian theory. My first worry is that, insofar as Shoemaker claims that the puzzle to be solved is the fact of our ambivalent responses to marginal agents, it is not clear that the tripartite theory is really necessary. Shoemaker says very little to characterize the phenomenon or what he actually means by “ambivalent” responses, other than that the “unease of ambivalence” is not the unease of uncertainty, before diagnosing it in (the already quite theory-laden) terms of feeling that agents merit some responsibility responses rather than others (3). There might be alternative ways of explaining this ambivalence, however. It might not be genuine ambivalence, for instance, if our responsibility responses are simply keyed to certain facets of the cases which feel warranted or not depending on whether those facets are made salient at a given moment or not. In other words, like optical illusions that flip from duck to rabbit, young girl to old woman, depending on which cues we focus on – but where the picture is either of a duck or a rabbit, and not a part-duck/part-rabbit – perhaps, too, a marginal agent could be responsible when her case is viewed under a certain light, and not responsible under a different light, but it not be the case that under a single description some responsibility responses are appropriate while others are not.
Or, to take another visual metaphor inspired by Shoemaker’s own discussion of “local blindnesses” whereby an agent may be responsive to reasons only in some domains but not others (82), perhaps we could think of our ambivalent responses as picking up on domain-specific gaps in more unified responsibility-conferring capacities that are overall intact. For example, on accounts that would deny Shoemaker’s attributability-answerability distinction, it might be that a marginal agent is a responsible agent overall for her actions and attitudes in virtue of how it is possible for them to flow from her evaluative judgment, but that she lacks responsibility for specific actions and attitudes flowing from certain judgment “blindnesses,” or domains over which her capacity for judgment is blocked or lacking. Thus a person with depression might still count as a responsible agent in virtue of the fact that her evaluative judgment is intact overall, as evidenced by the fact that she manages to sustain quite a few minimally requisite actions, e.g., feeding herself, keeping her job; but there are large and important swaths of a full human life, e.g., her relationships, her activities, in which the operation of her evaluative judgment is too distorted for her to be responsible for them. This last observation might be related to the fact that Shoemaker claims to be giving an account of responsible agency, rather than responsibility for particular actions, which suggests, finally, that some of our ambivalence toward marginal agents might also be handled by distinguishing between how we feel toward them as agents versus how we feel toward them as agents in light of specific instances of behavior.
I suspect, however, that the puzzle of ambivalent responsibility responses might be (at least somewhat) less central to the motivations behind the tripartite theory than suggested, and we could simply think of marginal agents as exemplary case studies for illustrating its power. This brings me to my second set of worries, however, which is that the trifold sentimentalist strategy and framework – marvelously conceived though it is – may not be enough to sway those who prefer unified accounts of responsibility that can still save the phenomena. The costs of relatively minor or esoteric counterexamples may not outweigh the benefits of simplicity. Out-of-character actions and whims, for instance, which Shoemaker takes to be instances of answerability without attributability (59, 83), seem to me still attributable to agents as manifestations of some kind of character trait, even if not the obvious ones: a wandering mind, an active curiosity, sublimated anxieties and desires, a love of spontaneity, and so on. (This move would be akin to one Shoemaker makes in his own analysis of scrupulosity, according to which such agents’ general “moral orientation” and perfectionist stance renders many of their thoughts and attitudes still properly attributable to them.) Or they may manifest pro tanto evaluative judgments rather than all-things-considered evaluative judgments about the worth of some action.
I also found myself worried at times about proposals that, while innovative, struck me as potentially ad hoc or insufficiently grounded in deeper justification. If debates about the deep self have centered around Platonic versus Humean accounts, for instance, is it a satisfying resolution to simply combine them into an ecumenical position, without further diagnosis, explanation, or motivation? If the dominant philosophical and psychological view is that anger fundamentally involves revenge, is it enough to point to the existence of some cases in which people feel frustrated if they cannot communicate to the objects of their anger that “This is for what you did to me!” (105)? (For surely we can imagine agents whose anger leads them to want simply to annihilate and destroy the objects of their anger, or whose anger is satisfied when revenge can be carried out anonymously such that their objects “never even knew what hit them”.) Is it fair game to simply declare that we have “empathic control” when identifying with others’ perspectives leads us to certain kinds of emotional or reasons-responsiveness, such that these are “up to us” in the way that things over which we have voluntary control or rational control are up to us? (For the latter have been understood as “up to us” because they derive from our wills or our evaluative judgment, which have been argued to be constitutive of moral agency; but such an argument has yet to be made for empathic capacities.)
Finally, there were some moves that seemed to betray some artificiality in the tripartite taxonomy of sentiments. In the case of admiration (one of the emotional syndrome pair for attributability), for instance, Shoemaker restricts the sentiment to agential admiration, setting aside cases in which we admire non-agents, e.g., the Grand Canyon; but when it comes to finding the emotional syndrome pair for answerability, Shoemaker simply sets aside disappointment on the grounds that it is not restricted to agents. This leads him to adopt a first-personal emotional syndrome pair for answerability (pride-regret) that does not match the third-personal pairs for attributability and accountability. And although Shoemaker acknowledges that we may sometimes feel regret even when we absolutely do not manifest any flaw in evaluative judgment, he dismisses these as non-paradigmatic cases of regret which do not count as genuine responsibility responses. Of course, any theory – especially new and ambitious ones – will contain anomalies. But since Shoemaker’s job is to convince us that there really are three fundamental pairs of sentimentalist responsibility responses and since his work is otherwise so thoroughly grounded in empirical evidence, I am hopeful for more reason to think that the tripartite theory has successfully latched onto natural kinds in our actual practice rather than being a theoretical framework imposed from the armchair.
This brings me to my final worry, about the sentimentalist fittingness approach to justifying responsibility responses. In developing his tripartite theory, Shoemaker has broadened his responsibility responses beyond the responses of resentment and indignation on which other theorists have focused. To be sure, Strawson himself does identify a wide range of reactive attitudes, including “gratitude, resentment, forgiveness, love, and hurt feelings” (49). But this is in the first stage of Strawson’s argument, in which he is pointing out the existence of reactive attitudes in general; the second stage of his argument is to explore whether an understanding of specific reactive attitudes can “bring us, if possible, nearer to a position of compromise in a more usual area of debate” (56), where the usual debate, of course, centers around “desert, responsibility, guilt, condemnation, and justice” and the problem of free will (64). Moreover Strawson is clear that he is interested primarily in moral responsibility, that is, in the “concept of moral responsibility and of the practices of moral condemnation and punishment” (62). It is no accident that desert, condemnation, justice, and above all free will – precisely those concepts that Shoemaker sets aside in his last chapter – are concepts that intimately involve concerns about fairness. Thus when Shoemaker declares that appeals to unfairness constitute “the wrong kind of reason,” since they are orthogonal to questions of whether some responsibility response is fitting to its target in the way that aesthetic responses are (201), this seems to me a significant deviation from the Strawsonian project. Even if it is (quasi-aesthetically) fitting to feel contempt toward a vicious agent, concerns about determinism and free will – Strawson’s target – arise only when we worry about whether it is morally appropriate for us to feel that way toward an agent who did not have, e.g., the (fair) opportunity to avoid becoming vicious. Similarly, when Shoemaker disavows the centrality and relevance of harsh treatment to responsibility, this seems to depart altogether from the Strawsonian starting point that begins with our practices of moral condemnation and punishment.
Shoemaker, of course, is aware of this difficulty, stating: “I want to insist on the crucial distinction (a distinction I believe has long been overlooked) between the fittingness of various sentimental responsibility responses and the appropriateness of harsh treatment of offenders” (223). I cannot help but suspect, however, that this final, insisted-upon distinction suggests that the fundamental distinction might hold between just two faces or concepts of responsibility, as defended (in different ways) by theorists such as Gary Watson (2004), Tim Scanlon (1998), Iris Marion Young (2011), and myself. If I am right about this, then Shoemaker will have offered us an exceptionally elegant and richly-detailed Strawson-inspired theory of the first (aretaic or attributability) concept of responsibility, while more or less setting aside the second (substantive or accountability) concept of responsibility with which Strawsonians typically concern themselves. But none of this detracts from the huge contribution that Shoemaker has achieved in this book with his exciting and fruitful new framework for thinking about responsibility.
Scanlon, Thomas. 1998. What e owe to each other. Cambridge: Belknap Press of Harvard University Press.
Smith, Angela M. 2012. “Attributability, Answerability, and Accountability: In Defense of a Unified Account.” Ethics 122.3: 575-89.
Strawson, P.F. 1962. “Freedom and Resentment.” Perspectives on moral responsibility. Eds. Fischer, John Martin and Mark Ravizza. Ithaca, NY: Cornell University Press, 1993. 45-66.
Wallace, R. Jay. 1994. Responsibility and the moral sentiments. Cambridge: Harvard University Press.
Watson, Gary. 2004. Agency and answerability: selected essays. Oxford: New York: Clarendon; Oxford University Press.
Young, Iris Marion. 2011. Responsibility for Justice. New York: Oxford University Press.
Zheng, Robin. 2016. “Attributability, Accountability, and Implicit Bias.” Implicit Bias and Philosophy, Volume 2: Moral Responsibility, Structural Injustice, and Ethics Eds. Saul, Jennifer and Michael Brownstein. New York: Oxford University Press, 62-89.
 Or, depending on how invested one is in Strawsonian exegesis (the temptation of which I try, but perhaps not hard enough, to resist as far as possible in this review), three main interpretive extensions.
 The latter simply refers to the tendency of some emotions to remain even when certain beliefs that constitutively define that emotion are given up, e.g., continuing to fear a spider even after one has acquired reason to give up the belief that it is dangerous.
 This sort of fittingness view has been defended with regard to blame in particular; see, e.g., Arpaly (2002) and Hieronymi (2004).
 This is true, at least, for nonmoral judgments. But they may lack the capacity for moral judgments that require having moral regard for others, and hence lack answerability in these domains.
 A form of OCD involving obsessive thoughts about morality, e.g., that one has committed a moral wrong merely by imagining a certain event.
 Whether there is an objectively best way of describing the case might depend on deeper commitments about the nature of responsibility, e.g., whether responsibility is primarily a metaphysical or practical matter.
 The difference for Shoemaker consists primarily in the fact that answerability is limited to evaluative judgment, while attributability ranges more widely across commitments and cares that are distinct from or not grounded in specific judgments.
 This addresses the second of Shoemaker’s three arguments for the distinction between attributability and answerability. In response to the third counterexample of an agent who holds two conflicting attitudes that are singly unobjectionable but irrational when combined, a unified account theorist might endorse Smith’s (2012) reply and argue that what deserves criticism is not the irrationality of this configuration, but the irrationality of failing to take steps to alter the configuration once the conflict has become so salient. For most of us likely harbor at least some irrational configurations of conflicting attitudes (like contradictory beliefs) which are not worth the time or effort to resolve.
 A unified account theorist might use this to argue against Shoemaker’s first argument: cares and commitments might be grounded in pro tanto rather than all-things-considered judgments.
 See, most notably, Wallace’s (1994) arguments for narrowing the class of reactive attitudes to those which hold someone to an expectation, e.g., resentment, indignation, and guilt (25-33).
 More fully, Strawson writes: “The concepts we are concerned with are those of responsibility and guilt, qualified as ‘moral’, on the one hand— together with that of membership of a moral community; of demand, indignation, disapprobation and condemnation, qualified as ‘moral’, on the other hand—together with that of punishment” (62).
The Kennedy Institute of Ethics Journal will be publishing a special volume on ethical and social issues arising out of the 2016 US presidential election and the transition to the Trump administration. Papers will be anonymously reviewed and judged according to the scholarly standards typical for the journal, without regard to political orientation. Creativity in form and approach is encouraged.
Among other topics, contributions may explore ethical and social questions concerning:
- The election and campaign, including campaign propaganda, voter enfranchisement, districting and the electoral college, voter demographics and divisions, ‘filter bubbles’ and media access, etc.
- The ethical limits and possibilities for protest, resistance, and managing conflict in a divided nation, including questions surrounding the proper place of violence, if any.
- The rise of nationalist, white supremacist, and Islamophobic rhetoric and activism during this election season.
- Public allegations of sexual assault, and the politicization of those allegations.
- The rise of the ‘forgotten white working class’ in reality and in rhetoric.
- What to expect from a Trump administration, including explorations of his particular proposals (on immigration, Muslim registries, abortion, and so forth).
Papers may be of any length, up to approximately 10,000 words. Short pieces are encouraged.
In order to make this issue timely, we are requesting submissions by February 28, 2017. Papers will be published online and open-access by June 2017.
Please direct any inquiries to Rebecca Kukla, Editor-in-Chief, firstname.lastname@example.org or to Hailey Huget, Managing Editor, email@example.com. Papers should be submitted both via the journal’s online submission system and by email to firstname.lastname@example.org, with a note saying that they are for the special issue.
Becoming Human by Jennifer Greenwood is one of the most thought-provoking books on emotion and its expression I have read. At its core, it attempts to provide an account of the development of full human emotionality and in so doing argues the emotions are “transcranial.” Emotions are radically realized outside our nervous systems and beyond our skin. As children, we are functionally integrated affectively with our mothers; so much so that in a sense our emotions are not ours alone. Regardless of whether one agrees with her radical claims, it is a must-read for those interested in emotion and expression. In order appreciate the significance of this book, let me sketch its contents and raise a few criticisms.
Many, but certainly not all, psychologists and philosophers assume that there are basic emotions (BEs) and higher-cognitive emotions (HCEs). The former include fear, anger, disgust, happiness, surprise, and sadness; and the later include guilt, shame, and pride amongst others. BEs are thought of as natural kinds involving facial expression, homologous traits shared with non-human primates, specific brain structures, and stereotyped behaviors. HCEs differ in that they often do not have unique physiological profiles, facial expressions, dedicated brain regions, and culturally vary quite a bit. Greenwood argues that there are affective precursors that develop into BEs and HCEs. However, the distinction between BEs and HCEs lulls us into naïve views about nature and nurture, biology and culture. We have not taken their development from childhood as seriously as we should. Both develop through time.
Greenwood has us consider human infants. They are completely dependent on their caregiver who is usually their mother. They can cry and exhibit motor unrest to convey how things are going for them. Their emotional precursors are ostensive and expressive. They are ostensive insofar as they direct the attention of the mother to sources of displeasure and they are expressive insofar as they signal that displeasure. They are referentially opaque but through time become less so. Thus, these emotional precursors are natural signs which occur when proprioceptive and interoceptive thresholds have been crossed and help is needed. Crying and motor unrest are assistance-soliciting devices. Mothers are equipped with “intuitive parenting” skills by which they can identify what things are helpful and harmful to their child. They instinctually respond to the child’s stress and try to remove the sources of it. This also involves mimicry in speech and mirrored facial expressions of their child. These are assistance-producing devices. Through repeated interactions of these assistance-soliciting and assistance-providing devices, the child’s emotionality advances through functional integration with the mother. Not only do these interactions provide feelings of pleasure but also new neural machinery develops as the result of these dynamic interactions. There are complex causal interactions between child and mother, which scaffold the child’s emotions and their expression. It is also through the same mechanisms that language appears as well. “Motherese” helps the child to understand the boundaries between clauses and how to command, request, declare, and to question. Thus, our first conversations are with our mothers. Greenwood offers an explanation of how infants begin with affect expressions and species-typical behaviors to express themselves, move to communicating with gestures and inflected vocalization, and finally develop language. And, referential clarity increases with the development of the emotions and language. The child’s species-typical behavior patterns coupled with the mother’s intuitive parenting skills provides the necessary and sufficient conditions for generating a semantic lexicon. These natural and conventional signs have their declarative and imperative content secured by a kind of teleosemantics inspired by the work of Ruth Millikan.
These are bold hypotheses that Greenwood has offered. She additionally argues that the hypothesis above gives strong support to Transcranialism, or the Extended Mind hypothesis, about the emotions. It says that mental states and processes extend outside the nervous system. Intracranialists deny this claiming that the scaffolding provided by the world outside the body is simply that of “support”. That is, they claim Transcranialists conflate causation and constitution. Greenwood utilizes the work of Robert A. Wilson (2004) on the metaphysics of realization to challenge this. Roughly, a property R realizes G if it is plays the G-role or has the G-function. Philosophers of mind have typically assumed that the physical properties sufficient for mental roles or functions were exhausted by the intrinsic physical properties of individuals. However, this is exactly the assumption that Wilson and Greenwood challenge. According to Wilson, there are core and non-core realizers. Core realizers are those parts of a system which play a “crucial role” in producing or sustaining a property of interest. Non-core realizers are necessary but are not crucial for the producing or sustaining the property of interest. For example, a core realizer for fear is the amygdala whereas the thalamus is a non-core realizer. Transcranialism about emotions claims that the realization of emotions is radically wide; a total realization of an emotion can have core and non-core realizers located outside the individual experiencing the emotion.
As we have seen, Greenwood claims emotions are essentially ostensive-expressive devices that evolved by natural selection for interpersonal tasks and only later for intrapersonal ones. She also argues that Wilson’s model of radically wide realization provides the metaphysical machinery for defending transcranialism about human emotions. Going beyond earlier externalisms, she contents the internal and external resources are deeply functionally integrated and play complimentary roles in our emotions. The mind extends our emotions into the world, and the world extends into our emotions. It is “synchronous modulation” of the child and mother during the development of emotions and language which widely realizes those emotions.
Greenwood’s claims and arguments are extremely bold. Let me conclude by raising some points of criticism. Greenwood has effectively argued that human infant’s emotions develop through a dynamic coupling with their mothers. They are functionally integrated. I find the evidence she presents fairly convincing. If child and mother are functionally integrated with respect to the child’s emotions, then they are widely realized. If they are widely realized, then those emotions are transcranial. Therefore, those emotions are transcranial. First, like Victor of Aveyron, some feral children develop without the benefit of a mother or even a direct caregiver. They are raised by wolves as it were. Though they may be developmentally challenged in various ways, one might argue that they experience a full range of human emotions. This suggests that the dynamic coupling with a caregiver, and specifically a mother, is not necessary for the development of human emotions. Without good empirical evidence, I am suspicious of this claim. Anecdotal reports of feral children strike me as inconclusive at best. Second, let’s suppose that this dynamic coupling is required. Still, one might object even accepting that it is through this functional integration the emotions are widely realized, we needn’t accept that they are transcranial. Striking a match causes a fire at the end of the stick but only so if there is oxygen present. We treat the striking as the cause and the oxygen as a background condition. Thus, even if we grant that a core realizer of a child’s fear is the amygdala and non-core realizer are the mother’s assistance-producing devices, it seems that we can still appeal to the cause/background condition distinction. Through this, we can resist the more radical transcranialist’s claims. Of course, much more work is needed to make good on this claim. For example, the cause/background condition claim must be more than pragmatic. However, if we can, then I think we can argue that functional integration is causal and not constitutive. Third, let’s suppose that Greenwood has made her case that the emotion experienced by human children are transcranial. She grants human emotions move from interpersonal functions to intrapersonal ones. I doubt that emotions are generally interpersonal or intrapersonal en masse. Still, it is open whether at least some human emotions after childhood are exaptations to new intrapersonal challenges. If this is correct, then even if human emotions during childhood evolved to be transcranial they become intracranial later in life. The emotions of adults are screened-off from those of human children in a way that doesn’t threaten the project of psychologists and philosophers I mentioned at the beginning.
Regardless of my worries, Greenwood’s is an impressive book from which I learned quite a bit. I strongly encourage those interested in emotions and expression to read it. Your mother would have wanted you to.
Department of Philosophy
Lewis & Clark College
Portland, OR, USA
Wilson, Robert A. 2004. Boundaries of the Mind: The Individual in the Fragile Sciences Cognition. Cambridge University Press.
Our Editor’s Pick for September 2016 is Jing-Bao Nie and Ruth Fitzgerald’s article, “Connecting the East and the West, the Local and the Universal: The Methodological Elements of a Transcultural Approach to Bioethics.” Nie and Fitzgerald argue that scholars working in transcultural bioethics have “seriously problematic methodological habits in approaching cultural differences,” such as “radically dichotomizing the East and the West, the local and the universal.” In light of this, Nie and Fitzgerald’s paper seeks to develop new methodologies for transcultural bioethics.
In On Immunity: An Inoculation, essayist and author Eula Biss has given academics and clinicians interested in the public’s skepticism of vaccines, and of science skepticism more generally, a fresh look at what drives these phenomena. Despite public health’s continued success in maintaining high rates of coverage for vaccines across the United States, recent measles, mumps, and rubella outbreaks in the U.S. (and globally for that matter) have harmed lives and indicate cracks in the vaccine uptake façade. From a public health perspective, it’s all hands on deck to make sure vaccine coverage stays high. Biss’s outsiders’ view of these issues offers bioethicists, public health practitioners, and physicians much to consider as we address ongoing challenges to vaccination.
Do not read On Immunity expecting a scholarly analysis of the state of vaccine refusal and resistance. The book is instead part self-reflection (how Biss samples but rejects anti-vaccine sentiments), part observation (the ways vaccines both capture and reflect popular understanding and anxiety about the body, about germs, and about medicine more generally) and part research (into the history of anti-vaccine thought as well as its contemporary impact).
Throughout the book, Biss’s physician father acts as sort of a scientific straight man, laying out both the joys and challenges of medical and scientific practice. In one of these moments, Biss recalls how her father taught her about blood types, and about how both he and she were universal donors. With type O negative blood, Biss would come to understand her universal donor status “more as an ethic than as a medical concept” (18). This belief in a communitarian ethic runs throughout the book. “If we imagine the action of a vaccine not just in terms of how it affects a single body,” Biss writes, “but also in terms of how it affects the collective body of a community, it is fair to think of vaccination as a kind of banking of immunity.” “Contributions to this bank are donations to those who cannot or will not be protected by their own immunity,” she concludes (19).
For those of us who spend time considering vaccine policy, these are obvious points, as are the conclusions to be drawn from them. But what Biss offers its academic readers is a less jargon-filled and stilted way to talk about the importance and fear of vaccines, and thus provides some insight into what we might do to shore up vaccine coverage. One suggestion Biss has is to abandon the term “herd immunity.” In her analysis, it is a negative metaphor, one that “suggests we are cattle, waiting, perhaps, to be sent to slaughter.” “And it invites,” she continues, “an association with the term herd mentality, a stampede towards stupidity.” In its place, Biss suggests the concept of “shared immunity,” rooting the metaphor instead on natural examples like the cooperation of honeybees and collective problem solving. If the herd assumes we are foolish, the notion of shared immunity roots the nature of vaccine coverage in cooperation (21).
Some have read On Immunity as a weak embrace of anti-vaccinationism, if only to have the reader take a taste of it, understand its essence, and be “inoculated” against its impact (Oppenheimer 2014). But I read this book differently. In fact, this is less a vaccine-world Rashamon, and more of an opportunity for scholars and policymakers to view the challenges and mindset of anti-vaccine thought, through the eyes of a sympathetic yet disapproving observer.
Biss’s chapter on how popular misunderstandings of toxicity have seeped into anti-vaccine thought, for example, is especially relevant as policy makers and ethicists consider how to respond to the threats to herd or shared immunity. Fears of toxicity, which she acknowledges is a loosely defined idea in the public’s mind, can at once refer to the ingredients in vaccines, the accumulation of vaccines in the body, or environmental exposures more generally. Biss argues that such references to toxicity by both anti-vaccine boosters and the Gwyneth Paltrow-set “strikes me as an old anxiety with a new name” (75). While she acknowledges the impact and dangers of environmental pollutants, Biss believes that what the pre-germ theory idea of filth once represented “with its moralist air, the evils of the flesh,” today is now expressed in terms of toxicity. “The word toxic,” she writes, is a catch all term that “now condemns the evils of our industrialized world.” Theories of filth and toxicity “allow their subscribers to maintain a sense of control of their own health by pursuing personal purity” (75). This gets played out in a variety of ways, including our search for the “natural,” as well as in vaccine resistance.
An academic reader of the book may also consider Biss’s failure to correct the misinformation that the anti-vaccine community thrives on as a shortcoming, or even fatal flaw of the book (142). I do not share this concern. This book is not meant for the vaccine doubters or resistors who tout their wares on the internet and at alternative medicine conferences. It is instead meant for us: the ethicists, clinicians, and policy makers who are struggling with the challenges we face in an increasingly vaccine resistant or hesitant public. It may well be that the response to anti-vaccinationism is a question of policy and public health ethics: how much should we limit people’s civil liberties to protect the public health. But when I hear studies and pundits suggest that anti-vaccine skeptics are immovable and that we must institute our most draconian policies to preserve our collective health, I find myself the skeptic and worry that we as a field have given up too easily. At the very least, On Immunity offers a retort to this line of thinking, providing vaccine ethicists and policy makers with both rhetorical and practical ways (see above examples about a communitarian ethic, herd immunity, and toxicity) to view and push back against the anti-vaccine movement.
There is one line in the book that continues to resonate with me. Biss writes that “the belief that public health measures are not intended for people like us is widely held by many people like me” (24). While her thinking here is not surprising, it is perhaps the most fundamental challenge to the current anti-vaccine trend. And it is thinking like this that has given largely white, highly educated, and middle and upper middle class families the rationale to resist or refuse vaccination. It is a position of privilege that threatens the public health, a sense of privilege that is not simply the fault of the non-medical public. It is rooted in class and racial tensions that Biss highlights. In a visit to her son’s pediatrician, Biss questions the necessity of the hepatitis B vaccine. Her doctor tells her that it is a vaccine for the inner city, “designed to protect babies of drug addicts and prostitutes.” “In retrospect,” she recalls, “I am ashamed of how little of his racial code I registered.” “Relieved to be told that this vaccine was not for people like me,” she concludes, “I failed to consider what exactly that meant” (24).
But that failure is not hers alone. It is our failure—in ethics, in public health, and in medicine. If people continue to assume, as Biss puts it, that public health “is for people with less—less education, less health habits, less access to quality health care, less time and money” (24), then we will continue to struggle with this novel strain of anti-vaccinationism and be threatened by public health challenges that lie ahead.
Dornsife School of Public Health
Philadelphia, PA, USA
Oppenheimer, Mark. 2014. “This Book Empathizes with Anti-Vaxxers, Who Don’t Deserve Empathy.” The New Republic. September 29. Full article »
In this original and insightful new work, Alice Crary proposes that we see human beings and animals as creatures that are “inside ethics,” which is to say that they possess “characteristics that are simultaneously empirically discoverable and morally loaded” (4). This view rejects what Crary sees as the dominant paradigm in moral philosophy, wherein empirical observations about human beings and animals are viewed as morally neutral and shorn of any evaluative characteristics. Her view has implications for a range of topics in moral philosophy and bioethics, including debates about disability, moral status, moral individualism, animal ethics, and animal mindedness. Here, I’ll focus primarily on summarizing chapters 1-3—which contain what Crary refers to as the work’s central argument—before turning to a few thoughts and criticisms of that argument.
Chapter 1 lays out the broad paradigm in moral philosophy that Crary opposes—that of seeing human beings and animals as “outside ethics,” or devoid of empirically discoverable and objective moral characteristics. She traces the tendency to see human beings and animals as outside ethics to what she describes as a “hard metaphysic,” where objective moral values are not viewed as part of the fabric of the world, but things that we impose on a world that is itself morally neutral (14). Chapter 2 is devoted to arguing for the work’s central claim: that human beings and animals have empirically discoverable and objective moral characteristics.
In making this argument, Crary begins by establishing what moral characteristics are and discussing how we ascribe them to humans and animals. Moral characteristics are ethically inflected psychological categories—such as, for example, jealousy, guilt, fear, or happiness. Importantly, these categories “resist any meaningful reduction or translation to physical terms” (37). This is because, in applying these psychological categories to humans and animals, we necessarily invoke certain ethically loaded conceptions of what makes a good human or animal life that are not themselves reducible to physical terms (80). When, for example, researchers set out to study jealousy in dogs, “their efforts depend for their success” on an “understanding of canine life and of the place of jealousy within it” (79). Psychological characteristics are, in this sense, “only at home in human and animal lives in which some things matter in that they are, say, to-be-feared, to-be-sought, to-be-eaten, to-be-protected, or to-be-befriended” (88). In other words, we bring ethically loaded concepts of what makes a good human or animal life to bear on our understanding of the psychological characteristics of humans and animals.
But there is still the further claim that such moral characteristics are objective and empirically discoverable; in other words, that one can apply these characteristics in a genuinely descriptive manner. It might be the case, for example, that in attributing the concept of jealousy to dogs, we make a mistake—perhaps even a mistake that stems from a problematic tendency toward anthropomorphism on our part. If this thought is right, then our claims about dogs being jealous or afraid would not be truth-tracking or objective; they would be merely subjective expressions of our own emotions, preferences, or biases.
Crary resists this possibility by proposing that we reconceptualize our understanding of objectivity. She thinks that her opponents—in denying that moral characteristics are objective—rely on what she calls a narrow conception of objectivity. The narrow conception of objectivity takes the world to be “available to thought” in a manner that is “unmediated” by concepts (55). Further, proponents of the narrow conception think that this kind of connection with the world provides a firm foundation for empirical knowledge. Proponents of the narrow conception would deny that moral characteristics are objective because objectivity, for them, involves accessing the world in a manner unmediated by normatively- or morally-inflected concepts. To argue against the narrow conception of objectivity, Crary marshals arguments made by Wittgenstein, McDowell, and others, who resist the idea that there exists a non-conceptual “given” that can provide this kind of foundation for empirical knowledge (47-55). These arguments lead Crary to suggest a “wider” alternative to the narrow conception. Proponents of this wider conception of objectivity deny the existence of a non-conceptual “given” that can provide a foundation for empirical knowledge and affirm the conceptualist view that deploying normatively loaded concepts is necessary for acquiring empirical knowledge. If this wider conception of objectivity is right, then Crary has opened up a space in which we can start to see the ascription of moral characteristics to humans and animals as objective and truth-tracking—in other words, we can start to see humans and animals as “inside ethics.”
But in relying on a conceptualist view to defend the wide conception of objectivity in chapter 2, Crary recognizes a threat to her argument that non-human animals are “inside ethics” in virtue of their psychological qualities. This threat comes from the fact that conceptualist doctrines like the one that Crary defends in chapter 2 are often taken to imply that non-human animals “lack any but the most primitive qualities of mind” (93). In order to avoid this, and thereby show that our attribution of morally inflected psychological qualities to animals is not misguided, she urges us to recognize a continuum of concept-use that runs from being governed by immediate, biological drives, to primitive concept-use, to full rationality. She thinks that, just like we consider young children to be primitive concept-users, we should think about many non-human animals—she focuses primarily on dogs—in this way (113-18). So we should read certain dog behavior, for example, as trustworthy as opposed to “merely predictable” (120). Showing how conceptualism needn’t result in skepticism about animal minds allows Crary to claim that non-human animals have empirically observable, objective moral characteristics, so that when we label a dog’s trustworthy behavior as such, we are not engaging in mere misguided anthropomorphism.
The latter chapters of the book draw out what Crary sees as the moral upshot of understanding humans and animals as “inside ethics”: the recognition of moral characteristics in humans and animals calls for certain forms of moral response, like attention and concern (88). Furthermore, given that our empirical knowledge of humans and animals’ psychological qualities must draw on ideas about what matters morally in their lives, she argues in chapter 4 that this means that all human beings and animals are of moral concern, qua their status as human beings or animals (121). Chapter 7 applies her view to two issues in applied ethics: eating animals and experimenting on them. Here, she focuses on two nonfictional works: Jonathan Safran Foer’s Eating Animals and the documentary Project Nim (255). She argues that both works urge us to see animals as “inside ethics,” insofar as they portray various animals as “living lives of significance” that deserve certain sorts of moral attention, like sympathy or respect (265).
Throughout the work, Crary claims that her argument shows that all humans and all animals are inside ethics (121). However, I wonder whether—by Crary’s own lights—she is in fact able to retain this claim (121). Given her commitments, it seems to me that the scope of creatures who are inside ethics must be either narrower or broader than this: either it is the case that not all animals are inside ethics, or it is the case that all animals as well as all plants are inside ethics.
Let’s start with why the scope may have to be narrower. Consider Crary’s response to McDowell’s arguments about animal mindedness. McDowell draws a distinction between world and environment (1994, 105-07): humans occupy a normatively structured world, while non-rational animals merely occupy environments that are structured by mere biological imperatives. For McDowell, this means that all animals are not minded in the relevant sense and are controlled by mere biological drives. Crary’s denies this universal claim by showing how some animals are not best characterized as mere automata, following only biological drives (107).
However, in this discussion, Crary exclusively focuses on the ways in which domesticated animals, like dogs, are inside ethics (113-18). We can see how it makes sense to speak of dogs “who are integrated into household routines” as trustworthy as opposed to merely predictable, for example, because they are trained to abide by social norms in various ways (120). Trained dogs would be capable of having some degree of the “free, distanced orientation” from immediate biological impulses that McDowell attributes exclusively to rational human beings (1994, 117). But what of non-domesticated animals, wild animals, or animals that otherwise take no part in the human social world? By arguing that dogs are at least proto-concept-users, Crary may have successfully blocked the implication that all animals are mere automata; however, that does not entail the further claim that all animals, including non-domesticated ones, truly possess the kinds of psychological qualities Crary is interested in. Given this, I think Crary needs to give an argument for why non-domesticated animals possess such qualities. If such an argument is not forthcoming, then it seems like all Crary has shown is that domesticated animals are properly described as “inside ethics.”
There are (at least) two ways of avoiding this problem. One would be to argue that there is more than one route to being a concept-user. Perhaps, for example, domesticated dogs and wild bottlenose dolphins are both concept-users, but in different ways. This seems to me the most promising route out of this problem, but Crary does not develop this line of thought in Inside Ethics.
A second route is to drop the commitment that moral thought in her sense is truth-tracking or objective. Perhaps we ascribe concepts like fear or shame to non-domesticated animals anthropomorphically. Maybe there is even a case to be made that we should anthropomorphize non-domesticated animals this way, insofar as it increases sympathy for them or amplifies concern for their welfare. In other words, perhaps there are independent reasons we should think about creatures as being “inside ethics,” even if that sort of thinking is not objective or truth-tracking.
However, if Crary drops this commitment to objectivity, she runs into other problems. Namely, it then becomes unclear why we shouldn’t consider a much wider class of creatures to be “inside ethics.” Why not, for example, see individual plants as things about which we can have morally loaded empirical knowledge? After all, in order to understand features of any given plant—why its leaves droop at night, or why its stems turn certain colors when lacking nutrients—we must draw upon ideas about what makes life good for plants of that kind. Goethe, for example, takes up this attitude toward plants in his work The Metamorphosis of Plants:
The nub of tranquil life, kept safe and dry,
Swells upward, trusting to the gentle dew,
Soaring apace from out the enfolding night.
Artless the shape that first bursts into light—
The plant-child, like unto the human kind—
Sends forth its rising shoot that gathers limb
To limb, itself repeating, recreating… (2009, 2-3)
Here Goethe clearly anthropomorphizes plants, attributing to them certain kinds of psychological properties that they do not, in fact, have. But there is no question that this poem attempts to achieve a certain kind of sympathetic understanding of the goods of plant life, and what it might mean for that life to go well. Does this mean, then, that we must extend moral concern to individual plants, as Crary suggests we should to humans and animals? This would make the scope of beings that are inside ethics much broader than Crary claims. This implication would also be unwelcome: if beings that are “inside ethics” call for “certain forms of moral attention and concern” (88), and if plants, too, are inside ethics, then it seems we must devote moral attention and concern to individual plants. This requirement could make moral thought far too demanding.
Crary needs the objectivity component of the project in order to block this move. With this in place, she could argue that our interpretation of a plant as possessing psychological properties— “trusting to the gentle dew,” for example—is mere poetic anthropomorphism, because we know that plants do not possess concepts, and are thus not minded in the relevant sense. But this move risks coming at the cost of Crary’s commitment to the idea that all animals—not simply domesticated ones—are “inside ethics,” since the apparent moral features of non-domesticated animals may also be appropriately characterized as mere poetic anthropomorphism. What is in fact included inside ethics may therefore be either broader or narrower than Crary claims.
That said, this work has much to offer, and is a breath of fresh air in many respects. Crary is right that the argument of her second chapter fleshes out and defends previously undefended aspects of Philippa Foot’s project in Natural Goodness (2001). Inside Ethics can also be read as a way of elaborating upon and defending Cora Diamond’s brief, suggestive, and intriguing remarks in her famous essay “Eating Meat and Eating People,” wherein Diamond urges us to think of non-human animals as creatures deserving of pity (1978). Crary’s work also poses a distinctive and welcome challenge to the dominant trend in moral philosophy of seeing living beings as “outside ethics,” and calls for those who subscribe to that outlook to defend it. Though not without its flaws, Inside Ethics ultimately offers a fresh way of thinking about moral philosophy that is stimulating, ambitious, and original.
Washington, DC, USA
Diamond, Cora. 1978. “Eating Meat and Eating People.” Philosophy 53 (206): 465-479.
Foot, Philippa. 2001. Natural Goodness. Oxford: Oxford University Press.
Goethe, Johann Wolfgang von. 2009. The Metamorphosis of Plants. Cambridge: MIT Press.
McDowell, John. 1994. Mind and World. Cambridge: Harvard University Press.
Our Editor’s Pick for June 2016 is Brian Earp’s groundbreaking article, “Between Moral Relativism and Moral Hypocrisy: Reframing the Debate on ‘FGM.’” Earp tackles the ethics of female genital cutting or “mutilation” (an ethically loaded term). This is a difficult topic that brings on board gender inequity, the integrity of the body, the value of cultural traditions, sexuality, colonialism, ethnocentrism, and other fraught axes of reflection.
This issue of KIEJ also features three commentaries on Earp’s article by Richard Schweder, Jamie Nelson, and Robert Darby that you may read here.