Category: Book Reviews

Book Reviews

Sarah S. Richardson, Sex Itself: The Search for Male and Female in the Human Genome, University of Chicago Press, 2013

Following the glorious tradition of feminist philosophers and scholars of science from the 1980s onward such as Evelyn Fox-Keller, Helen Longino, Anne Fausto-Sterling, and others who revealed how popular notions of masculinity and femininity infiltrated and shaped the content of scientific knowledge, Sarah S. Richardson’s book Sex Itself: The Search for Male and Female in the Human Genome (2013) deserves a place on the shelf with this canonical literature. It addresses one of the most celebrated symbols of biological sex binary: the X and Y chromosomes. The X and Y chromosomes, we learn, were not given the role of “sex chromosomes” upon their discovery in 1890 and 1905, respectively. Their transformation into the ultimate biological signifiers of male and female during the next five decades was neither inevitable nor free from significant theoretical and empirical challenges. Rather, the X and Y chromosomes, objects of scientific study, were gendered via the various stages of scientific inquiry and methodology. The implicit promise embedded in the human genome project to decode human differences and identify the genetic elements of maleness and femaleness make Richardson’s book a crucial contribution that outlines a much-welcomed reflection of this scientific endeavor.

Whereas during the late 19th century biologists understood “sex” as a “complicated, spectrum-like, and highly variable phenomenon” (24), the beginning of the 20th century saw biologists expressing a dimorphic vision of sex differences, with models that attempted to identify clear and distinguishing elements between males and females. The discovery and study of the X and Y chromosomes fit well within the emerging dimorphic vision of sex overall. Moreover, it led to the gradual replacement of metabolic and hormonal models of sex differences by a genetic model of sex, casting the X and Y chromosomes as the new symbols of biological dimorphic sex.

Richardson’s book addresses an issue that has become important to ethicists, jurists, and scientists in recent years: how to account for biological differences between humans in an ethical, productive manner. With respect to genetic differences between males and females, the book takes up the incredibly daunting challenge of how to conduct genetic research on sex differences that yields beneficial results but that also avoids the pitfalls of biological determinism that feed sexist agendas. Through the book’s historic narrative and analysis of the future trajectory of genetic research, Richardson argues that although gender conceptions have a history of distorting scientific research, they could potentially be used constructively. Beliefs about gender are part of the social backdrop in which scientific research operates and therefore cannot simply be identified and surgically removed. Instead, Richardson offers a theoretical approach she calls “gender modeling,” which aspires to understand, on a descriptive level, “what work does gender do in this case?” rather than focus on the possible prejudice that led to gender conceptions in (16). After reviewing the different chapters of the book, I will advance the speculation that the paradigm of “sex itself, the idea that scientific inquiry into the deep biological layers of the body could reveal the essence of sex, might be fading away.

Sex Itself proceeds in ten chapters. Chapter 1 introduces the bio-cultural concept of “sex itself” within the context of genetic research and feminist analysis of science, and the overall argument of the book. Chapters 2 through 4 provide a historical chronology of scientific research leading to the theory that the X and Y chromosomes are the biological markers of sex and gender: maleness and femaleness. When the X and Y were discovered, they were first called the “odd chromosomes.” The growing interest in fertilization and biological sexual dimorphism in early 20th century drove scientists to try to link the function of the odd chromosomes to existing theories about sex differentiation. Nettie Stevens and Edmund Wilson created a fundamental theory of the odd chromosomes as the biological element that determines sex, transforming them from “odd” into “sex” chromosomes (34). The theory of X and Y as sex chromosomes implied that femaleness and maleness are separate, distinct routes of development. Many decades of research using this framework did not produce any workable theory of genetic sex differences; nevertheless, the emerging molecular science of sex of the time gendered the X and Y chromosomes in effect by focusing on their empirically nonproven relationships to maleness and femaleness.

In 1959, it was discovered that the existence of a Y chromosome is critical for the development of testes (77). This discovery bolstered the notion that the Y chromosome is the biological “seat of maleness.” Chapters 5 and 6 provide two exemplary case studies on how gender conceptions attached to the X and Y chromosomes produced empirically invalid and methodologically shaky theories regarding their operation. One such hypothesis was the “XYY super-male” theory. After blood samples collected in a high-security psychiatric hospital indicated a high rate of males with extra Y chromosomes, it was theorized that an extra Y might be a cause for propensity to aggression. This theory provided an easy causal chain from chromosome (Y) to gonads (testes) to gender (maleness). Despite later studies demonstrating that XYY males had no greater propensity for aggression and that their offences were actually less aggressive and violent than those of XY males, the theory persisted for another decade and a half. After Chapter 6, which discusses a parallel process associating the X chromosome with femaleness, partly through theories that focused on the connection between the X chromosome to female autoimmunity, Chapters 7 and 8 take us to a new period in genetic research in which feminist criticism of science has taken root and began exposing gender biases in biological and medical research.

When the SRY gene was discovered on the Y chromosome in 1990, it was given the role of the “master gene,” which allegedly switched on and off masculine sex development. This theory did not last and, today, the SRY gene is known to be one among other possible genes that direct the genetic development of testes and ovaries. This realization is, at least partly, attributed to feminist critiques of science that applied a gender-conscious perspective to the model’s assumptions and revealed theoretical and empirical failings. Biologist Jennifer Graves, a leading scientist in the field of sex chromosomes, was among the first to expose the gap between existing evidence and envisioned expectations regarding the “switch” model for the SRY gene. In a 2000 paper, she located her criticism of the “switch” model within a feminist discourse about science and argued that masculine ideas about the dominance of the Y chromosome and “macho” conceptions of the SRY gene misled researchers to ignore contradictory evidence and sustain the weak theory (137). As Richardson further demonstrates, by the time Graves identified her criticism as “feminist,” gender criticism and critical perspectives in science had become a normalized practice that contributed to a constructive thinking on how gender ideologies infiltrate and shape scientific knowledge about biological sex differences.

In Chapter 8, we learn about Graves’s later feminist criticism of a different genetic theory addressing the deterioration of the Y chromosome. The revelation that special genes located on the Y chromosome have been slowly vanishing for the last 300 million years became conceptually interlinked with social anxieties about the disappearance of maleness. Were men doomed, or would the Y chromosome’s resourcefulness save them? Two leading scientists in the field took up this controversy. Based on the rate of gene deterioration, Jennifer Graves and another scientist, Ross Aitken, predicted the Y chromosome would become extinct in approximately ten million years. David Page a medically trained geneticist, took offence at the degeneration theory and thought the Y chromosome was a victim of negative male stereotypes promoted by feminists (158). He later suggested a counter theory—that the Y chromosome would acquire male fertility genes that would overcome the projected deterioration (162). Although public judgment of their explanations for the phenomenon was asymmetrical, as Graves alone was accused of being “gender biased,” Richardson suggests that recognizing the role that gender plays in these models is a blessing. The creation of highly developed scientific models and hypotheses that are conscious to their interaction with contemporary gender politics by Page and Graves cannot be explained as mere “gender bias”, but rather should be called “gender valence.” Unlike biases that operate invisibly and unreflectively, “gender valence” brings gender to the forefront and exposes it to critical observation—to be, we hope, applied symmetrically.

The last two chapters discuss the prospects of gender/sex genetic research in the genomic and post-genomic age. In Chapter 9, Richardson examines the claim news reports had made, interpreting the work of scientists L. Carrel and H. F. Willard, whereby males and females differ genetically by 2%—greater than the difference between chimpanzees and humans, stating that females and males are “different species.” Richardson seeks to debunk each part of this claim, on both empirical and conceptual grounds and offers an alternative, more perceptive way of explaining genetic sex differences: “sex as a dynamic dyadic kind” (197). Richardson suggests that we regard this case study as an example of how a powerful new language about the genome can be used to revive old frameworks of conveying differences between groups of humans that disturbingly echo a comparison to apes.

Chapter 10, which concludes the book, uses the lessons learned from research on the X and Y chromosomes to forge concrete analytical tools that could be applied in the field of genetic research on sex-based biology and medicine, which currently enjoys enormous political and institutional support by the US women’s health movement. Within the justified efforts to advance a better understanding of women’s particular health issues and to remedy systematic failures of scientific methodology that led to historic ignorance regarding women’s disparities, Richardson reminds us that research on sex differences within the sex-based biology movement can be a double-edged sword and that we should therefore elaborate to construct a gender-critical perspective about this new, robust strand of research as it moves forward.

One of the most central concepts the book expounds on within its chapters is “sex itself,” construed by Richardson as an object of scientific quest into the body. The fascination with finding the essence of sex within the inner, unknown layers of the body in the 20th century seemed both feasible and promising at the time. Ironically, the separation between sex and gender promoted by feminist advocates further cemented the notion that a biological element tattooed on the body’s infrastructure can represent the true essence of sex. Unlike sex, gender was located in the cultural and social worlds and understood to be flexible and not necessarily dichotomous. However, biotechnological advancements transformed some biological elements such as hormones, genitals, and tissues to also become flexible and easy to alter through medication or plastic surgery. These developments placed even greater weight on the order and clarity provided by genetic sex theory, as opposed to the “soft” easy-to-change biological sex elements, that sex chromosomes served as a stable, unchangeable, and irreducible biological truth. “While hormones and culture help to shape gender, genetics alone, it is thought, can reveal, “sex itself” (9).

Richardson is correct to recognize that the search after “sex itself” is, in many ways, a search for stability in times of changing bodies and social norms. The “natural body,” often conflated with the “biological body,” is often imagined as a site of consistency and order that yields a set of normative and practical implications. As legal scholar Liz Emens demonstrates, if a subject is treated as “natural,” a set of implications is likely to apply to that subject: first, that the subject is immutable as a descriptive matter (or at least, difficult to change), and second, that the subject should not be required to change as a normative matter. As Emens shows, these assumptions have some force in different legal doctrines pertaining to discrimination and accommodation and, therefore, different identity groups, including people with disabilities, sexual and racial minorities, women or the elderly, use this set of assumptions as a matter of legal strategy. This, for example, helps explain why some groups such as sexual minorities or trans people often promote a “natural” characterization of their differences through various biomedical theories and studies. The popular logic of ‘nature’ somewhat endorsed in the law suggests that if a condition is immutable it enjoys an inherent normative value and should not be forced or expected to change. Opponents to reforms led by such groups often argue that these differences are fictional, having no bearing on the body itself, and ought to be ignored or even eliminated.

In this context, Richardson’s identification of the sex chromosomes as a crucial site in which both natural and social orders are negotiated and justified is revealing. One of the most vivid examples for this concept can be found in recent public debate about the use of bathrooms by transgender students in educational institutions. Conservative voices usually bring the X and Y chromosomes to make the point that sex is fixed and immutable: “There are only two things that make me a man, and they are my X chromosome and my Y chromosome . . . . People have the right to feel that they should not be the gender that God gave them . . . . However, the fact that some people do not live in reality or that some wish reality were not true, does not entitle them to a special bathroom in a public university.” (Gershenson) In this cultural and legal context, the sex chromosomes viewed as the locus of “sex itself” are not only biological carriers of genes and DNA but also normative carriers of social values and arrangements.

One of the most intriguing questions that arises is this: what does the future hold for the sex chromosomes in the age of gene editing? It seems that with biotechnological developments, even sex chromosomes—the hard core of “sex itself”—are becoming emendable. Studies from recent years examined the possibilities of ‘sex reversal’ on mice through modifying genes related to gonad determination. In 2009, a research group found that ablation of the FOXL2 gene in mice ovaries can reprogram their development into testosterone-producing testes (Uhlenhaut et al). A 2011 study found a parallel process in testes, which were reprogrammed to produce estrogen after the DMRT1 gene was deleted (Matson et al). Just recently, a lab succeeded at using CRISPR technology to masculinize female cattle by adding the SRY gene to their X chromosomes (Rosenblum). Not surprisingly, these developments are publicized in highly gendered “clickbait” language including: “From Minnie to Mickey (and all they did was turn off a gene),” (Connor) and “Researchers Discover Sex-Change Gene.” (Anderson-Minshall) Moreover, these articles speculate about the future implications for sex change in humans, to be used by the transgender community, or for DSD conditions (Disorders of Sex Development) (Geen).The emerging capacity to edit, change, or add genes to living mammals seems to relocate “sex chromosomes” from the hard-core to the soft-changing elements of sex. Accordingly, we can expect that future biotechnological advancements and research will continue to hollow out “sex itself” from other purportedly stable and immutable biological elements.

If so, what then is the future of “sex itself” in the age of mutability? Would the increasing malleability of bodies boost scientific motivation to search for the essence of “sex itself” in other unexplored inner locations of the body or, alternatively, if biological sex in no longer understood to be a constant and stable element, would that somehow make the sex/gender distinction useless or the normative attachments to “nature” collapse altogether? Looking ahead to the growing sex-based medicine movement, it appears that scientific research on sex differences is prospected to grow. Nevertheless, it might be that research in the context of sex-based medicine will revert to the old contingent, spectrum-like concept of sex, or alternatively progress toward a model of individual differences or to an alternative related grouping basis, like the brain mosaic approach (Joel). Possibly, this grand research project would orient its hypotheses, working models, and studies to fulfill the purpose of improving health, rather than of finding the holy grail of sex differences.

Richardson’s book is highly recommended to anyone interested in a skilled and illustrative gender analysis of a scientific field and theory. Other than its monumental contribution to classic works on the intersection of science and gender, many of the book’s qualities make it especially educational for graduate and undergraduate students. Its language is clear and guides the reader through argument’s various stages. The book does an excellent job of translating complex genetic and chromosomal theories for the nonexpert reader, without over-simplifying them, along with preserving a richness of theory, evidence, and context. The book does a great service to the field of feminist analysis of science by illustrating how sensible skepticism to empiricism from a gender-conscious point of view can generate a constructive contribution to a field of knowledge.

Maayan Sudai

Harvard Law School

Cambridge, MA, USA

 

References:

Anderson-Minshall, Diane. “Researchers Discover Sex-Change Gene.” The Advocate, 21 July 2011.

Andrew Rosenblum, “Meet the Woman Using CRISPR to Breed All-Male ‘Terminator Cattle,’” MIT Technology Review,accessedApril 12, 2018, https://www.technologyreview.com/s/609699/meet-the-woman-using-crispr-to-breed-all-male-terminator-cattle/.

Clinton K. Matson et al., “DMRT1 Prevents Female Reprogramming in the Postnatal Mammalian Testis,” Nature 477, no. 7363 (September 2011): 238, https://doi.org/10.1038/nature10411

Connor, Steven. “From Minnie to Mickey (and All They Did Was Turn off a Gene).” The Independent, 11 Dec. 2009.

Daphna Joel et al., “Sex beyond the Genitalia: The Human Brain Mosaic,” Proceedings of the National Academy of Sciences 112, no. 50 (December 15, 2015): 15468–73, https://doi.org/10.1073/pnas.1509654112.

Geen, Jessica. “Gene Discovery Could Make Gender Reassignment Easier.” PinkNews, 11 Dec. 2009, www.pinknews.co.uk/2009/12/11/gene-discovery-could-make-gender-reassignment-easier/.

N. Henriette Uhlenhaut et al., “Somatic Sex Reprogramming of Adult Ovaries to Testes by FOXL2 Ablation,” Cell 139, no. 6 (December 11, 2009): 1130–42, https://doi.org/10.1016/j.cell.2009.11.021.

Olga Gershenson, The Restroom Revolution: Unisex Toilets and Campus Politics, in Toilet: Public Restrooms and the Politics of Sharing 200 (Harvey, Molotch, Laura & Noren eds., 2010).

Book Reviews

Jesse Wall, Being and Owning: The Body, Bodily Material, and the Law, Oxford University Press, 2015

Jesse Wall’s Being and Owning: The Body, Bodily Material, and the Law addresses the legal status of ‘bodily material’; items which used to be, but are no longer, part of a living human organism: especially, ‘separated’ materials like gametes or tissue samples, and (to a lesser extent) cadavers and other mortal remains. Wall’s discussion, however, ranges widely across jurisprudential and philosophical issues concerning our relation to our bodies and our rights in them. His central, plausible contention is that body rights, though a kind of ownership right, need not and often should not be protected by property law. Rather, in many cases, rights in body parts should be protected by a legal regime that more closely resembles that governing our rights over confidential information.

Wall proceeds by drawing our attention to a number of interlinked distinctions. First, and most helpfully, Wall goes to great pains to distinguish ownership as a generic right to exclude, from property as a particular sort of legal regime for specifying and protecting that right. On the dominant Honorean view, to have property is to have a relation to a thing with some, but perhaps not all, of a set of legal features or incidences; including: rights to exclude, rights to use, rights to profit; certain sorts of remedies if these rights are violated, responsibilities when they are not, and so forth. (Honore 1961) Whatever it takes for a set of rights to have ‘enough’ of these features to count as a kind of property right, it is plausible that the broader set of rights with some smaller (but non-zero) number of these features constitutes a morally interesting category as well. This thinner sort of ‘ownership’ is interesting, not least, because it may be where we should slot in rights in body parts and bodily materials, if (like Wall and many others) we are uncomfortable regarding our moral and legal relation with our bodies entirely on the model of our relation with our ordinary property.

There is, then, something promising about Wall’s general strategy. However, the way he executes it is puzzling, in places. Property, Wall argues, is appropriate only for protecting rights that are in a certain sense contingent, rather than necessary, with respect to the rights-holder. Ultimately he explicates this contingency in terms of the thought that entitlements in property are essentially those that “enable […] choices and preferences that can exist independently of the rights-holder” (2015, 126). This criteria, however, is hard to understand. Can any of my choices and preferences exist independently of me? It is hard to see how; if I did not exist I could not prefer or choose anything. Perhaps the idea, instead, is that only the content of my preferences that must be in some sense independent of me; so that property rights are those that protect preferences that are not self-regarding. That distinction makes more sense, but it does not seem to mark a difference relevant to the demarcation of property rights from other sorts of rights. To borrow Wall’s own example, against his purposes: the preference protected by a wine-collector’s property in his wine is, precisely, his preference that he and not others have that wine in his collection.

Still, Wall does seem to be on to something that is intuitively right here: going back to Kant, the thought that there is something distinctively ‘contingent’ about property rights has seemed like a promising one. Perhaps, then, these are mere problems of formulation. Less promising, it seems to me, is the substantive principle Wall offers for determining when our rights in our bodily materials are ‘contingent’, and thus suitable subjects for propertization. Here Wall takes us back to the basis of our rights in our ordinary, attached body parts. He builds here on the fashionable thought that our experience of the world or ‘subjectivity’ is necessarily embodied, drawing on work by Maurice Merleau-Ponty to distinguish the phenomenological relation we bear to paradigm body parts from the relations we can bear to external objects. (Merleau-Ponty 2003). The body, Wall suggests, is ‘for-itself’; not experienced as an inert separated object (what it is ‘in itself’, irrespective of how we experience it), but rather as the surface where self meets world in action and perception.

But this sort of phenomenological account of why we have rights in paradigm body parts faces serious, and possibly insuperable, problems. Felt embodiment is clearly no necessary condition for body ownership – if all goes well, I may never feel any embodiment in my peritoneum, or my bone marrow, or in many other internal organs. The thought that phenomenological properties are sufficient for bodily status appears more plausible at first sight. But even that is hard to make out, on further reflection. Merleau-Ponty himself famously argued that our sense of embodiment can extend to tools in transitory use; a cane or a pen can present as part of the embodied, oriented ‘for-itself’ to fluent performance in the world. Still, for moral and legal purposes, it seems hard to deny that a pen remains a distinct, non-bodily object: to touch or damage it is not to touch or damage me.

Wall’s extension of the phenomenological account to separated bodily items raises these problems particularly sharply. A bit of bodily material is, he says, ‘for-itself’ (read: part of the embodied self) when it remains “directed to a current or possible task” (2015, 61). If I have brought only one pen to the coffee shop; then even when I set it down it for a moment, it remains directed to the task of making notes in my book. Yet, surely, it is in that case mere property, not deserving of the special protection we give to items that are properly ‘bodily’. Damaging it is mere vandalism, not assault and battery. But if recruiting a previously ‘felt’ item into an ongoing task does not produce a ‘bodily’ right in this case, why would it in contentious cases regarding bodily materials? It is not at all clear to me, then, that the phenomenological tradition Wall appeals to has the resources to demarcate between relevantly contingent and non-contingent rights in separated body parts.

These objections raise real concerns, I think, about some of the philosophical substructure of the book. They do not, however, take away from Wall’s many rich and interesting observations about case law regarding bodily materials or the utility and interest of the structural distinctions he draws between property and privacy as two distinct paradigms of ownership. I recommend this book to philosophers and bioethicist looking for a subtle and informative discussion of recent and prospective legal developments regarding ownership of bodily materials.

Sean Aas,

Department of Philosophy and Kennedy Institute of Ethics, Georgetown University

Washington, DC

 

References

Honore, A. M. 1961. “Ownership.” In Oxford Essays in Jurisprudence, ed. A. G. Guest. London: Oxford University Press, 107–47.

Merleau-Ponty, Maurice. 2003. Phenomenology of Perception. ed. M C Smith (tr). Oxford: Routledge.

Wall, Jesse. 2015. Being and Owning: The Body, Bodily Material, and the Law. Oxford: Oxford University Press.

Book Reviews

Travis Rieder, Toward a Small Family Ethic: How Overpopulation and Climate Change Are Affecting the Morality of Procreation. Springer, 2016.

The global human population is currently about 7.6 billion people, and our numbers are still increasing. Although human population growth has not been a popular topic to discuss in the last quarter-century, its contribution to various environmental problems is becoming harder and harder to ignore. Travis Rieder’s Toward a Small Family Ethic confronts the effects of population growth and addresses what individual procreative obligations might follow from it.

This short book consists of five chapters. Rieder begins with a description of the population problem. More people need more land, more food, more fresh water, and more energy consumption to survive. Thus, a growing population puts greater strain on the environment that provides these vital resources. Rieder places a particularly strong emphasis on climate change and the ways in which mitigating climate change is made more difficult by the annual increases in emissions that result from population growth. Thus, the first chapter carries two important lessons: “population is a major driver of climate change, in addition to raising concerns about other limited resources” and “climate change is a morally urgent problem” (9).

With the nature of the problem established, Rieder turns to the main question of the book: in light of the impacts of human population growth, what obligations do individuals have with respect to their procreative decision-making? More specifically, might there be an obligation to limit one’s number of biological children? Ultimately, while Rieder does not affirm the existence of obligations to limit one’s biological procreation, he does conclude that “something disconcertingly close to this suggestion is true” (10). Or at least, he believes so with respect to wealthy individuals with large per capita ecological footprints.

In chapter 2, Rieder focuses on one of the strongest objections to the existence of duties to limit our procreation in response to the effects of population growth – the claim that one additional child makes such a small contribution to the large-scale environmental impacts under discussion that it really doesn’t make a significant difference in the grand scheme of things. Such reasoning reflects a moral principle akin to the following: “If the consequences of an act make no significant difference to the extent or severity of a moral problem, then the agent is not morally required to refrain from acting in light of the moral problem” (16). Consequentialists – those who regard the morality of an action as being determined exclusively by its consequences – are likely to find this line of reasoning persuasive. But Rieder believes such reasoning is misguided because there can be non-consequentialist reasons to refrain from certain activities even when one’s individual contribution makes a negligible difference to the overall effects of those activities.

In chapter 3, Rieder examines three non-consequentialist principles that could generate obligations to limit one’s procreation even if we grant that individual acts of procreation do not make a significant contribution to climate change and other environmental problems. The first is a duty not to contribute to massive systematic harms. Climate change, on Rieder’s assessment, is one of these harms, and along classic deontological lines, it can be considered objectionable to contribute to it regardless of how small one’s contributions are. The second is a principle of fairness. Overpopulation disproportionately harms the poor, and yet the wealthy, due to their carbon-intensive lifestyles, are the ones who contribute most to the problem. Such an arrangement is deeply unfair and violates the basic demands of social justice. The third is a duty to protect the interests of our possible children. Perils of the future – both environmental and otherwise – could cause serious harm to our children, and we ought not to expose them to severe risk of harm.

The first two of these three principles are better supported than the duty to protect our children from serious harm. The duty not to contribute to systematic harms is consistent with why many would find it wrong to buy cotton produced via slave labor even if individual purchases of cotton made no difference to the slaves’ welfare or their overall numbers. Certain practices are so morally repugnant that we are obligated not to participate in them even when our non-participation does not make a difference to thwarting them. Moreover, the unfairness associated with having a large, carbon-expensive family will resonate strongly with those who are aware of the enormous ecological footprints tied to western lifestyles and fact that developed nations have historically contributed so much more to the climate change problem than the global poor.

The risks to future children, however, do not seem severe enough (at least at present) to carry much weight in these decisions. People in the developed world are still very well-positioned to protect their children from serious harm. Rieder acknowledges this point briefly (37-38), but I think he overestimates the risks that people born in the near future (at least in the developed world) will face. Those who are more pessimistic about the future might find the duty to protect our children to be more stringent.

So what do these three principles entail? Rieder states that it is “plausible” that the moral considerations surveyed “entail a duty for many of us to have at most two children” (37). With this established, Rieder then examines objections to procreative obligations in chapter 4. The first major objection is that a moral duty to limit procreation threatens our integrity by hindering our abilities to pursue procreative projects – a central part of most people’s life plans. This objection is rather strong if the duty on offer requires having no children (since it would eliminate the possibility of biological parenthood), but its persuasiveness is less clear with respect to, say, a duty to limit oneself to two biological children. The second objection is that people have a right to have as many children as they want. Although Rieder acknowledges that rights can have limitations, he concedes that people may indeed have a right to unlimited control of their family size (50).

Interestingly, although Rieder suggests we might have the right to have as many children as we like, he thinks individuals in wealthy countries who have large families may still be subject to moral criticism. In chapter 5, Rieder notes that judgments about what is morally permissible can be separated from judgments about praise, blame, and our moral character more generally. Drawing on considerations tied to virtue ethics and the balance of reasons, he argues that many individuals will not be justified in having large families. Some people may be justified in having more than one child, but “the burden is on them to make the case” that their behavior is morally justified (66).

Toward a Small Family Ethic covers a lot of terrain given its length, and its brevity and accessibility make it a suitable introduction to the issues under discussion. Nonetheless, a 70-page text will inevitably have to gloss over or omit some important material. I will highlight three places where additional content would have been helpful.

First, the book does not feature much discussion of the positive externalities tied to procreation. For instance, as Julian Simon (1993) noted, a higher population means that there are more people with ideas that might lend themselves to technological innovation. More people who are well-educated and well-intentioned could, to some degree, be a good thing with respect to tackling a massive problem like climate change. Many also believe that, other things equal, the world is a better place when there are more people on it who are living good lives. I do not think these considerations outweigh the moral considerations that Rieder highlights, but other readers may disagree.

Second, Rieder briefly alludes to an argument by John Nolt (2011) that the average American could be responsible for the severe suffering or death of 1-2 future people, which would be quite morally significant even if the individual’s relative contribution to climate change is small. This argument could provide a straightforward refutation of the claim that one’s contribution to climate change is not morally significant and would hold more sway with consequentialist readers than Rieder’s non-consequentialist arguments. Thus, it is unfortunate the argument is mentioned and dismissed only in a footnote.

Third, the discussion of offsetting (21-22) proceeds too quickly. Offsetting one’s emissions would be an obvious strategy for justifying the additional carbon footprint created by procreation. Rieder points out that some offsetting strategies effectively involve replacing long-term carbon sinks with short-term ones, which is not an optimal solution. However, since the costs of offsetting are not presently that onerous, a person could offset substantially more than what seems necessary to account for the possibility that some of the offsets turn out to be short-term. Additionally, some forms of offsetting do not have this feature. Certain offsetting schemes involve the creation of renewable energy (e.g., wind turbines), and while it might take a much larger financial contribution to ensure that one’s individual donations actually make a difference, such a strategy can be viable in some circumstances. For some individuals, it may also be possible to offset their own emissions by purchasing and installing solar panels on their own homes. Ultimately, Rieder needs to say more about why offsetting is not a permissible strategy for rendering one’s procreation justifiable.

Beyond these considerations, I also wonder whether Rieder is right to back away from the claim that we have concrete obligations to limit our procreation. Until the end of chapter 4, he appears on the path to endorsing the view that people living in nations with high per capita carbon footprints have a prima facie obligation to have two or fewer biological children. He shies away from this claim because he is unable (perhaps due to space) to examine how our right to procreate might be limited by the demands of others. Given the trajectory of the text up to this point, this concession is surprising. Rieder highlights in chapter 1 that climate change threatens many people’s most vital interests. The victims of climate change may have their rights to life, health, and the means of subsistence jeopardized. These rights seem much more fundamental than a wealthy person’s right to have an unlimited number of biological children, especially if adoption is a viable option for the family in question. Rieder (2016) has argued elsewhere that procreative acts only contribute to causing harm to future people, and so we cannot straightforwardly weigh the right to unlimited procreation against the harms future people will suffer. Yet when the most fundamental rights of future people are threatened in large part because of the collective exercise of a much less fundamental right, there is a plausible case to be made that the less important right should be curtailed. Thus, I am not sure Rieder needs to concede that the right to procreate carries so much moral weight, and I would have rather seen him explore this issue in depth instead of devoting chapter 5 to a discussion of other moral considerations.

Nevertheless, despite my critical remarks, this book remains essential reading for those working on moral issues tied to population growth. Toward a Small Family Ethic presents novel arguments on a vital and underexplored moral issue. Problems tied to population growth will only get worse as the 21st century progresses, so we are fortunate that philosophers like Rieder are getting us started in thinking about this subject.

Trevor Hedberg,

University of South Florida

Tampa, FL, USA

 

References

Nolt, John. 2011. “How Harmful are the Average American’s Greenhouse Gas Emissions?” Ethics, Policy and the Environment 14 (1): 3-10.

Rieder, Travis. 2016. “Review: Sarah Conly, One Child: Do We Have a Right to Have More?Kennedy Institute of Ethics Journal 26 (2): E-29–E-34.

Simon, Julian. 1996. The Ultimate Resource 2. Princeton: Princeton University Press.

Book Reviews

Sarah LaChance Adams, Mad Mothers, Bad Mothers, and What a “Good” Mother Would Do: The Ethics of Ambivalence, Columbia University Press, 2014

When a mother deliberately harms her child, it is tempting to assume that she must be either insane (a “mad mother”) or lacking the “natural” love of a mother for her children (a “bad mother”). We want to believe that such mothers have almost nothing in common with “good” mothers. Drawing extensively on empirical research, Sarah LaChance Adams’ Mad Mothers, Bad Mothers, and What A “Good” Mother Would Do shows that maternal ambivalence, simultaneous desires to nurture and violently reject one’s children, is both common and reasonable, the result of genuine conflicts between mothers’ interests and those of their children. Both appropriate support and deliberative agency are necessary to avoid maternal ambivalence finding its expression in filicide. As LaChance Adams shows, it is because of not in spite of these tensions that motherhood is an instructive case for ethics. When we appropriately reflect the lived experience of mothers, rather than relying on long standing stereotypes, we find a new paradigm for ethical relationships. This new paradigm reveals that we require an ethical theory that recognises human needs to care for, to be cared for, and to maintain independence.

The book begins with a notorious example of purposeful filicide: LaShanda Armstrong, who deliberately drove her minivan into the Hudson river with her four children inside. Armstrong and all but one of her children died. LaChance Adams argues that dismissing such cases of purposeful filicide as simply the actions of “mad mothers” or “bad mothers” oversimplifies both these tragedies and the character of maternal love in general. Most maternal filicides do not meet the legal requirements of insanity, but nor can they be simply categorised as bad mothers. Indeed, in many cases, mothers who kill their children see doing so as, in the circumstances, being a good mother (Meyer and Oberman 2001 89; LaChance Adams 2-4). In the first chapter of the book, LaChance Adams connects our inadequate understanding of maternal filicide to a widespread idealisation of the mother’s relationship to her child, which takes a loving willingness to self-sacrifice as a given. She outlines the major flaws in philosophical treatment of motherhood and shows how her more nuanced account will build upon and improve the philosophies of care ethics, Emmanuel Levinas, Maurice Merleau-Ponty and Simone de Beauvoir.

Chapter Two explores the mother as ethical exemplar as portrayed in care ethics. Care ethics challenges individualistic ways of understanding ethics, which start from a conception of human beings as autonomous, independent beings whose main duty to others is non-interference. As LaChance Adams notes, simply thinking about human reproduction undermines the individualistic picture: “We do not pop out of the ground like mushrooms, as Thomas Hobbes would have us imagine, but out of the womb of a woman. Without a mother, or someone acting as a mother, no human infant would survive for a day.” (18). Unsurprisingly, therefore the mother-child relationship is repeatedly used in care ethics as an ethical exemplar. However, LaChance Adams argues that care ethics focuses too much on the interdependence between mother and child and does not pay enough attention to ways in which the needs of mother and child might conflict. It ignores the mother’s need for individual flourishing. LaChance Adams argues that motherhood is most useful as an ethical exemplar when we recognise both the interdependence of mother and child and the ways in which their needs can conflict.

LaChance Adams argues that maternal experience reveals deep internal conflicts that are relevant to all human beings: “we have simultaneous needs to nurture, to be nurtured, and to maintain independence.” We are pulled between two selves: the self as independent and the self as “entangled in indissoluble bonds with others” (LaChance Adams 24). Traditional rights-based ethics and care ethics each recognise one, but only one, aspect of the human condition. To bring the two together, LaChance Adams argues, we need a third approach which: “will be aware of the fundamental ambiguity at the heart of our existence”, addressing the need for constant negotiation between interconnection and independence.

In Chapter 3, LaChance Adams provides her new, nuanced account of maternal experience. This account provides a foundation, not just for the ethics of ambivalence which LaChance Adams develops in further chapters, but for better philosophical engagement with motherhood more generally. It is in many ways, the keystone of the book. Earlier, LaChance Adams stresses the need for an interdisciplinary approach approach to studying motherhood, making use of all available perspectives (LaChance Adams 23). This chapter provides a model for such an interdisciplinary approach: LaChance Adams weaves together first-person narratives, psychiatry, psychology, sociology, anthropology and history to show just how complex maternal experience can be. In her own words: “I… describe the experiences of women who are neither self-immolating saints nor pathological murderesses. Their feelings about their children are mixed and varied – not just from woman to woman but within the selfsame woman. A loving mother can be mean, a giving mother can be selfish, a content mother can be filled with rage” (LaChance Adams 28). The phenomenon of maternal ambivalence revealed by LaChance Adams shows a deep love for one’s children co-existing with a wish to “reverse the fact of their child’s existence” (LaChance Adams 28).

The breadth of research discussed by LaChance Adams brings home how pervasive maternal ambivalence is. The evidence of maternal ambivalence spans cultures, classes, races, and historical time periods. This is not simply a 21st century phenomenon. Indeed, LaChance Adams claims that maternal ambivalence is the result of mother’s needs for both connection to and separation from their children, which is likely to be part of all mother-child relationships. Nonetheless, LaChance Adams is careful to recognise the relationship between maternal ambivalence and cultural or individual pressures and constraints: the precise situation in which a mother is trying to negotiate these conflicting desires can either support her endeavours or undermine them by exacerbating conflicts.

Maternal ambivalence can lead to tragic outcomes: dramatically, as in the murder-suicide with which the book opens, or mundanely, as when a mother simply resigns herself to her identity quietly slipping away. Nonetheless, we should not see maternal ambivalence simply as a problem. LaChance Adams argues that we should recognise it as “a psychological achievement” (64) with a “wisdom of [its] own” (70). “The acknowledgement of ambivalence makes possible [a] genuine discovery of relationship as it unfolds and sensitivity to the developmental needs of both mother and child”(65).

Ambivalence is particularly striking in the maternal case because of the child’s vulnerability, the high expectations of society and the bodily connection between mother and child. Its lessons are relevant much more widely. First, relationships in general require both intimacy and individuation: even in the most intimate relationships we cannot “overcome the insurmountable alerity of the other” (70). Second, the thinking about maternal ambivalence, and its relation to situation, shows the need to both embrace our responsibilities to the defenceless and to provide caregivers with opportunities for independence – and that this must be the responsibility of both individuals and society as a whole (71). Third, recognising the possibility of failure to help others is a critical part of an ethical orientation in both the maternal case and more generally (71).

The next three chapters engage with Levinas, Merleau-Ponty and Beauvoir in turn. Existential phenomenology provides a deeper exploration of the idea, already recognised by care ethics, that from the beginning of experience, I understand myself in relation to others. It recognises both the way that our relationships to others pervade us to the core and the chasm between self and other. LaChance Adams shows how this aspect of existential phenomenology allows the work of each of these three philosophers to provide elements that are missing in care ethics’ approach to motherhood – while also identifying the ways in which a more nuanced account of maternal experience may have helped the existential phenomenologists. The structure of this section of the book is progressive: each philosopher is shown to contribute something that their predecessor missed, moving towards a more robust account of maternal experience and the ethics of ambivalence.

In Otherwise Than Being, Levinas uses pregnancy and motherhood as the image of all ethical relations. For Levinas, to be an ethical being is to be summoned to give despite oneself, without having chosen to give (Levinas 105). Indeed, on his view, this ethical responsibility is the true foundation of the self. Until we are compelled to face our responsibility to others, we do not become ethical subjects (Levinas 1998 114). The demands of the other interrupt our enjoyment and self-creation (Levinas 1998 72-72), enabling us to forge a new identity. Although our relationships with others are central to our self-identity, there is a gulf between the self and the other that cannot be overcome. This ‘radical alterity’ is a central concern of Totality and Infinity. LaChance Adams draws on the personal accounts of mothers to show that maternal experience does indeed reflect this kind of ambiguous intersubjectivity: unchosen compulsion to care for another coupled with awareness of the other as other.

Nonetheless, LaChance Adams argues that there are serious problems with Levinas’s account of maternity. “Unfortunately, Levinas appropriates the maternal perspective without consideration of the experience for actual women” (LaChance Adams 108). Levinas’ solution to conflicts of interest is to yield to the other, to be like the mythical mother who is infinitely compassionate. Levinas does not recognise that infinite demands deplete us, undermining our ability to respond to others (LaChance Adams 101). Even if we see this as simply an ideal for mothers to aspire to, this still lets mothers down: “When mothers think they should be able to give to their children infinitely and are unable to do so (as no human could), they feel guilty, angry worthless, ashamed, depressed and fearful of the judgment of others… What is more helpful to women is an accurate understanding of their own experiences; for this, the maternal icon must be dethroned.” (LaChance Adams 102).

LaChance Adams turns to Merleau-Ponty and De Beauvoir to provide what Levinas is missing: “a more careful logic of ambiguous intersubjectivity, an understanding of how asymmetrical relations can nevertheless be balanced, the factor of social context and support, and, finally, a better idea of how ethical failure relates to ethical success”(LaChance Adams 108).

LaChance Adams argues that Merleau-Ponty provides the best characterisation of the ambiguity of our relations with others, enabling us to recognise our fundamental interconnections with others and our separation from others as two sides of the same phenomenon (153). LaChance’s discussion of Merleau-Ponty is rich, with many overlapping themes. I will only give a brief outline here. The understanding of maternity as a case of “dehiscence in the flesh” plays a key role. “The flesh” is Merleau-Ponty’s term for the continuity between the self, other and world (Merleau-Ponty 1968 123). According to Merleau-Ponty, we each perceive a prereflective coherence between ourselves and others: prior to reflection, we do not distinguish between ourselves and our perceptions. This continuity extends to others as well. We meet others as fellow sentient beings in a public world that we hold in common. (LaChance Adams 112) Nonetheless, inherent to the very idea of the flesh is a gap or dehiscence: “We both encounter the world through smell, taste, vision and thoughts. She sleeps she dreams, and wakes up, just as I do. Yet, there is always something of her that I cannot reach.” (LaChance Adams, 120). Pregnancy and motherhood in general bring this apparently paradoxical simultaneous interconnection and separateness “into relief” (LaChance Adams, 120). However, it applies much more widely, to all our connections with others. LaChance Adams argues that to fully understand Merleau-Ponty’s conception of human relations, and how he can see these two seemingly contradictory aspects of human relations as “two moments of one phenomenon – ambiguous intersubjectivity”, we must explore his use of Hegel’s immanent logic of human experience to (LaChance Adams 140).

In the fifth chapter, LaChance Adams explores Beauvoir’s understanding of motherhood and how it supports, and can be further supported by, the interdisciplinary work on maternal ambivalence. She argues, “Beauvoir’s characterisation of the mother-child relationship is a vivid, and at times raw, example of her philosophy of intersubjective ambiguity. Beauvoir realises that mothers often find themselves in violent opposition to their children, whose wellbeing is also essential to them” (LaChance Adams 170). Nonetheless, Beauvoir is sometimes optimistic about motherhood: it is a possible venue for transcendence (Beauvoir 1949 55) and enriching (Beauvoir 2010 554). Many of her negative evaluations of motherhood are best understood in the light of her emphasis on situation. Having children threatens a women’s wellbeing because of the oppressive circumstances in which mothers find themselves: the combination of the dependency of their children and the cultural belief that women are naturally solely responsible for them (LaChance Adams 174, 178, 183). “In a properly organised society where the child would in great part be taken care of by the group, where the mother would be cared for and helped, motherhood would absolutely not be incompatible with woman’s work.” (Beauvoir 2010 569).

In her exploration of Beauvoir’s work, as in earlier chapters, LaChance Adams displays maternity as both unique and an exemplar for human life in general (LaChance Adams 158). On Beauvoir’s account, we must all face the possibility of ethical failure: our own freedom depends on the wellbeing of others, but conflict – and thus failure to fulfil everyone’s needs – is inevitable. Because the mother, more than anyone else, is expected to provide complete care for her children, this ethical failure is a constant threat to her. The ethical ‘failure’ can be positive: “the ongoing struggle to meet the conflicting, yet interdependent, needs for care and freedom of both the self and the other- can contribute to both their flourishing” (LaChance Adams 171). It can help the mother to form an identity of authentic ambiguity (LaChance Adams 185), in touch with a central truth of the human condition (LaChance Adams 186). Indeed, Beauvoir sees failure as a necessary condition for ethics (LaChance Adams 185). Nonetheless, it can also be tragic. Sometimes, the needs of everyone cannot be met (LaChance Adams 171) and we must face the real pain of sacrificing the freedom or care of one for another (LaChance Adams 158, 174-176).

In the final chapter, LaChance sums up her proposed ethics of ambivalence. Our relations to others combine insurmountable conflicts and deep connections that are necessary for our own freedom and identity. This combination makes both ethical failure, and ethics itself, possible. These conflicts require active negotiation: the ethical subject needs to use deliberative agency to balance her own needs and those of the other – noting that each needs both connection and freedom. Sometimes, not all needs can be met. Sometimes, we must deny others even what is needed for life itself. “Love, even maternal love, does not conquer all” (LaChance Adams 151).

Mad Mothers, Bad Mothers, and What A “Good” Mother Would Do has important lessons for both philosophers and for wider society. As a society, we must debunk the myths of maternal self-sacrifice and recognise both the reality of maternal ambivalence and our collective responsibility for the lives of children. Philosophers must engage properly with the realities of mothers’ lives. Rather than drawing on idealisations or shallow stereotypes, they must take seriously the complexity of motherhood. In doing so, they can both help to improve the way society understands and treats mothers and gain access to a rich philosophical resource for understanding our ethical life.

Fiona Woollard,

Department of Philosophy

University of Southampton

Southampton, UK.

References

Beauvoir, Simone de. 1949. The Ethics of Ambiguity. Trans. Bernard Frechtman. New York Philosophical Libraries.

Beauvoir, Simone de. 2010. The Second Sex. Trans. Constance Borde and Shelia Malovany-Chevallier. New York, Knopf.

Levinas, Emmanuel. 1998. Otherwise Than Being or Beyond Essence. Trans Alphonso Lingis. Pittsburgh, Duquesne University Press

Levinas, Emmanuel. 1969. Totality and Infinity. Trans Alphonso Lingis. Pittsburgh, Duquesne University Press

Merleau-Ponty, Maurice. 1968. The Visible and the Invisible. Trans Alphonso Lingi. Evanston IL, Northwestern University Press.

Meyer, Cheryl L. and Oberman, Michelle. 2001. Mothers Who Kill Their Children. New York. New York University Press.

Book Reviews

Nancy Bauer, How to do things with Pornography, Harvard University Press, 2015

Nancy Bauer’s How to do things with Pornography is a difficult to review book. It sits in a somewhat liminal location somewhere between monograph and thematic collection. Bauer takes the reader on an intellectual journey that crosses a number of philosophical sub-disciplines but also moves between philosophical writing for a general audience and more technical writing exploring the same themes.

As the title suggests, Austin’s How to do things with words and the uses various feminist philosophers of language have put Austin’s ideas to are central to the book. Bauer argues for an interpretation of Austin much more radical than that often given to him in contemporary philosophy of language, and suggests that it is precisely because of a widespread embrace of the more common conservative reading of How to do things with words and the general development of “speech act theory” post Austin that the development of Catherine MacKinnon’s claim that pornography silences women has been unsatisfactory.

But Austin and the philosophical (mis)uses to which his ideas have been put are not the only central figures in contemporary philosophical discussions of women’s sexuality critiqued by Bauer. In her chapter on objectification she takes on Nussbaum’s classic article in which she attempts to provide a exhaustive accounting of types of objectification, and then provides an account of which forms are morally objectionable. This whole approach, Bauer argues, misses out on an essential component of the concept of objectification in feminist analysis, which is that possessing the concept changes how you see the world. Readers familiar with L. A. Paul’s work on transformative experiences will recognize the similarities to the phenomena Bauer is describing.

Part of Bauer’s underlying concern with Nussbaum’s work are the tensions inherent in being a feminist philosopher, a subject which she also explored in her 2001 book Simone de Beauvoir, Philosophy, and Feminism . For Bauer the philosophical stance is inherently one that aims at neutrality — a pursuit of truth, regardless of where that takes you. This is not to say that actual philosophers in practice are neutral, or even have adopted methods that plausibly would aim at such neutrality, but just that the goal of neutrality is part of the philosophical enterprise as she understands it. In contrast, being a feminist is to adopt a political stance, even in its most minimal form as the ”radical belief that women are people” (Marie Shear). It is to adopt a way of seeing the world which is not open to all possibilities.

Nussbaum’s attempt to provide a definition of objectification is philosophical in its method, and in that, argues Bauer, it inevitably falls short of the concept as introduced and understood by feminist thinkers. For the feminist, objectification is by its nature bad, and to see something as a case of objectification is ipso facto to appraise it morally and find it lacking.

Despite this felt tension and frank acknowledgement of it, Bauer is clearly engaged in a philosophical enterprise. She starts the book not with the analysis of Austin alluded to above, nor with discussion of Nussbaum, but by turning her clear philosophical eye to the sexual experiences of college aged women in the US. She observes that there is plenty of judgment of “hook up culture” in the media, but little close attention to the motivations of the participants, and even less attention to the experience of women in particular. Bauer starts with her own puzzlement: why would these confident and accomplished young women enter again and again into a casual sexual encounter centred around un-reciprocated performances of fellatio? What exactly is in it for them?

Bauer is  not engaged in a sociological study of women aged 18-25. Rather she is reflecting on the sorts of things young women say in her classes and to her as a mother of a peer, and reflecting, in the tradition of both analytic philosophy and feminist theorizing, on what those sorts of utterances reveal about the society in which those young women are embedded. Her foil is a certain kind of ‘post-feminist’ theory, on which these young women, accomplished, independent, and ambitious as they are, no longer need feminism.

Bauer argues that they do still need feminism—that equality still eludes even these privileged, accomplished and ambitious women—and that this can be seen perhaps most clearly in their sexual relationships. Understanding the appeal of seemingly one-sided hook-ups requires us to return to de Beauvoir. One might think that heterosexual relationships had progressed since the publication of the The Second Sex , but from Bauer’s point of view the progression is largely at a superficial level. Men and women are still splitting the difference when it comes to the inherent difficulty of experiencing oneself as both subject and object, with women agreeing to play the role of sexual objects to men’s sexual subjects. Nor should we be particularly surprised by this. De Beauvoir is quite clear that the role of sexual object comes with numerous benefits for women. Bauer explores this in great detail in her chapters on the allure of self-objectification and on Lady Gaga . It is precisely because the role of object bestows upon young women an intoxicating sense of their own sexual power—even if they don’t exercise that power—that they continue to participate. The young men get an orgasm, and the young women get the rush of being able to walk away and leave him hanging.

For Bauer the practice of genuine feminist philosophy requires that one use your experiences of the world to ground philosophical inquiry while allowing that inquiry to transform your understanding of your experience (ix-x). Her critique of contemporary writing about pornography, objectification, and ‘hook-up’ culture is at the most basic level that it falls short on both grounds. The methodological status quo for thinking about these issues among feminist philosophers is, she argues, fundamentally flawed. Her goal for How to do things with Pornography is primarily to show what goes wrong in this way of thinking about things, though the book is not without positive theorizing.

There is something strange, in Bauer’s view, about the general acceptance among feminists of the US legal system’s treatment of pornography—and other visual media—as a form of speech, as if this was not just a legal contrivance but a decisively established philosophical analysis. The dispute about the role of ‘uptake’ in successful illocution, or communication; the staunch avoidance of attention to perlocutionary consequences; and the lack of attention to philosophical work on the rhetorical impact of photography and film are all consequences of this uncritical acceptance.

What is the relationship between the quest for knowledge of the thing itself, or things in themselves, and human sexual desire? What sort of epistemological wish, if any, is involved in the desire to gaze at pornographic photographs and films? Whatever answer one might be inclined to propose, it is clear that this wish cannot be identified or accounted for simply by the idea that pornography is a kind of speech. One wants to ask: who is doing the speaking? The subjects of the photographs? (And are they subjects or objects—or both?) The pornographers? And what exactly is being said? And to whom? And why are people so aroused by looking at photographs and films of other people’s naked bodies and their sexually explicit activity? (85)

The first two chapters of the book replicate two pieces Bauer wrote for a general audience, “Pornutopia” and “Lady Power”. Bauer’s goal in these pieces is primarily to draw our attention to our lived experience as sexual beings, and contrast this experience with common theorizing about this experience. In “Pornutopia” both the idea that pornography is not something that ‘decent’ people have interest in or find arousing (a line of thought found in the report of the famous Meese commission on pornography and in much feminist theorizing) and the idea that while we all find some pornography arousing we should inhabit a sense of deep shame about this arousal (a view advocated by Andrea Dworkin) are held up to scrutiny. The problem with the Meesian view is that we all, at least sometimes with some people, find objectification arousing. The problem with Dworkin’s view is that it is soul crushing.

Feminist philosophers, Bauer suggests, have an abiding faith that reason can be used to destroy desire. That is, they take if for granted that we come to properly understand objectification and what is wrong with it, then pornography will lose its power to arouse us. But this is to fail to understand how pornography operates. Within the pornutopia there is no space for the concept of objectification, because in porn everyone is desired by everyone who they desire, and in gratifying your own desires you automatically gratify the desires of others as well.

This same criticism lies at the heart of Bauer’s scholarly critique of Martha Nussbaum’s well known account of objectification. Nussbaum’s listing of the various forms of objectification, carefully distinguishing of one from another, and acknowledgement that some forms of objectification can be delightful, misses the point says Bauer. The concept of objectification, she argues, serves feminists by transforming their understanding of certain experiences. With the concept in hand one can transition from moving through the world uncomfortably to identifying the source of your discomfort.

The main problem  with the feminist treatments of objectification and pornography in Bauer’s view is that they fail to account for our enjoyment of either — of the happiness that one can get from playing by the rules. De Beauvoir’s observation that men and women have agreed to ‘split the difference’ when it comes to our phenomenological experience of ourselves as both subject and object, with men taking on the role of sexual subjects, and women the role of sexual objects, is salient here. De Beauvoir explains the powerful allure of self-objectification. By playing the role of object, women can exploit their own sexual power as objects for pleasure—and that pleasure is real. The alternative—what de Beauvoir calls an ‘authentically assumed existence’ is hard, and among other things, it requires both material and psychological means that women lacked in Beauvoir’s day and, albeit to a lessor extent, continue to lack now. The incoherent striving to be an object persists—and is intractable—because the system works, more or less. Women have achieved much great parity with men than they had in de Beauvoir’s day, but their physical vulnerability remains. Self-objectification is a risk reduction strategy—by objectifying ourselves we avoid something worse. And, as de Beauvoir was aware, the line between self-objectification and full personhood is whisper thin.

What about Austin? On the usual reading of Austin by analytic philosophers of language, How to do things with words inaugurates a new sub-discipline within the philosophy of language, the study of what is usually called pragmatics. On this ‘standard’ reading, Austin’s discussion is to be understood as leaving the usual study of syntax and semantics untouched, its practices endorsed, and as advocating merely that philosophers turn their attention also to the use of language in the wild, as it were. Bauer points out that if this is the correct reading of Austin then How to do things with words is unique among his writings. In every other area of philosophy on which Austin wrote he advocates nothing less than a complete upheaval of the sub-discipline, “and yet curiously, Words is routinely taken “straight”, as though here—and only here—Austin was perfectly content to till the same old philosophical soil and wished merely to draw attention to some adjacent virgin land”(55). In contrast, Bauer reads Austin’s ambitions to be as radical here as they are everywhere else. In Words she argues, Austin accuses his fellow philosophers of not understanding the first thing about language.

On Bauer’s reading of Austin he asks us to look anew at language, and at our history of philosophizing about language, and aims to point out the absurdity of imagining that words “bespeak themselves”—that they bear their meanings and truth conditions and nothing else openly for all to see; independent of the people who speak them, the people who hear them, and the histories and circumstances of their speakings. Austin, Bauer suggests, is arguing that our ability to mean things with our words is a consequence of our ability to do things with them. This is of course precisely the reverse of the standard picture, on which it is the meaning of words and sentences—the semantic content of language—that is a precondition for pragmatics.

Understood this way, Austin’s critique of philosophy of language is structurally similar to Bauer’s critique of feminist philosophy: Austin charges us with failing to pay sufficient attention to our experiences of using language in the world. Traditional philosophical theorizing about language, even that falling under the heading of pragmatics, suffers from a disconnect with the practical realities of using a language. And contemporary feminist theorizing suffers from an disconnect with the practical realities of women’s lives. In particular, on standard feminist understandings of sexual objectification and pornography, the day to day experiences of women (and men) remain something of a mystery.

The last three chapters of the book turn to Bauer’s positive and programmatic views. In ‘On Philosophical Authority’, she argues that our failure to pay attention to the experience of being a language user extends to philosophy itself, and in particular that we have failed to pay any attention to what is required for philosophical speech to be effective. The profession encourages writing, Bauer suggests, ‘as though the sheer rationality of our ideas and argumentation should be enough to effect change’ (117). This is, she argues, patently not true. Instead we must recognize that whatever cultural authority we have is to be found in our power to incite interest in thinking, and when we do not write with this in mind we abrogate that authority, and with it the ability to do things with philosophical speech.

In ‘Getting things right’ Bauer turns her attention to the issue of progress and diversity in the profession. The central thesis of this chapter is that both the demographic homogeneity of professional philosophy and the failure of philosophy to make much of a specific kind of progress are interrelated. Bauer’s particular target here is the view, advocated by Timothy Williamson, on which philosophy, like science, is and ought to be in the business of theory-making and nothing else . Whatever the merits of theory-making—and Bauer is clear that it has merits—we ought also, and perhaps more centrally, be concerned with the kind of progress that results when people work to make explicit their most deeply held assumptions and subject them to scrutiny (136). Focus on theory promotes a gap between philosophical discourse and the way in which people speak and experience the phenomena about which we theorize. As an example, Bauer asks us to reflect on the dominant understanding feminist meta-physicians have of gender as a product of social forces. We don’t, Bauer notes, reflect very much on how difficult it is, even for us, to actually live this view, or on how much it fails to easily mesh with our experience of our own gendered bodies. This is not to say that we should not theorize about gender, or that the idea that gender is a social construction is wrong. Rather Bauer is calling us to care about bridging the gap between theory and experience. But this is something that neither the scientistic model of philosophy advocated by Williamson nor the ‘great man’ model of philosophy which is seen by Williamson as the salient alternative make space for. We need, Bauer argues, to make space for voices that are neither great men–that is to say white men of a certain class–nor foot soldiers in a collective enterprise of philosophical theory-making. In doing so, she suggests, we will make space both for philosophical progress of the human kind, and for a more diverse range of philosophical voices.

Finally, in ‘Reel Girls and Real Girls: What becomes of women on film?’, Bauer returns to pornography, this time with the focus on the ‘look and see’ approach to philosophical theorizing, as advocated by Austin, Stanley Cavell, and Wittgenstein. In particular, Bauer urges us to take seriously that large amounts of pornography is not something done with speech, but with film, that is, with images. What Cavell teaches us, Bauer suggests, is that we must pay attention to the evocative and expressive powers of film, and in particular to the very real desires and pleasures we experience as viewers. These powers can obviously be used to objectify. But what Bauer argues in this last chapter, following Cavell, is that it is film itself which is best situated to reflect upon and call into question its own power to objectify.

The central theme of Bauer’s book is now perhaps obvious—whether our concern is with pornography, objectification, language, or philosophy itself, Bauer calls for us to attend to our experiences as sexual creatures, as women and men, as speakers and hearers, as viewers and makers of film, as philosophers and as people in the world. We must allow those experiences to interact with and shape our theorizing. We must also live with the threat that to do so will radically alter our theories.

Nicole Wyatt

Department of Philosophy

University of Calgary

Calgary, AB Canada

References

Austin, J. L. (1962). How to Do Things with Words . Clarendon Press.

Bauer, Nancy (2001). Simone de Beauvoir, Philosophy, and Feminism . Columbia University Press.

Beauvoir, Simone de. (1989, c1952) The second sex . New York, Vintage Books

Cavell, Stanley (1979). The World Viewed: Reflections on the Ontology of Film . Harvard University Press.

MacKinnon, Catharine A. 1993. Only words . Cambridge, Mass: Harvard University Press.

Nussbaum, Martha C. (1995). Objectification. Philosophy and Public Affairs 24 (4):249-291.

Book Reviews

Lisa Tessman, When Doing the Right Thing is Impossible, Oxford University Press, 2017

Lisa Tessman’s When Doing the Right Thing is Impossible offers an engaging and accessible exploration of the complex philosophical issues surrounding moral dilemmas and moral failure. Are there genuine moral conflicts? Is it true that in some situations a moral agent cannot help but fail? Tessman offers her own answer – yes, in some situations, moral failure is unavoidable – while guiding readers through the debates surrounding these questions, clarifying the various positions sympathetically and carefully.

Part of what makes the book so immediately gripping is the case study it begins with in Chapter One: Tessman focuses on the case Memorial Medical Center in New Orleans during Hurricane Katrina. During the storm, the hospital was full of patients as well as a number of community members, off-duty staff and their families who were seeking shelter. In the aftermath, the hospital was seriously compromised—the air conditioning stopped working, the water became unsafe to drink or wash with, toilets stopped working, and medications ran low. Some critically ill patients were evacuated by helicopter, but many more were not. As time went on, exhausted staff and volunteers made mistakes, and doctors and administrators made pressured judgment calls, including the decision to go into lockdown and post armed guards to keep out desperate people (seen as potential looters) trying to get in. After being trapped in the hospital for four days, the backup generators failed and the situation worsened further. Staff, nurses, and doctors acted heroically: they pumped oxygen by hand for patients who had required ventilators, and designed IV drips that would not require electricity. But, in desperation, they began to make decisions about who would most deserve evacuation, now with a plan to leave those who were either most sick and therefore least likely to survive evacuation, or too large and unwieldy to move, for last. When it became clear, given complex and horrifying circumstances, that not everyone would be evacuated, according to some accounts, some doctors and nurses gave injections of morphine and other drugs to hasten the deaths of those who would not be.

The question Tessman raises from this case is the one at the heart of the book: are there situations in which what agents are morally required to do is something that is impossible to do? As in the case of the doctors and nurses, we might think they were both morally required to not leave patients in the hospital to suffer and die, and at the same time that deciding to give patients who might survive a drug to hasten their deaths was morally reprehensible. Or, put differently, we might think they were morally required to save their patients but also that saving their patients was impossible—they were morally required to do something they could not do. Giving a philosophical account of how this can be the case is complicated, given some fundamental commitments that shape much of philosophical ethics. For one thing, as Tessman notes, if we agree with her that there can be impossible moral requirements, then we must be willing to contradict the Kantian principle “ought implies can” (Tessman 16).

Chapter two takes up the question of whether moral dilemmas can in fact exist. Tessman distinguishes moral conflicts (i.e., situations in which there is a moral requirement to do both A and B and one cannot do both A and B) from moral dilemmas (i.e., situations in which there is a moral requirement to do both A and B, one cannot do both, and neither ceases to be a moral requirement as a result of the conflict). In the case of dilemmas, even if an agent judges that moral requirement A overrides moral requirement B, B does not stop being a requirement. Failing to do B, even in order to successfully do A which the agent judged to be more important, would still be a moral failure. As Tessman notes, many philosophers believe that moral dilemmas do not exist. She canvasses two “anti-dilemma” philosophical positions: those who argue that there are no moral conflicts at all (the ‘no-conflict approach’), and those who argue that there are no moral conflicts that count as dilemmas (the ‘conflict resolution approach’). Tessman ultimately rejects both approaches, the first by rejecting the principle that ‘ought always implies can’, and the second by arguing that there are some cases of conflicting moral requirements where both requirements are non-negotiable and neither can be overridden or cancelled. As she concludes, “as long as some moral requirements are non-negotiable, then if there are conflicts among these kinds of requirements, there will also be dilemmas” (42).

The third chapter of the book considers how to distinguish between negotiable and non-negotiable moral requirements. Those that are negotiable may conflict without producing circumstances of moral failure: we can simply prioritize the more important, non-negotiable requirements over those that are less important. But where non-negotiable requirements conflict, moral agents can find ourselves failing no matter which requirement we fulfill. Tessman distinguishes different kinds of moral requirements—there is a plurality of kinds of moral values (47), and because not all moral values are of the same kind, they cannot always substitute for one another. In some cases, the value of an action can be replaced by some other value. In other cases, an action’s value is irreplaceable. In particular, there are cases of some values which, if sacrificed, could never be replaced. Tessman gives the example of the murder of someone you love. Nothing can substitute for what you have lost: it is a loss of an irreplaceable value. Irreplaceability seems to be one component of what makes some moral requirements non-negotiable, but not the only component, since some irreplaceable losses are not substantial enough to count as non-negotiable moral requirements (e.g., a child losing a beloved balloon may be an irreplaceable loss but not one her parent is obligated to prevent at all costs). As Tessman argues, drawing on Gowans (1994) and Nussbaum (2011), the more serious, non-negotiable requirements, are ones which nothing can substitute or compensate for fulfilling, and ones which provide what is of deepest value in human lives.

In the fourth chapter, Tessman turns to the work of empirical moral psychologists to consider further how moral agents could judge ourselves to be facing non-negotiable moral requirements. Contrary to the common philosophical assumption that processes of moral judgment are chiefly processes of reasoning, Tessman surveys Jonathan Haidt and Joshua Greene’s work on dual process models of moral judgment, which consider how moral judgments of non-negotiable requirements might more standardly occur through automatic, unconscious, intuitive processes. The difference between reaching moral judgments through intuitive processes and reaching them through reasoning processes suggests a way of distinguishing negotiable and non-negotiable requirements: the alarm bell emotions that accompany the intuitive process of moral judgment may be part of what distinguishes judgments that some moral requirements are non-negotiable. As Tessman writes, “If you see a vulnerable person in danger, for instance, and this immediately provokes an ‘I must protect!’ alarm bell, then you’ll experience the moral requirement indicated by this ‘I must’ as non-negotiable” (Tessman 76).

In chapter five, Tessman considers the evolutionary development of moral practice more broadly. Focusing on multilevel selection theory, Tessman explains how traits tied to abilities to cooperate and be altruistic (specifically, the traits of individuals in groups who successfully practiced alloparenting) have been seen as more likely to be passed on (82). Having gone into detail on the view and common misconceptions to be avoided, Tessman highlights this as a plausible evolutionary explanation of why morality in general would have involved, and proceeds to concentrate on evolutionary explanations for the specific experiences of intuitively judging that we are required to do something. In brief, she notes that we have good evolutionary explanations for why humans rely on system 1 (the quick, intuition system of the dual system models) associating certain perceptions (e.g., of an object that looks like feces) with certain feelings (e.g., yuck) and behavior (e.g., do not eat) (94-95). Moral responses (e.g., “vulnerable person in danger/empathic fear for the person/protect the person!”) could have evolved similarly (Tessman 98). The presence of such moral responses does not ensure that they are ones we can enact, of course, since we cannot always protect the person. In such cases, we may face impossible moral requirements.

Tessman turns in chapter six to a consideration of second-order judgments about our first-order judgments of what action is morally required. In particular, she argues that a specific class of first-order judgments arrived at by intuition should not be subjected to verification by a reasoning process, because to do so would actually undermine the value expressed in the first-order judgment. For instance, a parent’s first-order automatic judgment that they must stop their toddler from running into a busy street should not be subjected to second-order evaluation (Tessman 108). To do anything other than stop the child is unthinkable. As Tessman writes,

“If intuitively judging some actions to be unthinkable is part of what constitutes loving someone, and if judgments of unthinkability preclude double-checking our intuition through reasoning, then in order to love in this way we’ll have to trust some of our intuitive judgments about what actions are required or prohibited, and to do so without relying on any reasoning about them” (Tessman 109).

On Tessman’s view, this amounts to both a first order intuitive judgment (i.e., one must stop the child), and a second order intuitive judgment [i.e., “Don’t think the unthinkable by reasoning about what to do in this case!” (110)], at the same time. In some cases, agents might face either doing the unthinkable (e.g., not protecting one’s child) or doing the impossible (e.g., lifting a 5000-pound car off of them). In these sorts of tragic cases, one cannot help but fail.

In chapter seven, Tessman continues the consideration of unthinkable actions, but now in contexts of relationships beyond those of intimates. In some cases of moral action, it can be wrong to arrive at a moral judgment via controlled reasoning rather than an affect-laden, automatic, intuitive process. For instance, we should not need to think very hard about whether to save a child’s life. In the words of Bernard Williams, it can be possible to think ‘one thought too many’. As Tessman writes, “We should treat other people as beings whom it is unthinkable to do certain things to, and the mark of our finding these things to be unthinkable is that we don’t have to reason, or find justification, in order to grasp that we mustn’t do them” (Tessman 133). While recognizing and honoring sacred values can be at the core of much of the most important moral actions, doing so can also be dangerous—we must also remain attentive to the values that conflict with them.

In chapter eight, Tessman concludes that, contra constructivists and theorists who think we should reach consistency among moral values by processes of reflective equilibrium, morality is not necessarily made up of a consistent set of judgments reached by reasoning. In fact, the set of our moral values is often arrived at through an automatic, intuitive process, and may persistently contain conflicting values. We should not respond to the existence of conflicting values with an attempt to tidy them up and produce a unified, consistent set.

One of the most important dimensions of Tessman’s work in this text as I see it is its reflection on why the possibility of unavoidable moral failure can feel so troubling to moral agents, despite the fact that such situations are not rare in our moral lives. As Tessman notes,

“It’s very distressing to think that, due to something completely outside of your own control, you might be caught in a situation in which you’re inevitably going to have to commit a moral wrongdoing. Perhaps we like to think that we can control how morally good or bad we are. If there are dilemmas, then even if we always try to do the right thing, we might end up with no right thing that we can do…We can expect our moral lives to be less clean than we might have previously imagined because we might fail in ways that we never would have, if only it were always in our control to avoid moral failure…The point of recognizing the phenomenon of unavoidable moral failure isn’t to identify more things that people can blamed for. Instead, the main point is to acknowledge how difficult moral life can be” (Tessman 2017, 29-30, 159-160).

Her reflection on the allure of control in moral lives will be helpful both at the level of philosophical developments in moral psychology, as well as at the level of on-the-ground first-person moral experience.

This is an excellent book not only for philosophers working in ethics and moral psychology, but also for a much broader audience . It would be ideal for use in ethics classes, and is accessible enough for readers beyond academic contexts who are interested in understanding the complexities surrounding these all-too familiar experiences. Throughout, Tessman helpfully frames questions to the reader (e.g., “are you willing to agree that…?”), making the text especially engaging, and facilitating its use in classrooms and discussion groups. The book manages to maintain what is deeply relatable about situations in which moral agents cannot succeed, while introducing readers to the philosophical controversy surrounding such situations.

Ami Harbin,

Department of Philosophy and Women and Gender Studies

Oakland University

Rochester, MI

References:

Gowans, Christopher. 1994. Innocence Lost: An Examination of Inescapable Moral Wrongdoing. New York: Oxford University Press.

Greene, Joshua, Brian Sommerville, Leigh Nystrom, John Darly, and Johnathan Cohen. 2001. “An fMRI Investigation of Emotional Engagement in Moral Judgment” Science 293 (5537): 2105-2108.

Haidt, Jonathan. 2001. “The Emotional Dog and its Rational Tail: A Social Intuitionist Approach to Moral Judgment” Psychological Review 108 (4): 814-834.

Nussbaum, Martha. 2011. Creating Capabilities: The Human Development Approach. Cambridge MA: Harvard University Press.

Book Reviews

Françoise Baylis and Carolyn McLeod (eds), Family-Making: Contemporary Ethical Challenges, Oxford University Press, 2014

This fascinating anthology focuses on the question of how we make families, and how bionormative assumptions shape or distort our collective thinking about parenting, children’s welfare, and state obligations to parents and children. The editors are primarily interested in the question of whether parents’ moral responsibilities toward children differ for children produced through assistive reproductive technologies (ART) compared to children brought into the family via adoption. As the editors point out, in the realm of ART, most of the philosophical literature has been focused on parental autonomy and rights to assistance in reproducing, while the adoption literature is almost entirely focused on the protection of children. The anthology does an excellent job of exploring this disconnect, and probing assumptions about moral responsibilities within family-making. Taken as a whole, the chapters explore “whether people should rely on others’ reproductive labour in having children, whether they should ensure that they will have a genetic tie to their children or that their children will have some connection to genetic relatives, whether they should bring a new child into the world at all, whether they should agree to what the government would require of them for an adoption, where they should live if the family they make is multi-racial, at what age they should forgo having children, and the list goes on” (6).

The first section of the book sets the stage with two excellent chapters on the goods of parenting (Harry Brighouse and Adam Swift) and the goods of childhood (Samantha Brennan). The goods of parenting are distinguished from other related goodsintimacy with another adult or friend, friendship with a child, being an uncle, having a pet, etc.and understood to be extremely valuable and non-substitutable (13). Brighouse and Swift identify at least four things that distinguish parent/child relations from these other intimacies: 1) they cannot have equal power, given that children do not enter the relationship voluntarily, are dependent, and cannot exit at will; 2) parents have the power to (indeed are often expected to) coerce children; 3) parents set up the environment that creates a child’s values and possibility for autonomy; and 4) parents receive unconditional intimacy from the child, and presumed trust (15-16). These distinct features of the parenting role lead to unique goods of parenting, and highlight some of the reasons we often consider access to family-making to be a fundamental right. The authors note that parenting is “likely to be one of the most important things one does with one’s life” (19). Like romantic relationships, parenting may not be necessary for a good life, but it is often a very significant component. Importantly, though, the goods of parenting are not necessarily tied to biological parenthood, but are instead gained through the intimate, unique relational role and resultant experiences.

Brennan’s chapter on the goods of childhood takes on the question of how much of children’s welfare (and parental obligations to promote it) is attached to the present child vs. the future adult she will become. A parent’s job isn’t simply to get the child to survive until adulthood, or even to have an “open future,” but also to help her enjoy the unique goods of childhood, including for instance, free play, a sense of time as endless, a sense that all doors are open, and absolute trust in others (43). On Brennan’s view, children aren’t small or deficient adults, but developing relational, autonomous creatures who need help to pursue their own temporal goods.

Part two of the book critiques the ways in which bionormativity (the idea that the “gold standard” of the family is having parents who are genetically related to the child) influences our thinking and policy-making on family creation. The chapter by Charlotte Witt takes on David Velleman’s arguments (2005, 2008) regarding the importance of having “family resemblance” for developing a healthy and adequate identity or sense of self. Velleman considers it to be “universal common sense” to think it better to have one’s own biological parents (quoted on 54), and argues explicitly against making children with anonymous gamete donors. In his view, “Not knowing any biological relatives must be like wandering in a world without reflective surfaces, permanently self-blind” (quoted on 52). Witt does an excellent job of showing just how limited this view is, given the multiple ways we can see ourselves reflected in the behaviors, beliefs, and practices of our rearing parents, even if they are biologically unrelated. The fact that many adoptees seek information about their biological parents may show curiosity or the desire for medical information rather than “genealogical bewilderment” that impinges on healthy identity formation.

A more empirical chapter (Lucy Blake, Martin Richards and Susan Golombok) reviews the evidence regarding the health and well-being of children and families formed through natural sexual reproduction, ART, and adoption, and concludes that there is no good evidence in favor of the bionormative conception of the family. Children produced through ART with donor gametes had no significant health or psychological differences from children produced via natural sexual reproduction (78), and ART parents were just as likely (or more so) to have positive parenting ratings. Their comparisons for adopted children show somewhat greater psychological and behavioral issues, but they argue that these are more likely to occur in children adopted later in life, and are probably due to the lingering effects of early stresses (e.g., neglect, abuse, malnutrition) prior to the adoption rather than to having biologically unrelated rearing parents.

Part three looks at becoming a parent, with chapters from Christine Overall on the value of procreation, and Tina Rulli on the value of adoption. Overall argues that most of the reasons given in favor of procreation (e.g., bringing intrinsic value into the world, creating happy people, enjoying the experience of pregnancy, childbirth, and breastfeeding, fulfilling duties to family, obeying religious requirements, maintaining choice and control in reproduction) fail to justify procreation over adoption, because they misunderstand the parent/child relationship, have too narrow a vision of what parenting is, or lead to troubling implications.

Rulli offers a look at the unique goods of adoption, highlighting the ways in which adoption “provides a morally noble opportunity to extend to a stranger benefits usually withheld for one’s genetic kin” (110). She argues that adoption is sometimes superior to procreation; it’s a “pure and exemplary model of what is most valuable about parenthood” (110). Consider Rosalind Hursthouse’s claim (1987) that it is tempting to consider “bearing a child as analogous to sacrificing a fair amount of time and effort to saving someone’s life” (quoted on 114). Rulli uses this insight to note that not only does adoption satisfy the moral features that give procreation value (e.g., having the courage, fortitude and endurance to create something of intrinsic value, investing time and energy toward “saving” lives, developing intimate relational connections that are central to morality), it does so in clearer ways, given that adoption involves the risk of taking on a stranger in need, rather than creating a new life. (“Procreation doesn’t meet needs; it creates them” 113.) As such, Rulli suggests that “adoption is not second-best. Morally speaking, it is the exemplar” (115). Importantly, she is not arguing for a duty to adopt, but against the assumption that adoption is always second-best. Rulli also considers objections about the “myth of the world orphan crisis” that may create a demand for children (and a market for babies in less developed or more impoverished parts of the world). She rightly notes that concerns about unscrupulous adoption markets and practices call for better oversight, not abandoning or maligning the value of adoption.

The fourth part of the book looks at state interests related to people who want to become parents. Jurgen De Wispelaere and Daniel Weinstock consider whether the state has an interest in restricting access to ART (or at least not subsidizing it) in order to address the needs of already existing children who are awaiting adoption. They note that while some have argued for a positive right to ART (under the banner of a right to reproductive health), using ART often looks more like enhancing reproductive function as opposed to restoring it, and the reproductive health right frame over-medicalizes the process of family-making. One might make a claim instead to a positive right to parent, but that right does not require any biological connection between parent and child (137). If the state should recognize a fundamental right to parent, but remain neutral between modes of fulfilling that right (i.e., natural sexual reproduction, ART, and adoption), then it might seem that the state would have no justification for promoting any one mode of family-making. But third party interests (those of existing children in need of adoption) alter the situation, giving the state reason to promote adoption and perhaps restrict access to ART. Nonetheless, the authors resist the conclusion that access to ART should be restricted, because they recognize costs of the adoption process, the limited pool of potential adoptees (especially given restrictions on international adoptions), and the potential difficulty in providing a good home for a child with special needs. A solution might be to open up the adoption process a bit more (making it more feasible for some prospective parents), and to institute some restrictions on access to ART. Regarding the latter, they suggest that we manage demand for ART through pricing (with the state partially subsidizing it only for impoverished infertile people). They recognize the right to parent, but think that right ought to be focused on intimacy and special relations rather than biological connection.

In their chapter, Carolyn McLeod and Andrew Botterell offer lessons from their own experience as adopting parents. They note that prospective adoptive parents are in for a time-consuming, frustrating, sometimes intellectually numbing process that involves extensive interviews, home visits, required parenting classes, letters of reference, criminal background checks, and more, in a process that can last more than two years. Their question is whether the state should have the right to impose these constraints on adoptive parents (and, to be specific, on non-related adoptive parents) but not on “natural” parents (or familial or step-parent adopters). They argue that the differential treatment is not morally justified, because all the reasons offered to justify licensing only non-familial adoptive parents (harm to prospective children, feasibility of licensing, transfer of parental responsibility during adoption, and lack of claim by prospective parents to a particular child) are not non-familial-adoptionspecific worries. They conclude that we either ought to support licensing for many more prospective parents, or not licensing at all (155).

Julie Crawford’s chapter takes on the issue of bionormativity in the law’s treatment of “second parent adoption” vs. parental presumption. As a lesbian co-mother who helped with the “ontological choreography” of creating a child with her partner, Crawford was nonetheless required legally to adopt her child in order to be considered a legal parent. Contrast this with the legal practice of parental presumption (176-177), which allows a man in her role to bypass the adoption requirement. An anonymous sperm donor for a couple using ART is removed from the legal parenting equation and “the social father seamlessly takes his place” (174) and is automatically the baby’s legal father. (This is what Elizabeth Bartholet (1995) calls a “technologic adoption.” What could possibly justify this difference, given their structural similarities? Crawford notes also that second parent adoptions can run $4,000-6,000 and take time, during which the second parent does not have legal parental rights. She advocates for extending the parental presumption to parents in committed relationships (whether married or not).

Part five turns to special responsibilities of parents, with chapters on responsibilities of parents using ART (Jamie Lindemann Nelson), post-adoptive parental obligations in regard to openness and disclosure within and outside of the family (Mianna Lotz), and obligations for parents who adopt transracially to morally consider the geography (neighborhood of residence) of their new family (Heath Fogg Davis). Nelson’s chapter highlights how parental responsibilities are not the sorts of things that can be “unilaterally dissolved” (186). Nelson notes that what we cause to happen can matter morally, so even if we didn’t intend a particular effect, we can be morally responsible in relation to it (188). This means that the anonymous sperm donor may have some responsibility toward the child produced through ART, if only related to the provision of information. Similarly, parents who use ART and rely on a gamete donor may have the responsibility to share such information with their child. As Nelson smartly points out, “If some adults can find biological relationships with children so important that it makes going through ARTs with all their costs, risks, and inconveniences a rational choice for them, why should we assume that biological ties in the other direction won’t also matter greatly to some children?” (189).

Lotz argues that adoptive parents have obligations to communicate openly about the adoption within their family, in order to help address three vulnerabilities of adopted children: identity development, development of a sense of familial belonging and security, and development of emotional independence (201). Post-adoptive parental obligations, then, may involve initiating discussions about adoption and the child’s heritage rather than only being responsive to questions from the child. Still, she distinguishes between obligations of openness within the family, and outside of the family, noting that concerns about adoptee welfare may make extra-familial openness optional rather than required.

Fogg Davis’s chapter takes up the intriguing question of whether parents in transracial adoptions are morally obligated to make their homes in non-predominantlywhite neighborhoods. Fogg Davis argues that they are, not because a black adopted child cannot form a healthy self-concept in a white neighborhood (we have many examples to the contrary), but because such parents have a “magnified version of the general moral responsibility that we all have to make residential decisions that do not perpetuate longstanding patterns of racially segregated housing” (222). In transracial adoptions, the family itself is a site of racial integration (223), and the parents have assumed leadership roles in relation to racial integration. Parents are morally obligated to convey the message to their black adopted children that the racial integration of the family will not be entirely unidirectional, that they are willing to physically move out of their geographical racial comfort zones. The parents show good faith in leading the family’s process of racial integration by interrupting the unthinking cycle of selecting a neighborhood that is racially familiar to them” (227). He acknowledges that this obligation is held by all parents, but suggests that it is magnified in the case of white parents who adopt black kids.

The final part of the book includes chapters on contested practices, including the use of “right to know” analogies between ART and adoption practices (Kimberly Leighton), contract pregnancy in India (Françoise Baylis), and age restrictions for the use of ART (Jennifer Parks). Leighton argues that the circumstances of ART and adoption are different enough that the purported harms of not knowing one’s genetic parent are not easily comparable across these practices.

Baylis offers a damning look at contract pregnancy (surrogacy) practices in India, which in her view amount to unfair exploitation of impoverished Indian women by privileged Westerners, despite some surrogates’ testimony to the contrary. When a surrogate complains about the exhaustion of pregnancy but notes that her regular job (crushing glass 15 hrs/day for $25) is truly exploitative, Baylis acknowledges the truth of her testimony, but focuses on the structural injustices that make this kind of “choice” the best available option (268). She also points to less sanguine testimonies from women who say that contract pregnancy is far from what they would otherwise choose, but they really have no other feasible optioneven as their contracting couples from the West claim that the women think they are doing something good, and “in their eyes, they aren’t being exploited” (269). Paying the women more would not resolve the situation, given that in their situation, more money would simply constitute undue inducement (272). Baylis focuses less on the responsibility of individual women, and more on the governmental policies that encourage such international contract pregnancy: “The job of government is not to expand the range of exploitative work options available to its citizens, but rather to guard against exploitation and oppression” (274). She starts by examining the harms to the women who are exploited, but also considers the harms to the children who are created this way, including the potential difficulty of living with an autobiography that is incomplete or that includes complicity in exploitation, or being understood as a commodity. Finally, she does not let the contracting couples off the hook, but appeals here to the work of Iris Marion Young (2007), noting that we are individually responsible for structural injustices, given the ways that we play our parts in the process (282).

The final chapter takes on the issue of age restrictions for the use of ART. Several sensational media cases depict women in their sixties and seventies using ART in order to become parents. Critics raised concerns about the prospect of orphaning the children at a relatively young age, the parents not having the energy or ability to guide the child well (given the exhausting if joyful work of parenting), and the physical and psychological problems that might be associated with older age parenting (288). Parks argues that many of the reasons offered against the use of ART by older women) are not exclusive to them, but might be leveled against women in their usual reproductive years who use ART because of cancer or other health-related concerns. Additionally, she argues these objections could be assuaged through careful planning for help with chronic care, plans for transfer of guardianship, etc. Parks also notes that cryopreservation of one’s own eggs for possible use in IVF can aid women who want to be mothers beyond their typical reproductive years. While Parks recognizes critiques of those who frame cryopreservation as a feminist technologyBarbara Katz Rothmann (2012) wonders why we don’t make other options feasible during women’s reproductive years (quoted on 289), and Patricia Smith (1993) worries it is technology that reinforces the importance of a women producing a biologically-related child for her partner (299)—she ultimately argues that it is rightfully considered a feminist technology because it provides “tools plus knowledge that enhance women’s ability to develop, expand, and express their capacities” (quoting Linda Layne et al. 2010, on 297). It offers women the option to put off reproduction while they pursue careers or other interests, and can serve as a kind of “insurance policy” for the future. Cryopreservation also decreases the number of women who would otherwise rely on donor eggs to attempt procreation, and thus may help to address concerns about exploitation and physical risk related to third party donation of eggs.

In sum, Family-Making is filled with philosophically rich explorations of the nature and limits of parental obligations to their children, whether the children enter their families through sexual reproduction, ART, or adoption. In reading these essays, I found myself longing for the goods of childhood, cherishing the joys of parenting, and marveling at the many-splendored nature of our familial structures and the weighty (and sometimes confusing) moral responsibilities that attach to them.

Sara Goering

Department of Philosophy
University of Washington

Seattle, WA, USA

REFERENCES

Bartholet, Elizabet. 1995. Beyond Biology: The Politics of Adoption and Reproduction. Duke Journal of Gender Law and Policy 2 (1): 5-14.

Hursthouse, Rosalind. 1987. Beginning Lives. New York: Basil Blackwell.

Layne, Linda L., Sharra L. Vostral, and Kate Boyer, eds. 2010. Feminist Technology. Chicago: University of Illinois Press.

Katz-Rothmann, Barbara. 2012. Yet Another Technological Fix to a Social Problem. Retrieved 25 August 2017 from http://www.barbarakatzrothman.com/2012_07_01_archive.html.

Smith, Patricia. 1993. Selfish Genes and Maternal Myths: A Look at Postmenopausal Pregnancy. In Menopause: A Midlife Passage, edited by Joan Callahan, 92-119. Indianapolis: Indiana University Press.

Velleman, J. David. 2005. Family History.” Philosophical Papers 34 (3): 357-78.

— 2008. Persons in Prospect.” Philosophy and Public Affairs 36 (3): 221-88.

Young, Iris Marion. 2007. Global Challenges: War, Self-Determination and Responsibility. Cambridge: Polity Press.

Book Reviews

Jeremy Howick, The Philosophy of Evidence-Based Medicine, Wiley-Blackwell, 2011

The idea that prescribing physicians should be guided by the most reliable scientific evidence seems obvious, but the actual methodology of evidence-based medicine was only introduced in the early 1990s by an international group of clinicians and researchers led by Gordon Guyatt. Since then it has provided a new paradigm for the scientific foundation of medicine and has influenced other disciplines outside of medicine, for example, evidence-based psychotherapy, science and government. The novel concept of evidence-based medicine is based on hierarchies of evidence from opinions of respected authorities, mechanistic reasoning (pathophysiologic rationale), and reports of expert committees at the bottom to various levels of observational studies and finally to randomized clinical trials (RCTs) at the apex of the pyramid. Since RCTs provide the most rigorous testing of therapies, they are the gold standard. When treatments long believed to be safe and effective are subjected to RCTs, many turn out to be as useless as the quackery of snake oil or as harmful as mercury. So, attention to RCTs as the evidence informing clinical judgment and practice is perhaps analogous to results of rigorous experiments in physics which turn out to be very different from our intuitions. Everyone, it seems, is on the bandwagon, from medical societies and pharmaceutical companies to general practitioners and surgeons, in the quest for an evidence-based practice.

Since evidence-based medicine was conceived with the practical aim of improving the efficacy of medicine, it does not appear that there is much of philosophical interest in the concept until one raises the epistemological question, as Jeremy Howick does in this book: What is the evidence for evidence-based medicine philosophy of evidence (9)? In other words, what is the evidence that evidence-based medicine is any better in improving patient outcomes than medical practice before the new paradigm? So, evidence-based medicine requires evidence and this is what Howick attempts to achieve in this splendid treatment of the subject. With an eye on the philosophical, Howick is also concerned with various paradoxes that arise concerning the hierarchies of evidence-based medicine; for example, many treatments in whose effectiveness we have the most confidence have never been subjected to RCTs, including simple procedures such as the Heimlich maneuver and tracheotomy. Howick’s thesis is that the evidence-based medicine hierarchies are sustainable provided that we take into account certain modifications, for one that “strict hierarchies should be replaced by the requirement that all evidence of sufficiently high quality should be admitted as evidential support” (xiv, 187). This being the case, we need not subject treatments we know to be effective to RCTs, for this would be as redundant as the need to test parachute effectiveness against parachute placebo.

In order to qualify as good evidence for an evidence-based medicine, outcomes must be clinically effective (clinically significant, rather than merely statistically significant) according to which: (i) patient-relevant benefits outweigh any harms, (ii) the treatment is applicable to the patient being treated, and (iii) it is the best available option (24). The evidence must demonstrate that the patient will live longer or better. Good evidence also rules out plausible rival hypotheses (33). So, RCTs generally maintain their position in the hierarchies because when well-designed and well-conducted (double-masked and randomized), RCTs minimize confounding factors such as the expectation of patients to recover by knowing they are given the experimental treatment. Observational studies cannot meet this standard because they involve observations in routine practice that cannot rule out the confounding factors. Certain observational studies will claim a treatment to be effective and safe but, when subjected to rigorous RCTs, show the very opposite. The same relationship holds between conclusions drawn on the basis of mechanistic reasoning and well-conducted clinical studies. Faced with contradictory conclusions from results in the hierarchies, Howick says it is rational to bet on the results form RCTs since RCTs are less likely to suffer from bias (53).

However, Howick introduces his rule of evidence: comparative clinical studies (or observational studies more generally) provide good evidence when the effect size outweighs the combined effect of plausible confounders (56). In cases in which the effect size is dramatic, potential confounders ruled out by double masking are outweighed by the effect size. So, for example, a retrospective or naturalistic study of the effectiveness of a new antidepressant in which eighty percent of the patients responded to treatment would not be good evidence since confounding factors for subjective ratings could provide alternative explanations, but in a similar test in which antibiotics for meningitis produced dramatic results, potential confounding factors are unlikely to account for the outcome of the study. Generally, RCTs provide better evidence than observational studies but it is not true that RCTs always beat other forms of evidence. Many RCTs will tout statistical significance with a marginal success for the primary outcome measure but fail to demonstrate any clinical significance.

Mechanistic reasoning is inferences about a treatment’s probable efficacy based on an understanding of a cause-effect relationship. In some instances, we have reason to believe that we understand the causal mechanisms; at the very least the success in patient outcomes leads us to believe this is the case. In other instances, the causal mechanisms are unknown or so complex that there are gaps in our knowledge and little confidence in intervention. Where the mechanisms are well understood and there are no gaps in our knowledge, mechanistic reasoning certainly contributes to the total evidence, but by itself, it remains low in the hierarchies. Howick writes: “many lives would have been saved had the requirement for mechanistic reasoning been dropped in cases where we had evidence from high-quality comparative clinical studies” (136). He lists cases in which mechanistic reasoning led to the adoption of therapies that were either useless or harmful. These strongly suggest skepticism about therapeutic claims without support from high-quality evidence from clinical studies (154-56). Howick concludes that high-quality mechanistic reasoning should be weighed alongside results from comparative clinical studies since hypotheses supported by both are less likely to be spurious than hypotheses supported by one type of evidence (135-36).

When Howick turns his attention to expert judgment, it is clear why this form of evidence either remains at the bottom of the hierarchies or is excluded altogether. Reverence for experts lionized by the profession has led to the retention of therapies that are either harmful or useless. Moreover, all clinicians regard themselves as better than average when evidence from studies demonstrates otherwise. Nonetheless, there is a role for expert judgment of skilled clinicians when it comes to knowledge of how to respond to the individual circumstances and values of the patient using the best research evidence (178).

As a bare, abstract structure without regard to the merits and demerits of particular studies, mechanistic reasoning, or expert opinion, evidence-based medicine is therefore inadequate as a guide to clinical practice. One sort of evidence has to be considered within the totality of evidence to determine whether a medical intervention is likely to have clinically relevant benefits.

One of the main obstacles to achieving the ideal of evidence-based medicine is only briefly discussed in the conclusion of Howick’s book, namely, the proverbial fox guarding the henhouse—i.e., the great majority of RCTs are conducted by industry in partnerships with academic physicians. This is perhaps because the problem is deeply practical and political rather than philosophical. Howick draws attention to the fact that industry-sponsored trials are more likely to show positive results than non-industry funded trials (189-191). Due to the intensely competitive profit motive of marketing drugs and medical devices, the industry-sponsored RCTs have become notorious for misrepresentation of the efficacy and safety results. A good example of this was revealed in the manipulation of data to downplay safety results and ‘hide dead bodies’ (statistically speaking) in the clinical trials of Merck’s rofecoxib (Vioxx), which is estimated to have caused up to 120,000 cardiovascular events in the United States, including 40,000 to 60,000 that were fatal.

Prescribing physicians who are well aware of this problem are rightly skeptical about much of what passes for medical knowledge from RCTs, observational studies and respected authorities, i.e., ‘key opinion leaders,’ hired as product champions for the drug companies. Since physicians and researchers are never in position to know which trials are reported honestly and which are infected with statistical spin and blatant misreporting of outcomes, all bets are off regarding the reliability of evidence-based medicine. Where we do get some insight into the extent of the problem is from government inquiries and plaintiff’s lawsuits, but what comes to the surface in the public domain is only the tip of the iceberg. Thousands of medical journal articles reporting the results of industry RCTs cited over and over again remain unchallenged and when the very few subjected to re-analysis are proven to be fraudulent, editors of the journals and their owners refuse retraction.

Howick’s The Philosophy of Evidence-Based Medicine is valuable for the clear and cogent case that he presents for understanding the problems of evidence-based medicine and its solutions. Insofar as his primary goal is a critical evaluation of evidence-based medicine, Howick makes no attempt to explain where in the philosophical spectrum he stands regarding problems of confirmation or falsification of hypotheses or the all-important matter of how the paradigm of evidence-based medicine constitutes an advance, if indeed it does, in the progress of medical science. These issues remain for a more comprehensive philosophical investigation.

Leemon McHenry
University of Edinburgh
Edinburgh, Scotland

Book Reviews

Mari Mikkola, The Wrongs of Injustice: Dehumanization and its Role in Feminist Philosophy, Oxford University Press, 2016

Mari Mikkola identifies three primary forms of social injustice—oppression, domination, and discrimination—and asks what makes them wrong. She argues that feminist philosophy has thus far focused heavily on gender as a lens or anchor through which to understand and respond to injustice. In Mikkola’s view, this orientation around gender (and what she terms “the gender controversy”) is limiting feminist philosophers’ theoretical engagement with the roots of injustice. To remedy this problem, she builds a case for moving toward a more broadly humanist conception of injustice. The humanist feminism that she puts forth centers dehumanization as a way to theorize injustice; dehumanization, for Mikkola, is the very foundation of injustice.

Following an introductory chapter that frames Mikkola’s approach and argument, the book is divided into two parts. The first part of the book is dedicated to articulating Mikkola’s argument for moving beyond the “gender controversy” in feminist philosophy. She explains that the perspectives debated in the gender controversy produce two kinds of puzzles: one semantic, the other ontological. The semantic puzzle asks: “Given that ordinary language users tend not to distinguish sex and gender (treating ‘woman’ largely as a sex term, or a mixture of social and biological features), what precisely are feminists talking about when they talk about ‘women’? What are the necessary and sufficient conditions that the concept woman encodes, if any such conditions exist to begin with?” (28). The ontological puzzle, by contrast, is concerned with: “How should we understand the category of women that is meant to undergird feminist political solidarity, if there are no necessary and sufficient conceptual conditions underlying our gender talk? Do women make up a genuine kind? […] What kinds of entities are gender and sex anyway?” (28).

Chapter 2 reviews aspects of how gender has been and is currently debated by feminist scholars. Mikkola articulates foundational feminist theorizations of the sex/gender distinction, the problem of biological determinism in thinking about sex and gender, and the social construction of gender. Core to this chapter’s exploration of the sex/gender debate is the problem that defining sex and/or gender relies on women sharing some common features that identify them as women and define their objectification as women. This poses a problem because not all women are equitably incorporated into this category; other vectors of perceived difference (like race, ethnicity, class) shape how women experience and define what it means to be “woman.” Thus, she reviews how a thicker and more inclusive definition of womanhood has been advocated through an intersectional approach to feminist politics and theory.

In chapters 3 and 4, Mikkola details nominalist and realist responses to what she terms the semantic and ontological puzzles of the gender controversy. Chapter 3 explains the gender nominalist position that “denies that there is some normatively and ethically significant feature that women qua women share; still, it holds that there is something that unifies women’s social kind, which is normatively significant” (46). In Mikkola’s view, nominalism lacks enough boundaries of what defines woman to effectively enact a feminist politics, while still maintaining woman as a category that likely will, in fact, slip into defining particular features of womanhood. Gender realism is explained in chapter 4 as perspectives that “hold that there is something women as women share, and this ‘something’ unifies their social kind” (71). The problems Mikkola identifies in both the gender realist and nominalist perspectives are that ideas about gender are far from unified (i.e., a single conception of what it means to be woman is impossible to achieve), they tend to be exclusionary (i.e., including only certain people in the category of womanhood), and there is limited potential for political transformation in these formulations.

Chapter 5 argues that semantic and ontological issues in understanding gender “are not as pressing as feminists make them out to be;” indeed, Mikkola writes: “I contend that we need not know ‘what it is to be a woman’ or to define woman in order to identify and explain gendered social inequalities or in order to say why patriarchy damages women” (105). Semantically, she argues that the way ordinary language users deploy the term woman is sufficient for identifying ‘women’s type’ (110). Ontologically, Mikkola suggests abandoning the sex/gender distinction to interrogate the foundational ontology on which this distinction rests. She advocates instead for an approach that frames the conversation through attention to “descriptive traits (traits of which there are ‘facts of the matter’) and evaluative norms (normative reactions to descriptive traits)” (117).

In moving beyond a preoccupation with the category woman and the gender controversy, it is not that Mikkola believes that women or gendered forms of discrimination, oppression, and domination are no longer important sites of social justice politics and theory; rather, she argues that sexism and gendered forms of injustice can be more effectively ameliorated not through an interrogation of the concept woman, but through the lens of dehumanization (what she argues is a more inclusive, humanist perspective). Thus, the second part of the book envisions what humanist feminism, organized around the concept of dehumanization, can do for feminist philosophy dedicated to a liberatory politics of responding to social injustice.

In chapter 6, Mikkola defines dehumanization in the following terms: “an act or a treatment is dehumanizing if and only if it is an indefensible setback to some of our legitimate human interests, where this setback constitutes a moral injury” (145). She then explores the case study of rape and how other philosophers have understood it to argue that rape is a dehumanizing act. She makes this argument based on the fact that rape violates fundamental interests for the well-being of human beings, and she lays out what, for her, are universal human interests, extending from the biological definition of human beings. In short, this chapter is about what makes certain injustices wrongful.

Chapter 7 explains three different forms of injustice—discrimination, domination, and oppression—and what constitutes each. Discrimination is about unjust “differential treatment” (192), domination is about unjust (and for Mikkola, dehumanizing) exercise of power over others (199), and oppression is a more complex process that, at its core, “has to do with unjust constraints” (204). Whereas chapter 7 focuses on the different forms injustice takes, chapter 8 explores the contours of social injustice. Mikkola identifies how injustice functions at the individual (attitudes and beliefs) and the institutional (social structures) levels (224). These contours of injustice involve understanding the effects of racism, sexism, trans*phobia, etc. and how they operate through the individual and structural levels.

In the final chapter, Mikkola points out that it would seem that logical responses to the three forms of injustice that she has identified would involve freedom, human flourishing, and equality. She articulates why freedom and human flourishing are not sufficient to uphold her conception of social justice, arguing for a conception of overcoming dehumanization that responds to the distinct features of social injustice (discrimination, domination, and oppression). In proposing a path forward for a humanist feminist approach to social justice, she posits that: “Equality of opportunity is the condition at the heart of nondehumanization” (239). In so doing, she offers up a framework on which further theorizing on normative ideas of social justice might be based.

There are two areas of the book that I felt could be enriched. The first is in Mikkola’s conception of the human. Shifting the focus away from woman to the human, Mikkola argues, “will avoid the current theoretical pitfalls” of a focus on woman as a category (149). But the human is no less fraught a category than woman and, I would argue, perhaps an even more troubling and difficult term to define and contain. In order to sidestep this complexity, she argues that, rather than trying to understand what constitutes the human or humanity through an approach that identifies certain capabilities or qualities or social processes, the human should be defined in strictly biological terms. “Members of such a kind,” she writes, “are of the homo sapiens sapiens species (anatomically modern humans); they are typically ‘featherless bipeds’ with certain dispositional cognitive capacities (like language and reasoning skills), which develop given the appropriate environmental conditions” (147).

Dehumanization, though, is a socio-political process, and put into action in the context of the human defined as the biological homo sapiens, there is a disjuncture in what these offer together. Dehumanization does not routinely strip a body of its biological taxonomy, so what is lost in dehumanizing acts is much more complicated, much more social. Mikkola’s interest in reducing the definition of human to a biological kind does not attend to the socially and politically contested notions of the human. I was left wanting a much more robust discussion of the human (since this is the category on which both humanism and dehumanization rely), and this enrichment could come from an engagement with postcolonial and Black feminist theories of the human (such as those articulated by Frantz Fanon, Sylvia Wynter, Alexander Weheliye, Hortense Spillers, or Katherine McKittrick). Coming out of these literatures are complex understandings of the human as a deeply contested category whose boundaries have been drawn and redrawn through not just gendered logics, but deeply racialized ones; and these contestations extend to the racialized histories of taxonomic ordering and the biological sciences. Thus, I found that Mikkola’s conception of the human as homo sapiens flattens these histories and the fraught ways in which the human is and has been defined.

The second area of the book that left me troubled was in its entrenched humanism that precludes any inclusion of other-than-human life. Mikkola, in fact, anticipates this critique and includes one footnote (168-169) that explains her exclusion of nonhuman life by saying that other-than-human life does not warrant inclusion in “our moral communities.” As a feminist scholar dedicated to researching human and animal relations and thinking about the consequences of dehumanization in a multispecies context, I found Mikkola’s call for a renewed humanism—and her stark definition of human as homo sapiens—to be limited in what it can offer broader notions of injustice or how injustice works in profound and deleterious ways beyond the bodily confines of homo sapiens. Dehumanization, as a framework, necessarily maintains hierarchical categories of being: the human, subhuman, and nonhuman. To dehumanize is to strip a body of the things that make it count as human; to make it other; to render it less-than-human, subhuman, nonhuman. And this act of dehumanization relies on the maintenance of these hierarchical orderings; in order to dehumanize, there must be a ‘less than’ or ‘sub’ category in which to drive humans who are the subjects of violent acts. Maneesha Deckha (2010) argues that, in fact, it is the subhuman and the maintenance of these categories that enables violence and Othering to occur against certain lives; for her (and for me), it is imperative to challenge these very hierarchies. Thus, while I am interested in the interrogation and use of dehumanization as a frame for understanding and responding to injustice, I worry over what (or who) it entrenches, reaffirms, and excludes.

Kathryn Gillespie
Wesleyan University
Middletown, CT, USA

REFERENCES

Deckha, Maneesha. 2010. “The Subhuman as a Cultural Agent of Violence.” The Journal for Critical Animal Studies 8 (3): 28-51.

Book Reviews

Dominic Wilkinson, Death or Disability: The Carmentis Machine and Decision-Making for Critically Ill Children, Oxford University Press, 2013

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.

David Wasserman
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.

REFERENCES

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.